End of Ward 75, beginning of psych, and a new coin

I was on call in Ward 75 on Sunday, for the last time in block 2 (I'll be back there in block 6). It was a really, really quiet call (which is a very good thing), and I actually got sleep, but we did have a bit of excitement. Right after the med student returned with dinner (we one out to grab us food every time we're on call), we were all sitting around eating and checking things on the computer, and suddenly he jumped out of his chair and said, "Hello, sir!" Just my luck--I had just taken a rather large bite of food. I turned to see who he was talking to (thinking it was our attending), and saw Lieutenant General Schoomaker, the Surgeon General of the United States Army (ie, my boss, after the President and Chief of Staff), standing in our team room. He was walking around the hospital on a Sunday evening, just getting a feel for the place and a reminder of what really happens in Army medicine, at the very bottom of all the decisions he makes. So he stayed and talked for a bit, joked about college football (he went to Michigan; I was wearing an OSU tee-shirt), and traded internship stories. He was an intern before the 80 hour work week (obviously), but still recorded his hours, just out of curiosity. There was one week that he worked 158 hours. He still doesn't know how he did it. Then he gave us coins (above), and resumed his wandering of the hospital.

And just to put things into perspective about how nice we have it now, in Block 2, I worked a total of 260.17 hours, which is 65.04 hours per week.

Well, I was supposed to start on PCLS (Psychiatry Consult Liaison Service) at National Naval Medical Center (better known as Bethesda) on Monday, but as I was post-call in Ward 75, I didn't start until today. It's going to be a really laid-back rotation, especially after MICU and Ward 75. We currently have three patients and three interns. I showed up at 0730 and left at 1600, and maybe worked two hours. The rest of the time, I sat around and twiddled my thumbs. Tomorrow, I'm bringing some fun reading, and after work, I'm going to Barnes and Noble and seeing if they have a USMLE Step 3 study book so I can pretend to study while I'm at work. It's going to be a good month.

Team lunches and winning the game

Yes, I know, it's been pretty much forever since I last wrote a post--sorry about that.

Life on Ward 75 has been, well, pretty much like purgatory. You just have to bid your time here until it's time to move onto something else. We've had a few interesting cases, but for the most part, all I do is pretend to be a social worker and get people discharged and back to their retirement homes/nursing homes/back to their units.

Since the rotation is almost over (just one more night of call!), we had a team lunch yesterday--the attending, resident, two interns, sub-intern, and two third year medical students--at a Thai place in Silver Spring. The food was quite good, as was the conversation; with the exception of my fellow intern occassionally treating me like I'm quite useless (despite the fact that I have twice discharged all of my patients, a feat he has yet to accomplish), we had a really good team. The two med students we currently have are quite sharp and work hard, but have good senses of humor (of course, they thought I was joking when I told them that I gave low passes on their evaluations...)

Anyway, today I started the day with two patients, one with a fairly simple pacemaker placement, and one who had been admitted with high fevers and chills after returning from three weeks in Africa (we thought it was malaria, but those tests came back negative; he got better on his own, and we still don't know what he had). Both got discharged today, so I had no patients--that's what we call "winning the game" (the game being treating patients; winning being discharging all of them before the next night on call). So I won the game, for the second call period in a row :) My sub-intern calls me a discharging machine. That's certainly true. And because I won the game on Friday, and we aren't on call again until Sunday, I get Saturday off :) This makes me happy.

Not taking 'no' for an answer

One of the jobs of preventive medicine physicians is to tell colonels and generals--pretty much, people who outrank you by quite a lot--that they can't do something because it's too dangerous/stupid/etc. In other words, prev med docs aren't typically easily intimidated and don't really take no for an answer eaily. I guess I'm getting an early start on that.

Yesterday I was the only doc on the team (except the attending, who doesn't really count); the resident and other intern were both out. So I was taking care of all the patients, which fortunately, was only four, as well as our two new third year medical students. Unfortunately, I didn't have time to do anything educational, as I was spending most of my morning running aorund trying to get a patient discharged to a rehab facility. The transport was scheduled to come at 1400; at 1310, the nurse told me that the facility wouldn't take him. He still had a bed, but there was something about not having enough therapists. They social worker didn't bother arguing with them, so I called them and essentially said that I don't care about their therapists--if he has a bed, he's going. They had me write an order saying that it was okay if he didn't get therapy until Thursday, which I gladly wrote, and he got out of there.

I'm currently working on taking this not taking no for an answer to get the internship director to say that it's okay for me to go to Peru during my research month. Stay tuned for more details.

Anyway, it's been two and a half weeks on ward 75, and the vast majority of what I've done in that time is stuff that they don't teach in med school--social work. Talking on the phone with rehab facilities, setting up follow-up appointments, etc. For as exhausting as the MICU was, at least I didn't have to deal with any of this stuff associated with discharging patients. When we were ready to get rid of a patient, we just called the on-call medicine team and had them take the patients to their service, and then they could deal with all this discharge stuff.

Okay, enough of that. I'm going to go back to enjoying my day off, and by 'enjoying my day off', I mean waiting for my eyes to return to normal after being dilated for my eye exam, and then heading back to Bethesda in about an hour for another doctor's appointment. Fun, fun.

Welcome to Ward 75

I officially began my general medicine month (Ward 75) on Tuesday, after having been post-call on Monday. It's going to be a rough month.

To start with, my fellow intern is a jerk (and that's being polite). He thinks he knows more than I do because he's an internal medicine intern (which to me just proves how little he knows), because he went to USUHS (the military medical school), because he's just a jerk, I don't know, but he was trying to tell me how to put in orders, which I definitely don't need help with, as I probably put in more than 50 a day in the MICU. And he seems to think he's exempt from doing the 'scut work' (the little things that need to get done that have nothing to do with the four years we spent in medical school), for unknown reasons. He actually told off the discharge planner, which is probably his biggest mistake ever (don't piss off the person you're going to have to be depending on for the next three years), by saying, "I went into medicine to do medicine, and since starting this rotation, I haven't done any medicine, I've just been making all these calls to get this guy discharged, which is supposed to be your job, so tell me what you need from me that's keeping this guy from getting out of here." Yes, doing all that stuff is annoying (I spent half an hour being shuffled around the VA on the phone trying to get my patient's out-patient follow-up appointments scheduled today when I just wanted to go to sleep), but that's what being an intern is about. You don't do medicine; you do everyone else's scut work. They say to put an order in, and you say, "Yes, sir" (or "ma'am", whatever the case may be).

Anyway, enough about him (I'll probably be complaining more about him in the course of the next three and a half weeks). We also have med students, two third year med students from USUHS and a fourth year HPSP (Health Professions Scholarship Program, which is what I was--sponsored student at a civilian med school) student from the University of Buffalo. The third years aren't too bad for it being their first rotation (they've done four and a half weeks of their initial six week rotation), but to quote Scrubs (the most accurate medical TV show out there), a good med student is only who only doubles your work load. I'm pretty quick about getting my orders in and getting my notes written, but they're supposed to write their notes first, and then I'm supposed to correct them and sign them. Since they're still so new to note writing, it takes them forever to figure out what's important and what's not, so I waste time sitting around not doing anything, just waiting for them to finish their notes so I can get around to writing mine. It's rather frustrating.

Having a fourth year (a "sub-i", as I'm sure you remember from my experience in April), is actually quite helpful, especially when getting slammed with new admissions on call, which is what happened yesterday. Our team can take up to ten new patients a night, which is typically split 5/5 among the interns. With a sub-i, though, we had three people to split it between. We ended up taking nine (which is a lot; the team on the night before us took three, and two of those were transfers from the MICU, which come early in the day). I took four, my fellow intern took three, and the sub-i took two.

So that brings us to this morning, after dealing with these admissions and being paged from the nurses on patients from other teams (when on call, the other interns sign their patients out to me, so I manage them overnight only knowing what is on the slip of paper they hand me), it was time to round and get my work done on all five of my patients (four new ones, one from before). I thought I was getting rid of two, so I was frantically trying to get their discharges done (something we didn't do in the MICU; they just got transferred to the wards), and being shuffled around the VA trying to get appointments. As it turned out, neither was quite ready for discharge, so in addition to doing all that and getting them more or less squared away to go home, I had to go back and write a daily note on them and figure out how to get them medically ready for discharge, hopefully tomorrow (because I work for the government, nothing happens on weekends). Great fun.

I left the hospital after 29.5 hours of work (legally, I can't exceed 30), hit the gym (typical post-call activity to get the adrenaline running and keep me awake to drive home), then it was home for lunch before collapsing into my usual post-call coma.

And tomorrow, it's back to work for more Ward 75 fun.

Done with the MICU!

At noon today, I ended my last call--and last shift--in the MICU. Ever. It was a very happy moment. Or, rather, it would have been if not for the fact that I was exhausted and frustrated (which happens when I'm exhausted).

Technically, today was the first day of the new rotation, but since I was on call last night (the last day of the old rotation), it kinda carried over to today. So, everyone was new at rounds (well, by 'everyone', I mean the doctors, not the patients), which meant that rounds took forever, because everything that had happened to all of the patients had to be discussed. The only 'old' people there were me and CPT McDonald, the oral surgery resident (their schedules are different than ours; he still has a few more days in the MICU). Not only that, but there were three interns who had never been in the MICU and didn't know how rounds go or how to work with the computer system, which really just added to my frustration. But I survived (as did the patients, although one was actively trying to die yesterday/last night), and now I am done with the MICU forever, because despite MAJ Holley and LTC Cuneo's (the attendings for the month) best attempts, I am not switching from preventive medicine to internal medicine. No way, no how. I don't see how anyone puts themselves through three years of that and stays sane. It is prev med, all the way, for me.

One of the things that we have to do is log our duty hours, to make sure we don't violate any of the rules--average of 80 hours/week over four weeks, no more than 30 hours at a time, at least four days off in a four week period, etc. So the final verdict on my hours in the MICU: total hours, 284. Average per week, 73.6. I did have a lot of days off (six, instead of just four), so I can't complain about that too much.

And from what I hear, general medicine wards (where I'm going next) is much worse. I went up to introduce myself to my team (resident, fellow intern, two med students) after finishing my notes and work in the MICU, and my fellow intern essentially tried to convince me that it's easier for both of us if neither of us takes any days off.

Yeah, that's not happening.

Should be an interesting experience.

4 star coins and the light at the end of the tunnel

For those of you who read my Facebook status update, you know that I now have coin from a four star general. Here it is:

And now story time. There is a lieutenant colonel in the room across from the MICU workstation. He was hit by an IED in Afghanistan (I believe... he's a SICU patient, so I don't know much about him). It's pretty rare that someone that highly ranked gets himself blown up (he was a Ranger or Special Forces or something), so he's gotten quite a lot of attention. I have now seen the Secretary of the Army and more stars than I can count. Anyway, on Monday morning, I was writing down lab values on my patients, and when I looked up from my computer, I saw stars. A line of four of them, right down the front of this man's uniform. He thanked us for all that we're doing to care for all of our patients, and then gave us coins.

As far as the light at the end of the tunnel, I had lunch yesterday with my future residency director, just to check in and see how my first month of internship is going and give me more information about the residency. Let's just say that I was really excited about what is to come. It really was a nice reminder that all of this being on call every third night and rounding for six hours thing doesn't go on forever.

I can't wait for next year.

Air evac messes

It's been awhile since my last post, because I'm generally too wiped out to motivate myself to sit and type out what happened that day, but we had an air evac come in from Landstuhl (Army hospital in Germany) on Friday that warrants a post.

The two intensive care teams--MICU and SICU (medical ICU and surgical ICU) split the evacuees, so no team gets slammed if the Iraqis and Afghanis had a busy week. There was only one on Friday (thankfully), and we had fewer patients, so we took him. I was looking through his discharge records from Landstuhl and saw that he had facial burns, so I asked why he didn't go to BAMC (Brooke Army Medical Center, in San Antonio). Apparently, the person doing triage for the air evacs thought that his orthopedic injuries were more severe (still has all his limbs, but both of his arms have wound vacs), which is ridiculous, because they have orthopedists at BAMC as well.

Anyway, he showed up, and the surgeons (the orthopods and the general surgeons) got to work on taking down his wounds, and the general surgery chief resident said, "He should be at BAMC. He needs to get these burns taken care of." So I called the air evac office at WRAMC and explained the situation. The air evac nurse came up and handed me a pile of papers, and said, "To transfer him to BAMC on the flight at 0600 tomorrow, you need to get an accepting physician and fill these out, then contact pharmacy and get the medications for transfer sent up. Oh, and our office is closing in an hour and a half. If you don't get it done, there will be another flight on Monday." Well, burn treatments run on a tight schedule, so we knew we had to get him to BAMC as soon as possible, so we went to work, and to make a very long and complicated story short, we got an accepting burn surgeon and filled out the papers in time, and then spent the next several hours coordinating things between surgeons, with pharmacy, and filling out documentation. So I didn't get any sleep that night, but it was worth it, because I did something for this soldier that's going to make a difference to him. I'm never going to actually fight in a war; my job in the Army is to take care of those who do, and doing that is worth a sleepless night every now and then.

DA Form 3894

Last night on call, I got the joy of dealing with DA Form 3894 for the first time: Hospital Report of Death. Yes, that's right: in addition to a death certificate, the Army has a form for hospital deaths. The Army really does have a form for everything.

Anyway, it was not an unexpected death, nor a bad one. The patient had metastatic ovarian cancer and was DNR (Do Not Resuscitate). Yesterday afternoon, she and her family decided that enough was enough, and switched to comfort care only. So we turned off her pressors (medications keeping her blood pressure up to survivable levels), and gave enough pain medicine for her to be comfortable, and died half an hour later.

Overall, it was a pretty rough night on call (not because of that). We were getting slammed the entire night; as soon as it seemed we had a handle on things, we got a new patient. It didn't help that I didn't get much sleep the night before going on call; I've probably slept a total of six hours in the last three days. The life of an intern, I guess.

One thing that was impressed on me, at 0100 by the wife of a retired major general (two stars) who came in with a possible stroke, was how lucky I am to be doing my internship here. It's something I don't think about much (honestly, who feels lucky when working a thirty hour shift every three days?), but this is Walter Reed Army Medical Center. It's a place with history, with reputation (most of it good), and some pretty spectacular accomplishments. The other day, when I was at the gym after being on-call, I saw someone sit down at the quad press and calmly remove his leg so it wouldn't get in the way of working out the other one. How often do you see things like that?

When I was driving home through base today (since it was a weekend, most of the roads were closed, forcing me to drive the entire way through base to get to the one open gate), I took some pictures:

This is actually from the outside of base, one of the closed gates. The red crosses aren't to tell drivers that it's a closed gate; it's to make sure we're under protection of the Geneva Convention as a medical facility.


This is one of the historic buildings on base (it now houses random administrative stuff, like transportation and finance and parking). When WRAMC closes in two years, it's one of the protected buildings that the State Department (which is taking over the base) is not allowed to tear down.


And this is the original Walter Reed General Hospital, which opened in May 1909 when ten patients were transferred from another Army facility to the brand-new, state-of-the-art facility named after the late Major Walter Reed. It was state of the art because it had running water and an elevator. There aren't any patients in the old hospital ('Building 1') anymore, but it's still a nice building. It's another one that the State Department can't tear down.

And one last thought, by that wife of the retired MG. She asked my resident if she should go home to sleep or if there was a place for her in the hospital. My resident replied that he didn't know what she should do, but he wouldn't want her to be lying awake at home worrying. She just looked at him and said, "Doctor, I think you're underestimating my faith in this hospital. I would go home, read a chapter of my book, and sleep for eight hours without a single worry. That's how confident I am in the doctors at Walter Reed."

How's that for a reminder that this is a good hospital?

On-call, post-call, pre-call

When you're on call every third night, you're always either on-call, post-call, or pre-call. So I was on-call Sunday night. Things started pretty slowly--we had rounds, wrote our notes, and then kicked back and watched our patients and waited for the pages to start coming in. There were a few random pages about fairly simple problems throughout the afternoon, but nothing that took any longer than a few minutes at a time to deal with, so I was starting to get bored. I spent a lot of time in the transition year call room, where two of my fellow transition year interns (one pre-anesthesia, who is in the cardiac care unit, and one pre-physical medicine and rehab, who is on OB/GYN) were also hanging out with their equally slow afternoons. I discovered the hospital cafeteria doesn't have anything good on the weekends (when Subway is closed), and was going to order pizza with the internal medicine interns on call, but we were too late on the uptake (pizza place closed at nine, and we didn't think about it until 8:50). Then, right at nine, my resident paged me and told me to get to the ER, and things went non-stop from there.

Two unresponsive patients came in within five minutes of each other, which is never a pleasant situation. One just had surgery three days before, so the surgery team came and handled him and ended up taking him to the SICU (surgical intensive care unit). The other had been in asystole (flat line) or PEA (pulse less electrical activity; electrical impulses go through the heart, but it can't contract enough to push blood through the body) for 45 minutes, which is a pretty bad situation. We ended up getting a pulse again and getting him on the ventilator before moving him up to the MICU, where they had to get him somewhat settled in before going down for a head CT. Since I knew that that would take an hour or so, and it was already 1:45am, I reminded the nurses to page me when they were ready and went to lie down in the MICU call room. Then an hour later, it was time to take him to CT (with me ventilating with the bag-valve-mask as we rolled him down the hall and into the elevator), and then back up to the floor. The whole process took about an hour to get a five minute head CT (which was pretty ominous looking when we saw it at rounds on Monday morning). Then when I got back, I had to deal with being sleep-deprived and trying to explain the events of the night to the family. It wasn't until I finally got to lie down again that I realized how scary this must be for them; for me, it was another random unresponsive victim who came in and will never wake up. For them, a few hours before, he was walking around and talking, and now he's in the ICU, on a ventilator and all sorts of IVs, and some doctor they've never met is trying to tell them bad the situation is.

It was a banner night. Then I went back to bed until the pages with the morning lab values started coming in.

At rounds on Monday, I was grilled about the electrolyte abnormalities in the acute kidney failure of one of my patients (and stumbled through the answers), and then after writing my notes, was out of there. I decided to hit the base gym before going home, which was a really good idea--it completely woke me up so I could drive home. Then I made lunch, did some cleaning, and went down to the pool, where I promptly fell asleep. I probably would have stayed that way (ending up rather burnt) if one of the general surgery interns hadn't paged me asking if I wanted to do dinner. So I changed, took the Metro into Bethesda, and enjoyed the 1/2 priced bottles of wine at Olazzo (their Monday happy hour special) with some surgery interns (I spend a lot of time hanging out with surgeons, for some reason). And then it was back home, where I went to bed early in anticipation of getting up to go in for a "work day" today.

"Work day" means you go in, see your patients, learn everything that's happened to them in the last 24 hours, and then round (which took forever today, for some reason, but I did get to look impressive by properly interpreting an EKG), and then write notes and get to noon conference (which was cancelled today). After leaving the hospital, I met with one of the fourth year preventive medicine residents about on-going research projects that I could join, and then headed home for a run. I've just been lounging around since, will probably go to bed early again tonight, because I'm pre-call.

Three down, 362 to go

Yesterday I started my first shift as a doctor--in the MICU (Medical Intensive Care Unit)--and today at noon, that shift ended. Nothing like a 30-hour on-call shift to say, welcome to the field of medicine.

On Wednesday night, I got a call from the on-call resident saying that since I was on-call on Thursday, I didn't have to worry about showing up until 8. So on Thursday, I got up, showered, dressed in civvies, and headed for the hospital, where I changed into scrubs and my white coat (a long white coat now, which is a little weird), which is my 'uniform' while I'm in the MICU. Since it is a uniform, uniform standards apply, which means that my hair had to be up, etc. It also means that for some guys, they have to shave their five o'clock shadows while on-call.

Anyway, so I arrive to the MICU around 7:30, to discover that I should have been there at 6, because I was assigned a patient. Fortunately, my resident bailed me out and went with me to see the patient while explaining how things work in the MICU.

Rounds, of course, took forever. It's internal medicine; they like to round. And they like to throw around big words and quote studies and whatnot, so after a year of living the easy life as a fourth year medical student, it was feeling rather intimidating. After rounds, I asked one of my fellow interns if I could go somewhere and cry. He laughed and said there was too much to do to have time for that (which was true). We also have a Oral/Maxofacial Surgery resident (dentist) on the team, who is somewhere between an intern and a resident in terms of responsibility. It was pretty funny; at one point, I asked him what sort of clerical error allowed me to earn an MD, and he replied that at least I spent the last four years in medical school, and that I should just imagine doing all of this after four years at dental school. He had a good point.

I wrote a note on Facebook about my on-call experience. Because I'm too lazy to type it twice, I've copied and pasted it here:

So here are a few things I learned in my first on-call night as an MD:
1) After four years of wearing a short white coat and knowing that everyone around you knows that that means you have no responsibilities, it's a little weird to be in a long white coat. It took me a few hours for it to actually sink in that that's what I was supposed to be wearing and that nobody was going to get me in trouble for impersonating a doctor.
2) For military personnel, scrubs are a uniform while you're in the hospital. That means hair must be maintained to uniform standards (short for guys, above the collar/in a bun for girls). It also means that when on call, a lot of guys have to, at some point in the night, shave.
3) After the fiftieth page about blood pressure, you start to feel comfortable handling that alone without calling the senior resident.
4) ICU-trained nurses are AMAZING. I'm serious. When a patient was beginning to circle the drain, it took me about three seconds to realize that my job was to stand out of the way, and when the nurses asked, "Ma'am, do you want to give _____?" the proper response is, "I'll go put that order in right now."
5) Non-ICU trained nurses working in intermediate care, on the other hand... not so amazing. See point three about answering pages about blood pressure.
6) Doctors at Walter Reed wear their pagers clipped to the front of the scrubs top instead of at the waistband of the pants. This isn't to look cool. It's so when you're getting these constant pages, all you have to do is glance down to see what number you need to call back.
7) You very quickly learn to recognize the phone numbers on your pager of the units/nurses that will keep you up all night. See points 3 and 5.
8) At WRAMC, they have a policy where patients who are on a monitor must be accompanied by a doctor whenever they leave the floor. All ICU patients are on monitors. That means that when Mrs. X is going down to her MRI at midnight, the intern gets to go with her and sit there until it's time to go back.
9) The computers in the MRI suite don't have the program necessary to write patient notes. So while sitting there while Mrs. X is getting her MRI, there's nothing to do (assuming she doesn't suddenly crash), and notes that have to be written aren't getting written.
10) It's not Gray's Anatomy (well, I knew that point already). The on-call rooms are used for sleep, storing things in lockers, and grabbing thirty seconds to wolf down a meal at 0300 that was supposed to be dinner the night before. Nobody has the time or energy for sex while working. At least, I hope not. I caught an hour and a half of very interrupted sleep (see points 3, 5, and 7) on one of the very uncomfortable beds in the Transition Year call room, and I don't want to even think about when the sheets were last changed.
11) Brownies stolen from the Internal Medicine work room at 11pm taste really good at 4am.
12) White coat pockets are large for a reason. That way, in addition to carrying around reference books and patient notes, you have room for food, gum, chap stick, and a water bottle. And a stethoscope, if you get tired of wearing it around your neck.
13) After awhile, answering the phone, "This is Dr. Hesse, I was paged," loses its novelty.
14) You realize, sometime around 0200, that you almost know what you're doing, and maybe you didn't waste the last four years of your life in med school after all.

A few other things that I didn't add to the list that I just thought of:
1) Leaving the hospital after being indoors for 30 hours makes you feel like Rumpelstiltskin. You have no idea what day it is or why it's sunny outside.
2) When you don't know what day it is, it makes getting around a military base a bit difficult. This really only applies to today. Since the 4th is a Saturday, the 3rd is a training holiday, which meant the hospital gym was closed (and thus, there went my plans of working out after work), the road from the parking garage to the main gate was closed, and the 16th Ave gate, which I usually take, was also closed. To get from the garage to the main gate on a weekend or holiday (the only gate open), you literally have to drive all the way around base, and for everyone who has ever driven on a military base, you know that that's easier said than done--roads aren't gridded, they're narrow, and there are stop signs and speed bumps in seemingly random places. Now imagine doing that after working for 30 hours (when you're as impaired as someone who is legally drunk). All sorts of fun.

Anyway, that was my first day as an intern. I have tomorrow off (I'm planning on watching the fireworks from the Washington Monument), and then I'm on-call again Sunday (another 30-hour shift... yipee). Only three weeks of this, and then it's onto general medicine wards (which I'm not thrilled about, either).