At the opera

In my past life as a musician I've spent a lot of time in theaters -- I've done my time onstage, backstage, in the orchestra pit, and behind the scenes. However, last weekend I had a chance to see a new aspect of theatrical life. One of the faculty in our program is house doctor at the San Francisco Opera, and he took me along to house call for La Boheme. We hung out in the actor's lounge ready to deal with any sore throats, sprained wrists, or broken ankles that might arise. Fortunately it was a quiet performance, medically speaking, but it was also a nice reminder of the diverse sort of opportunities available in emergency medicine.

Tower of power

Like many fans of the Bay Area, I've had a long-time fascination with Sutro Tower, the huge structure perched on Mount Sutro and visible from most parts of the city. With some free time one afternoon a while back I finally did something I've wanted to do for a long time: climbing up to the darned thing. Turns out you can walk right up to the fence at the base. Here's the proof:

Life imitates blog

Last night Lady M and I went to a party. As we walked in, someone shouted "it's Lady M!" Now the thing is, the only place she's ever been called that is in this humble blog. Which means this online ephemera is having a bit of influence on the real world. I guess I'd better be careful what I call people.

From the Grand Canyon to the mean streets

Commenter Tom B was my Grand Canyon guru. He taught me the basics of hiking and foot care when facing a mile-high climb with minimal water, and yes, that background came in very useful during Friday's Wilderness Medicine Adventure Race. Fortunately we never had to make use of trauma management skills on any of our hikes together. He sends a link to this Grand Canyon Hikers thread with his response. The poem at the top is uncredited, but Tom's inimitable style shines through. ("Advice given here is not guaranteed. / Before you go a hikin' and wind up birdfeed....")

Finally, I nearly had a chance to put all this training to use just last night. It was a beautiful evening and Lady M and I were eating dinner outside at a downtown restaurant when a guy went past on a motorcycle. Once he was down the street, out of sight, we heard "screech" and then "crash." Lady M looked at me and mouthed "go!" and I ran over to the scene. On the way there I was wondering "will I need to start CPR? splint a leg? needle a chest?" As it turned out, the dude was already walking his bike to the curb, having sustained only minor ego lacerations and pride contusions. But it was nice to feel that if there had been a serious situation I might have been able to help. Eager to help, in fact. Maybe I have learned something in medical school after all.

The best day of medical school ever

Yesterday the med students and ER interns met at a state park on the shores of a lake. It was a lovely summer day, not too hot or humid (something we were very grateful for by the end of the day). We started off with a brief talk on wilderness medicine. One of the topics was how important duct tape is. The speaker said that part of the fun would be seeing how we would improvise with it during the exercises, but there wasn’t time to give the lecture on "formal" uses of duct tape. Looking forward to hearing that one someday.

We split up into groups of four and spent the afternoon running, biking, canoeing, and otherwise making our way from one checkpoint to another. At each checkpoint we had a medical emergency to manage, overseen by one of the instructors. At some stations one of the team would get a card with instructions on being the victim. They also brought one of the CPR simulator manikins. My team ("The Intubators") was all young guys--in fact, I was the only member of the group older than the average age of the group. So I wound up really having to push it to keep up with the young 'uns. And it was a race, so we had to make time both getting to the stations and efficiently managing the crises.

We started off running to where the bikes were, and before we even got there one of our group got "disoriented" and "belligerent" and had to stop. The director of the residency program was standing there with a clipboard to see how we managed heat stroke. Then we got on the bikes for a five-mile ride interrupted by a bow hunting accident (yes, as we pulled up the paramedic handed one of us an arrow!) and a broken shoulder/arm. We used our multipurpose tool to perform a thoracostomy on the arrow victim, then made a one-way flutter valve out of duct tape for the wound. We also used much duct tape over the course of the day for splints.

As soon as we got off the bikes we had to deal with a woman who had been run over by an SUV in the parking lot. By this time we were starting to feel the pain, and it was getting a bit harder to focus on proper medical management. Which was the point, of course. The woman died, unfortunately, but there was no time to linger--we had to run down to the beach to deal with a diving accident. The victim was floating face down in the water with a possible C-spine injury.

After getting the diver to shore on a back board we had to cross the lake with two guys in a canoe and two in a paddleboat (because you never know what you'll have available in a real emergency). Turns out it's very frustrating trying to cross a lake in a paddleboat when you're in a race--they're maddeningly slow. On the other side we came across a dramatic scene. The instructors said that a sudden storm had come up. There was a flash of lightning and two young boys were lying on the ground up the road, one of them not breathing. We ran over, making our plan for two-man teams, but when we got there we found a third victim behind a tree. The victims were played by the sons of one of the people in the department and they did a great job. The boys had a great time as we performed "CPR" and splinted them.

We had to bushwhack up a hill to the next scene. At the top we dealt with a broken leg. We had to splint it and then carry the guy 100 yards. Unfortunately the chosen victim in this scenario was the biggest guy on our team. Finally we ran back down the hill, got back in the boats (we didn't have a proper place to land and had to lower the canoe four feet into the water, during which the canoe tipped and dumped me in the lake), and crossed the lake back to the finish line.

When we got back there was food and beer, and then they read the results. Each of the six teams' times were announced, along with penalties (such as 2 minutes added for making a mistake in managing a trauma). We came in second place (six minutes out of first place--if we hadn't tipped the canoe we would have won!). There were also awards for things like Best Splint. I got a best acting award for my portrayal of a clavicle and humerus fracture. Everyone agreed that this had pretty much been the best day of medical school for all involved.

Survivor: Final Exam Edition

Tomorrow is the last day of the emergency medicine elective that has occupied me for the last four weeks. It's been a wonderfully educational and colorful month and has certainly piqued my interest in the field. Usually clinical experiences like this end with a final exam, often a quite difficult one. However, there's no final exam this time!

So does that mean that we're off the hook? No, medical students are NEVER off the hook. Allow me to quote, verbatim, the e-mail from the course director regarding our activity for the last day of class:

Just a brief note about Fri. We’re planning on starting at 11 am at the beach lodge at ________ State Park. I thought about requiring you to bring the classic “10 Essentials for Surviving in the Wilderness” http://seattlepi.nwsource.com/getaways/216076_essentials17.html , but thought that was too hokey. Required equipment for each participant will be 1) Drinking water, 2) Bandana, 3) 4 Safety pins, 4) Sunscreen 5) 25 yards of duct tape, 6) Clothes that can get really wet and dirty (a change of clothes isn’t a bad idea either). Each team should have a compass and a multipurpose tool- let me know if you need to borrow one. You’ll get a course map and race rules once you are there. Disciplines may include running, biking, swimming, canoeing, improvising, and sweating. I’ll have some food and beverages for dinner, but you may want to bring something for snacks and/or eat ahead of time.

See you at 7 am tomorrow.

Of course, I'll take this over an exam any day of the week.

Jaws of Life

To help us learn about what happens to patients before they arrive in the Emergency Department, on Monday our group of med students and interns went to the city's firefighter training center. And, boy, was it cool! We started off learning the basics about the lingo and equipment of firefighting and rescue, which was fascinating enough. But then it was time for us to do a mini version of the training that the firefighters undergo themselves.

It started off in the SCBA (Self-Contained Breathing Apparatus) Confidence Course. This is a custom-built second story loft in a vehicle barn. It's about 50 feet square and only about five feet high inside (so you can't stand up straight). The interior is a maze of low plywood walls, gates, rooms with furniture, and all sorts of obstacles such as large plastic tubes and tangles of wires. And once the door is closed, there's no light. Several manikins representing fire victims were pre-positioned in hard-to-find places (under chairs, behind obstacles). We then divided into groups of three. Each group had to crawl through this maze in the dark, locate the victims, and carry them back to the starting point. And, since structural conditions in a burning building are constantly changing, the instructors latch and unlatch plywood gates behind the teams--in other words, you can't get back the way you went in. Best of all, the instructors brought out the infrared scope, so those of us waiting for our turn could watch the ghostly thermal images of our colleagues stumbling through this maze. (Eerily, the scope shows the reflection of each person's heat in the corrugated metal roof.) It was very hot, and we had the luxury of wearing summer clothes; the real training is done in full protective gear with oxygen tanks. And, of course, the building wasn't really on fire. The point of this is to keep trainees' nerve up when facing a dark, unfamiliar environment, as well as to practice getting around in the dark in a complicated space.

Next, it was into the Buckman Box. This is a custom-built wooden structure measuring about 40 x 30 x 20 feet. It features ceiling/floor platforms that are hinged so that their angle can be changed, and doorframes that are not square--again, this is to simulate conditions in a building that has lost its structural integrity. Basically, you climb through an 18-inch hole up a six-foot, 45-degree ramp to get into the box. Inside it's a three-dimensional maze of sudden sloping dropoffs, ladders into attic spaces, dead-end crawlspaces, and other obstacles. All of this is done on hands and knees or crawling on your stomach. And all in the dark, natch. In fact, there are several paths through the box and you might come out any one of several exit points. Half a dozen of us would crawl in at a time and then gradually emerge from various holes.

Finally we were taken outside to a row of junked cars. Yes, it was time for the vehicle extrication exercise! We suited up in helmets and protective gear and then went through the process of stabilizing a vehicle and opening it up to remove trapped drivers and passengers. We got to use the hydraulic rescue tools, including cutters and spreaders. They taught us some of the finer points of shattering tempered glass, popping car doors out of their frames, cutting through window posts, and pulling up dashboards to get trapped legs out. It was fantastic! And we got an added dose of realism, because while we were out there it started to rain. And then started raining hard, in sheets. And then the lightning started. All the while we're taking hydraulic and electric tools to large chunks of metal. As the instructors pointed out, conditions in the field can get a lot worse than that. But it was still an impressive storm; this one wound up spawning two tornadoes.

Truly one of the most memorable days of medical school.

Why does Ben-Bob wear red suspenders?

What with all the tornado action yesterday evening I didn't even get to describe the day's main event. I've got an ER shift tonight (and then I've got to read and analyze some journal articles a for a public group debate at school) so I'll have to write about it later. Until then, suffice it to say that the day involved wearing a firefighter's helmet....