Day 6--Tuesday: "Gas, gas, gas!"

Today we had a lecture about burn-out in health-care providers (which kinda made us laugh, so that should tell you what we thought about it) before loading up with our gear again and heading back to the five-ton to go to the field for almost an entire day of activities.

We started with learning procedures for guarding a convoy under attack and how to take care of our casualties when under fire while still protecting the convoy. Since I'm somehow a squad leader, I had the fun and exciting job of yelling orders and commands and radioing in for evacuations and all that stuff. Quite interesting. I think we all ended up dead.

Our next activity was a litter obstacle course. We loaded up a litter with a “casualty” (dummy) and had to navigate through this course in the woods. Somehow, my squad ended up with the heavy dummy, and first squad had the light one, and we still beat them to the end (because we're awesome... and we have more tall, strong guys than they do). I wasn't a litter carrier (thankfully); instead, I was providing security from the front and shouting commands behind me. And let me tell you, low-crawling with kevlar and a flak vest and my BCGs (pretty much indestructible combat glasses) is not easy. As I said when I was about halfway through that step, “They don't teach this in medical school!”

The next thing we did was march toward the next station (full gear, weapons at the ready, watching for enemy activity), when we came under chemical attack. That meant that I had nine seconds to take off my kevlar and my BCGs, pull out my gas mask, and get a good seal. And then they told us to get into full MOPP gear (and don't ask me what that stands for, because I don't know), which is eight minutes for the full suit, boot, and gloves, which is definitely not easy with a gas mask on. I have prescription inserts for my mask, which supposedly means I can still see with it, but the prescription was wrong, so they let me take off the mask and put my glasses back on and continue the march without it (but still in the other chemical gear). It felt really good to take that stuff on, but even in that short walk, I sweated completely through my uniform, so I was soaked for the next hour or so.

We played with the simulation dummies for awhile, pretending to be working at a level 2 battalion aid station of a FOB (forward operating base) that had come under attack. That was fun and all (and it was good to be doing something doctor-ish, instead of pretending to be medics), but it was definitely not easy with kevlar and flak vests. However, I did successfully intubate every dummy I tried to intubate, so I considered that a success.

The next station was learning how to do chemical decontamination, which wasn't really all that exciting, and then we had another road march, during which we came under attack. This time it was just people with explosives and guns, no chemical warfare, but it was still pretty hectic, and I think we killed our three casualties. I got really beat up from all the times we had to drop to the ground (which was very rocky), and my legs got so tired from hauling myself up with all that gear that I couldn't really do it anymore. I started using the butt of my M-16 as a crutch to get up, which we're really not supposed to do (but whatever). Our instructors decided that we did such a good job at that one that we could go back to camp early (the next platoon came in about an hour after we did). All around, a much better day than yesterday. They actually treated us like adults, not basic trainees. It was a nice change.

Day 5: Monday--Welcome to the field

Today was a combination of death by PowerPoint and killing us in the field. In other words, an all around great day (sarcasm).

This is most of what we did the in the field... hurry up and wait

Reveille was at 0430 this morning, which gave us an hour and a half for “hygiene” (going to the bathroom, getting into uniform, etc), eating an MRE breakfast, and getting into full gear to get into formation at 0630, to be marched over to the theater for seven hours of PowerPoint lectures (not an exaggeration). The first three hours were so incredibly boring that I had to stand up in the back to stay awake, all while holding an M-16 and wondering how I was going to survive in the field, because I was already sore from marching over to the theater in gear.

Anyway, after those seven hours of lecture, we had an MRE lunch outside the theater before getting back into gear (while some sergeant in the Air Force yelled at us to hurry up) and then hauling ourselves into the back of a five-ton transport to make our way to the field site for all sorts of funness.

Always fun to be had in the 5-ton...

We started with litter carries, buddy carries, and learning how to load up an ambulance (which aren't really used, because they're not armored). I really don't know what the point was; in combat, the litter teams aren't even medics—they're cooks, mechanics, etc; soldiers who aren't trained to treat. So if a doctor is ever required to go out to where bullets are flying to carry a litter, something seriously wrong has happened, and we're all about to die. But I did successfully lift 2LT Kuyt (Army nurse; the lightest in our squad, although she was probably 150 or so with all her gear) up into a fireman's carry.

The guys practicing a two-man carry

After that we marched over, while holding our fake M-16's in the ready position, to a shed where they had stations set up to demonstrate the things that medics had in their packs. Again, not really useful for doctors and nurses.

Our last station, after being yelled at by more sergeants and corpsmen to hurry as we marched around the field in gear with our weapons, was weapons familiarization, where they showed us how to dissemble and reassemble M-16's and M-9's. In other words, nothing I didn't learn four years ago. Then we got into chemical protective gear, took it off, loaded our stuff back on, and got back into the five ton transport to go back to the cantonment area. By the end, we were all very frustrated with all the activities, as well as the fact that they treated us like basic trainees the entire time. Someone is going to snap tomorrow. I just hope it's not me.

2nd Platoon, 2nd Squad, AKA "G-Row"

Day 4: Sunday---ATLS Testing

Today was testing day at Doctor Trauma School (aka, ATLS). We started the day doing mock trauma scenes, then did the same thing for testing. I somehow passed, even though I think that before the Army makes me go anywhere I might have to do any of this stuff, they better have me retrain on it. Then we talking about triage situations, which is definitely something that I will have to do. The job of triage officer when deployed goes to the medical (or dental, as it is in some cases) officer with the least clinical experience, because you want all the clinical people to be inside the hospital treating the people who are being triaged.

The basic tenets of triage are to treat the maximum number people with the resources available. There are four categories of triage: red, yellow, green, and blue. Red are your first priorities, the ones who need treatment as soon as possible. Yellow patients come next—they'll be fine for 24 hours or so, but should be treated sooner rather than later. Green patients are the “walking wounded”, the ones who maybe need a cut sutured or aspirin for their headache or something like that. They definitely don't need care in the next 24 hours if there are other people who around who need care. Blue are the expectant group, the ones who are going to die no matter what you do, so there's no point in wasting resources on them. It sounds cold, but you have to treat as many people as possible, and if you spend time working on the people who are going to die, that means that there are red patients, those who need care and will probably live if they get it, who will probably die. Obviously, if there are blue patients who are still alive after the critical patients are taken care of, you would go back to them, but that generally doesn't happen.

Anyway, after that was the paper test for ATLS, for which most of the questions could be answered by choosing the answer that said something about intubation. You always take care of the airway first (ABCDE—airway, breathing, circulation, disability, environment), and intubating someone and establishing a definitive airway is usually the first thing you have to do.

MRE lunch at Ft. Sam

We were supposed to have a burn lecture in the afternoon, but that was canceled, so they bussed us back to Camp Bullis and gave us lectures on providing medical care in a combat situation (as in, bullets are flying over our heads) and how to do medical evacuations. It was interesting stuff, but it boils down to, doctors are not expendable and should not be in situations where there are bullets flying, and medical evacuations are organized by medical service corps officers. Then we had a couple of hours of freetime, during which I went on the four mile loop, and then sat around and laughed with (at?) some of the guys in my squad. They are absolutely hilarious, and could just feed off each other for hours at end. And then it was back into uniform to go to the DFAC for dinner, and then time to pack our rucksacks for the field tomorrow. We have one nurse in our squad who was ROTC in college and knew how to pack a ruck, so she helped us with ours. We also broke down our MREs (which mostly involves trading side dishes and throwing out the ones we won't eat, like the cheese spread and the strawberry dairyshakes) to make them lighter so we have less to carry in our rucks. And then we tried on all our gear to make sure everything fits—from inside out, it's person, uniform, flak vest, ammo belt, camelback, and rucksack, with a kevlar helmet on top. I felt like a turtle with everything on.

Me and 2LT Kuyt in gear

It's going to be an interesting day in the field tomorrow.

Day 2: Friday--First day of ATLS

Today started with reveille at 0500 and all of us in my hutmet reluctantly crawling out of our sleeping bags. Fortunately, it had cooled off significantly overnight, so it was a really nice morning—as nice as 0500 can be, of course. After a quick breakfast at the DFAC, it was back into formation to march over to the theater, singing cadences on our way to our lecture.

We had a couple hours of lectures about general military medical things—traumatic brain injury, followed by a preventive medicine lecture I could have given in my sleep—and then the nurses headed off to Trauma Nursing Care Course (I think that's what it stands for), the dentists to Pre-Hospital Trauma Life Support, and the doctors to Advanced Trauma Life Support, over at Ft. Sam Houston, which involved a bus ride by old school buses that have been painted white (and are therefore no longer school buses, I guess).

Waiting for formation

It was kinda nice being in air conditioning for the entire day, but six hours of straight lecture (they let us eat our MRE lunches at 1400), followed by three hours of practicing procedures (inserting central lines, intubating dummies, etc). And then it was back onto the buses to make our way back to Camp Bullis and the hutmets (eating the M&M's from my MRE on the way, of course).

After another squad leader meeting (we have them every night, to get the schedule for the next day), I decided the weather was mild enough for a run. We have to run in buddies (which I would want to anyway, as it was already dark by then), while carrying flashlight cones—the roads out here at camp don't have streetlights. I asked a few people, who were somewhat intimidated by my nine minute mile pace for a four mile run, and finally found a Navy family medicine intern willing to run with me (and in boots!). He's stationed at Bremerton, so we chatted about Washington and various intern complaints while we ran. And in the dark, with him wearing boots and me carrying a flashlight and both of us talking, we still managed to run faster than a nine minute mile pace.


Well, it's definitely time to go to bed (almost 2200), considering the 0445 reveille tomorrow, so we can get back to Ft. Sam to sit around and learn some more ATLS.

C4--Day 1:Thursday--Welcome to C4

Today started ridiculously early—my alarm went off at 0245 so I could shower and throw some last minute stuff in my bags before SuperShuttle arrived at 0330 so I could get to Reagan National Airport for my 0600 flight. Packing was actually pretty easy—it doesn't require much thought when you're not allowed to wear anything that isn't a uniform, so I just threw everything I had that said 'Army' into a bag. Anyway, it's a good thing they got me to the airport that early, because when I arrived at the airport and tried to print my boarding pass, I discovered that the Army didn't actually pay for my ticket. So, after almost an hour on the phone with the emergency line at Carlton-Wagonlit Travel, everything was taken care of and I got on my plane. And then promptly fell asleep for a good portion of my DC to Dallas leg of the trip. After a brief visit to the Dallas USO, it was onto another plane to San Antonio, and then another brief visit to the San Antonio USO before the shuttle came to take me to Camp Bullis, and C4 officially began.

They started with the standard briefs—this is C4, this is what will be going on in this week, etc—and then they issued us our gear. And what fun that was. Rucksacks, kevlar helmets, flak vests (and those things are heavy, in case you were ever wondering), canteens, ammo belts, fake M-16s (not just unloaded, but fake), sleeping bags, duffles, etc, etc. Lots of stuff. And then they stood us out in the sun and made us try everything on and told us at least twenty times to hydrate—but didn't let us go to the water buffalo (water tank on a trailer) to fill our canteens, which would have been nice, considering it was 90 degrees with 95% humidity—quite the change from the 50's-60's in DC.

The gear

We had our first formation a bit later, after most of the class had arrived, and then they marched us to the DFAC to pay for our MREs and feed us dinner. We were each issued a case of MREs, which is a bit intimidating, considering each MRE is probably about 3000 calories and could feed a small Ethiopian village. Needless to say, I'll be taking MREs back home. Christmas presents, perhaps?

What passes for food in these parts

Somehow in all of this, I ended up being made squad leader—yeah, bad idea on their parts. When nobody volunteered, the sergeant glanced at the list and called out a random name, which just happened to be Captain Hesse. Fun, fun. The other Walter Reed people all thought that was pretty funny (there are five of us here, but none of the others are in my squad).

Well, I am now finally clean(ish), which feels very, very good after sweating through my ACUs for half the day (I wore civvies while I traveled and changed at the San Antonio USO). Tomorrow we start with reveille at 0500, and then it's a day of Advanced Trauma Life Support (ATLS) at Ft. Sam Houston (yay for air conditioning!). That goes on for a couple of days before we get to the field portion of the course (which is when we have to start wearing the flak vests and kevlar and ammo belts and all that fun stuff). Should be interesting...

Pediatrics Clinic

I actually started in the peds clinic at NNMC (Bethesda) on Friday, after returning from C4 on Thursday (and I'll start posting entries from C4 as soon as I'm done with this one), but nothing really exciting happened then, and I didn't think anyone would want to read about the kid with the scraped nose or the other kid with the flu.

Anyway, the way peds clinic works for transition year interns is that we aren't assigned patients (as the pediatrics interns/residents are), but choose an attending and work with them. Today I tagged along with a pulmonologist, because the idea of doing well-baby checks was really boring to me. The morning was mostly asthma patients (not that exciting), but we did CF (cystic fibrosis) clinic in the afternoon.

Depending on the patient's age and how he or she is doing clinically, patients are seen either quarterly (every three months), semi-annually, or annually. Overall, it's a pretty simple appointment--ask them (or parents) how they're doing, if they get short of breath, energy level, any GI symptoms, and what kinds of medications they're taking.

The first two patients were siblings, a 22-month-old boy and his eight-month-old sister. Both of them were doing really well, so that was good. Like I said, pretty simple appointment, and we ended up just telling the father to keep doing what they're doing and come back in three months. The third patient, on the other hand, is not doing so well. She's seven and has been pretty sick (pneumonia, diarrhea, etc) for about five weeks. At some point in there, she had the flu (don't know if it was seasonal flu or H1N1) and had a course of Tamiflu, which definitely didn't help the nausea and such. Then her cultures came back as a bacteria in the Mycobacterium family (same family as TB), which automatically buys her at least a year of four more antibiotics, in addition to the other medications she was already taking.

All sorts of fun. Really.

The Army 10 Miler

On Sunday, the Metro opened a couple of hours early, a few streets in DC were completely closed, and about 20,000 people flocked to the Pentagon for the Army 10 Miler, which is one of the most popular races in the DC area (another being the Marine Corps Marathon; both races fill up within three days of registration opening).

I met up with a couple of other interns, as well as the husbands of a couple of interns, at the Forest Glen metro stop at 6am Sunday morning (when the Metro opened), to begin our journey to the Pentagon stop. We ended up arriving a little after 7, which was almost an hour before the race began (although closer to an hour and a half to when we actually crossed the start line). I ran with Beth and Emily, an orthopedic surgery intern and general surgery intern, respectively, for the first six or so miles, before I lost them at a water stop around the sixth mile marker.

With my dramatically bad performance at the half marathon a couple of weeks ago, I decided to take it fairly easy for the last four miles, which meant that I didn't get that great of a time (1:38 or so; a bit faster than 10 minutes/mile), but I was still standing at the finish line, which was the ultimate goal. Of the five of us, though, nobody ended up with that great of a time, so I didn't feel so bad (Beth and Emily ended up coming in only a few minutes ahead of me). After crossing the finish line, we got our coins (above), and then it was off to our meeting place, the Pentagon Metro sign, which worked out pretty well. While we were waiting for the menfolk to wander up(they must have been spending a lot of time in the food tents), I saw someone in an Ohio State shirt, so we chatted for a few minutes. Turns out, he's a sports medicine physician at Nationwide Children's Hospital, so that was pretty interesting.

Anyway, it was another long Metro ride back to our cars (by the way, cramming a bunch of sweaty, stinky people into Metro cars is not pleasant), and then we went our separate ways to go home and clean up before heading out to breakfast (which we ate at 1 pm...). Then I spent most of the afternoon taking a nap. All in all, a pretty good day. Emily decided that we should do it every year of residency. I agree.

"Peeing for freedom"

That's what we call the random drug screens that are yet another fun and exciting part of Army life. This morning was my turn.

I turn my phone to silent at night (because, let's face it, my sleep is much more important than anything that anybody would be calling me about in the middle of the night), so I missed the 0400 call telling me to report to Student Company for a urine drug screen at 0600. Well, I woke up at 0545, because I don't have to be at work until 0800, so I just said, "Well, that's not going to happen," and went on with my morning. I figured I was going to be late no matter what, so I wasn't in a hurry. I ended up getting in a little after 0700. I shouldn't have even hurried that much, because they completely didn't care that I was there more than an hour late. The sergeant just handed me a cup and said, "Okay, ma'am, Specialist *** will be going with you." (it's all supervised... quite awkward).

Pretty standard day in clinic. I was in the GIMC (General Internal Medicine Clinic) again this morning. Three patients, two of which were sick call (if you're sick enough to miss work, you're sick enough to go to the doctor. Army efficiency or something). The first wanted a profile for a sprained ankle from seven months ago. He had been seen in Ortho already and had been told that he has to go back to Ortho for any further profiles, so I just reiterated that and sent him away. Then there was a case of diarrhea--just wrote him an order to go home.

I spent my lunch in the general surgery call room, where I discovered that I didn't have the worst random drug screen story, by fall. My friend Emily was on call last night. She doesn't get reception in the hospital, so she didn't get the 0400 call to come in. She finally got the message when she was on her way home, after 1200. So being the responsible officer that she is, she turned around and went back, only to be told that they were done doing the drug screens and she had to go to the ER to have it done. Well, they don't do supervised urine drug screens in the ER, so they sent her away as well. By this point (30+ hours awake, having to deal with this, etc), she was pretty much in tears when she called the company commander to explain the situation. He just let it go.

Anyway, here's a picture of post-call Emily after having to deal with all of this. The "cat ears" on her head is actually the neck tabs for her uniform. Being post-call makes you do some strange things.

Block 4: Ambulatory medicine

Yesterday I started my block 4 (of 13) rotation: ambulatory (out-patient) medicine. In other words, clinic. Lots and lots of clinic, a different one every day.

I started in the Medical Evaluation and Treatment Unit (METU, because everything has to have an acronym), which is for internal medicine patients who need medical clearance for surgery or have simple procedures (such as a joint aspiration) that has to be done. I had two patients in that clinic, both for medical clearance for surgery. Those are pretty simple: just go over their risk factors, most of which are cardiac (history of heart attacks, strokes, etc) and the risks of the surgery (an arthroscopic knee surgery is a lot less risky than an open abdominal surgery), to determine their overall risk and if they need any further testing before the surgery. Both of my patients were low-risk for medium-risk surgeries and didn't need any further testing. Seeing the patients took about five minutes; writing a note on AHLTA (the DoD's electronic medical record system) took about forty-five minutes. I hate that system.

Then I moved to the General Internal Medicine Clinic (GIMC, pronounced gem-see) in the afternoon. Since I don't have a group of patients that I see on a regular basis, I get all the walk-ins, which are very simple cases. I had two yesterday that both came in with "I used to take ___, can I have a prescription for that again?" to which I said "sure, why not?" Then the third patient was a specialist who pulled a muscle playing flag football the day before. He got ibuprofen and a muscle relaxant.

Today I started in back in the GIMC, where it was more of the same--simple cases, followed by spending a long time trying to write a note. The afternoon was spent in the optometry clinic, which is pretty much just learning what they do there and what cases should be referred to optometry and which are ophthalmology issues.

Tomorrow... I have no idea. I guess I'll figure it out when I go in and check my schedule in the morning.

One really bad run

This morning, I had a half marathon through Rock Creek Park. Yeah, didn't go so well.

We had been having all sorts of fall weather lately--perfect running weather--but we weren't so lucky this morning. On top of that, I took the first part of the run out too quickly, and the result was that by mile eight, I was feeling pretty much done. However, after a marathon, at least ten half marathons, and a smattering of races of other lengths, I've never not finished a race, so I kept going. I walked a lot, but kept going. I kept thinking that I should stop, but figured it was a mind-over-matter type of thing. And besides, I've never not finished a race.

And then I passed out a little after the tenth mile.

I don't really remember what happened after that, because the next thing I knew, I was surrounded by paramedics who kept asking me my name and what happened (and all I could tell them was, I passed out), and they decided that I needed to go to the emergency room, which since I couldn't stand, I agreed with. I told them probably five or six times that they had to take me to either NNMC or Walter Reed since I'm active duty (NNMC was only about a mile away), but they kept trying to talk me into a civilian hospital that was closer. I finally convinced them, mostly because the last thing I needed on top of everything else was to get an ER bill and trying to get TriCare to pay for it when a military medical treatment facility was only a mile away.

I also got to discover just how it feels to have altered level of consciousness (when the nurses in the ER asked how I felt, I said "altered". They looked at me funny until I informed them that I was an intern). Things felt funny and looked funny and kinda felt like an out-of-body experience. When they asked me my name and social and birthday, I had to seriously think about it before I came up with the answers. Then they asked me where I was, and I said "Navy," which wasn't good enough for the nurses (I don't think they know that that's what Army doctors call NNMC; they made me tell them that it was National Naval Medical Center, which again, took me a minute to come up with). And then they asked the date (which I didn't know), the day of the week (which I knew because I had asked the paramedics about ten minutes before), the month (I randomly guessed September, but I was pretty sure it could have just as easily been August or October). I did know the year, which made them happy.

Well, they got three liters of fluid in me (so I was in the ER for a little more than three hours), and I was feeling much better after the first half liter (although my heart rate and respiratory rate were still pretty fast, signs of dehydration), so I got to stick around for the remaining two and a half liters, reading People magazines from five and nine months ago. Great fun. Fortunately, I had the foresight to put my Metro card in my pocket before starting the race (finishers get Metro passes to go back to the Rockville station, where the race started), so I was able to get back to my car and go home.

Great fun. I just hope none of the Navy interns knew that I was in the ER today. It could make work tomorrow fairly embarrassing.