Goodbye, Madigan

After crashing at Rachel and Jason's last night, I got up this morning and headed over to Madigan for the last time, for my out-processing, which is really just wandering around the hospital and getting signatures for doing things like turning in my white coat and badge.

This is a picture of Madigan I pulled off of Wikipedia. It's actually a fairly old pictures; the short buildings between the hospital and Mt. Rainer is the Annex (otherwise known as Old Madigan), which is where I was working. I know it's an old pictures because there are about half as many buildings there now. My building is near the middle of this group, which is now the edge of the group of buildings (there's a large field there now).

After a month at Madigan, I will have to admit that I am going to miss the place, especially things like always being able to find a parking place, hanging out with the interns, listening to LTC Wiesen talk about making President's Hundred on the rifle (he's one of the top 100 riflists in the country), trying not to laugh at the guys getting lost on their way to STD clinic, running on base in the morning when it's still cool, and enjoying the view of Mt. Rainer. However, there are also things I'm not going to miss, like that windowless box of an office I shared with the interns (windowless and without air conditioning), the strange animosity amongst the residents, documenting everything in AHLTA, and the like. Overall, it was a good month, and if it weren't for the fact that the residency program is focused on the things I find most boring about preventive medicine (public health department-type stuff), I would really enjoy doing my residency here. We'll see how things go at Walter Reed Army Institute of Research next month.

Anyway, after out-processing, I drove back down to Camas and proceeded to spend the entire afternoon stuffing my junk into suitcases so Mom and I can begin our cross-country trip back to Ohio tomorrow. And when I say stuffing my junk into suitcases, I'm not joking. I have three suitcases, three book bags, four boxes of wine bottles for Adrienne, and still more stuff that will just go into whatever crevice we can find in the car. That's a lot of junk.

See? A lot of junk. Hopefully it will all fit into the car tomorrow.

Interrupting my day with work

My days at Madigan are quickly dwindling down, as is my workload. Pretty much, I've finished everything that's on my list of things to do, with the exception of giving my scoliosis presentation (I've already finished the powerpoint slides), so I spend most of my time twiddling my thumbs and waiting for something to happen. Well, I occasionally do things out of extreme boredom to break up the boredom, like on-line training modules that aren't due for about a year or taking extra time for lunch to walk to Madigan (prev med is in the annex, not the actual hospital), buy lunch, walk over to the park, and eat and read my novel.

I did have to interrupt that nothingness with TB clinic this afternoon, which was fine by me. It's my favorite clinic of the three I do (TB, STDs, and travel), but travel is a close second, and I got to do that yesterday. I like TB clinic because there's some detective work (you have to decide if it truly was a positive TB skin test, and then what their exposure might have been), and a chance for patient education, and I feel like the patients leave with a better grasp of what is going on than they had coming in, and often feeling better about the situation. I can imagine it would be pretty scary to come back from deployment to be told that you have TB, and they don't really understand what a positive skin test means, and so we get to explain that to them and let them know it doesn't mean that they're dying or infecting their loved ones.

Tomorrow is my last full day of preventive medicine at Madigan, and then I'm out-processing on Friday. It's been a good month overall.

On my way back home

I'm sitting at the Phoenix airport now, enjoying my three and a half hour layover on the way back from Albuquerque at the Military and Veteran's Hospitality Suite, which is like the USO rooms, only not sponsored by USO. It's all the same--free internet, free snacks, and Marines playing cards and video games. Not much else to do.

Anyway, the conference ended on a strange note. Throughout the week, I noticed a definite lack of cohesiveness among the Madigan PM residents, which is unusual. Most residency classes are rather close-knit, but not this group. We had one van for the group of us, and at any given time, about half of us knew where it was and when it was leaving either the hotel or conference center. One of the majors was left behind in the morning almost every day, because nobody made any effort to make sure that they communicated the day's plans to anyone. This morning, for example, the two interns and I assumed that we were leaving at 7:30, because the first session started at 8. Well, we were sitting around at the continental breakfast, and finally saw one of the residents at about 7:50, who then informed us that the van was leaving at 9. In other words, we could have gotten an extra hour and a half of sleep. Not only that, but we missed the one good session today, which was at 8:30. And then, by the time we arrived at the conference at 9:40 (the hotel is about ten minutes away... we were just that delayed in leaving), we were too late to walk into a 9:30 session, and 10:00 was a break session. In other words, we had nothing to do until 10:30. So, to recap--the interns and I did NOTHING but sit around not knowing what was going on for three hours. By this time, CPT Wilson and I were so annoyed that we decided to go for a walk around downtown Albuquerque (which is not all that exciting, in case you're wondering) instead of going to any of the sessions, which we weren't interested in anyway.

Tonight, Kit's picking me up from the airport, and then Kit, Alex, and I are headed over to Moses Lake tomorrow to see family and for Thea's baptism on Sunday.

"Actually, that's 'thanks for the cake, sir.'"

Okay, so nobody's ever said that, but that's how I feel sometimes when I forget that in the Army, you're supposed to attach "sir" and "ma'am" to the end of everything when you're talking to a superior officer. It's not as if I was familiar enough with my attendings at OSU to call them by their first name, but I didn't end a conversation by saying, "I'll keep that in mind, sir," either. Often I realize about two minutes after LTC Littell or LTC Wiesen walks away that I should have done that, at which point it's obviously too late. CPT Peik seems good about remembering that (which is probably why I keep realizing that I forget it; I keep hearing him say it), but CPT Wilson doesn't seem to say his sirs and ma'ams all that regularly, either, so maybe I'm not as insubordinate as I sometimes think I am.

Anyway, proper address of senior physicians aside, today was a fairly normal day around PM at Madigan. The morning was spent going through AR 600-110, which is the Army Regulation on HIV testing and surveillance. Quite a lot of legalese and government-speak in there without ever really saying anything, which by the end of the morning made me feel like my head was going to explode. Then we had an award-giving ceremony for COL Barraza, the PM department chief, who is going to be leaving Madigan for Germany in a couple of weeks. There was cake, which was where the title of this post came from.

The afternoon was one long education session for me. The residents take turns going over chapters of the epidemiology textbook with me, and today they caught me for two chapters (they had been slacking, and realized that the week was almost over, so they had to get caught up on their educating responsibilities). I also did some work on my scoliosis project, which is currently looking longer than anticipated. Well, it's always easier to remove slides than put them in, so I'm not too worried about that.

After work was another not-so-fun aspect to being on a very, very large Army post. Today the power went out on Ft. Lewis everywhere except the Madigan Annex (I don't know why; we don't have a generator). This meant that all the streetlights were out, which made driving around a post with a couple thousand other people quite the experience. I was headed up to Uniform and Supply to buy more tee-shirts for under my ACU's, which requiring driving across post, only to be told that they were closed due to the power outages. So what would have normally been a twenty minute diversion on the way home turned into an extra hour and a half--and I had nothing to show for it. Such is life, I guess.

Bad car! Bad med student!

Hmm... I don't know which story to start with. I guess I'll go chronologically.

I managed to wake up on time this morning, so I went running for about an hour, then showered and changed at the gym before going to work. The morning was pretty low-key, with a giant conference of all sorts of preventive med people (PM, public health nursing, occupational medicine, industrial hygiene, health physics, and others I'm probably forgetting). After that there wasn't much going on, so I finished the online smallpox vaccine course and did some work on my scoliosis project before latent TB clinic in the afternoon.

And here's where the "bad med student" part comes in. So I'm interviewing the patient, who had a skin test of 13 mm after returning from Iraq. Unlike most that we get, he's never had a completely negative skin test, so he wasn't quite sure why he was referred to the TB clinic this time. Well, after finishing the history, I present the case to the attending to determine whether or not he's in a risk category that would make 13 a positive test (low risk is only positive if it's over 15 mm; medium risk is 10-15). Then we went back in together to get more history to figure out his risk factors. Yeah. Apparently, in addition to being deployed in a country with TB (which we sometimes consider a risk factor), he used to work in a chiropractor's office (patient care is a risk factor), lived in large cities in Texas (where there was possible contact to Mexican immigrants with TB), and spent a weekend in jail (another risk factor). So if I had bothered to take a complete history, I would have realized without a doubt that he was medium risk and 13 was a positive result and he should get treated. Oh, well. I'll do better next time.

Now for the "bad car" part. After our day was over, I got in my car, and the key did not turn. At all. I tried jiggling the steering wheel, pressing the brake, arming and disarming the alarm... nothing. So I called Volkswagen roadside assistant, and they called for a tow truck (it was very interesting to try to describe where I was parked, but that's another story). Fortunately, Bubba the tow truck driver showed up fairly quickly. Yes, his name was Bubba. I couldn't make that up if I tried. Well, he couldn't get it to turn, either, so onto the tow truck the car goes. Then we got it to the Volkswagen dealership here in Tacoma, at which point it starts up on the first try. So now my brand-new car seems to like making me look like an idiot. Hopefully it's done playing games now.

Can we make this any more awkward?

Actually, to be fair, STD clinic wasn't nearly as awkward as I feared it would be. Most of the guys (and the vast majority are guys) have been through this before and know what to expect. Most also realize that them being there is their own fault.

I saw three patients today, and they were all pretty straightforward--one got a phone call last night saying someone he slept with tested positive for chlamydia and he should go in for treatment, so we ran some labs and gave him some medicine. The other two were a few days early for what we jokingly call "green light Friday". They don't have any symptoms, don't have any contacts with anyone with an STD that they know of, they just want to be screened to make sure everything is okay. So we draw blood and take a urine sample and give them a phone number to call if they don't hear from us first.

After that, the day was significantly less exciting. I went through the CDC's online TB course (which mostly consists of reading mind-numbingly boring powerpoint-type slides and answering questions) and then went over the first chapter in the epidemiology textbook with one of the residents. Then I went to the DA's online smallpox vaccine course (more powerpoint slides, more questions). Those were even more mind-numbingly boring than the CDC's TB stuff, and not even laughing at whatever the interns were talking about was helping me stay awake. It didn't help that our office was probably over eighty degrees even with the fans on.

Since I overslept this morning (my cell phone for some reason froze at 4:45 am, so there was no alarm), I didn't get to run before work, so I tried running after work, when it was almost ninety degrees outside. Needless to say, I didn't run far. Hopefully there will be no repeat performance from my cell phone, and I'll be able to run when it's still cool out tomorrow.

Travel clinic

After an uneventful weekend of shopping and hanging out in Camas, I was back up to Madigan this morning to do more prevention of diseases. The original plan was for me to be in STD clinic this morning, but that didn't happen--they were already lined up out the clinic door when I arrived at 7:20 (clinic starts at 7:30 and it's all walk-ins), plus there was a new resident running clinic (they switch every month, so this is the August resident), and it was just too hectic to try to see patients and train a med student at the same time. By the time the morning was over, they had seen 18 patients. The record for that clinic is 22. I did hear some stories though, which left me and Captain Wilson (the intern who wasn't in clinic this morning) shaking our heads in wonder.

So instead of working STD clinic, I spent the morning doing more of my research for the scoliosis project. I found a timeline of scoliosis screening in Washington, which I thought was interesting. It didn't take them much to make school screening a requirement after the first recommendations from the Scoliosis Research Society and the American College of Orthopedic Surgeons in the 70's, but then after the US Preventive Services Task Force made the recommendations against in 2004, they've been trying to repeal the law requiring it, which has taken quite some time. Apparently it's much easier to make a law than get rid of it.

There were three patients in the afternoon for travel clinic, all three of which are what are referred to in the travel medicine world as "VFRs"--Visiting Friends and Relatives. In other words, they were born in foreign countries (in this case, Asian countries), became Americans (one couple immigrated, the other woman married as serviceman), and are now traveling back to their home countries to visit. In other words, they are experienced travelers who know more about what is needed than I do. They were good patients to start with, though, because they were fairly straightforward. It just took me awhile to figure out how to document everything in AHLTA.

After work, I swung by Rachel and Jason's for some free food (thanks, Rachel :)) and just to hang out. Kit was there, too, so the four of us talked about all sorts of random things from gossip about who is dating whom and applying for police jobs and nuances of the Army and things to do in Hawaii. We did have a quote of the night (which is probably on Rachel's blog, too): someone knocked on the door, and Jason got up to see who it was. After looking in the peep hole, he said, "Oh, it's Mormons," and then opened the door, at which point, one of the missionaries said, "Yep, it's the Mormons, just like you announced. Would you like to hear about Jesus Christ?" We got a good laugh at that one (of course, after we politely told them we were in the middle of dinner and closed the door). Good times, good times.

STD day

No, I didn't get an STD, I just spent the entire day reading about them. Seriously, I probably read 150 pages of information about STDs in preparation for working in STD clinic (which is the biggest clinic we have; it runs every morning).

In between articles and guidelines for STD treatments, I worked on other things, like my journal club presentation for tomorrow. Sure enough, on the paper to fill out to "guide our thinking" (read: questions we will be asked about), the last category was "impact on clinical practice". So I stared at that for awhile and then figured if I did something else, it would come to me. The article I chose was about how people order at fast-food restaurants when the calorie information is visible while they're in line, so I couldn't figure out what that would have to do with a clinical practice. When nothing came to mind, I asked Captain Peik (one of the interns) what I should put. After describing the results, he said "Oh. Just put 'require fast-food restaurants to post calorie information at point of purchase'." That's right, I can do that; this is preventive medicine. My 'clinical practice' has nothing to do with one patient, but rather one community (such as an Army base) and about making changes that would make everyone healthier.

And after I did that, it was back to STD reading.

Latent TB clinic

Today was TB day in Preventive Medicine. After arriving at 7:30 and finding the office I share with the interns still locked (the lieutenant colonel who has the key forgot his Army ID at home, so when he got to the gate he had to turn around and get it and was a bit late), I sat in the conference room for awhile reading from the epidemiology textbook I have to get through this month. After my room was unlocked, I logged onto the computer and spent the next three or so hours reading the TB materials in the Preventive Medicine database. It would have gone faster, but I spent a lot of the time laughing with one of the interns, which somewhat impeded both our abilities to get work done.

Once I got those out of the way, I spent some time flipping through the various public health and preventive medicine journals we have in the office, trying to find an article for journal club on Friday. Journal club isn't nearly as much fun as it sounds--pretty much, the lowest people on the totem poles (so in this case, me and the residents) pick articles, describe the research methods and the results, discuss whether or not it's applicable to our current situation (so in this case, for preventive medicine in the Army), and point out the flaws in the research and reasoning. Then after we present that, the higher people on said totem poles (the attendings, and in my case, the residents) ask all sorts of questions and pretty much make me feel like an idiot. I couldn't find anything all that exciting in the journals, so I finally settled on an article on visibility of calorie content on menus and purchasing decisions in fast food restaurants in New York City. The conclusion: when people can easily see the calorie contents of the food, they're more likely to buy things with fewer calories. Subway was the winning restaurant on making those visible to the customers.

Anyway, back to TB... the afternoon was latent TB clinic, which is people who had a positive TB skin test, but don't have symptoms and don't have any findings on chest x-ray. They come to us, and we decide 1) if we believe the positive TB test, 2) if we want to treat them, and 3) what to treat them with. There's no requirement to be treated for latent TB (unlike active TB, which you not only have to be treated, but they have to see you take your medicine), so part of #2 is the patient's preference. If they decide to be treated, and we decide that's a good idea, they get isoniazid (also called INH) for nine months. They can't do this if they have abnormal liver function tests, are pregnant, take other medications metabolized by the liver, or can't go nine months without drinking. I didn't do much in clinic today; I pretty much shadowed one of the residents and watched closely to learn how to document things in AHLTA, the DoD's electronic medical record system.

I have no idea what I'm doing tomorrow, but I'm guessing it will involve reading from my textbook, preparing my journal club presentation, and researching my scoliosis project.

Computer training

Today, I had the fun and exciting (that's sarcasm) experience of training on the computer systems used around Madigan. We were to report to the classroom at 0800, and expect to be there until 1600. We were less than thrilled with the idea of eight hours of sitting in front of computers learning what buttons to push to see lab reports.

Fortunately (or unfortunately; I haven't decided yet), I didn't have to be there for the first hour, which was training on Essentris, the inpatient system (I don't see patients in the hospital in preventive medicine; it's a bit too late to prevent anything at that point). I've also used Essentris at OSU, so I already know the system. The unfortunate part was that they didn't tell me this until I had already arrived in the morning, so I missed out on what could have been an extra hour of sleep. So I figured I'd use the time to go to the PX and buy some stuff I needed (such as a black backpack, green highlighter, pens that fit in my ACU pen pocket, etc). Well, I learned after walking across the Madigan parking lot, driving across base to the PX, and walking across that parking lot, is that the PX doesn't open until 0900. Sigh. Such is life.

After returning to Madigan empty-handed, I sat in the computer classroom for a couple of hours before lunch break, which was really too long considering the hospital cafeteria was right there and there was nothing else for us to do. So we occupied space in the cafeteria and talked for about an hour, likely to the annoyance of other cafeteria visitors. Then back in the classroom for more training. It didn't take as long as scheduled--we were out around 2:30--so I hit up the PX (which was open), went shopping, and headed over to Rachel and Jason's to hang out, hear about Tennessee, and listen to Jason's stories about Iraq (and eat their food, of course :)).

Pretty chill day, which will not be the case tomorrow. I have to review the CDC's guidelines on TB in the morning to prepare for TB clinic in the afternoon, while hopefully getting started on my project. We'll see how that goes.

First day at Madigan

Today I began the fun and exciting adventure that is a 4th year HPSP student on Army rotations. For the first time ever, I put on my ACU (Army Combat Uniform) in its entirety (when I went through Officer Basic Course, we were still in the old BDU, or Battle Dress Uniform). Of course, I had a brief panic attack thinking that I had the flag on the wrong arm, but it was all good.

I left really early from Ann and Norm's to give myself enough time to get a visitor's pass and get through the gate... that was a mistake. After more than half an hour at the main gate, they finally called my number and I handed over my proof of sale and proof of insurance for the car. The lady at the counter looked at it, and then told me that if I have temporary tags, I don't need a pass, I can just show my ID and get in. That would have been helpful half an hour before! So, I ended up being five minutes late for in-processing. What a great first impression.

Fortunately, I in-process with the Graduate Medical Education people, not the Preventive Medicine people, so they'll never know. There were three of us who are doing the rotation without orders (called non-ADT, or non-Active Duty Training), so we filled out our papers pretty quickly and then were done, so we went and got our hospital ID badges and white coats. I won't wear my coat (they don't wear them in Preventive Medicine), but it was an interesting novelty to check out a long white coat, instead of the short med student coat that I've been using for the last three years (we aren't allowed to wear the coats from our schools while on rotations in Army hospitals). Anyway, after that, it was back into the car to drive to the Madigan Annex, where the PM department is located (it's in the old hospital, not the main hospital).

Since I haven't been trained on the computers yet (that's tomorrow, all day), there wasn't a whole lot for me to do, so they gave me a tour of the place and introduced me to the interns, one of whom I met last February at the American College of Preventive Medicine conference, and then I started researching my project for the month (picking a recommendation from the US Preventive Services Task Force and describing the recommendation and the evidence behind it; I think I'm going to do scoliosis screening for adolescents, which is actually NOT recommended by the USPSTF). I also met some of the third year residents, one of whom is an OSU grad--go Bucks! I did have the misfortune of informing him that Dr. Stang, one of our former associate deans, passed away about two months ago, which was hard for him to hear. Dr. Stang was a mentor to him, as he was to many OSU grads.

After a longish day of not doing much, I decided my boots weren't all that comfortable, so I went to the uniform shop and bought myself a new pair of boots, which are very nice. I think I've had more uncomfortable tennis shoes. Anyway, tomorrow is eight hours of computer training through the Graduate Medical Education office, and then we'll see what PM has in store for me after that. I think it's going to be a good month.