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.

Traumatic Brain Injury Clinic

Yesterday was my first day of PM&R (Physical Medicine and Rehabilitation; or Plenty of Money and Relaxation :) ), which is a nice change after four weeks on the medicine wards.

Every Tuesday morning in the PM&R clinic is TBI clinic--traumatic brain injury. When I did PM&R as a med student last March, I was on the TBI service and did a 1/2 day a week in TBI clinic, but today was completely different than that, because TBI in the military is completely different from TBI in the civilian world. Most of the patients I saw back at OSU were there as a result of drunken stupidity, which is most definitely not the case with the patients I saw today.

The first patient was an infantry specialist (gunner on an MRAP) who literally just got in from Afghanistan (he was on the Friday MEDEVAC). On Sept. 11 of this year, his MRAP was hit by an IED, and he ended up with a concussion that left him with persistent migraine headaches (nausea, vomiting, sensitivity to light, the whole bit). He ended up going to one of the field hospitals and got a CT, which didn't really show anything. He kept telling everyone that he felt better so he could go back to his unit, despite the fact that he was still having the headaches. After a few more concussions, it got to the point that his unit's medic realized that he wasn't fine, despite his insistence otherwise. It took the medic pointing out that a gunner who couldn't concentrate on his job was putting his unit at risk to get him to agree to be evacuated from theater for further evaluation.

It really puts things in perspective--here was a guy who was being fired at on a regular basis, who felt terrible on a daily basis, and didn't want to leave his job.

While the PM&R resident I was working with went to fetch the social worker, I chatted with him about his military history. His contract is up in a year and a half, and after that, he wants to go to OCS (Officer Candidate School) to become an infantry officer. Right now, he's still having headaches, and is having difficulty concentrating and sleeping. I really hope he gets back to where he was before these IED blasts.

The other two patients I saw had been established with the TBI clinic for awhile--one had a gunshot wound to the head and is almost back to where he was before he was shot, and the other was another IED blast, who now has some personality changes, problems with his memory, and pretty severe depression.

So like I said, traumatic brain injury in the Army is completely different than traumatic brain injury in the civilian world.

And tomorrow... amputation clinic.

End of PM&R and looking forward to internship!

Today was my last day of physical medicine and rehabilitation, which is both a good and bad thing. Good because it means I'm that much closer to graduation, and bad because PM&R was pretty easy, and now I have my sub-internship to look forward to (ugh).

We ended the day with the typical start: checking on our patients, writing notes about their progress, and going to panel discussions, where we hear the inputs from the nurses, social workers, and therapists (physical, occupational, and speech). Fortunately, no surprises on any of our patients.

After panel we checked the board and discovered that we had four new patients coming today (that's a lot). Since there's not much that medical students can do, we wrote up the histories from the computer and copied the orders (that's about all we can do; for billing purposes, everything else has to be done by somebody who already has a degree). Then our resident sent us home early, which made me happy.

I spent the rest of my afternoon going over my internship information, which I got today. I have 13 blocks (four weeks each), which includes 2 blocks of internal medicine, 1 ICU, 1 ER, 1 pediatric clinic, 1 OB/GYN (ugh), 1 PM&R (should be a different experience at Walter Reed), 1 adult clinic, 3 electives, and 2 selectives (and no, I don't know the difference between an elective and selective). I chose research, allergy/immunology, and dermatology for my electives, and psychiatry at Bethesda and pediatrics at Walter Reed as my selectives (my other selectives choices were general surgery, cardiac ICU, general medicine, NICU, orthopedic surgery, and surgical ICU). Now I just need to figure out when to take leave. I get one month around Christmas (either the week of Christmas or the week of New Year's), so I need to choose another week for next year. I'm thinking sometime in the spring.

Obviously, there will be more on internship to come (probably a lot more to come, throughout my internship next year).

Sick professors and endless didactics

So, it's been awhile since my last post... sorry. There's just not a lot going on in Dodd Hall.

I had a couple of new patients yesterday--a man who was ejected from a single-car crash on Jan. 31 and a woman who had had a burst aneurysm in her head after being pushed against a wall at work (a center for "troubled" teens). The woman is rather easy and probably won't be at Dodd for very long, but the man has quite a few problems, including a broken pelvis (surgically fixed but still healing) and several other surgical sites. He also has quite a lot of pain in his foot due to nerve damage. The hospital where he was staying since the accident (not OSU) had him on all sorts of narcotics, which aren't that great for nerve pain, so we're working on changing him over to better medications. It'll be a long process, but on the plus side, his brain injury isn't too bad, so he might actually get to return to a somewhat-normal life, unlike many of the patient on the traumatic brain injury service.

This morning I saw these patients, then headed over to Children's for didactics and a quiz this afternoon. The topic this week was domestic violence and children with complicated cases (either medically or developmentally). Not too thrilling, and none of us really wanted to be there--tomorrow is match day for most of my classmates (the military matches in December, but civilians match tomorrow), so nobody was thinking about didactics anyway. As one of my residents put it, match day is one of the three important days that dictates the path of your life; marriage and birth of a child are the other two. So it's a really big deal, and I'm looking forward to celebrating with my classmates tomorrow.

Didactics and free food

Not much exciting has been going on the last few days (hence the lack of posts), and not much happened today, but I felt the need to update, so this is what you get. We started the day with didactics and a quiz (which was, fortunately, fairly easy), rounding out the morning with 'geropardy' (Jeopardy questions about old people... my team lost because we liked to bet it all on daily doubles).

Anyway, I ducked out of class a bit early at 11:30 to head over to Meiling Hall, where I spent way too much time my first two years of medical school, to hear MAJ DeZee, an OSU College of Medicine alum and current internal medicine residency program director at William Beaumont Army Medical Center in El Paso, TX give a talk about humanitarian missions with the Army. I've actually heard him give this exact same speech before, during my first year. I also met with him at the American College of Physicians conference during my second year, so he was rather disappointed when I told him I decided to go into preventive medicine instead of internal medicine. I'll probably get to see him around Walter Reed next year, though, as he's taking over as the General Internal Medicine fellowship director at WRAMC. I hope that I'm working with him during one of my internal medicine ward months. He would be a really fun attending to have.

Between the lunch and the 'networking' (which was really just the Army students standing around and catching up), it was about 2pm when I first arrived at Dodd for my rotation. Apparently the attending didn't believe the residents when they told her that we were at didactics all morning and that I had a lunch, because she was grilling me what I was doing and why I hadn't seen my patients yet. Whatever. I just have to pass this rotation in order to graduate.

And now I'm tired, so I'm going to bed so I can get up early tomorrow and go to a case conference about testing sacral nerves. I'll give you a hint: it's not a test I would like done.

Home health care

Instead of working on the traumatic brain injury floor at Dodd yesterday, I went out with a home health care nurse to see what home health care is about (it's a rotation requirement; I had no desire to do this). It was not a worthwhile experience.

Not much happened on these visits. I expected there to be some education to the patients about how to care for their ailments at home or how to get around better, but there was none of that. There wasn't even any sort of home "inspection", so to speak, to figure out what changes could be made to make things easier for the patient. In the first building we visited, the patient couldn't walk stairs, yet there were steps leading to the apartment, without an elevator or wheelchair ramp. In the second, the furniture was so cramped into the house that to get past the couch, the patient had to lift her walker over the corner of the couch because there wasn't enough room between it and the wall for her walker to get through, and the nurses didn't say anything about rearranging her furniture to make it easier for her to get around.

Maybe it's just my experience on my occupational medicine rotation (where I learned about the importance of making small changes to reduce injury/increase abilities), but I was rather taken aback by the fact that these things weren't addressed at all. I guess I don't see the point in having someone come out to the home to provide care if they're not going to address the issue of the home.

My first day as a "resident"

One of our vice deans gave us an interesting proposition: a half day off of being a fourth year medical student a week in exchange for a half day of being a resident for a week. It was an interesting offer; five of us on PM&R took him up on it.

So after a morning of being a fourth year (on PM&R, the translation there is, standing around looking like you're doing something while, well, not), we grabbed lunch and came back for our first afternoon as "residents". Near the end of second year, students take a course to teach how to take histories and perform physicals. Usually, these are facilitated by residents, but our students get, well, us.

It was a rather enlightening experience. For one, it forced me to remember how to do a complete history from scratch. Usually, we start by looking the patient up on the computer, and then talking to the patient to fill in the gaps, but the students are taught to start knowing nothing about the patient, which is much harder, and kinda pointless. Talk about reinventing the wheel.

The second thing that was enlightening was how much we've learned in two years. These kids know, well, nothing about how to take a history. They've practiced on each other and standardized patients, but everything there is scripted. These are real patients. So while they know the right questions to ask, they don't really know how to ask them. It was quite entertaining, actually. More so (and a bit painful) when they were presenting these histories to said vice-dean. Fortunately, Dr. Clinchot is probably the most laid-back vice dean in existence. He spent as much making fun of the fourth years for being mentally checked out pre-match (civilian match is on March 19; that's all my classmates think about) as he did correcting the students. Most of their mistakes came from being nervous about presenting to attendings, and the only way to get over that is to practice presenting to attendings.

Oh, and my med student did a good job, which makes me look good :) As a med student, the most valuable lesson learned is that your primary job is to make your residents look good. My med student will go far.

Clinic day

Okay, I know I'm slacking on the posting. I meant to write this last night, but, well, forgot. Sorry.

Yesterday was my first real day on PM&R. We started with rounds (eh), and then went to a panel session, which was about an hour and a half meeting about the patients with the doctors, social workers, therapists, etc. It was incredibly boring, and my co-med student and I were both struggling to stay awake. After that, our attending, Dr. Fugate, taught us how wheelchairs should be fitted to the patient, and then demonstrated the full wheelchair exam on one of the patients. It's quite a bit more complicated than one would think.

After lunch I had clinic, which was rather difficult. Not because of anything I was doing--clinic is clinic, not too hard--but because of the patients I was seeing. Everyone had had some sort of traumatic brain injury that left them somewhat not-normal. Most of them weren't the brightest bulbs in the box to begin with, but now can't even hold even a menial job, and have very poor impulse control--and they know this isn't normal. After our last clinic, the attending and I talked about this and about how lucky we were that we could "think for a living", and I said I didn't know what I would do if I couldn't think for a living anymore. If I were in an accident or something that resulted in permanent brain damage and leaving me obsessive-compulsive or impulsive or something...well, losing my mind (literally) is one thing that I hope never happens to me.

Anyway, I need to go get ready for another fun and exciting day in Dodd Hall.

Physical medicine and rehabilitation

Today was my first day on physical medical and rehabilitation, hereafter referred to as PM&R. All in all, it was a fairly perfect first day: I didn't even have to touch a patient! The day started with orientation, as they always do, and after having my brain numbed, I headed over to Dodd Hall (the rehab hospital) after lunch to begin work.

I and my fellow med student met up with our residents a little after 1, and got the brief rundown about how things work on the traumatic brain injury service. Even after that, neither of us was really quite sure what we'll be doing this month. All we know is that we have to show up around 8:30 tomorrow morning (sleeping in!).

And that's all I know. More to come later.