The best part of spending two weeks with medevac? Not what you might think.

As my third year was winding down last month, I had the opportunity to do a two-week elective in anything I wanted. Supposedly it had to be medically-related, but given that some of my classmates were approved for two weeks of wakeboarding or a 3-hour first aid course*, spending two weeks in paramedicine made me look like an overachiever.

The elective was pretty incredible from a medical point of view. Among the dozens of calls we attended, we picked up a young lady whose ATV had gotten away from her, crushing her leg to the point where she might never walk again. We also treated a few patients who had fallen off ladders or nearly drowned, and a nailgun injury. As well, there was a variety of medical patients too complex for the rural hospitals who needed to be brought to the big city for super-specialized care.

There were things that I didn't anticipate. There were heart-wrenching moments, like talking to one of our patients, a young lady who had been poisioned by carbon monoxide...intentionally. Sadly, she was not the only suicide survivor that we saw during my two weeks. As well, we went to a few car accident scenes and I saw some things, tragic things, that I wish I hadn't.

One thing about the elective really surprised me. Those of you who have read this blog for a while might remember that I have shadowed flight paramedics in the past. Back then, it was fascinating for me to see what the paramedics did...treat and transport the sickest patients in the province. What surprised me is that this year, my time with the paramedics served as a stunning eye-opener, revealing to me how little I knew about not only paramedicine, but medicine in general back then.

In other words, until I had completed my third year of medical school, I had no comprehension of just how sick the patients were that we were transporting. Not only that, but I had no idea the elite level of training of the flight paramedics. Back then, I did not understand the skill demanded when handling ventilator settings for patients with severe lung disease, or the implications and specialization required in order to keep alive a patient with bacterial infection coursing through their entire body. I only now realized just how sick these patients were, having been involved in identifying and treating sick patients myself, and also that some of the drugs that the paramedics were trained to prescribe are typically only used by intensive care specialists.

It was exciting to be able to understand at a deeper level the diseases affecting our patients, and to be able to have a new level of conversation with the flight paramedics, actually discussing treatment options with them. To put it another way, before I had completed three years of medical school, I didn't even know what questions to ask.

Needless to say, my understanding of the complexity of the patients and the difficulty of their management gave me a new level of respect for the critical care flight paramedics.

Retrospect, for me, is a valuable, meaningful experience. In fact, one of the reasons I started this blog was so I could look back and see how far I've come; in a program that is years in length and where you rarely realize how much you have learned from day to day, sometimes looking back is the only time you'll realize how much you are learning. It was a huge privilege to be invited back to spend time with these highly-trained paramedics, and it was a great surprise to discover that without realizing it, I had signed up for two weeks of seeing how much I have learned. Glad the $45,000 I've spent so far on tuition seems to be paying for something!

*In defense of my classmates, they did have to write a 500-word essay relating their elective to medicine

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Sometimes it seems as though the world's greatest people are dealt the worst hands in life

Happy birthday Dad!!!

The flight paramedic I worked with this week started his job the year I was born. He has seen patients of all sorts, at all stages in life, with all sorts of background stories. Yet, the story of the patient we flew into the big city, and what she did right before we loaded her onto the helicopter, he told me later really moved him.... something that means a lot considering how hardened he is and how much he has seen.

Actually, considering the several shifts I've had with the flight paramedics over the years, I have been surprised at how sensitive they are to their patient's needs while serving in a job that could have the tendency to see them slip into the mindset of a courier transporting inanimate packages. Even in the little things. "You're gonna feel a poke here" is something the lab tech should have said (many times) when she was digging to find a vein; instead, it was the paramedics who were keeping an eye out for the patient in that time. Treatment of a patient like a pincushion is something you never want to see... it is even harder to watch when the patient receiving the bludgeoning had been admitted for treatment of a suicide attempt.

But back to this inspiring patient.

It was a sweltering day in the city, and I had been regretting trying to dress nicely to impress the paramedics beacuse in my pants and long-sleeved shirt I was doing more sweating than shadowing. I wished we could stay in the air-conditioned ambulance station at the airport but instead when the pagers went off. I was hoping for an exciting scene response trauma call, but no, we had to head to the helicopter to answer yet another boring transfer call.

Rachel, a 33-year-old mother of two, was being brought in to the big city to see a specialist for a growth in her throat. It hadn't been biopsied, but it was pretty obvious to everyone that it was the cancer coming back.

You see, ten years ago, after a dental procedure, she started having trouble swallowing some foods. She ignored it for a few days because she assumed it was inflammation left over from her root canal, but it didn't go away, and finally looking in the mirror with a flashlight revealed a growth that made her weak at the knees. Her worst fears were confirmed when she was given the diagnosis of cancer.

The tumour grew incredibly fast, and she soon lost feeling in her face, control of her facial muscles, and had to soon start eating through a tube. That seemed like a minor inconvenience when she had to have a tube put into her throat because the tumour was blocking her airway. Surgery was attempted, followed by chemotherapy and radiation, which took the pressue off her trachea and allowed her to breathe again, but left her bedridden.

Then, miraculously, her strength began to come back, and so did the feeling and control in her face. She soon was talking, sitting up, then standing. Nobody seriously expected the day to come when she would leave the hospital, but she did... walking entirely on her own.

Unfortunately, the road to recovery soon came to an end. Three years after that, shortly after the birth of her second son, the cancer relapsed, this time much worse. It had spread to the bones in Rachel's vertebrae, paralyzing her from the waist down. Again, she had to undergo surgery, chemotherapy, and radiation. And, amazingly, against all odds, she again had a complete recovery, more miraculous than the first - all of the feeling and mobility in her legs returned. She could walk again!

It would have been nice if it could end there, but the story goes on, and not in the direction anybody would want for her. Earlier this week Rachel was having dinner with her family when she got some food stuck in her throat and started choking. She was unconscious for some time before anyone could revive her, and the preliminary tests suggest that not only was the cancer returning, but she had lost some cognitive function while her brain was deprived of oxygen.

Right before we picked her up to take her to the big city for some more tests, a few more results came in. It seemed as though the tumour was growing around some crucial arteries and veins, and that surgery would not be able to reach it. Treatment this time around, if any, would likely be palliative.

Despite all of this, she was one of the most genuinely nice people any of us had ever met. She thanked all of the paramedics profusely, and didn't complain about anything. "Thank you for serving me," she said to the paramedic I was shadowing as we took her into the hospital. He replied, "No, you have been the one serving me."

When it comes to life, it seems that sometimes it's the world's greatest people that end up getting dealt the worst hand. I don't know how I would cope if I had to go through everything she had in the past ten years. She truly put a face to courage and grace, and since then I have found myself remembering her every time I think I have it rough with traffic or something else minor in comparison.

Like I said, though, the paramedic told me he was also really moved by something she did right before we loaded her onto the helicopter. As we pulled her out of the ambulance, and were readying the aircraft's stretcher support, she did something that made me regret cursing the sun the whole day. She was strapped in to her stretcher, but her arms were free, and she spread them out and looked into the sky. "It is such a beautiful day," she said. "I love the sun!" And, knowing full well that she would likely be on a cancer ward for the next several weeks or months, and that this could be the last time she would be at home, she added aloud with the most beautiful smile on her face, "And who knows when I'll see it again."

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Paramedics have great stories

Hanging out with paramedics is always fun, because they all seem to never run out of great stories. From scrotal lacerations to decapitations, they’ve seen it all. Here's another story I picked up when I shadowed paramedics.

There was a patient who had a cardiac arrest during intercourse. The paramedics picked him up, and revived him on the way to the hospital. When the doctor phoned his wife to tell her that her husband was going to be OK, she said, “What? My husband’s in the hospital?”

Think about it... then you'll get it.

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I've got blood in the back of my cab

The other day while I was shadowing paramedics, we had just dropped off a patient and were sitting by the emergency department entrance, waiting for one other paramedic to finish up on a phone call before we left the hospital.

A cabbie pulled up and rolled down his window, and shouted at us through a thick accent, “I’ve got blood in the back.”

“Huh?” one of the paramedics replied.

“Blood – I’ve got blood in the back of my cab,” he said again, using his thumb to point at the back seat.

We looked at each other, not sure what to do, until one paramedic turned to the cabbie and said, “Here’s what you do – get some water, and some hydrogen peroxide, and you’ll be able to scrub it out real nice.”

The cabbie mumbled something, and drove off.

We started shaking our heads when he pulled up to the front door of the hospital.

“What’s he doing?? Does he actually want a nurse to come out and clean the back of his cab for him?”

He popped the trunk, got out of his cab, and walked to the back. He reached into the trunk and pulled out a big cardboard box.

“Ohhhhhhh,” we all said, as the lightbulbs went on.

Here we’d been trying to picture the cabbie wanting to clean up after some drunk ride all cut up from a bar fight bled all over in the back seat.

Instead, I had simply witnessed for myself the apparent courier system for the blood bank.

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The day we'll all never forget

Susan and Marcus are very different people.

They’re different ages, they have different hobbies, and live in different cities.

They have likely never met each other before, and they probably never will.

But today, suddenly, they both had a few things in common.

They both woke up thinking it was going to be like any other normal day. They both soon realized how wrong that was – instead, they both had a day they’ll never forget.

As well, they both sat inside an air ambulance beside a first-year medical student as they were airlifted to a downtown hospital.

That’s right, I finally had another chance to shadow air paramedics again, and this time, it was unbelievable. We took calls from the moment we began our shift until the very end. It more than made up for the last time I shadowed, which involved sitting in the station for twelve hours straight and was just about as exciting as watching the Montreal Canadiens stumbling attempts to set up a defensive hockey play.

Susan woke up with the back pain that she had felt since New Year’s, but for some reason today it just wouldn’t go away. She took some more of her prescription pain meds. Nothing. More pills. Nothing. “Honey,” she said to her husband, “can you drive me to the hospital?” The nurses there realized quickly that no matter what they threw at Susan, her pain wasn’t going away. They checked on her throughout the morning, and faithfully charted her pain levels: six out of ten…9/10…8/10…20/10, defying the constellation of pain medications that were being pumped pretty much non-stop into the veins in her arm. When the doctor came to see Susan, he thought she could be suffering from a crushed vertebrae, a tumour pressing on a nerve in her mediastinum, or perhaps even the rare possibility of an aortic aneurism or dissection. It was past time for Susan to get some medical imaging done. In the big smoke, no big deal. Out here, though, well…impossible. In a rural centre like this, a CT scan wasn’t an option. Susan had to be sent somewhere where it was. The doctor picked up the phone and called for a helicopter, and we came and took her to the imaging machine that so many people, unlike Susan, have such ready access to. I felt bad as the paramedics resisted Susan’s husband as he begged to join her on the helicopter. I knew I was taking his seat.

Marcus woke up sad that the first camping trip of the summer, an early one, was coming to an end. The weekend had been perfect – great fishing, canoeing, beer drinking and quality time with his four best friends in the whole world - they’d grown up together, and did everything together. As they were driving home together, though, the driver lost control, destroyed a van carrying a young family, flipped over and over and ended up in a ravine. Three of his friends joined two little girls in the minivan who went straight up to heaven the instant the vehicles hit. When the ambulance got there, they paged the helicopter right away, as well as the community’s only trauma doc, a board-certified general practitioner and an experience-certified specialist in everything. The doctor struggled to get Marcus intubated as the ambulance raced to the soccer field at the edge of town, where a police officer had put out some orange pylons to set up a crude landing site, and radioed the coordinates to the incoming helicopter. We touched down, blowing over the little pylons, and quickly got the patient transferred into the chopper.

As the helicopter blades sliced through the air and we quickly gained altitude, I looked out the window and watched the two fire trucks and two ambulances, representing most of this small town’s emergency resources, form a convoy back into the town. The smell of the patient’s vomit quickly filled the back of the helicopter. The paramedics worked to start an IV and keep his vitals stable, and when we finally landed, we went from the helipad down the elevator to the emergency room where I watched the waiting trauma team spring into action. The flight paramedic called out the details of the crash, then the resident went through a full-body assessment of the naked victim, surrounded by a respiratory therapist setting up the ventilator, the X-ray techs setting up films, a lab tech taking blood, a medical student ogling, an attending doctor overseeing, a nurse hooking up monitors, and another nurse writing down the details the doctors shouted out.

I stood, my back against the wall, for the first time realizing what “fingers and tubes in every orifice” actually meant as a foley went in, a doctor checked for bleeding from the ears and prostate, and vomit and air fought for the right to use the mouth or nose as an entry and exit point. The last I saw of the patient was when they took him to get his head CTd, apparently something doctors like to do when the side of the head looks like a giant bruise and feels like mush.

These were just two of the cases that I saw first hand today. Overall, we flew four separate patients – two transfers, two traumas – went to five hospitals, worked two hours extra beyond what should have been a 12-hour shift, and spent more than four hours in flight. For me, it was a dream come true. All the money in the world couldn’t have bought a non-stop action-packed day like that. The experience was outstanding, the paramedics were so hospitable and so glad to have me join them. It was a day I would never forget, and I’m going to spend a some time this summer once school settles down not only accepting the paramedic’s invitation to come back, but also looking for places in North America that train and hire helicopter physicians.

As fantastic as an experience as I had, it was bittersweet. Sitting right beside these patients whose lives have been immeasurably affected was sobering. It’s likely that two – possibly all four – of the patients I met today will be dead within a week. Even if they make it, though, today will be a day they’ll never forget, either.

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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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Premedasaurus extinctus

When I started my undergrad, I wanted to become a doctor, so I simply signed up for the "pre-med" major at my university. I didn't realize that I was jumping on to the last glimmers of a dying wave.

Musings of a Dinosaur is hosting Grand Rounds v3.23, and in an attempt to fit with the theme and thus get listed, I'm writing about the one thing that, this early in my medical career, I know about which has gone the way of the dinosaur: the "pre-med" degree.

Most "pre-med" students are aware that "pre-med" degrees don't actually exist anymore. My degree program wasn't even technically that; it was a B.Sc. in Biology, Pre-Med stream, or simply a collection of courses in and extraneous to the Biology degree requirements which happened to be common prerequisites for medical school. As a matter of fact, it was discontinued in my second year or so, leaving me slightly embarrassed and feeling without compass or sense of direc.... no, actually, I didn't really even notice.

That didn't keep me from shamelessly using "I'm in Pre-Med" to try and pick up members of the female gender. Surprisingly, this was so unsuccessful that I abandoned it in favour of pursuing getting struck by lighting while holding a winning lottery ticket and getting mugged by Chuck Norris at the same time. I figured my chances were better for the latter, and hey, who needs a girlfriend when they can say they were mugged by Chuck Norris, anyways?

In actual fact, I soon lost all enjoyment in introducing myself as a "pre-med." I found that common responses to this declaration were:

• "Oh, so you're going to be a doctor?"
• "You must be smart!"
• [pointing and shouting] "Hey, look, Mom, a nerd!"

These were combined with that which anybody in pre-med has had to deal with... the one thing that dominates every action you as a pre-med do: the thought of "getting in." Almost every pre-med wonders about everything they do, "Will this help me get in?" (ie. regarding a summer job) or worse, "Oh no, will I still be able to get in now?" (ie. regarding getting busted for what you thought was a harmless prank and then finding out that your high school's administration has less of a sense of humour than you first expected... uh, fictional situation, of course). It ends up being in the back of your mind all the time and soon gets pretty annoying.

Take that and add a bit of humility (ok, fine, insecurity), a bit more not wanting to let down people who thought you were smart, and a a lot of realistic awareness regarding the admissions process and the brutal odds that are involved, and you soon find that you'd much rather not tell people that you're 'pre-med.' By my second year of undergrad I told everyone that I was taking a Biology major. I hadn't even realized that by this time my university had pretty much phased out the 'Pre-Med' stream.

Clearly, though, Vitum avoiding the term 'Pre-Med' didn't drive it into extinction. So why isn't it offered any more, and what's the alternative now? Well, I'll take this opportunity to answer a question from Carrot Juice, who took the time to get in touch with me via e-mail and ask for advice about applying for medicine. I'll start here and continue to address this question in a few other posts.

Med schools are more and more in favour of diversity these days. People with diverse backgrounds make a better medical school class, so the story goes. This, in fact, is the driving factor behind allowing 43-year-olds to begin medical school, something which a lot of people are a little confused about because after all, there's a good chance they won't have many years to practice after they graduate. So now you can have a math major who becomes a surgeon, or a economist who becomes a general practitioner. Our class has engineers, a nurse, a paramedic, a school teacher, an Olympic athlete, an entrepreneur, a city councillor; we've also got PhDs alongside students who didn't even finish undergrad. In fact, the first semester of our curriculum is in a sense a compressed physiology undergrad degree, to catch up everyone to the same science level despite their diverse backgrounds.

Thus, no longer can you get through with your basic 'pre-med' combo of biology, biochem, organic chem and expect to be an A-1 applicant. Nowadays it's all about standing out. What else would you expect, though? With Canadian med school acceptance odds of something like 1 in 11, that's what has to be your focus; making your admissions essay, your interview, your application stand out from the other 1000-3000 applicants (depending on where you apply).

It's all about diversity; being one more 'pre-med' in a pile of 3000 'pre-meds' doesn't cut it anymore. And so, as can be expected, the 'pre-med' degree ended up where most of those bland, un-unique applications end up: in the 'gone forever' pile.

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The Politics and Red Tape of Paramedics

Riding along with the paramedics was indeed thrilling, though at about 11:00 am on the day of my ridealong, that would've been a hard sell.

"My friends think this job is all blood and guts," said Jim, the paramedic I was shadowing. It was funny because we were in our second hour of waiting around at a hospital. If there are no beds in the emergency ward for the patients that paramedics bring, then there is no nursing coverage for those patients, so the paramedics are required to stand around and wait at the hospital. "At some hospitals, there will be an ambulance crew standing around for entire shifts." This pulls ambulances off the roads, and if someone needs help, the nearest ambulance is then called in. "Nearest" is used loosely - the next community over may be fifty kilometers away.

I got another glimpse into the red tape tangle that is the ambulance service. While there are transfer ambulances, glorified taxicabs dedicated specifically to transfer patients who can't get a ride on their own to get simple tests done, (ie. patients in nursing homes and the like), there aren't enough of those cars, so the load invariably spills over into the lap of the paramedics who are trained to save lives. Some provinces / regions have private transfer ambulances but apparently we don't. This means that instead of being able to respond to a call within minutes, the paramedics are taking Papa to his stomach ultrasound. Well, I shouldn't make generalizations; it's not all old people that are transferred. One of the people we transferred was a young man of about 35. He was involved in a car accident years ago, and had no family or insurance to really take care of him. So, he spends his days in a nursing home surrounded by geriatrics, paralyzed, unable to get out of bed on his own or do anything for himself. My heart went out to him.

At one point the paramedics told me, "When you're a doctor, don't order an ambulance for people who clearly don't need it." Doctors apparently have this power. The paramedics were getting pretty frustrated taking this old woman home from the ER who clearly could have just gone in a cab. I could see their annoyance... they could've been out doing a real call instead of playing cabbie. "I thought taxicabs were supposed to be yellow," I joked.

The best example of red tape, which had the paramedics I was shadowing hopping mad, was the time we dropped off a patient at a hospital for a test. When we pulled in, there were 4 other ambulances plus a supervisor car. "Is there something going at St. Sickkus Hospital that we should know about?" radioed in the driver. Turns out the hospital was closing down the ward, so they brought a bunch of ambulances to bring the patients out. Eight paramedics and a supervisor milling about waiting to be told which patients they would take. It turned out there were only eight patients in that ward. "They could've just double-stretchered and gotten the transfers done in one trip."

The politics don't end at paramedics, though; I've got some good times to look forward to, apparently. My friend shadowed in the ER the other day and told me that they had a patient who was bleeding from his rectum after his surgery. The ER docs called surgery, who sent down their first-year resident - a doctor of, oh, perhaps six months - to deal with the problem. Surprise surprise, he had no idea. He suggested they call GI. "Not my problem," said the GI doc, and wouldn't show up. "Call internal" somebody suggested - no dice. Frantic, they called trauma surgery as a last resort, and pretty much got laughed at as they tried to advocate for the patient and explain how this could be considered trauma. The ER doctor ended up having to deal with the situation on his own.

But I suppose every job is like that. I interned in an office where you couldn't go elsewhere for your graphic design needs because everything had to have a uniform look, but then again, the graphic design department there took weeks to get even a simple invitation or notice done. People caught wind of my knack for composition and I started getting a lot of requests to help other departments with their design needs. The funniest part was having to be discreet about it. Can't let the designers catch on. Don't want to get a talking-to.

You think I would have learned my lesson working in one office... perhaps I haven't. In a feeble attempt to figure out what I want to do this summer, I put in an application this week to work for the national medical association as an intern. I have a funny feeling that such a job just might end up being laden with politics as well.

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