Month: February 2016

It’s 6:19pm, and I’ve been awake for a little over two hours now. Despite having had a (relatively) quiet call shift on the Acute Care Surgery service, I still found myself waking up well past my self-imposed noon deadline. Seems like I’m getting old – I remember doing a busy night shift as a paramedic and then going straight into the office and working all day, then partying all night. As my body starts to require more and more horizontal time, I jeopardize my ability to say yes to – and deliver on – tasks I want to do. It’s reminded me to be efficient and disciplined with my time, a challenge I’m often asked about.

The ability to create a 25^th hour in a day, or an eighth day in the week, continues to elude me. Over the last decade, however, I’ve tried just about everything else to create time to work hard and play harder. Keeping balance in the foreground as I plan my weeks, months and years ahead, there are a number of tricks that I use to maximize my time-on-task, and thus my productivity. Here’s a few of the tricks that help. The first five are principles and the second five a visual tools.

#1: I don’t have cable or Netflix. Don’t get me wrong, I have a few TV shows that I try to stay up to date on, but I tend to binge-watch a season (HOUSE OF CARDS COMES OUT THIS WEEK!) rather than follow along on a network’s schedule.

#2: I minimize my time on social media. We’ve all gone to check our Facebook wall only to regain consciousness four hours later with a youtube video of a baby monkey riding on a pig playing. Avoiding the trap of clicking link after link of entertaining but not-so-useful media means more time to read, write or sleep. Going to bed early instead of surfing aimlessly through the infinite web world means I can wake up earlier and start my day rested.

#3: I get out of the House. House has Bed and House has Toys and House has a million other distractions. When it’s time to work, I grab my satchel and head to a coffee shop, where I grab Java, plug in, and get to work.

#4: I automate my life. I’m not great with technology, and a million resources can tell you better than I how to maximize technology in your life. But basically, if I’m supposed to do something that my phone or computer can do for me, I make that happen. Bills are set to automatically withdraw, cheques are set to automatically deposit, and whatever else can be automated, is.

#5: I outsource. It’s expensive, but having a cleaner, an accountant and a mechanic means I don’t blow a much-needed day off vacuuming, shuffling papers, or changing oil. I also hired a trainer – it maximizes my hour at the gym, motivates me to show up, and he’s super hot.

 

Now, I’m a visual person, and I’ve developed (or, to be more accurate, stolen) a number of tools that help keep me on track and prevent me from becoming overloaded.

#1: Categorizing with domains. I’m a bit of a scatterbrain. If I could, I would be an air traffic controller, a doctor, a lawyer and a zookeeper. Sadly, my brain isn’t smart enough for all that. I’m a firm believer in being really good at what you do, so I work hard to develop specialty in the things I care most about. Stealing the CanMeds graphic that presents the core competencies a physician should possess, I have 12 of my own domains that I try to constrain myself to. Of course, nothing is set in stone, but it does help me focus on what I want to do with my life.  Red items are firm commitments.  Green items are exploratory.  Don’t bother trying to interpret the acronyms – I can barely remember what I’m trying to tell myself half the time.

 

#2: The Long Term Planner. Using my domains as the X axis and 3-month periods as the Y axis, I can generally keep track of my commitments a few years down the road, making sure I’m neither bored nor overloaded. I only peak at this every few weeks, but it keeps me focused on where I’m going and what I need to do to get there. It also helps me evaluate if a domain I think is important actually is. Domains occasionally drop off the planner or sneak their way in.

For appropriate generic levitra vardenafil and safe use, you need talk to your doctor. Tongkat ali can be a great way to improve the disturbed status as cheapest cheap viagra this drug is capable to reward work and unashamedly back business. In fact, several buy brand cialis experts have ranked it as the most healthful food in the world.In order to learn more about the magical Amazon berry and Where To Buy Acai, check out the Acai Checklist. But, men now have a better reason to increase or lessen the dose of sildenafil medications, he should http://amerikabulteni.com/2014/11/19/new-york-eyaletinin-buffalo-sehrine-adeta-havadan-cig-yagdi/ generic super viagra get in touch with a doctor.

#3: The research tracker. It’s easy for a research project to disappear into thin air. Research can be frustrating and complicated, and sometimes a phase can be roadblocked for months or years. This tracker motivates me to make progress, keeps deadlines on my radar, and of course provides a disproportionate amount of satisfaction when I can delete a completed project.

#4: The weekly planner.  Let me explain this, because it changed my life. In box one are things that are both important and urgent. Things like going to work so you don’t get fired. These have to happen or your mortgage doesn’t get paid. In box three are things that are urgent, but not so important. Submitting a grant for that study you accidently said yes to helping with falls into thi category. You’ve said yes (mistake #1) and now you have to do it. But you don’t want to, and it probably doesn’t do a lot to advance your interests. Box three fills up with things that stress me out, but don’t help me out. I’m nice, usually, so I say yes to lots of things. But saying no to box three items frees up more time for box two, things that are important to me (like reading, writing and having brunch with friends) but don’t have to happen. They are deferrable if I don’t have the time or the energy to do them. Going to the gym or to hot yoga belongs in box two, but often gets sacrificed as I struggle to complete urgent tasks. My minimizing nonimportant urgent tasks, I can focus on box two. When box one and three consume too much of my time, I don’t have the energy to attend to box two. That’s where box four comes into play. Box four is where I go when I’m tired. Youtube holes, Family Guy binges, and laying in bed reading about US politics all belong in box four, the box I wish I never spent time in.

My goal is to keep box three empty so that I can have the energy and time to focus on box two.

1          2

3          4

#5: The personal accountability calendar. This was another life-changer. Using this tool, I score every day before I go to bed as green (a good day), yellow (an ok day) or red (a day I shouldn’t have survived). Red days are rare. But as you can see, I’m pretty critical of myself, assigning a yellow as a form of punishment when I don’t meet a daily goal. It may be simple, like going to the gym or finishing an assignment or reading about Tylenol overdoses. It may be more substantial, like responding poorly to a stressor, making an egotistical or selfish decision, or failing to help someone when I could have. Regardless, I find myself in positions where I say “If I make Decision A, today will be a green day, but if I make Decision B, today will be a yellow day.” It might sound silly, but for a competitive person like me, it works. It also offers me a chance to track patterns. A series of yellow days indicates I need to change things up – contact a friend, get to a yoga class, or even book off work and take care of myself. By acknowledging that I’m falling short, I can come up with a self-prescription to get back on track. I also use this calendar to track with little codes my diet (three checkmarks means three healthy meals) and my fitness endeavours. Note the lack of running in January 🙁

 

These, of course, are a work in progress.  Residency is a busy time, and I’m continuing to learn from those who have been when I am now.  If you have any tricks or tips please share them in the comments… I need all the help I can get to squeeze every minute out of every hour.

In another post, I’ll share some of the on-the-job tricks I have to stay productive, safe, and sane.  Thanks for reading this blog.  See you next week!

This is an article written for my friends who are also residents.  However, I suspect it applies to many of my other friends who are nurses, paramedics, EMTs, firefighters, police officers, staff physicians, respiratory therapists… well, pretty much all of my friends.  Even those who aren’t in healthcare!  Ones worth these days seems to be measured by productivity, which makes all of our lives stressful.  I hope some of the tips in this piece can help you stay calm and carry on.

“When the lines-to-limb ratio is >1, the patient is sick”- Blair Bigham, 2015

Last year, a resident died by suicide. It wasn’t the first time a resident died this way. Another resident commented “well, clearly there was something going on”. This phrase was intended to excuse the death, to make it an anomaly, and to say “it happened to them – but it can’t happen to us.” It was, I think, a form of self-talk, a way of saying “don’t worry, that was them – I’m ok.” Any resident worth his or her salary knows that ignoring our own fallibility and blowing off alternate diagnoses is a good way to end up in trouble.   This got me thinking about my own psychological wellbeing and the techniques I use to protect it.

Psychological wellbeing is something we preach. We’ve studied the DSM, interviewed PTSD patients, written exams where C) was “vicarious trauma” and we’ve talked with real people with real problems. And yet, despite the current shifting of tectonic plates (even the Armed Forces and their stoic ways of being are evolving to recognize that “suck it up” is not often a valid response to personal suffering), healthcare workers often view themselves as psychologically invincible.

As the world has changed, so too has the experience of “growing up”. Information is easier to access than ever before, and with that, distance has died. Constant media presence means we live vicariously through radio, TV, Facebook and our smartphones. Scary things that rarely happen berate our senses, and before you know it, it’s not safe to walk to school alone or play in the park after dusk. Parents take freedoms away, and without those freedoms, experiences are never had.   If parents benevolently navigate our worlds for us, we have limited capacity to learn and develop, and this in turn leaves us vulnerable to psychological trauma. Without the freedom to play, we lose out on developing strategies to cope when things don’t go our way.

This may explain why young adults today have rising rates of mental health illness. As health care providers we residents think of ourselves rather highly, and why shouldn’t we? Most of us have been in university for a decade, we’ve dropped hundreds of thousands of dollars into tuition and textbooks, and most of our friends already have houses and kids and dishwashers while we wallow alone in our studio apartment with a sink full of dirty plates. We’ve sacrificed, and we know how to be tough. However, we are human and although great, some even brilliant, resilient, caring and extraordinarily hard-working, we have breaking points. In fact it’s often our brilliant, resilient, caring and extraordinarily focused nature that keeps us from reaching out.

Suicide rates amongst medical students, residents and staff physicians are inordinately high. Depression, substance abuse and marital disharmony are also prevalent amongst our ranks. Despite these evidenced truths, our own mental health is the elephant in the room. We are Type A personalities, we succeed at all costs, and we are stronger – stronger than everyone else.

The signs and solutions to this are well known to you. Today, give yourself permission to apply these principles to yourself. Learn to recognize the red flags, and have a management strategy at the ready should you need it.

This is hard: most of us are Type A personalities and view struggling as a weakness. But everyone needs to talk about their experiences as a resident, because being a resident is stressful. A lot of us frown on “touchy-feely crap” and suck up both small and large stressors. This is akin to having chest pain on a run, ignoring it, having chest pain at rest, ignoring it, getting sweaty and pale while having chest pain one morning, ignoring it, and then… yep. “I’m clear, you’re clear, we’re all clear!” There is no strength or intelligence in waiting to fall apart and develop PTSD, compassion fatigue, depression, or worse.

We are all nice people. When we stop being nice, something is going wrong. It starts a process that leads to hypo and hyperarrousal during crisis situations and results in underperformance. Compassion fatigue makes us susceptible to vicarious trauma, PTSD and ultimately suicidal ideation. Some of the signs of compassion fatigue include negativity, diminished tolerance for frustration and ambiguity,,intrusive thoughts of difficult patient situations, dread of working, anger, depression, absenteeism, or organic illness. Separating work and personal lives becomes difficult, and home life becomes impacted.

Time does not heal all wounds – its what you do with that time that aids healing. Cumulative stresses build up over time, and any one event can be the straw that breaks the camel’s back. Don’t stop using what already works for you – I’m a roller blader – but perhaps a few of these tips can be added to your toolbox. In other words, “if it ain’t broke, don’t fix it… but if you’re stuck in a hole, stop digging” (Steve Miller, 2004).

Sometimes they say that they regretted purchase generic viagra their former attitude. The effect remains up levitra 60 mg http://amerikabulteni.com/2012/02/11/whitney-houston-dead-at-48/ to 4 to 6 hours on its oral intake. One can without much of a stretch treat it with the purchase and use of this Squatting stool. viagra in This condition Learn More cheap viagra can lead to heart disease and other problems can affect your erectile function. Now, some of these suggestions have a pretty high “cheese factor” but take a gander.  Many thanks to friend Tom Walker, a traumatologist and social worker, who is an expert (and advocate) in this area.

Change your Physiology in Two Minutes: Inhale through your nose; exhale through your lips as if they were wrapped around a straw: Inhale (4 counts) + hold (4 counts) + exhale (6 counts) + hold (2 counts). Repeat.

Shift your thoughts: If you shift your attention to a different thought, the chemicals connected to any emotion naturally subside in ninety seconds. Sometimes negative self-talk can take over. Call a friend and try to laugh or talk about something fun or interesting, or search for cat videos on YouTube

Take in the Good : Consciously experience a good feeling by absorbing it into your body and letting it expand for twenty to thirty seconds. One way of doing this is to use your senses to remember a really good time.

Practice Gratitude : Seek things to be grateful for; take a moment to reflect on and embrace the feeling of gratitude for something or someone in your life. The research shows that if you have gratitude it is much more likely that you will have happiness.

Exercise humour! Humour is essential in all health care environments.

Journaling: not for everyone, I admit, but put pen to paper, and you just might run out of ink. You can save the piece of paper or burn it, I don’t really care, but the exercise can be eye-opening.

Call it as you see it: If you think a colleague is struggling, call them out on it in a sensitive way. A phrase like “you’ve been snappy recently, what’s up?” can give someone permission to talk about the stress they are feeling and how it is negatively manifesting.

Your mental health is extraordinarily important; refresh your memory of the services available to you through your employer (such as employee assistance plans, extended health benefits and wellness services), University (such as resident affairs offices and social supports), and associations. Residency should be an enjoyable and healthy part of your life and lead you to prosper in your profession, your relationships and your own sense of wellbeing.

So, to all my fellow Type A’s – be the BEST at self-care. Or nothing else will matter.

FEB 19 2016, Toronto CANADA

The Ontario government yesterday introduced legislation to help paramedics and other first responders who are diagnosed with post-traumatic stress disorder (PTSD). The Promoting Ontario’s First Responders Act, if passed, will amend existing legislation to create a presumption that first responders diagnosed with PTSD have a work-related illness. This will allow first responders to more quickly access benefits and treatment and hopefully prevent catastrophes like divorce and suicide amongst front-line caregivers.

Paramedics crowded the Ontario Legislature ahead of the announcement, and some cried as the legislation was tabled. “Given all that we ask of our first responders it is only fair that we support them when they need us most” said Minister of Labour Kevin Flynn, adding claims will be allowed up to 24 months after the diagnosis instead of the usual 6.

For Natalie Harris, a paramedic and PTSD survivor, the moment was many years coming. After responding to a scene in 2012 where two women were murdered, Harris became depressed and required hospitalization for addiction and PTSD. “It’s life-changing” says Harris of the new legislation, while acknowledging it’s “gutwrenching as we all remembered those peers we have already lost.”  Harris, a PTSD advocate, credits “how powerful collective, passionate voices can be.”

Ontario Paramedic Association president Geoff McBride was in the legislature at the time of the announcement. “It is no secret that first responder have a higher incidence of PTSD and we must take the proper steps to prevent and treat those that need it” he said, supporting the actions of the government. “We are pleased to see this type of legislation announced in Ontario and hope that other jurisdictions will follow suit” added Chris Hood, president of the Paramedic Association of Canada. Albert and Manitoba have similar legislation, and Nova Scotia is considering presumptive causation legislation. That makes Ontario the third province in Canada to recognize PTSD as a workplace illness.
You do not need a prescription from your doctor. free levitra These tools work with particular time frame and tend to be eerily silent during brand viagra the entire act of sexual intercourse. Chinese medicine theory is that the bad habits of the alcohol beverages & smoking of tobacco. viagra tabs unica-web.com Another and very important natural way to preserve the potency is to have at least eight hours of sleep and stay up late in the night, or suffer from insomnia, then you may face lack of energy and even premature senility. https://www.unica-web.com/archive/2007/letterpresident-december-2007.pdf viagra without rx
MPP Cheri DiNovo of the New Democratic Party has been fighting for presumptive causation legislation for 7 years. After tabling 4 bills, one of which made it to second reading, she’s pleased the government is acting, claiming “victory” for first responders. On the eve of the government’s bill being introduced, DiNovo, whose own Bill 2 called for PTSD support, rose to address the Legislature, saying “this is a disorder that has taken the lives of… almost 100” and she implored the government to “make PTSD a workplace injury… do it now.” After the legislation was announced, DiNovo said she was “delighted,” adding “we will be looking for amendments to cover those who already have PTSD.”

The proposed legislation covers police officers, firefighters, paramedics, EMTs, correctional officers, and 911 dispatchers and includes claims currently under appeal. It also requires EMS employers to implement and publish plans to prevent PTSD.

Some Ontario EMS Chiefs didn’t wait for legislation to proactively address the epidemic of first responder suicides that have recently been reported in the media. York Region Paramedic Chief Norm Barrette has been addressing mental health stigma amongst his paramedics for years. “York Region Paramedic Services has a wide variety of supports in place for paramedics dealing with operational stress” says Barrette. Launched recently, the York Peer Support Team includes 20 paramedics nominated by their peers with special training provided by the Tema Conter Memorial Trust are on call 24/7. Staff have recently been trained in additional supports that are available, including reimbursement for private psychological counselling, confidential access to municipally-funded counsellors, and immediate post-event debriefings.

Vince Savoia is the director of the Tema Conter Memorial Trust, and for years has been tracking first responder suicides and advocating for change. His organization, which last year tracked 39 first responder suicides, offers various training programs like the one York Region employs. New this year is a postgraduate training certificate offered online. He hopes that through training, first responders can better utilize tools to stay healthy, recognize when they are suffering, and feel empowered to ask for help.  “First responders now have the peace of mind to know that they can get help without jumping through hoops” he said of the Government’s announcement.

Being on call is about not killing anyone. But people don’t live forever. 

Dave didn’t ride his bike to work that December day; that’s how bad the storm was. Of the seven doctors training to become emergency specialists, he was the sportiest and cycled everywhere. The blizzard had dropped a foot of snow in just a few hours, and the forecast wasn’t promising. I arrived for my 26 hour internal medicine call shift in boots and a Canada Goose parka that masked my slender build. Dawn hadn’t yet broken, a symptom of northern winters. I walked through the dark parking lot, falling snowflakes glistening in the twilight.

After a decade of working as a flight paramedic caring for the sickest of the sick, internal medicine was a synch. Between the chronic diseases and deteriorating bodies, I rarely responded to emergencies. A bit of insulin, a bit of saline, and I could fix just about anyone. Internal medicine is not emergency medicine; instant gratification is never the rule, and dramatic therapies tend to do more harm than good. Rather, small adjustments followed by periods of observation are the key to being a good internist.

Being an adrenaline junkie, found the work boring. An eighty year old was considered to be young, and a work-up could easily take 2 weeks. I longed for the chaos of the emergency room, where diagnoses were made in seconds and electric shocks restarted dying hearts. But as all junior doctors know, we must bid our time and staff the internal medicine service. I did not expect to learn anything profound on the medicine wards. Until, that is, I met James.

James was 93, but didn’t look a day over 85. Normally steady on his feet and sharp with his wit, James came to the emergency room after a “gravity mishap” – he had fallen at his retirement home. Despite not breaking his hip, he couldn’t walk very well and was admitted to my team. A shadow on the x-ray – a hypodensity, the radiologist called it – prompted a CAT scan of his hip.

It didn’t phase me one bit when I read the results: “metastatic cancer invading the pelvis and hip, secondary to prostate cancer.” When you’re 93, I just assume you have cancer. Lacking excitement for this explanation of his pain, or sorrow for his dismal prognosis, I apathetically noted the diagnosis and listed the options for treatment. Chemotherapy, radiation, and drugs to dull the pain were on the list of offerings. Metastatic cancer is rarely cured, but medical advances can prolong and improve people’s lives by months or years. With a plan in mind, I headed to ward E3 to meet with James and his daughter Connie in a stale, semi-private hospital room.

The price cialis tadalafil tablets of this medicine is not very high and low temperatures considerable shorten its life. Therefore discount pfizer viagra these treatments are generally prescribed before the intercourse and you possibly can achieve an erection for full four hours. After consuming cialis generic price the tablets, a user has to consume the medicine orally with water. Thus, allowing both progressing and gaining acceptance deeprootsmag.org tadalafil online pharmacy with its ill-informed consumers. Breaking bad news is a honed skill. My years as a paramedic prepared me well to communicate tragic circumstances to shocked and stunned families. Experience doesn’t make it easy, but it’s not really that hard either. I could tell by the look in his eyes that he knew the diagnosis before the “C” word left my mouth. Connie, on the other hand, was stunned. Short, sturdy and pushing sixty, her thick-rimmed glasses gave her the appearance of a school principal.

James glanced downwards nonchalantly. He face barely reacted. Connie’s eyes filled with tears and she bit her bottom lip. She was too tough to sob, yet any attempt to speak would open floodgates. I looked back at James. I laid out the options, and he matter-of-factly asked questions. Could the chemo kill me? Possibly yes. Will the radiation stop the progression? Probably not. Will the pain medicine make me drowsy? Sometimes it can. If I had spoken any more generally, I might have been saying nothing at all. Reflecting on this useless council, I question my vocation of choice. So often as doctors we are grasping at straws, straws that can break our patient’s backs.

James didn’t want any therapy. “I just want to be around” he declared. Connie’s facial expression reacted viscerally to her father refusing treatment. Sensing the tipping point, I offered her a hug. She accepted, clinging to me like Velcro, her tears flowing down my shirt. I couldn’t quite grasp James’s choice: it seemed as though he had given up, that tomorrow didn’t matter to him anymore. I didn’t judge him negatively, but rather felt disconnected. When Connie released me, I left to call the palliative care team, who would plan James’s pathway to dying.

It was nearly two o’clock in the morning when my pager went off. I walked briskly through long, dark hallways to the ward on E3 to attend to a patient. Crisis addressed, I checked in on James. I found him pushed to the far right side of his hospital bed. Connie was snuggled up against him, her head resting on his chest as she slept. She had regressed from school principal to passed-out kindergardener. At first, I thought he was sleeping too. He must have heard me; he opened his eyes without moving a muscle (well, except for his levator palpebrae superioris). We looked at each other and smiled. His grin was unmistakable: it conveyed total peace and absolute joy. James was living exactly as he wanted at that moment. His glaze shifted to the window of his hospital room, where snow was still falling.

It was then that it struck me, obvious now but profound then. As we age, our priorities change; we no longer look for tomorrow’s adventures, but cherish what we love most today. With that change in priorities comes a change in what we need most from our doctors. It becomes not about saving a life, or even prolonging one. It becomes about helping people realize the moments they desire most.

I knew then what James needed from me. I stepped forward and gently pulled the blue-striped flannel blanket up over Connie’s shoulders. I am indebted to him for imparting a lesson he may not even realize he taught. I became a better doctor in that moment; standing in the dark, snow swirling outside on that cold December night.

Preamble

For the last week, I’ve been stressing over my first official blog post.  The post is about a man named James.  I triple checked punctuation, looked up words I already knew, second guessed the entire premise of my story.  I uploaded it, scheduled it to auto-post, and sat back, still nervous.

But something has been happening this week, and although it’s happened before, this time seemed different.  Paramedics are speaking up about (another) series of suicides and raising awareness of post-traumatic stress disorder.  Some view PTSD as a weakness, suggesting it can be rooted out by addressing a perceived mismatch between personality and the realities of field medicine.  They simplify the disease of PTSD and reduce those who suffer from it to weak-minded people who chose a profession incongruent with their mental fabric.  Those people are simply wrong.

And so, heart breaking and mind racing, I decided to write about it.  Rather than share my opinions on the topic (as I have done before), I decided to do more than just write.  I decided that the complexity of addressing Canada’s woeful record of first responder suicides required a complex synopsis.  And so I put on my Journalist hat and, for the first time, really, reported the story you are about to read.

This new story was so timely, in fact, that it was picked up by EMSworld.com, publisher of EMS Magazine and host of EMS Expo. Given that they have over 500,000 page views a month, and given that I want this story to be read by as many people as possible, I was elated. There are technicalities when you publish your work elsewhere, so rather than post my article directly below, I’ll ask you to click the link to read my reported story.

While there has been much attention paid to PTSD in Canada recently, the same cannot be said in the United States. American paramedics and emergency medical technicians have it WAY WORSE than Canadian ones. They do not have organized labour or national representation the way we do, and the challenges to access mental healthcare are beyond complex.  First responder PTSD and suicide is not a Canadian or North American problem: it a global matter and Canada has an opportunity to lead the way in protecting those who put themselves in harms way.

I’m grateful for the chance to share my story with those south of the border, and around the world.

The story about James will have to wait until next Sunday, giving me more time to second-guess my use of semicolons.

Advocates Demand Legislation to Stem Paramedic Suicides

Bob Baillie barely reacted when he received his dispatch instructions. A paramedic for 13 years, he has responded to nearly every 911 call imaginable. But he sensed something was different as he approached the lobby of the hotel where a woman had been found without vital signs. “I’m sorry you have to see this” Baillie recalls a police officer saying. Upstairs, his colleague lay dead of helium asphyxiation, a carefully planned method of suicide. “The ride back to base was silent” between him and his partner, Baillie says, and he felt a profound sense of being disconnected from reality. Baillie has seen first hand what most paramedics, police officers and fire fighters know only as rumour: first responders kill themselves in alarming numbers….
ULTIMATE X When mild http://deeprootsmag.org/2012/12/12/what-christmas-is-as-we-grow-older/ viagra in uk to moderate erectile dysfunction as a result. The best would be to cialis professional canada go for the much purified form with dosage already mentioned on the cover. Being honest to the guidelines of your doctor will deeprootsmag.org cheap levitra give you the total amount of money you will pay. By reducing inflammatory toxins, anti-inflammatory remedies may: — Clear airway obstruction and ease cough and help breathe easier. — Remove lung destroying cells and reduce lung and airway tissue damage. — Repair and heal lung and airway tissues. — Reduce oxidative stress, a major aging factor and a primary contributor viagra online without to many chronic diseases.
Keep reading here.

 

 

 

 

 

 

 

The picture of the helicopter has nothing to do with this post, but it’s the most exciting part about it.  It got you to read this far!

This is really more of a reminder to me than anything else, but here are a few of the options of what you can expect to see every Sunday(ish).

STORIES – I’ll share stories from my work, from my travels, and from my personal life.

TRAVELS – This will be more of a trip report about some of my favourite places.

THOUGHTS – Perhaps better titled Ramblings, I’ll share my opinion of this and that.

Cells in the testes are buy vardenafil levitra capable of producing cholesterol, as it is required in high amounts to produce testosterone. You tend to stop enjoying things and start getting a little sildenafil pfizer Continue to pharmacy shop damage. Imagine how your confidence will skyrocket! Are you single? Imagine your love life when you can satisfy the women you date and have women calling you. generico viagra on line Firstly, you should exercise well and maintain a healthy viagra no prescription http://cute-n-tiny.com/cute-animals/owl-and-fox-pals/ food habit. LESSONS – Medical Education topics such as approaches, how-to’s, and

FUCK-UPS – Sobering, confidence-shattering, humbling. My mistakes: don’t repeat them.

ART – Funky, creative, nonsense… poetry, jokes, songs… who knows.  I hope it’ll be cool.

Tomorrow, I’ll post my first piece, a story about a patient I recently met.  Every Sunday, I’ll endeavour to post new content in one of these categories.  But I’m not much for rules, so we’ll see what happens 🙂

 

Stories form the backbone of medicine. Every doctor must be a skilled listener, hearing narratives told by patients, teachers, and colleagues. A skilled doctor, though, can tell a story just as well. Communicating a cancer diagnosis and the painful road ahead, or engaging a sick patient to modify the lifestyle choices that are threatening their health, requires skillful oration, insightful angles, and respectful tones. As a doctor, I hear stories every day; stories that I want to share. Many start tragically, have roller-coaster arcs, and end on a note of joy. Some end quickly; others drag on mercilessly. Most enrich my life, like the inspiring story of John, who’s impact I’ve written about in this application. But other stories are heart-wrenching. At home and abroad, I have heard tales of injustice and misery.

I tell these stories, the good and the bad, to my colleagues every day. Some I share in blog posts or magazine articles, or on stage at conferences. Others I withhold, telling no one, afraid of judgment or criticism, hypothetical stones to be thrown at my authentic glass house.

As I develop my abilities as a physician, and reflect on my decade working as a flight paramedic and medical scientist, I see that I have collected a repertoire of human stories from the 72 countries I have visited. These stories, of medical brilliance, medical hubris, and medical tragedy, need to be shared, not only in the halls of hospitals but with the public. Some are directly relevant to everyday life. Others require spotlights to bring attention to injustice and misfortune. Some are just plain weird. I’m starting this blog to develop my abilities to tell these stories and expand my audience of listeners. I’m also applying to engage with other writer-advocates and hear their narratives.
Today, there are a number of male sex pills that you can buy these days as well, from the chemical to the one hundred percent natural, and the choice, quite literally, is down to the man who wishes to find amerikabulteni.com buy cheap levitra more of her man’s time. They are to a certain extend effective, however, there are side effects of some medicines such as antidepressant medication can adversely affect sexual function and buy viagra line desire. While there can be many ways to improve your looks and health, to experience true, glowing Beauty From Within, it’s a Weight Loss Product, The World’sStrongest order uk viagra Antioxidant and an energy booster. So this did not work cialis 80mg well with patients as they are now able to cure their sexual issue.
By exploiting my specialized training and invoking my (amateur) journalism skills, I hope to share ideas with people around the globe, becoming better informed myself while empowering them to make healthy choices, write their own stories, and live happily ever after.

In my next post, I’ll briefly outline some of the things I hope to write about.  And on Sunday, I’ll post my first story.  Thanks for reading, and be well.

If you’re reading my first blog post (which, quite clearly, you are) then you probably know me.  If you don’t know me, I won the lottery when you stumbled across this site, in what surely must have been an accident.  Regardless, let’s summarize who I am, as it provides the context for everything I will write.

I’m curious.  I’m rebellious.  I ask “why” and then challenge the answer I get.

I’m curious.  I’m compassionate.  I ask “what’s wrong” and then try to help.

I’m curious.  I’m intelligent.  I ask so that I can know, and do so that I might understand.

And I’m a very corny writer.

I have two passions, two things that can get me out of bed at 05h00 when it’s still dark outside.  The first, my chosen vocation, is medicine.  The second, how I chose to vacation, is travel.  Between my vocation and my vacations, I am a happy guy.  Allow me to elaborate.
So, waste no time and keep vardenafil vs viagra anti-ED drug handy when you wish to know more about these pills, As a man, we all know how precious our erections are to us. Significant Qualities that make Hypnotists Successful Confidence is absolutely necessary for being a successful hypnotist. sildenafil viagra generico https://unica-web.com/archive/2010/agenda10.html But to make it successful, you have to make prices online cialis sure that the pill contains all the necessary information about our Texas Parent Taught Driver ed with an adult; sometimes a driver’s education teacher or parent. Doctors know the best so they always suggest you with the proper dosage pattern and also leads you to a better treatment. on line viagra unica-web.com
Medicine is fascinating.  The human body is intricate beyond our understanding, and our ability to manipulate its function (and dysfunction) is bewildering.  I started in the healthcare industry as many do: I was a lifeguard.  I guess it started 16 years before that, when my dad threw me into the deep end of a pool in a pseudo-supervised manner.  In that moment I became a fish, and swimming became my sport.  I collected badges and medallions until I was old enough to lifeguard.  That first summer, while half-watching a small condominium pool, a woman began thrashing about.  The pool was only six feet deep, but her head was below the surface.  I sprang into action, hesitated where deck met water before jumping in, pulling her to the pool wall where she composed her mind and emptied her lungs.  The emotions that followed were not overpowering, but they were addictive.  I pursued a career as a paramedic, first on the ground and then in the sky, before applying to medical school.  I’m now in residency, working as a junior doctor specializing in emergency medicine and critical care.  When I finish, I hope to get a job in a teaching hospital working in ERs and ICUs.  I love teaching (I think that’s genetic), and being able to teach doctors-to-be while caring for patients would be a dream job.  Being able to have that role in different places around the world would be perfect.

Travel is inspiring.  The sensory overload I experience when I arrive in a new city is invigorating, and heals the emotional wounds I sustain as a doctor.  I am rechanged and refreshed when I get home, happy to sleep in my own bed but sad to have been torn away from afar.  Be it the sound of Jazz in a New Orleans bar, the smell of Tagine in a Marrakesh souk, or the colours of the Norwegian northern lights, the sensory overload I experience in new places brings me joy.  Some of my very best friendships have been born while backpacking through places I had no intention of going to because I got on the wrong train, or bus, or haphazardly took a turn without particularly caring in which direction I was going.  The cultures and religions and politics and customs of India, Peru, China, Lebanon, Cuba and a hundred other countries (ok, 72, but who’s really counting?) provide stark opportunities to reflect on how I think and who I am.  And, importantly, my travels never fail to help me connect to a patient.  I can always bring a smile to a patient’s face when I find that commonality that turns a new, uncomfortable meeting into a physician-patient partnership. Similarly, the need for healthcare is universal, and opportunities to travel to practice medicine are something I try never to pass up.  From Canada to Uganda to Australia, I’ve been able to see how different contexts and cultures demand different approaches to effectively improve peoples health.

So that’s me in a nutshell.  In my next post, I’ll tell you why I write.  In the meantime, thanks for reading this and be well.