020909

Some Advice to Future Military Doctors…

Midn Dan Trembula, USN

1.    Patient Interactions:

a.    “Your reputation precedes you.” One of the greatest complements you can receive is to have a patient tell you one of his shipmates referred him to you for care. Word of mouth works both ways and one of the last things you want is to have patients avoiding you because of horror stories they heard from their buddies.

b.    “Benefit of the doubt.” There are few things more frustrating than having something wrong with you and having the Corpsman or Doctor tell you that “it’s nothing,” or “It’s in your head.” You may have spent years in schooling or practicing medicine, but they are the resident subject matter experts on their own body. If they say something is wrong, please take them seriously. It may have taken a great deal of persuasion from their shipmates (“Dude, there really is something wrong with your shoulder… it’s been bothering you for two months now, you should get that checked out.”) and mental struggle (“If they find out about this injury, this could keep me from getting to go to ________ school.”) for the patient to come to you for treatment. Turning them away because of an overly harsh attitude, or discouraging them from seeking future treatment from you is the last thing you want to do. There are two major exceptions to this however:
I.    Indoctrination/Training Environments – Certain types of injuries (shin splints, for example) are so common that almost all the time that is the true nature of the problem.
II.    Patient’s Prior History – Sometimes the patient has a prior history that raises your suspicions or the request is so outlandish as to seem ludicrous. (Example: the patient is requesting heavier painkillers and he has a documented history of substance abuse).
In examples of these, a little bit of firm treatment may help, especially in the training/indoctrination environment. (“Suck it up Marine…”)

c.    Chits/Profiles: A Profile that is too generous may encourage laziness and “Chitsurfing,” whereas on that is too restrictive may aggravate the injury by not giving the patient enough time to recover. This is another case where it behooves you to know the types of people you are dealing with and their duties. Sometimes a chit can help reign in a patient who is overzealous with their rehabilitation by making their command and peers aware of the restrictions on their activities. The expiration date on a chit can help motivate the patient to take their therapy seriously because they have a deadline to make. Some aspects of chits, specifically uniform and grooming modifications can have a detrimental effect on those around the patient and the appearance of the unit.

2.    Support from their Command: Getting their unit and chain of command on board with their treatment and recovery is key. “Visit your Marines and their family members who are sick or incapacitated; it’s the most effective cure for their ailments!” (BGEN Joe Weber, USMC). From personal experience I can tell you that he is 100% correct. Do not let their CO, 1st Sgt, Division Officer, or anyone else be the one to disprove the saying that “(unit name here) takes care of their own.” If their geographic location makes physical visits impractical, then the command should send e-mails, letters, postcards, and make regular telephone calls. Encourage their unit to use their connections around the world to make sure that someone is looking out for the patient, even if they don’t know him personally. Home-cooked food, a favorite magazine, or a movie can really hit the spot. Making the patient feel like they are still a part of the family (both on a unit and service level) is important for patient morale. Too much attention can be physically and mentally draining though. Sometimes the patient just needs to rest or needs some time alone. Visits from seniors, peers, or subordinates that the patient abhors for any reason are also detrimental. There is not much that you can do about the former group, but if you are aware of any personal or professional conflicts, you can do a great deal about the latter two groups.

3.    Interaction with your Unit: make it a point to go to events (picnics, receptions, sports tournaments, promotions, physical training, etc.) that your unit – and the units you serve are having.

4.    The difference between civilian medicine and military medicine:
-    In the civilian world, they tend to start with the least common and most serious possibility (generally requiring the most expensive tests and making the health care providers / HMO the most money) and work from there towards what the problem most likely is.
-    In the military, health care providers generally start with the most likely possibility and if that is not it, then work gradually by process of elimination to the most serious possibility. Not only is this cheaper, but since the patients are normally healthier to begin with, it usually works.

5.    Humility: If your prescribed treatment is not making the patient any better or you cannot pin down the diagnosis, refer them to as many of your colleagues and superiors as you can. It takes a mature person to admit that they “just don’t know” and are not afraid to send the patient to someone who might. Do not be the one that did not order the test that would of found their ailment or refused to send them to a specialist who deals with that sort of malady on a regular basis. Do not discount the advice of a “salty” Corpsman or experienced nurse who might have seen the problem before either. Your patients will be grateful and your conscience will be lighter. Medicine is not an individual competition. It is a group effort and the winners are the patients who benefit. Which doctor, or what rank insignia they are wearing is irrelevant when people’s lives, careers, and well-being are on the line.

Midn Dan Trembula
U.S. Naval Academy
Annapolis MD
trembula@usna.net

Reprinted here with permission
Ed., 29 December 2005. From the Annapolis Capital:

Obituaries

Daniel Trembula

Services for Navy Ensign Daniel Allen Trembula, 25, of Annapolis and previously of Hart County, Ky., were held Nov. 22 at the Naval Academy Chapel. Burial followed at the academy cemetery.

Ensign Trembula, who was known as "Dan," died of Ewing's sarcoma, a type of cancer, in Annapolis after a four year illness.

Born Nov. 9, 1980, in Armuchee, Ga., he was a 1999 graduate of Hart County High School in Munfordville, Ky. Despite battling his illness for four years, he graduated from the Naval Academy in 2005 and was chosen by the Commandant of Midshipmen to assist in improving the martial arts curricula at the academy. Following graduation he worked in officer development.

He was an avid member of the academy's ham radio club, a member of several martial arts clubs and founder of the Close Quarters Combat Club. He also loved dancing and enjoyed attending debutante balls.

Surviving are his parents, Ruth and Joseph Trembula; two brothers, J.D. and David Trembula; and one sister, Rebecca Trembula, all of Cub Run, Ky.; and his grandparents, Joseph and Alfreda Trembula of Trenton, N.J., Wayne and Gloria Blakely of Louisville, N.Y., and Nita Whatley Blakely of Gadsden, Ala.

Arrangements were by Chamber Funeral Home in Riverdale. In lieu of flowers, memorial contributions may be made to the National Cancer Institute, Attention: Director, Building 31, Room 11A-16, 9000 Rockville Pike, Bethesda, MD 20892.