The Thrill of Flying with Helicopter Paramedics

Last week I had a lifelong dream come true: I lined up the chance to shadow with a helicopter paramedic crew.

Today, the day finally came, and on the drive there my heart was racing. It was a gorgeous, clear day - perfect for flying.

Throughout the day I saw so many exciting things that I don't even know where to start. Well, I'll start with the unexciting things - two coffee shops, a Subway for lunch, and a bunch of errands around the station.

And...well, actually, that was it.

For the first time in over a year, none of the helicopters even left the ground. I sat around in the station for the entire twelve-hour shift, waiting for a call.

That picture? Not one that I took. I didn't even touch a stretcher today. I prayed for disaster, death, and carnage all day, and God wasn't listening.

At one point we got called to the tarmac to help lift an infant incubator into an airplane. Apparently a few years ago, some weak paramedic threw a kink in his back trying to lift the box and its 8lb 4 oz contents, so now they have a policy that they must call a second ambulance crew to help load it in. That was the most exciting part of the day.

Other than that, I sat around and read homework and napped all day.

Not what I was expecting.

I'll sign up for another ridealong. Maybe then I'll have some good stories.

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Pimped, finally.

Unlike the impression you may have gotten from reading this blog, not everything in med school is rosy and wonderful.

I've finally had one of the dreaded 'pimping' experiences that I've heard so much about.

For those of you who don't know what 'pimping' is, it refers to the age-old practice in medicine where a medical professional will ask a difficult question of someone lower on the medical education pecking order than themselves. From what I've learned, the pecking order goes something like this: chief of medicine > department chief > attending > fellow > resident > intern (archaic term for a first-year resident) > clerk (third or fourth-year medical student) > medical student > pre-med volunteer. The pre-meds have nobody to pick on. Some of them try to pick on nurses. They don't go far, rightly so.

The smarter docs know that nurses transcend the pecking order... after all, who do you think knows more about emergency medicine, the resident in his second year of an ER residency, or the underappreciated traige nurse who has worked in that ER for thirty-five years? Again, you get it. Kids, respect your nurses.

True 'pimping' relies on the art of progressively difficult questions: if you get a question right, then you will be asked a harder question; if you get that one right, then you will be asked yet a harder question, on and on until you answer one wrong and look like a fool. Pimping. You get it.

Anyways, we are learning about the cardiac examination right now, and we go to clinical skills practice rooms in various hospitals in small groups, and are set up with a tutor, an M.D., who is supposed to train us about the basic cardiac exam.

All is well and good, until we match with this guy, who took it up on himself to drill us like there was no tomorrow. Rather than let us practice on the patient, he simply asked us question after question after question. We all ended up feeling like a bunch of idiots.

Okay, it wasn't too bad the first time. At that point it was actually helpful. You see, I didn't know my stuff when I went in there and the whole time I was thinking, "I should have done the pre-reading." At the time, I didn't even know that he was in actuality asking us stuff way beyond what we had to know for this intro session.

So, knowing that I would have him as my tutor for one more session, I went home and studied. Boy, did I study. I won't make that skip-the-prereading mistake again.

Move ahead to week two. He quickly realized that since last time, we'd all studied, and knew our stuff. Fair enough. However, rather than follow his instructions which probably said something like "Teach these young 'uns the basic steps of the basic cardiology physical examination," he decided to get intimidated.

So, he started asking us progressively difficult questions about the material. Once he realized we knew all those answers, he started talking about things that people only learn in fourth year or cardiology residencies. Or, better still, he'd ask an ambiguous question, then feel happy when we got it wrong...strictly because we couldn't understand what he was getting at.
It began right near the start of the 2-hour session. "Vitum, what is pulsus paradoxus?" he asked, reading off my name tag. Question 1.

He picked the wrong guy to ask about Latin phrases. Apparently he doesn't know I take a fancy to them.

"Latin for paradoxical pulse," I replied, feeling brilliant (shut up, I know it's an easy one). "Refers to the difference between systolic blood pressure between inspiration and expiration."
I was unfazed. So was he.

Dr: "How does it change with breathing?"

Question 2. Serial questions. I could see he was pimping. I was game. I had studied this.

Me: "The systolic pressure increases with expiration, and decreases with inspiration."

Dr: "What's the normal difference?"

Question 3.

Me: "If the difference between inspiration and expiration exceeds the normal physiological variable range of approximately ten milimeters of mercury, the pulsus paradoxus is considered abnormal."

Dr: "What major condition does it indicate?"

Question 4.

Me: "Cardiac Tamponade."

At this point I was pretty glad I had studied for this. It was in our notes. Still fair game. He was getting a little agitated that I knew the answers but wasn't going to let it show.

Dr: "What is cardiac tamponade?"

Question 5.

Me: "When blood fills the pericardial space."

Dr: "What does result in?"

Question 6.

Me: "Difficulty for the heart to contract?" I was starting to feel a little unsure.

His face lit up like he had chanced upon a dancing leprechaun in a forest.

"Actually, that is wrong. When there is cardiac tamponade, it becomes difficult for the heart to relax."

Dammit. I knew that. This two-hour session was starting to feel like a whole day.

Still, he wouldn't let up. He had to prove that I was still the student and he was still the teacher, and ask me one more question. One question that was so vague that I couldn't possibly get it right.

Dr: "What is that effect?"

Question 7. I had no idea where he was going. He could be asking about the effect on anything. I asked him to clarify, and he mumbled something that didn't help, so I ventured a guess: "Increased afterload?"

Dr: "Ummm....", he replied, apparently surprised that I knew what afterload was, or never having considered the effect of cardiac tamponade on the afterload of the heart; probably the former. "Uh... no, that's not correct." Dammit, I knew that one too. I should have thought about that a bit more and realized that wasn't the case. I was nervous. I hadn't been pimped before. It wasn't fun anymore.

He went on. "Preload would be decreased. But what I was referring to is the ..." ...and on he went, explaining some advanced pathophysiology of cardiac tamponade, something that we definitely haven't been taught yet and aren't supposed to know in our basic intro to cardiac exam. I tried to understand, but couldn't.

I know what you're thinking. "Doctors should know this stuff." I'm not disagreeing with that; we should learn this stuff. But you see, we aren't supposed to learn it all at once. Our faculty knows that it will be overwhelming to learn everything in first year. That's why they made med school four years.

In fact, they clearly wrote in the course manual for today's session of this clinical skills course, and I quote: "Understanding the reasons for performing cardiac manoeuvres requires an appreciation of the underlying physiology of the manoeuvres and the pathophysiology of the murmurs that they affect" and that this is "beyond the scope" of this first-year course.

Which is why they provide a list of what we do need to know now, and a separate list of what we do need to know by fourth year. Right there in the book. So, when he decides to ask us about Osler's nodes and Janeway lesions, we know we aren't expected to know those things until fourth year. And when he decides to drill us on things like frikkin' leg-elevation and amyl nitrite auscultation maneuvers, we can see right in our book that he's pulling stuff that we don't have to know until a residency in cardiology, let alone before we graduate.

But aside from all that, this guy clearly wasn't asking us questions for our benefit. He was taking pleasure in putting us on the spot and watching us squirm. When, other than in boot camp and in horror stories of medical residency in decades past, is that okay? I doubt that's how Michelangelo learned from his instructor. We probably wouldn't have the Mona Lisa if he did. (I'm just kidding. I know my art history...Leonardo da Caprio panted the Mona Lisa).

I thought about calling this doc out on some stuff that I knew he was doing wrong ("shouldn't we inspect the hands and feet for cardiovascular signs such as clubbing or pitting edema before we look at head and neck and do the jugular venous pressure?"). He probably would have just shot me down.

In fact, he did shoot someone down when she called him out. "Why do we roll someone into the left lateral decubitus position when we auscultate?" he asked. "Mitral stenosis," she answered. "Nope," he replied. "I was referring to aortic stenosis." In disbelief, she double-checked what she had just read in our course manual. Sure enough, it says, "Mitral stenosis is an example of a murmur that is more easily appreciated in the left lateral decubitus position." She didn't bother to try and correct him.

Later on, he told us about "IHSS" and how it stands for Idiopathic Subaortic Hypertrophic Stenosis. Even if that is the proper term for it, his abbreviation letters didn't match up with his term. Idiot. I didn't bother being 'that guy' who says "don't you mean ISHS?"

The worst part was, even though we might have learned something had he talked slower and brought it down to our level, at the end of the day, we never accomplished the single objective of the entire session: practicing on the volunteer patient.

Listen, man, a little constructive criticism: Clearly you know your stuff. We expect that. You're a cardiologist. But, there is no need to show off here. And, don't take it personally when we know the answers to your first-year level questions. Instead of responding by asking us third- and fourth-year level questions that we haven't studied and will just confuse us, maybe try encouraging us.

If you're incapable of doing that, then how about you let us actually practice our skills on the volunteer patient, who has given up their afternoon so we can practice, and which is why we're actually here. They're getting bored of laying there and listening to you lecture, too.

Oh, and P.S. - the big yellow letters that say "Roll Up the Rim Contest" on your coffee cup mean that you should roll up the rim before you discard it on the counter. I rolled it up after you left and won a prize.

Boo-yeah. I feel better now.

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Ever since he was a little boy...

This kid would eventually grow up to brave the competitive pre-med scene, apply to medical school, and get in and become a doctor. He's in my class.

Is that cool, or what??

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Check one more thing off my 'can't wait to learn' list.

This picture means different things to different people.

To those who haven't been trained in EKG, well, it's how I used to see it as recently as a week ago: a squiggly line on a paper. I knew it resembled a heartbeat. That was it.

Now, though, it is a different story.

I can tell if an EKG suggests that a patient has had lack of blood flow to the heart, heart damage, poor conduction of the heartbeat signal, enlarged heart size in response to disease, electrical axis deviation, and the basics like pathologic rate or odd rhythm.

Here's a nerdy admission: Learning how to read EKGs has been a dream of mine since I first saw a doc read one in the ER. A nurse went up to him and asked, "Is this normal?" I couldn't tell, but in half a glance the doc said "No." I was blown away. How could someone know so quickly? Now, though, having received preliminary training in EKGs, I could probably tell too.

Reading EKGs, I've found, is a lot like doing well at organic chemistry. Learn the language and the principles, and apply them to real-life situations, and you can figure anything out. Especially important because we were warned by the resident teaching us, "All of these examples are computer-generated textbook examples. None of the EKGs on the ward will look similar to these, so knowing the principles is important for interpretation."

Check off one more thing from the list of things I looked forward to learning in med school.

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Everything had been routine...until Judith's phone rang.

Judith* made a living out of being even-keeled. As a counsellor, she was used to being in control, and not acting surprised when even the most shocking things were said. Nothing ever fazed her.

She took care of herself, too. She was always prim and proper, well dressed, and looked great – she was turning sixty in a month, and looked ten years younger. Looks mattered to her, and to her clients. She always looked in control, and she always was in control.

But right now, she was losing control.

Everything about last week’s appointment had been routine. The doctor’s visit before, the casual mention that ‘you know, we might as well get a mammogram,’ not putting on deodorant that morning, the trip to the cancer centre, the damned squeezing of her breasts as if the technician was making some sort of compressed breast sandwich using plastic bread, and the expectation of a letter about a week later saying that everything was fine. Judith had been through it a dozen times.

Everything had been routine, except the letter never came. She got a phone call, instead. Confusion, instead.

“You need to schedule an appointment with your family doctor.”

She pushed away the feeling of fear that began coming out of nowhere. “It’s nothing,” she said out loud to herself. But she was having trouble convincing herself.

After three days of a million thoughts, all ending in ‘Cancer?’ here she was in the doctor’s office, listening to him describing the results in medicalese.

“Calcifications… anomaly… zone one…. abnormal…” More confusion.

Her heartbeat was pounding in her head. She realized that she had started fidgeting with her watch, her fingertips were getting sweaty, and now she was swinging her legs over the end of the bed.

She looked like a scared little girl.

She never showed any sign of losing composure, and yet now, she was losing it. Even worse, she was showing it.

The doctor stopped talking for a moment. Then, he placed a hand on her knee.

“Judith, you always have a heart for everybody.

“But right now, you need to have a heart for yourself.”

He was right, and she knew it. She had suppressed her emotions for years, out of necessity. In her work, she had distanced herself from her feelings for the benefit of her clients. Now she couldn’t even tell what her own feelings were.

When he said that, though, she started to feel again, just a little bit.

She began to cry. She cried for the first time in years, right there in the doctor’s office, right in front of the doctor.

As the doctor finished his paperwork, she tried to understand what would happen next. There was nothing conclusive from the results, so she would have to go for more tests. Something about a focused scan, higher resolution, more radiographs.

As she wiped her tears away, the question marks in her mind didn’t go away. She still didn’t know if things would be okay. She wouldn’t know for a while if she even had anything to feel worried about.

But she was feeling again.

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Question for Vitum: Should I take a MCAT course?

Despite the narrow topic of this post, hopefully it will be entertaining for those of my readers not even considering medicine, due to my random attempts at humourous comments throughout. Those who have taken the MCAT, well, post a comment with your experience.

Every so often I get a question from pre-med students, and here's another one. I've gotten it a few times, so in a combination of laziness (I don't want to have to repeat myself 100 times) and desperation for attention (by directing the asker here instead of e-mailing him back, this will get my blog 1 more hit) I figured I'd post my standard answer here, with aforementioned random attempts at humourous comments throughout.

Q: Should I take an MCAT review course?
- Scotty, my very capable pre-med buddy. I'm rooting for ya.

Ohhhhh the dreaded M-word. I hated the MCAT and am exceedingly glad that it is behind me. In the spirit of the cliché that putting together a medical school application is like a several-year process of 'jumping through the hoops' (GPA, reference letters, application, interview, extracurriculars, volunteering, additional items to make the application well-rounded)... the MCAT is one of the higher, slightly more intensely flaming hoops. I would much rather take a five-second polar bear swim in dilute hydrochloric acid and succumb to a quantity of international scorn and jeers such as Bush goes through in a day, then repeat that ordeal of studying, preparing, writing, waiting and waiting for results, and going through dehydration from my three-week-long cry session when my marks did arrive. (I didn't do that bad, actually, so I only had to take it once. Praise Allah.)

A bit of background, first. For those who aren't aware, companies such as Princeton Review and Kaplan have a business plan stemming from the incredibly brilliant idea that someone had one day: "I bet people pursuing their life dreams and ambitions would pay money for help." In that spirit of taking advantage of the vulnerable, they charge exorbiant amounts of money to help people who will do virtually anything to 'get in.'
(For those who really aren't aware, the MCAT stands for the 'Medical College Admissions Test' and is an 8-hour ordeal, usually preceeded by months of studying, testing your knowledge in general biology, chemistry, physics, organic chemistry, essay writing skills, and reading comprehension.)

Actually, test prep companies are not as bad as I just made them sound. Their courses are based on years of experience, they can indeed prepare you well, and in fact, on their websites they also have a lot of really good, free resources for admisison to many professions, which might give you an idea of what the application process is like or if it's right for you. For example, thanks to them, just now I was able to learn in 30 seconds that unlike the MCAT for med schools, for many law schools, an applicant's LSAT score accounts for over 50% of the admissions decision. There you go: something I didn't know before, but will be useful should I come to a career crisis in 2 or 20 years (unlikely. I'm happy where I am). The more you know.

So, my answer? Well, here's the short answer: In general, I'd recommend it and I'm glad I took one. But, it is expensive, so it depends.

That ambiguous response is unfortunately the best I can offer. Everything here on in will be basically serve to reiterate that. Sorry, but unlike scientific questions, there is no absolute, universal answer... okay, that was a little joke for people who are quite aware of the fact that there seem to be rarely any absolutes in scientific research (a hasty example: MedPage tells us that Aspirin is great for your heart by reducing heart attacks; a year later, the same source tells us it's bad for your heart by upping hypertension).

Back to MCAT courses: While I took the course and am glad that I did, whether or not you should take one depends on your personality type. Some people will benefit more than others. Let me explain: here are the reasons you might choose to take one.

Study motivation. Personally, I did take a Kaplan course before studying for the MCAT and felt it benefited me greatly. The general concensus of people in my class - which I agree with - is that a class is very helpful if you have trouble motivating yourself to study regularly. I do best with pressure to meet my study goals, so this aspect really helped for me. As well, if you can choose a course that starts several months before the actual MCAT, and then you'll be getting quality studying done well in advance.

Mock test experience. Second to that, the most valuable part of the course for me was the experience of writing several mock full-length MCATs in a large-group environment, in a huge classroom with a hundred or two other people, just like the real thing was going to be. Because it was full-length it got me in the groove of getting good rest the night before, packing a lunch, getting up early, and getting the timing down complete with breaks and the like. However, this might not be as big an advantage for you because the test is now going to be all online, rather than pen-and-paper like when I took it, so here I'm already dating myself. You might make fun of me for being that old, but hey, at least all my questions matched my passages (an error I've heard actually occured on a computer-based MCAT).

Resources. The question banks that these companies include with their courses are an asset in themselves. You get access to a huge amount of mock questions of varying difficulty just like you'll find on the actual test, which they write themselves based on the AAMC mock questions. In fact, you can imagine how far my jaw dropped when I opened my actual MCAT booklet and saw that the first question was on a topic that I'd seen a few times in the practice tests, with IDENTICAL diagrams (the questions were slightly different, though one or two were identical as well). A moment likes that makes you feel like all that money handed to the test prep company was worth it.

Lectures. As well, if you're someone who learns a lot from lectures, then this will help you out a lot, because they have some decent (and some not-so-decent) lecturers on the major topics. I don't fall into this category, so instead, for me lectures were a good chance to review on my own and distract the serious learners while I chit-chatted with other pre-med applicants and looked up NHL playoff game scores on my cell phone. However, for being someone who doesn't do well in lectures, there were still some outstanding lecturers that I learned a lot from, and in fact, I still refer to the notes I took in those MCAT course lectures.

People. If you're a social butterfly, and aren't sick to death yet by being surrounded by other keener pre-med types, then that in itself might be another reason for you to take a course; you'll meet lots of people with similar goals and aspirations, always good for sharing stories / advice / seeking out a potential life partner. I still keep in touch with or randomly bump into people I met in my MCAT class; two of them are in the year ahead of me in my med school, and I saw another one who was applying for admission at my school this coming year. Then again, the people might be just the reason you choose not to take an MCAT course. See my friend's quotes below.

Aside from my lengthy answer, you might be thinking, what do other med students think? Look how helpful I am: just for you, I actually asked a few people in my class who happened to be on MSN right now. They all had different answers:

• "I didn't take the course but I didn't do well on the MCAT. It probably would have helped but I saved myself a thousand bucks or so."
  - My friend the wink.
  
  
• "I did take the course, and it helped because I am not adept at standardized tests."
  - My friend the little med student with a big heart (and mouth). (She chose that name herself).
  
  
• "I took one, and it definitely helped. They actually teach you what you need to know, have homework and a schedule that you strive to keep up with, and it just pushes you. The people in the class are intense pre-med keeners, though. They thought I was dumb and such a slacker, especially since i went travelling during the course too."
  - Kitty, my slacker friend.
  
  
• "I didn't take a course and I did fine. I didn't want to do the course thing because pre-med type people are too stressy for me. I studied from some Kaplan books I got from a friend. I just wish I studied harder for verbal reasoning."
  - Annie, my friend who was too unoriginal to choose a nickname. Actually, maybe I shouldn't mock people who are helping me. Sorry Annie.
  

So, if by now you think the course is right for you, then this inevitable question will be brewing somewhere in your cranium:

Which course should I take, Kaplan or Princeton Review?

Easy. All the people I know who took Kaplan say that Kaplan is the best (myself included), as opposed to the people who took Princeton Review. They say that Princeton Review is the best. I'll leave it at that.

For you? They both cost roughly the same. If they don't, find one which suits your budget the best. But obviously, most importantly, choose the one that fits your schedule best.

Final advice: Choose a course that starts well before your MCAT date. Despite the fact that you might want to get it over with quick like ripping off a bandaid, you'll probably find that more info sticks / you get to know how the test makers think better when you've been going over it for a few months as opposed to a few weeks.

Hope that helps. This was a hefty post, but I know that pre-meds usually don't complain about too much help. I also hope you didn't get lost in my answer full of random ADHD diversions. All the best as you tackle the MCAT giant for yourself, and remember, it's not that bad. Hopefully you come out alive.

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Question for Vitum: Are med school lectures hard?

Answer:

Yes, when the lecturer annotates his slides and they end up looking like this.

Thanks to Ng for having the presence of mind to take a photo and letting me post it.

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