Infectious Disease Consults and More Tests

On Tuesday (seeing as Monday was a holiday), I spent one day on the Infectious Disease Consult service at National Naval Medical Center (Bethesda). Then I had two days of incredibly fun testing: USMLE Step 3.

The United States Medical Licensing Exam has three steps: Step 1 is between the second and third years of medical school, Step 2 (which itself has two parts, CS and CK) is at some point before medical school graduation (I did mine July 2008), and Step 3, which is sometime after graduating medical school and before becoming a licensed physician (for most people, during internship).

Like Step 1 and Step 2 CK, Step 3 started with a seemingly endless series of multiple-choice questions on the computer. That was day one. Then, on day two, more multiple-choice, and then patient simulations--ridiculous cases on the computer where real time and case time aren't the same. It's really confusing to try to explain how it works, so we'll stick with, it was strange.

And now, I have to wait six weeks until I find out if I passed or not.

Anyway, I returned to the Infectious Disease service today (in my Class B uniform, because I forgot to wash my ACUs... I discovered today why I haven't worn those uniform shoes since the first time I wore them. My feet are killing me). Anyway, on Fridays, its all the same on consult services. Realizing that consultants don't do much on weekends, all of the primary services (the doctors on the wards, the ones writing the orders) will put in any consults that might need to happen in the next three days. So, on pulmonary services, it's "patient has lungs, please evaluate and treat", and on ID, I guess it would be "patient once complained of having a fever, please evaluate and treat". So we got a few consults like that.

The first one was "patient had a fever, chest x-ray looks like pneumonia, please assist with antibiotic treatment." This is actually pretty simple: you open the books to 'Hospital Acquired Pneumonia' and pick the antibiotics listed; then, when the bacterial cultures grow (usually takes 2-3 days), you figure out exactly which antibiotic is best, so you take them from getting two or three antibiotics, down to just one. So our recommendations were, "Continue antibiotic regimen, when culture and sensitivity returns, tailor antibiotics as necessary." Pretty simple.

The next one went to the med student (pretty similar to that one), and the one after that was mine. It was a little old lady with multiple cancers (colon, lung, esophageal...) and something on her chest CT. So we pretty much just gave advice about what they should test for.

And then we wrote our notes and went home (where I finally got to take those shoes off). Time for a nap.

Rehab consult service

Yes, I realize that it's been a long time since my last post (sorry). Since returning to DC from Christmas, I had two more weeks in the PM&R clinic, and then a week of the PM&R consult service, which I'm on this week (tomorrow is the last day).

For the most part, the consult service is pretty slow. Almost everyone who comes in from Iraq or Afghanistan gets a consult, for either amputations or traumatic brain injury, but most of those don't go onto the in-patient PM&R service--they either don't need in-patient rehab, or they need a service we don't offer (ie, blind rehab), or they want to go somewhere closer to home/family. And even for the ones who do eventually come to the rehab service, they don't need to be followed all that closely until all of their surgeries and whatnot are done.

I've seen a patient a day since starting on the consult service. The first patient was hit by an IED (improvised explosive device) in Afghanistan, with his injuries almost entirely on his face. He lost one eye in the explosion, and had a piece of shrapnel lodged in the other, and is now completely blind (at twenty-two years old). Once his facial injuries heal a bit more (he also has his jaw wired shut), he'll probably be going to the VA rehab hospital in Palo Alto, CA, which is the VA's center for blind rehab.

My patient on Tuesday was actually a patient I had seen in amputee clinic before Christmas. His leg was amputated below the knee about seven months ago in Afghanistan, and was readmitted to the hospital on Monday for a revision of the residual limb (the stump, in colloquial terms), because he was having difficulties getting a good fit with his prosthesis. The ortho team didn't really need to consult us, since he is already established with all the amputee services (physical and occupational therapy, prosthetic fittings, etc), so I pretty much just went in and chatted with him and told him that after ortho is done with him, that he'll just go back to the Mologne House (essentially a hotel on base where all the rehab patients stay until they can go home) and keep coming back to the hospital every day for his physical therapy, just like he had been doing. That was no surprise to him, because he was pretty much expecting that to be the case.

Yesterday's patient was another one that they didn't really need to be consulting us for, a patient with a mild traumatic brain injury who wanted to do his rehab at the Richmond VA hospital, because it was closer to home. So we said sure, sounds like a good idea, and left it to the trauma team to arrange the hospital-to-hospital transfer. I think they were just trying to get us to take him on the PM&R service so we'd have to do that work for them.

Today's patient was one in which they jumped the gun a little bit in consulting PM&R. After an IED blast in Afghanistan, he essentially only injured his right hand (which is, unfortunately, his dominant hand) and ended up with a lot of fractures and an amputation of his middle finger. The trauma service wanted to know if he had any sort of nerve injuries, but with his hand in a splint and all sorts of pins in his bones and broken tendons, there's no way that we could do a decent neuro exam on the hand. So after chatting with him for a few minutes, we said continue the course, and after all of his surgeries are done and the hardware is removed and the bones are healed, we'll follow up with him as an outpatient (so, after he's discharged) to do a full exam and look for any sorts of neurologic deficits, but he definitely doesn't need inpatient rehab for that.

Another patient I saw, who was actually not a consult patient but one from amputee clinic, was readmitted to the hospital today for a wound infection on his residual limb. He just had his amputation about three weeks ago, after trying to save his leg for about a year, and just has not had much luck with it. I saw him yesterday, as well as last week, in amputee clinic, and he just fits the description of bad things happening to good people. But he's really upbeat about things, and his wife (who is also in the Army and works in personnel at Walter Reed) has a good sense of humor and I think keeps things in perspective for him. I ran into them as they were checking in for him to be admitted (getting a wash-out procedure tomorrow) and wished them luck. I'll probably swing by tomorrow after his surgery to see how he's feeling.

So I spend most of my time studying for the boards (USMLE Step 3 is next week) and spending a few of my eight or so hours at work looking up these guys' complete medical histories and figuring out exactly where all of their injuries were and what kinds of surgeries they had had done. I have to say, after doing PM&R here and doing it at OSU, that it's much more rewarding (and interesting) to do it in a military setting.