Happy Thanksgiving, and farewell to Tripler

As some of you know, I am now back in Ohio, having left Honolulu at 4:50 pm HST on Thanksgiving. Somewhere in the process, between the long flight and time zone changes, I lost an entire day. I'm still having a hard time believing it's Friday. I'm also having a hard time staying awake, so I apologize if this post doesn't make much sense (as tempted as I am to get sleep, I'm trying to go to bed at a reasonable Ohio hour to ward off jet lag).

Anyway, before leaving, one of the other med students and I hit up Safeway for a Thanksgiving feast we could prepare using only a microwave. Here was our pre-"cooked" spread:

It was actually pretty good, and it was nice to spend one last morning/early afternoon with a few other med students.

Unfortunately for me (fortunately for some of you), I bought way too many souvenirs/Christmas gifts, and couldn't get everything in my suitcases, so I had to fly in uniform. It's not too uncomfortable, but I always feel awkward with people asking if I'm coming or going, and all I can say is "coming from a month of training in Hawaii". Not quite what most people have in mind when they thank me for my service. However, it did earn me a last-second upgrade on my last flight (the 1.5 flight from Atlanta to Columbus). I slept for most of it (remember: time zones are all screwed up), but it was kinda nice.

Anyway, before I left, Tripler already had some Christmas decorations up. Well, they've had some up for the entire rotation, but the departments each had their signs up, some of which were fairly clever. Here's the department of Radiology:

And of course, I wouldn't be me if I didn't include the department of Preventive Medicine (not nearly as clever, but whatever):

So, that was that. I'm sad to see Hawaii go (I was really sad when I got off the airplane in Columbus and promptly froze). Now I have the weekend to study for the exam I should have taken on Wednesday (had I not been five time zones away), and I begin my next rotation (occupational medicine) on Monday.

Last day at work

Today was my last day in the Allergy and Immunology clinic. It was a typical day at work, albeit a bit short (no patients scheduled for the afternoon--yay!). I evaluated a couple of patients, wrote a couple of notes, chatted with COL Yang and LTC Marks for a bit, and then headed to noon conference before heading out for the day. I decided to hit the gym for what will probably be my last time swimming in an outdoor pool in November for awhile.

Anyway, here's the "office" I've been using for the past month. It's not as much an office as a storage space for extra stuff that just happens to have a computer.


So, tomorrow I have outprocessing--ugh. Walking through the hospital getting signatures from various departments (security, computer IT, etc), asking for permission to go home when I don't want it, is never my idea of a good time.

Transient hypogammaglobulinemia of infancy

No, the title of the post wasn't me slamming my hands against my keyboard. That was the disease (well, not really a disease...) one of my patients had today.

The reason why I say it isn't really a disease is that transient hypogammaglobulinemia of infancy is a normal variant of the immune system of children. When born, babies have their mother's antibodies. As the months go on, those antibodies begin to fade, and the baby's own immune system is supposed to take over. Sometimes there's a bit of a lag between those two things happening, leaving the kid with low (hypo) antibodies (gammaglobulins). So, there are low levels of antibodies in the blood (-emia), you get hypogammaglobulinemia.

The kid today was a twin born at 34 weeks (remember from my OB posts, a full-term pregnancy is anything between 37-42 weeks). Since he didn't have as much time being fed from the placenta as he should have, he didn't have as much of his mother's antibodies as he could have used, which meant his levels got lower than they should have. At Ft. Knox (where he was born), he had several ear infections starting at 3 months old, which prompted a referral to the immunologist. He did blood tests and saw that there were low levels of antibodies, so he diagnosed transient hypogammaglobulinemia of infancy. Technically, the "transient" part can't be diagnosed until it goes away, which is why he's following up now--to get blood drawn again to check the levels. Since he hasn't had many infections in the last six or so months, we're pretty sure even before getting his blood that he has appropriate levels of antibodies for his age.

On a completely different note, I've mentioned a few times the hills of Tripler, so I included the elevation map (green line on the graph) of my usual run from my GPS watch. That loop takes me completely around base--like Walter Reed and unlike Madigan, Tripler is a stand-alone base, not part of a larger one. So it's a pretty small world I'm living in this month (obviously, as there's not even a place to buy food on base).

Medical board

My first (and only) patient of the day was already in when I arrived at clinic from morning report, getting his skin tests. He was a bit unusual in that he wasn't a new patient; he had been seen by COL Yang about a year and a half ago, before he was deployed to Iraq. At that point, he was being evaluated for his deployability, due to his history of allergies diagnosed and treated by a civilian allergist since he was a teenager. Needless to say, COL Yang determined him deployable (ie, his allergies wouldn't be enough of a problem to prevent him from doing his job in Iraq).

Well, unfortunately for the patient, he got in a motorcycle accident while he was on R&R nine months into his deployment, landing him in the hospital and rehab back in Hawaii. He messed up his shoulder during the accident, and there wasn't much a motor transport operator (88M for those of you familiar with Army MOS) could do, so he's been spending most of the last year on a medical profile. When it became obvious that he wouldn't be able to do his job again, he was referred to the medical board for a medical discharge. One thing that happens on medical board is they go through your medical record (obviously) and go over everything they've seen a specialist for. So, he had to go back to COL Yang to be evaluated for his allergies again. Guess what? We discovered he still has allergies (surprise, surprise). So we refilled his prescriptions, recommended he get hypoallergenic mattress covers and pillows, and determined that while he does have allergies, it wouldn't prevent him from retention (staying in the Army), which gave him a 10% disability with the VA (from what I figure, that means they have a condition that requires specialty care, but doesn't really cause disability). Conditions are summative; if someone has five conditions that each cause 10% disability, he is considered to be 50% disabled. In the case of this patient, his shoulder/back injury from the motorcycle gives him more than enough to get his medical discharge and to get full medical care from military facilities for life.

So, my one case today was yet another example of government red tape--a man who quite obviously can't do his job requiring him to lift 200+ pounds of equipment being evaluated for the dust mite allergy that causes him to sneeze.

Rain, rain, go away...

I tried to post this last night, but the internet connection is a bit patchy, so it didn't take.

Anyway, Sunday night, a few of us grabbed a taxi down to the NEX for a quick dinner (which still took an hour...it takes awhile to get things done when you have no primary mode of transportation). While we were there, the sign said Aloha, so I decided to pass it along.

Anyway, yesterday I woke up to the sound of rain, and it didn't let up all day (or if it did, I was indoors the whole time). Fortunately, the walk from the Lodge to the hospital is a short one, because it's never fun to walk around with a wet piece of wool on top of my head. Also fortunately, rain in Hawaii is still rather warm, so while I had to start my working day in a wet uniform, at least it wasn't a cold and wet uniform.

Here's what Hawaii in the rain looks like (from the Allergy and Immunology clinic window):

Long commute to see the doctor

Yes, I know, it's been quite a few days since my last post. Unfortunately, not much has happened.

On Thursday (I think it was it Thursday), we had a patient who had quite the commute to see the allergist--all the way from Okinawa, Japan. He moved to Okinawa about two years ago, and about a year ago, began to notice a really itchy rash that instead of going away, got larger. He tried allergy medicine, tried washing his uniform every day, and tried just about everything else that people recommend for exzema. It got so bad that he was going into sick call almost every day, and had to be transferred from his job outdoors to an office job. Finall, his PA got him an appointment with the one dermatologist at Okinawa (after a few months waiting, of course). They tried him on over 20 different medicines; some made it slightly better, some did nothing. Finally, they got him an appointment with the closest allergist, which just happened to be COL Yang here at Tripler.

So we saw him and said, yep, that's exzema. So we got him some different medicines, one that he had tried and two that he had not, and then sent him back to Japan and told him to continue following up with the dermatologist. Hopefully this will take care of it. Since he can't really do his job with this exzema, the next step is to move him away from Okinawa, probably back to El Paso, TX.

Anyway, that was the most exciting patient all week (week-ish, I guess). Yesterday I walked down to the NEX at Pearl Harbor (about 4.5 miles) and did some shopping (not much, since I had to walk back). Today was another diving day. We went out of Waianae Bay, which is on the west side of the island (Tripler is close to the south). It was beautiful weather for diving while we were diving, then it instantly started raining as soon as we got the boat back to dock. Here's a picture from the boat.

I didn't get back to base until about two, and then I was tired from diving, so I didn't do much the rest of the afternoon. Then around six (when it started raining again), a couple of other students and I grabbed a cab and went down the NEX for dinner and do some grocery shopping.

Tomorrow, it's back to work, for my last (and second) full week of work at Tripler.

Back to work...kinda

After four days of vacation, it was time for me to go back to work... and I use that in the loosest sense of the word. After morning report, Dawn (the University of Hawaii med student) and I headed down to the Allergy and Immunology clinic, logged into our computers, and found that there were no patients scheduled for the day. COL Yang was working vaccine clinic in the morning and had an administration day in the afternoon, so nothing for the med students to do. He gave us the morning to study and told us to report back at 1300 for lectures on allergic rhinitis and urticaria (hives). So I did some OSU on-line lectures in the morning (as this is a required rotation), headed back for a noon conference lecture on anorexia, and then back down to clinic for two hours of lecture. In other words, it was a long day of lectures.

But here's a picture from the allergy and immunology clinic window.

Both a doctor and a soldier

As Army physicians (and future Army physicians), we know that our daily lives force us serve two--or more--masters, but never had I had such a good demonstration of this as today during a rather unusual noon conference--COL Salerno, the Internal Medicine Residency Director, giving his farewell address before deployment tomorrow.

An Army doctor, even a colonel, being deployed is not an unusual event, but his story is a little different, because he is a residency director. In 2005, the Army and the ACGME (American Council of Graduate Medical Education) formed a written agreement allowing residency directors to deploy for no longer than 90 days. This was a concession on the part of the ACGME, as previously residency directors could not deploy, due to accrediting regulations that require residency directors to be on-site, supervising their residents.

That being said, COL Salerno is not going to be gone for 90 days--he'll be gone for 10 months. After several "deployment scares" that prevented him from joining various committees that would be good for his career, he decided to volunteer for deployment, to get the waiting and wondering over with. Instead of taking a simple 90 day deployment working at a CSH (Combat Support Hospital), he volunteered for a position as an administrator of an Army-Iraqi medical team (he kinda explained, but I didn't really follow). He was going to split the deployment with another colonel, which would allow him to be gone for his 90 days and return to Tripler. He had written promises from a brigadier general and the other colonel that he would only be deployed for 90 days, to avoid any problems with the ACGME. However, as things have a tendency to do with the government, it fell through. After scrambling for two months trying to rectify the situation and applying for exemptions with the ACGME, nothing changed. Since 10 months is obviously a violation of the 90 day rule, he had to officially step down as Internal Medicine Residency Director at Tripler, which was not in the career plan he had set for himself.

However, things did work out for him. When he returns from deployment in August, he'll take over as the Director of Medical Education at Madigan. I was a little sad to hear about this, which had nothing to do with COL Salerno. LTC Wiesen, the Preventive Medicine Residency Director at Madigan, was applying for that position, which would have caused a shuffle in the preventive medicine residency programs beneficial for LTC Littell and MAJ Soltis, two staff members I enjoyed working with at Madigan and WRAIR, respectively. However, COL Salerno does outrank LTC Wiesen, so it's not too surprising.

Medical education positions aren't always easy to come by in either the civilian or military worlds, but rarely do civilian physicians have to worry about what will happen if their 90 day vacation to a war zone gets extended.

Pictures

As promised, here are my first pictures from Hawaii. Dan (the HPSP student from West Virginia) and I went down to Waikiki on Sunday for dinner. Here's a picture from the beach:


And here's the Mountainside of Tripler (the two main buildings--which are connected--are called Oceanside and Mountainside). I took this on my walk up to the Tripler Lodge after work on Monday.
And more of the same from further up the hill. By the way, these hills do NOT make it fun to go running.

More pictures to come later (as I take them, of course).

It was more of the same at work today. COL Yang was doing vaccine clinic again this morning and had Dawn (the University of Hawaii fourth year med student) working with him, which left Tracie (the PA student) and I with nothing to do. After lunch and noon conference, we had one new patient, a woman with some sort of environmental irritant in the building she works in that has been preventing her from going to work. Even though the history wasn't consistent with allergies, we did skin tests on her anyway, which were, not surprisingly, negative. Chemical irritants (ie, perfume, cleansers) aren't allergies, and can't be treated with medicine like allergies. So we scheduled a follow-up (for what, I'm not sure) and sent her on her way.

After work, I decided I needed food, which is not to be found at the Tripler base, so after one of my usual laps on base, I ran to Ft. Shafter (about two and a half miles away) to visit their very small PX/Commissary before making the trek up and down the hills back.

Not sure what's on the schedule for tomorrow, but I'm guessing it won't be too different from any other day.

Free vaccines in the Allergy and Immunology clinic

Okay, technically, there are always free vaccines (at least to military personnel, dependents, and contractors) on military bases, but I saw it first-hand today while working in vaccine clinic. It was pretty fun, actually--people were lined up with their papers saying which vaccines they needed, COL Yang would chat with them for a couple of seconds, sign their papers, and send them to the Specialist to get their shots. I realized that since I'm on active duty this month, I also qualify for free shots, so I grabbed my own sheet of paper, gave it to COL Yang, and got my third Japanese Encephalitis shot, saving myself about $100, which is what it would have cost to get it at the OSU Health Center.

After a fun and exciting day in vaccine clinic, I got off work at 1500, went on a run (running up and down a Hawaiian mountain may sound fun, but it's actually hard work) and then grabbed a taxi to go into Honolulu for dinner. There is absolutely no place on base to get food--at all. There's not even a PX or commissary.

I did get a new sync cable for my phone, but it still isn't working, so there's something wrong with either the phone or the computer. Hopefully it's something I can fix.

Aloha from Tripler!

Yesterday, after a very long day of flying (hour and a half to Atlanta, nine and half to Honolulu), I arrived in Hawaii, got my two very large bags from baggage claim, climbed into a taxi, and checked in at the Tripler Lodge. During the flight, I met another HPSP student, Dan, so it was nice knowing one person on the island at least. After unpacking all the stuff I need for the month (and calling Adrienne and bragging about how sunny and warm it was), I discovered that there is no food to be found on base on Sunday nights. So Dan and I hopped on a bus toward Waikiki, wandered around the touristy areas for a bit, and had dinner at a nice Thai restaurant before heading down to the beach for a bit (can't arrive to Hawaii and not go to the beach on the first day, after all). I took pictures, but they're on my phone, and I discovered this morning that I grabbed the wrong sync cable to connect my phone to my computer, so until I get another one, no pictures from the phone.

This morning started the same as every other Army rotation: wake up, eat breakfast, wander around the hospital for a couple of hours in-processing. Then I met the chief resident of Internal Medicine and got a tour of the medicine department before he took me down to the allergy and immunology clinic. Turns out, the attending who was coordinating my rotation is now deployed, and forgot to share with the other attendings that I would be coming. Oops. So we laughed about that for a few minutes, then I went and started seeing patients.

Other than seeing a couple of patients a day in clinic, I have morning report every morning at 0730 and noon conference at 1215. There are no calls (yay!) and no weekends (yay!), so I have the evenings and weekends to myself. So far, that means I did (well, I'm still doing, technically) some allergy reading tonight, and called the dive master Daniel Christian recommended. My first dive in Hawaii is at 9 on Saturday morning, and I'm really excited about it.