things patients say.

My last week on Midway, today is my last Friday and as I count down the final moments in all their glory today I received a small inoculation, a reminder if you will as to what awaits me back in the ER. March has actually been a busy month for me so far, I have almost needed to shake my funk considering in the first nine days of the month I have nearly seen as many patients as I did in all of February, ten.

So the whole drug allergy thing is about as out of control as the pain scale. You know:

Me: “How would you rate your pain on a scale from one to ten, ten being the worst pain you could possible imagine”

Pt: “Oh, it’s at least an eight, no more like a nine…” [Meanwhile pt is currently playing Angry Birds on iPhone, just finished bag of Fritos (+Fritos sign), vitals: BP 115/70, HR 64, RR 12, SpO2 100%RA, T 37°C]

When I was in PA school, having actually had some prior direct patient care experience, I would attract a critical glare on occasion during history taking practicum when I’d bust out with the truism “Well all patients lie…” for instance, or maybe it’s just because I’m a wiseass. At any rate, the point is you have to utilize those critical listening skills, even if the patient isn’t deliberately trying to deceive, which most the times they’re not, they are trying to tell you their story and not what you need to hear to diagnose or exclude disease.

Just revisit my previous example of the pain scale patient, imagine that patient is complaining of abdominal pain, do you think the patient needs an emergent CT scan of their belly and a battery or lab tests before being whisked off to the operating room or can you sit on them a little while?

Another example, and this is what cracked me up today:

More and more commonly patients report being “allergic” to everything: prednisone, aspirin, glucose, epi… (Need I go on?) Sometimes they are talking about an effect (desired) or a side effect (undesired) of the medication. “Um.. yeah I’m allergic to warfarin, it makes me bleed… Morphine makes me really sleepy…” Well I thought I had heard it all until today, Pt just told me: “I’m allergic to all mammal meat…”

[internal dialogue]

Hmm, well, maybe you’re just allergic to myoglobin, in which case you should just fucking explode… Dude, you’re fucking MADE of mammal meat… WTF!?!

Oh, and too bad, I’m sorry you’re having an anaphylactic reaction but all I can do is give you this epinephrine but you’re fucking allergic to that too…

the last rodeo

During the two weeks that have elapsed since I last published a word, I have opened a browser, selected new post and sat in front of a white screen for more hours then I can count. Invariably some distraction would arrise, someone to chat with, a phone call, some weak-minded reason or compulsion to open a new window and survey the same tiny corner of the interweb I seem drawn to; and after the perusal of some half-dozen job sites, news outlets, banks I owe money to and gear and clothing vendors I give up on the whole enterprise.

Perhaps a soul possessed by loftier ideals, someone less prosaic might wax poetically about cackling seabirds, about wayward souls whom dimly toil, drink and while away the days here on Midway, or about the passage of time and the human footprint being steadily eroded like this ancient atoll itself into the sea.

But that’s not me, in fact I’m at my wits end. I can officially state that the count down has begun, 25 days until I relinquish my post and return the reins to my predecessor. I have been asked repeatedly by both my current employer and the island residents if I will be returning for another rotation and I have given a polite yet firm no. While I am pleased to have left a favorable impression and hope that I have represented the company and my profession well I will not be back.

The feathery denizens may launch their careers as great pelagic aviators on this desolate island, but for men it is a place for careers to end rather than to begin. There is no need, no desire I can fulfill nor benefit I can reap professionally or personally by further tenure as the perfunctory medical authority here on Midway.

I have enjoyed my experience here, to a point, and will certainly take away those lessons learned, but I would be delusional to think that additional learning could occur in this environment, rather I expect only further frustration, which I will gladly cede.

As I wind down my stint, begin packing my bags, already thinking of home and the next adventure, there still remains the possibility of crisis or the next melee. As the motliest crew of roughnecks I have yet to see here stepped off the plane only last week and the visitors continue to arrive twice weekly, eighteen at a time, the stage is set for catastrophe.

I’ll keep you posted.

birds of a feather

Yesterday was a drag. Beyond my Sunday ritual, in which coffee is enjoyed with eight panels of Doonesbury, instead of the usual four, of course to the prerequisite Donald and Walter soundtrack, the day was generally a bust. It also marked the mid-point of my three months out here on Midway, a cause for celebration to be sure and perhaps also reflection.

Up until today my end date here still was uncertain due to available space on the chartered G2; it takes coordinating my relieving PA on an available inbound and a vacant seat on the same aircraft outbound as we tend to spin the flights in about 45 minutes. When I came on island in December, I had enough time to count controlled meds with the outbound PA and get handed the keys before driving her back to the waiting plane, the pilot already warming the turbines. I look forward to being on the other end of that transaction, the date had been pushed around allover the month of March and now it looks like we are back to the original date of March 15th, making it a twelve week rotation exactly.

Midway is an unusual place, perhaps unique in some respects, but just your typical remote posting in others. There is of course the history, which for the most part isn’t really alive anymore, what visible features remain are quickly being reclaimed by time and the elements; and there is the wildlife, which is fascinating not only biologically but also in it’s interplay with humans, human policy and politics. It’s strange how this place, which will eventual descend beneath the waves as it moves slowly northward, is in this time so important and worth fighting for. As it does move into colder waters, by an approximate rate of some five to ten centimeters per year, the coral deposition will eventually be unable to keep up with erosion and the island will be no more and if in those intercedent few million years the birds have outlived us, perhaps in part because of our stewardship, they’ll just have to find some other place to go.

Well at this time there are people and at least a few government agencies at odds as to the usage and future of Midway, it seems that this tiny spit of sand is a refuge for more then birds and seals. As I put my sixth week behind me, thinking of what I am missing and what I am in want of (I could really use some real beer and real cheese), I can’t imagine the circumstances or internal circuitry that would compel someone to spend ten years out here.

A brief accounting of my fellow castaways might shed some light. There are of course the Thai for whom this is a desirable position, I’m told. At least they must make a higher wage than the Sri Lankans whom they replaced, I’ve heard their predecessors were paid one dollar an hour. Then there are those whom have been shipwrecked by life and for whatever reason: personal, professional or legal prefer life out here in self-imposed exile to whatever they fled on the mainland. Honestly, I can’t see this place leading to career advancement any more than being the captain of a sinking ship. The volunteers are short timers like myself and for the most part are bird obsessed, but in either case here for the experience and then they’ll move on. There are, surprisingly, a few who return almost as reliably as the albatross not due to instinct but because of some personal attachment or perception of beauty not unlike a child might have for a sandcastle or a mudpie. Their maternal devotion is laudable, I guess Ms Lennox is right, everybody is looking for something.

In an interesting twist of fate and politics (and I so try to keep politics out of it) the W. did, in 2006, incorporate this place into the largest National Marine Monument under U.S. jurisdiction, while at the same time declaring the absolute necessity of drilling in the Arctic National Wildlife Refuge. Now maybe, I’m biased because this is rocknicepac and not Beach Blanket Bingo, or because perhaps I place greater stock in caribou than seabirds, but damn it I was brought up to Never Cry Wolf not Finding Nemo.

Midway is the most expensive wildlife refuge managed by the Department of the Interior and perhaps the least visited outside of Alaska. It’s expensive not because of the protection or restoration measures in place, but rather because it is also an FAA ETOPS runway. ETOPS stands for extended operations, the ETOPS rule allows civillian twin-engine aircraft to fly long-distance routes previously reserved for four-engine airframes. It provides a safety margin during, for instance, trans-Pacific flights should an aircraft lose an engine. Obviously there aren’t many suitable locations for an ETOPS airstrip in the middle of the North Pacific, short of building one that floats. The FAA as well as companies like Boeing, who manufacture large twin-engine civillian airliners capable of intercontinental flight, have a vested interest in keeping Henderson Field, or PMDY, open.

But that seems to be directly at odds with the mission of Fish and Wildlife since an unscheduled emergency landing here would endanger hundreds of birds. Needless to say bird strikes bring down aircraft, thus endangering the lives of people.

For this very reason all scheduled air traffic on Midway, November through June, is conducted at night. There are too many birds on the runway and in the air, multiple bird strikes are guaranteed. The last comercial emergency landing was a Delta 747-400 on June 16, 2011, which fortunately landed safely after striking at least two birds causing flap damage, there were 378 people on board.

It seems then there is both a symbiosis and a gamble taking place, both on the part of Fish and Wildlife and the FAA. The FWS gets FAA money to help maintain the air facilities, the FAA and the aerospace industry get their ETOPS airstrip and everybody hopes nobody needs to make an emergency landing during bird season.

 

the trust issue

A wise man, not book smart but a wise man none the less, once told me “when in doubt, throttle…” It’s been a while since I’ve posted anything with any substance, so I figure at this juncture it couldn’t hurt to go straight off the deep end.

Here’s my hypothesis on human relations, hell, make it all animal relations, you could bring the plant kingdom into it but you’d just be anthropomorphizing and quite frankly, that’s way too peanut allergy, vegan, kumbaya for me (remember that rant I promised you?)

“Back-off man, I’m a scientist.”

So, unifying hypothesis, right, I include animals because they have an inherent nature. Please, don’t imagine I am suggesting that they experience human, big brained, cuddly feelings. What I am implying is fundamental to any organism capable of making choices, regardless if those choices are cognizant in the manner we are accustom; what I am implying is that those choices are based on trust.

Recently an article appeared in the New York Times declaring that disgust was the new phenom emotion. Disgust, it seems, has captured the hearts of a number of burgeoning social scientists whom regard it as the long lost, red-headed stepchild emotion. Though neglected for ages in favor of fear and anger, disgust finally seems to be sharing the limelight.

They propose that disgust is an adaptation that protects us from hazards in the environment, whether they be lack of sanitation or inbreeding. I just have to guffaw, I mean who couldn’t spout endless examples to the contrary and only out of tonight’s primetime newscast.

I’m willing to raise the ante. While I’ve witnessed disgust and I’ve even been grossed out myself, I sincerely doubt disgust has a significant evolutionary impact. Let’s ignore outliers, simply google the most disgusting thing you can imagine and I guarantee there is a porn site devoted to it. If there isn’t I seriously suggest you invoke rule #37 of the internet, claim that url and consider yourself retired.

Back to the topic at hand: I was, if I’m not mistaken attempting to single handedly debunk disgust and trump trust as the most evolutionarily (read socially) important emotion. Now, I’m being honest here, this type of discourse could span careers, but for the purposes of this blog, there is too much, I sum up.

Trust is binary, while disgust is a spectrum. You have trust or you don’t, disgust is something you grow out of. Once girls had cooties, now they don’t. Once sex, vaginal, oral, anal was gross, now it’s not. Once your enemy was an equal, now he is a subhuman and to be defiled. Five-second rule, flush with your foot, we all have standards we are willing to cross when the odds are in our favor, but, trust is win or lose, you have it or you don’t. Man, woman. Parent, child. Candidate, constituent. Brother. Friend. People make the most significant mistakes of their relationships, careers and lives, based on false trust. People place their bodies and reputations in harms way daily while repeating the talisman: he really loves me, he wouldn’t hurt me, it’s for my own good, I trust… and often at a substantial loss.

This same principle applied to an animal model: the Laysan albatross for instance, demonstrates the same tendencies. You seem reliable, you come back, you are a provider, I will breed with you is a clear manifestation of trust. While the hen standing on the neck of her expired chick or the juvenile feasting from the decomposing gullet of a deceased neighbor seems to invalidate disgust.

At this point I would forgive you for imagining I was speaking of distrust, as if I had been wronged , harmed and lying wounded. On the contrary trust can be empowering, like nothing else I’ve ever known. Whether faith in a woman or a solid anchor beneath your feet on a necky lead , though I would never confuse the two even if either can lead to your peril. Trust is magical, it requires a faith to be realized and once that faith is lost. like a childhood superpower, it is lost forever.

rule #18 – limber up

Nine posts, I’m not even counting the last two, all as different from the last as from the first, not by design but by mere happenstance. Playful, serious, informative, autobiographical, factual. Perhaps those who know me a little better and recognize the economy of words are surprised at the absence of a rant, don’t fret it’s coming.

I’ve consciously held back that inevitable feature and with good reason, I might not stop, there is so much to rant about I’m not sure how any of us communicate otherwise. But, I did not choose this exercise to relate a laundry list of complaints and grievances, at least with out the application of some reason and critical thinking.

Honestly, remember a few posts back when I said the holidays had interrupted my burgeoning “routine”? Well, this was part of that routine and while I found the exercise at first stimulating; it provided me food for thought and subsequent prose, however the hiccup seems to have cascaded or reverberated into this place.

The initial collision of my less then proactive lifestyle with the new need to set my own schedule and short-term goals here on the island was enough to provide a few posts. Now the inevitable disruption has resulted in a latency period in which I seem refractory to the stimulus of thought; or at least interpreting that thought into a usable internal dialogue which would be acceptable, or even comprehensible, to anybody not inhabiting my skull. And no, I have not gone mad, thank you. More to come stay tuned.

refuse to just lie there and bleed

I swore, I swore, I swore tonight would be the night that I would get something up here. After a couple of false starts over the past two weeks and it’s time I cowboyed-up and hit the publish button.

I just read over the unhatched inklings that were my last two posts, having never grown more then a few measly sentences they’re headed for the dust bin. The language seemed dated and the point, well there wasn’t any, so rubbish it is!

I can’t explain the flurry of activity, on my part, followed by nothing, I guess as in medicine and in keeping with the subtitle of this blog “it’s multifactorial”. I’ve been distracted, for sure, but that isn’t even the start of it. I’ve been processing a lot and working through some tough choices, or at least the melancholy that accompanies not making them.

In part I’m wondering what next, too in part I’m wondering what can I do presently to improve myself moving forward, while at the same time I’m trying not to get lost in the ferment and actually live for today. Whether it be my impulsiveness or my sense of mischief, one or the other seems set against the former two. Compound this with the abstraction I make when I look at an assemblage of words, produced by me, and find it less interesting then the most passive observer might and you get the general picture.

Or, maybe I’m just stalling.