10 MPG…

Portland, OR to Taos, NM in one weekend. This was the first time I tested out the ol’ RV for real. Over 1,500 miles with a gas milage of 10 MPG at best equals a lot of time behind the wheel and a lot of time filling up with gas!! I had decided to try and cut the costs of traveling and post on craigslist for rideshare and see if anyone wanted to catch a ride between Portland and Taos. At one point I had 3 people confirmed for the ride to Denver, but all 3 bailed at one point or another. So at the last minute I called back one other person who had e-mailed me prior who was looking for a ride for him, his bike, and his Bob trailor. With only 5 hours until the time I was planning on heading out, I figured he would not have the ability to get all of his stuff together in time, I was wrong though.



After getting off the phone with Mark, he did a 5 mile run from his current location to where he was storing his bike, to get on and ride back to his orginal location. At that point he picked up his Bob tailor, gathered all his belongings, and biked over to the Gateway Transit Center. I, in the mean time, was running around Hillsboro getting all the final logistics squared away before I leave the pacific NW for the next 7 months. After arriving 1 hour after my predicted departure time, I met Mark with in 10 minutes of arriving at the transit center.





Friday evening was spent driving long hours and sharing lots of stories. Mark had just finished biking across the country and was heading down to Prescott, AZ to re-incorporate into a less transient life style. He had many crazy stories of long hours in the saddle, big mountain passes, amazing generosity found along the way, and many other anecdotes. On Sunday morning we pulled into Ogden, UT where Mark jumped ship and aimed his bike south towards AZ in much awe of how many miles we covered in such a short time compared the rate of speed he had been doing over the past several months.






Summit and I continued on in our journey, driving across the incredibly flat and amazingly boring state of WY. We made to the Colorado border without being blown off the road too many times and with great expectations of meeting up with friends in Denver. Sunday morning I met up with my good friends Mike and the very pregnant Mary Bateman. We walked down to the local breakfast diner and spent a couple hours catching up on life. After wishing Mike and Mary the best with their new house and, soon to be, new baby Summit and I headed over to the local park. Within 20 minutes of being at the park (which has no posted signs about dogs or leashes) we attracted the attention of the dog cops and a $50 ticket. Summit’s first ticket; I’m so proud. The county of Denver is going to be receiving an appeal…







At the Colorado, New Mexico border I was able to watch my engine heat gage slowly rise to the red line as we crested the pass that separates the two states. A little rest for the tired old RV and we were back in business. I rolled into Taos and was greeted by an amazing sunset looking over the sagebrush and the Pinon Trees.

Catching up…

So I have been a slacker and have neglected this blog for most of a month; but here goes an attempt to bring the cyber world up to date with my life. The return from Alaska was bitter sweet. There were many thousands of miles of amazing hiking and exploration that were left untouched and unseen by myself, but it was also time to move on in my clinical year. (I think the ratio of play time to clinic/study time while in AK was very much one-sided: so leaving such an amazing playground might do well for my studies!! I do have to pass a board exam at sometime.) I know that I will return to Alaska at sometime in the future and will come back for more adventures, though this was a great introduction to the largest state in the nation, punctuated by meeting lots of really cool people.

I was met in Portland by some great friends who were gracious enough to store the old RV at their house while I was away and we re-connected over breakfast (after flying all night). Thanks Jordan and Cecily. Next stop was to reconnect with Summit up in north Portland and the amazing Missy who gave Summit lots of love and caring over the past 6 weeks. Summit had the “wiggly-bottom-syndrome” when he saw me and was so excited to play frisbee yet again.
This week was supposedly focused on a week of lectures bolstering our knowledge and bettering ourselves as a PA student back in Hillsboro, OR. By Monday afternoon I was wondering how I lasted a full year sitting in a chair for 8 hours of the day, 5 days a week. Much of the time, however, was spent catching up with classmates, sharing stories of being flung to the far reaches of the country, and crazy stories of seeing patients and getting pimped by your preceptors.

There were also a lot of extracurricular activities that filled the week. Monday night my friend Ryan organized a night ride at Tillamook Forrest which was an absolutely amazing ride and much overdue ride!! I was able to reconnect with my bike and give Summit a chance to really stretch his legs. A group of 7 or 8 of us headed out on the Brown’s Camp loop which is one of the greatest rides around the Portland area. Right about dusk, my Yeti mountain bike decided to punish me for neglecting it for the past 6 weeks and ejected me from the saddle after I didn’t see the rock covered by grass on the side of the trail. One quick flight through the air sent me rolling down the lush green hillsides of Tillamook Forest. Thanks for a great ride Ryan!!

Tuesday night I reconnected with some friends in Portland who were storing my car and my kegerator. I reaped the benefit of loaning a kegerator by sampling some excellent home brewed beer. On Wednesday night most of the class met up for the 2nd annual PA Bowl Off. It was a night filled with great costumes, a lot of trash talking, a little bowling, and some great live blue grass provided by 3 PA faculty members. It was great to intermingle with other PA classes and hear the trials and tribulations of the classes above and below us.

Thursday night Jessica and I met up with the victim from the dirt bike accident (see entry on 4/21/09) for dinner. Galen is doing remarkably well and was just released from his halo head stabilizer the week prior. For the extent of his injuries, it is amazing that he spent less than 2 months in the hospital and transitional care centers. He is doing well marked by his biggest concern of whether he will be given his driver’s license back next month or not. After going through such a horrific accident, it is great driving is his biggest concern! Best of luck to you on your driver’s test Galen.

20,320 feet of rock…

You can’t be in Alaska and at least make an attempt to see Mt. Denali (the original and native name for Mt. McKinley). With the rain for the past 2 weeks I had all but assumed that I was going to be looking at a bunch of clouds imagining looking at Mt. Denali, but Mother Nature smiled on us and allowed the clouds to part on Saturday and provided us with clear blue skies and absolutely stunning views of the mountain!!


Friday night we piled 5 people and all our camping gear into Colin’s 2 door Ford focus (which was quite impressive) and headed north out of Eagle River. Four hours later we threw down at a campsite just inside Denali National Park boundary. The car was left at the campground because no private vehicles are allowed in the part past mile maker 18 of the park road; instead there is a great bus system to make all of us gas guzzling, isolationist, Americans do something good for the environment and possibly interact with each other. A darn good idea!!


The bus ride out to Wonder Lake Campground, the campground furthest into the park took almost 5 hours with numerous stops for wildlife viewing and blowing through megapixels on amazing vistas. Denali’s big animals put on a great show for us starting out 15 minutes into the ride when a moose came meandering across the road in front of the bus. This was followed up by numerous caribou, bald eagles, ptarmigans, and many other smaller animals.


We saw a great interaction of survival and the food chain play out in front of us. The bus came to a stop because there was a red fox just ahead of the bus, then the eagle circling above came to a perch just 20’ from the fox. With his tail up straight and puffed out, the fox was trying to look domineering and scare away the eagle from his road kill meal. The eagle was eyeing both the road kill and the fox as a possible meal. When the fox finally left his road kill, the eagle began circling the fox and following him down the road, setting up the scenario for a possible survival of the fittest contest. The eagle soon lost interest, however, and went off to soaring on the thermals high above all of us.


What about the almighty grizzly?? About half way through the drive we were traversing a hillside with the bus and looking down at the river bed below when there was the first sighting. Momma bear was running down the river bank with 2 cubs in tow, with one little trouble maker trailing far behind momma. Momma was being playful with the close by and took a few playful swats at him as they were running. According to Cindy our bus driver, the cubs were probably 2 years old and over the next year or so momma will become less hospitable to the cubs and force them to strike out on their own. These were the first 3 of 6 grizzly sightings throughout the trip, with one of the big guys walking with in 20’ of the bus!


What about the mountain?? About 2/3’s of the way into the park rode we had our fist view point of the Mt. Denali. We came around the corner and saw the huge base of the mountain pushing itself up into the clouds that were shrouding the peak. As we got off the bus the clouds began to part as if on cue and suddenly there was the amazing peak as if sitting on top of the layer of clouds covering the waist of the mountain. Thirty minutes later the peak was completely shrouded in clouds again. I was happy; I had my 20 minutes to see the top of Denali and I could have gone home a very content man.


Denali, however, decided to reward us with more amazing views throughout the weekend. Saturday night, as dusk set in at midnight, the clouds left completely and the entire face of the mountain was visible in the incredible low level light that only certain times of the day can offer. We woke to clear skies and amazing brilliant light bouncing off each ridgeline of Denali providing an amazing sense of the topography of this mountain.


“Today is the best viewing day we have had of the mountain all summer,” was the comment from a park ranger as we ascended one of the mountains near the Eilsen visitor center on Sunday. That is a pretty impressive statement given this ranger looked at the mountain on a daily basis. We hiked up to the top of the ridgeline behind the visitor center which provided amazing views across the valley at Denali. The entire sky cleared out and there was only the occasional cloud blowing by in the sky.


This was another amazing Alaskan hike punctuated with a couple of caribou, numerous arctic squirrels, a few marmots, and some amazing arctic tundra. It was incredible to look across the valley at the ridgeline of mountains which were relatively comparable to the continental divide in Colorado, but these mountains were dwarfed by Mt. Denali which is another 8,000’-9,000’ taller. This is by far the largest mountain I have ever seen and I am in awe of the shear mass and majestic beauty of her. Thank you Denali.

80% of the town lives in that one building…

It was 50˚ F, rainy, and only 1 mile of visibility: but it was a great day to be out on the water. It has been a long time since I have been out on a sea kayak, and Whittier, Alaska provided an incredible opportunity to do just that regardless of weather. Huge, green forested cliffs ending abruptly in the ocean. Innumerable thin, twisting waterfalls draining the glaciers where the water was racing and rushing to reach the ocean. Our kayak tour led us into many inlets and bays, exploring all the crevices of the coastline.

My partner in Alaskan adventures, Colin, and I, as well as Brian headed out for a custom kayak tour. Our trip (which was just the 3 of us) was geared more towards pushing the tempo up a little bit to see more terrain rather than the tourist idea of lily-dipping and gawking at every bird that flies by. We had a great guide who was pretty psyched to be able to go further out Passage Canal than the average trip.

We were geared up in multiple layers of polypro, fleece, paddle jacket, vinyl raingear, and a spray squirt to top off the ensemble. Once on the water I soon found the joy of kayaking once again. It is a unique feeling of sitting in the water, feeling the heaving of the ocean, finding your rhythm of paddling, and being able to get up-close and personal with the coastline unlike most other boats. We were able to see several bald eagles, a few seals, and a million and two Kittywake gulls, with a couple Kittywakes picking up fish 10’ off the bow of my kayak.

As a part of the whole deal we were supplied an extravagant lunch spread out on a table cloth on the beach. Smoked salmon, pasta salad, crackers and cheese, trail mix, hot apple cider, and lots of other great things to fill your stomach. The 4 of us worked hard at putting down all of the lunch, but 4 young active people couldn’t even polish off all of the food supplied.

“80% of the town lives in that building right there, and another 18% lives in that smaller building next to it,” our guide said. The rest of the town’s population squats in RV’s, pickup trucks (like him), the back of their store, or some similar location. When the cruise ships dock and release there 2,000 plus guests onto the docks of Whittier, the population literally doubles until the cruise ship guests are whisked away by the waiting train to other parts of Alaska.

The only way into Whittier by land travel is through a one lane, 2 mi. long tunnel, shared by cars and trains. When I say 1 lane, it was truly 1 lane with rock on either side and cars driving on top of the train tracks when going through the tunnel. We waited for the oncoming train, then oncoming traffic, then waited for the train to go the other direction, then finally we were allowed through. Evidently the military picked Whittier as the best deep sea port that would be least likely to be bombed during WWII due to the weather conditions there. This led to the saying: “it’s sh*tier in Whittier.”

When not on the water the weekend was rounded out with a couple of amazing hikes. We hiked Winner Creek trail (I’m a winner!!) which headed out of Alyeska Ski Resort in Girdwood, Alaska. This was a great hike with amazing views and the opportunity to take a hand tram across a large river crossing. Saturday night we threw down tents at the Passage Canal trailhead above Whittier and found a couple of people who were scheduled for the same kayak company the next day as well. They were on break from doing research way out in the remote areas of Alaska on Eider ducks, so to them Whittier was a “big city.” We did a quick hike up to the vantage point of the nearby glaciers and found ourselves working hard not to let the wind push us over. Great views, and a great place to enjoy a beer!

7/21/09: Grandma rides snow machines!!

Here is a short list of the cast of characters I saw today:


1) 99 year old woman presents with an episode of palpitations and chest pain in the middle of the night. “I woke up from a scary dream and had these chest pains.” She recounts the dream: “I heard they were digging up the graves on Fox Island across Resolution Bay, and I have family over there. So I was going across Resolution Bay on my snow-machine and, (in a very quiet voice) I don’t usually use this word, but I “goosed” the gas to get up and over this high point. And then I woke up with chest pain.” This 99 year old woman who had full mental capacities and only used a cane to get around the house was escorted by 70-something year old daughter who was just as alive and vibrant. It is amazingly refreshing and inspiring to see people who have aged gracefully. My hat is off to these two wonderful women who I had a chance to meet.


2) These two gentlemen come in together, and they gave the movie “Grumpy Old Men” a run for its money!! If you combined the procedures done on both of the men, it would probably cover nearly all of the procedures that could possibly be performed on the heart; but they were still alive and kicking. They were also slinging the mud back and forth so fast to looked like monster truck pull:

“6 cigars a day!?! You bought a case of 100 cigars at the beginning of the month and they are all gone now!”

“Sugar, don’t talk to me about sugar. I bought a dozen donuts and only got one because he ate the whole box by himself!”

And on, and on, and on the bantering went. If we raised any lifestyle changes, the focus was always pushed to how the other guy was worse off about that specific vice. The bantering could only come from two people who knew each other for years and who actually care deeply for each other.

The full story is very touching: “George” is 65 years old and is about 10 years older than “Bob.” George is an ex-cop who worked in New York City, lives with and cares for his wife with multiple sclerosis, and lives in the same apartment building as Bob. Bob has no family, is in very poor health, has a difficult time with many of the activities of daily living, and has a history of severe depression. George brought Bob under his wing about 8 years ago. He takes him to doctor appointments, fills his pill box, makes sure he has a freezer full of packaged dinners, gives him companionship, and genuinely cares for Bob as if he were a brother. George brought Bob to my preceptor specifically because he felt she was the best cardiologist in Anchorage and has set up his wife and now Bob with only the best providers in the city “in case anything should happen to him.” Though George’s heart is very sick, it is also very large and he cares deeply for those around him.

3) The 67 year old engineer who was trying to engineer his health. He presented us with a perfect spreadsheet with documentation of every single medication he was on, what dosage, what time taken or if he missed the medication. He also informed us that he had taken the liberty to tinker his Coumadin dosages just like a carburetor of an engine. Unfortunately if you tinker with you Coumadin levels too much you either turn your blood into water or you can start throwing clots. He received stern orders not to mess with his Coumadin dosages, but once an engineer, always an engineer.

7/20/09: “Would you rather it be opium & cocaine??”

Stress test report:

“Mr. Addict decided to have a few cocktails prior to his treadmill stress test today. After a few minutes of running Mr. Addict lay down on the treadmill and fell asleep.”
This was the report from about 3 weeks ago, fortunately Mr. Addict either decreased or eliminated (highly unlikely) the amount of liquid courage he needed for the pharmacological cardiac stress test 4 days prior. At any rate, he showed up to the clinic today reeking of alcohol demanding the results from his test. When confronted about his alcohol and tobacco consumption he exclaimed: “have you ever heard of addiction!?! Would you rather it be opium or cocaine?” Later in our conversation he dropped the not so subtle hint that the cost of opium in Egypt (where he was when he had his heart attack and stent placement 6 weeks prior) was incredibly cheap.

Choose your battles:

When my preceptor was confronted with the choice of opium or cocaine, she readily suggested that opium (by far) is the lesser of 2 evils for his heart.

Despite his multiple life style choices, Mr. Addict passed his stress test 4 days prior and it did not show any significant heart disease going on now.

Go figure: you can be a marathon runner and in the best shape of your life and drop dead secondary to a heart attack if genetics are not on your side, or you can put every poison known to man into your body and your heart can still be as strong as a bull’s. I guess the moral is that you should have fun in life no matter what it looks like, but I’m going with the have fun and be healthy choice.

7/20/09: The heart bone is next to the skin bone, right?!?

Day 2 I of this rotation I look at my preceptor’s calendar. Over 2 weeks of the 6 weeks I will be in Alaska he would be off on fishing trips, grizzly bear viewing trips, and a multitude of other trips. The limited days we were working sometimes had as few as 2 patients scheduled, and on any given sunny Alaskan summer day, half of the patients would cancel or not show for their appointment thinking that fishing is much better thing to be doing on a sunny day.

I cautiously called the PA program clinical team (knowing I was opening a can of worms: but with no idea how big the can was) to ask about other clinics I might be able to work with another clinic in Anchorage to bolster my educational opportunity. This request was quickly turned into a desperate search for another clinic when I was told I would not have enough patient contact hours at the dermatology clinic and I would have to repeat this rotation after my expected graduation date. For 2 days I was in a constant state of logistical juggling to make something work out for this rotation until I heard that “ooops, actually dermatology should have enough patient contact hours and you are all good.”

The ball had already been put into motion in a couple directions for alternative clinic experience, one of which was the Alaska Heart Institute. With the reassurance that my derm rotation would suffice, I was able to piecemeal together a combination of dermatology and cardiology into the same rotation!!

The process was a painful rollercoaster ride, but the net result has turned out to be an amazing opportunity!!

7/19/09: They ran this??

The winning racer took 2 hours 57 minutes to complete the Crow’s Pass Marathon; we took 2 days. I think they are insane.

Crow’s Pass goes from Girdwood, Alaska to Eagle River, Alaska and each year there is a select group of people decide to run this mountainous pass at a masochistic rate trying to break the 3 hours barrier. The 24 mile trail takes you from near sea level up to 3,500’ in 4 miles, down the other side to traverse a 45 degree angle snow field, cross a raging glacial fed river, run past the numerous (fresh) bear scat, and finally finish the trail at the Eagle River Valley Nature Center.
Running at this rate you would easily miss the beauty of seeing Raven Glacier, Paradise Peak, Polar Bear Peak, and all the other beauty that Chugach State Park has to offer. So we didn’t run. We walked and soaked in all that the wilderness can provide you.

I jumped onto this trip at the last moment through a friend of a friend. A bit of last minute scrambling and borrowing provided me with a 10 pound rectangular Colman sleeping bag that filled well over half of the backpack (which I also borrowed). A quick trip to REI for bare essentials like water purification and I was ready to go. I fully expected someone else to have hammered out all the logistics since I was a last minute add on. When we were about to leave the trailhead and I asked, “does someone have a rope for a bear line?” and all I got was blank stares I realized this was not the case…

Unbeknownst to me, there were several “never-ever” backpackers on this trip. The trip was the brainchild of three friends who all work in the same office together who added in: siblings, housemates, friends, and friends-of-friends to create the group of 8 who completed the trail. This random combination of people led for some great stories, great friendship, and lots of laughter throughout the entire trip!!

This was the first in a long time that I found myself, as a white male, in the minority. It wasn’t the fact that I was white (we are in Alaska after all), but it was a 5:3 female to male ratio. This was also the 2nd most significant river crossing I have ever done, second only to a river in the middle of Patagonia, Chile. The frigid glacial melt water almost came up to my waist and made every vessel in my legs clamp down to 1 nanometer. My years of trip leading forced me to slip into a leadership role at the river crossing, and we created a train as I was taught to do in Patagonia by my NOLS instructors. I can’t imagine running 12 miles, throwing myself in a raging river (probably causing muscle spasms), only to get out on the other side and run another 12 miles!!

Through the entire 24+ miles the bear bell (98% effective according to some “literature…” though, I am still waiting for the evidenced based research on this one!) kept away all the bears and our only big animal wildlife viewing was a dall sheep grazing on the hillside. This was a great introduction to the Alaskan backcountry with a totally awesome group of people; couldn’t have asked for a better Alaskan adventure weekend.

7/16/09: Greatest excuse ever!!!

“Mom, I can’t paint the fence, there’s a moose in the back yard!!” George said with great excitement in his voice. Clearly the greatest TRUE excuse to get out of chores I have ever heard.

I was walking back to the house from work and I suddenly realized there were 2 eyes staring at me from OVER the fence, not around, but over the fence. The eyes were attached to the head of a very large moose, and beside her was a young moose calf. They were munching on all of the wonderful green plants around the house, including the potted plants.

I ran downstairs to get my camera thinking the moose would be exiting stage left in the very near future. I was wrong. After getting their fill of potted plants and other delicious goodies, the curled up next to the swing set for a nice 3 hour nap. After waking up, munching on a few more bushes on the way out, the moose wandered over to the neighbors’ house for desert. A little “Northern Exposure” for you.

7/15/09: Non-Skinny Dipping

So my preceptor is going “dipping,” or “dip netting” this weekend. When he asked me if I knew what “dipping” was, I held my tongue for the blatantly obvious wisecracks about nude bodies slipping into the water and obediently said “no.” I was informed that this had nothing to do with slightly illegal water activities and was actually a type of fishing, though I use the term “fishing” loosely.

Dipping instructions:
1) stick your 5 foot diameter net in the water, 2) wait 10 minutes, 3) pull your net out of the water, 4) look in your net for any fish.

Not exactly the most physically demanding, or technically precise sport around, but if it brings home the fish, then I guess it works (plus, if my preceptor is successful there may be a fish coming my way…).

7/15/09: Either septic tank water or hydraulic fluid…

“I’ve had these white bumps on my hands for 1.5 weeks and I can’t figure out if it was the septic tank water I had my hands in, the hydraulic fluid on my hands, or the new gloves I was wearing.”

“I’m not sure either, but I’ll go out on a limb and say the gloves are the least of your worries,” is what I wanted to say.

Turns out this gentleman was working on fixing the septic system at his cabin when the hydraulics broke on his back-hoe. That explains the hydraulic fluid, the septic tank water, takes a little more explaining I didn’t bother to ask about.

Since the white papules were responsive to over-the-counter hydrocortisone, my treatment plan included a higher potency topical steroid and careful monitoring. I presented the case to my preceptor and I watched his eyes lite up when I mentioned the word hydraulic fluid. We go into the room and my preceptor commences a repetitive interrogation of whether the hydraulic fluid was under pressure and was injected under his skin or was a simply soaked his skin. I stand there pretending like I know where this line of questioning is going surprised at the intensity of the interrogation.

I have always intuitively known that hydraulic fluid is probably not good for the body. What I didn’t know (and my preceptor has seen before), is that someone can actually lose their hands if the hydraulic fluid is injected into the hands. The quintessential story is that the someone grabs a hold of the hydraulic fluid line to either connect or disconnect the hose about 4” from the end of the hose, right where it usually bends, the hose cracks and sends a thin line of high pressure hydraulic fluid right into the person’s hand. The person my look at their hand and see a tiny little hole on their palm and think it is very inconsequential, though this little hole allowed a very necrotic substance into their body.

The treatment for this (and only treatment) is immediate surgery. Immediate as in this minute, not let me call the wife/husband/kids first then I’ll go to the emergency room; this is get yourself to a surgical table NOW!! The surgeon would slice open your hand and start doing mass irrigation of the immediate involved tissues and continue doing this until the cows come home, then do it for another 4 hours.

Moral of the story: don’t mess with pressurized hydraulic fluid lines!!

Our patient was lucky enough to avoid having the hydraulic fluid injected into his body, but my preceptor was nervous enough (even 1.5 weeks post incident) that he made the patient return in 1 week to see how he is doing.

7/14/09: Looks can be deceiving…

We got the pathology report back for “Mr. High Risk” (see “6/29/09: Dimples aren’t always good”) which was a little surprising. Turns out our presumed squamous cell carcinoma from physical exam and history turns out to be nothing more than an itchy spot. “Lichen simplex chronicus,” read the pathology report. Going back to my trusty friend Fitzpatrick (derm book), this condition “results from repetitive rubbing and scratching.” Though Mr. High Risk denies every scratching at this lesion, he may be doing so during his sleep or without consciously realizing what he is doing. The now much relieved “Mr. –used-to-be High Risk” went home with a tube of steroid cream to take away the inflammation and orders not to scratch his leg anymore.

7/11/09: Bear Paw Festival

Bear Paw festival, your typical summer carnival but with a little Alaskan flair added:

1. To become a “Bear Paw Princess” you must, among other things, gut and fillet a fish
   
2. To win the “Slipper Salmon Olympics” you must open a can of soda (pre-shaken), pour it into a cup, place on a tray, carry the tray and a 20-30 lb. salmon through an obstacle course, toss all of this to your partner and he/she must race back through obstacle course
   
3. To win the “Outhouse Race” you must push the wooden outhouse on wheels with a “pooper” (a real person) sitting inside down and back on a race course.
   
4. To win the “stinky shoe contest” you must be a really dirty person
   
5. To win the “Dog and Owner Look A-like contest” you have to, well… you get it by now.

7/8/09: Don’t Bundle up!!

Evidently the insurance companies never listened to their mothers when they went out to play in the winter. You can’t “bundle procedures…”

So let’s say you have couple skin lesions you are concerned about and you make an appointment with a dermatologist and you say:

Pt.: “I have a couple moles on my back and on my arm, as well as a wart on the bottom of my foot.”

Me: “No problem, I can take care of those. I can do a shave biopsy of the moles, and I can freeze the wart with liquid nitrogen. But not today.”

Pt.: “Why not?!?”

Me: “The insurance companies will pay for a “clinical evaluation,” and they will pay for a “surgical visit,” but will not pay for both if they are on the same day.”

Pt.: “Ok… so I will schedule an appointment tomorrow.”

Me: “Great, which procedure do you want done tomorrow.”

Pt.: “What do you mean ‘which procedure,’ can’t you do them all tomorrow?”

Me: “These are 2 different types of “surgical procedures” and your insurance will only pay for one procedure a day.”

Pt.: “Ok… so I will have you take the moles off tomorrow and then do the wart the next day.”

Me: “Great, which mole do you want taken off tomorrow?”

Pt.: “What!?!” usually staring in disbelief at this point.

Me: “Since the nevi, or ‘moles,’ are the same billing code we can’t do the shave biopsies on multiple body parts on the same day, or the insurance won’t pay for it (sounding like a broken record at this point). We can do all the nevi on your back one day and the ones on your arm another day.”

Pt.: Ok, lets remove the moles on my back tomorrow, the ones on my arm the next day, and the wart the day after.”

Me: “Well… actually we have to wait 2 weeks between doing the shave biopsies on the nevi because they are the same diagnosis codes. We can do the shave biopsy of your back tomorrow, freeze the warts the next day (because it is a different diagnosis code), and do the shave biopsy on your arm in 2 weeks.”

…and so it goes with almost every new patient. If you do have multiple types of clinic visits or procedures in 1 day the insurance company simply picks the least expensive procedure or visit and covers that one but not the other. I think the goal of this scheme is to not allow a provider to do excessive and “unnecessary” procedures in 1 visit. I think the underlying goal is to frustrate the patient so much that they simply do not return for the procedures and then the insurance companies get to keep your money. Either way, all of these hoops that we all have to jump through are designed to keep money in the pockets of the insurance companies.


We as providers aren’t completely in the clear from all of this billing fiasco that our medical system is now deeply entrenched in either…

So lets say you come in to have a spot checked out on your forehead that has been concerning you. I take a look at it and say I’m not sure what it is but it would be a good thing to freeze it off. I can code for the “destruction of a benign lesion” and receive $300 for that procedure. OR… I can code for “destruction of a PRE-CANCEROUS lesion” and receive $700 for doing the exact same thing. If you are a business owner and you can sell an “apple” for $300, or you can sell the same thing as a “golden delicious apple” for $700, which one do you think you would sell??


Pretty soon everyone in healthcare will all be working for the Government in some form or another and we will be able to trade one bucket of issues for a whole new bucket of problems; but at least they will be different problems…

7/7/09: The unexpected…

So one of the first days I was at the dermatology clinic my preceptor offers to let me leave my lab coat in his closet while I am working there. I take him up on the offer and close the office door (which is almost always open) to get access to the closet. I am pulling out a coat hanger when I get distracted by a scantily clothed woman starring at me from the back side of the office door! The Sports Illustrated Swimsuit Calendar is hanging from the backside of the office door. This is additionally surprising because the office had just been re-painted and there was almost nothing back up on the walls as of yet, just the calendar hiding behind the door. Who would have thought… guess things are a little different up here in Alaska.

7/6/09: Worst acne ever!!

I am handed a chart by the MA who informs me that the mother is already requesting antibiotics for her son’s acne. I open the door expecting to see a mirror image of myself at age 15 suffering through school with constant pustules, cysts, and other eruptions.

2 papules (bumps), 3 macules (colored spots, no bumps) clustered around the corner of his mouth, all healing well and probably receding.

I look at the forehead expecting the hair hiding a few jems; nothing! I pull up his shirt to look at his back and expect to see a new constellation of acne eruptions; denied again! At one time I would have killed to have skin that looked like this, yet these 5 lesions were the center of his universe and he could not look past the mountainous eruptions of 1 mm each.

We give him some education on acne, some facial cleanser, and instructed him to come back if things got worse.

3 hours later it all became clear: The mother of the prior patient returned to the clinic with her “next” patient, her husband. At 33 he had been fighting adult onset acne for several years (and was relatively poorly controlled). Just more proof we are a product of our upbringing, and it is only as big of an issue as you (or your mom) make it.

7/5/09: Chugach Mountains, Alaska in the raw…

Jaw dropping, eye popping, mind blowing beauty! Chugach State Park was my first opportunity to get up close and personal with the backcountry of Alaska. (Check out “Chugach State Park” album under the photos tab)

Standing in the driveway of the house I am staying at, someone could blindfold me, spin me around, and tell me to start hiking in any given direction and I could very quickly hit some amazing mountains (or end up with wet feet in the Kink arm of the Gompertz Channel). On the hike today, Brian and I headed up Hiland Road about 7 miles to the South Fork Eagle River Trailhead. Brian was the second person to reply to my Craigslist posting; his family was away for a week and so was looking for an adventure to get him out of the house.

It was a relatively mellow hike with a gradual gain in elevation up to a pair of lakes, Eagle Lake and Symphony Lake. We were following the South Fork of Eagle River, a wide open valley seemed like perfect grazing territory for bears, though luckily we did not encounter any hungry bears on the hike.

We converted this mellow hike into a significantly more strenuous hike with the desire to stand on top of one of the peaks surrounding the lakes. We picked one out, kept walking past the end of the trail and found ourselves hiking straight up a 45˚ angle slope.

We had blue skies and a clear view of glacially carved beauty that surrounded us. Eagle Peak (6,909’) stood proudly due east from us, though we could not see the aptly named (and smaller) The Fledgling, or Raptor Point. We hiked about 15 miles and well over 3,000’ of elevation gain. One amazing day and a great introduction into the wilderness of Alaska, just 663,253 square miles of Alaska left to explore…

7/4/09: They weren’t counting on someone like me to show up…

All you can eat Salmon and fly by, at the Alaska Aviation Museum. Somebody didn’t think this one all the way through. $25 got you into the museum and all the salmon, burgers, hot dogs, and coleslaw you could eat. Colin and I took full advantage of the proposition, spending over 4 hours indulging ourselves on sockeye salmon.

We saw planes built in the 1940’s flying around, several float planes take off and land about 10 feet from where we were, and a lot of amazing feats of gravity. Some of the pilots started to not only buzz us just above our heads, but also banked into the turn so hard we could see entire top side of the plane.

Though the planes were amazing and unique, Colin and I did not allow any plane to interfere with our mass consumption of salmon. Each of us devoured about 7 servings of salmon and were never distracted too much by all the peripheral food offered up on the same table. I definitely ate my $25 worth of salmon!!

7/3/09: Hope, AK, population 137

The Eclectic Group #5, was what the trail register read after we left the parking lot. My housemate (and landlord) connected me with a few people from work who were going for a hike today: Jessie grew up around the area and knew many of the trails like the back of her hand; Shelby was originally from the Philippines and said she had only been on one other hike prior; Victoria was 64, an Alaskan native, and more vibrant than many 50 year old people I have met. In addition to this mix Colin (see note from yesterday) came along to round out the “Eclectic 5.”

The end of our hike put us about 7 miles south of Anchorage, but the drive was almost 1.5 hours. We jumped on the Seward Highway and followed along the northern border of the Turnagain Arm of Chickaloon bay (also connected to Gompertz Channel). This road is the ONLY road down to the Kenai Peninsula, is a one lane, and is carved out of a rock wall that comes right down to the ocean. This provides a multitude of rock climbing sites, but also makes the road less than perfectly straight.

After reaching the end of Turnagain Arm, and passing Alyeska Ski Resort, we turn back west to follow the same distance on the southern border of the Turnagain Arm. At this point we are almost due south of Anchorage and only a limited distance away as the crow flies. We have also driven past some amazing mountain ranges and glaciers up in the distance.

We blew through the town of Hope, with all 10 buildings clustered together it really wasn’t hard to miss. The road dead ends in a campground and we find the trailhead. This trail played right along the edge of the water, though we couldn’t see the ocean for most of the time. This is a temperate rainforest which receives over 1,400 mm of rain each year has a mean annual temperature between 39˚ - 54˚ F. This also means the trail is lush and overgrown with green biomass, therefore obstructing the view to the ocean.

During the times we did pop out to a clear view of the ocean, it provided an amazing interplay of green cliffs ending in muddy tidal flats, that gave way to the deep blue of the ocean, crowned by the snow capped mountains looming in the distance.

It was a great day of meeting new friends, hiking a great trail, and seeing some amazing sights.

7/2/09: Small world experience #539084

What did we do before Craigslist?? I posted on the Alaska Craigslist looking for other adventurers to get together for some exploration. The first e-mail I get is from a guy who is up here working on his masters thesis. He left his name and number on the e-mail so I dialed his number, and as I hit send his name popped up on my phone!! Turns out that I ran into Colin on the trail while riding bikes on Mt. Hood over a year ago. We had a great time riding bikes, but had never connected again until now up here in Alaska. Colin will be up here for about 2 weeks longer than I, and is just as excited about exploring Alaska as I am. Here’s to finding random connections in great places!

7/1/09: Old ladies in wet suits…

“We stick a bunch of old ladies in wet suits and take them down the river.”

This was the response from the guy sitting next to me on the city bus who was loaded up with all sorts of gear. I had asked him where he was going; he is a raft guide working up near Denali National Park. He explained that all the cruise ships dump their guests at Seward and some of them chose to take the train north and jump in a boat with him for 2 hours, then back on the train they go. Evidently it wasn’t a as extreme as rafting the Futaleufu in Chile.

7/1/09: Captured on film…

Just got this great video that was put together by the organizer of the Tour De Gulch. Jim, thanks for a great day of riding and all the amazing trails you have built out there in the Gulch!!

Check it out: http://writeteknorthwest.com/archives/1289/tdg-xii-draws-record-crowd

6/30/09: “$700 for a prescription! Is that right?”

“Julie,” one of the medical assistants hands me a chart with a phone message note paper clipped to it. The note says a patient called in wanting to know if the $700 price tag for the medication he just purchased was correct. My knee jerk reaction is “there is no way that can be correct,” but I pull out the palm pilot and call up e-pocrates which has all kinds of information about drugs including the MSRP of each drug. Aldara; for actinic keratosis or basal cell carcinoma. $524.96!! And this isn’t a life-time supply, this is 24 packets of cream to treat actinic keratosis or basal cell carcinoma for 1 month.

I sit back in disgust over the pharmaceutical companies and the incredible prices they can charge for medications; but I can also taste the amazing scallop and prawn curry dinner I had last night for free thanks to the manufacturers of Pioglitazone. I guess I am submitting to THE MAN already, but I am also a poor grad student. Maybe I will find my morals again once I am less than $150,000 in debt again…

6/29/09: Dimples aren’t always good

“Did Mr. “high risk” tell you it started out as a dimple 2-3 years ago??” my preceptor was reading over the note I had written for the patient encounter.

“Yes,” I say thinking it was a minor detail left out of the initial patient presentation.

“Well that pretty much confirms the diagnosis.”

I had verbally presented the case to my preceptor about 20 minutes earlier but had left out that little detail to highlight more of a description of the current lesion on his lower left leg. It was 4 cm by 3 cm, a non-healing, scaly wound that bled with scratching; and it was getting larger in the past 6 months. My provisional diagnosis was atypical psoriasis.

We looked at the lesion together and in consult away from the patient my preceptor provided the argument that we might be looking at squamous cell carcinoma (SCC). After reeling back from what would have been a missed diagnosis for me from a benign (though painful) condition to a pre-cancerous or cancerous lesion, I go and look up SCC again.

Not that it makes me feel any differently about possibly missing an possibly harmful lesion, Fitzpatrick (my guide and bible for the next 6 weeks) tells me I fell into a common trap: “SCCIS (squamous cell carcinoma in situ) may be mistaken for a patch of eczema or PSORIASIS and go undiagnosed for years, resulting in large lesions with annular or polycyclic borders.” From Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. This quote was about 2” above a picture of SCC that might as well have been taken of the gentleman who I had just seen.

In reading over my note in the chart, my preceptor commented that, “if you see a dimple that wasn’t there at birth, start looking for the cancer because it is there!” I vaguely recall this as being one of the 2 million and 52 “DON’T MISS” nuggets of information crammed down our throats in the past year, but this time it has stuck (and it didn’t require a lawsuit either).

6/28/09: The last frontier…

Looking out the airplane window I could see huge, snow-capped mountains shooting out of the water, islands with glaciers that looked like big white pillows that crumbled as they came down to touch the water. Miles and miles of endless beauty, in an area I have never been to before. I have never been this close to the North Pole. My mind fills with amazing adventures that could be had on the land down below; I have the strong desire to climb to the top of that peak, and that peak, and that peak, and…

I get my luggage, and come outside just in time to meet up with Erma. I am renting a room from Erma for the 6 weeks I am up here and she was incredibly gracious and offered to pick me up at the airport, give me the guided tour of Eagle River including a drive by of the clinic that I will be working at, and then sing by “Wally World.” Yes, in case anyone wanted to know, all the big box stores have started to infiltrate Alaska already. Wal-Mart is less than a mile from the house and I suspect I will be giving “Wally World” a lot more money than I ever hoped.

From a very early age Jack London provided me with numerous visions and stories about the last great wild area of the United States. The long flight, years of anticipation, and build up of the great wild of Alaska I almost believe I am in a different country (but all the familiar store names remind me I am still in America).

Eagle River is nestled right up in the mountains, with many “fingers” of mountain chains coming right down to town. It is clear the glaciers just recently finished their work of reshaping the mountains and disappeared into the ocean once again. The Knik arm of the Gompertz Channel forms the western boundary of Eagle River, and provides access to the ocean and the lucrative business of fishing. …And all of this is my playground to explore for the next 6 weeks!!!

6/27/09: Looking back through bars

• 217 inmates seen, 84 hours, averaging 7 per day
• Break down by race
  1. White: 52.1%
  2. Hispanic: 24.0%
  3. Black: 21.2%
  4. Asian: 2.8%
• Break down by gender
  1. 99.5%: male
  2. 0.5%: transgendered
• Top 10 Diagnoses:
  1. Allergic Rhinitis
  2. History and physical exam
  3. Affective psychoses (depression / bipolar)
  4. Cellulitis and abscess
  5. Back pain
  6. Hemorrhoids
  7. Sprains and strains of knee
  8. Dermatophytosis & Onchomycosis (athletes feet and fungal infection of toe nails)
  9. Diabetes Mellitus
  10. Essential Hypertension
• Top 10 Medications prescribed (by type)
  1. ENT (for allergies)
  2. Analgesics (pain meds)
  3. Dermatology
  4. Infectious Diseases
  5. Gastrointestinal
  6. Cardiology
  7. Psychiatric
  8. Endocrinology
  9. Urology
  10. Neurology

6/24/09: Top quotes heard from behind bars

“Doc, I gotta get a medical note to have a bottom bunk,” said within the first minute of the intake physical from the guy who has been in prison for 4 days and is already in a bottom bunk (he learns the system fast). This was followed 5 minutes later with, “Doc, you gotta clear me for work duty. I need to get a job while I’m here and I worked maintenance before.” All of this for a reported 10 year old meniscus tear in the right knee; a very unique injury that allows you the capability to do any kind of physical labor except to climb into the top bunk in your cell?!?


“Hey Doc, you know I only got 6 more days here,” says the little Asian man with an 8” pointy gray goatee.

“That’s great Mr. XXX. How many years you been down?”

“43 years.”

After the patient had left the room I comment, “He is going to have a difficult time incorporating into the work world. Just think about all the technological advancements in the past 43 years.”
This was followed by an eruption of laughter by both my preceptors and the simultaneous comment that, “He’s never going to work again.”


“Do you think HE has a uterus?” asked my preceptor after pimping me on the biggest concern of prolonged estrogen use. “Uterine cancer” was my knee jerk response, forgetting momentarily the “woman” in front of me was a transgendered person (M to F), sitting in an all male prison.

6/16/09: “I’m turning into a pot plant”

“I am getting telepathic messages. I am hallucinating. I have arachnophobia. I am losing my memory. I am turning into a pot plant. I am numb to feelings. I keep having nightmares where someone is trying to kill me; someone chopped off my arms and my head in a dream.”

This soliloquy was delivered to the panel of 4 of us sitting across the table in response to the simple question of, “how are you doing today Mr. Smith.”

He continues: “I have visions of being in an electric chair. I have visions of someone raping my mom. I have visions of raping a nurse.”

The psychologist redirects him at this point and reminds Mr. Smith that he has never raped a nurse and these are visions that are not real. This 33 year old man sitting in front of me is obviously dealing with some intense thoughts and can’t distinguish between dreams, visions, and reality. His thoughts are on a different plane than you or I think. He is clearly in turmoil. I am glad there is a psychiatrist sitting next to me who knows what to do in this kind of situation. Right?!? What do you do in this situation?

The psychiatrist mostly sat, listened, and after taking in this truckload of loaded statements, says that we should increase the Risperidone dosage. WHAT!! NO crisis counseling? NO intervention? NO resetting the framework this person is using to think about things? I don’t have any experience with someone who is this deeply affected by Schizophrenia, but I have to believe that there is more that can be done in the acute setting such as this one; I just don’t know what!

This was the 6th or 7th patient we had seen today. We were a formidable bunch the inmates walked into. We were in a standard conference room with 1 large wooden desk in the middle of the room with several chairs around the table. The inmate would be escorted in by the nurse and take a seat in the middle of the table closest to the door. Directly opposite the inmate was the psychiatrist; he was an older gentleman with a friendly face and a brightly colored Hawaiian shirt depicting images of Caribbean islands, airplanes, and vacation get-aways. “Are you serious,” is my internal reaction; thinking about vacation get-aways is the farthest thing from the daily routine for these inmates.

I am sitting on the left flank of the psychiatrist wearing my white coat helping to create a foreboding wall with the nurse who is on the right flank wearing his duty uniform including a white shirt. The psychologist is sitting next to the inmate and directly across the table from me. He has disheveled hair, crooked and bent glasses, and a slouching posture that I imagine is from the weight of being responsible for 2000 inmates.

We are a wall of authority and far outweigh the power of an individual inmate. Most of the encounters were about 5 minutes and consisted of, “how are you doing today Mr. so-and-so?” “Feeling more depressed? Lets increase/decrease/change/or otherwise alter your medications.” Next. “How are you doing today Mr. so-and-so?” “Feeling more depressed? Lets increase/decrease/change/or otherwise alter your medications.” Next… and so on. How can we expect an inmate to come in and within 5 minutes reveal his deep dark thoughts and help identify what the best treatment might be for him? I don’t think I could get in touch with my personal feelings within 5 minutes, let alone talk coherently about them to a bunch of strangers (and they haven’t diagnosed me with a psych disorder… yet!)

6/2/09: Found it!!!

Summit has now discovered the great benefit of playing Frisbee in a field immediately adjacent to a river: 1) catch Frisbee, 2) run down to the river, 3) jump in and get all wet, 4) bring Frisbee back to someone with an arm, 5) repeat.

Problem is, multitasking is not one of Summit’s strong points (actual sequence): 1) Jump in water, 2) put Frisbee down, 3) shake off all the water (Duh! Forgot to get out of the river first), 4) look for Frisbee I put down right in front of me (in a moving river mind you), 5) spend 10 minutes in shoulder deep water looking like an ostrich with my head underwater searching for the Frisbee, 6) FOUND IT!!! Run up to Aaron and extremely proud of my re-found toy, and proceed to shake all over Aaron (on solid ground).

Not the sharpest crayon in the box, but he’s my “crayon.”

Note on upcoming rotation in Alaska:

Preceptor e-mailed offering to be called Tom or “T.” I suggested I could call him “Mr. T” so we could “Mr. T and the ‘A’ Team”

6/1/09: 60 days in the Hole…

“I am here to pick up my knee brace. They didn’t give me the brace at last visit.” Says the second patient I have seen for triage that morning.

Ok, so I’ll pull up the old chart, figure out what happened, and go from there. Nothing documented for the past several months for any sort of knee injury. Nothing about a knee brace for the Pt..

“Dr. ‘Doolittle’ said there should be a knee brace waiting for me.”

“There isn’t any visit for your knee documented in your chart. I can schedule you for another appointment to examine your knee and determine if we need to give you a knee brace at that point.”

“This system doesn’t do anything for you!” Followed by many more lively comments about “the system.”

“I can offer you two options: 1) schedule an appointment to look at your knee, or 2) you can leave without an appointment.”

“You don’t know anything. I demand to talk to Dr. ‘bail-me-out’” followed by many comments about “the system,” and now me as well.

“Dr. ‘bail-me-out’ said you have two options: 1) schedule an appointment to look at your knee, or 2) you can leave without an appointment.”

“F-you!” “you are a piece of sh**!” …and add your favorite string of expletives that raised in volume as the inmate walked through the waiting room full of other inmates.

Ten minutes later: “inmate ‘swear-too-much’ report to the closest staff member,” came for the compound wide intercom system.

60 days in segregation (or more): 1 hour of interaction with others and time outside of your cell. No phone calls, no prison store privileges, nothing but you, yourself, and concrete. If this is a repeat occurrence, it’s off to a higher level security prison for you.

Note to self: if I ever find myself in prison and want to curse out someone, don’t!!

5/30/09: I think they are PA’s…

Riding bikes in Tillimook State Forrest: 18 miles of amazing singletrack bliss! Met up with a big group ride and so some friends I hadn’t seen for a while. At one of the breaks a group of us split off to do an extra loop of technical riding. I meet back with the group to see we had grown in numbers. “Hey, you should go talk to those two women over there. I think they are PA students.” Not only PA students, but first year PA students at Pacific University out to explore the trails around school after the first week of classes. Here’s to random meetings in the middle of the woods.

5/29/09: The follow up…

My gentleman who decided not to show up to any of his appointments was finally brought into the clinic. So how do you tell a person that HIV is winning and that his body is losing? How do you tell someone this information when you have never met them before?

I decided to go through a quick history physical exam looking for any signs of opportunistic infections and to try and build a rapport before breaking the bad news to him. Note to self: don’t ever try this method again!

The patient began to become very suspicious of me and frustrated that he did not know why he was here and why he was not seeing the doctor he normally does. I had to start from ground zero and explain my training, my role here at the prison as a student, and why the doctor was not seeing him today. He relaxed, ever so slightly. I broke the news.

I discussed his CD-4 count and viral load and talked about what this meant.

He looked caught off guard.

I offered the pros and cons of starting the anti-retrovirals for HIV.

He was hanging on my every word.

We talked about his health and what he can do to help his body fight off the HIV.

He was completely invested in doing the right thing

At the end of the visit I said, “thank you for being willing to work through this with me.”

“That’s all right Doc. I am just nervous about my health, and I didn’t know what your experience was. You’re all right”

As we were walking out he is joking around with me; his face has completely softened and I can see the smile lines shine through his weathered face. I feel like he and I just ran a marathon together and we have made it to the finish line, but for him the race is only beginning.

5/26/09: The missed appointment

I have skipped appointments too. But I wouldn’t miss the appointment that was going to tell me that my CD4 count is too low and I need to start treatment for the HIV virus that is taking control of my body. I have missed appointments too. But I wouldn’t miss the appointment that would tell me that my liver is starting to fail but I can’t receive treatment for my Hepatitis C because my HIV CD4 count is too low and my body can’t handle both treatment regimes at once. I don’t think I will ever miss an appointment again.

5/26/09: Week of NSAIDs and a brace…

It is 15 minutes before I am supposed to be escorted out of the prison by my preceptor. There is a patient with a knee injury to be seen. He has been grinning and bearing it for 5 days now. He was too much of a man to come in Friday, Monday was a holiday, and today is the first time there has been “sick-call” since his injury. Others are packing their things and making a dash for the door. I call him back and hear out his story:

“I planted my foot, but the rest of my body kept rotating. I heard a big pop, my knee came out of place and then it popped back in. I feel like my knee will give out when I am walking.”

So this isn’t going to be a simple cough and cold done in 10 minutes, is it?

This guy needs a thorough assessment and careful deliberation on the severity of his injury. I have 5 minutes to make it out the door with my preceptor or wait around until the next person can escort me out.

Decreased range of motion on the left. Pain on medial side. Anterior drawer and posterior drawer tests negative (no ACL / PCL involvement). Negative varus stress test (LCL is good). Positive valgus stress test on the left (MCL, not looking so good). Positive Apley compression test (looks like the meniscus is damaged too, good job!)

MCL is damaged and probably took a piece of the meniscus with it. Ok, so this guy needs an MRI to determine the extent of the injury. I’ll X-ray first to rule out bone involvement…

“What is the protocol to get an MRI done on an inmate?”

“You have to do a week of NSAIDs (ibuprofen), a brace, and then you can make another appointment.”

“…and if I have a strong suspicion of significant ligament damage?”

“week of NSAIDs and a brace.”

The look on this guys face was priceless when I told him the plan. He dealt with this pain for 5 days, but he didn’t deal well with being put off by the Federal Bureau of Prisons for a week. I handed him two 4” ace wraps (which wouldn’t do much of anything for a guy this size) because the staff member was running out the door and didn’t have time to look for 6” ace wrap or, more appropriately, a knee brace proper. You’re on government time, even in the medical world.

Net result: 1 likely torn MCL and meniscus injury of the knee, 1 X-ray, 2 flimsy ace wraps (designed for the knee of a 12 year old girl), and a script for meds that will probably just punch a hole in his stomach. Thanks Uncle Sam!

5/23/09: How white is your trash?

So I am living here at River’s Edge RV Park in Willimina, OR about 10 miles from the prison. I made the reservations sight unseen. I roll into the dirt driveway and see the gate house (a small trailor 15’ x 6’) that looks to serve as an office. There is a piece of paper in the window to see the manager in site 24. There is a community bath house consisting of 2 shower/bathroom combinations, and 1 room with a washer & dryer; all of this, mind you, in a trailer itself (of course). We even have the dude with a bad-ass handlebar moustache, and a black El Camino missing the front bumper. There are probably 30 to 40 RV’s parked here, and probably fully 75% of them may not have moved in the past year. Several RV’s have mini wooden patio’s attached to the side, or potted plants surrounding the base of the RV, or multiple outside plastic storage closets. These are very clearly permanent residents, not your vacationing couple rolling in the $100,000 mobile luxury home. Smoking and obesity are at epidemic levels here in this little microcosm.

Summit is in heaven being that there is a huge mowed grassy area about 20’ from our RV and a river that travels along the far side of the field. After an intense game of playing frisbee Summit can jump into the water to cool off, come out refreshed are ready to chase frisbee some more. What more can a puppy ask for in life?

Greatest RV park quotes so far:

1) “Where is he going in all them clothes?” said about me in professional dress, from the lady wearing a turquoise tank-top, a different shade turquoise sweatpants, and slippers, sitting in her small patio smoking a cigarette.


2) “Shut-up Scruffy,” said by the same women in turquoise to one of her 4 yappy dogs all under 15 pounds. “Shut-up Scruffy!” “Shut-up Scruffy!!” “Shut-up Scruffy!!!” “Harold, tell Scruffy to shut-up!”

“You tell Scruffy to shut-up!” Says the man in response.

“He isn’t listening to me. YOU tell Scruffy to shut-up!!”

5/21/09: It’s 4:30 am, do you know where your bed is?

My alarm goes off. It is 3:45 am. I go through the mechanics of getting up. I let the dog outside. I put food in my mouth. I get dressed for the cold, dark morning. I find what I need for the day. I put it in a bag. I find myself sitting on top of a bike. It is 4:30 am. I am pedaling in the dark. The cold air is invigorating. The cold wind and the increased blood flow to my muscles gets me moving. I look down the road due west. The horizon is beginning to lighten. I look to my left. There are gorgeous rolling hills covered in rows and rows of perfectly aligned grape bushes. I am in the heart of Oregon wine country. There is a mist that rises up from the dew on the grass and hovers about five feet off the ground. I look back to the horizon and there is a magnificent orange glow beginning to form welcoming the new day about to begin. Suddenly there are huge light towers rising out of the earth shining down on an expansive compound of buildings and barbed wire fences. I am alive and well after an invigorating 10 mile ride into work. This is the way the day should start every day.

5/19/09: Prison life

The cold, hard, steel door slams behind me, and the one in front unlocks and opens up into a court yard. There are flower gardens, a beautifully manicured lawn stretching between me and the next building, and the sun is bright and gorgeous shinning on everything. Is this really prison? The only indications are the few men in all tan outfits working in the courtyard.

Where are the armed guards? Where are the snipers’ towers that can shoot down any man at 500’? Where are the gigantic, towering cement walls shadowing over everything that are so impenetrable?

My first impression of this prison is that it is aesthetically beautiful. I later learned that this was one of the last prisons grandfathered in to allow flower gardens and landscaping within the walls of the prison. This facility will be 20 years old in one year. Inside the buildings they are clean, well lit, and well taken care of. The inmates can get jobs to earn small amounts of money by working in food service, janitorial services, or even (in some circumstances) watching other inmates who are on suicide watch.

“Have you been involved in activities that are high risk for getting Hepatitis?” questions my preceptor.

“No,” says the 40 year old inmate wanting routine screening labs.

“Did you get those tattoos here in prison or on the outside?”

“Here,” says the inmate with tattoos completely covering both forearms, and I have no doubt much more of his body.

“That alone puts you in the high-risk category for getting hepatitis. You know that don’t you?”
There are no tattoo parlors in prison, only improvised needles with the ink from ball-point pens that are often shared among many inmates.

I had the preconceived notion that all of my patients would be coming in after some huge brawl, or some contagious disease that has spread throughout the compound; not so. These guys are just like any other patients: strained back, runny nose, headache, rashes. The only difference is that these guys aren’t very original in the clothes they wear (tan is very popular), and they don’t travel very much.

5/17/09: Scrape, scrape, scrape…

I have never done this much scraping in one day prior in my life. Most of the day was spent scraping all the old and cracking sealant off of the RV and applying new sealant. A few months ago I paid someone (way too much money) to reseal the roof because of a leak. Now I am paranoid of water and I am waging a personal battle against all water to never enter the inner workings of my RV again. Every window, vent, seam, or other possible water inlet has now been completely scraped clean and re-sealed with white magic.

5/14/09: Anticipation…

One week testing all of our knowledge we have learned over the past year: how to look like you are completely engrossed in what the lecturer is talking about, while in all reality being completely disconnected. This is the final week we have the comfort of sitting in class before we will face patients in person and the real test begins.

Over this past week my feelings have ranged from complete excitement, to complete fear, to complete confidence, to complete ignorance, and back again. My guess is this was a micro-rollercoaster that will mimic the entire clinical year to come.

Regardless of what my anticipation may be, the time is drawing near and in only a few days I will be applying my knowledge base and will have the responsibility of making judgment calls that influence people’s lives and can write prescriptions that can kill with the stroke of a pen. This scares the hell out of me.

5/9/09: Tumalo or bust

Yesterday was one of those great epic days of riding bikes that only come around once in a great while. New-to-me trails, amazing weather, and perfect trail conditions: tacky enough you can really lean into every turn with complete confidence your tire will hook-up with the trail with ease, but not too wet to get create mud holes.

The trails in Bend are clearly made by people who ride bikes. The trails slalom through the trees, taking every opportunity sweep through the natural curves of the land, and if there is a natural rock element to increase the level of difficulty, the option is there to go up and over instead of around. My goal was to reach Tumalo Falls which is fairly high in elevation and with the run-in with snow 2 days prior I wasn’t sure if the trails would be clear. After riding over several patches of snow I popped out onto the road to finish the last 3 mile push up to the falls. It was a majestic sheet of water cascading over a cliff with a gorgeous run-out heading downstream.

Rolling back into camp after riding 35 miles my legs were fighting the twinges of cramping but the conversation of fellow bikers at the trailhead lifted my spirits and re-instilled the excitement for the ride the next day. Feeling guilty that Summit had been in the RV while I was out playing, I turned around and completed another 5 miles for Summit to stretch his legs.

Today was spent searching out the “technical trails” of Bend. To this point the trails have been amazingly smooth and with short sections of rocky, technical areas. The first thing out of everyone’s mouth after “where are the technical trails” has been C.O.D. (Not sure if that is in reference to any rental bike that is Cash On Delivery post riding this trail or not.) It is a great trail with many more rocky sections than other trails I have ridden in Bend, though the Colorado trails could teach the Bend trails a few things about rocky, technical sections. It was still another amazing day of riding with great flow to all of the trails.

Three days of solid riding; I am heading back to Portland area for one final week of classes before the clinical year begins.

5/7/09: Pole Position

Bend is known for its amazing mountain biking, and tomorrow I will be waking up about 50’ from the trail that accesses most of the trails in the area. Not bad.

Today was spent riding the Mrazek trail, basically riding 12 miles up a gradual, but steady grade, on amazing singletrack, finding lots of snow, then bombing back down to the trail head. This trail had great flow, lots of burmed turns, and miles of twisting singletrack. Summit is a trooper, but 12 miles of constant descent after 12 miles of climbing, and the extra 12 miles he runs while I am stationary and taking a break took a toll on him and he was a little slow on the final miles of the ride. I think Summit will get a rest day tomorrow.

There have been a few unexpected problems of being an RV owner, but there have also been some great unexpected perks of owning an RV. Case in point: I come back from a ride all sweaty, dirty, and smelling something less than a bed full of roses; 10 minutes later I am fully showered and ready to hit the town in style. A few minutes after taking a shower I grab the leftover pesto pasta and chicken sitting in the refrigerator and have a full belly; and all of this without leaving the trail head. Pretty damn cool!! Tonight I moved over to a different trailhead and have enough water and supplies to live and shower here for the next few days. I don’t think I will ever go back to living in one of those confining and stationary houses again!!! (I’ll try to remember this feeling when the next RV mishap comes down the road again.)

5/6/09: Wally World night #1

My first night living Wal-Mart style! I rolled into the parking lot at 9:30 pm and found myself parking next to 8 other RV’s.

Mother Nature had something else on her mind than biking today. I woke up to intense rain in Hood River, spent a few hours at Dog River Coffee shop and decided to start heading south to Bend and drier weather. After being blown nearly off the highway multiple times, I did the touristy thing on the way down and stopped by the Peter Skene Ogden Viewpoint; I even parked in the RV parking lot. This was a deep canyon with 300’ cliff down to the river. Summit didn’t like the sign that read, “many dogs have died here” with a picture of a dog jumping over the guard rail! The second stop was at Smith Rock. This is the classic rock climbing place in Oregon and is a little slice of Moab, UT. A gorgeous area with many rock spires, cliffs, and other great rock formations including the “monkey face.” After a trail run / hike around Smith Rock, we headed down to Bend for the night. Time to finally get two wheels on the trail tomorrow!

5/5/09: RV life living to the fullest…

This is the RV life. I have the week off, a full tank of gas, a full tank of fresh water, and am off to find adventure. I write this while sitting in my RV, off I-84 a few stops before Hood River. Summit and I made it out here late afternoon and found a great trail to go hiking and exploring. We found one of those crazy mountain goat trails that goes straight up the hillside with no regard for elevation gain. Today has been the life of a true vagrant. I left Hillsboro with little plans other than to get down to Bend, OR to go ride bikes in the next few days. I found this wonderful sidetrack, and having no itinerary, pulled off to go exploring. Tomorrow I will ride here in Hood River and then probably head down south to Bend, but if the road convinces me to go somewhere else, I may go there.

Post hike tally:

Aaron - 3 ticks

Summit - 11 ticks, Summit wins!

5/3/09: The final weekend

Friday 5/1/09, 11 am, take a shot with my classmates to celebrate the end of the clinical year: check. This was the official end of didactic year of school!! Only one more year to go. The weekend commenced with the Super Hero party/BBQ at a classmate’s house. The party really got going when we all tried to use our super powers and make it through a 3-legged race, dizzy-bat, or other crazy race. This was followed up by a “crazy wig” party on Saturday that was equally as insane. This party was punctuated by the placement of a roman candle stick into the BBQ air vent with everyone running for cover… All houses in the neighborhood were still standing in the morning so it must not have gotten too crazy later in the night. I took full advantage of having a house on wheels this weekend and strategically parked near the party, my liver, however, is now paying dearly for this maneuver.

4/26/09: Update on dirt bike victim

C1, C2, C7 spinal fractures, widespread brain injury, abdominal bleeding, mandible (jaw bone) fractured in 2 places, and dissection of both carotid arteries and 1 vertebral artery (translation: 3 of the 4 arteries supplying the brain were stretched and torn, but did not tear completely through – he was incredibly lucky). He is in the ICU and his condition is improving. He is able to initiate taking a breath (though the ventilator assists his breathing), he has had motor reflexes in all four extremities, and purposeful movement in one arm. He is doing amazingly well considering all the injuries he sustained. My thoughts are with him and his family.

4/24/09: Run-in with the cops #2

This time they weren’t after me… I wake up this morning to find a police car parked on the street in front of me. In a few minutes there were a total of 3patrol cars. Turns out a neighbor had tied a cat to a tree, but the rope broke so the cat was running around with a rope attached to him. Unfortunately, the cat tried to jump a fence, the rope snagged on something, and the cat used up it’s 9th life. This is one of those stories crazy enough that you can’t make it up, but live in a “van down by the river” and you will probably find plenty of crazy stories like this one.

4/21/09: Clinicals have started early…

We just completed Advanced Cardiac Life Support class and were released at noon. A classmate and I take full advantage of this and head out to Tillamook State Forest to enjoy an afternoon of mountain biking. We are at the end of the ride about 1 minute from my car when a guy on a dirt bike asks the classic question that either pumps you full of adrenaline or strikes fear in your heart: “do you know first aid?” We found his riding buddy on the trail about a ¼ mile away. Un-witnessed crash from his motorized dirt bike wearing a helmet. Unresponsive, even to pain, with gross amounts of blood coming from the mouth, nose, and ears. Gurgling respirations at 30/min, and heart rate at 80/min. Obvious abdominal injury, and thigh injury, with clear signs of a massive head injury. My classmate and I controlled the airway and took spinal precautions as best we could, and with the help of a prison crew that just happen to be nearby, carried the patient to the trail head on a folding cot. The ambulance arrived, intubated the patient, and whisked him off to the waiting helicopter.

4/7/09: Hard knock life lesson #584923

I am now living about 1 mile from school; I found the connection through a second year student. Again, I found myself backing into the location at about 9pm, but this time I fit. My new landlord hands me an extension cord and agarden hose, more excited about getting some food and then crashing out for the night I get everything hooked up and go inside the RV. Everything is working out well, finally. But then… I wake up the next morning, take Summit outside and hear water dripping. There is a constant stream of water dripping out from the back panel of my RV under where the garden hose connects into the RV. I have a sudden, deep, sinking feeling as I realize that I had not connected the flow regulator still attached to my garden hose safe in storage… $100 later I have a new ball valve to replace the one blown out by high water pressure and hope there has not been too much water damage done.

4/6/09: Bliss only lasts so long…

Part of the vagrant lifestyle is that your home is wherever you chose to park. That is why I don’t understand why I am commuting over 1hour and 15 min. one-way to get to school. Much respect to my classmate who has survived almost an entire year with over 2 hours of her life every day spent commuting; I wouldn’t have made it! Also, the closest sanitation dump location is back in Beaverton. Who know it would be so hard to get rid of your sh**! All things considered, I am trying to procure a location closer to school to park the RV.

4/3/09: The bail out

One of my classmates was incredibly generous, and willing to take in a vagrant who is looking to park a set of wheels. I am now parked in NW Portland and have a legal place to park, electric and water hook up, and great neighbors.

4/2/09: I’m too fat

After last nights encounter with Beaverton’s finest, I decided I needed to make it over to my friends house in Portland where I had it all set up to park in his driveway. After finally making it over to his house at 9pm I proceed to start backing in. Long story short, his house has a significant overhang encroaching on the driveway and a solid wood fence on the other side. If the overhang were 5” taller, or the fence 12” over it could have worked. Since neither of those were the case, night #2 was spent parked on the street near his house. No cops this night, Yea!!

4/1/09: Run in w/ the law

Technically I am homeless now. My first night living in the RV was abruptly interrupted at 2:30 am by the banging of a mag light on my door, firmly held by a police officer. We will get to that story in a minute but first a little background…

I am currently enrolled in the Physician Assistant Program and am about to start the second and final year of the program. This first year I have been sitting in a classroom for 7 hours a day, 5 days a week, attempting to cram mass amounts of information into my brain. Now that my brain is completely saturated with random facts, and most of the information has leaked out by this point, it is time to put it all together during the clinical year. During the second year, every 6 weeks I will be starting a new rotation that can be anywhere in the United States including Alaska or Hawaii.

I have very little control over where my rotations will be, I am responsible for finding housing for 6 weeks, and for transportation between rotations. I also have a faithful companion and side kick in my adventures. Summit, my yellow lab/golden retriever mix has been a constant companion and that was not going to miss out on the adventure of the coming year. Considering all of these factors, and to avoid paying pet fees at every location I decided to purchase an RV.

I bought a 24’ Class C, 2000 Four Winds Majestic RV in mid February. I purchased it from a private owner and despite having paid $200 for a “buyers inspection,” I have encountered numerous little “unexpected gifts.” (Do NOT ever trust the work of Lassen RV in Albany, OR) One month after the title was in my name I noticed significant and active leak in the roof that was allowing water to accumulate in the walls of the RV. A quick visit to the local RV dealer (not Lassen RV) revealed numerous indications that there has been longstanding water damage to the walls of the RV over the cab of the vehicle, as well as many other locations. The bottom line; over $5,000 to fix the leaks correctly, or over $500 to simply stop any further water leaking in. $500 worth of resealing and I was back on the road again.

At midnight on 3/31/09 my roommate and I finished cleaning our apartment in Beaverton, OR. That is when I officially became homeless. All of my material possessions were now either in my RV or in a storage facility nearby. My first night in the RV I decided to find shelter under the comforting wing of a local church’s parking lot; evidently they don’t take to kindly to vagrants. I was awakened by the loud thump of a mag light on my door and the disco ball effect of the police lights on the RV shades. Summit, being new to his surroundings, just about hit the roof secondary to the rude awakening. After a little smooth talking, I was able to keep the RV parked where it was with the promise of moving in the morning and saying three hail Mary’s.

The laundry list of what is stuffed in my RV:
1. Yeti 575 mountain bike
2. Klein road bike
3. Trek commuter bike
4. Panniers for commuter bike
5. Tent
6. Sleeping bag
7. Hiking boots
8. Backpack and all the gear to go backpacking
9. Pair of telemark skis
10. Ski boots
11. All of the gear to backcountry skiing
12. Climbing harness and chalk bag
13. Basic rock climbing equipment
14. A few books to make it look like I am smart
15. 2 lawn chairs
16. Enough refrigerator space for a case of beer
17. And 1 gecko attached to the side view mirror

7/12/09: Catch up...

I have been pretending to blog on my facebook page, and have finally decided to jump ship and start an actual blog. The following mass posting will be an effort to get this blog caught up with 3 months of "blogging" done on facebook.

If you have already been following this saga on facebook, kick back and wait for the next real-time posting. If you have not been following on facebook, stop reading this pos and start getting caught up...