I have a friend who will be beginning PA school this year, this is something I wrote for the incoming class as a second year PA student having just completed my didactic year.

When we were in your shoes, just one year ago, we met a second year class that seemed refreshed, excited and energized, and more than a few of us probably thought: the first year of PA school is supposed to be hell, right, the hardest thing anyone of us has ever undertaken? These guys look great! How bad could it be? What we failed to realize is that their exuberance was less an expression of what lies ahead but more a sense of relief and accomplishment.

So before we lull you into a false sense of security with our calm and easy demeanors we want to tell you, while it’s still fresh in our minds, that no part of what you are undertaling is going to be easy. It is hard as nails but we, every class before us and 60 000 practicing PAs are proof that it is not impossible either.

Each of you are here for a single reason as individual as you are, it is that reason, that trait, whatever it may be that you expressed on your CASPA, confirmed during your interview and admission committees recognized as what it takes to succeed as a PA. That reason is not because you want to practice medicine, there are plenty of people who want to practice medicine; it is not because of your transcript, no matter what your GPA there is someone out there with a higher one and if you had a 4.0 then there is someone who has more credit hours then you; it is not because you have 10 000 hours of health care experience, hit the reset button because it has no bearing here; it isn’t even because you want to be PAs, because most people who fill out a CASPA never even get an interview.

Make no mistake, whatever it is, that characteristic is what got you here and more importantly it is what will get you through the first year. Some of you are strong students, some of you have thousands of hours of healthcare experience, some of you are tenacious survivors, some are unflappable, some are type-A and some have sheer willpower, focus or resolve, it doesn’t matter. There is going to be a wall, you’re all going to hit it and it is that quality you possess that is going to get you over it.

You are becoming one of a select few, unique is a hard word to justify but we are unique, we are given the privilege of practicing medicine without attending medical school. We are bestowed with the trust of our patients, our supervising physicians and our nurses and staff.

So damn straight it’s hard to become a PA, it has to be, all of you will be charged not only to uphold the prestige of a very young profession but the responsibility for the care of other human beings; to help heal them, to ease their suffering and to help them die with dignity.

You are all going to overcome this challenge, over the next year you are going to devour and digest an absurd amount of information. You are going to suffer and rejoice and when it’s all over you will be standing here lulling next year’s class into a false sense of security.



Being located at 177°22’W longitude and thus about 140 miles from the International Date Line I with the other inhabitants of Midway were some of the last people on Earth to ring in the New year. You just can’t get much further west and still be standing on dry land. Even Samoa, this year, jumped into the future by skipping Friday and joining their trading partners on the other side of the IDL. So there you go, no matter which way you go when you leave Midway you lose time, and that’s what this place is, lost in time.

You may have noticed by my photos that the birds really do rule here, much the way they have done for eons, before the arrival of westernized man, before the arrival of early polynesians; all of us of course being aficionados of the multitudinous fowl, for the table, for their feathers, for the albumin in their eggs. If we ourselves found the creatures unpalatable or unusable our traveling mammalian friends certainly didn’t waste the opportunity, rats and pigs made short work of whatever avian appetizer they could get hold of.

These islands are so remote that there are no native mammals, unless you count monk seals and dolphins. But the birds don’t seem to hold a grude, maybe it’s the Auld Lang Syne. In any case the placid and naive creatures will let you get as close as you please, of course there is often a lot of clacking (their complaining) and I treat the more then occasional bird nip, but the stay put and are unabashed and unafraid. It’s no wonder so many of their feathered brethren have gone the way of the dodo.

Well speaking of extinct the other photos, and there will be more, are representative of the Navy’s former presence here on Midway. I’m unsure, what amazes me more, the amount of infrastructure which was in place or the degree to which it has been reclaimed by time and the tropics, the sheer scale and ephemeral nature of our leavings, to which we attach such permanence is astounding.

Obviously we alter our environs and our ability to do so is unrivaled in the animal kingdom, but we are not the ultimate power in the universe that in our vanity we imagine ourselves to be, nature will always be waiting patiently to clean up our messes, or sweep them under the rug, which ever you prefer. If Midway is any example, given a little bit of time and the absence of man we and our ruins will be erased. If anything I’m going to side with the late great Gorge Carlin on this one, maybe we are really the penultimate step in evolution, maybe we’re simply here to give the Earth plastic.


“Today is a good day to die…” is said to be the war cry of Crazy Horse, holy man of the Oglala Lakota. If indeed “Hóka-héy, today is a good day to die!” were ever uttered by the great chief, as they may well have been, then at the very least the words have been taken out of context and in that manner have entered the lexicon.

Surely, a warrior must harden his spirt, a leader encourage his men, but no man goes cheerfully to his death. We can only surmise that in the shaman’s own visions, in the rich tapestry and culture of his people he felt a connectedness and a knowledge that death was not an end and to live honorably and without regret is to leave nothing undone when the circle of your life closes.

Today was not a good day to die, because there are no good days to die. Despite this, today I became aware of the closure of three circles of life all far from my tiny island, however close by friendship and bond. While there is no mending the rent in the hearts of those that have lost, perhaps we can take solace in the honorable actions and lives well lived by those we grieve.

pattern recognition

I was having a conversation with the youngest of my brothers, this was years ago; I’m fortunate to have the kind of brothers with whom I have conversations that are generally poignant and memorable or completely forgettable, I don’t know, maybe it’s that way with everyone. Well anyway being my younger brothers, it seems to me when they interject some insight I feel that it is either a perspective I’ve lost, or I skipped over entirely in the race to be a grown-up. That in and of itself is amusing in that I always fancied myself a Peter Pan. But, invariably it’s a race we all run and of course lose in the end; the fact that I was endeavoring to be a grown-up who acts like a kid makes no difference.

So, he and I, were bouldering, or mountain biking, or we had just finished one or the other and were having the obligatory beer afterwards. We were contemplating the afternoon and whatever it was we were or had been doing was something that my brother had only recently been turned on to. Anyway, I guess while discussing the finer points of bunny hopping a log or climbing out an overhang, we decided that I was good at “stuff”, but generally sucked at life, while he was quite the opposite.

That was an amusing notion at the time, and I felt it a great complement in that I could still impart something to my sib, whether it be how to climb harder or ride faster, while he was already embarked on a career, owned real property and had a bank account.

Well, I’m looking back on that revelation and rethinking it or maybe finally realizing the truth behind the words. To be truly good at anything, whether climbing or life takes time and it takes practice, obviously some people are more deft than others just by chance and have a leg up, but that gift only gets you so far, the rest requires effort. I think that’s what my brother was saying, not that he’d ever be able to pull harder then me and really what does it matter, but he was willing to put the work in and develop himself, to make the investment in time and if need be humiliation to do better next time.

Practice at anything had always been antithetical to my whole world view, climbing everyday was different, that was just climbing everyday, it was just something I did because it made me feel good, because it was fluid, because I was good at it. Even my heros, who if anybody I tried to emulate, by reputation subjected themselves to hellacious workout routines to prepare for their projects. Obviously it takes drive and dedication to pursue those kinds of goals, whether they be in your career or in the mountains, and it requires a routine.

So here’s my epiphany, I’ve been here two weeks and was just beginning to get into a routine when the holiday came along and derailed me, and prior to that it felt good, though I hate to admit it. With little distraction and set clinic hours, which is a paradigm shift for an ER provider (though I am on call 24/7 there’s little business) it isn’t that hard to maintain a schedule, of course the set meals probably don’t hurt either.

I’ve always been terrified of routine, to me it seemed like a small death, giving up that spontaneous part of yourself that was ready at a moments notice to breakaway. But, it turns out a constant state of readiness is not obtainable without putting in the work, and I’m going out on a limb here but without some kind of routine life is just a series of accidental experiences.

I’m not throwing in the towel, it’s that I just now recognized or rather accepted my own pattern, my own meta-routine, which is a constant rejection of any routine. I’m choosing to break the pattern.

inclusion criteria

I’d like to follow up on my previous post and my allusion to family. Personally, I entertain several meanings of “family” both as a word and as a group of persons. You may yourself harbor strong feelings as to which is correct and you may very well attach a great deal of significance to that definition and it’s correctness.

As people we tend to be either exclusive or inclusive, in that we, each of us, expresses one or the other as a base tendency, while to the degree it is expressed is often a matter of mood, or sometimes chemical enhancement. Those of us whom are inclusive favor the definition of family as a word which we then use to incorporate a body of individuals with whom we feel a particular kinship. While those of us being of the exclusive variety favor the definition as a group and consider it to represent people with whom we have an inherent, usually ethnic or nationalistic bond. Without ascribing rightness or wrongness to either of these axioms, I merely wish to point out the contrast, the taxonomy of social divergence.

So, in any respect the notion of family becomes important, perhaps a little more so at this time of year and as it applies to men and women whom come together from dissimilar backgrounds yet become a family even more so.

Most of us spent our holidays with the family of our choosing, whether by birth or association. However many, a few whom I count as friends did not have that luxury and unlike yours truly it was not of their own choosing, except in the regard that they chose to be professionals, they chose to be soliders. Does that make those men and women heroes? I think anyone of them would strongly disagree, does it make them more or less human? Maybe, maybe not, but they certainly put the good of others before their own selves and that is commendable. No matter where you stand I don’t think anyone can disagree that in regard to their sacrifice all the politics pale in comparison.

dark > light

It’s an interesting time of the year and I believe we, as a species, are predisposed to it.

I’ll put it this way: I bet at some time in your life you’ve been exposed to one of those nifty little night lights with the electric eye, most likely in a childhood bedroom or at least at gramma’s house, probably in her guest bathroom, the one with the soap shaped like seashells that you weren’t allowed to touch. I’m sure if you close your eyes for a moment and regress into your five-year old self you can remember the fascination of that wondrous eye. You’d place your finger over the convex crystal and marvel as the light came on, remove your finger to watch the light go out; hesitant at first because it looked so much like a real eye, a little more nervous when it seemed to respond to your presence. Of course, now as a grown-up, you are sure of your place in the world and know that it is simply a switch, a photoelectric cell, which merely closes a circuit in the absence of ambient light.

But, take for a moment our own neuro-electric infrastructure, eons of evolution and we are still susceptible to the “thumb over our third eye”. Humans are diurnal creatures by habit and as modern men and women we’re forced to work in caves of steel and glass, often at off hours. By this time of year leaving for and returning from work in the dark and for most of us, unlike our friend the night light, shielding us from the sun does not set off an inner glow. But we do have the advantage of knowing that the days are lengthening again and maybe we’re looking forward to that trip coming up in February when we’ll spend a week in Jackson, or Mammoth, or St Maarten.

Yet still we cling to a Bronze Age convention, a holiday season, pick your flavor, which has become a parody of itself. Culture, like any organism, evolves and in doing so it doesn’t eschew all that came before it; the commonalities remain between extinct and extant, if only as vestigial appendages. Maybe that’s why we get a little gloomy as the days get shorter and less sunlight traverses the retina, over the optic nerve, finally and faintly exciting the suprachiasmatic nuclei and pineal gland setting our internal clock and rhythm. The same analogous structures and pathways we share with all vertebrates. Edison’s lightbulb may have extended the work day but it did not cause these organs to atrophy and die.

So likewise we celebrate, as our neolithic forebears did, the winter solstice. A commonality across the planet, where it was spawned independently by dread of the coming darkness and hope of surviving until the vernal equinox. After being usurped, blended and transmitted by conquering culture after conquering culture it continues in some fashion in every culture across the globe. It survives in part, perhaps unfortunately, beacuse we need a reminder to take time out of our chaotic lives, to sit down for a meal with family and friends, to open that bottle of wine we’ve been saving for no good reason at all and to just be.

twas the night before christmas

Twas the night before Christmas, when all across the atoll,

The PA was roaming, he was out for a stroll.

The volunteer bird counters, had been bandaged with care,

In hopes that tomorrow’s half-day counting they could bear.


The albatross were nestled, all snug in their nests,

While bonin petrels, danced over their heads.

Monk seals on the beach, and sea turtles by the bay,

Had all come ashore, to soak up the evening’s last ray.


I stopped at the clinic, to see if anything was the matter,

Swinging my bright beam, I watched the geckos scatter.

Into the pharmacy, I flew like a flash,

Unlocked the door, and flipped open the latch.


The light on the shelf, cast nary a shadow

There weren’t many meds, a few IV and a few more PO.

When what to my wandering eyes should appear,

A narcotics safe, but inside only nalbuphine, oh dear.


“Now, labetalol! now, lorazepam!, now morphine! now, vasopressin!

On, vecuronium! on, ketamine! on, etomidate! on, nitroglycerin!

Fill up my crash cart and the holes on the wall,

Come on the next flight, come one and come all.


The trauma bay is not state of the art,

But it’s reasonably lit, and there’s a crash cart.

Any patient on this stretcher is a medevac for sure,

Assuming I can keep them alive, with a pharmacy so poor.


I fixed the vent, you see there was a hole in the circuit,

It seems corrugated tubing is tasty, mice like to chew it.

While CPAP would be a luxury, here in this tiny encampment,

With limited O2, a mixed gas vent should be standard equipment.


What here, a working laryngoscope, a mac three and a four,

And ET tubes 5.5-8.0, all arranged in the drawer.

For difficult intubations, a four miller would complete my set,

But wisely this PA brought a his own bougie, to hedge his bet.


Though expired the ET tubes are plenty and still new in their box,

When I found two copper stylets, I was knocked right out off my socks.

It was sure reassuring after finding nothing but flimsy green wire,

I wonder what other surprises I’ll find in this mire.


Moving on to circulation, and for whatever odd reason,

There are TQs galore, and on the NWR there’s no hunting season.

I don’t worry about access even with a difficult stick,

Believe it or not I have an IO and that should do the trick.


The IV pump works great, I gave it a test,

Believe it or not, I have matching drip sets.

First it told me “distal occlusion” and “air in the line”,

But now I can set a rate, and bolus just fine.


For diagnostics there’s a microscope but it needs a torch,

And the X-ray machine I may figure out by March.

There’s tons of old not very useful equipment on the shelf,

And I laughed when I saw it, in spite of myself!


A corneal foreign body presents another fine problem,

Even though I have a Wood’s lamp, and drops to numb them.

You see, the slit lamp has rusted beyond repair,

And the fluoro strips have been ruined, by the sea air.


Most the Americans have Framingham scores greater than 53%

If one busts a plaque, in their widow maker, they’re spent.

There are only two other guys, airport firefighters to be sure,

Who would grab an AED, when that coronary hits the floor.


I have a 4×4 Mule, outfitted in all of the latest antiquated kit,

She’s stubborn to start, she’ll sputter and spit.

I might get there in time, but then to transport a patient,

There’s a van marked ambulance, but it’s derelict and vacant.


Lucky for all I plan for just such a contingency,

And minus the drugs, have all I need for the A,B and C.

Just remember this tale, next time you try to pack light.

“Happy Christmas to all, and to all a good-night!”