"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.

Dodging work, one inappropriate consult at a time

Life on PCLS (psychiatry consult liaison service) at NNMC (National Naval Medical Center, known in the Army Medical Corps as "Navy" and in most of the world as "Bethesda") is very slow. It's been a week, and we've had a total of three patients, for three interns. One of them, my patient, had a history of depression and anxiety and had been admitted to the hospital four times in three months with abdominal pain, that the medicine and surgery teams had completely worked up and couldn't find a medical cause for. So they consulted us to see if there was a psych component to her complaints. I chatted with her for about an hour, presented to my attending, and we recommending increasing her anti-depressant (she was on a pretty low dose) and following with a psychiatrist after discharge. Done and done. One of the other two patients that we had was just as simple, and the third, the only one we were seeing for more than a day, was a retired Marine colonel with chronic pain (from combat wounds), who had been taking a lot of narcotic pain meds and self-medicating with alcohol. He pretty much admitted himself for detox, and we had been making recommendations for detox/withdrawal and following with him until he could get into an actual rehab program.

So, what do we do the rest of the time? Well, a lot of sitting around the intern room at NNMC and being made fun of by the surgery interns, who were actually doing work (and we mock them in return for having to do work), and dodging inappropriate consults. We've actually only had two of those: one from a surgery resident who had a patient coming into clinic. The patient had a pretty complicated post-operative course, with a lot of chronic pain issues, and had a lot of anger, so the resident wanted someone to come by to the outpatient clinic and talk with her. Well, we don't see outpatients (just inpatients and in the ER), and besides, how would you feel if you came in for your post-op appointment and saw a psych intern sitting there wanting to talk to you? So we told her that if there was nothing acute (suicidal or homicidal ideation, etc), that she should talk to the patient and find out if she wanted to talk to mental health profession, and if so, put in a referral for her to see a psychiatrist/psychologist as an outpatient.

The other one, and I felt sorry for the intern for this, because I could tell it wasn't her idea, was on an ICU patient in a coma, who had a family who was being difficult to the ICU nurses and docs. Patient relations and social work was already on board, but the attending "wanted to cover all the bases". So I asked what the PCLS issue was, and the intern said, "Well, there's some question about whether or not they can make decisions for the patient." I asked if they wanted capacity evaluations for the family, and the intern said no, that's not what they wanted. So I told her that I didn't think it was something for us to be involved in (especially since they already had patient relations and social work involved already), but that I'd talk to my attending about it and get back to her. Well, my attending laughed and said that we don't see the families of patients, no matter how much they're annoying the primary team. I did apologize to the intern when I told her we weren't going to see family, and explained that I don't want her to think we're dodging work (especially since we weren't doing any), but that it really wasn't an appropriate consult. She thanked me, and that was that.

In all, I went from working ten + hours a day, six days a week (plus being on call) for two months, and now I work about six hours a day and get weekends and evenings off. It's weird, and I'm trying to get used to having down time again. I've been running more, and since NNMC has a pool on base, have been swimming a couple of miles a couple times a week. Life is good.

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.