It's been more than a few weeks since I've posted anything. Part of that is just being busy. Part of it is just being lazy, I guess. It's not that I haven't been writing down little notes, I just haven't put them into posts. I think what I need to start doing is to write small posts more frequently. Those long early posts really took it out of me. I guess what I'm trying to say is, "Damn you Jayna! For creating this blog and guilting me into doing it! Damn you!" (By the way, I've enjoyed reading your blog)
My credentials paperwork didn't go through until the second week of August, and I started seeing patients the next day. I had 30-minute appointments the first week back, which I definitely needed while getting used to the new layout of our electronic medical record (which really isn't any better and is just as slow) and figuring out where things are in the clinic. Plus, I didn’t have my regular tech who knows where everything is, so it was slow going. I realized that I hadn’t seen a real patient since the day before residency graduation - almost 2 months prior. But being a doctor's like riding a bike, right? Once you learn how to do it, you never forget? Although I think my problem isn't what I forgot, but what I never knew in the first place.
That very same night I started my first week of call. The arrangement is that everyone takes a week of call starting Friday night and going through the next Thursday. You see anything that comes in over the weekend and after hours during weekdays. There usually isn't a lot to do, but by the end of the week, I was exhausted. Just knowing that the phone could ring makes it difficult to fall asleep, and having fallen asleep, I didn't always sleep well. And I'd have weird dreams. It's been nice not having angry dreams of punching patients in the face or somber dreams of seeing a girl I dated in medical school (I was oddly sad for 2 days), though I never had any dreams of punching old girlfriends in the face, thank goodness.
I did get called in a few times. My first night a kid came in at 2am Saturday morning who was drunk and had punched a wall, cutting his hand. By the way, does it mean I'm becoming an old man when I call all enlisted people younger than 25 years old "kids"? Anyway, his injury wasn't serious (didn't even need any stitches) and he definitely didn't need to come in. So on the way in I'm thinking to myself, "I'll teach this kid a lesson and make him come in first thing in the morning, hungover and all, and he'll wait until I finish seeing any other patients." He was pleasantly inebriated and cooperative and I changed my mind. I guess I'm a softy that way, and I told him he could come in Sunday morning.
Another kid came in the next night with stomach pain and I sent him to one of the nearby hospitals for further workup. To his credit, he tried to tough it out, but after vomiting 12 times and having three bouts of diarrhea, and as the pain worsened, he finally stumbled into our Immediate Care Center (ICC), which is the closest thing we have to an ER. I thought he had appendicitis, which it turns out he did, and they operated on him the next day. One of our lab machines wasn't working and we don't have a CT scanner, so I couldn't use those to get more clues, and sometimes you can be fooled. Like the time I was 21, working construction, had horrible belly pain, and was convinced that I had appendicitis. So I went to the bathroom and explosively relieved myself. Only I didn't feel any better afterwards, so I was definitely convinced I had appendicitis. So I went to the bathroom again and explosively relieved myself. And then I felt fine. And more recently, another kid came into my clinic and I really thought he'd strained a stomach muscle since he says his pain started after working out, he didn't have the usual symptoms of nausea or lack of appetite, and the pain was up towards his left upper abdomen, the complete opposite side as where appendicitis usually hurts. And it turns out he came back a few days later, pain in the same place, but his white blood cell count was really high. Turned out he did have appendicitis. I give up trying to be a physician.
Speaking of a stupid kid trying to play doctor, one of my favorite patient encounters during the past few weeks was with a 19 year old kid who told me that he’d had some fever and chills, cough and runny nose for a few days. I proceeded to ask him some more questions about his cough and runny nose. And then he added that he’d also been having some diarrhea. So I proceeded to ask him some more about his diarrhea. You know, the regular stuff: frequency, blood or mucus, watery or just soft. You know, the usual. When I asked him what he’d tried to do to make himself feel better, he answered that he’d been taking TUMS and milk of magnesia. And I couldn’t help it – I started laughing at the poor kid. “You realize, don’t you, that milk of magnesia is a laxative and gives you diarrhea? I think you’re diarrhea will improve once you stop taking it. And I’m not so sure the TUMS are doing much for you cough.”
I finally gave in and did a rectal exam on the first kid with appendicitis, which in general I think is an over-rated part of the physical exam. There are old school, crotchety surgeons who will tell you that there are only two reasons not to do a rectal exam on a patient: first, the patient doesn't have a rectum, and secondly, you don't have a finger. I can't say that I agree with this. I honestly think that some of this fondness for tickling the prostate is the masochistic martyr complex culture of some physicians. It's like the more you suffer for your work, the better doctor you are. And the rectal exam is a vital part of that self flagellation. It's kind of like how that Opus Dei albino dude in Da' Da Vinci Code wore a spiked chain around his leg, thinking it brought him closer to God. It's crazy.
Another example is how there are still physicians, young and old, who complain about the relatively new 80-hours per week work laws for residents. Like this should even be an issue? “Well, you won’t see everything you need to see,” and “You have to learn how to work even when you’re tired.” B.S. No one benefits from that. You don’t get smarter when you’re tired. I know because I pulled overnighters all the time during med school, probably passed the test the next morning, and couldn’t remember a thing I studied the day after that. Plus, being tired all the time makes you hate patients, like it's their fault that their heart attack brought them in and interrupted the precious few hours of sleep you occasionally get. Yet you still resent them. It's odd how going through our medical education system seems to make people who went into the medical profession for - to a greater or lesser degree - altruistic reasons, come out of it hating everyone.
Honestly, a little part of me was hoping that I'd have another few days/weeks off before I started back. Oh well. The silver lining is that my call week started on Friday night, and on Saturday the medical group commander had everyone come in for "Pride Day," which sounds more like a gay parade than anything military. We had to come in and clean up, shred tons of paper, that kind of stuff. So I guess this was as good a week as any to be on call.
So I feel like I've settled into a routine now, and overall I'd say that things are going pretty well. I usually try to wake up around 0530 and 0600 (depending on what type of shenanigans did or did not occur the night before) and try to work out. Still doing my best to bring it and forget the rest with p90x, which I guess is working for me. I show up for work at 0750, and we see sick call patients from 0800-0900. They're supposed to be patients who are acutely ill, but sometimes they let the "3 months of ankle pain" get through. My regular clinic starts at 0900 and I usually see a patient every 20 minutes until about 1130 or so.
Most days I'll work through lunch, usually doing admin stuff: following up on results, returning emails, stupid military computer training (the terrorists are after our medical information!), and the like. My rationale is that by working through lunch, I don't need to stay until 5pm everyday. My go-to meal is triangle kimbop, which are these little sandwich thingies you can buy here. They're really simple: rice, a little meat (tuna fish or whatever), and wrapped in some seaweed. Afternoon clinic starts again at 1300 and my last appointment is usually at 1530. Most days I can be done with all my notes by 1600, and then I get the hell out of there. On Thursdays I have my colposcopy clinic and that same afternoon I have a half day of administration time.
Colposcopy is a procedure we do for abnormal Pap smears, where you literally look at a woman’s cervix through a telescope-like device. You then apply different solutions to the cervix to make the abnormal cells stand out. If you see abnormalities, you take samples and send them to the lab, and finish things off scraping the inside of the cervix with a metal scaping device and send those cells, too. It’s kind of barabaric, but effective.
Jess had a patient who needed one a few weeks ago, and I don’t think she knew beforehand that Jess wouldn’t be doing the procedure. She was caught a little off-guard when I walked it, and explained to me that no man had ever been able to perform any type of pelvic exam on her without having to ask for help from a woman. “I don’t know, maybe it’s something about being a woman and they’re more familiar with all the parts in there.”
So what I’m thinking is, “That’s the dumbest thing I’ve ever heard.” Occasionally, you’ll have a cervix which points off in a different direction or something, but being a female gives you absolutely no advantage in finding a cervix and taking samples, unless maybe having smaller hands and fingers better enable one to manipulate instruments in small spaces. But what I say out loud is, “Well, I’ve never had problems so far – knock on wood. I don’t expect we’ll have any problems today, but if we do, we can ask Dr. Lotridge to help out.” Everything went fine.
An hour or so later, one of the flight docs comes into my office and tells me that one of his female friends here is friends with the girl who just had the colposcopy. His friend tells him that her friend told her that she just had a colposcopy by a guy doctor and that now she can’t flirt with him because he’s seen all of her girly-down-there business. And later that same night, Jess said she was verbally abused at whine night, uh I mean, wine night (all the female officers get together one night a week and drink wine). “Jess, you have to get credentialed in colposcopy NOW! We need a female doctor doing colpos!"
Most of the day-in/day-out problems I see are musculoskeletal - sprained ankles and knees, back pain, and "it hurts when I pee" type stuff. Most of you know that I used to run a lot and really enjoyed it - for a while I was logging up to 60-70 miles/week; after two ankle surgeries, I've drastically cut back. As I'm seeing all of these people, as I'm getting older (I'll be 34 later this month), and even though I really used to love it, I don't think that frequent running is the right exercise for lots of people. (I've also become anti-heavy weight lifting). Thing is, in the regular world, you would just take a few weeks off from whatever workout program you do, and you'd let your body heal itself. In the military, on the other hand, you have to basically have a doctor's note (called a profile) saying you can't run or do certain activities for a specified amount of time, so everyone with a complaint like that has to be seen.
As expected, I’ve already seen plenty of cases of STDs and screened some others who were informed by previous partners that they tested positive for an STD. At newcomer orientation the public health guy spoke about the problem here in very open terms. Apparently, this base used to lead the Pacific Air Force in STD rates, but we’ve recently been pushed out by Osan. One in 70 people has chlamydia, and 50% of the new cases are transmitted from military to military. The others are most likely contracted from the Juicies, most of whom are Filipinas. I guess there used to be a lot of Russians, but they got deported for one reason or another. The presenter called it “sharing the Kunsan love.”
Funny thing about some of these people coming in with STDs (if you're allowed to describe anything STD-related as funny) is how in-denial some of them can be. Cheech tells a story about a guy who swore that he had no penile discharge, and when Cheech examined him, he said it looked like Bill Murray in Ghostbusters after he got slimed. Another favorite is, when asked whether a guy had unprotected sex, the patient initially said no. But then he qualified his "no" by saying, "Well, maybe for just a second." Apparently the Juicy girl he was with, "just kind of snuck it in there. Just the tip, though." Suuuure. Go ahead and blame everything on the Jews and the Juicies.
The typical set of questions I ask include the following: Are you wrapping up EVERY time? Is your partner wrapping up EVERY time? Any off base activities (i.e. Juicy girls)? Any goop coming from your man-business? I then tell them, "All right, here's my soap-box speech I have to give you: Use a condom every time. Guys here are dirty and so are most of the girls. You don't want herpes or something worse. If you don't YOU WILL GET CHLAMYDIA AND YOU WILL DIE!" Then I put some gloves on and examine guys' wieners and balls. My mother would be proud. I also frequently put my finger in other guys' buttholes. Being a doctor really isn't that great.
It definitely helps that I have two techs and a nurse working for me (it's kind of nice being the boss). I have my techs do a lot of the mundane paperwork (e.g. putting profiles into the computer and filling out paperwork for them to stay home if they're sick - I just sign and go). My nurse is a Korean woman, Miss Jenny, and she takes a lot of the phone calls that come in, manages the cervical dysplasia stuff (abnormal Pap smears), and the STD stuff as well. She's in her early 40s (could pass for late 20s/early 30s) and has two kids. We share an office, and she's really nice. Her English is really very good, although sometimes her pronunciation is a little off. Like the time she told me she had dog for lunch. "Dog?" I asked. "No," she answered. "Dog. D-U-C-K." Ohhh - duck. I'm sure that my Korean will give her more than a few things to laugh about.
I've been going biking as much as I can after work. There's a reservoir surrounded by hills and trails about 8 miles from the base, and as much as I hate to do it, I drive there most of the time. Jess sometimes gets mad that I'm done so early, but I tell her it's because 1) I type faster than she does - top 5 Lance skills - and 2) she cares more and is a better doctor than I am. One day last week, it was almost 1700 and she came by my office to tell me that she was leaving. And she was SOO excited that she was beating me out of the office for once. I didn't have the heart to tell her that I'd spent the last 30 minutes reading Tuesday Morning Quarterback on espn.com.
Lance.
