Traumatic Brain Injury Clinic

Yesterday was my first day of PM&R (Physical Medicine and Rehabilitation; or Plenty of Money and Relaxation :) ), which is a nice change after four weeks on the medicine wards.

Every Tuesday morning in the PM&R clinic is TBI clinic--traumatic brain injury. When I did PM&R as a med student last March, I was on the TBI service and did a 1/2 day a week in TBI clinic, but today was completely different than that, because TBI in the military is completely different from TBI in the civilian world. Most of the patients I saw back at OSU were there as a result of drunken stupidity, which is most definitely not the case with the patients I saw today.

The first patient was an infantry specialist (gunner on an MRAP) who literally just got in from Afghanistan (he was on the Friday MEDEVAC). On Sept. 11 of this year, his MRAP was hit by an IED, and he ended up with a concussion that left him with persistent migraine headaches (nausea, vomiting, sensitivity to light, the whole bit). He ended up going to one of the field hospitals and got a CT, which didn't really show anything. He kept telling everyone that he felt better so he could go back to his unit, despite the fact that he was still having the headaches. After a few more concussions, it got to the point that his unit's medic realized that he wasn't fine, despite his insistence otherwise. It took the medic pointing out that a gunner who couldn't concentrate on his job was putting his unit at risk to get him to agree to be evacuated from theater for further evaluation.

It really puts things in perspective--here was a guy who was being fired at on a regular basis, who felt terrible on a daily basis, and didn't want to leave his job.

While the PM&R resident I was working with went to fetch the social worker, I chatted with him about his military history. His contract is up in a year and a half, and after that, he wants to go to OCS (Officer Candidate School) to become an infantry officer. Right now, he's still having headaches, and is having difficulty concentrating and sleeping. I really hope he gets back to where he was before these IED blasts.

The other two patients I saw had been established with the TBI clinic for awhile--one had a gunshot wound to the head and is almost back to where he was before he was shot, and the other was another IED blast, who now has some personality changes, problems with his memory, and pretty severe depression.

So like I said, traumatic brain injury in the Army is completely different than traumatic brain injury in the civilian world.

And tomorrow... amputation clinic.

No more medicine wards!

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

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


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




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

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

Update

Okay, so I now I'm doing an absolutely horrible job of keeping my blog up-to-date, which kinda defeats the purpose of having one in the first place. Here's what I've been doing the last month or so:

I'm back on Ward 75, the general medicine ward, this time on Medicine Green Team instead of Blue Team. There's absolutely no difference between the teams, except which team room (office) is used. We, and the other medicine services, actually (there are five: gold, green, blue, white, and red), have been taking quite a hit every time we're on call. Being on call means that if someone comes into the hospital who needs to be admitted to a medicine, they go to the on-call team. The cap for admitting patients to one team is ten, and after that, the senior night float admits them to other teams. Everyone has been hitting the cap, which is a lot of patients, and we can't seem to get them out of the hospital. We're on call again tomorrow night, and still have nine patients on the board. That means if they can't discharge people today (it's my day off today), we could potentially have nineteen patients on Friday, which is far too many.

I have had a few interesting patients, though. There was one the last time we were on call, a nurse with a thigh mass who we essentially admitted so she could get an MRI overnight ("expedited work-up"). Well, the MRI read wasn't as good as anyone hoped, and we called ortho (whom she had already been seeing for this thigh mass, as she had had it for two months), and today they're taking her to the operating room to do a biopsy. In other words, after looking at the MRI, they're concerned in might be a bone or muscle cancer of some sort.

There was another, a ninety-year-old man who really liked to talk (and was very sharp, for any age, especially ninety; a former Special Forces captain during WWII and clinical psychologist during the Korean War, retired at major), and during one of our longer-than-necessary conversations, he asked if I had gone to USUHS. When I informed him that I recently graduated from Ohio State, he got an incredulous look on his face.

He graduated with a Ph.D. in clinical psychology from Ohio State in 1951. Apparently, Buckeyes really know how find each other.

For the most part, unfortunately, the patients aren't interesting, just frustrating, and I'll be very glad when I'm walking out of the hospital Sunday, because that will be my last day on Ward 75--forever.

As far as other aspects of my life, well, it's difficult to have a social life while working eighty hours a week, spending every fifth night in the hospital, and only getting one day in seven off. The one date I went on (blind date, set up by a friend), was a complete disaster. He asked how long I "have" to be in the Army and then started talking about how things will be different once I get out. At one point, I made some joking comment about something about my uniform, and he said, "Well, at least you don't have to wear it at work."

???

Just what does he think being an Army doctor is? When I told him that I do, in fact, wear my uniform almost every day to work, he thought that was the stupidest thing ever. So overall, he seemed to think being a doctor in the Army was the worst thing ever, and I must be counting down my days until I can hang up my uniform and be done with it for good. I don't know if I'll be hanging up my uniform in eight years--it all depends on the opportunities presented to me at that point. For what I want to do in my career, I may be staying in forever, and I don't appreciate some guy I just met assuming he knows otherwise.

In other words, no second date.

So, in the meantime, I've been pretty much doing all that I can to keep my head above water as I finish up this rotation, and spending time with my fellow intern friends whenever I can, which isn't all that easy, when it always comes down to getting schedules to line up. On Monday, I start on PM&R (Physical Medicine & Rehabilitation), so that will be a nice change of pace.

Training Day

Today I got another reminder of why military interns/residents make more money than our civilian counterparts: training, or more specifically, training day. Not pleasant.

Since we have all sorts of mandatory training, about once a quarter, they put together a training day, providing multiple lectures for the in-person training we have to do, and lists of the electronic training. And for some reason, these always happen when I'm on in-patient wards or at Navy.

I started back on Ward 75 (aka, hell) on Monday, and my first day of call is tomorrow. Since we're the day pre-call, we have a pretty light census (we only admit on days when the team is on call), which I thought would translate into a little bit more sleep, but when I opened the email last night informing us of training day, I knew that wouldn't be the case. The first presentation was Alcohol and Substance Abuse Prevention (ASAP) at 0600--required annually, by fiscal years. Then I ran back up to the seventh floor from the second (that's more flights of stairs than it sounds; we have half-floors, but that's another story for another time), to get vitals and lab results on my patients and start rounding. Then at 0900 was Equal Opportunity/Prevention of Sexual Harassment (EO/POSH) (required quarterly, for some stupid reason) back on the second floor, and then back up to the seventh to write my notes and try to get work done. And then 1000 was Patient Safety (annually, and pretty much just consists of people talking about what kinds of mistakes interns make when writing orders), then back up to Ward 75 to finish work and prepare to sign out to the on-call team. There was also Warrior Proficiency Tasks (or something along those lines), which is required annually for everyone captain and below, from 1300-1700, but I skipped that. It's cold and raining, and I wasn't in the mood to practice dissembling/reassembling weapons or practicing litter carries or any of that. They'll tag me for that later in the year, I'm sure, even though I just did all of that at C4.

I also spent a good deal of time in the last couple of days doing online training to prepare to go to Peru for my research rotation in February. I've done Antiterrorism and Survival, Evasion, Resistance, and Escape (SERE), neither of which can really be taught online, realistically. Really, do they think answering a few questions about being held captive is going to help if it happens (especially since medical personnel can't technically be held captive, according to the Geneva Conventions)? Government efficiency, I guess.

And tomorrow, the first of five calls for the month...

Day 7: Last day in the field

Today started ridiculously early, with a wake-up a little after 0400, with just enough time to run to the bathroom before forming up for PT (we sleep in PT gear, so no changing was necessary). The PT—a four-mile run in formation—was pretty easy, except I was in the front and it was very hard to keep a pace slow enough for everyone to keep up. We finished without anyone falling out of the run, and also picked up stragglers from the other two platoons, so I guess it was a success.

Although we had two hours before we had to head back out to the field, none of us in my squad bothered showering, because we knew we would just get dirty and sweaty once we got into the field. Instead, we just sat around the hutmet and ate breakfast (MREs—yum, yum), until one of our instructors came and brought us donuts as a reward for everyone finishing the run in formation.

And then we loaded up into the five-tons again and headed back to the field, where our first stop was the rappelling tower. After a long demonstration by our instructor (her shirt got caught in the rope, so it took awhile for her to get out), we got harnessed up and made our way to the top—fortunately, not in any gear except our kevlar.

Rappelling was fun, even though I ended up upside down on my first rappel (apparently I didn't do a very good job walking down the wall before I began jumping). I did much better the second time around.

Sergeant Henry yelling at me for hanging upside down from the rapel tower

Righting myself on the tower

After gearing back up, the next stop was back to the tactical simulator, where we again were doctors (and nurses, but I was a doc) at a Level II treatment center, and then we simulated running a decontamination area. Then the five-tons took us up a ridiculously steep and rocky path (I ended up falling off the bench and landing on the floor, losing my rucksack in the process), where we had lunch. Then it was back into gear, defending and rescuing casualties from a C-130 again, and then a road march about a mile (with all our gear) to the litter obstacle course, where we got everyone safely to the end. I really do not like low-crawling, by the way.

During a calm part of the drive

All in all, not a bad day, and after formation, they granted us liberty. We're going to be heading out to dinner in a bit; until then, I think I'll be taking a nap.

Our last time hanging out in G-Row

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...