Author: Steph Louka

Stephanie is an EMS Physician and Life-Member of the Virginia Beach Volunteer Rescue Squad. She lives in Richmond, VA with her husband Amir.

Exploring Virginia: A Day Trip to Tangier Island

Tangier Island has always been a place of intrigue in my mind – a mythical island of less than 500 people, disconnected from daily life. When we were young, my sister took an overnight boat trip there with family friends. A hurricane led to a near stranding and peaked my interest in visiting. In medical school, we learned of Tangier Disease, a genetic disorder causing reduced levels of HDL (good cholesterol), named after the island’s inhabitants who have a rather shallow genetic pool.

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So when Amir suggested a day trip, I Googled “tangier ferry” and discovered Tangier Rappahannock Cruises, a 2 hour ferry service that leaves from the coastal fishing town of Reedville, VA. I recommend selecting the same-day return trip, and skipping the suggested lunch at the Chesapeake House (more on that in a bit).   Total cost round-trip for the two of us was just $57.24 including all taxes and fees. While you can just show up at the dock and buy tickets the same day, I recommend booking online to save yourself time and ensure your reservation.

We sat on the bow to get the best vantage point of blue skies and glassy seas. Osprey, fishing boats and crumbling barns float by, demanding the attention of your camera lens. I, as usual, captured them through the lens of my iPhone, Amir through his Canon DSLR.

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Tangier soon turned from a distant mirage to a beautiful green world just ahead. The skyline was low, consisting mostly of simple two-story houses with a rare deviation in height for a church steeple and a water tower. As we entered the man-made channel lined with little white houses and docks, our ship’s captain revealed that Tangier is the world’s source for soft shell crabs. The crabbers live in these tiny white shacks – shacks that are filled with blue crabs, checked diligently on the hour in anticipation of the golden moment when the crab molts its shell. The crab is then scooped up and placed on ice or into a freezer and sold to restaurants for a feast later that day. It’s a practice as unique as the island itself.

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We stepped off the boat and onto the dock, the end of which was lined with locals in golf carts offering 15 minute tours of the island, and friendly women with sun-aged skin offering coupons for the best lunch spots (there are only 7). We opted to skip the carts and create our own walking tour.

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Instantly we were struck by the strange collision of worlds. Tangier is part what you would expect – fishermen, boats, flip flops and simple life at a slow pace – everything I love about Chesapeake Bay living. But it’s also part Cuba, part 3rd world country. For an isolated island, bringing goods in is expensive, so you see signs of old everywhere you turn. 1970s motorbikes, rusted chain link fences, refrigerators from 3 generations past. If you want new and shiny, this is not the place for you.

And while old often equates with charm, there’s something a bit off in Tangier. Like bringing things to the island, disposing of them is also a costly task. So, garbage is everywhere – broken down golf carts, bottomless boats, and 20 year old Pepsi cans littering the land and the water. It makes you cringe. It doesn’t fit. A proud people so dependent upon nature for their existence, so careless in protecting it.

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For a half second my mind contemplated the missed opportunity – “What if they just picked up the trash?” “What if they had some eco-friendly activities?” I imaged the potential for increased tourism, and the subsequent revenue that could benefit this island and its people. And then I wondered, maybe this is deliberate.

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We decided to try Fisherman’s Corner for lunch. We entered the brightly painted, simple square building to find a bustling room tightly packed with tables of both tourists and locals. The menu was typical Chesapeake Bay fare – she crab soup, crab dip, fried shrimp, crab cakes and soft shell crabs. Clearly we had to try the soft shells. The food was simple, home-cooked and a tad pricy, but delicious. My soft shell crab was sandwiched between two slices of white Wonder bread. While I was initially skeptical of my minimalist bun, when topped with the zesty tartar sauce, the flavors combined perfectly. We skipped dessert since we’d already cheated and devoured hand-dipped ice cream cones on our earlier walk.

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Soft shell crab sandwich at Fisherman’s Corner | Tangier, VA
We continued our ambulatory tour of the island, scoping out the picturesque little houses and the oddly placed graveyards in each front yard. Tangier is only 4 feet above sea level and losing 10-15 feet of land mass per year, so space is limited. A brief scan of graves reveals repeating names – Crockett, Pruett, Pruett, Crockett, Crockett. I begin to better understand the origins of Tangier Disease.

There are two churches, one fire station, one police officer and one school. On an island with 450 people, you make do. The sign outside the fire station explains that until very recently, every household was provided with a single leather bucket. When a fire broke out, the entire town would arrive and form a bucket brigade. I wondered what hurricane preparations took place today.

In just 3 short hours, we’d experienced 90% of what Tangier has to offer. We heard a dialect I can only describe best as Old English garble. We marveled at the eccentric locals like bird watchers spotting a never-before-seen species. Tangier is a dichotomy of beautiful and ugly, but special none-the-less.

~Steph

5 Things I Learned in Business School I Wish I’d Learned in Medical School

These days, many people enter medicine as a second career.  I am no different.  I was an undergraduate business major and worked in the corporate world of internet marketing for 6 years prior to medical school.  Perhaps a science major would have been more practical when I was spending 7 hours struggling to understand some fundamentals of molecular biology; however, my business background did occasionally give me a leg up. Going back to school at 30-something, surrounded by recent college grads, I realized a few lessons I picked up along the way weren’t necessarily obvious to others.

1. Everyone has a job, and they all matter

Despite modern movements away from it, medicine is an extremely hierarchical world.  Medical students pine for that long white coat.  Doctors bark orders at nurses without introducing themselves or asking nicely.  Phlebotomists, lab techs, housekeepers and others largely go unnoticed.

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Copyright: Michelle Au | theunderweardrawer.blogspot.ca

One beautiful reality of capitalism is that jobs don’t exist unless they are vital… IMPORTANT.  In medicine, we need janitors, doctors, accountants, secretaries.  Everyone with a title has responsibilities and is therefore necessary for the organization to function.  Companies with excess overhead from superfluous staff don’t stay in business very long (VA Hospitals aside). So when the surgical consultant steals a computer terminal from the ED Tech so she can finish her note, this disrupts work flow, and sends a message that somehow the doctor’s work is more important than the ED Tech’s.  It’s just not true.  Be mindful that everyone on the team has a job to do and people will want to be on your team.

2. “For-profit = evil” is not always the case

Yes, pharmaceutical companies are responsible for their reputations as greedy, evil, for-profit companies.  Just ask Martin Shkreli.  And while it would be great to provide free medications to any and all who truly have need, research and development (R&D) of new medications is risky and costs money.  A lot of money.

 

On average, a new drug takes anywhere from 11-14 years to make it to market, and that’s IF the drug makes it that far.  Of any new drug developed in a lab, there is an 8% chance that drug will actually make it to market, meaning it’s prescribed by doctors for actual patients.§ The money spent on R&D for 92% of unsuccessful drugs is a true cost, and those bills still need to be paid.  Smart R&D focuses on modular development, so that one lesson learned developing a drug that failed can be applied to new research that will hopefully help a different drug get to market.

Yes there is excess and greed.  Yes Big Pharma develops drugs based on profitability, not strictly based on need.  People with “orphaned diseases” have to create non-profits and raise funds for R&D since the pharmaceutical companies won’t do it.  It’s not ideal.  Attracting the brightest minds to develop major pharmaceutical innovation requires paying people well, and I’ve yet to hear anyone tout how well-paid they are at their non-profit organization.  In the end, it’s not as simple as saying “just lower the prices or make it free.”

3. Product perception is reality

Marketing is everything.  You can have the best product in the world, but if no one knows it exists, or if consumers don’t understand what it can do for them, they won’t buy it.  Similarly, you can get all the science right in medicine, but if results, diagnoses and plans aren’t communicated, getting it right doesn’t matter.

If anything this is even more applicable in medicine than business.  While people have some innate understanding of what makes a good vacuum cleaner, they probably need more help understanding their liver failure and what treatment they need. I never assume patients understand their disease.  Taking 5 minutes to explain the relation between the liver and ascites goes a long, long way.

4. Dress & Look the Part

Being a medical professional requires knowledge, honesty and altruism.  Most people get that part right.  But professionalism in medicine also means being on time, dressing professionally, and remembering that people are always watching.  So for the EMT: put down the cigarette, tuck in your shirt and wear your gloves when needed.  For the medical student: be the first one arriving to rounds, wash your white coat (not just once a semester either), lose the stubble and open toed shoes and ditch the piercings for the day.  Doctors: wash your hands, put down your iPhone and give patients your undivided attention. All the knowledge in the world can be quickly overshadowed by a distracting or detracting exterior.

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“The Doctor” by Luke Fildes

5. Listen to Customer Feedback

This is not “The customer is always right.” Medicine is different.  Just because a patient thinks he needs antibiotics for his cold doesn’t mean he should get them.  But your customers do know their bodies best and how they are feeling at the time.  If you are handing a patient discharge paperwork and they “still don’t feel right,” stop and listen.  In this case, the customer feedback is critical, and the price to pay may be high – both for the patient and for your wallet.  Any seasoned Paramedic will tell you, “When the patient says they are going to die, I believe them.”  We’ve all been there.  And if you haven’t yet, it’s just a matter of time.


So that’s it, 5 small things.  What lessons have you borrowed from an earlier career and applied to medicine?

~Steph

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§ http://www.fdareview.org/03_drug_development.php

If pages came as emojis

Right now there’s a whole new crop of medical school students graduating in a month who will start their careers as doctors on July 1. There are two things every medical student looks forward to receiving as an Intern – a long white coat and a pager. But any Resident will tell you: after your first night on call, you want to throw that pager against the wall and then stomp it into little pieces.

But what if pages, instead of boring B&W text, arrived as an emoji puzzle to decipher? That just might make getting 84 pages in a 12 hour Trauma shift slightly more tolerable.  See if you can figure out these common pages.


The “Frequent Fliers” of Pages

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Answers to “Frequent Fliers” Pages

  1. Mrs. Jones has a headache, please order tylenol
  2. Mr. Smith has post-op pain, please increase his pain meds
  3. Code Blue, Mr. Jones
  4. Please renew Mr. Smith’s order for restraints
  5. Mrs. Jones needs a diet order
  6. Baby Davis is febrile and has no PRNs
  7. Mr. White needs zofran for nausea
  8. Another ED admit
  9. The transfer from the OSH is on the floor
  10. Please call Pharmacy, you messed up your order again
  11. Who is going home today? -Bed Flow
  12. Mr. Smith needs a laxative
  13. Mr. Jones needs CIWA scoring

And, just for fun, some not some common but ridiculous (and true) pages:

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FYI: 3AM page for a “fever” of 99.0F

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Mr. X had a nightmare. He’s awake now.


Add your own favorite pager stories (and emoji puzzles) in the comments!

~Steph

 

EMS in the Hot Zone: Not so Fast

Yesterday I attended the 17th Annual Rao R. Ivatury Trauma Symposium hosted by VCU Health. I took away multiple “nuggets” to incorporate into both my prehospital and ED practice. The conference is geared towards anyone taking care of trauma patients – not just doctors but nurses, social workers, nutritionists, therapists and EMS providers, too. I highly recommend checking it out next year. Save the date: Wednesday, March 29, 2017.

Always a leader in EMS advancement, members of the Richmond Ambulance Authority (RAA) presented a poster on delivering “Good Medicine in Bad Places.” To the credit of RAA, they have developed a council with their partners in Police and Fire, to address regional response needs to unique and dangerous situations (i.e. active shooters, bombers, terrorist attacks). The data they presented is accurate – the number of incidents is rising, and the fatalities climbing.

Tactical Combat Casualty Care (TCCC) is specialized training that originated in the military. TCCC is currently being tested and studied in the civilian public safety setting. The TCCC conversation is an important one. Specialized training for these situations is an unfortunate necessity in the United States. A little background info on how these things are currently handled – most cities have specialized SWAT Medic teams comprised of talented, elite individuals adept at not only the delivery of prehospital medicine, but also in things like shooting, hand to hand combat and law enforcement. These providers are a special breed – in most cases considered the best of the best in their public safety organizations. I’ve been hearing the rumble and chatter over the last year, and it was again echoed by RAA yesterday. There is current shift in conversation towards training 100% of EMS providers to enter the warm and hot zones, to render care to patients while under fire.

It’s well known and proven that the current model of Fire/EMS waiting to enter scenes causes treatment delays that increase patient morbidity and mortality. In the December 2015 issue of the Journal of Emergency Medicine, Peter Pons of the Hartford Consensus commented that “fire/rescue and EMS personnel must work with law enforcement agencies to enter these scenes earlier than has been traditionally performed, intervene promptly to stop ongoing external hemorrhage, and incorporate basic concepts of tactical combat casualty care/tactical emergency casualty care into their education, training, and practice.” I don’t disagree with that, but I’m not sure it makes sense for us to immediately assume ALL Fire and EMS personnel should be entering scenes with active shooters – as if it’s simply one more bullet point we can just tack onto the job description.

If you think about our existing public safety system, some firefighters enjoy both patient care and fighting fire, while others if given the choice, would only ever fight fire. Similarly, some Fire and EMS providers might be part cop/soldier at heart – both capable and interested in taking on TCCC. I can assure you that not everyone on an ambulance has that police/soldier side that wants to run into an active shooter scene. Yes, EMS is a dangerous job; I’ve been punched and had a knife drawn on me in the back of the ambulance (no one tell my Mom please). Of course you can never predict what may happen and need to be ready for anything. That’s not what I am talking about in this instance. What I’m saying is that if a call goes out for an active shooter, it might not be wise to require 100% of the Fire and EMS personnel to be able to enter that active scene. Here are just a few reasons I think that could be a bad idea.

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Figure 1: Crossover of skills/interests in various professional fields

Negative Effects on Recruitment

As I mentioned, not all EMS providers want to take on the police/military type role of being armed with a weapon, entering dangerous scenes and providing care under fire. I don’t know how big of a chunk of people that is, as it hasn’t been surveyed yet to my knowledge. I can say personally, having been in a building with an active shooter, I have zero interest in doing so again, even with the most state of the art training. How many of the 840,000 certified EMS in the US might we lose if that bullet point gets added to the job description? Additionally, 22% of those 840,000 certified EMS personnel are volunteers. Some volunteers might want to play a part in TCCC, but if you have a family and derive no paycheck or medical benefits from your volunteer EMS gig, can you really afford to enter that scene? And what will become of all the career providers who want to do patient care, but don’t want to risk their lives. Perhaps we will we see them shift into the hospital in ED Tech, CNA and RN roles.

Distraction Away from the Medicine

Even right now, EMS education has two large components: 1) the medicine, taking vital signs, deciding what drugs to give and when and 2) operational aspects, entering a scene safely, driving an emergency vehicle, operating a portable radio, etc. As an ED Physician, I admit my bias towards the importance of #1. We’ve all had the trainee who wants to drive lights and sirens before he’s mastered taking a blood pressure. With only ~160 hours of instruction in the current NREMT course, I worry that adding the required training for TCCC will shift focus away from the medicine and negatively impact patient care, potentially leading to more morbidity and mortality across all patients, improving outcomes for those victims requiring TCCC, but leading to a net decline in overall care. Perhaps the solution will be increasing the course length. I’m not saying it can’t be done; I just hope someone studies and considers that before implementing blanket curriculum changes.

Are EMS Providers Physically Fit Enough?

Sadly, three quarters of active emergency responders in the US are overweight or obese, and 75% have been diagnosed as hypertensive or prehypertensive. All in all, we are not a healthy bunch when compared to our counterparts in Police, Fire and the military. How many EMS providers will meet the physical demands required for TCCC? Even if people want to take part in TCCC, will they meet the physical requirements to do it safely, or perhaps be pushed out of a job they love, despite providing excellent medical care.

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Would it actually improve care?

To justify the risk associated with TCCC, you must be able to prove that more lives would be saved than lost, and not just during active TCCC situations, but across prehospital care as a whole. It just hasn’t been studied yet. Perhaps once studied, it will prove to be net beneficial, but right now we just don’t know.


So those are my thoughts; I’m curious to hear yours.

~Steph

 

Simple Steps for Throwing a British Themed Party

The great thing about a British theme is you can apply it to most types of parties. Whether you are throwing a baby shower, birthday, bon voyage, or simple dinner party, the theme is flexible and can be expressed in a number of creative ways.  My husband is 1/2 English, so we decided to throw a England/London/British themed Valentine’s Day party and called it “Love in London.”


Food

British food has a reputation for being a little dull and boring, but your spread doesn’t have to be. There are so many amazing recipes online, it can be hard to decide just what to make. We opted for sausage rolls, beef wellington (labor intensive & expensive, wouldn’t do it again), fish & chips (just buy ’em & fry ’em), cucumber & tomato salad, cucumber sandwiches and more. You can add some easy flare to your finger foods with these union jack toothpick flags.

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Simple sausage rolls with union jack flags
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Marinated cucumbers, onions & tomatoes add a flavorful vegetable dish

Last but not least, don’t forget proper condiments for your amazing food.  Buy a bottle of malt vinegar for your fish & chips, and a bottle of HP sauce, and you’ve got your bases covered.

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Don’t forget the condiments!

Drink

Ok, depending on your crowd, this might be the most important aspect of the party.  There are lots of great drink options, but a British party wouldn’t be complete without Pims cup.  There’s no exact recipe you have to stick to – I like taking whatever fruit looks fresh at the store and adding it to Sprite and/or ginger beer.  For ease, you can also mix up a whole pitcher to have ready to go, similar to a sangria.

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A spin on the traditional Pims cup

Fortunately we can thank England and Scotland for having a number of great beers.  Head to your local beer/wine outlet and find the “England” section.  We went to Total Wine.  You only need a 6-pack or so of each if you are buying a big selection.  Guests enjoy trying new beers as well as old favorites.

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Assorted British beers we found at TotalWine

If you want to try something really special, and have some time to plan ahead, take a chance on a home brew and create your own.  We made a delicious London Porter in just 4 weeks using this easy home brewing kit.  We also customized the bottle to fit our theme using these handy waterproof labels for your home printer. We sealed the caps with union jack flag stickers for a finishing touch.

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London Porter Home Brew

Dessert

There are many creative options for desserts to fit your theme.  I’m not much for baking, so I cheated and outsourced a bit of this.  The classic English dessert is a trifle, which is simply a layered dessert, typically with pudding, sponge cake and fresh fruit.

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Strawberry trifle with fresh berries

The hallmark of English tea time, after the tea of course, is small cookies.  Any small simple butter cookies will do.  You can make these, but I opted to buy pre-made.  For a mixed display, buy a box of chocolates to add to your 3-tier cake stand, and you’re ready for tea time.

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Traditional 3-tier cake stands with tea time floral designs
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Store-bought coconut macaroons on the bottom tier
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Add a frilly tablecloth to complete the authentic tea time look

For another dessert option (which is a great go-to for any party or theme), consider some custom decorated cookies.  These sugar cookie masterpieces are from Cookies by Design in Virginia Beach.  They are also a hit if you have little kids attending your party.

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Hand-painted London themed cookies by Cookies by Design

Decorations

The easiest way to convey “British” visually is with the union jack flag.  You don’t have to be an artist to create cool and creative decorations.  Add a $5 union jack flag over a white tablecloth to create a bold canvas for your delicious food.

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$5 union jack flag adds an easy visual punch

Simple things like adding a sticker to your cups or nametags can help carry your theme forward in an easy way.

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Cute and easy cups thanks to $3.25 union jack stickers

Another option that requires no artistry, is to apply this $4 union jack duct tape to simple objects.  For this project, buy 3D cardboard letters to spell whatever you choose.  Then wrap them in the duct tape and viola!

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“LOVE” decoration made with 3D letters and duct tape for just $8

If you do consider yourself artistic or crafty, and don’t mind putting in some time cutting objects out, consider making your own garland.  Find any image you like online, print it on photo paper, cut it out, hole punch it and string them together.  Add a lace paper doily for an extra English touch.

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“Love in London” hearts strung together with lace doilies and twine
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Itty bitty hearts strung together with silver thread to make a precious garland
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Template for tea time heart garland
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Search your house for any knick knacks that fit your theme and display them together
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Colorful tissue poofs are cheap and high impact

Music

Pandora has an array of great themed channels.  The best fit for an all-ages England themed party is British Invasion Radio.

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Games & Fun

Party games and activities are tricky.  Everyone’s been to a party where games feel forced and grueling, but you don’t want a party with everyone just standing around.  Two simple activities I love are photobooths and trivia.  They are great because guests can participate on their own time throughout the party, and they don’t take any bandwidth away from the host or hostess.

Photobooth

Grab some simple props (hats, glasses, boas) and if you want to go big, a life-size celebrity cut-out.  Kate Middleton and Queenie were the life of the party.

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If you entertain a lot, consider investing in the modern polaroid, the FujiFilm Instax mini camera.  It instantly prints a polaroid-style photo that makes a great takeaway memory for your guests.

Trivia

Create a set of questions related to your theme and post them, along with pens and ballots, for guests to fill out.  Winner gets a prize!

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So that’s it, ideas for food, drinks, music, decorations and activities for your next London/British/English themed party.  For additional ideas not mentioned here, check out the Love in London Pinterest board.

~Steph

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