Wilderness Medicine

A few years ago I was at a horse show on a really hot day.  As “horse show mom”, my duties were simple:  get up early, drive child to show, groom and saddle horse, and stand around all day while trying NOT to offer helpful advice to said child.  On this particular humid day the temperature was in the nineties, and at high noon, the halter classes were taking place.  Twelve or thirteen little girls, and one lucky little boy (my son) were lined up side by side with their horses, standing rigid in the heat while the judge performed a detailed inspection.  As he made his way to the last pair, the little girl who had been patiently waiting her turn keeled over in a dead faint.  And then I heard the dreaded words called out in a panic—“Is there a DOCTOR in the house?”  I sent my son dashing to the car for my first aid kit, which contained a thermometer and smelling salts, and the trainer for ice.  Soon the girl was revived, having suffered only heat exhaustion and not the more serious heat stroke.  I had realized long ago that there were situations I would find myself in where I would be the only doctor, and somehow saying, “Sorry, I can’t help—I’m a highly specialized radiation oncologist” just doesn’t pass muster.

I bought that first aid kit already prepared and loaded with the necessities at the first Wilderness Medicine conference I ever attended, in Aspen Colorado.  In three or four fun filled days, my husband and I learned about snake bites, and heat stroke, and shark attacks, and how to make a makeshift splint, and what causes weird rashes on your nether regions (squatting in a bed poison ivy, or stinging nettles) and how to treat altitude sickness and traveler’s diarrhea and all of the other practical things one needs to know if venturing outside the confines of one’s sheltered home.  We learned about wilderness survival from a very articulate and handsome man who taught the SERE (Survival, Evasion, Resistance and Escape) course that saved the life of Captain Scott O’Grady who was shot down over Bosnia in 1995 and who survived for six days on bugs and rainwater.  We learned that being lost in the wilderness due to weather, accident or injury is more common than we could ever imagine, and to this day I carry a flashlight, a solar blanket, a heavy plastic bag, matches, water and a whistle in every vehicle I drive.  Fifteen years after our first Wilderness Medicine conference, we went back last May to the same conference, this time in Santa Fe.  The basics were the same, but there were new classes in how to deal with an urban disaster such as a terrorist attack, or an earthquake.  This time I learned that the Space Station carries pregnancy tests in its medical kit—apparently despite the anti-fraternization rules for astronauts on duty,’ tis better to acknowledge the possibilities than deny them.

On Wednesday,  I sent my daughter to Hawaii for her first Wilderness Medicine conference—a vacation and graduation from medical school present.   She sent me a bubbly text message after the first evening of lectures—she had already learned some sage advice –and I would like to attribute it properly but she didn’t tell me which lecturer coined it: “ Don’t get bit, don’t eat shit, don’t do “it” and take your own kit!” Robert Baden-Powell, the founder of the Boy Scout movement, said it a little more simply:  Be Prepared.  Words to live by.

Like a Freight Train

Sometimes, you can see cancer coming.  What I mean is that when we sign up for that mammogram, or that PSA blood test, there has to be some tiny little part of us that says, “Ok, this time it’s my turn.  This time I’m the one who’s going to get the call.”  Sometimes the cancer sneaks up on us—that nagging little cough that makes us want to—suddenly and belatedly—quit smoking.  Or that little bit of blood in the stool that we’d rather think is a hemorrhoid, or that lump in the neck that doesn’t go away even when our doctor treats us for the strep throat that we know we don’t have.  But sometimes, as it happened to my patients yesterday, that cancer hits us like a freight train.  Just flattens us and leaves us in fragments, speechless in surprise and terror.  And when that train hits, we know in an instant that life will never be the same again.

I had two of the freight train kind of patients yesterday.  The first was a man in his 70’s, previously healthy, an avid stamp collector.  One day in August, he suddenly had difficulty finding his words.  A CT scan done without contrast dye showed no stroke or bleed in his brain, and he was sent home from the emergency room.  His wife persisted with the primary care doctor—“My husband is just not right!” she said, and last month an MRI was ordered which revealed a  large ugly looking brain tumor, and the patient was taken to surgery.  The pathology returned as glioblastoma multiforme, the most aggressive type of brain cancer.  He was seen in outpatient oncology clinic by a young neuro-oncologist, just out of his training. By the time the patient came to me, every shred of hope was gone.  The man, still having difficulty with his speech, told me that the doctor said that at most, he would live a year, if he chose treatment, a few months if he did not.  He said that the doctor told him that the tumor would spread like a spider web over his brain, and that he would lose all function.  The patient cried when he told me this.

The second patient was a very fit man in his early sixties, a retired school teacher who had surfed and been a life guard all his life.  In July, he had a surfing accident (his wife said, “Can you believe it?  He surfed some of the greatest waves in the world and he wiped out in two feet of water here at home.”)  He broke his collarbone in three places, which required surgery to repair.  His pain got worse however, and he started to have back pain.  Spine films showed a compression fracture, also thought to be related to the accident.  As this tan, fit, athletic man began to seek more and more narcotics for his pain, an MRI of the spine was obtained, which showed the bones to be brittle and riddled with tumors.  Yesterday the biopsy of his sacroiliac area came back positive for multiple myeloma, a disease of plasma cells in the bone marrow which destroys the bones that cultivate it.  In an instant, this nice couple’s dreams of a happy retirement were shattered.

When we first moved to the West Coast, I was offered two very different jobs.  In one practice, I was to be the person that rotated through six different outpatient facilities, covering the regular doctor’s vacations.  I would see the patients for consultation, and perhaps treatment planning, but would never see them through their treatment or in follow up.  The other job was a hospital based practice where I would be the director of the department and have longitudinal care of the patients.  I chose the second, of course, because being the linear task oriented person that I am, I could not conceive of not seeing each patient through from start to finish to follow up.

I see things differently now, twenty years later.  I have a calling in life.  I want to be there when that freight train hits.  I know I can put the pieces back together, and I know that when that shattered patient leaves my office, for the first time in hours, or days, he will be able to notice the sun shining in our Southern California sky, and taste a faint flavor of salt on the warm breeze flowing from the Pacific. In turn, I will have the deep satisfaction of knowing that I did something good that particular day.  And that, actually, is quite enough.