Category Archives: Internal Medicine

Medical Mystery Case: What Landed This Pregnant Woman in the Hospital? – Medpage Today

Internal medicine and rheumatology specialist Siobhan Deshauer, MD, reviews the case study of a pregnant woman who was hospitalized.

Following is a partial transcript of the video (note that errors are possible):

Deshauer: Hey, guys. I'm Siobhan, an internal medicine and rheumatology specialist. Today, I'm going to tell you about Emma. She is a 31-year-old woman who landed her dream job, first violinist in a prestigious orchestra, and she has never had any health issues until recently.

Emma and her husband have been struggling to get pregnant over the past 2 years and she is now seeing a fertility specialist. Anxious to find a treatment that would work for her, Emma also started seeing another health practitioner who recommended various supplements that she was told were safe and effective. Unfortunately, she has been hiding this from her doctor and little did she know that decision would land her in the hospital and change the next few years of her life.

Over the past few weeks, Emma has had abdominal pain, nausea, and vomiting. She had a glimmer of hope thinking she might be pregnant, but the tests kept coming back negative. Her symptoms just kept getting worse and it was starting to affect her ability to perform at the orchestra. She was sure that her colleagues were starting to notice. After one particularly poor performance, she decided to go to the doctor. Her doctor checked her vitals, ordered some blood work, along with an abdominal ultrasound. Everything looked fine, so her doctor thought it might just be stress from the new job, but the pain and nausea worsened to the point that she was barely able to eat anything.

Finally, after a horrible episode of vomiting, her husband brought her to the emergency department. Her blood work showed mild anemia. Her red blood cells were a bit too low. After her vitals were normal and her imaging was normal, she was sent home with an iron supplement and told to follow up with her family doctor in about 2 weeks.

Over the next few days, her symptoms just continued to progress. She had to call in sick from work and was spending most of the day in bed exhausted and in pain. But Emma didn't want to go back to the hospital, wait for hours, and then just get sent home again. Then one day she was getting out of bed, she became so dizzy that she fell to the ground on her knees. Her husband heard the sound, ran upstairs and found her on the ground. That was it. They were heading back to the hospital.

In the emergency department, her heart rate was a little bit fast, but it was her blood work that was alarming. Emma's hemoglobin was much lower than before, so low that she required a blood transfusion. Emma was actually relieved to hear that they had found something to explain her symptoms, but the question remains why was her hemoglobin dropping so dramatically? The emergency doctor explained that she might be bleeding from her stomach. That would explain her abdominal pain and the drop in her hemoglobin. The plan this time was to admit her to hospital.

A few hours later, a tired-looking internal medicine resident came to assess Emma. When asked about medications, Emma responded that she is taking levothyroxine, a thyroid supplement, and follitropin alfa injections for infertility. When asked about supplements, she only mentioned her prenatal vitamins.

Now, remember Emma is also taking supplements for infertility, but she didn't want to tell the doctor because she was worried about being judged and she couldn't imagine that it was relevant in this situation. Emma's blood tests not only showed that she was anemic with too few red blood cells, but that the cells were too small. We call this microcytic anemia. In situations like this, her bone marrow should be going into overdrive, pumping out as many new red blood cells as possible, but another test called the reticulocyte count proved that this wasn't the case for Emma.

When I see a patient like this with microcytic anemia, a whole bunch of causes come to mind. But by far, the most common cause is iron deficiency, especially in a young woman. Think about iron deficiency like this: either you're not eating enough iron, your body is not absorbing that iron, or you're bleeding and then losing the iron.

Emma's blood work is consistent with iron deficiency with a ferritin level lower than expected. This suggests that she has a low amount of iron stored away in her body and maybe the bone marrow wasn't creating enough red blood cells because it didn't have enough iron available. But iron deficiency itself doesn't cause abdominal pain, so her doctors wondered if she might be bleeding somewhere in her abdomen, maybe a bleeding peptic ulcer.

In the emergency department, Emma already had a CT scan of her abdomen and an ultrasound, both of which were normal. You may be surprised to learn that often a CT scan or an MRI won't actually find the cause of a GI bleed. Often the bleeding is coming from an erosion in the protective layer of the gut and you really need to camera down the GI tract to be able to see that.

The next day she was wheeled down to the endoscopy suite and sedated. First, a camera was inserted into her throat, no signs of bleeding. Then she had a colonoscopy and again totally normal. Okay, so no bleeding in the GI tract where we can see.

Another thing we have to consider in a woman who is having abdominal pain and unexplained anemia is endometriosis, which is a disease where tissue similar to the lining of the uterus grows elsewhere in the body. Just like the uterus does, the tissue thickens up, breaks down and then bleeds with each menstrual cycle. This could be a hidden source of blood loss. It can also cause severe pain, especially in the pelvis, and it can also cause infertility. This could actually tie together all of Emma's symptoms including her recent diagnosis of infertility. Endometriosis is notoriously difficult to diagnose and it can be missed on imaging, which is why surgery is often needed to help make the diagnosis. Emma agreed to go ahead with the exploratory laparoscopy and a few days later she was taken to the operating room.

She was put under general anesthetic and the surgeons got to work. They poked small holes in her abdomen and inserted a small tube with a light and camera attached. They also insert another tube that pumps air into the abdomen. This raises up the abdominal wall so it's possible to look around at the organs and then operate if necessary.

The surgeon carefully examined each of Emma's organs, looking for any signs of endometriosis, which would look something like this. But they only found one abnormality, a simple cyst on her ovary, far from a slam-dunk diagnosis and probably unrelated to her symptoms. But nonetheless, the surgeons took a biopsy of the cyst and sent it off to the pathology lab to be examined. But if it doesn't look like endometriosis, what else could it be?

Emma's medical team went back to the drawing board to rethink her case. She eats a diet containing enough iron. She has no signs of malabsorption and they couldn't find any signs of bleeding, so maybe the blood work showing iron deficiency is just a red herring and there is another cause for her anemia that hasn't been considered. Could this be a production problem, an issue stemming from the bone marrow where the red blood cells are made? Well, there is only one way to find out, going straight to the source.

Emma was prepped for a bone marrow biopsy where a needle is inserted into the bone to take a sample of the semi-solid tissue inside. Making over 500 billion blood cells per day, our bone marrow is constantly working hard to keep us alive. Now, it's a waiting game. The results from the bone marrow won't be back for a few weeks, so Emma was discharged home with a diagnosis, anemia NYD (not yet diagnosed). But on a positive note, her abdominal pain had improved and as she was leaving the hospital she was told to restart her usual home medications and to come back if things got worse. When she got home, she restarted her fertility injections and those fertility supplements again.

Emma was still really tired and soon she developed a new headache and she was never someone to get headaches. Plus, tinnitus, that high-pitched ringing in her ears that just wouldn't go away. She kept track of her symptoms until she had her follow-up appointment 2 weeks later. Hearing about her new neurological symptoms, the internal medicine team decided to expand their diagnostic search to include another rare cause, porphyria.

This is a very rare group of conditions that affects how your body makes heme, an important part of hemoglobin, and some patients experience porphyria attacks, which can include anemia, neurological symptoms, and abdominal pain. It was a stretch and they knew it. But if you never look for those rare causes, you'll never find them, so her doctors ordered a urine test to screen for the disease.

Two weeks later Emma had another follow-up appointment to go through results. She was nervous, but hopeful that she might walk away with some answers this time. First, the surgical biopsy. It was normal, no endometriosis or cancer. Good. Next, the bone marrow results. It showed some increase in iron stores, but it was otherwise normal, so again no diagnosis.

Then a result that finally gave them a lead, Emma's porphyria screening show high levels of copper porphyrin III and delta-ALA. Okay. Now, porphyria screening is a whole can of worms that we don't have time to unpack right now, but the key point is that this particular result really narrows things down to either porphyria or lead poisoning.

Emma was sent back to the lab this time to have her blood lead levels drawn. Two days later, Emma got a phone call from her doctor's office. Her blood lead levels were off the chart. Finally, she has a diagnosis. Emma is suffering with lead poisoning. This explains all of her symptoms: abdominal pain, nausea, and vomiting. These are classic, early signs of lead toxicity.

Neurological symptoms take some time to develop, which explains why her headache and tinnitus came on later. This also explains her anemia. Lead accumulates in the bone marrow, blocking certain enzymes that produce heme, an important part of hemoglobin. Less heme means smaller red blood cells and it also limits the bone marrow's ability to create more cells, ultimately causing hypoproliferative microcytic anemia.

But why did her porphyria testing come back positive? Well, as lead blocks important enzymes that produce heme, that leads to a buildup of byproducts. Think of it like the conveyor belt in the factory that's making heme is broken and as a result there is a buildup of raw materials. Those raw materials are copper porphyrin III and delta-ALA. That's why her porphyrin screening came back positive. It's so cool, right? Everything leads back to lead poisoning. Had her doctors ordered a blood lead level earlier, it would have saved Emma so many needless investigations.

Siobhan Deshauer, MD, is an internal medicine and rheumatology specialist in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.

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Medical Mystery Case: What Landed This Pregnant Woman in the Hospital? - Medpage Today

NYU Langone Health in the NewsWednesday, December 27, 2023 – NYU Langone Health

News from NYU Langone Health

Xenotransplantation Can Change the Paradigm Around Organ Donation Scripps News December 23 -Robert Montgomery, MD, DPhil, the H. Leon Pachter, MD, Professor of Surgery, chair, Department of Surgery, Division of Transplant Surgery, NYU Langone Transplant Institute

Owning a Pet May Slow Rate of Cognitive Decline, Study Suggests UPI December 26 -Thomas M. Wisniewski, MD, the Gerald J. and Dorothy R. Friedman Professor of the Alzheimers Disease Center, Department of Neurology, professor, Departments of Pathology, and Psychiatry

Envisioning AI That Expands Civil Rights Politico December 22 -Pasquale E. Rummo, MPH, PhD, associate professor, Department of Population Health

Remembering Betty Rollin, Who Told Her Breast Surgeon That Post-Operative Appearance Mattered to Her and Other Women STAT News December 27 -Barron H. Lerner, MD, professor, Department of Medicine, Division of General Internal Medicine & Clinical Innovation Faculty, and Department of Population Health

Medical Tattoos Serve a Purpose Bigger Than Body Art The Grio December 26 -John Belanich, chief radiation therapist, Department of Radiation Oncology

Winter Skin Woes? Heres What to Do and What Not to Do WebMD December 26 -Julia E. Tzu, MD, clinical assistant professor, the Ronald O. Perelman Department of Dermatology

What to Know About Colored Contactsand Why You Shouldnt Buy Over-the-Counter Brands Elle December 22 -Brieann K. Adair, OD, clinical instructor, Department of Ophthalmology

Can Sleeping with a Fan on Make You Sick? What Experts Have to Say Good Housekeeping December 23 -Purvi S. Parikh, MD, clinical assistant professor, Department of Pediatrics, Division of Pediatric Allergy & Immunology, and Department of Medicine, Division of Infectious Diseases, Allergy and Immunology

Many Consider Weight-Loss Drugs to Support New Years Resolutions TODAY December 26 -Natalie E. Azar, MD, clinical associate professor, Department of Medicine, Division of Rheumatology

Live Longer, Sleep Better, Feel Calmer with Best Health Hacks of 2023 TODAY December 22 -Natalie E. Azar, MD, clinical associate professor, Department of Medicine, Division of Rheumatology

What Is Holiday Heart Syndrome And How To Avoid It (Subscription required) National Geographic December 22 -Shaline D. Rao, MD, assistant professor, Department of Medicine, the Leon H. Charney Division of Cardiology, chief of medicine, NYU Langone HospitalLong Island

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NYU Langone Health in the NewsWednesday, December 27, 2023 - NYU Langone Health

Internal Medicine Specialist Discusses Weight-Loss Medication – News On 6

Weight-loss drugs have been promoted and advertised much more recently, but are they right for you?

Tuesday, December 26th 2023, 9:37 am

By: News On 6

Weight-loss drugs have been promoted and advertised much more recently, but are they right for you?

Internal Medicine Specialist Doctor Stacy Chronister with OSU Medicine joined the News On 6 at 9 to discuss weight-loss medication.

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Internal Medicine Specialist Discusses Weight-Loss Medication - News On 6

Beebe welcomes award-winning infectious disease specialist – CapeGazette.com

Beebe Healthcare announced the appointment of Jimmy Chua, MD, to the hospitals medical staff. He is recognized as an award-winning infectious disease specialist, trained to treat a wide range of complex clinical conditions.

Chua sees patients at the Margaret H. Rollins Lewes Campus and Beebe Medical Groups Infectious Disease and Travel Medicine office on Savannah Road in Lewes.

Chua treats all forms of surgical infection, along with complicated skin and soft tissue infections, HIV infection, sexually transmitted diseases, pneumonia, endocarditis, osteomyelitis, meningitis, sepsis, viral hepatitis and other infections related to the liver. He also addresses all forms of infection related to viruses, bacteria, fungi and parasites.

Chua is a fellow of the American College of Physicians, the Infectious Diseases Society of America, and the American Association of the Study of Liver Diseases. His clinical and leadership experience is extensive. In 2001, he founded a medical practice in southeastern Washington state, at which time he launched the annual Whats New in Medicine regional medical education conference for medical practitioners. The Washington Chapter of the ACP repeatedly recognized Chua as a role model and ultimately honored him with its Internist of the Year Award in both 2005 and 2023, citing his excellent clinical skills, dedication to patients, enthusiasm for the practice of medicine and outstanding leadership.

The ACP also presented Chua its laureate award, an honor bestowed upon senior physicians with acknowledged excellence and peer approval in the field of internal medicine. Chua also served as a faculty member at the Pacific Northwest University of Health Sciences and at the WSU Elson S. Floyd College of Medicine.

My motto in practice is to do my best with Gods guidance, to help each patient manage and overcome their medical condition, said Chua, who was born and raised in Manila, Philippines. I am grateful for the opportunity to practice medicine at Beebe, which allows me to live in close proximity to my family.

Chua earned his medical degree from the University of Santo Tomas, recognized as the oldest university in Asia. After practicing in Manila, he relocated to Marshfield, Wis., to pursue internal medicine residency training at the Marshfield Clinic. His clinical training concluded at the Cleveland Clinic in Ohio, where he completed fellowships in both infectious disease and clinical microbiology. In his free time, Chua enjoys swimming, traveling with his family, taking care of his aquarium, harvesting his vegetable garden, listening to audiobooks and playing chess. He speaks multiple languages including English, Tagalog, Mandarin, Taiwanese and Spanish.

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Beebe welcomes award-winning infectious disease specialist - CapeGazette.com

People rally around doctor who refused to provide medical assistance on flight for a valid reason – Upworthy

They say, "An apple a day keeps the doctor away." However, in this story, there's something else that keeps a doctor away from treating a personduring a flight. In many cases, emergencies on a flight are usually sorted out by the doctors who are on the flight. Sometimes, a few unfortunate situations may require the flight to be landed mid-way. Given the importance and necessity of profession, u/ThrowAwayFoodie22, an internal medicine hospitalist, never ignored such requests from the cabin crew. This time, he had a valid reason. While his co-passenger found his lack of response inconsiderate, the internet came to his rescue, saying he made the right choice.

The doctor was on a long-haul international flight and decided to enjoy his waking hours by utilizing the in-flight entertainment and free drinks. "I had already been drinking even before the flight while I was in the lounge. I was not slurring or excessively drunk, but I was feeling a strong buzz," he explained in the post. During his flight, the mid-30s doctor chatted a little with his co-passenger, exchanging pleasantries about each other's work. A while later, when he was enjoying his movie, the cabin crew made an announcement requesting a doctor.

"Normally, I would present myself to the cabin crew and help out, but after several hours of on-flight boozing, I was pretty drunk," the doctor wrote and added, "I was not able to think clearly and probably would have done more harm than good in such a situation. I didn't react to the announcement at all." As he continued with his movie, the co-passenger insisted he respond to the call. "I replied that someone else would help or they would get instructions from the medical team on the ground," mentioned the doctor.

The 30-something-old lady, unaware of his reason for ignorance, said that he would be the reason if the person died. "I said, 'Listen, lady, just because I'm a doctor doesn't mean I'm not on call 24/7 to provide medical care on demand. I work when I'm at the hospital, outside, I'm just like everyone else and I'm entitled to drink and relax,'" he explained.

The physician didn't want to engage anymore with the woman. Since there were no more announcements after that, he assumed the person who required medical assistance was safe. "In my mind, I'm very clear that since I was intoxicated, I could not provide medical assistance," the doctor clarified. Pointing his right to a relaxed journey, the physician said, "I was drinking on my own time and there was no expectation that I would need to be sober. Doctors get to enjoy life too, I can't stay sober on every flight just in case there's an emergency." However, having been called an a*****e by his co-passenger multiple times, the doctor was concerned if he made the right decision and many backed him up.

"The crew would not have used you in your capacity as a doctor as you were intoxicated. By law, they cannot as you are well aware. They would've gotten assistance from another sober doctor on board and the ground medical team. Your fellow passenger is TA for saying those things to you. Hopefully, after the flight, she learned that couldn't have helped because you were drinking," commented u/Affectionate_Face_71. "NTA, but I could see why she'd think so. You were right for not responding to the call as you were impaired, but why wouldn't you explain this to the woman? As far as she could tell from your response, you were just being apathetic and hoping someone else would handle it," pointed out u/lessthandave89. "You did the right thing but the way you presented yourself sucks," wrote u/Hazz3r.

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People rally around doctor who refused to provide medical assistance on flight for a valid reason - Upworthy

Adventist Health Tillamook welcomes new top Internal Medicine Provider – Tillamook Headlight-Herald

December 5, 2023 (Tillamook, Ore.) Adventist Health Tillamook is proud to announce another enhancement to healthcare services in Tillamook County with its exceptional team of local, community-focused internal medicine providers, including Tana Haynes, MD, Amy Echelberger, MD, and the newest addition, James Borden, MD, FACP, starting January 2 at Adventist Health Medical Office Plaza in Tillamook at 1100 Third Street in Tillamook.

Meet Our Internal Medicine Providers

Dr. James Borden, board-certified with over 30 years of primary care experience in Northwest Portland, is known for his compassionate care and transparent communication. His approachable nature and dedication to building patient connections make him an invaluable asset to our community.

Dr. Tana Haynes, who began her tenure in 2020 at Adventist Health Medical Office Plaza, is a board-certified internal medicine physician with experience in both inpatient and outpatient settings. Passionate about individualized care, she specializes in preventive and wellness care as well as managing complex medical issues.

Dr. Amy Echelberger, joining Adventist Health Medical Office Manzanita in 2021, is a board-certified internal medicine specialist with roots in Idaho. Having graduated from Southern Illinois University School of Medicine and completed her residency at Wayne State University, Dr. Echelberger brings a wealth of knowledge and dedication to the Oregon Coast.

What is Internal Medicine?

Internal medicine provides comprehensive care for adults, encompassing preventive services, wellness care and the diagnosis and management of complex medical conditions. Our providers are committed to understanding each patients unique health needs and goals, offering a holistic approach to healthcare.

Enhancing Community Health

With these skilled physicians, Adventist Health Tillamook continues its commitment to providing top-tier medical support, focusing on the unique healthcare needs of coastal communities. This expansion underscores our dedication to ensuring residents receive the best possible care from providers who work and live in the community.

For more information about our internal medicine services and the exceptional care provided by Drs. Haynes, Echelberger, and Borden, please visit our website at adventisthealthtillamook.org or call to schedule an appointment at 503-815-2292.

Since 1973, Adventist Health Tillamook is a faith-based, nonprofit healthcare organization that includes: a 25-bed critical access medical center located in Tillamook, Oregon; the largest hospital-based ambulance service in Oregon with four stations located throughout Tillamook County; and rural health clinics and urgent care medical offices serving the northern Oregon coast as well as the communities of Sheridan, Vernonia, Estacada and Welches. Adventist Health Tillamook employs over 550 associates and healthcare providers and is part of Adventist Health, a faith-based, nonprofit integrated health system serving more than 80 communities in California, Hawaii and Oregon. For more information about Adventist Health Tillamook, visit AdventistHealthTillamook.org.

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Adventist Health Tillamook welcomes new top Internal Medicine Provider - Tillamook Headlight-Herald

Perceived Preparedness of Internal Medicine Interns for Residency and the Value of Transition to Residency Courses – Cureus

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Perceived Preparedness of Internal Medicine Interns for Residency and the Value of Transition to Residency Courses - Cureus

Remembering Vice Adm. Michael Cowan, the 34th Surgeon General of Navy Medicine (2001-2004) – American Military News

On December 10, 2023, Vice Adm. Michael L. Cowan, the 34th Surgeon General of the Navy died. He was 78.

Vice Adm. Cowan served in a wide-variety of clinical, operational, staff and leadership positions over the course of his 33-year career. His career culminated in 2001 with his selection as the 34th Surgeon General of the U.S. Navy and Chief of the Bureau of Medicine and Surgery (BUMED).

Cowans career legacy includes pioneering the concept of Force Health Protection, redefining deployable medicine in the 21st century, and serving as the Navy Surgeon General during the attacks on September 11th, 2001, and the start of the wars in Iraq and Afghanistan.

It could be stated that medicine was always in the sights of the Fort Morgan, Colorado native. Following pre-med at the University of Colorado at Boulder and after attending medical school at the Washington University School of Medicine, Cowan went to Temple University to study internal medicine and hematology under his mentor Dr. Sol Sherry (1907-1983). Sherry was already a medical giant whose research led to the development of clot-dissolving drugs to treat heart attacks. Cowan envisioned following in Sherrys footsteps and spending his career in academic medicine, but all that would change in 1971 when he was drafted into service.

At the time I was a free spirit, related Cowan. My hair was too long, and I could have put it into a ponytail. I had the attitude that most people had in 1971 about the militaryI was very anti-war, anti-military. I really knew nothing about the military, and everything I thought I knew was wrong.

Although he entered the Navy, as he later jokingly remarked, kicking and screaming, he was soon hooked. While serving as a general medical officer at Naval Hospital Camp Lejeune, N.C., Cowan learned the important role the Navy played in supporting the Marines. I particularly took pride that I was taking care of these young men and women who were serving their country, said Cowan. And it felt good as a physician to know that I didnt have to worry about their insurance. The phrase I always used was, I didnt have to ask them how sick they could afford to be. My job was just to take care of them to the best of my ability, and my paycheck didnt depend on anything else.

Camp Lejeune would remain a special place for Cowan throughout his career. Just over twenty years after entering the Navy, while serving as the Commanding Officer of Naval Hospital Camp Lejeune (1993-1996), he was selected for flag rank.

In 1972, Cowan continued his residency in internal medicine followed by a hematology/oncology fellowship at the National Naval Medical Center (NNMC) in Bethesda, Maryland. It was at Bethesda that his love for Navy Medicine was born, and his decision to stay in the Navy was made.

I was at a change of command ceremony at Bethesda, and as the band started playing the march, as the flags came in, I got a tingle, recalled Cowan. As we were standing at attention in front of the flags about to witness this time-honored, old military ceremony, the hair on the back of my neck went up and I thought, Okay, thats it, thats the answer to my friends question as to why I stay in. The hair on the back of my neck goes up and Im reminded of what this is all about.

Over the ensuing years, Cowans love for the Navy and his role as, he described it, a physician-leader continued to grow. He served as Chief, Internal Medicine, at Naval Hospital Rota, Spain (1975-1976), and Chief of Clinical Investigations for the Navy Malaria Vaccine Research Program at the Naval Medical Research Institute (forerunner of todays Naval Medical Research Command) (1979-1982).

In 1982, Cowan was selected by Dr. Jay Sanford (1928-1996), president of the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland, to serve as the schools Deputy Director of Operational and Emergency Medicine in the Department of Military Medicine. In this position, Cowan taught the military medicine course and led fourth-year medical students through the Bushmaster exercise. It was a role that would leave an indelible mark on hundreds of future military physicians.

In Bushmaster, we wanted to push people to their limits in a controlled way, explained Cowan. It was a leadership lab that tested what people are really made of when they are really tired and frustrated and just dont think they can do it anymore. Over time we learned how to push people to grow, but in the early days we didnt know how far to push.

On one of his earliest Bushmasters, Cowan, Dr. Sanford, and his team of instructors, started a drill at eleven oclock at night after the students had had a long day. We simulated an attack on the camp with boomers and machinegun fire, recalled Cowan. They were supposed to respond, but they didnt come out.

Cowans team then threw several tear gas canisters around the tent. But still no response. Dr. Sanford slowly walked over, picked up the tent flap, kicked a tear gas canister under the tent flap and walked to the observation area. Still nothing. Cowan and Sanford then turned to each other and at that point knew they had overworked the students and called it a day. The students had just had it, so they had put their gas masks on, pulled their sleeping bags up over themselves the best they could, and just stayed there, recalled Cowan. They slept in their gas masks.

One of his students forever impacted by Cowan and the Bushmaster was Vice Adm. (ret.) C. Forrest Faison III, the 38th Surgeon General of the Navy and a USUHS graduate.

I dreaded this course all four years [at USUHS], recalled Faison. Over the next two weeks we started running back-to-back mass casualty, and combat scenarios. Youre doing this around the clock, and youre exhausted. Then comes the main event, which is a main mass casualty drill where they wrap it all together, and were so sleep deprived. Its hot, its muddy, and its just nasty. And we get through the scenario and were doing a hot wash, and Admiral Cowan gets up there and he goes, Youre cold, youre wet, youre tired, youre hungry. So why do you do it? You do it because that guy on the stretcher is depending on you to do it. And his family back home are depending on you to do it. And its the right thing to do.

Cowans time leading the Bushmaster would follow him throughout his career, even to distant places around the globe. While serving as Task Force Surgeon, Operation Restore Hope in Mogadishu, Somalia (1992-1993), Cowan recalled that many of his former students were serving as medical officers in Marine units and as command surgeons. I was able to delegate far more and had far more confidence in the abilities of these folks than I ever would have if they never had that field experience.

It was in Somalia that Cowan also recognized the unique values of each service, a piece of knowledge that would later serve him well as Joint Staff Surgeon (1997-1999); Chief of Staff, Office of Assistant Secretary of Defense for Health Affairs, The Pentagon (1999-2000); and Deputy Director and Chief Operating Officer, TRICARE Management Activity (2000-2001).

Cowan took the helm as the 34th Surgeon General of the Navy in August 2001. He was on the job for just 30 days when the attacks on September 11th occurred. Instantly, the world had changed, and Navy Medicines course would forever be altered to meet the new challenges ahead. He recalled, On September 11th, I walked to my desk about 10:30 in the morning and threw [my priorities] in the trash can. Priorities had just changed.

Within 24-hours of the attack Cowan updated the Navy Medicines motto from Standing by to assist to Steaming to assist and deployed the hospital ship USNS Comfort to New York City where it served as a relief valve for the rescue workers.

Primary care and physical therapy and messmen and general duty hospital corpsmen boarded he Comfort, and they steamed up to New York, related Cowan. While there they provided up to 1,000 people a day [with] hot meals, a shower, a berth, and laundry service. So, youd go aboard, theyd take your dirty laundry, feed you, put you to bed, give you a shower, wake you up, give you your clean clothes back, or new clothes, and send you back to work. We took criticism for that. There were people who thought that that was an undignified mission for a war ship of the United States Navy and I shouldnt have done that.

Yet, it had a positive impact.

A year later, while attending a reception for exercise BALTIC OPERATIONS (BALTOPS 22), he walked over to a group of Navy messman to congratulate them on doing a nice job. As we were talking and laughing, I said, By the way, how many of you were on the Comfort last year? And most of the hands went up, said Cowan. And this one kid, a 22-year old, kept trying to put his hand up and the others kept slapping him down, good naturedly. He said, I was on the Comfort in New York, but I wasnt crew. I was a New York City fireman. After seeing what the Navy did in New York I was so impressed that I joined the Navy under the condition that I become a messman assigned to the Comfort.

Admiral Cowan was a soft-spoken, caring, and impactful leader who always saw the bigger picture and thought outside the box, said Rear Adm. Darin Via, the 40th Navy Surgeon General. He was way ahead of his time and Navy Medicine is stronger because if him.

One of Vice Adm. Cowans greatest legacies was a humble leadership and his trust of others. This is captured when describing his philosophy of service:

I think a big part of my philosophy was formed by a phrase my dad used to use that I really glommed onto. He said, Your life finds you far more often than you find your life, stated Cowan. Had I not been drafted I never would have come into the military. I would have been an academic, probably stayed at Temple [University] . . . That would have been my life, and I would have been very happy. But this detour happened, and it became a better life, one that I would have never sought after and the direction of that detour I would have never sought out. My whole life found me almost against my will.

So, when people, young officers in particular, ask me, Can you give me some career advice? I say, I will, but its not going to be very good. What Im going to tell you youve got to take with a grain of salt. I tell them, Just dont worry about it. The one thing you must do in life is to do your job. No matter what job youve got, do the hell out of it and then position yourself to try to get jobs you enjoy doing. If you enjoy a job, youll do it well; if you dont enjoy your work, then life isnt worth living.

Admiral Cowan was predeceased by his wife of 60 years, Linda, and son Dr. Mark Cowan, both passing earlier this year.

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Remembering Vice Adm. Michael Cowan, the 34th Surgeon General of Navy Medicine (2001-2004) - American Military News

Enhancing the Comprehensive Integration of General Medicine Education in Rural Japan: A Thematic Analysis – Cureus

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Enhancing the Comprehensive Integration of General Medicine Education in Rural Japan: A Thematic Analysis - Cureus