Happy Thanksgiving, and farewell to Tripler

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

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

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

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

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

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

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

Last day at work

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

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


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

Last dive in Hawaii

Sadly, today was my last dive with Gabe and Kaimana Divers. We went out to Waianae again (on the west side of Oahu) and did two different dives than we did last week. No sunken ships or airplanes this time, but we did a cave dive and a reef dive, so there were all sorts of fish and such to see. On the first dive (the caves), we also see a sea turtle, and on the second dive, we saw a couple of octopi (?). That was rather fun, especially when they squirted ink. There's nothing dangerous about the ink; it's just to cloud the water so predators can't see the octopus, giving it time to get away (in theory).

Anyway, here are some pictures from between the dives. This is me and Jack (one of the other divers). Today was her birthday, so she got to pick the dives.

And here are some other divers. It was kinda cold today (75ish), which is why people are bundled up.

So, that's that. I got in six dives this month, which isn't bad. I just wish I knew when I'll be someplace warm enough to go diving again.

Transient hypogammaglobulinemia of infancy

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

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

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

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

Medical board

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

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

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

Rain, rain, go away...

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

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

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

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

Long commute to see the doctor

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

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

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

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

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

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

Back to work...kinda

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

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

North Shore

Happy Veteran's Day! Since it is a holiday, clinic was closed, which meant (another) day off from work. A couple of the other med students and I decided to drive up to the North Shore of Oahu and check out those beaches and watch the surfers.

This is no one I know, but it's the best surfer picture I got.

And of course there was sand castle building.

And then one of my fellow med students decided to demonstrate why weak swimmers should not go out too deep in the ocean when there are 5-15 foot waves. He got caught in a current and the lifeguards had to come bring him in.

So that was the last day of the four-day weekend. Tomorrow, it's back to the Allergy and Immunology clinic.

Pearl Harbor and more of the beach

Today we went in to Pearl Harbor (actually, just outside Pearl Harbor) to the U.S.S. Arizona memorial. It's actually a really neat program--there's a video about the progress of the war (in the Pacific) leading up to the events of Pearl Harbor on Dec. 7, 1941, and then a lot of stuff on that day specifically, such as which ships were destroyed, which were damaged, and which had loss of life. The most significant of those was the Arizona. When the bomb hit, it ignited the ammo (or fuel, I don't remember which), which caused a fire locking everyone inside.

Here's just about all that's left of the Arizona:

And here's the wall in the memorial with the names of those lost. There's also a section for those who made it off the ship, and chose to have their ashes buried with the Arizona after they died.

Here's a model of the ship (while it was in one piece, obviously):

And, of course, Tripler Army Medical Center from the Arizona memorial:

I have more pictures from the Arizona if anyone wants to see them (just let me know.

After visiting the Arizona memorial, I went to the NEX (Navy EXchange) on Pearl Harbor, which is the nicest exchange on the island. If most exchanges are K-mart, and the MCX at Henderson Hall was Macy's, this one is the entire mall. It was quite amazing. The commissary itself was larger than most Safeways.

And then there was the standard late afternoon trip out to the beach (Waikiki again, this time). We saw some sailboats while the sun was setting.

Tomorrow a small group of us is driving up to the northern shore of the island. I don't know what we'll see, but I hear that's where all the professional surfers go (someone said something about twenty foot waves). Should be interesting.