September 2006 Archives

I'm supposed to be studying. I have approximately 3 more weeks until I take Step 2, and am attempting to do most of my studying in the evenings after I get home from the Poison Center. Attempting. Today its not going so well, and by that I mean that I haven't actually tried yet. After an extensive and very slow apartment-tidying and tv-watching session, I have atleast made it down to the coffee shop, where I have only succeeded in getting very distracted by the internet. So here I am.

For my current low energy state, I only have one man to blame: Samuel L. Jackson. Last night I watched Snakes on a Plane. There were several fantastic bonuses of this experience:
1. I got to hear The Line ("I'm sick of tired of these mothereffing snakes on this mothereffing plane!" - censured for the children by me).
2. I got to learn some important things about snake physiology, like, for example, when snakes are enraged by pheromones they love biting people in their private parts, and when they have been infected by the bloodlust snakes can often be stopped by a pile of luggage, and once a person is bitten by a frenzied evil venomous snake they decompose into a rotting corpse in a matter of minutes, and snakes have the ability to burrow through bone into the human skull, and snakes see the world through a hazy green fog.
3. I got to learn about some toxicologic principles of venomous snake bite management. For example: if a cute but stubborn little boy shows you a picture he drew of the snake that bit his little brother, and that snake looks like a king cobra, and the boy who was bit is unconcious, then you should immediately administer 25 mL of lactated ringers. Lactated ringer (LR) is a kind of IV solution. My friend Tracy (another med student) and I had quite a good laugh at this: it is like saying "Give that boy one teaspoon of saline - stat!"

This was a very timely and educational way to spend an evening, given my current area of study and my future career plans. I dream of the day when, as an accomplished Toxicologist and poisonous snake expert, I am consulted by a crackpot FBI team and have to meet a planeful of venomous snake victims at the airport with vials of anti-venom and 25 cc syringes of lactated ringers. It will be a glorious, glorious day.

Needless to say, watching this movie necessitated the consumption of beer. Which is why, if I fail the boards because I was too hungover to really concentrate on Hematology, then a certain actor will be getting a very nasty letter in the mail. And that actor is Samuel L. Jackson. Or maybe that nurse from ER.

[Stay tuned for facts about poisonous snakes, and other Toxicology gems]

I just had one of those moments where you think you might be catching a glimpse of your own future. Check this out: Environmental Third World Medical Toxicology.
Can I get a Hell Yeah?

I have recently become enthralled with the idea of being a medical toxicologist: a student of poisons, a provider of antidotes. This is one of the few subspecialties that falls under the Emergency Medicine umbrella, and only requires an additional two years of study (why stop at 24?). In a field that is so broad, that requires knowledge of so many other specialties of medicine, there is something exciting to me about having a specific area of expertise. And what better area than heroin overdoses and suicidal tylenol ingestions and poisonous mushrooms and rattle snake bites?

I was just searching for the website of OHSU's toxicology department, in preparation for my one month elective that is to start tomorrow. And I came across an old press release entitled "Toxicology in Third World Settings" which described a 2004 regional toxicologists conference that focused on "the latest research on everything from hazardous foods to air pollutants believed to cause debilitating and crippling disorders that strike tens of thousands in sub-Saharan Africa, the Indian subcontinent and Southeast Asia."

This sounds absolutely fascinating to me. Granted, it is not within the usual scope of the emergency physician's scope of practice, but when you consider the number of, say, organophosphate pesticide poisonings that occur annually among migrant farm workers, you realize that even "third world" toxicology is all around us. It is a symptom of the many social and economic injustices that are poisoning this world. Get it? Poison.

Get it? Poison.

Also. It seems unfathomable that I have been a student for 21 years of my life - 24 by the time I finish residency. Boy do I love studying. Man! I just can't get enough of that studying gig. And good thing, because tomorrow also officially marks Day 1 of studying for Step 2 of the United States Medical Licensing Exam. Known affectionately as "the Boards." I took Step 1 two years ago and it was only one of the most agonizingly soul-crushing experiences I have lived through. And the beauty of it all is that it never ends - there are basically 5 huge horrible Board exams that you need to take to be licensed to practice medicine in a certain field. And then you have to take renewal exams every few years. Straight from the mind of Satan himself. Boy oh boy do i love studying.

Other memorable experiences from my epic train journey:

- Splurging on an overpriced dinner in the Amtrak dining car while riding through Glacier National Park at night. I spent $11 for a bowl of cheese ravioli and $4 for a can of Budweiser. No joke - $4. Sometimes you just want a beer. The best part, though, was my dinner companions: a goth kid from portland (complete with black nail polish and black leather dog collar necklace) and an Amish farmer from montanta!! Well, I suppose he wasn't Amish or he wouldn't be riding the train and wearing modern day clothes - but he spoke with a german accent and had a beard without a mustache and I swear he said he was something that rhymed with Amish. But the three of us sat there and ate our salads and asked eachother polite questions about our respective travels. I felt that I was somehow living inside of an elaborate joke punchline.

- Sitting in the sight-seeing lounge, looking at Montana, while a moderately retarded young gentleman in a baseball cap sang "This Land is Your Land" over and over again to himself. Right on, brother.

- Waking up to dawn over the Columbia River Gorge. I went down to the lower level of the car and did stretches in front of the window, balancing on the swaying floor, watching the sun rise higher over the brown cliffs.

- Being met at the train station in Portland, Oregon by a very nice tall man holding a pot of yellow flowers.

24 hours to go, and the plains of North Dakota sail past. From my window seat in the Amtrak Empire Builder 27, scraggly clumps of yellow-tinged maples slide past, staking their claim on the seemingly endless expanse of flat brown grassland. Some cows now. Some abandoned cars here and there, rusting on the outskirts of stunted towns. Hills start to rise and fall in the distance, and the grey sky hangs over all. I stretched my legs briefly in the town of Williston, ND and was startled by how cold it was outside. Winter is coming. I am not ready.

At times I feel like my life is ruled by the irony of circumstances. Like how, in a train that is fairly empty, where the majority of people have 2 seats to themselves, I get assigned to share a row with a man who is going all 37 hours with me to all the way to portland. A man who snores - loudly. A man who, when I open my book to begin studying for the boards, points to pictures of people and imitates their poses for my benefit, seeing as with my headphones on I can't hear his comments. As if to say, "this person has their eyes closed - like this!" He was also kindly and generous and offered me sips of his orange juice and handfuls of nuts, but I am relieved to have moved. My own private solitary row. My own view of the cold yellow-brown world passing outside.

A nice long train ride is good for getting your bearings. You understand your place in the context of things, you understand how far away from home you really went when you left for college ten years ago. And that there is a lot of space between things. And how nice it feels to be anchored to a place, pulled in by the strong tide of family, of friends. It also gives time for some reflection on recent events.

My last night in St. Paul I spent sitting by a fire with my brother and good friends, watching heat lightening wip across the sky, warm storm-wind creating waves in the marsh grass around us. I saw the plane carrying my mom and stepdad fly overhead, oh precious cargo.

I think about my recent experiences in the Emergency Medicine program, many of them excellent blog content. Like how last friday I found myself spattered from head to toe with blood, my hand inside the warm body of a living sheep, my hand around its heart, squeezing rhythmically, prolonging the inevitable. Or how I stitched up the forehead of one of the members of the hospital governing board. Or how I saw a woman with a dangerously elevated potassium level resuscitated from ventricular tachycardia. Or how good it feels to poke needles in people and how surprising to find that I actually remembered that pityriasis rosea can look like ringworm. These are things I think about and hope that someday soon I will have the energy to write them all down. But staring out the window sometimes takes precedence.

'Make sure you keep your headset on,' Candy said, 'because even 15 minutes of cumulative helicopter sound exposure has been shown to cause hearing loss.'

This was yesterday morning. Candy the hard-edged flight nurse was going through my safety debriefing before my day-long ride-along with LifeLinks, the helicopter ambulance service that transports critically ill patients from rural areas to better-equipped large urban hospitals. This involved me getting up at 4:45 am, driving the 1 hour to the tiny hamlet of New Richmond, Wisconsin, and then getting lost and showing up to the unmarked hangar half an hour late because said tiny hamlet in Wisconsin unbelievably has two Fourth Streets, one of which, I discovered, does in fact NOT intersect with county road CC. My late arrival was immediately followed by my admission that no, I did not bring anything warmer or bluer to wear, and that no, I did not have gloves, at which point I was instructed to get on the scale and prove that I weighed less than their 225 lb limit. Which, fortunately, I did.

Once we had all those formalities out of the way, I settled in to my day with the flight team, which consisted of two nurses, one helicopter pilot, and the maintenance guy who spent most of the morning trying to figure out the cause of the pesky blade wobbling that everyone was complaining about the day before. They were all incredibly nice and incredibly good at their jobs. After helping them go through the entire inventory of medications and supplies in the helicopter, I was given my safety debriefing. Candy continued:

- The pilot is in charge. Every move you make needs to be cleared by him.
- When in front do not touch the pedals. The pilot will get very mad at you.
- Do not lean on the windows. They serve as detachable fire exits. Last year somebody broke the front window and it cost $30,000 to repair.
- If there is a hard landing, sit up as straight as you can. The downward impact will hopefully cause vertebral compression fractures instead of severing your spinal cord.
- In the case of a crash landing, whoever has survived will meet up in the direction of 12 noon from the nose of the chopper.
- In the case of a fire, just get out, duck, and run. You have 30 seconds.
- In the case of a fire, do not use the fire extinguisher while in air. It is made of halon and will suck up all the oxygen in the cabin.
- In the case of an emergency, you can attempt to rescue the patient if they are a baby or small child. Otherwise, just leave them. Its every man for themselves.
- Duck if you are walking in front of the nose; the upper blades are flexible and can dip down as low as four feet off the ground.
- Do not walk anywhere near the back end of the helicopter. The smaller rear propeller spins four times faster than the upper one – and is invisible. {pause} It has happened.

Needless to say, I handled this information with calm composure while silently reeling inside, images of a blood-splattered Indiana Jones playing on repeat inside my head. With thinly veiled composure, I tried to ask oh so casually if she had ever been involved in any crash landings. 'Oh yeah,' Candy said, looking me straight in the eye. 'This is serious.'

A couple hours later, when the alarm went off alerting the team to a critical transport, I found myself strapped in to the back seat of the helicopter, a large headset protecting my delicate little cochlear hair cells, thinking about what it would be like to spiral out of control in a flaming helicopter, sitting up straight in the hopes of mere lifetime debilitation, and then running from the burning wreckage straight into the invisible propeller blender of death. But once I felt us lift easily off the ground, these morbid thoughts were quickly replaced by awe and exhilaration at the sight of the beautiful lush Midwestern farm-scape that was flowing beneath me. Flying is amazing. Amazing. Wow.

But my own personal rejoicing at the miracle of flight was tempered somewhat by the gravity of our mission. We were transporting a seriously injured kid who had been attempting Jackass-style BMX stunts. Once we bundled up our cargo and took off from the rural Wisconsin hospital, the flight nurses went to work. In a flurry of activity and tubing, they hooked up IVs and oxygen, administered medication, prepared suction, attached the monitor... sitting at the patient's feet, I helped by replacing the oxygen tube when it fell out. Saving lives - its what I do. Underneath us, cornfields were intersected by knobby oak groves, a flock of ducks reposed on a small marshy lake, dirt county roads turned to small highways and farmland gave way to the barren flat-tops of suburban company headquarters. Suddenly we were in Minneapolis, circling around the top of a tall hospital helipad. And without tv-style drama or teams of frantic doctors sprinting to meet us, we delivered up our charge to his fate.

They let me sit up front on the way back (after promising not to touch the pedals). Its funny how the downtowns of major metropolitan areas look so dinky and gray from a bird's view. I saw the Minnesota State Fairgrounds, where days before I had gorged myself on mini donuts and funnel cake (and a pickle on a stick). I swooped over my old boathouse on the Mississippi river. I spilled scalding hot water all over the floor and myself at the downtown St. Paul airport. And then I was back in farm country, weighing the pluses and minuses of dropping out of medical school to pursue a career in helicopter piloting.

And the crazy part is that that evening, I pretty much went directly from the emergency helipad in Wisconsin to my 10 year high school reunion. I put on a name tag, and walked sheepishly into a roomful of vaguely familiar people, saw some friends who I have't talked to in literally one decade (as incomprehensible as that amount of time is), took liberal advantage of the bar and the Central High School Class of '96 sheet cake, and found myself repeating over and over again, 'So what are YOU up to?' in a weird high-pitched voice. And, as people where handing out business cards and claiming to have not recognized me, I kept thinking to myself 'I just spent the day rescuing people in a helicopter and SAVING LIVES. Sorry, what did you say you were up to again?'