ketamine

The FDA must not restrict healthcare provider access to ketamine, this includes any rescheduling domestically or by international accord. Ketamine is a vital medication in emergency medicine, prehospital and anesthetic communities for this reason it is on the World Health Organization list of “Essential Medications”.

The safety profile of ketamine as an anesthetic agent is unrivaled, and it’s efficacy for both sedation and analgesia make it an ideal agent for procedural sedation and pain control in the emergency department and prehospital environments, in developing healthcare systems it is often used as the sole anesthetic for general surgery!

Unlike opioids ketamine has been proven time and again to be safe and have a low abuse potential, it is carried by US Armed Forces medics and corpsmen for treating our own soldiers and Marines when they suffer catastrophic injuries in the field.

Perhaps ketamine’s vital importance can not be illustrated more clearly than by a single quote from a US physician whom was part of the international response to the 2010 earthquake in Haiti which left hundreds of thousands dead and tens of thousands more requiring surgery including hundreds of field amputations: “An InSTEDD* [sic] doctor who returned to the U.S. from Haiti on Thursday said the medicine most needed by physicians there is “ketamine, ketamine, ketamine” — an anesthetic.” -NPR article on January 21, 2010 *InSTEDD – Innovative Support to Emergencies, Diseases and Disasters

Ketamine has an undeniable place in routine emergency medicine and surgery as well as a critical role in disaster medicine. While no medicine is a panacea, ketamine may be as close as we come for anesthesia and analgesia in the critically ill.

I personally use ketamine routinely in my practice of emergency medicine for pain control and anesthesia in the gravely ill and injured. When administered by an appropriate healthcare provider ketamine not only eases pain and suffering it literally saves lives! Please ensure that we, the medical community, retain this indispensable tool, keep ketamine accessible to healthcare providers worldwide.

Do PAs really order more imaging studies? One PA’s Response.

As well as being a physician assistant I am interested in the equity and economics of care, so naturally my interest was piqued when: A Comparison of Diagnostic Imaging Ordering Patterns Between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits. Hughes, et al was published online in JAMA Intern Med. November 24, 2014. As its authors are active in the online FOAMed (Free Open Access Medicine) community and its publication happens to coincide with the Radiological Society of North America annual meeting, it was quickly disseminated on Twitter with the associated claim: “When ordering images, NPs, PAs far more trigger-happy than docs.” (@NeimanHPI) This is not only misleading but is a gross and irresponsible generalization.

I emphatically agree that this is an important area of study, there is and will be a growing shortage of providers for an aging population. The shortage in primary care is amplified by fewer and fewer graduating physicians moving into primary care practice while at the same time many current providers are late career and nearing retirement. It is simply a fact that you will see mid-level providers providing more care in the primary care setting, this seems to be the area of concern in regards to scope of practice and quality of care. Keep in mind the majority of supporting research cited by the authors was aimed at examining expanding scope of practice and/ or more autonomous practice of nurse practitioners (NPs).

While I do not work in primary care, I practice emergency medicine, I have worked in a number of both private and public institutions across the country and in doing so have developed a robust sense, albeit anecdotal, of practice patterns of: board certified physicians, family practice physicians grandfathered into emergency medicine, residents and non-physician providers alike. I can firmly attest that in my experience I have witnessed mid-career physicians order the bulk of imaging studies in the ED especially advanced imaging, CT/ CTA. While seeing the same acuity I am often coerced by these same physicians into ordering additional studies on my patients when they supervise my care. Briefly the three most common reasons cited for what I perceive to be unnecessary imaging are: defensive practice (been sued/ know someone who has been sued), expediency (scan the patient instead of physical exam/ serial exams/ admission/ observation/ close follow-up)  and patient satisfaction/ expectation (it’s what the patient expects/ demands/ sent by PCP).

The authors lump PAs and NPs together as: advanced practice clinicians (APCs). While this may seem reasonable and makes sense from the stand point of data collection and analysis, the authors used medicare billing data for their study, when teasing out finite variables in medical practice this lumping is bound to be confounding. While PAs and NPs are increasingly being used interchangeably in clinical settings it cannot be overlooked that there are marked differences in PA and NP training. It bears repeating that PAs are trained on a medical model, albeit PA training is shorter than that of physicians and does not include a residency. I expect that a PA-C (certified PA) in clinical practice for 3-5 years would be held at least to the same standard as a graduating resident in his or her given specialty, at least in regards to practice patterns. Furthermore, while I do not have data at hand I believe it would be a reasonable assumption that nurse practitioners rather than PAs account for the majority of mid-level primary care for patients in the studied population . So what are the authors really studying?

The authors cite a previous study to bolster their premise in the introduction however, that previous study by Seaberg, D.C., MacLeod B.A., et al. Correlation between triage nurse and physician ordering of ED tests. Am J Emerg Med. 1998;16(1):8-11 examined concordance of ED physician orders with triage nurse initial order sets and did not involve mid-level providers at all as stated by Hughes, et al. The Seaberg study was two phased and designed to determine differences in triage nurse ordering of diagnostic studies (lab work and plain film radiography) from that of emergency department physicians and whether the differences could be reduced by protocol based order sets. While the authors of the Hughes study state: “Previous research investigating the concordance of APC and physician radiography orders in the emergency department (ED) setting found that in 34% of ED patients, APCs recommended imaging studies when physicians had not.” Again, this in not only misleading, but erroneous.

Despite our best efforts to standardize care medical practice is variable due to regional differences (standard of care) and even within the same institution inconsistent from provider to provider. By the nature of my own practice, emergency medicine, I utilize a lot of diagnostic imaging, although I rely heavily on clinical decision tools such as PECARN, NEXUS, Ottawa, etc and together with shared decision making I am successful in avoiding ionizing radiation in many of my patients and strive to do so whenever possible. I concede that these tools are intended to reduce imaging for more routine presentations in the emergency department rather than the primary care practice environment.

Furthermore, the authors do mention in closing that: “Also, under some circumstances work performed by APCs is coded by their supervising physician. This would create downward bias, i.e., our reported estimates underestimate the magnitude APCs order relative to PCPs, if many episodes of care treated by APCs and presumably ordering more imaging are actually coded in the PCP reference group.” However, this fails to take into account that visits may occur in tandem or with the physician in a consulting capacity while the visit is still coded as a mid-level visit. Finally, the authors themselves state that their data would not correlate to a measurable effect at the individual patient level but instead represents population size differences in practice pattern which are again extrapolated from a small and inherently unreliable dataset.

the PA problem

I have received a number of questions from PA students and prospective PA students regarding what it’s like to be: a PA, an emergency medicine PA and a remote PA; enough that a blog post seemed more sensible than replying individually, this is my overly wrought answer.

Part of the daily reality of being a PA or PA student is the necessity to answer time and again two questions: what the heck is a PA and what do PAs do anyway? This occurrence is frequent enough to be a well established internet meme with a host of requisite youtube videos. Every PA develops their own 30 second spiel to answer both these questions in one fell swoop, some good and some not so good. I can attest to having heard explanations that have sounded to my ears like finger nails on a chalkboard and on one occasion, just in the past week alone, which literally, I think, caused something to go pop in my head.

So, please if you are already a PA/ PA student and your patients seem confused or ill at ease with your explanation or your colleagues cringe and leave the room when you begin your exposé please do us all a favor, work on it. Likewise if you are headed to your PA school interview be prepared to answer those questions, they will be asked.

It is not my intention here to correctly define the PA profession or answer those questions; there are plenty of places you can find those answers and part of the practice of medicine is life long learning so you just might as well get used to it. I intend instead to offer a point of view that you perhaps have yet to consider and hopefully will.

This is a post for those students who already are seriously and earnestly considering a career as a PA and already know more than roughly what it entails. They may already be PA students and/or have worked in healthcare with PAs or have done some shadowing. These students have a small n, if you will, of PAs they have been exposed to and are looking to increase their sample size. One of the difficulties I had throughout school and training was the feigned hierarchal and dogmatic idea of deference disguised as professionalism that affects medicine and medical training and with that being said maybe I am a good person to ask for advice, maybe not.

Typically the questions I am asked relate to autonomy, scope of practice and job satisfaction, I will try to summarize the factors that I feel strongly affect these professional attributes, it may not come as any surprise that they are dependently interrelated. I began writing this as a reply email and got carried away, I think it easy enough to follow without too much difficulty. So without further prologue the truth or as I like to put it the PA problem.

Quite frankly there isn’t one simple one size fits all truth; at best I can only serve as an anecdotal bias in one direction or another. The answer is of course, it depends; it depends on a host of factors that would be impossible to enumerate here but I will cover the perhaps not so basics.

The only truly definite answer I can give regarding the variable autonomy and the scope or “level” of practice bestowed upon PAs is that no two PAs practice precisely the same medicine and there is a reason for this that is unique to PAs.

When you examine the practice model you will find that while MD and DO practice varies by training, experience, practice environment/culture and intellect, PAs have an additional yet overwhelmingly important variable, that being, their relationship with their supervising physician.

This fact cannot be understated and it exists anywhere there are PAs. I would not say that the differences between the practice of EM by any two PAs is entirely different from that of differences between PAs in any other sub-specialty. Firstly, as in any hospital based specialty emergency medicine (EM) PAs and MDs for that matter do not practice in a bubble, they are beholden to the culture of the institution.

Regarding institutions, you mentioned academic and non-academic, you could also throw in for profit and not for profit as well as community hospital and tertiary care center. All institutions will approach the “PA problem” differently and grant privileges as they see fit. This is one external factor.

By the letter of the law a PA may practice within the scope of his/ her supervising physician, but you must realize that physicians have set limits as well. Physicians too must be privileged, typically by the same credentialing process, to perform procedures or even admit patients to the hospital and these privileges vary from institution to institution.

These prescriptions, while ostensibly in place for patient protection can at times be non-sensical and/ or be maintained for other reasons entirely. For example the use of a particular drug or the performance of a certain procedure may be the providence of another specialty such as anesthesia, orthopedics or cardiology and the emergency department provider (EDP) may be effectively barred from its utilization.

Another example is that of antibiotic stewardship; it has become a hot topic and at many institutions, rightfully so I believe, powerful antibiotics are non-formulary and must be approved by infectious disease physicians regardless of who the ordering clinician is.

As a singular PA example, as EDP at one institution I was credentialed to place an endotracheal tube (ETT), but not administer the sedatives and paralytic agents that would facilitate its passage other examples abound.

What does any of this have to do with PA practice or autonomy? So far I have mentioned a few external factors to the MD/ PA relationship, but there are also internal factors beginning with interpersonal dynamics, mutual respect and professional confidence/ trust. Additionally you must take into account the training and experience of a supervising physician.

One of the criticisms of the PA profession is lack of a standardized skill set amongst providers, this is an inevitable reality of the apprentice system and medical training in general and it is folly to think physicians or other providers are exempt.

While physicians have many more years in school and residency to acquire skills and experience PAs have less opportunity and once graduated are expected to “hit the ground running” it is my feeling that it is the notion that a PA is ready for practice that has perhaps left more than one PA disenfranchised and more than one physician feeling burned. But to say all physicians by conference of their degree are more knowledgable or more skilled than all PAs would be a blatant falsehood.

Apply the above to your notions of fast track. “Fast Track” is not a noun as you might presume, it is not a place, it is instead a verb describing the disposition of a patient whom does not require intensive emergency department work-up or treatment and you are not alone in this misconception. A patient doesn’t GO TO “Fast Track”, a patient GETS fast tracked.

With that in mind a common question I receive is: as a PA will I be stuck in Fast Track or how do I keep out of Fast Track?
While there does seem to be a prevalence of PAs flying solo in emergency department “Fast Tracks”, you will almost never see a resident placed in this position. I will express the reasoning behind this fact two different ways that when combined you will find illogical and in fact a Catch-22.

You may have the preconceived notion that all fast track patients are low-acuity and/or suffering from some self-limited condition that will get better on its own anyway; that for a resident there is nothing to learn and for an attending physician fast track would be sheer boredom and time wasted. Perhaps, but I have personally caught surgical abdomens, heart attacks, blood clots, strokes and open fracture dislocations in “Fast Track”, in other words real emergencies that without proper and timely intervention would have had bad outcomes and I’m just one PA.

So why put a PA in a position where he/she could miss a heart attack? As a PA I can see, treat and discharge a patient without an attending physician laying eyes on the patient, a resident may not and that is the reason PAs are placed in “Fast Track” if the attending had to come and lay eyes on every fast track patient the ED would grind to a halt. Now, I am not claiming to be the reincarnation of Osler’s ghost but I am making the point for argument’s sake that a green PA is not any better suited to being left alone in “Fast Track” than is a PGY-2. It is simply the compounding of two cultural biases: PAs have less training and therefore should see lower acuity patients and PAs as a deliverable product are fully formed the moment they pass the PANCE. So naturally lets stick the untested undertrained providers where they will only see low-acuity patients and they can’t hurt anybody. The truth is that in many EDs patients are triaged to main ED or “Fast Track” prior to being seen by an EDP and naturally sickies fall through the cracks. The truth is that good emergency medicine is the differentiation of the sick from the not sick most pitfalls lie in the missed diagnosis not in failed treatment.

I mentioned earlier endotracheal intubation, a means of definitively controlling a patient’s airway by placement of an ETT. Imagine if you will the dramatic example of two providers: a PA who prior to PA school worked as a paramedic and has placed a thousand of out of hospital non-elective ETTs and has performed a hundred emergent surgical airways and his supervising ED physician who is family practice trained and has placed a handful of ETTs outside the OR and has never performed a cricothyrotomy outside of cadaver lab. Who is best able to handle the next airway emergency? Should the PA be “trusted” when the physician is the less experienced “back-up” provider? I am not that PA and I will not conjecture an answer, my hope is that it elicits thought on the matter.

Another, less dramatic example: a double coverage, MD/ PA practice the PAs do much of the minor procedures whether it be suturing or incision and drainage due to the fact that the procedures are time-consuming in addition to other factors. In this hypothetical practice the MD picks the next chart off the rack and examines the patient, a handsome young female with a complex facial laceration. The PA is perfectly comfortable closing the wound, because he has repaired three similar lacerations this week and it’s only Tuesday. The MD rarely sutures any longer and is ready to call plastics. Who should sew up the child?

In the above examples to the correct answer of course lies in what is best for the patient, I am assuming a favorable outcome in either case. However, as a final Gedanken I offer for your consideration an extension of the previous. Obviously we bill for services, within an EM group PAs may be eligible for RVUs or relative value units these units are directly tied to reimbursement and compensation, in the above examples both “critical care time” and procedures, such as suturing are high RVU generators and would net the PA more income for services rendered as opposed to going to another consulting service.

Hopefully if I’ve done what I intended I have raised more questions than I have answered and the reason for this these are very personal as well as professional questions, there is no simple or one size fits all answer. Some PAs might not be satisfied in a professional relationship in which the felt under utilized while others might enjoy the comfort of making lower risk clinical decisions. It has to do with personality and aptitude more than it does the rules per se, the question is: how do we modify the rules to best utilize highly trained healthcare providers in the most befitting manner without sacrificing patient safety? I’m not advocating independent practice for PAs but better cooperative practice with physicians. It has been shown over and over that PAs improve patient safety and satisfaction, PAs are here to stay, the question remains how do PA provide the greatest good and in turn realize the greatest career satisfaction?

money well spent?

NB: I wrote this in a hurry a few weeks back, it’s been sitting in the drafts folder since then. I’ve been reluctant to post something as it’s been so long since I have posted anything, well need to start somewhere.

It’s been a while since I bothered with the blog; a lot has happened in the interim, however perhaps not quite as much as I had wished and it’s just possible that this fact has contributed to my silence. But I felt compelled to share this and it wouldn’t fit in a tweet.

This past week was ACEP13, or the American College of Emergency Physicians 2013 annual scientific conference, here in Seattle. I enjoyed interacting via twitter and on the web with some of the dedicated and intelligent attendees, hopefully I did not antagonize anyone too badly.

The ACEP conference for those outside of emergency medicine, is generally billed as the future of the specialty, and I believe as do many involved in EM that it has a large influence on the delivery of all forms of healthcare. Now…

The other day while leaving the building I ran into my neighbor. He told me he spent five hours in the ER over the weekend as he rolled up his sleeve to demonstrate a bulky bandage encompassing his left forearm. He is a craftsman and works in wood as well as other materials. Apparently a few days earlier he had a piece of furniture grade plywood kick back at him while using a table saw, and slice open his left arm. The wood fragment lacerated the dorsum of his distal forearm. I had a pretty clear picture in my mind of my friend there in his workshop managing to call his wife while simultaneously bleeding through the rag with which he held pressure.

Naturally, they drove to the emergency department. I myself had been out of town at the time and in any case during the confusion they forgot about what I do for a living and I could see by the look on my neighbor’s face that that fact only registered when I said that I wished I had been around for you. I told him oh well, chatted a bit more and told him I’d be happy to take a look at his arm take the sutures out after ten days.

This whole story would be completely unremarkable except for the post that was forwarded to me from Facebook, it was written by my friend’s wife.

Redacted post appears here:

“Just opened the bills from {Xxxx}’s ER visit when he cut his arm using the table saw. I almost fell over. $97.76 for pharmacy (2 advil and 1 tylenol) $639.17 for an xray, $1904.03 for ER visit and $57.50 for preventative care service – are you Fricking kidding me!!! and another bill from {X medical group} for $556.20 not sure what for – the doctors maybe. Total $3254.66 so convenient with our $3500 deductible. SHIT!!!! I’m thinking we should just ditch the insurance altogether. Why are we paying $600 a month?”

*Brackets are my own.

This is my take:

I removed my neighbor’s sutures, to be specific (as if it were a medical record) I removed four simple interrupted sutures of 4-0 Prolene in their entirety and without complication, the pt tolerated the procedure well and three steri-strips were applied.

The wound had been well cared for, the wound edges were satisfactorily approximated, the sutures were taut, the knots were left over the laceration, there were adequate tails.
There was mild erythema as one would expect in a healing laceration of this acuity. There was no purulence, dehiscence or signs of an infection. In short, this was an uncomplicated laceration affecting an otherwise healthy male the trauma occurred by a minor MOI.

There would be no medical indication whatsoever to perform a radiographic study, even if there was a suspected foreign body it would be radiolucent, it’s wood! Perhaps you could argue for the use of bedside ultrasound if you really suspected retained FB, wait a minute, with US you could assess for fracture too all in less time then it would take to transport the pt to radiology never mind perform the study, return the pt to the exam room and wait for the PACS to load.

I fully respect pharmacists, they have saved my ass before and I understand we all need to get paid but please nearly $100 for OTC medication. Because of what, redundant allergy and dosing checks? Can’t we just assume that is covered in the hospital and provider fees? Don’t we always check: right med, right dose, right patient, right route?
I don’t even want to tear into charging for “preventative health maintenance” because the provider mentioned smoking.

Look, I’m a reasonable guy if I go into a particular kinda restaurant and order the Omakase or the Chef’s tasting menu where over in the price column it says MP, I know what I’m signing up for. But a) at least there is a menu, b) I chose this restaurant, I know, roughly, what the tab is going to be c) I know it is completely hedonistic to eat like that (I love it) but it’s a choice!

Now compare this to our healthcare (ahem) sickcare delivery system. a) there are no menu’s the public has no idea what these services cost or what they are being billed for, most providers don’t know the costs! b) a person who feels that they are having a medical emergency probably does not realize they have a choice or what those choices are.

Before this gets too expansive, I will say: could they have gone to an urgent care and not be subject to the costs related to running an ED 24/7 365? Of course. But for any providers reading this, ask yourself have you ever, ever, seen a patient in the ED or at triage and said: “You know, It’s gonna be really expensive for you to be seen here, you don’t look like you’re having an emergency that requires our services, you might wanna go to an urgent care”. Of course not.

We can do better than this, we have to do better then this.

return to midway

After having seen all of Midway last year I was in no hurry to return, especially for another three months, however I was approached to fill in for one month of coverage and my financial state of affairs being what they are I said yes.

This is what I awoke to on my first morning. I am hoping Midway is not another Bermuda triangle.

Thread in chronological order:

From: rocknicepac
To: xxxxxxx.xxxxxxx@us.army.mil
Subject: Found: Pelican Case
Date: February 4, 2012 12:42 PM GMT-11:00

Priority: Normal

Soldier,

I am trying to return lost property to a Xxxxxxx X. Xxxxxxx, US Army. If
you are indeed the same person, please describe contents of the lost
Pelican case and an address. Your property will be returned forthwith.



Regards


_____________________________________________________________________________

From: Xxxxxxx, Xxxxxxx X PFC MIL USA

To: rocknicepac
Subject: Re: Found: Pelican Case (UNCLASSIFIED)

Date: March 29, 2013 8:26:31 AM GMT-11:00


there should be a GA drivers license number XXXXXXX71 along with
military id with PFC rank. there was also a car key.
_____________________________________________________________________________

From: rocknicepac
To: Xxxxxxx, Xxxxxxx X PFC MIL USA
Subject: Re: Found: Pelican Case (UNCLASSIFIED)
Date: April 1, 2013 12:59 PM GMT-12:00

Thanks for getting back to me, it’s been a while.

I no longer have the little box nor it’s contents and I believe at this point they have most likely been disposed of, but allow me to amuse you with this little tale.

When I wrote you a year ago February a volunteer with the Fish and Wildlife Service had found your box on the beach while doing marine debris collection. She showed it to me and there being a MIL ID I figured it would be easy enough to locate the intended party, you. In and of itself not terribly interesting I’ll admit.

What is interesting is the beach being cleaned happened to be on Midway Island Atoll in the smack dab middle of the North Pacific where I was for three months last winter. As it so happens when I left Midway a year ago March I had no intention of coming back, ever.

Fast forward a year, the company I work for was in a bind and I wasn’t busy so I am actually back on Midway right now for one month. Now here’s the fun part, your email arrived in my inbox the very morning I awoke here on Midway after having just flown in the previous evening!

I know you must be as impressed by this little coincidence as I am, so in the cause of making it all the more interesting, two questions: 1) Where did you lose your box, I figure you were on R&R either in Hawaii or Japan? 2) What took you so long to respond, were you deployed? I figured you had either left the service, although you might still retain the email address but check it rarely or were article 15 for losing the ID in the first place and had been busy on KP or in the latrine.

Cheers,


-A

_____________________________________________________________________________

From: Xxxxxxx, Xxxxxxx X PFC MIL USA

To: rocknicepac
Subject: Re: Found: Pelican Case (UNCLASSIFIED)

Date: April 4, 2013 9:56:49 AM GMT-11:00

lol yes very interesting. i lost the pelican case while scuba diving near north shore beach which isnt far from schofield barracks. i was stationed there for a year. i only got a counseling for the id card lol but believe it or not my chain of command was only joking with me about it. i took the pelican case because i had a soft top jeep wrangler so wanted to keep important stuff on me but the case got disconnected somehow. i did get an honorable discharge about a month after this for single parenthood. i am now in the army national guard then finally got access to my ako when i got your email. thanks for looking me up though just crazy that little box made it so far.

Holly

This morning I wrote my friend Holly an email, we don’t keep in regular contact, but she was on my mind and I missed hearing from her.

The last time we were in touch was a year ago, I was on Midway, Holly was living in Yosemite still recuperating from her November knee surgery. Holly had left a real-estate finance job in Manhattan, which I could hardly comprehend and had taken to the open road in her orange Honda Element to live the climbing life. This was something I knew well and needless to say I was jealous.

Holly maintained a blog while she was on the road and an hour after I had sent my email I thought to check to see if she had made any updates. I could catch up on the world of Holly, the part of herself that she shared with the world.

I expected to read a recent trip report to learn what Holly had been climbing or where she had been lately getting turns, instead I found that Holly had died a year ago, she was 32.

I met Holly at a time when I was transforming my life and I guess she was too; I was embarking on my undergraduate degree and getting out occasionally to remember what climbing was like, she had only recently discovered the climbing world. I met Holly walking along the carriage road in the Gunks, she had been climbing with some friends earlier that day and now finding herself partnerless resigned herself to call it a day. I had just stopped by the Trapps to try and partner up for the afternoon, after a quick introduction It didn’t take much convincing for Holly to change her mind and we were soon tied in together and cruising some moderates.

My climbing was becoming what I always considered substandard, school and other responsibilities took their toll despite that Holly was a positive influence throughout that time she was always game to get out and offered a patient belay.

An enduring memory I have with Holly doesn’t involve climbing at all, during PA school I was hospitalized for the first and only time in my life, I don’t remember much of it. It was around nine thirty that evening and I was just waking after being passed out in a hospital bed when my phone buzzed. It was Holly, hysterical, on the other end of the line trying to make herself understood through stifling sobs.

I was in New Haven, Holly was in New Paltz but she implored me to come to help her, she told me I was her nearest friend, she was scared and couldn’t be alone. I couldn’t figure out what had happened or what might be happening, she was inconsolable and beyond reasoning with, I didn’t know what to think, I was terrified.

Fully awake now, although some might say having not come to my senses I pulled out my IV and after much haranguing by the nocturinst signed out against medical advice, I don’t think I mentioned I was going for a two-hour drive to New Paltz.

I arrived without incident and found Holly still hysterical and curled in a fetal position she didn’t answer the door, I put her to bed, she may have slept an hour that night perhaps two, I didn’t sleep at all. I was relieved from my vigil by another of Holly’s friend who had driven in from Boston. I headed back to New Haven and to bed.

We got out together a handful of times after that before she hit the road.

I never told Holly the circumstances of my being by her side that night. Before today I never needed to share it with anyone, but I would take those same risks and more to tie in with her again. I discovered today that that will never be.

From: rocknicepac
Subject: Me again
Date: March 9, 2013 7:58:24 AM EST
To: holly

Hey Hols,

Annual update I guess, hope your doing well and getting in more skiing this year then last. I didn’t spend this winter on an island so I got a couple of days in.
I’m still based in Seattle, for what it’s worth, it’s a funny town for climbers I think. I miss being near the rocks and on the rocks.

I finally got to France, last April I spent a week in Font but after that I can count my climbing days on two hands.

Truth is I’m frustrated, more so then I’ve ever been and I feel stuck, trapped, before I would get in a bad way but there would be a definite end, like a section of rotten ice or bad rock there would always be an end, and all I had to do was suck it up for a time. Now there’s no end in sight.

Are you still in Yosemite, I can’t even tell you how envious I am. The best I’ve felt in a year was the two days I spent in Squamish last May. It had been ten years since I had been there last when I was on the road. I felt energized and renewed moving over that granite. I felt like I had purpose, like I belonged.

After I started working as a PA I lost touch with who I am, I don’t like this other me. I miss being on a wall and feeling apart of the world. I think of you often.

Hope the knee is back up to spec. Hope you’re getting some for me.

-A

back on the air

I am back in the Pacific Northwest and experiencing the long awaited Seattle summer. In the four months elapsed since handing over the reins to the returning PA and alighting from Midway Island I have been fairly busy, certainly busy enough to provide fodder for the digital regurgitation that is my blog.  However, after sensory deprivation on the northern most coral atoll in the world I’ve been trying to get my fill of everything that makes living on the mainland so much better than being a castaway and have  not taken a moment out to write about any of it. The next series of posts will be a recounting of the past four months and hopefully they will be at least as entertaining as my trials and travails on Planet Midway.

Can we say teaser?