Traction splints have been around since the late 1800s and were first employed during WWI. Given the lack of alternatives and atrocious environment, they were credited with massively lowering the mortality rate of soldiers suffering femur fractures on the battlefield. The idea was simple – take the long, sharp shards of broken bone, which exist within millimeters of the largest artery in the body, and stabilize them to ease pain and help control or prevent massive bleeding.
A century later, little has changed. There are a few basic flavors, but all have the essentially the same design of a long rod that runs against the affected leg and something which with to pull tension upon and secure the foot or ankle. Despite a lack of continued innovation and even less in the way of empiric research, an almost identical device to that which made its debut with the British Army in 1915 is required aboard every ground ambulance in the country. And almost every one of them resides in a cabinet or under a bench, forgotten and ignored until the biennial state inspection rolls around.
The “Thomas Splint,” c. 1915
All EMTs are taught the procedure for applying a traction splint, but too often it is done in the classroom then never again. In my own experience of almost a decade of EMS, I have had the opportunity to apply one only once. As an ER physician for the last three years at the largest, busiest trauma center in Virginia, I have yet to have a patient arrive with one in place. My theory is that providers often do not consider it when appropriate, and even when they do their familiarity and comfort with the procedure is lacking, so it is skipped. In fact, one study found them to be applied in only 38% of appropriate cases and of those, 2/3 were placed incorrectly.
In other words, if you happen to break your leg, there is only about a 13% chance someone will correctly stabilize that razor sharp bone jostling against your femoral artery while you bump along to the hospital.
Since accurately practicing the procedure without crippling and otherwise healthy recruit is difficult, I looked up available traction splint training models. They cost around $1800, and are full of unnecessary bells and whistles, well beyond the means of many small EMS agencies. So I took matters into my own hands and created a rugged, reliable, anatomically and physiologically accurate model for less than $75. I’m offering it here, open sourced, to anyone who may want to replicate it for his or her training department.
Rubber exercise bands were stretched along the length of a two foot long section of 1 ½” PVC pipe, using duct tape to secure either end. The pipe was then cut diagonally in the middle, simulating a fractured bone.
A six-inch section of the mannequin’s thigh was removed.
Matching holes were drilled in the proximal and distal sections of the “broken femur” and the mannequin leg.
The simulated bone was inserted and secured at both ends with long zip ties passed through the holes.
At rest, the proximal and distal segments of the mannequin leg fit together, accurately simulating the shortened extremity one would expect with such an injury. The exercise bands create a physiologic level of tension, and the leg can be pulled to length and stabilized using any commercially available traction splint. At length, the gap created allows the learner to visualize the physiology of the injury and intended function of the device.
If you do make one, please post a comment and let us know how it turned out!
American College of Surgeons (2009). Equipment for Ambulances. https://www.facs.org/~/media/files/qualityprograms/trauma/publications/ambulance.ashx
American College of Surgeons (2012). Chapter 8 Musculoskeletal Trauma. Advanced Trauma Life Support Student Manual. 219-220
Abarbanell, N. (2001) Prehospital Midthigh Trauma and Traction Splint Use: Recommendations for Treatment Protocols. American Journal of Emergency Medicine. 19 (2). 137-140.
Skelton MB and NE McSwain (1997). A Study of Cognitive and Technical Skill Deterioration Among Trained Paramedics. Journal of the American College of Emergency Physicians. 6 (10). 436-438.
Daughtery, M., Mehlman, C., Moody, S., LeMaster, T., & Falcone, R. (2013) Significant Rate of Misuse of the Hare Traction Splint for Children with Femoral Shaft Fractures. Journal of Emergency Nursing. 39. 97-103.
One of the things I’ve most looked forward to since Steph and I toured all over the country interviewing at 20+ residency programs was the prospect of an “elective” month. Almost every program had a month carved out for residents to choose an area of (educational) interest and immerse themselves however they pleased. Finally, after three years of waiting, this year was my chance.
I researched for months and finally settled on traveling to London to work with and learn from the London Ambulance Service, one of the world’s premier prehospital agencies. Combined with the emergency physicians aboard the London Air Ambulance, they are doing some cutting edge stuff – including point of care ultrasound, field thoracotomies, REBOA and true prehospital critical care. Plus I’d have a chance to visit Grandma.
So, needless to say, I was bummed when the opportunity failed to materialize.
But as luck would have it, just a few days later I bumped into Dr. Ornato, the chairman of our department at VCU. I mentioned it to him, and without skipping a beat he asked, “Want to go to Singapore?”
Fun Fact #1: Singapore is a tiny island city-state, meaning the entire country is one big city (think Ancient Greece, but Asian). It has been at the center of the global economy for hundreds of years, from a refueling port for the British East India Company to what is now one of the largest shipping ports in the world, with up to 100,000 vessels traversing the Strait of Singapore yearly.
Now when I say Singapore is far away, consider this: the Earth is roughly 24,000 miles around and this was a 12,000 mile flight. If I’d have gone any further I’d have been on my way back home. (And did I mention I was in a middle seat? My knees, back and bladder were not amused. But I digress.) Roughly two days after setting off I landed as far from home as I’d ever been and will likely ever be (until I make it into orbit, that is).
My first impression both in the airport moving through customs and in the taxi on the way to the place where I’d be stay for the next ten days was pleasant surprise at just how clean, efficient and organized the whole place seemed to be. No pushing or even a raised voice, just well designed infrastructure ready to welcome visitors, students, investors and most importantly: me.
Marina Bay Sands with the Art-Science Museum on the left
I decided to try AirBnb for the first time. I was traveling alone and found it to be much cheaper than hotels, so why not give it a shot. There was of course the possibility of being murdered in a stranger’s home, and every listing looked far too good to be true, but hell what’s life without a little risk of being drugged and dismembered in your sleep every now and then. So I settled on a condo in an upscale residential district which boasted four swimming pools, a hot tub, free wifi, private bedroom and bathroom, plus walking distance to two subway stations, restaurants, shopping, and a few of Singapore’s ubiquitous dining halls (more on that later), all for less than $60/night. See what I mean?! Must be too good to be true.
But it wasn’t! I found the apartment to be exceptionally comfortable and convenient, precisely as advertised. I met my hosts – an American/Chinese Harvard grad and a Moroccan/French banker – who didn’t seem like serial killers at all. Again, pleasantly surprised and more than a little relieved.
I arrived early and had slept for 16 hours all the way across the Pacific, so after getting settled I was ready to explore. I stepped outside to an instant reminder that the country lies just one degree north of the Equator – instant, drenching perspiration. Nevertheless, I spent the first two days exploring the tiny country on foot, sweating profusely.
Gardens by the Bay
Singapore is about half the size of London or Los Angeles with a population of just over five million. One of the most striking things about it was the diversity – a nation made up of Chinese, Indian, Malay, European and dozens of other nationalities living in near-complete harmony. That, combined with an effective, non-corrupt government, has attracted tremendous investment, and in just one generation the little city-state has blossomed to become a global center of commerce, ranking 7th in GDP per capita world-wide.
Hand carved decorations at the Sri Veeramakaliamman Temple in Little India. Next door were two Buddhist temples.
Fun Fact #2: After independence from Britain following WWII, Singapore briefly merged with its big brother to the north, Malaysia. But thanks to racial strife between the Malays and predominantly Chinese Singaporeans, the island was kicked out in 1965. Singapore has gone on to become an economic powerhouse and first world nation while Malaysia currently ranks 79th in GDP. Whoops!
After eating my way around downtown, having coffee with some very pampered cats and strolling around the stunning Gardens by the Bay and exceptionally impressive Art-Science museum it was time to do some actual work. I spent the first two clinical days at Singapore General Hospital, in the emergency department with Dr. Marcus Ong and his staff. Here’s an excerpt from my Facebook travel diary with my first impressions:
“Spent my first day at SGH today. It’s a remarkably similar place, facing many of the same issues we do in the US. Grumpy consultants, slow throughput, ED boarding, and misuse of emergency services. That said, they see almost zero violent trauma, drug seeking is nonexistent, and psychiatric care is managed outside of the ED. Overall, the care is excellent and very up to date, with all the latest technology readily available but used in a more cost effective way.”
Efficiency is key. Patients are brought to private areas long enough to be evaluated and have any procedures done but are then moved to a holding area to maintain throughput. There is an observation unit for those needing a little more TLC.To combat the ever-present risk of communicable disease the city’s ERs have separate treatment areas for febrile patients. They learned this lesson from outbreaks of SARS, MERS and, most recently, Zika.
I was impressed with the care but noticed it to be somewhat less aggressive than what we do in the US, with invasive procedures done emergently if necessary, but more often left to be sorted out upstairs. While they see very little violent trauma, I was fortunate to see how they managed a motorcycle accident victim – a wealthy British businessman with broken ribs and a collapsed lung. At VCU he would have had a team of 12 providers standing-by on arrival, been stripped of every stitch of clothing and irradiated from head to toe by our CT scanner. At SGH he cracked jokes for an hour while a nervous intern tried his best to place a chest tube.
PSA in the subway station
Like everything else in the country, the healthcare system in Singapore is modern, effective and efficient (ranked most efficient in the world in 2014). Coverage is universal under the principle of no care being completely free which reduces wasteful over usage. Co-payments (typically 3-10% of the cost) and optional supplemental private insurance are paid from a compulsory personal savings account called MediSave. With the 3rd longest life expectancy worldwide Singaporeans spend just 1.6% of GDP on healthcare. For comparison, the US spends over 17% of its wealth on medical services yearly, and its citizens live just slightly shorter lives than the people of the Turks and Caicos islands at number 43 globally.
A cardiac arrest case, eventually with ROSC. Note the built in xray in the ceiling and LUCAS device in action. This is not a 3rd world nation.Waiting for admission in the ED
After my time in the hospital I spent a full day with the staff of the Unit for Prehospital Emergency Care (UPEC) which is led by Dr. Ong. Just a few years ago the government of Singapore sent experts around the world collecting best practices and poured tens of millions of dollars into the project, tasking UPEC with modernizing the EMS system. At the heart of that effort is the SCDF.
The Singapore Civil Defense Force is a quasi-military 4th branch of uniformed national service which includes both the fire department and ambulance service. Unlike the US, the two branches are almost entirely separate, with firefighters generally providing no medical care and responding only to fire incidents. One exception is the new “firebiker” program, with an EMT trained firefighter on a motorcycle able to respond quickly through traffic to cardiac arrest cases. The ambulance service, on the other hand, is well equipped and staffed by paramedics on every ambulance. A unique aspect of both branches is the inclusion of conscripts, young men completing their two years of national service. While most are drafted into the traditional military branches, others fill the ranks of the SCDF.
Morning inspection and roll-call at SCDF station Paya LebarDART – Singapore’s elite technical rescue/USAR team maintains 24/7 readiness for deployment anywhere in South East Asia.DART HRT – Heavy Rescue Tender, with a mission-adaptable, modular back half.
Fun Fact #3: There are two emergency numbers in Singapore. “9-9-5” is reserved for emergencies, with a government SCDF ambulance responding. “1-7-7-7” is available for non-emergencies, and staffed by unregulated private ambulance companies. Calling 9-9-5 for a non-emergency can result in a hefty fine.
I had a chance to spend time both aboard an SCDF ambulance and in their command center, where over 50 ambulances are dispatched to almost 1000 calls to 9-9-5 daily. Many unique challenges exist, ranging from the use of four primary national languages (English, Tamil, Malay, and Mandarin), to cultural and religious differences, not to mention a complex environment including dense urban centers and the surrounding swamps, jungle and sea. It was there I first heard the term “vertical response time,” the extra minutes which have to be factored in when lugging a stretcher and equipment to the 40th or 60th floor of an apartment or office building. To combat that particular challenge, the government has funded AEDs being placed in the lobby of every other housing complex as well as community hands-only CPR training, all organized by UPEC. The coordination of such an effort is a remarkable achievement.
Much of the same capability at a fraction of the costRed Rhino fire service QRV
UPEC/DARE – Community CPR course. The government aims to train 50,000 first responders in the next few years.
Fun Fact #4: The government LOVES fines. Jaywalking? $20. Smoking in an elevator? Better have $1000 to spare. Even drinking water on the subway or spitting out chewing gum on the street will set you back $500. But most Singaporeans will admit the loss of a few simple freedoms is worth it and has led to a safe and orderly society, with essentially no crime.
You don’t even want to know what they would do to you for eating a durian on the train.
As my time was coming to a close I had one last clinical opportunity, the one I was most looking forward to: race medical support for the Singapore Grand Prix. Now I’ve never followed Formula 1 racing, but if I learned one thing from the UCI Road World Championships in Richmond last year it’s that you don’t have to be a superfan to get excited when a big event comes to town. With an all-access pass, a chauffeured golf-cart, the scent of high octane gasoline and that distinct TIE-fighter whine of the engines I was soaking up an intoxicating atmosphere. The medical facilities were impressive, with the SCDF, dozens of volunteers from St. John’s Ambulance and the elite Disaster Assistance Rescue Team (DART) on standby. There were even fire-boats positioned to evacuate patients by sea if necessary, avoiding the inevitable gridlock of a city hosting a world-class event. Like everything else I came across during my time there, every detail was planned out and meticulously accounted for with robotic precision.
Ferrari 458s compete in the warm up to the Singapore Grand Prix
After the race, having completed my educational syllabus, I used my last day in the country to be a shameless tourist. The highlight was undoubtedly the stunning botanical gardens, a UNESCO World Heritage site. I spent most of the day strolling through various areas like the Evolution Garden, Healing Garden, Bonsai Garden and of course, the jaw-dropping National Orchid Garden. Next time you find yourself in the area, do yourself a favor and pay it a visit. You won’t be sorry.
The National Orchid GardenThe Bonsai GardenThe cable car to Sentosa island – in the distance, the whole world’s commerce passing through the Strait of Singapore
Although it may seem I was in a veritable utopia, by the end of my time there I was ready to come home. Not only was I missing my wife, but in a weird way the predictability of the orderliness, combined with the brutal heat became somehow… monotonous. Full of new knowledge and tremendous respect for the work being done to develop Emergency Medicine in Singapore, I caught the last seat on a full flight home after saying goodbye to my new friends at UPEC, SGH and the SCDF. Did I mention Singaporeans love abbreviations?
Dr. Ong and I
But what about the food?! Up to this point I’ve purposely avoided mentioning it to prevent an irreversible segway into what I can only describe as the best, cheapest, most diverse cuisine I’ve ever come across. It was simply too good for words, with each meal better than the last. Singapore more than lived up to its reputation as an international foodie destination, so I can think of no better way to conclude than with a stream of epic food porn. Enjoy!
~Amir
“Hawker centers” are Singapore’s answer to street food – delicious, clean and cheap. What more could you ask for?Bak Kut Teh – roughly “meat bone tea” – The most savory, flavorful broth with tender pork ribs. Sides include fried bread for soaking up the broth, various greens, a soy-sauce egg and braised pig intestine.Singapore Chili Crab – one of Lonely Planet’s “7 Iconic Dishes” worldwideBeef and Kailan greens with fresh sugar cane juiceBelieve it or not, this is a Michelin starred meal. Chicken Rice is just that – but better. On the left, roast pork two ways. Price? $5Fancy restaurant? Nope. This roasted Peking Duck is standard hospital food!The local coffee – “Kopi” – is thick and flavorful, sweetened with a dollop of condensed milk.Laksa – a rich Malay coconut noodle soup with various proteinsCurry three ways: Rice with chicken curry, fish curry, and tandori chicken. Roti bread to soak it all up.Grilled garlic king prawns with fried rice, greens and fresh mango juice.
In April, 2016, Richmond became the first city in Virginia to partner with the CPR crowdsourcing app PulsePoint, bringing their technology to our city. Across the US the incidence of sudden cardiac arrest is over 300,000/year, and survival rates are generally less than 10%. Early CPR and defibrillation can triple that number. Other municipalities have had success with the technology, with early data showing it to be an effective way to get a bystander’s hands on the chest prior to the arrival of EMS units.
While neither Steph nor I have been alerted by the app yet, one of our interns has had it go off not once but twice in just three months. I spent a while picking his brain about it last night so we could share his experience.
Amir: Ok Mike, you were telling me a couple of weeks ago that your PulsePoint actually went off. Could you just explain to anyone who maybe hasn’t heard of PulsePoint exactly what it is and why you have it?
Mike: Sure, PulsePoint is an app that’s tied with the local EMS dispatch. Whenever there’s someone nearby who needs CPR, people with the app get a notification and can respond to help. Essentially trying to do for CPR what tinder has done for online dating.
Amir: Perfect. Except preferable not to wait for the other person to swipe right as they have only moments to live. Got it. So it’s on your phone, just monitoring the EMS dispatch, waiting for some unsuspecting person to drop – and that’s where your story starts. Lay it on me and the rest of the English speaking world.
Mike: When the alert went off I was enjoying my day off watching Game of Thrones. I had received one alert previously that I didn’t respond to (that one was while I was in the hospital), so I recognized the alert. It was a nearby address, and “CPR Needed,” no other information. I threw a shirt on (always don appropriate PPE first) and ran out the door. When I got there, I identified myself as a doctor (liability much?) and was let in. The victim in question didn’t actually require CPR; I did a jaw thrust to keep the airway open, and literally 45 seconds later an EMS crew made their way in. And from there, EMS basically was running the show.
Amir: Ok so most importantly, have you seen this season’s finale? It was amazing.
Mike: I can’t believe they killed off [insert character you’ve only just finally felt an emotional connection to]. So unexpected.
Amir: Speaking of killing off, back to this maybe-dying person. How did you even know where to go?
Mike: Pulse Point has a pretty clean interface. When the alert came up it has a Google Maps type street grid.
Amir: How far away was the spot?
Mike: Just a block or so, looking into it the app will typically alert a provider within 1/4 of a mile, depending on the agency.
Amir: So pants on, shirt on, out the door – leisurely stroll down the block? Or were you hoofing it?
Mike: I think I had a decent clip going. Not a full on sprint.
Amir: You live about 1/4 mile from us. If that app ever puts a pin on our house I expect you to transform into Usain Bolt.
But ok so you’re keeping it cool, it’s their emergency not yours after all, and you show up. What kind of place? Apartment? House?
Mike: House; one I had biked past many times around the neighborhood.
Amir: What’s the etiquette here? Politely knock on the door or charge in like Superman? I imagine the latter comes with the risk of being, you know, shot to death. But for all you know it’s an innocent baby dying in there, and you’re literally the only person who can save her, right?
Mike: Yeah, the thought crossed my mind. There’s definitely a can of worms to be opened here: how do Good Samaritan laws apply to physicians, was the correct address sent through the app, the list probably goes on. But I knocked and was let in, so cross at least one of those concerns off the list.
Amir: Did they ask who you were or how you knew what was going on or what you were doing there? I mean no uniform, badge – you’re Joe Schmo for all they know.
Mike: It was pretty hectic and everybody just seemed to accept that I was there to help. No other questions asked.
Amir: What did you find in there?
Mike: Respiratory distress, cause unknown. As somebody who doesn’t have a background in EMS, approaching this in the field is definitely a different thought process than undifferentiated respiratory distress rolling into the ED. Differential diagnosis isn’t too important when your treatment options are limited to what you bring with you, which in this case was nothing.
Amir: Great point. Something more docs should keep in mind when EMS rolls in with a hot mess. So not breathing, could be overdose but could also be massive head bleed, who knows? You don’t even have gloves. So you jaw thrust, trying to avoid any and all fluid leakage, and just hope the cavalry arrives soon. You weren’t up for mouth to mouth?
Mike: In retrospect, I did have my Red Cross pocket mask in the depths of my closet. Now it’s been moved to the shelf in my kitchen.
Amir: That’s a great tip. If you’re going to use this app and respond to god-knows what, be as prepared as possible. Maybe a little kit for the car and home with some basic stuff – gloves and a barrier mask.
Mike: But that does lead into another thing I’ve been considering about PulsePoint. The cavalry in this case was less than a minute away. From their website, PulsePoint costs over $10,000 to implement, and another $10k to $28k a year to maintain. So the agencies most likely to be able to afford an extra service like PulsePoint are also the agencies that are well funded, and most likely to have an EMS crew right around the corner.
Amir: Ah so you think maybe we need to see some pre/post implementation outcome data. I’d say if that guy had been in cardiac arrest though, those 45 seconds could make a significant difference.
Mike: Oh sure, it’s definitely a good idea. Especially considering that you don’t need to be a doctor to get the app. Anybody who’s BLS certified or better can join up. And unless there are some hidden costs involved, it’s still less expensive than a lot of the other “bells and whistles” that EMS agencies can add to their toolkit.
Amir: {{*cough* ACLS drugs *cough*}} Any other tips for potential heroes out there?
Mike: Just the usual things that I’m sure are second nature to EMS providers. Expect the unexpected, prepare for as much as you can, and the number one rule, first do no harm to yourself. “Survey the scene, don’t expose yourself to harm” doesn’t get drilled into us a ton as docs, but there’s a reason it’s the first step in BLS training.
Amir: Perfect. So to sum up:
Get Dressed.
Don’t show up empty handed.
Watch your back. And your front.
Have a good lawyer, just incase.
Mike: Couldn’t put it better myself.
Amir: I love it. Thanks for sharing the story. I can’t believe it’s gone off not once but TWICE for you. I’ll let you have the last word to your now adoring public.
Mike: Flarhgunnstow.
I had to look up that last word. Apparently it’s this:
If you know CPR and are willing to help someone whose life depends on it, go to PulsePoint.org and see if your city has partnered. If you don’t know CPR yet, the American Heart Association website can help you find a CPR course.
~Amir
Michael Billet, MD is now a PGY-2 in Emergency Medicine at VCU Medical Center in Richmond, VA. He attended the University of Virginia for both his undergraduate and medical school training. He likes long walks on the beach, Settlers of Catan, and is definitely the guy you want on your trivia team.
I always prefer the window seat. Mostly because I will hold my urine to the edge of kidney failure rather than try to cram my 6’5″ frame into an airplane toilet, and having to get up repeatedly to let my weaker-willed neighbors past makes my eye twitch. But there’s more to it than bladder control. I control the shade, and at my leisure I can peer out and down, unobstructed, over the great expanse below.
Just a few weeks ago, I found myself in that prized position, looking down on the vast Senoran Desert, on my way to Phoenix, Arizona. From twenty-thousand feet, it’s a wasteland. Seemingly random outcrops of red stone rise and fall away, separated by endless miles of nothing at all, except every few minutes we’d drift over one of those mega-farms with the funny patchwork of circular fields. With nothing else to do but think of the bone-crushing pain being inflicted by the seat in front of me, I found myself wondering, “Just how could those first settlers have made it all the way out here in their Conestogas?” Gold or not, it looked impassable.
Soon after, we landed in Phoenix, a quilt of strip malls sewn together with massive highways. I was there for a conference, but arrived a day early to explore with my wife. We settled into our hotel and quickly planned a trip to Sedona, just a few hours north, and set off early the next morning with our GPS aimed for Barlow Adventures.
We arrived around ten, and our hearts sunk to find half-day rentals start at 8 AM or 1 PM. They were kind enough to squeeze us in anyway, and with just a glance at my insurance card handed over the keys to Jenny. Oh Jenny. A red four-door Rubicon with the hips of a belly dancer and treads of an M1 Abrams. To my wife’s mixed dismay and delight, I fell immediately in love.
The folks at Barlow gave us a quick, but thorough, tutorial of the best trails to suit our style – an easy climb to get acquainted, culminating in stunning views, followed by a technical crawl down into a valley full of history. With that, we put the top down, turned the radio up and got rolling.
Immediately, with a blue sky above us and red rocks all around, we felt we could conquer the world, just my wife, Jenny and I. Within a mile or two, we made it to the first trailhead and checked our notes. “When you pass the gate, put her in 4-HI and reset the odometer.” Done and done.
Schnebly Hills Trail is a winding, bumpy fire road up the side of what I can only assume was Schnebly Hill. Jenny plowed over everything in her path. The only thing limiting our progress was that we kept stopping to take photos because the scenery just kept getting better. Massive, imposing rock formations surrounded us with hardly another human in sight. Cacti, iron woods and the hot sun above us – it was the setting of every spaghetti western. At first, I tentatively wove my way along, afraid to test the limits of the $25 tire and glass coverage we’d added. But my lack of experience with off-road driving and the sharpest, most punishing rocks proved no match for Jenny’s sheer brawn. We made it to the top, where we went on foot to explore the “Merry-go-round,” a rocky outcrop boasting a jaw-dropping panorama of the entire valley. We sat down for a few minutes to soak in the sun and bask in the diem we were thoroughly carpé-ing.
If the way up was a learning experience, the way down was an education in fun. A downhill slalom, probably at higher speeds than Barlow would have liked, with a Pearl Jam soundtrack provided by Jenny’s Sirius XM radio, Schnebly Hill melted away. At the bottom, once again on pavement, we consulted the maps provided to us to navigate our way to the next trail.
Soldier’s Pass was an entirely different beast altogether. This time our notes said, “4Lo, nice and slow.” I dropped Jenny into low gear and flipped the sway bar disconnect switch, allowing the axles to move more freely. Free is good. Let’s go.
The first thing we came across was a sign telling us if we couldn’t make it down the first boulder crawl, not to bother with the rest of the trail. Needless to say, Jenny took it all in stride, and again more than compensated for my lack of having any idea what I was doing. We rumbled down the flight of rocks, coming to rest on a trail just a few inches wider than our Wrangler. For the next hour, Jenny took us back in time. We clambered up and down some gravity-defying inclines on our way to an enormous gaping sink hole exposing a few million years of sedimentary layering. On the way back we visited the Seven Sacred Pools, from where General Crook marshaled his campaign against the last of the Apache. Jenny never missed a step. From start to finish, all I had to do was point her in the direction we wanted to go, and our girl’s 285hp took care of the rest. Sadly, with our first two trails down, we were nearing the end of our four hour escapade. We turned back towards Barlow and, with heavy hearts, turned over the keys.
Needless to say, getting back into our rental car was rather disappointing. If it hadn’t been for the unbelievably good taco truck we found on the way back, I may actually have shed a tear to leave Jenny behind. The next day at our conference was even less exciting, but the last drops of adrenaline still had me feeling like Superman. I finally understood why people buy those burly, lifted, totally unnecessary vehicles – because they must turn even the most blasé commute into an experience.
On the flight home, I thought again of the rugged pioneers who trekked across a continent in rickety wagons with every one of their earthly possessions in tow. I imagine they’d be pretty annoyed to know how easily some guy from the East Coast can do it now but undoubtedly proud that they paved the way. I tried to look out the window to catch one more glimpse of the great cactus strewn expanse where roads are once again optional, but I was stuck in an aisle seat. I didn’t care. We’d had an unforgettable adventure. And, more importantly, I was in an exit row.
In just two short months, thousands of newly minted young physicians will be walking into new hospitals, new jobs, and new responsibility. They’ll notice something unfamiliar tickling their calves on that first day – a long white coat having replaced the short one, which in our case went up in flames just days earlier. They’ll be excited and terrified, nervous and naïve.
A doctor’s “intern year” has become something of a legend in pop-culture, portrayed as twelve months of rude awakenings, sleep deprivation and verbal abuse, +/- a love triangle or two. Having been there, done that and proudly owning the t-shirt, I can say the reality couldn’t be further from the truth – at least it doesn’t have to be.*
To all the newbies out there – yes, there will be long hours and sleepless nights. You’ll occasionally go a full week without seeing your loved ones and eat whatever/whenever you can. Med school will seem a lifetime ago when you’re being asked at 3am what to do for a dying person, and you’ll wonder why they never taught you all the things that matter. But Steph and I have stumbled across the solution to all of that.
Champagne celebration for med school graduation | Photo credit: Amy McClure
We celebrate the small stuff.
Sure we popped champagne like we’d just won a Grand Prix on graduation day, but we’ve also raised a glass to finishing tough rotations, making a clutch diagnosis and running our first double cardiac arrest. We’ve made a ritual of rare Sunday mornings off together with a supply of cinnamon buns always available, just in case. Sometimes we just celebrate because it’s Tuesday and we can. By making a big deal of small victories, the roadblocks become surmountable.
Don’t get me wrong – residency is tough. In the past month, three of my patients have died, and I’ve told four others they have cancer. But for every bad day I have had there have been a dozen that left me thinking, “I have the best job in the world.”
I encourage all the newbies out there to approach this next chapter the same way. And remember: when the champagne runs out, there’s always more coffee.
n in fun. A downhill slalom, probably at higher speeds than Barlow would have liked, with a Pearl Jam soundtrack provided by Jenny’s Sirius XM radio, Schnebly Hill melted away. At the bottom, once again on pavement, we consulted the maps provided to us to navigate our way to the next trail. 
TeamLouka 