Monday is a typical day in wound care. I perform forearm squamous cell excisional biopsies. and suture the 3 cm incision. We chat about reimbursements. Wound care can be quite lucrative from debridement and graft procedures and marking up devices. “Our wound care clinic is not greedy,” said Daniel Boone. “We frequently use devices that are not reimbursed. The patients love the SNaP vacs [Smart Negative Pressure, a disposable mechanically powered vacuum]. If their insurance won’t reimburse for a stem cell-based graft that has a chance of working, we’ll find leftovers from another patient. We make enough from the debridement and graft procedures to make it work. Administration at the rural hospital gives us a little more wiggle room compared to the [flagship hospital].”
Lunch is provided by a salesman from a home health agency. Most wound care patients require help at home with 2-3 times per week dressing and re-wrapping. The 45-year-old rep comes in with his company’s head nurse and food that we’d selected earlier that morning. While eating my $24 ribeye, I learn that this agency provides coverage seven days/week in our rural area, that they have two certified wound care nurses, and that a nurse will answer a help line 24 hours/day.
Clinic ends at 4:00 pm. Daniel Boone and I drive 45 minutes in his pickup truck to a trailhead. We are joining a continuing medical education (“CME”) course in which the wilderness medicine week attendees backpack for three days with evening lectures in the field. We hike for two hours to meet the class at their Day 2 campsite just as it is getting dark. I set up a tent while Daniel Boone strings his covered hammock cocoon between two trees.
At the campfire, we join 25 attendees from across the country. Half are emergency medicine physicians; the rest an assortment of general surgeons, orthopedic surgeons, and internists. The course is led by four EM physicians, two of whom regularly work at the Mount Everest base camp. We learn how to construct a rope carrier for an immobilized victim in the field. Around 8:30 pm, Daniel Boone gives a 30-minute lecture on tick-borne illness. I prepared some remarks on alpha-galactose hypersensitivity reaction (“alpha-gal”), an increasingly common allergy to red meat that leads to “midnight anaphylaxis” (delayed reaction).
Daniel Boone, a 35-year-old EM physician, a 55-year-old general surgeon who works in a rural hospital and I stay up late chatting around the fire. The EM physician got married last year at the Everest base camp. She explained that she works extra shifts when she’s home so that she can spend one third of the year in the mountains while earning a full-time income. This is doable in EM because a full time schedule is only twelve 12-hour shifts per month. The general surgeon covers a 50-mile radius in rural Tennessee. “I love it. I get to do things I would never be able to be able to do in a larger hospital. It makes no sense. I’ve been doing C-sections, amputations, and complex hernia repairs for 15 years, but good luck getting credentialed by clueless MBA administrators of big health systems.”
We wake up at 4:30 am to hike back in the dark, but we’re still late to clinic. We skip our showers and change into scrubs.
Friday: Daniel Boone is a certified provider of hyperbaric oxygen therapy (HBOT; requires only a weekend course). “Almost everyone can benefit from HBOT,” he says, “but patients are limited by insurance coverage.” Insurance approves HBOT for refractory soft tissue injuries and radiation injury (e.g., proctitis after prostate radiation), but physicians are experimenting with a wide range of conditions. Daniel Boone is testing HBOT on a chronic Lyme disease patient, for example, and believes that stroke patients will also benefit from HBOT. “We don’t have enough chambers for the demand.”
Our institution has small individual hyperbaric chambers that hold just one person at a time. If the patient starts choking or simply panics due to claustrophobia, the staff has a 5-minute decompression protocol to get the patient out of the 3-atmosphere, 100-percent oxygen environment. (3 atm is the pressure experienced by SCUBA divers 100′ below the surface.) “It’s a massive bomb.” I expected to see the chambers located in a specialized room; instead, the chambers are behind a curtain next to the nurses’ station. Patients are patted down before going in to ensure no jewelry or flammable materials are worn.
One future candidate for HBOT is convinced that she was bitten by a brown recluse (Loxosceles reclusa) super spider that started her chronic, bilateral lymphedema ulcers (conventional medical wisdom would attribute these to her morbid obesity). This is her initial consultation at the wound care clinic. “DHS interviewed me. 14 people were bitten; I was the only one who survived. The superbug was engineered by a foreign government and is a test biological weapon.” Daniel Boone, “This is the beauty of being a specialist. Her PCP can deal with her concerns about DHS and the spider.”
Daniel Boone is able to wind up clinic by 3:30 pm and fit in two house visits that had been planned for the weekend. The first patient is a 30-year-old overweight diabetic female struggling with a cesarean section incision from three months ago. “We were using Dakin’s (dilute bleach) wet-to-dry dressings until I was able to get a fresh supply of SNaP vacuums. Once she got negative pressure, the wound started to make progress.” He explained, “It’s just easier for the family for me to go to the house and change the dressings and restock them with gauze and silver and silicone dressings for the husband to apply.” Our second home visit is with a debilitated 30-year-old with severe mental retardation and skeletal malformations. He is unable to speak, cannot walk, and is dependent on a ventilator and feeding tube. “It’s really a tragic situation,” says Daniel Boone. “I keep calling him a child but he is a grown adult. The parents shouldn’t have continued to care for the child, but those goals of care discussions happened years ago. We’re here to deal with a stubborn sacral ulcer that is to bone [has eaten through skin and tissue and is now destroying the bone].” Although the parents have been turning the patient every hour, even in the middle of the night, and providing hospital-grade care, the ulcer continues to expand from too much pressure combined with malnutrition. “My plan is to debride some of the bone and put a wound vac on,” says Daniel Boone. The father works overtime to fund what is essentially a mini hospital in the house, but the family was still struggling financially despite Daniel Boone’s provision of complimentary wound care materials. The mother is on duty 24 hours/day, 7 days/week. She dismissed the home health nurses due to their not being as competent as she is. “They would have learned about these genetic defects in the second or third trimester of pregnancy,” says Daniel Boone, “but the disorder does not have a name or a well-understood prognosis. By the time the mental prognosis was revealed, he was part of their lives.”
Daniel Boone sends me off with a weekend Advanced Wilderness Life Support (“AWLS”) certification course that he is helping to teach. Practicing physicians, medical students, Physician Assistants, Nurse Practitioners, and EMS personnel from all over the country gather in our medical school’s auditorium. I thank him for signing me up and paying the $245 cost. He responds, “This is a great learning opportunity, I did not want you to miss it. Pay it forward when you’re an attending.”
Type-A Anita’s Facebook opinion on the climate protests of 2019:
Greta is great, but if we’re only centering and uplifting white youth leaders on an international scale, we risk recreating the exact same dynamics of instilling a culture of white supremacy and silencing BIPOC [Black, Indigenous and People of Color] voices that is present in modern, adult organizing spaces. We must work to center the most marginalized voices, especially since Indigenous youth and young adults have been tirelessly leading the fight for climate justice for millennia. So here’s a list including other amazing young climate organizers and activists! …
@Isra.Hirsi [16] is the co-founder of the U.S. Youth Climate Strike and the daughter of Congresswoman @Ilhanmn. She says the climate crisis “is the fight of my generation, and it needs to be addressed urgently.” [via @vice] …
@GretaThunberg [16] is a Swedish environmental activist attempting to hold politicians to account for their lack of action on the climate crisis. Greta is known for speaking about her school strike activism and having Asperger’s. She is currently organizing #FridaysForFuture all over the world saying, “Everyone is welcome. Everyone is needed.”
This was the same week that the Trump administration disagreed with “everyone is welcome” and “everyone is needed” by proposing to cut the number of refugees admitted as immigrants to the U.S. Anita responded: “fuck the patriarchy. fuck white supremacy. fuck trump and his supporters …did I miss anything.”
[Editor: all refugees are immediately entitled to Medicaid, so Anita’s passion for refugees could simply be a desire to maximize her future income.]
Statistics for the week… Study: 4 hours. Sleep: 8 hours/night; Fun: 2 nights, both after the AWLS class. Instructors and attendees go to a local brewery with live music. A PA from Colorado: “I feel like whenever I go to these wilderness medicine gatherings, the presenters are longing for a disaster to hit so that we can apply these skills.”
The rest of the book: http://fifthchance.com/MedicalSchool2020
> Anita responded: “fuck the patriarchy. fuck white supremacy. fuck trump and his supporters …did I miss anything.”
How can people who express values like this be allowed to practice medicine in the United States? If they have such obvious and deeply-held and complete hatred for those who may become their patients through no action of their own, how can a licensing authority let them do it? This verges on hate speech and implies that anyone they identify as belonging to those groups will receive neglect, abuse and substandard care. Why is the medical profession allowing it?
Good point. The poilicized activists tend to be incomptent, too.
> A PA from Colorado: “I feel like whenever I go to these wilderness medicine gatherings, the presenters are longing for a disaster to hit so that we can apply these skills.”
Heh. Human nature. Investment. Everyone’s got to feel needed, right? (Almost) every kid who sat through what they thought was a boring Math or History or English or Social Studies – aw, shucks – just about ANY class has also said: “What am I gonna use the Pythagorean Theorem for when I grow up?”
I also quote Vincent “Vinnie” Salvatore Delpino, Doogie’s BFF from “Doogie Howser, M.D.”, exasperated after cramming for some important test or another (I don’t remember the exact context):
“How much of this CRAP do I have to eat today? Who am I, JOB? [biblical]”
https://en.wikipedia.org/wiki/Doogie_Howser,_M.D.
However, they can be real world skills pretty quickly. In my semi-rural area, we once suffered through a power outage that lasted almost a full week. We had a gasoline powered backup generator, and we were able to drive to a location where we could refill our tanks and so forth. But after Day Three or Day Four – especially seeing some of what your neighbors are doing to cope – you realize how thin the veneer of “civilization” really is. If the outages had been spread over a significantly larger area – depriving us the ability to get to gas/food/showers – things would have been very very unpleasant. The woods start to close in on you, particularly late at night, when it gets eerily quiet, the road traffic dwindles to nothing, and there is no “light pollution.”