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.

USMLE Step 2 CK score

Yay! I passed Step 2 CK! I got an email this morning as I was getting ready to head out for the conference saying that my score was in. However, when I tried to click on the link, the settings on Internet Explorer were off or something, and it wouldn't open, and I didn't have time to fix it before I had to leave. So, I figured that I passed, because if I failed, it would say something along the lines of "click here to reschedule", and it didn't. I finally got to check when we returned to the hotel in the evening, and I did indeed pass, and beat the national average by 2 points (which was a closer margin than my Step 1 score).

Other than that, the most exciting event of my day was my "interviews" for residency positions with the two Preventive Medicine residency directors (Madigan and Walter Reed). I use that word lightly, because it was really just a conversation about why I'm interested in PM and how the two programs are different. That, and this was nothing scheduled--I showed up where I knew they were sitting between sessions in the conference (granted, LTC Wiesen told me where they were going to be and told me they would be there between 9 and 12, but that was it).

There were a few good sessions, a few boring ones, and when the day was over, we headed back to the hotel, ordered dinner, and watched the Olympics. All in all, a good day.

It's done!

After a month of whining and complaining about how much I have to study for step 2 of the boards, it's done! I left the house at 8 this morning and drove to Portland (not so far in that I had to deal with rush-hour traffic), and was seated at a computer, which became my home for the next seven and a half hours. It was a joy.

Here's pretty much what happens: I go in, check in, make sure everything is in the computer correctly, listen to the rules, and follow one of the proctors to my computer. This is just at a testing site, not specific to the USMLE, so there are people there taking other exams--for example, I saw at least four family medicine doctors there for their recertification exams. So after signing in, there's a ten minute "orientation" on the computer, pointing out what each of the buttons on the screen means. Then the test begins. There are eight blocks of 46 questions, with an hour given for each block. There's also 45 minutes of break time to use at any point between the blocks. Any time that isn't spent answering questions goes toward the break time--you don't get more time on the next section if you finish one early. I'm a fairly fast test-taker, so I had time left over after each block, so I signed out and walked around the courtyard for a bit, cleared my head, and went back in. By the end, the proctors were very used to seeing me coming up and signing in/out. I did four blocks, broke for lunch, went for a bit of a walk (since I had so much break time built up already) and came back for my last four. By the sixth block, my brain was fried and I was doing all that I could to just read the questions each time instead of clicking a random answer, but I made it through. The score for this one will come in about six weeks.

In other news, I bought a car yesterday. It really wasn't planned. When Alex and I picked up the parents at the airport, Mom suggested going in and test driving some cars so I have an idea of what I'm looking for. Well, before I knew it, I was signing the paperwork for a 2008 Volkswagen Jetta. We're picking it up tomorrow, so pictures will probably appear sometime after that.

A few thoughts on The Boards

Since the second half of the second part of the lengthy process commonly called "The Boards" is quickly looming (we're down to 36.5 hours), I decided to post a few of my thoughts about taking multiple choice tests to determine whether or not we know how to treat patients. Here are thoughts numbers 1 and 2:

Obviously, when faced with real patients, they don't come with charts that say "What is the appropriate next step in treating this condition? A) Chest x-ray. B) Chest CT. C) FAST scan. D) Emergent laparotomy. E) Transfer to surgical ICU. F) Draw blood for type and cross." In fact, in many situations, multiple things are happening at once, and it really is impossible to determine which one is happening first. For example, when you have a trauma patient come in, they are getting IVs put in, fluids running, blood drawn for type and cross as well as cell counts and electrolytes, someone is listening to the lungs while someone else is examining the legs, etc. In multiple choice tests, you only get to pick one next thing that is happening.

Thought number 3:

It's a soul-sucking process of sitting in front of a computer clicking little bubbles all day, and to study for it, you sit in front of a computer and click little bubbles all day. Ugh. It could be worse, though; it used to be sitting at a desk with a number two pencil, filling in bubbles all day.

And now a little Calvin and Hobbes:

Yeah, I just happened to find that when Googling for the other comics, so it was added.

So there you go; my thoughts on the evilness of The Boards. Oh, and if all this nonsense weren't enough, here's anything fun fact: each part of The Boards costs $480-$1000. So yes, we are paying for the privilege of being tortured like this.

The countdown:

CK: 36 hours, 2 minutes

Back in Washington

I arrived back from LA at about 10:30 last night, so I was home by 11 (I really enjoy being so close to the airport). After pretty much collapsing into bed last night, I was up again this morning for the same old routine: breakfast, run, shower, second breakfast, read cardiology, read practice cases, do practice problems, lunch, do more practice problems, go the gym, do more practice problems, dinner, and then contemplate doing more practice problems (which is the step I'm at right now).

I have learned a value lesson the last week or so: doing practice problems while sitting out on the deck enjoying the sunshine is probably not the best study technique I've ever come up with. First of all, I do much worse on the problems. Second, I never to think to put on sunscreen, so I'm getting some pretty interesting tan lines. Still, it's hard being cooped up in the house all day.

Good news: the dishwasher guy came this morning, and all is better again. Turns out it wasn't that big of a deal; for some reason, the detergent foamed up more than usual (I know I didn't add too much; it's hard to mess up on measuring an Electrosol tab), which hit some sensor in the dishwasher and blew the breaker. At any rate, it's working again, so I don't have to wash dishes by hand.

USMLE countdown:
CK: 5 days

USMLE Step 2 Clinical Skills

Yay! My step 2 CS is over!

Last night I flew down to LA and stayed at just about the most sketchy hotel ever. Here's a picture of the room:

Yes, that's a giant painting of parrots. Anyway, I was only there for about eight hours, from 11 pm until 7 am, because the stupid shuttle took about an hour after I called to come pick up and take me to a hotel five minutes away. I was not in a happy mood by the time I arrived.

After an abbreviated night's sleep on the world's most uneven mattress, I got all dressed up in my professional clothes and white coat and grabbed a taxi to the testing center. I ended up getting there about 7:15, so two of my fellow test-takers and I wasted some time by getting some breakfast and coffee (the breakfast was me, coffee was them). Then at eight, the whole thing started. Here's how Step 2 CS works:

8 am: orientation ("use the otoscope to look in the standardized patient's ears"...)

8:45ish-11:15: see five standardized patients. For each, there is fifteen minutes to get a history and physical, including history of present illness, past medical history, family history, social history, review of systems, and focused physical exam. Then there's ten minutes to write up a note, come up with a differential diagnosis, and "order" up to five tests to try to diagnose the patient. Then it's time for the next patient.

11:15-11:45: lunch (catered sandwiches with way too much mayo. Yuck)

11:45ish-1:45ish: four more standardized patients

1:45ish-2ish: break

2ish-3:30ish: last three standardized patients

So in all, twelve standardized patients, of which ten count (but we don't know which ten). We're graded on English speaking skills (which includes the ability to explain what we're doing in lay-person English), ability to elicit a complete history, physical exam skills, and differential diagnosis and ordering the appropriate tests. It's this magical, confusing process to come up with a grade, which I don't understand, but supposedly, in a couple of months, they'll let me know if I'm one of the 93% of US medical students who passes.

Because we're told to plan for the exam taking until 5 pm (you never know what kinds of delays might occur), my flight isn't until 8:40 tonight, so in the meantime, I'm hanging out at the USO at LAX, enjoying their free internet, free food, and the company of a whole bunch of 18 year old Marines playing video games.

USMLE countdown:

CS: done

CK: 6 days

Still here

Yup, I'm still here... and still doing more of the same. See, when I told you the life of a med student wasn't that exciting, this is what I'm talking about.

Kit came down this weekend (showed up Friday about noon), so that was a little bit of change from the usual nothingness. We had a barbecue on Friday night with Andrew and Megan, which mostly consisted of us putting burgers, corn on the cob, and salmon on the barbecue and wandering off to do other things. We're going to have to find a more efficient way to grill corn and salmon--both took about an hour and a half. After everyone was done eating and whatnot, I loaded up the dishwasher, started it, and went off to bed. Then Saturday I got up, headed down to the gym for my cross-training (swimming, exercise bike, and elliptical) and came back. When I opened the dishwasher to grab a bowl for my breakfast, I noticed there were bubbles everywhere. Very confused about this, I tried unsuccessfully to get the dishwasher to rinse again. That was about the time Kit wandered up to the kitchen and noticed the giant puddle that had been sitting on the hardwood floor probably all night. So, to sum it up, the dishwasher was clogged, water went everywhere, floorboards might be permently a bit warped, and there are very few places around here that repair Bosch dishwashers. Supposedly, someone is coming out on Wednesday to take a look at it. In the meantime, it's washing dishes by hand, something I loathe deeply and fortunately haven't had to do much of since the apartment I lived in first year.

Other than the dishwasher fiasco, it's been same old, same old, like I said earlier. Just a lot of studying. Kit and I were briefly considering going to a few car dealerships and test driving some cars, just to see what I like, but that didn't happen because I, again, started to panic about the fact that both of my exams are coming up way too quickly. In fact, I'm flying down to LA tomorrow night for my clinical skills exam... yikes!

USMLE countdown:
CS--2 days (well, 37 hours)
CK--8 days

Still studying...

I know, I've been a bit lackadaisical about my blogging again lately, but in my defense, nothing new has happened. My life consists of running, studying, going to the gym, eating, and sleeping. That's it. But I did decide to include a picture of what I've been doing:

Yup, those are a couple of my books. The top one is my cardiology text, the bottom one is the CK cases book. They're getting progressively more and more colorful (each colored highlighter means something different, don't worry), but I'm not sure how much of what I'm highlighting is getting absorbed. I'm scoring slightly higher on my online practice problems, but not in the "wow, you're so great, everyone will want to offer you a residency position" range.

My USMLE countdown:
Clinical Skills: 4 days
Clinical Knowledge: 10 days

Studying, studying, and more studying

In case you couldn't tell from the title of the post, all I've been doing is studying. Well, not all, but it sure seems that way. Here's a brief run-down of my day:

-wake up, breakfast, etc
-long run (about 10 miles)
-shower, get dressed, etc
-read chapter about heart failure in the cardiology text
-read 3 cases from the USMLE CS Complex Cases text
-a set of practice problems (25 questions)
-lunch
-work on my personal statement for my residency applications
-read 15 cases from the USMLE CK Cases text
-2 more sets of practice problems
-submit my abstract for the American College of Preventive Medicine conference in February
-discuss my personal statement and studying for CS with Adrienne
-dinner
-1 more set of practice problems
-writing in my blog

I know, it's terribly exciting.

Home

Okay, I am home now, and have been since Tuesday afternoon (the day, not the Moody Blues song), I've just been too busy/lazy to post anything.

After all our big plans of going hiking while on our cross-country drive, the first time we actually found somewhere to hike was Beacon Rock, which was about twenty minutes from the house. Oh, well. It was a good idea in theory.

During the drive, the fuel door on my car was getting progressively more and more difficult to open and shut, until it finally reached a point where it wouldn't close all the way. I resigned myself to the fact that I would have to put some money into fixing this, and made plans to go to a Nissan dealer after arriving back in Washington. Well, after our hike and about fifteen minutes from the house, my brakes started squealing, which just made me laugh, and I added it to the list of things that they had to look at when I took it in. So Wednesday morning, Mom and I took the car into the dealer, told them the situation, and then walked over to the mall to shop for things we didn't really need. A couple of hours later, we call the dealer and find out what the deal is. It was quite the list. 1) Some of the paneling/hinges on the fuel door were warped, and the whole assembly would have to be replaced. This is a custom job. Price: $390. 2) Leak in the oil pipe/tank (I was only half paying attention). Price: $140. 3) Leak in the power steering. Price: $160. 4) Front and rear brake pads are worn and would have to be replaced. Price: $440. Needless to say, I was a bit shocked and not all that happy about hearing that my car had over $1000 worth of necessary repairs, so I told him I needed some time to think about it, and we went back in to pick up the car and go home. Well, when we got there, he explained that most of the damage (brakes, leaky pipes, etc) were due to the excessive amounts of rust in the undercarriage due to 12 Ohio winters, where they salt the roads. So the car didn't have $1000 worth of repairs; it was actually much higher. So now I'm shopping for a new car. I'm going for a compact sedan, if anyone has any suggestions for which one I should get.

Other than the whole car debacle, not much has been going on around here. I'm actively (in theory) studying for the boards, step 2 of the USMLE (there are three steps; step 2 has two parts). I'm taking the clinical skills portion in LA on the 15th, and the clinical knowledge (multiple choice written exam) in Portland on the 21st, so most of my time these days is spent reading my cardiology textbook, my case books, and doing practice problems online. It's quite intimidating, and I don't feel ready for it at all.