1/2 Over

Exams are almost over. I did pretty well at them...never as good as my type A, anal retentive self would like, but that's just me. I was hoping to scale up and really get on top of the curve going into the last half, but I'm ok. If I maintain the same momentum, I'll be fine.  Today marks the 1/2 way point in the first term and there is some relief with that. The slide to #3 exams is coming. Built upon that knowledge is the impending fear of cumulative final exams...the enemy of aging memory. It starts again fast an furious tomorrow AM. I'm sure that we are behind in anatomy, but know that he'll make it up in the first hour talking about 500 words per minute and skipping over whole sections for our own digestion later. I love this part of anatomy...the chest. My early experiences in PA school in cardiothoracic surgery set the pace.

Flashback: I had the pleasure (or pain) of being a student under the guidance of Dr. John Kirklin, Sr at the University of Alabama-Birmingham before he died. To say that I was in awe of this man, surgeon, researcher, and teacher is an understatement.  What I learned was invaluable and my absolute love for the open chest was solidified there. I say pain because the hours were brutal; In house call every 3rd night, and regular hours from 4 AM until midnight...often.  But he was a consummate teacher and it was well worth the price. He was constantly asking pertinent clinical and basic science questions of students, residents and fellows (we had a huge team), challenging us to deeper understanding of anatomy, physiology, and surgical care. I only wish I remembered half of what I learned there 25 years ago. Then there was the hands on...

The operating rooms at UAB CV surgery were typically crowded with lots of folks learning...students, residents, fellows, visitors...all watching the well honed team of Dr. Kirklin and crew do their heart surgery thing. This one morning I was told to scrub, which wasn't unusual, but I'd never done it with him. 4 of us, including Dr. K, were at the scrub sink and I was too afraid to ask what my role was (that awe thing). We got into the room, gowned, gloved and the surgery began. I was told where to stand to "watch" and I did gladly...I LOVE surgery. Then it happened. About 30 minutes into the case, with the chest filleted open, he looked up and caught my eye and said, "come here"...I came hither, taking one step forward to the left, lateral position at the patient.

He held out his hand and asked for mine. He then positioned my hand around the beating heart of this 60 something patient and said hold that, and don't move. Holy coronary! I did as I was told and "held the heart" as Dr. K and team sewed in the vessel bypasses as planned. The heart beat was slowed but beating still. I was holding the heart in a position to allow him to see what he was doing (even though I couldn't) as ice cold cardioplegia solution dripped on fingers and rendered them numb. I didn't dare move. I didn't move. But I did it, and the surgery was successful and so was my education.

Needless to say, opening that cadaver last week at the costal sternal junctions with a small saw was not as satisfying and smelled much different, but my excitement for the chest instantly resurfaced. I love this stuff! Exploring the recesses of the mediastinum (cavities in the chest) the lungs, and all the associated structures that exit and enter the chest is exhilarating to me. Because I know that in that knowledge comes the ability to practice better medicine, auscultate more specifically, read chest x-ray and MRI's better. At least that is my hope. If not, it's been a heck of an "oh wow" flashback experience, none the less. The advantages of having been there. Nice.

Reading Break

I know that I'm a bit aberrant, but I actually "read" on reading day (today). I've got one more midterm and I read both textbook yesterday and today. Great information, but I may never dive again. Just kidding.

Hyperbaric medicine is a fascinating venture into the common understanding of the application of hyperbarics (high pressure) and hyperbaric oxygen or HBO (high pressure infused with oxygen). The applications are most commonly associated with the "bends" (decompression sickness) but many more maladies are approved for HBO including:  Air or gas embolism, Carbon monoxide poisoning, Cyanide Poisoning, Clostridal Myositis and Myonecrosis, Gas gangrene, Crush Injury, Compartment syndrome, Acute Traumatic Ischemias, Decompression sickness, Enhancement of Healing in Selected Problem Wounds, Exceptional Blood Loss, Intracranial Abscess, Necrotizing Soft Tissue Infections like Necrotizing fasciitis, Osteomyelitis, Delayed Radiation Injury, Skin Grafts & Flaps and Thermal Burns.

The unique environment that is Statia, and some of the best diving around, and my experience has made this venture very interesting. Not only have I gained much knowledge about the application of this technology in medical care, I've also learned bunches about my own dive safety. For example, I never understood the connection between pre and post dive exertion (exercise) and the bends. Now I do. As a result, I did not go diving on Saturday after hiking the volcano (2000 foot climb). So it is, I become more safer via education. I wish all of my classes had such direct application. Clearly embryology doesn't have the same appeal.

Barricade Mentality

Ok, so it's hardly Les Miserable, but I can dream. But the past few days have seen a more barricade mentality here as everyone, in all classes, is readying for exam week. Our class got a jump on it on Friday with the first exam of the block, anatomy lab, but the real "week" started today. The campus is pretty much deserted except for those that like to study here or those taking exams today. I chose to barricade myself in my apartment for the past two days. The rain helped to make that decision for me. No sense getting the laptop wet in transit from home to school. So I studied at home. Fortunately the Internet was up during the entire storm so I could Google questions if I need some instant answers to anatomy, histology, embryology, public health or hyperbarics...the tests du week.  The 20+ hours yesterday and today have really paid off. I feel pretty ready for Tuesday AM at 0800. I'll know for sure after an impromptu review session in a few minutes with some of my classmates. But in general, I think we are ready.

This is an important block to me as it marks the half-way point for the term. With solid scores, the downhill side of the term really becomes more downhill and puts much less pressure on the end during cumulative final exams. Yep...gotta know everything about everything in the term during that barrage in early August. Hopefully I won't forget much, but likely I will. That is one of the great risks of being an older student...KIAS, knowledge instant atrophy syndrome. We shall see.

The rain was long, and hard today...really drenched everything including the cisterns. I have shower water for a little while now, and the plants will look much greener by morning. I love island rain...something really nice about it.  Best of all it'll nourish the many mango trees here (I love mangos!). The trees are absolutely covered with them and what the cows can't reach, I can grab. Yes, the free ranging cows on Statia eat green mangos off the bottom branches. Does the milk they produce then taste like mango? I won't be the first one to try a sample. But I'll continue to fight them for the fruit.

Good Night

"This is your brain on medical school"

I'm fried. I'll start fresh in the morning. The combination of massive amounts of knowledge and formaldehyde, sprinkled with heavy a heavy dose of meat + 2 starch lunch...I'm done. The coffee and the adrenalin are giving way to my 50 year old joints.

ARRRRRGGGGGG

"Med Studs! Prepare for glory!"

A small group of the larger class has been getting together regularly and intermittently (regularly irregularly?) to study anatomy based on the objectives of the lab. The order of the recent days has been every anatomical piece and part of the lower extremity from the inguinal ligament to the tip of the toes.  After suffering the pain and anguish of the first lab exam, we decided on a new course of study with different focus, contact time, and with the benefit of hindsight...we have a sense of how the professor tests now. The study was efficient. The conversation took the content to new levels of understanding. We tested and prompted each other, verbally jousted over terms, directions, planes, spaces, branches....In the words of one of the females in the group, a "cacophony of testosterone."

Best of all we "peaked" at the right time. And this morning we nailed it! The average went up 15 points since the first exam. Most of us walked out confident, and with the knowledge that we had seen and discussed everything, and likely, knew all I need to know. Now, does this correlate with bedside manner, diagnostic skill, knowledge of preventive medicine and cost containment? Unlikely. Will this exercise do more than pump us up for the next Persian attack of the anatomy lab gods? Doubtful. But the 97/100 did feel good. Alas, I have never in my 24 years of clinical practice seen a needle probe stuck in an Anconeus Epitrochlearis muscle. And, I'm pretty sure I won't see that again either. I am going to reward myself with a DQ Blizzard. Wait, no DQ on Statia. Nuts.

F.E.A.R.

mne·mon·ic (\ni-ˈmä-nik\) - From the Greek (just had a "My Big Fat Greek Wedding" flashback) mnēmonikos, from mnēmōn mindful, from mimnēskesthai to remember. — 1: assisting or intended to assist memory, 2: of or relating to memory

I love mnemonics. I use them all the time. And for me, the dirtier, the better (and easier to remember). For fear of having this site shut down for violation of Dutch decency laws, I'll save the best ones for another time (like when I leave Statia for good).

An example of one is for this block of instruction is the order of contents, from medial to lateral, in the flexor retinaculum at the ankle:  "Tom Dick And Not Harry"...Tibialis Posterior, Digitorum longus tendon (flexors), Artery (Tibial), Nerve (posterior Tibial) and Hallicis (flexor to the big toe). In a pinch, it'll work wonders when the brain cramps during a timed exam. It is such an important technique that there are entire web sites devoted to this technique of learning medicine, like http://www.medicalmnemonics.com/ .

One of the professors talked about mnemonics as a memory tool. His example was an interesting one: F.E.A.R. He noted it to mean "False Emotion Appearing Real." This was a bit surprising since it's clearly not medical, or is it? Some my classmate talked about the example and some of our own fears, mostly about failure.

Fear of failure in medical school is huge Most of us have taken a huge leap of faith to be here, leave family and friends, halt careers or job, and move in the direction of our heart to learn and practice medicine.  Here, that fear is also linked and related to fear of criticism and rejection...something type A, medical science types loathe.  But we realize that success at this task is about overcoming that fear of failure, and shed the incapacities of the past.  There really is not failure, only the possibility of learning, and feedback to be better providers...at least after reaching the threshold of "passing" the exams.

Truth is that we limit ourselves by allowing the fear to prevent action.  This group of students is different. We all will achieve more than we think we are capable of since we have left a certain amount of fear behind us. But in the end, it is a "healthy" fear that has us moving diligently toward succeeding on the next set of exams.  We have, after all, taken the first step with bold, decisive action to be here, and it's scary.

I watched in lab today as the class helped each other study for tomorrow mornings anatomy lab exam, sans instructor for a large part of the time. We are really helping each other. The combination of fear and real caring is so evident in this environment. People are willing to help others overcome, or at least manage, their fears. Together, we are overcoming the inertia of fear, and really learning the science of medicine. It is so gratifying to be a part of it all.

Although, I am scared silly about those little brain farts that might prevent me knowing the femoral nerve from the obturator nerve tomorrow, I think I'll be OK. I just need a mnemonic. "Fear Overcome"

...femoral...obturator. I got it!! These really are my false emotions appearing real.

Testing: "I'll be back!"

"Examinations are as much for the staff as for the students - to get a better appreciation of their teaching techniques." (Steadism #154, p. 53)

 

 

Like a Terminator cruising away from the scene of carnage (the last block of exams), I heard it faintly..."I'll be back." Shonuff, "They're here!." Friday starts the next block of exams and, as before, I don't feel ready.

You try to keep up, read regularly, review the day's notes, pre-read the next day's content and review the stuff you need to remember...but somehow, somewhere it happens. You look down the road a piece and there they are...the next exams; And me with my scrubs down, not ready. So tenacity has begun to kick in and I'll do what I have to do...last night until, well, today (2AM). Anatomy is the kick for me...likely for most people. Like "drinking from a fire-hydrant with a Dixie cup", anatomy is a "gob" (is that a technical term?) of stuff in a very short period of time.

Too bad, since I love anatomy so much. But, I can't believe how much I've forgotten since PA school as I went thru a similar course of study 24 years ago. But I have to relearn it, in the way this professor deems necessary. By the way, teachers never align their "deem" with their students. In fact, it is contrary to the role. My professor is now locked into a battle with some of the better performers in the class to "trick" them on the nuances of the attachment of the various ligamentous retinaculum and septum of the ankle; Structures that are rarely part of any known medical or surgical condition. But it is entertaining to watch the interactions in lab.

However that bodes poorly for those of us who are struggling to know which is the thigh from the ankle, right before the exam. Let me repeat, I do not like anatomy lab exams, and after first assisting on about 5,000 cases, I struggle daily with the importance of this exercise beyond it's value for the teacher and the anal retentive performers in the group. We'll never have to do it this way again. Is it any wonder why many medical school have removed cadaver labs from their curriculum. Is it necessary? Dr. Stead said it was not. But then who am I to comment?

Dr. Dewey to OR Please

"Education is a social process; education is growth; education is not a preparation for life but is life itself." - John Dewey

I wish Dr. Dewey could experience this. This is not life itself. I wish it was.

Divorce Anatomy

In medical school we gain a greater appreciation for our own medical conditions and those of family and friends. We studied a little head neuro today. I now understand the anatomy of my divorce.

I'm not sure it'll be on national boards though.

Whoa...Slow Down!

"Education in medicine is just a way of becoming a free man. The more competent you become, the more opportunity you have to do as you please." (Steadism #166, p.55)

I am becoming a free man! There is hope to shake the shackles of PA serfdom...[LOL] My goal is to learn as much as I can, but hopefully, become competent at the knowledge I do attain. Now I know that this is not really possible at this level...too much...not enough clinically relevant experience with it (that comes in years 3 and 4 of medical school), but I have great hope that the competence will come. I have faith.

Let me repeat. Medical school is an infolanche! It is really incredible how much there is to learn (and I'm sure forget later right before the national boards). Dr. Nick van Terheyden, Chief Medical Officer for a large medical technology firm once said that "Clinical knowledge is estimated to double every 18 months."  Now I can't verify the stats (my public health professor would be proud), but that means that since I graduated PA school it has doubled 16 times. Might as well be a new profession. But there are many consistencies from the knowledge I had, and have obtained since. Thank goodness for that. And thank goodness for Wikipedia. It is a bunch of stuff. And I REALLY want to learn it all and become competent at it.

At the current rate, how will future medical professionals learn this, this way, and how will they retain it all? I'm sure this is not going to bet easier in the future. Are we moving toward a time that attaining the knowledge base is beyond the capacity of mortal man? Certainly, the way that it is being done. For now, I'm content of figuring out where the muscles attach on the tibia. That just in time knowledge is "due" on Friday with our next lab exam. I'll worry about the rest later.

Happy Father's Day

I'm leaving the study hall now, and it's tomorrow. Happy Father's Day to my wonderful father, and my child's granddad! I can't tell  you what your support has meant to me. And thanks to my Mom and Dad for staying together all these years. You've shown and demonstrated the meaning of commitment to each other and your family.

And Happy Father's Day to my wonderful daughter...who makes Fathers Day what it is...a magnificent reminder of those first hours I held her, and realized how precious life was. If I never spoke to her again (and that isn't likely), Father's Day would be a wonderful reminder of that amazing miracle and all the moments that have touched me about her since. Those thoughts help to fuel my studies and passions now.

"Anyone can be a father...it takes something special to be a dad." - Anonymous

I've made a lot of mistakes, but that wasn't one of them. I hope I've been a good "dad". I guess only time will tell.

Exams a Coming

There is a palpable crescendo of frenzy that is beginning to appear on campus. Exams are coming. Our anatomy lab exam is the first in a series of exams for us and all other students on campus. Testing "week" is essentially block testing...for everyone. And it's coming the end of this week. As was the case before the first block, there is an increase in activity at the study rooms during the late night and people seem to show up that I've never seen before. I know lots of people study at home, but with A/C, high speed Internet, few distractions, bathrooms and water the only thing lacking is food...and there is Chinese delivery for that in a pinch. You could actually live in the study rooms for the week, and some do. I've been tempted.

Anatomy lab will include the entire lower extremity (all muscles, bones, nerves, blood vessels and spaces. There is a significant amount of clinical testing possibilities here too. The dreaded lab exam is first (I hate these) and then the written exams will follow. Public health will cover 6 chapters of content, and histology another 8 lectures or so with lots of slide identification and practical application of micro anatomy. Example..what is this? (name the tissue) And then there is usually an application based question (how is it used, where is it in the body etc).

I'm sure that somebody in the class is thrilled with this knowledge (future pathologist) and I'm sure there is some question on the boards, but treating slides is about as exciting as watching grass grow to me. Although I have to admit, I'm enjoying learning that which I really did not know before. Amazing how you can practice medicine without this knowledge. It's not provided in PA school.

So it's been along day of setting the pace for the week. Lots of study to do before Friday and next weeks exams. I'm sure I'll be ready and have a plan already. BTW, during a short break today, we watched "Sicko" by Michael Moore (a presentation by one of the student organizations here).  I know that the movie is not without controversy, but after spending some time in the places represented, I must admit, practicing medicine in France, the UK or Canada is "romantic" and appealing to the person in me that hates the biz of medicine, ...but I'm not sure if it's really practical. Besides, my mother would hunt me down and kill me!

P.S. That is “Loose” Connective Tissue, the most widely distributed tissue in the body...It's in the skin, beneath the dermis, locations where epithelium connects to other tissues, orbit of the eye, underneath epithelial tissue of all body systems with external openings, mucus membranes (digestive, respiratory, reproductive, urinary system), and it surrounds blood vessels and nerves. Maybe I am ready for the exam?

My Spiritual Connection

Ok, it happened again today. A spiritual connection, a longing, through the stomach in my mind. It's hot (I've said that) and today as I was walking the path from immigration, to the tax office etc for the coveted laminated card of "temporary residency", it HIT me.

I MISS DQ. I had a total mind meltdown and fixation on one thing for the entire walk...a Dairy Queen Oreo Blizzard. I could almost feel the spoon stand up in the cup of frozen mix, see the chunks of cookie, smell the cold vapor drifting off the top of the heaped up mass of vanilla and such...I could feel the first bite when I usually close my eyes and let it slide down my throat, tasting every morsel of vanilla, chocolate, vanilla, chocolate...and that familiar flavor, Oreo (how do you describe that one?) Few things are more enticing and it certainly enticed me today.

Then I snapped out of it as the smell of formaldehyde from the cadaver lab, wafting from my tee shirt. hit my nostrils in the heat and steam of the Statia late morning. Few things are as incompatible as the smell of lab, and the smell of a Blizzard. I can't wait to get into my gas guzzling Expedition wander down to the DQ near my parent's house with AE, and get a Blizzard. But for now, I'm content knowing that it's out there somewhere, and that the smell of formaldehyde will never leave my clothes.

I'm Legal!

A letter came today in my mailbox at school outlining the process for completing my immigration papers. A mid-length walk to the police station where the immigration office is, over to administration, to the tax office to pay the ID tax, and then to the passport division....and it was done. About 3 hours of investment today (yes it's hot today), and I'M LEGAL! It's been a long haul, lots of paperwork, seemingly hundreds of copies of birth certificates, ID photos, and notary visits since I started this process several months ago...but it's finally DONE! I am officially a temporary resident of the Netherlands Antilles and Statia!

Now you may not think this is a very important thing in the scheme of life and the healing arts, but that little, manually-typed and laminated card is the key to being able to be here. They WILL deport medical students who don't have it by a certain period of time. It is stark reminder that we are visitors in this country, and have to have permission to be here. The card is that permission. One less thing to worry about so I can concentrate on upcoming exams...anatomy lab is next Friday (ONE WEEK!), and I don't know my ASIS from my pes anceranus. Lions, and tigers and bears, oh my! I've got time...no sweat (or maybe a little). Hey, it's Statia mon!

Whoa!

Any indication of slowing down, or break in the information stream that is the "infolanche" of medical school, was purely delusional. It has, in only 2 days, come with a vengeance as we enter this 2nd "block" of instruction moving toward midterms in 2-3 weeks. Public health is moving forward with it's "mini MPH" approach when we know that USMLE and the real world don't require this depth of knowledge. The facts, figures and equations are useless the way they are being presented without the benefit of clinical practice, microbiology, understanding of the literature etc. I am fortunate in that sense. Histology is already layering scores of slide to "identify" on the next exam in connective tissue, blood, muscle etc. Another totally useless skill except for pathologists and other microscope doctors.

Anatomy is working on both embryology and the entire lower leg (every muscle, nerve, artery and other structure). It is the class that I am most interested, and most applicable to really understanding pathology. A mentor once told me that command of normal anatomy and physiology was the key to good diagnosis skills and disease comprehension. I've applied that rule over the years, and believe it with my whole heart and soul. But the volume is truly unbelievable and really beyond the facile, complete understanding of most humans. But the key is laying a foundation for later learning in clinical education and repeat exposure in the other science classes.

Dr. Stead was completely right about medical education though. It is an educational system that is forged in distant history that has little application to the real world of using the information clinically. The world has changed in significant ways and the "infolanche" we are experiencing, in the method most medical school receive it (lecture), is mostly wasted time. I was sitting in lecture yesterday (except for breaks of 5-10 minutes) for nearly 11 hours. How much did I really learn, and how much "real learning" (reading and studying on my own) did I lose by having to be in class (mandatory attendance) assuming that presence is learning? For now, it is what it is and I am what I am, even if there is no ski patrol available for rescue if the infolanche overtakes me.

Darkness

The "age chasm" is alive in well, at least here. The is almost an isolation or segregation of aged students. Now I don't think it's me, or unique to this school, but since I've not been a student in a very long time, I do notice that there is a culture that doesn't include older folks. It's not a terrible thing. Frankly, there is a lot of wasted time, effort, conversation, pontification, and gossip involved, but there is also vital information if you can sort through it. I think that is where the concept of "out of touch" comes from...we are in a manner of speaking.

I am always surprised at what I "don't know" when it comes to class, schedules, stuff floating around, information in general...but in that is a sort of bliss and self preservation that has me finding what it is I need when I need it. "Just in time" information is something I'm used to and, in a way, more helpful to getting the work done.  I try not to worry too much about whether or not I'm fully informed. In the end the events of the day should either speak for themselves or give me the last bit of info I need to make the right decisions. I am blissfully becoming OK with my "out of touchiness", and at "one" with my inability to be part of the 20 something group.  

School

To address inquiring minds...everything about school, but you were afraid to ask (although some have) :

School is primarily located at one building for class, one building for anatomy and one building for administration, library and the testing center. I live near and spend most of my time at the classroom building. With A/C, water, bathrooms, large rooms with desks and high speed Internet, it is the location of choice for me and many others. It is where we spend most of our time during the week. It is the location where our white coat and orientation ceremonies were held and only one block from my apartment.

This building, called Suarez, is at the top of "cardiac hill" coming up from town and has patio with snack bar down stairs and classrooms and faculty office upstairs. The classrooms are comfortable (especially with the small class we have this term) and has full electronic classroom capability with everything we need for daily class. The podiums are fully electronic and have microphone, computer, project capability and Internet for faculty access and projection.  It has a great view of the Quill behind us, and the harbor (Caribbean side of the island) in front. Best of all, it is connected to a generator in the absence of provided power. This has helped on more than one occasion already.

Anatomy lab is held in a separate building with storage for the cadavers and dissection stations for testing. It is likewise air-conditioned and secure. It does not have a generator however, and can be stifling when the electricity goes out (and it has in the middle of class). We spend two-three days a week there as we navigate the systems and subsystems of the human body.  It is  located near downtown, and next door to a grocery store, and an outdoor restaurant & bar (Statia zoning at it's best). The bar is the yellow and white fence. The parking lot of the lab is often the location of local parties, drinking and frivolity spill over from the bar. But it is a fine place to learn and access to cadavers is always a special experience for students. I am resigned to watch others handle the formalin soaked contents. Done that...been there.

Lastly is the Administration, library and testing center. I have recently become all too familiar with the computer testing lab utilizing LXR testing software for our first battery of exams. Upstairs is the Hyperbaric Medicine offices and all the administrative offices for the school. The library, study hall, and testing center are downstairs.

The library is just ok, but a good place to study. I've checked out books from there, but with the world of the Internet, hard libraries are increasingly becoming unnecessary and moot. I have no less access to quality texts and evidence based literature than any medical student in the world. One of the advantages of waiting until now to go to medical school is the Internet. I can't imagine organizing the content, research, reference and dissemination of information before the Internet. For medicine, it is not longer a luxury; It is mandatory

That is school. Three buildings, one island and about 200 students, faculty and staff. It is, for the next two years, home in more ways than one. At times it is my living room and, hopefully, always a friend.

No Control

I dove this morning before starting my routine. One of the amazing things about being on Statia is the access to world class diving in our back yard. It would be hard not to take advantage of that. I don't.

Today I dove the wreck CHIEN TONG with instructor "M" (she's great) and a contingent of great young men from the Dutch Navy who  are in port while on patrol for drug runners in this part of the Caribbean.  They revealed to me that they hadn't much luck on this trip with collaring drug transporting  boats, but the diving has been great. If I fail to achieve my medical degree, I'm joining the Dutch Navy.

The wreck is a relatively new part of the reef development program on Statia.  She sits completely upright in a shallow "sinking crater" in about 80 feet of water and has been down about 4 years at this writing.  The wreck is 170 feet long and a former Taiwanese fishing vessel. She is "tethered" to another wreck, a smaller tug. Together with being relatively shallow, and having access to interior ports to dive "through", this is a GREAT dive. You can get a sense of the wreck from this photo right before it's sinking in 2004.

In the 35 minutes we were hovering around, and inside this wreck we saw barracuda, moray eels, sting rays, turtles and lots of fish. One of the turtles follow me up to the boat and swam around me during my safety stop.  This wreck is beginning to develop "life" and sea urchins, crusting of barnacles and coral are beginning to show. The number of fish alone attests to it's potential for reef development.

As we traversed the rear compartment, from outside door to a rear deck portal, my emergency regulator got momentarily "caught" on the structure. This is rule #1 of diving...secure all peripherals so that this doesn't happen. It was not problem...I unhooked the "catch" and was off again. Traversing the interior of the wreck was an awesome experience.

When I got back and was logging the dive, I contemplated that momentary feeling of complete loss of control and the power of external forces to exact control when and where necessary. I am not in control. I had a flash back to a day in Hawaii when I got slammed into a reef by the Pacific. That required 7 stitches. You  would think that I would better understand that in reality I am not in control at all, and can never be as long as I thrust myself into new situations, places, structures and experiences. Control is a fleeting power, even in real life. But in an international medical school, it is completely absent.  It is what it is. I like that.

Hurricane Preparation

I am acutely aware of where we are and the risk of hurricanes, but I am surprised at the lack of that thought here, on this unprotected island. Both among locals I've spoken too, and to fellow students, there is a sense of "safety" that really does not exist on this 2 x 5 mile island. Now I am sensitive...I know. I've cleaned up after a few good ones...Andrew, Wilma. So my sensitivity borders on panic when I can still smell the gas from generators and feel the "damp" of the walls. I know where the shelters are on Statia and have an "interior" bathroom.

Contrary to the opinions I've been hearing lately, Statia is not immune. Quite the contrary, if one was headed our way, I'd leave. No hesitation. South America is a hop, skip and jump from SXM airport. I won't need an excuse. The electricity and water is too tenuous here.  I doubt we could even get drinkable water if the shipping system was out. The current supply of bottled wouldn't last a week I bet. And I doubt the airport it long enough for big planes to land with supplies (just guessing there, but I've never seen one land there). Looking at the small harbor port, I'm sure it would be mostly destroyed and the lower road to town from there, flooded.

The Great Hurricane of 1780 hit this place and is a stark reminder of the power, fury and vulnerability here.  It was "perfect storm" and considered one of the most deadly on record. I don't want to inspire panic, just realism. You can't prepare enough, this close to the African coast. You may have a week or more in Florida, but big fast moving storms get to Statia in days or hours. We are pretty far east. Sometimes I think I can smell the Ivory Coast if the wind is right.

The Great Hurricane of 1780 killed almost 30,000 people and destroyed the Lesser Antilles (of which Statia is part).  The U.S. hurricane center wasn't set up then, so the details are not complete, but one thing is for sure, Statia was devastated. It was also the storm that brought down the most French, British and Spanish ships in the Caribbean. This area is strewn with wrecks from that storm year. Remember this was the U.S. revolution time. We have to remember too that this was October, very late in the "season".

I'm not fearful, and I'm certainly not shell shocked or debilitated by hurricanes, particularly those that happened over 200 years ago, but I do respect them. Sitting in the shell of my parents house after Andrew did that to me.  I'll forever be the guy that has too many flashlights, too many batteries and too many cans of fruit, veggies and meats in storage for the "just in case".  I pick a few new cans each time I walk by Duggins Shopping Center (an amazing misnomer).  Being without electricity after Wilma did that to me. I do have a gas stove though. And I have 3 can openers too. I can't even imagine what getting a generator, is like here...where there is no Sam's Club, WalMart, Home Depot or Lowe's. Not a chance.

I Need Fries!

I've had a craving all morning...Burger King fries. This is totally meaningless and is counter to my recent public health knowledge acquisition, but am craving fries. I have to admit that I have been known to slip my Expedition into the "drive thru" on occasion for a "fix" with a sloppy meal deal, burger, fries and soda. There is no such "fix" here on Statia and today, I feel like a good greasy edible with little or no nutritional value is exactly what I need after tests, and dealing with the obstructions in life. Fries usually help!  Compared to the pathogens that I am likely ingesting at the local eateries, the nutritional assault of greater than 30% saturated fats is likely easier for my body to take than the microbiological fauna that is Statia fast food.  For now, I will have to endure. God provides what she wants me to have. For now, it'll have to be fried plantains. Not quite the same, but it'll do.

Amazed

There seems to be a sense of self in medical school that becomes separate from the person we want to become...will become. Sometimes it takes just a photo to remind me of what it is that I'm connected with, and the services that I've performed in the past to touch the lives of patients and their families. I've been very, very lucky over the years to have such experiences as a PA. I hope for many, many more. It is our destiny. I need to stay "amazed." It helps with the distractions that compete for our attention.

Maldistribution

One of the more disturbing things about school, particularly as someone who actually studies and has taught before, is the maldistribution of content around the class. There is "content" floating around that seems to find it's way to some, and not to others. This is not unique to this school. I've seen this happen before in other programs I've been involved with.

This morning I found out that there was an instructor created review in Powerpoint for this exam I'm about to walk into. the only problem is that everyone in the class didn't have it or know about it. Worse those individuals that I've shared stuff with in the past didn't share it with me. That really sucks!

So as we walk into this exam, some have had a "preview" of the test and others have not. I cannot tell you how disturbing this is as I face this exam. Yet in the end, hopefully my overall studying of the content will pull me through, despite what I have or don't have from instructors and fellow classmates. In the end, this is a solitary experience based on my knowledge, experience and fortitude, not the content I possess. It is difficult sometimes to remember that in life, let alone medical school.

Addendum: The exam is over..and I nailed it. Thankfully I actually studied and read the content. The "review" that was floating around was bogus. If that is all you studied, you failed the exam for sure. I didn't. I was the first to leave the exam after going thru it twice. I'm sure I scored one of the highest, but it doesn't matter. I new it, and studied right. Just got to keep up with this one since the final is cumulative. Glad that is over. I have learned a great lesson.

Sailing

I've had the fortune to meet a few intrepid traveler's on Statia. They are nomadic sailors...couples, families, singles sailing around the islands from point all around the globe without a destination or purpose other than to sail, and discover places not yet seen. There are some truly amazing stories. One recent meet was a couple from the Midwest of the U.S. who traversed the Great Lakes to the coast and then down to Florida. When their vacation was to end, they chucked it all, and continued. Two years later they are still sailing the Caribbean with no plans to return. Life revolves around sailing, and daily recreating their relationship. I was enthralled listening to them speak about the who, what, where, when and how's of sailing indefinitely.

Statia seems to attract such folks as a part of the the "path" around the Caribbean. It's location certainly helps that...on the way to most everywhere in the island chain. I guess that is why there is a ship "gas station" here. Really a tank farm with large hoses for refueling really big boats. Almost 1/4 of the island is a "tank farm" dedicated to that purpose.

One of the sailing couples I met provided me this insight:

"Twenty years from now you will be more disappointed by the things you didn't do than by the ones you did. So throw off the bowlines, sail away from the safe harbour. Catch the trade winds in your sails. Explore. Dream." Mark Twain

I don't think it is by accident that I'm here studying. No matter how difficult this gets, I am thankful that I no longer have the bowlines and seemingly safe harbor. A romantic picture as I navigate anatomy, histology, embryology and public health.

Conversion

I know that some of us will end up in pathology, and I know that I should appreciate the nuances of histology, but I can't seem to remember the conversion from Centigrade to Fahrenheit and back.

We really are a retarded group, those countries that don't use metric. We feel entitled to use Fahrenheit and other forms of non-metric when nearly the rest of the world is content in metric; Well I certainly do feel entitled. Why convert? For some reason my histology professor doesn't agree.

Actually it is quite easy: F = (Cx2) + 32 will get you really close from C to F; and C = F - 32 / 2 will do the dirty deed from F to C. I am quite sure that I'm a better patient care provider for knowing this information. Or I'll just whip out my handy PDA and do the calc, if and when I actually ever need it.

Sometimes Missing the Point

One of my colleagues reminded me today that our education, in theory, should help us sharpen our attention, mental dexterity, problem solving and analytical dexterity.

However, medical school in its current form is not necessarily designed to develop these abilities.  Medical education places great prestige on rote-memorization and test-taking skills as the supposed predictors of one's future success as a physician. It is any wonder why so many patients can't connect with their physicians? Wouldn't be a great goal to have medical school select and develop skills that foster meaningful patient relationships and interactions with a sprinkle of essential communication skills?

Dr. Warfield Theobald Longcope is credited with saying, "Each patient ought to feel somewhat better after the physician's visit, irrespective of the nature of the illness." Shouldn't that philosophy be the guiding force behind the human aspect of our training? Alas, it is not, particularly in the basic science years. I love the science of medicine, but I miss (already) the patients. That will be a guiding "picture" in my mind about why I'm here on what my colleague referred to as the "penal colony" today. It's really not that bad. I feel right at home here, minus my Mom's great cooking, and my Dad's sage advice.