As The Sparks Fly Upward

I work in a troop medical clinic, on Al Asad FOB, in post-surge Operation Iraqi Freedom. Most of you know all of that already, but google tells me that I’d better mention it every so often, so that my blog is appropiately represented in searches. Plus, we occasionally have newbies stopping by.

As with all military things which need more than one word to describe them, the troop medical clinic has been acronymed into what everyone actually calls it, the TMC. A TMC is different from every other clinic in which I’ve worked, or in which you (most of you, anyway) have been a patient. There are 10 providers in our TMC, but only one is a doctor, one a nurse practitioner. The other eight are medics. A medic is a soldier specially trained to provide basic medical care to troops, especially battlefield trauma care. My medics do not currently see the trauma much (other than a fight on occasion), but some of them have seen it in the past. For three of my medics, this is their third deployment.

We are the second-highest level of care available at Al Asad; there is a hospital here as well, a.k.a. a Combat Surgical Hospital or CSH (pronounced “cash”). I get to the hospital once a week for grand rounds, and I have consulted on a patient there. There are also a number (I’ve heard from 7 to 14) little one-doc clinics in various areas of the post. In some cases, the doctor is multiply specialty-trained like me, in some cases the doctor is a General Medical Officer (i.e., has completed one “internship” year of training after medical school, but no specialty training yet). In some cases, the “doctor” is not a doctor at all, but a Nurse Practitioner, a Physician’s Assistant, or a medic.

In the morning, I wake up in the sixes or early sevens (depending, of course, on how many times I hit snooze) and roll out of bed, dreading the thought of putting on my dusty uniform and boots. Eventually, I am ready to head out, and I throw on my bike helmet and ride in to work. When I get there, the medics are hanging around the “TOC” (something like “Tactical Operations Center” which makes it sound very important, but really, it’s just an old, dusty table with some older, dustier Panasonic laptops on it). A lot of “good morning, sir”s fly around for a bit, and then I settle in front of my dusty, plywood desk and fire up the old laptop. Throughout the day, the medics come up to me (or LTC Bullock, depending on who is free) and they present “cases.” I have to be careful writing in a public forum about specific cases I have seen, and this has kept me from commenting more on the clinic. Even when I don’t say any names, I feel very uncomfortable talking about specific, recent cases, especially the unusual ones. But I’ll throw some generalities your way every now and then, to give you an idea what I see from day-to-day. Today’s topic: the profile-seeker.

Knee, back and ankle pains are the operative issue in at least 50% of my patients. I am becoming adept at distinguishing (for example) patellofemoral syndrome from patellar tendonitis. In a “real” clinic, with all the amenities available, some of these patients would get CT scans, ultrasounds, MRIs. But we don’t have those capabilities, so we generally end up treating the symptoms, prescribing non-medical treatments to aid in healing (i.e., stretching), and filling out forms which preclude the pained soldier from having to do daily physical training. These latter forms, which are akin to an excuse from school, are called “profiles” in Army lingo. Profiles are highly sought after, both by those who really really need them (I have been in that category in the past) and by those who really really do NOT want to take that Army Physical Fitness Test for which they have not been getting ready, and which they might fail, causing a black mark to appear on their permanent record (I can neither confirm nor deny whether I have been in this category before).

Part of my job is to distinguish the legitimate profile seekers from the bogus. Most doctors are annoyed by this part of the job, but I have to admit, that I sort of like it. Relish it, even.

When I see an obvious faker, I generally go along with them initially, acting very concerned about their aches and pains. These musculoskeletal problems, which are so very very crippling for the patient, occasionally will travel from one side of their bodies to the other, and back again, all in the course of a single exam. (Magic!) After I get the faker’s guard down a bit, I slowly give them a bit of rope, and let them talk or moan, or whatever it is they are doing, until I find an inconsistency. This is surprisingly easy in most cases. Then, I confront them with it. This either leads to a full confession, which is very satisfying, or else it leads to some Clinton-esque fancy tongue-work, which is very entertaining. Satisfying versus entertaining = win-win for Erik. Woo-hoo!

The patient side of the conversation usually goes something like this:

“Did I say that my right foot has nine-out-of-ten pain? I’m sorry doc, I meant my left foot—you know, the one I was just limping on a moment ago in front of you. Ever since my parents forced me to change from a righty to a lefty, when I was two, I sometimes get confused about which is my right, and which is my left, that’s why I made that mistake. Why was I limping on the opposite side earlier? Well, sometimes I do that just to ‘even things up’ between the right and the left side. But it really is my right foot that is hurting. Woah, hang on, I mean my left foot. [Points to right foot.] That one there, that’s the one that I need a profile for. I’m pretty sure that’s the one that hurts. But really, now that I am thinking about it they BOTH kind of hurt.”

Once, I had a soldier come in conplaining of disabling knee pain, and stating that he desperately needed a “no-running” profile. The knee pain had been going on for a month, he said, and would probably last another month—just long enough, it turned out, so that he would need a profile for the Army Physical Fitness Test in four weeks. Unfortunately for this poor guy, he had actually danced (fairly well, so I’ve heard) with one of my medics at “salsa night” just 18 hours before. And given her his name and address. (Oops!) When I had that medic come into the room to point this out to the soldier, he still vigorously proclaimed his innocence (something like “I am not having salsa with that woman”). Fortunately, this was the end of the day, and all that talk of salsa had made me hungry, so instead of kicking his butt, I calmly looked him in the eye and asked him to “Please come back when you have a better story.” He didn’t get his profile, and he didn’t come back, which leads me to the inevitable conclusion of all of this:

“Mmmmm, salsa…”