Internship graduation

Last week, we had internship graduation, which is a little like kindergarten graduation--it doesn't really mean much, except they got to get us dressed up in uniform and line us up for yet another graduation ceremony (because clearly, by the time we become doctors, we haven't had enough graduation ceremonies). I took a few random pictures of us "lining up" so you can appreciate a bunch of interns and residents more dressed up than we would normally be (ie, not in scrubs or camo). People in white are in the Navy, those in dark blue are in the Army, and I don't think I have any pictures of the few people in the Air Force who were graduating.

So we got all lined up, proceeded into the concert hall (yes, fortunately, it was indoors... it was probably 95 degrees at 1000, when the ceremony began), and sat through yet another graduation ceremony. The host was the commander of NNMC (Bethesda), so a two-star admiral in the Navy, and the graduation speaker was LCDR Jardik, a Navy urologist who wrote a book (On Call in Hell) about his deployment to Iraq, back in the early days of Iraq. Then we marched across the stage to receive our certificates, which say "Please go to the GME office to pick up your diplomas". Yeah, completely useless.

Since then, I haven't really done much involving a hospital. I had a few more days of dermatology, but then Thursday NNMC was closed (there was a big ceremony opening the Intrepid Center, whatever that is, and the President was there, so they closed the outpatient clinics to keep security risks down) and I was supposed to help with the transitional year interns (next year's class) orientation on Friday, but that was cancelled at the last minute. Tomorrow, I'm going into WRAMC to outprocess (that should be a fun time...) and then on Thursday, I officially start my preventive medicine residency.

West Point, and onto Dermatology

My friend Yolanda is moving out to California to work at Travis Air Force Base next year (which means, in two weeks), and she decided that she wanted to see all the service academies at some point. She had done a rotation at Annapolis, so she wanted to see West Point before she moved. We would have taken my friend Jen, who went to West Point, but sadly, she was on vascular surgery and was working all day.

Here's a picture of the quad, which is right outside the barracks (dorms), and where the cadets have accountability formations 2-5 times a day. Obviously, in June, after graduation and before the new plebes (freshmen) arrive, there weren't many cadets to be seen.

Here's the roof of the field house. The other side says "SINK NAVY", but I just couldn't get a good picture of it.

And this is the West Point Chapel, which is an absolutely beautiful building. Overall, a very beautiful campus, although Jen informs me that it's bitterly cold in the winter, with the cold air coming in over the Hudson.

So that was my Saturday. Didn't really do much on Sunday, and then yesterday I started my dermatology rotation--last rotation of intern year! So far, I haven't really seen much, but we (as in, me and the dermatology residents) did get a lecture this morning on how to moonlight as an attending and make a lot of money in the outside world. The main point, which was repeated over and over, was "This isn't the time for interesting cases and expanding your education. This is for making money." Gotta love dermatologists.

A Sunday morning bike ride isn't leisurely...

... when it's a five mile ride up and down hills after a night on call on the labor deck to get home. Here's the route, which I do twice a day (coming and going), because I have to get to work before the Metro is running. Great fun.

My night on call actually wasn't too bad. We had a fairly consistent flow of patients through triage, which is pretty much my domain. The med student follows around the second year resident to help with deliveries, and comes help me in triage when nobody is close to delivering. She was actually a huge help through call, because she was so eager to help with everything, even after I told her she doesn't have to try to impress me with anything. I think she really likes OB, but isn't really sold on the lifestyle (ie, still having to spend the night in the hospital as an attending). Since it is almost the end of her third year of med school and she doesn't know yet what she wants to do, she's thinking of doing a transitional year internship (what I'm doing this year) and then being a general medical officer for a few years. She's also getting married in a few months, which complicates matters further (she's Air Force, her future husband is Army but might be leaving the Army next year, etc).

Anyway, we weren't terribly busy, which gave me time to cyber-stalk one of my patients. One of the questions on the admission form, for some reason, is "level of education". So I looked through her pre-partum questions, and found "doctorate", which isn't that unusual, except for the fact that she was a sergeant first class, and there aren't many SFCs with Ph.D.s. I went through her medical record, all the way back to her entry physical, which listed her occupation as "Special Bandmember", and then got on Google. Here she is below (the one in the maternity uniform):

Yes, she is a professional flautist in the United States Army Field Band (one of the specialty bands, like the Marine Corps' "President's Own"). I thought that was pretty neat. And at about two this morning, they had a little girl.

So now I have all sorts of Memorial Day plans (no work tomorrow--yay!), including the Memorial Day concert at the Mall tonight. Maybe I'll get some pictures from that to share.

Yes, I am still alive

Okay, I know it's been a ridiculously long time since my last post, so here's a quick update on what I've done since then:

-Finished up my allergy/immunology rotation. Good times, easy work, got an excellent evaluation for the rotation (it helps that my program director was the one writing the evaluation)

-ER rotation in Fairfax, VA, at a civilian hospital. I had forgotten in the course of this year that not everyone speaks English, and medications aren't really free. That was a bummer of a reminder.

-Now onto OB/GYN, at both Walter Reed and NNMC. The first two weeks were gynecology clinic at Walter Reed, which was a combination of what my attending called "bitch and itch clinic" (acute visits), and annual well-woman exams. For everyone who thinks that gynecology is preventive medicine... NO. It's not. Performing pap smears is not preventive medicine; reviewing the literature and making recommendations about who needs pap smears is preventive medicine. I was rather disappointed that nobody seemed to know the recommendation that after 3 normal pap smears, they can be spaced to every three years. If gynecology was preventive medicine, they would have explained this to their patients instead of continuing to perform unnecessary, expensive, and painful procedures.

-So now I'm into the second half of the rotation, which is obstetrics at NNMC. It's pretty much the definition of hell. When not on call, it's twelve hours (0500-1700) at the triage desk, trying to determine if women are in labor not. Great fun.

So in life outside of the hospital (what? There's life outside of the hospital?), I got a book published! No, I did not write it this year; I wrote the story a while ago, but I decided I might as well see if I could get anything to come of it. I went through a self-publishing company, which pretty much means that I pay them, and they do the marketing and distribution and whatnot after that, and hopefully I get some money back in royalty payments. It's on Amazon, even, which is really cool, but here's the website for the book: http://thenetworkconvergence.com/ This does mean that everyone should buy a copy (and recommend it to your friends...) I'll even sign them for you. Or you can buy a copy directly from me for a discount. Let me know. Whatever.

Anyway, that's what I've been up to for the last two months. Hopefully it won't be another two months before I update again.

Penicillin desensitization

I spent Friday morning in the ICU for a penicillin desensitization. Sounds exciting, being in the ICU, but it was actually a lot of sitting around, doing nothing but talking to the patient. It takes place in the ICU so everything is there in case the patient has an allergic reaction (which is kinda expected; the reason why he needs to be desensitized is because he had a reaction in the past). Fortunately, he didn't this time. Like most things in medicine, boring is good.

Penicillin desensitization isn't something that's done all that much anymore, because there are so many other antibiotics that can be used for infections; however, for some infections, such as syphilis, penicillin is by far the best choice, so if you have a patient with a penicillin allergy, you desensitize them in the ICU and give them penicillin.

The way desensitization works is that after everything is set up in the ICU (EpiPen in the room, etc), you start with a very, very small dose, and then if everything goes well, there are eight more injections with increasing doses, separated by twenty minutes. The whole thing takes almost three hours (160 minutes), and then you keep the patient in the ICU for another hour or two after the last dose (which is a full treatment-sized dose) to continue to monitor for allergic reactions. So there's something to do (which takes two minutes) every twenty minutes, and the rest of the time is spent waiting and watching and chatting with the patient (and watching ESPN, because that's what people do during March Madness).

We spent most of the time talking about careers, of all things. The patient is a lieutenant in Navy intelligence, working in MTAC (yes, the real MTAC... it is not a fictional creation of NCIS). His orders are up in January 2011, so we talked about what he wants to do next. Since he's going to be up for promotion to lieutenant commander by then, he wants to deploy to Iraq or Afghanistan (outside of the medical corps, there are boxes that need to be checked for promotions); the problem is, he's HIV positive and therefore not sea-worthy (we say 'non-deployable' in the Army). You can remain on active duty with HIV, and like all medical information, that status is classified medical information, but when it's time for promotion boards, the question does get raised about lack of overseas duty. Fortunately for the patient, he did deploy and have sea time before he became HIV positive, so that shouldn't be an issue for this promotion board, but he does know that he won't make commander, so he's planning on getting out at his twenty-year mark, which is in seven years.

In all, chatting with a patient while doing absolutely nothing isn't a bad way to have to spend a morning. And then I spent the afternoon being enrolled as a healthy control in an asthma study, so it was a very low-key Friday. The hardest part about the whole day was getting skin tested for allergies (I'm apparently allergic to birch and cottonwood pollen; who knew?). As my surgeon friends tell me, this shouldn't even be allowed to be considered an internship, because I hardly ever have to do any work.

And back to the grind

Well, after many hours of travel on Sunday, I arrived back home on Sunday night, only to have to go back to work at WRAMC on Monday morning, to begin my Allergy and Immunology rotation. Fortunately, it's a pretty easy rotation, so that helps ease the pain of being back somewhat. In fact, it's even easier than my Allergy and Immunology rotation at Tripler last year, because there are fellows here (completed their residency, now getting advanced training in Allergy and Immunology), so I essentially just follow them around.

The first patient I saw on Monday was a two-year-old girl who suffers from maternal hyper-vigilant syndrome--pretty much, there's nothing wrong with her, but her mother thinks that she gets sick more than two-year-olds are supposed to, so she's being worked up for an immuno-deficiency syndrome. I'm pretty sure everything will come back normal.

Nothing too exciting on Tuesday or Wednesday, just the standard allergic rhinitis and hives. Today, one of the allergists at WRAMC was giving a lecture on immunology and occupational asthma to the second-year preventive medicine residents at USUHS (working on their MPH), and she invited me along. Of course, by the time I got back to WRAMC, all of the fellows were done seeing their morning patients, so I didn't really have to do except work on my application for a Virginia medical license (we have to be licensed; it doesn't really matter which one, and Virginia is one of the easiest and cheapest) and took off early to take some of the paintings I bought in Peru to the framing shop, where I spent an arm and a leg to get them framed. They better look pretty good when they're done.

Done with the rotation!

Today was the last day of my research rotation (I'm still in Peru; not leaving until early Sunday morning, but all I have left to do is hang out in Lima and spend money I don't have at the Inka Market). It was a pretty low-key day; all I did was give my presentation. Here's the title slide:

Both LCDR Maves and Wes (the Georgetown student) chuckled at the little bugs at the bottom. So, in case you can't tell from the title, I focused my research and my presentation on entomology (the study of bugs, not the study of language--that etymology) and its role in preventive medicine, starting with the history of diseases carried by bugs in the military, with a healthy amount of information about MAJ Walter Reed, because no self-respecting Army preventive medicine resident can do a project that has anything to do with bugs without talking about MAJ Walter Reed.

So that was that. As I was filling out my evaluations and preparing to email the presentation to my program director, though, I realized I never turned in a research proposal to her (supposed to be done one week before the research rotation begins) because I never filled one out. So I did that this afternoon, too, and amazingly enough, I did everything from my proposal during this rotation. I'm just that good (filling things out retrospectively doesn't hurt, though...).

Now I just need to figure out what I'm going to do tomorrow that won't end up costing me another few hundred Soles... (BTW, Mom, I found a painting I think you'll really like. Happy birthday. You'll get it a week after our birthday, when you and Dad come visit).

Neurologic Institute

Sorry about the delay in posts... my computer wasn't reading my SD card, so I couldn't get images from my camera to the computer, and I didn't want a bunch of posts with "and I'll get you the pictures later" all over them.

On Monday, we took a field trip to Instituto de Enfermedades Neurologicas, which is a neurology hospital where they do a lot of treatment and research on cysticercosis, a parasite (worm) infection that can travel to the brain. Most people, surprisingly enough, can have hundreds of cysts and not have any symptoms worse than headaches, which is how they remain undiagnosed long enough for them to have hundreds of cysts.

On site, they also have a museum of brains, with a few walls of specimens of brains with various diseases:

And here's a close-up of a brain with neurocysticercosis:

They also had some healthy specimens, including this one of the central nervous system:

So that was Monday. On Tuesday, we went to Instituto Alexander von Humboldt, which is a tropical medicine hospital. In the morning, we sat in on Leishmaniasis clinic (parasitic infection that causes open ulcers on the skin--got a lot of press in the early days of Iraq, when troops were being MEDEVACed with Leish after getting bitten by sandflies while they slept in the dirt), and then we rounded with one of the attending physicians, who showed us some very interesting cases, including a woman who complained of facial swelling, pain, and "worms coming from her nose". They thought she was crazy, then they actually saw maggots coming from her nose. A fly had flown up her nose and laid eggs, leading to an infection called myiasis (yes, maggots coming from the skin actually has a name). Disgusting.

Then yesterday was spent working on my presentation on Bugs of Military Significance, which is what I'll also do today. Apparently, people want to see something come out of this rotation... apparently, they aren't sending me to Peru just to sight-see for three weeks. Who knew?

Bus tour of Lima

Yesterday, a couple of us (Wes, the Georgetown med student; the vet tech; and myself) decided to do the touristy thing and took a double-decker bus tour of Lima. The tour started at Parque Kennedy, and before you ask, yes, it is that Kennedy. There's even a bust of him in Parque Kennedy.

Apparently, Miraflores is the sister city of Pensacola, FL. Why that means they need a bust of JFK, I have no idea, but there it is. There's also a statue of John Lennon in another part of town, so I think the Peruvians just like statues.

Anyway, driving around Lima, in Lima traffic, on the top of a double decker bus is a bit of a harrowing experience. This is definitely not the worst traffic was, but I want you to take note of the open manhole.

Although Lima is, overall, a pretty dirty city, they do have some nice architecture and whatnot. Here's a picture of what I think would roughly translate to the capitol building.

And this is the monastery San Francisco (as in, for St. Francis, not the city in California), which I think they were saying is the oldest Franciscan monastery in the Western Hemisphere. The catacombs are also located here, and for about two centuries, (1500's-1700's) they buried quite a few people here. When the catacombs were excavated, they found the remains of over 25,000 bodies.

And here's a random shot of a hill that somebody decided to paint a Peru flag on.

So that, and more shopping at the Indian Market, was my day yesterday, and today, I spent a good deal of my time at the hotel (by the pool, for a good bit), working on my presentation, which I'll be giving on Friday. I'm doing it on the roll of entomology (study of bugs) in preventive medicine, briefly discussing the history of vector-borne diseases on military populations (with a few slides dedicated to MAJ Walter Reed), the Army regulations on insect control, ongoing research projects at NMRCD-Peru, the role of bugs in the deployed setting (malaria, Leishmaniasis, and also the sleep deprivation/psychological impact of being surrounded by bugs and giant spiders... Jason, if you have any thoughts on the matter, I'd love to hear them), and directions for future research. In all, it's supposed to be a 30-45 minute talk, so we'll see how that comes along.

Hospital Dos de Mayo

On Wednesday, one of the doctors took me and a fourth year Georgetown student who's down here as well (Navy HPSP) to Hospital Dos de Mayo (second of May; one of the major battles against the Spanish back in the day), which is one of the public hospitals in Lima and a major teaching hospital for medical students and residents.

The main thing we did there was listen to morning report (well, listen to that doctor translating morning report for us), which was about a few cases of HIV patients. They have a lot of the same problems with HIV patients that we have in the States--mostly, people not being compliant with their medications, and thus getting complications--but they don't quite have the same lab capabilities or treatment modalities that most hospitals in the States have. It was interesting to hear about how some of their treatment guidelines differ because of this.

One interesting thing about the hospital and associated clinics is that they pay for lab tests at a window (as opposed to getting a bill in the mail later). So they have this large sign that has all the prices listed for various labs and tests. I know you can't see it well here, but all the prices are fairly nominal, at least compared to our prices. For example, an EKG costs S/15, which is about five dollars; an echocardiogram is S/60, which is about $20. There's no way you could get an echo for $20 back home. I don't think the few minutes it takes the cardiologist to watch it and declare it normal would even be that little, not to mention the technician's time or the actual procedure costs.

On the grounds is also the crypt of Daniel Carrion, a national hero in Peru, especially in medical circles. When he was a medical student, he proved that systemic (throughout the body) and cutaneous (on the skin) Brucellosis were caused by the same bacteria, by injecting himself with pus from a patient's cutaneous Brucellosis sore. Unfortunately, he died of his little experiment, which just proves one of my points--if you suspect something is going to kill you, don't do it.

So that was my morning on Wednesday. Then I spent the afternoon hearing about research in parasitology (mostly malaria) and virology (mostly dengue) going on in Peru, and yesterday spent the day in the virology lab, learning the various techniques and tests that they do.

Pre-Incan ruins, and back to work

Yesterday I went to Huaca Pucllana, which is a temple built to the water and sun gods of the Lima culture, a pre-Incan culture of around 800 AD. In fact, before the temple was excavated in the 1980's, nobody had any idea that this culture existed. When the Spanish conquered the Incans, they obviously learned about the Incans, as well as the peoples that the Incans had previously conquered, but before that, there weren't really any records. Anyway, before excavation, this was just a dirt hill in Lima (there were houses and whatnot built over parts of it as well. Here's what it looks like today (with some excavation still in progress):

I like this next picture, because it's a good visualization of these very old ruins amidst a fairly modern city. It's actually right in the middle of Miraflores (the district in Lima where my hotel is), and was walking distance from the hotel.

Here's a picture of a fairly famous dog in Peru. Not a famous breed of dog, but a famous dog. Apparently, the Obama's search for a hypoallergenic dog was worldwide news (I'm rolling my eyes), and the government of Peru offered this dog to the Obamas (it's about a year old now, so it was just a puppy then), because as hairless dogs, they're completely hypoallergenic. Obviously, the Obamas picked a different dog, and this one (it has a name, I just don't remember it), is still in Peru, hanging out at some ancient ruins.

And what blog from Peru would be complete without alpacas?

So that was my day yesterday. Today, I had to go back to work (I know, it's not just a free vacation courtesy of the government). I went to the naval hospital for ID rounds in the morning, which was fairly quick--they have three patients, all of which are simple enough that they would have been outpatients back home. Then over to the cafeteria to have lunch with the officers at NMRCD (while making fun of the vast number of uniforms the Navy has... there's an Army vet and an Air Force microbiologist at the lab as well, so we got to gang up on the Navy officers), and then a quick lecture from LCDR (Lt. Commander) Maves, the ID physician whom I'm essentially working under for this rotation, and then back to the hotel to hit the gym and do some homework (which is still sitting in my backpack, waiting for me).

Boat rides and malaria slides

Well, I figured now was as good of time as any to give you some pictures. This first one is the lab where I've been "working" for the last couple of days, NMRCD-Peru, Iquitos Laboratory.

And here's the picture of catching mosquitoes that I promised you yesterday. It's essentially a low-powered vacuum that sucks up mosquitoes and captures them live in a little cup, to be taken back to the lab to be counted and later processed.

Okay. So now what I did yesterday. The day started with arriving at the lab for what I thought was a lecture about malaria in the Iquitos area. What ended up happening was a boat ride to Padre Cocha, a village up a river that feeds into the Amazon. And no, nobody speaks English in Padre Cocha, including the microbiologists who study the blood smears to diagnose malaria. I did learn, mostly through pictures and hand gestures and whatnot (actually, a lot of science-type words are the same in any language), how to tell the difference between the different forms of malaria (P. falciprum and P.vivax) on a blood smear, and the research projects that they're doing on length of treatment for each of those infections. Of the two blood smears we had to look at for that day, one was positive for vivax, and the other was negative for any form of malaria.

Before leaving Padre Cocha to head back into Iquitos, we stopped by a butterfly farm/animal rescue, which is run by an Austrian woman who speaks no fewer than four languages (she was giving the tour simultaneously in Spanish, English, French, and German). They have there a boa constrictor, a few parrots (or similar large, brightly-colored bird), a couple of crocodiles that found their way in, a river manatee, a few monkeys, and a jaguar. The jaguar apparently costs about 1000 soles a week (about $350) to feed, because they only eat raw meat. Although the primary mission of this animal rescue is to return animals to health and find a place to release them into the wild, that isn't possible with this one, because it has completely lost its fear of people (and releasing a large cat that eats raw meat and isn't afraid of people into the wild is bound to result in a few people being eaten). So they keep it, which is rather expensive, and the reason why they didn't want to take any felines in the first place.

So, that was the morning yesterday. Then, after lunch, I went with some of the lab employees (and an entomology grad student from UC-Davis who essentially served as my translator) to see a patient with dengue. Very interesting, but didn't look like much fun. I've been staring at my mosquito bites ever since, hoping that none of them were carrying dengue. Guess we'll find out in 4-10 days...

Counting mosquitoes

Yesterday was my first day of doing 'work' in Iquitos, and let me tell you, doing work in a city where English speakers are very few and far between is not easy.

I started the day by going to IVITA (and no, I have no idea what that stands for, and it's probably in Spanish anyway), where they have mosquito experiment huts. These are similar (and yet different) from the huts that Walter Reed and the rest of the yellow fever commission used way back in the day to demonstrate that yellow fever was transmitted by mosquitoes: you have a sealed hut (sealed with mosquito net, not completely sealed from the elements; I think you'd suffocate) and people and mosquitoes inside. In the yellow fever commission days, they'd leave the people exposed to the mosquitoes and see what happens. In these huts, the person is under mosquito netting most of the time and is just there to observe the mosquitoes. The five huts all have different experiments, but the one I saw had different panels of cloth hanging on the walls, soaked with different concentrations of permithrin, an insect-repellent for cloth and clothing (not for skin). The mosquitoes are counted every hour to see how many land on the various panels, in efforts of determining the concentration that should be used in real life.

Anyway, after IVITA, they took me to the cemetery, where a group of entomologists (people who study bugs) were catching mosquitoes. No, this does not entail running around with a jar trying to catch them--they have these little vacuum mosquito-sucker things with enough vacuum to collect the mosquitoes, without destroying them. Since most people are 'buried' in crypts, they just run these vacuum things over the crypts and collect what they collect. I have a picture on my camera; I'll try to get it up soon.

After that was lunch, which was chicken noodle soup and a pasta with a pesto-like sauce and chicken (really good, but rather heavy for such a hot and humid day), and then it was back to the lab to count the mosquitoes that were collected. The joke about prev med docs, especially the ones who specialize in tropical medicine (like I will someday), is that we go to exotic locations and count mosquitoes--and that's exactly what I did. I learned how to differentiate between the three species of mosquitoes around here and tell the difference between the males and females, because only the females bite, and only Aedes aegypti carries dengue in these parts (malaria is carried by Anopheles mosquitoes, which are found in rural areas, not cities).

And that was the end of my work day, at which point I did my homework of occupational health questions (today I get to have blood drawn... fun, fun!), took a nap, and went out for fast-food chicken with plantain chips to eat while watching TV (something that the other American researchers here do every week). And then I went to bed, went running this morning at a soccer stadium, and am now ready for another day of work.

Writing from Iquitos

Well, I made it to Iquitos last night, after a long day in Lima, and will be heading out into the field in ten or so minutes, so this'll be quick.

Yesterday was a lot of in-processing type activities and in-briefing type activities, where they make sure everything is squared away with my itinerary and teaching me about the various labs. And asking multiple times if I speak Spanish, because apparently, no one outside of people who work for NMRCD seem to know English.

I did get a chance to go over to the medical school in Lima for a lecture the commander of NMRCD (a Navy commander) was giving on viral gastroenteritis for the Gorgas tropical medicine course, which is an international course for doctors who want to learn more about tropical medicine (and, fortunately, the course is in English). There wasn't really anything new in the lecture, but it was a nice review. Then it was back to NMRCD, lunch, more in-processing/in-briefing, and then a taxi ride to the airport to fly to Iquitos.

I'm staying at NMRCD's guesthouse, which is pretty nice--not as nice as my hotel room in Lima, but with electricity, AC, and internet (obviously), which makes it nicer than my accomodations in PNG. I am on my own for food, so we'll see how that goes.

Today I'm off to a cemetery to catch mosquitos, and then in the afternoon, testing them for dengue. Should be interesting...

On my way to Peru

This was written yesterday while I was on the plane. If I have internet in Iquitos tonight, I'll post for today.

And we’re off. Well, I’m off, and quite a few of my closest friends, all crammed into a plane I wasn’t supposed to be on.

So, things didn’t exactly go off to a smooth start today. Concerned that there might be travel problems (thinking about the last time the government bought my plane tickets, when I went to C4 in October and arrived at the airport at 0430 to find that the tickets hadn’t been purchased), I left home on the Metro at 0900 for a 1245 flight, got to Reagan a little before 1000.

And, surprise, surprise, the tickets hadn’t been purchased yet.

Unfortunately, it wasn’t as easy of a fix as it was last time. There’s all sorts of bad weather at Dallas/Ft. Worth, so the emergency line at Carlson-Wagonlit was quite busy. After being on hold for forty minutes, I was told that they didn’t have a copy of the authorization from the WRAMC travel office (just like last time), so I faxed the orders and called back. After another thirty-five minutes on hold, they told me of all sorts of other problems with the orders. Long story short, after spending more than two hours with my phone against my ear, I missed the opportunity to get on the flight I was supposed to be on, and ended up on a flight on Delta (instead of American) arriving two hours later. Unfortunately, the people in Lima had already arranged for me to be picked up at the airport when I arrived, and although I emailed them about the change as soon as I could, I don’t know if anyone was checking email today to get the message.

Guess I’ll find out soon enough.

I’m actually not in Peru yet—just off the coast of Colombia, according to the in-flight map, at 2115—forty-five minutes until I’m supposed to be landing in Peru, and two hours and forty-five minutes until I do.

Unsurprisingly, all of this stuff not going well put me in a rather bad mood (and I can see my parents feigning shock at that—‘what? Lisa not taking two hours of things not going the way they were supposed to, followed by a change in travel plans, well?’), which got me started on the “what am I doing and why am I doing it?” line of thought. I’m going to a country where I don’t speak the language, re-writing all sorts of internship rules while doing so, to research diseases that I find very interesting, but have little more than a passing knowledge of. Oh, and I’m doing this alone (at least until I get to the lab tomorrow morning), and I don’t know if I’m going to have a ride from the airport to the hotel or not.

And I spent six months working on making this happen. What was I thinking?

I’m sure that I’m just inventing all sorts of problems in my head and unnecessarily stressing myself out. After all, I’ve done this before—I landed at the airport in Papua New Guinea in pretty much the same state of mind and with the same uncertainty of the plans, and I ended up where I needed to be without any problems.

According to the flight information screen, two hours and nineteen minutes until arrival.

Visas and burgundy passports (or, visas in burgundy passports)

For everyone who doesn't know what's going on (a group that may include my parents, as they never seem to know what I'm up to, whether I tell them or not), I am taking off for Peru in two days (Sunday, 21 Feb), for three weeks of tropical medicine research.

The DoD (Department of Defense, for the less acronym-inclined) has several domestic and overseas laboratories--one owned by the Air Force, a few by the Navy, and most by the Army--which collectively make up GEIS, or Global Emerging Infection Surveillance. The overarching command, if one could even use that word, is in the DC area, which meant that I got to rub some high-ranking elbows, impressive them with my CV and career goals, and convince them that it's in their best interests to pay for me to go to one of these labs. Peru was chosen because three weeks is a bit short for a research rotation, and since it's in the same time zone as DC, I won't be losing any time to jetlag.

This whole process, of convincing people to let me go and to pay for me to go (two different groups--one to let me go, one to pay for it), started in August, and I got final authorization (ironically, from the 'let me go' group; the 'pay for it' group had already given the thumbs up) much later than that, after months of stubbornly not letting them say no.

Now that that was taken care of... Believe it or not, foreign countries aren't always glad to see active duty military personnel arrive on their soil, regardless of their reasons for being there, so all sorts of country clearance and theater clearance (theater being theater of operations, which in this case is SOUTHCOM--Southern Command) and things going through diplomatic channels and taking forever. The process to get my official (burgundy) passport started... well, I don't remember when it started, but the passport was issued on 11 Jan. Then I needed an official visa to go with the official passport, which requires a resolution signed by the president of Peru, which just came through on Wednesday (so yes, the president of Peru gave me personal permission to enter the country). So I went to the Peruvian Embassy on Wednesday for the visa, and was told that I needed a letter, on letterhead, from my command. Just showing them my orders wasn't good enough. I emailed my program director (who is not technically my commanding officer, but I prefer to leave my commanding officer out of as much as possible, because he loses things. Like leave papers.) and asked her to write the letter, which she did. So I brought all that stuff back again today and dropped it off, and was told to pick up the passport at 5.

Long story slightly less-long: after three trips onto what is technically Peruvian soil, I now have a visa in my burgundy passport.

And assuming no more freak snow storms close Reagan National Airport, come Sunday, I'll have a stamp in my burgundy passport as well.

In case you were wondering how an official passport is different than a normal passport:

This is not my actual passport, just a picture I shamelessly copied from Google. As you can see, it's not blue, it has the word 'OFFICIAL' on it (which blue passports do not), and that little electronic-chip looking thing on the bottom means that there are electronics embedded in the passport.

Anyway, assuming I don't get too lazy while I'm gone, and assuming I have adequate internet connections, stay tuned for tales from the southern hemisphere (it's barely the southern hemisphere, but it counts).

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.

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.

No more medicine wards!

Today was my last day on medicine wards--ever! It was definitely a good feeling to be walking away, knowing I wasn't returning. No more long internal medicine rounds, no more cross-cover call... If I had any doubts about wanting to do preventive medicine instead of internal medicine (which I didn't), that would have cinched it.

I told my resident and fellow intern when I came in for rounds today that my goal was to get out before 11am, and even with following and having to present four patients, I left the ward at 10:55. Of course, I had to sign out to the on-call intern before the other intern on my team to do so, but I did it.


I did, of course, have an ulterior motive for leaving the ward, other than just wanting to get away from Ward 75 as quickly as possible. I realized the other day that I have worked every single Sunday this block, and thus hadn't been to church at all during Advent, which is my favorite season at church. So, I checked the Walter Reed website, and found out that the Protestant services at the chapel are at 11am (hence the goal leave time). After switching out my white coat for my winter jacket in my locker, I had to practically run across base to get to the chapel (and still came in late), but I did get to enjoy a nice Advent service, so that made me happy.




The afternoon was spent doing as little as possible, which included a nap on the futon (I have a very comfortable futon) before heading out to dinner with one my friends, who was celebrating the end of her month on urology, going into a month of ER, which for a surgery intern is practically a vacation--predictable hours, no call, no residents to make life miserable.

Tomorrow I begin PM&R, and will get one of my four weeks on that rotation over before heading for the airport on Saturday to fly home for Christmas. I can't believe it's almost the end of the year already, but I'm definitely not going to complain about how quickly it's going--the sooner I can be done with internship, the better.