Baseball’s Elbow Problem

By James Colapinto

Credit to Wikimedia Commons.

Matt Harvey

It’s August 24th, 2013, and Matt Harvey is having an off night.

Over the 2013 season, Harvey has distinguished himself as one of the best pitchers in baseball. Amid an otherwise dismal season for the New York Mets, the 24 year-old has become the brightest young hope for the team. He will finish the season with the 3rd lowest earned run average (a rough measurement of the number of runs a pitcher allows his opponents to score) in the majors. Less than three weeks ago, he pitched a “complete game shutout”–throwing an entire 9-inning game without allowing the opposing team to score a single run. Mets fans eagerly look to him as a key prospect for their team’s future. Today though, he struggles, giving up 13 hits in a 3-0 loss to the Detroit Tigers. At first, nothing seems too concerning. Interviewed after the game, he reports that he feels “pretty tired”–understandable going into the final month of Major League Baseball’s 6 month-long, 162 game season.

The next day, Harvey reports having some tightness in his forearm. A seemingly innocuous complaint on the surface, it is recognized for its seriousness by the Mets medical team. Harvey is sent for an MRI, which comes back with devastating news: his ulnar collateral ligament (UCL), a triangular bundle of connective tissue fastening the medial epicondyle of the humerus to the proximal end of the ulna, is ruptured. He will not pitch again for 18 months.

The act of overhand throwing, as primitive as it may seem, is an evolutionary innovation as unique to humans as our bipedal locomotion and massive cerebra. The anatomy of the shoulder and arm allows for the throwing of projectiles with both significant velocity and accuracy, and these anatomical features appear 2 million years ago in Homo erectus. No other primates have this capability. Chimpanzees, despite being much stronger than humans, can only manage to throw projectiles around 20 mph. Untrained humans can fairly easily reach 60 mph. The vast majority of professional baseball pitchers can throw a fastball above 90 mph, with some reaching over 100 mph. 

There are risks involved in taking the body to its physiological limits, though. Soft tissue is only so strong, and the elbow undergoes tremendous stress during the act of throwing. The violent and repetitive act of pitching often ends up exceeding the limits of the elbow. In pre-adolescent players, the stress can cause the end of the humerus to fracture. In older players, the breaking point shifts from bone to ligament: specifically, the UCL.

A few weeks after his diagnosis, Harvey underwent one of the most well known procedures in professional sports: ulnar collateral ligament reconstruction. Most know it as “Tommy John surgery”. 

Tommy John and Frank Jobe

John in 1981. Credit to Wikimedia Commons.

On July 17th, 1974, Tommy John of the Los Angeles Dodgers felt a twinge in his arm while pitching during a game. Suddenly, he was unable to throw and his fingers were tingling. The MRI had not been invented yet, but the Dodgers medical team was able to discern that John had ruptured his UCL. At the time, this diagnosis was catastrophic for a pitcher. A few years earlier, the career of legendary Dodgers pitcher Sandy Koufax ended when his UCL gave out. Without the stabilizing force of the ligament, a pitcher’s arm was rendered “dead”.

In response to John’s injury, however, one of the Dodgers’ team physicians, orthopedic surgeon Frank Jobe, proposed a new procedure to recreate the damaged ligament. Jobe would take the tendon of the palmaris longus from John’s right wrist and thread it through holes drilled into John’s left humerus and ulna into a figure-8 pattern. John agreed to the procedure. He spent the entire 1975 season rehabilitating his repaired elbow, and returned to the Dodgers in 1976.

Jobe was cautious, wanting to make sure that the surgery provided long term benefit before attempting it again. After successful surgeries on several more baseball players, as well as a javelin thrower, he became confident in the procedure, publishing his results in the Journal of Bone and Joint Surgery in 1986. Three years later, Tommy John retired after a career spanning 26 seasons. 14 of those seasons came after his UCL reconstruction. The procedure that saved his career would come to be known by his name.

Tommy John surgery has become one of the most common surgeries in sports, both professional and amateur. In 2017, 26% of active major league pitchers were reported to have gone through the procedure at some point in their life. It is well-established as a safe and effective treatment for UCL rupture, and 90-95% of those who receive the procedure return to their sport. It is not unusual to return to pre-injury performance following the procedure, and the reconstructed ligament appears to demonstrate greater durability than the original. This surgery has become so ubiquitous and successful that some parents even seek to have their athlete children receive it preemptively, thinking it will make their child throw faster. In reality, evidence suggests that the surgery reduces throwing velocity, and that preventing injury is a far more pragmatic approach.

In 2014, Frank Jobe passed away at 88 years old. He left behind a remarkable legacy. In World War II, he served as a medical supply sergeant and participated in the Battle of the Bulge. He was a clinical professor of orthopedics at University of Southern California School of Medicine and founded the Biomechanics Laboratory in Los Angeles. And of course, he innovated a medical procedure that revolutionized baseball and continues to rescue the careers of pitchers, like Matt Harvey, to this day. On his medical accomplishments, Jobe mused, “Sometimes it just makes you want to cry watching those guys go on to great things. It really does.”

Current Challenges

Today, Tommy John surgery poses a new problem. With baseball becoming increasingly competitive, rates of UCL reconstruction rose 343% from 2003 to 2014, with the highest increase in the 15-19 year old age group. All of which begs the question: could baseball, from little league through to the majors, be doing more to prevent these injuries rather than relying on an invasive reconstructive surgery that requires over a year of recovery time? While major league pitchers often have tightly controlled pitch counts (not exceeding a certain number of pitches in a game) and rest days, youth baseball leagues often do not have nearly the same restrictions, and often any rules that may be in place are ignored. Little league pitchers are pushed to pitch for longer and more frequently than is safe, and managers can be ignorant of the risks or warning signs of arm injury.

Adding to this problem is a distinct shift toward specialization in youth sports culture. An increasing number of youth athletes are focusing on a single sport from a young age, and dedicating the majority of their physical activity toward participating in and training for that sport. Many youth baseball players join “travel” teams, where they can play as many as 70 games per year for up to 8 consecutive months. This culture of playing and training as much as possible is thought to produce elite athletes, but evidence suggests that young athletes who specialize early have a greater risk of injury than unspecialized athletes, even when correcting for hours of activity per week. Specific to baseball, pitchers who pitch in more than 8 months per year are at increased risk for shoulder and elbow surgery

Increasingly, sports medicine researchers are encouraging unstructured play and participation in a variety of sports to reduce overuse injury. Unfortunately, opportunities for multisport participation appear to be decreasing. Local sports leagues are being displaced by travel teams, which typically involve more specialized players, greater time commitment, and increased financial burden. The displacement of local leagues not only decreases opportunities for youth to participate in multiple sports, but also reduces the options available to families who cannot afford a travel league. Additionally, many school districts in the United States have decreased the time dedicated toward physical education and recess, in favour of increased time in the classroom. These cuts reduce the opportunities for children to diversify their physical activity and try different sports, especially those from lower income households. In order to reverse this trend, youth sports needs a fundamental realignment of ideals, moving away from producing elite athletes for families that can afford the price, and toward creating equitable opportunities that allow children to engage with multiple different sports, regardless of financial status. Until these changes occur, though, Tommy John surgery will continue to be a familiar phrase for baseball players and fans alike.

Author: James Colapinto

James Colapinto completed his B.Sc. in Developmental Biology and M.Sc. in Plant Development at the University of Toronto. He is interested in sports medicine, addiction and mental health advocacy, and classical music. He is an avid Blue Jays fan and mediocre right fielder.

This too shall pass:

So here we are, the last couple hours before the CaRMS match results are released. While there’s still the issue of the licensing exam and graduating at hand, this feels like the moment we’ve all been waiting for (or at least for me).

Now considering how this decision is kiiiiinnd of important, it has been a bit of a nervous period.   But since I don’t have a stache of Ativan hidden away at home, I needed to figure out how to deal with this in some other way. And of course, because this is the UWO blog, I have to put it in a list form.

So I guess this following list is more for future classes’ references than for this current group, but here are some strategies that I came up with to pass the time waiting for the result.

1) Netflix.

Go read another post, because we’re done now. But seriously, this one is pretty much all you need. I mean the 3rd season of House of Cards just came out, and Better Call Saul is on there (if you have access to the UK version). Okay nuff said.

2) Read a book.

Because when was the last time we had time to do some leisure reading (reading for the sake of having an answer to your CaRMS interview doesn’t count). Rummage a library or download an e-book. Who knows there might be a book out there on how to deal with CaRMS results stress.

3) Work out

Speaking about stress, a good way to get a handle of it is to let off some steam. A run, yoga, bike ride (maybe tough to do with the snow), or a trip to the gym can definitely help you feel more refreshed and revitalized. If you don’t mind the cold and the weather is amenable, checking out a local pond and playing some hockey is just a must for a good Canadian kid.

4) Travel

Because you want to beat the cold. Because Family Day weekend is happening. Because Mardi Gras and American spring break is happening. Because you aren’t sick of flights yet from interviews. Because you really want to make the most of your line of credit.

5) Go out and party.

My logic is that if you are going to be up all night sleepless anyway, you might as well be up all night having some fun.

6) Relax to some music.

Some suggestions I have are “Everything is Awesome”, or the classic “Final Countdown”.

Of course, there are also some really fun parody songs out there too. My current favorite is this one that spoofs T. Swift.

7) Study for exams

Because nothing is better at diverting panic and anxiety for one major life event than focusing it all on another major life event.

8) Write something for the UWOMJ blog

This is a great tip and I’m recommending it based off personal experience. The mere act of writing this little piece has killed the last couple hours before the results are released. Now time for me to go meet up with my roommates, drink some mimosas, and figure out the rest of my life.

CaRMS Tourrrghhhhh

I finish my interview, quickly changed out of my clothes, and pack my things. As walk down the stairs my phone buzzes, a reminder that my flight later is on-time.
That’s weird, I think, my flight is supposed to be on Friday.
I then check the date at the top of the screen. Friday. January 30th.
Right, yes. We’re interviewing in London now, so obviously it’s January 30th, that’s when it was scheduled.
With the end of today’s interview, I’ve hit the halfway point (cue some Bon Jovi) on this interview circuit, and boy arethedaysjustblurringtogether.
Seriously, where did the time go?
It all started off pretty easy enough, last week started with two interviews only: Memorial on Monday and Dalhousie on Tuesday. Since I didn’t have any interviews in Quebec I had a few days to rest and relax before reaching the first big obstacle. Ontario.
5 days, over 800 km of road travel, late night socials, and 4 interviews in 4 cities, I felt as if I was caught up in riptide that just dragged me through the days. I didn’t even have it that bad – I didn’t interview in either Toronto or NOSM, my admiration to my colleagues that were able to manage these cities as well. Even more intense were some of the Quebec applicants who virtually had no break as they spent the whole of last week going through Laval, Sherbrooke, and the 2 Montreal schools.
I can see that it’s affecting my fellow applicants as well. Ties hang a little looser. What were immaculately cleaned and pressed outfits are creased and salt stained by the road. Earlier this week I heard one person mistakenly say he was enjoying being in Ottawa while at the Queen’s social. Someone told me he no longer keeps track of time by day of the week but by whichever city he’s currently in.
One of the residents I met along the way likened the CaRMS interview circuit to being on a rock tour: every day in a new city, constantly meeting new people, up late in the bars only to wake up early the next day, to go perform the same gig to a different audience.
It feels like I’ve been on the road forever, but that’s not necessarily a bad thing. It’s a good time to just go with the flow. Next week will be a whirlwind through Western Canada, but it’ll be spent either interviewing or traveling. The actual day of the week, heck, the city I’m in, doesn’t even matter. It’s a weird and wonderful transient state to be in, and, pretty soon all over. Soon I’ll be grounded and back in a lecture seat, with just the worn out boarding passes and unused drink tickets to assure me that it all happened. Until then, I’ll be enjoying the fun.
Well, time to head out and catch my next flight. The tour must go on!

Insights off the run:

Ah yes, 4th year. The time when suddenly it becomes real: I’m going to be a doctor. That MD is so close I can pretty much touch the serifs. But before we can bust out singing to Vitamin C (yes, you know the song), there’s still a long trial before us. The long 16 weeks of electives.

Now electives are the shot for us to show off what we have to the various programs and locations across Canada (or even the world if you are so ambitious) that we have the stuff that it takes to be chosen for their program.

Through all the bedlam and rush of these electives, we get the added bonus party time fun of having to write personal statements, update the CV, scrounge together letters of reference, and fill out all the extra redundant paperwork that is required for a CaRMS application. 

Yes Natasha, I agree.

However, if we let ourselves take a step back from the daily double grind of working while being on show, move past the exhaustion from the long days, and separate ourselves from the stress of the applications, these elective times are great opportunities. They’re a time to really show off to yourself how far you’ve come. They’re an amazing opportunity to adventure through and live in (albiet VERY temporarily) different places. And you’re likely going to meet a bunch of new people who may become future co-residents, colleagues, or friends.

As the three quarter mark is approaching for the current elective tour, I thought it would be a great time to sit back and reflect on some of the subtler lessons I learned from the long haul.

1) Pack light, travel quickly (alternate title, scrubs are the best)

In one of my favorite movies, Up in the Air, George Clooney poses this question at the beginning of his seminars “What’s in your backpack?“. While his speech is focused on the metaphorical baggage that bogs a person down in everyday life, it’s a good prompt to examine the actual physical baggage that can encumber your peripatetic lifestyle during this year.

From one standpoint, it’s more economical: the airlines have recently implemented more fees for check-in luggage and driving around with heavier loads will also hike up your vehicle’s fuel costs. From another, it’s also easier to move around, you need less time to pack, and it frees up some of the clutter.

Which is why scrubs are awesome because I’ve pretty much cut down two-thirds of my clothing needs as a result. Plus you can look like a ninja at work, which is awesome.

For those without the luxury of having the scrubs option at work, there are still other ways to lighten the load. Simplifying outfits, or finding multifunctional pieces are one way. Eliminating excessive electronics, books, or other accessories are all options as well. Personally I thought that I was traveling pretty efficiently already but after my first couple electives I realized I still did not use a good chunk of what I packed. With my next stopover at home, I hope to be able to make like a bro in summer and cut down the excess bulk.

2) When in a new city, make friends with a local and do what they do

So you’re in a new city and like any good medical student you’ve done your research. You’ve never been to Toronto, Calgary, Halifax, or Vancouver (etc etc) before and want to see all the attractions (and more importantly eat all the food) before you fly out 2 weeks later (come to think about it, visiting medical students are kind of like a pack of cicada – we swarm in, drum up a bunch of cacophony, eat a whole bunch, and in a couple weeks of annoyance to the locals we’re gone).

Yeah, that’s a lot of fun and be sure to take part in it, there’s a reason why those places become the hotspot.

But at the risk of sounding a bit too hipster, it’s better to make friends with some locals or inquire a classmate who is a local and get tips from them.

Why? Well, A) they may have better knowledge on which places are worth the hype and which aren’t. This leads to much better use of your limited time. Secondly, they probably know some other up and coming trendy places that may not be listed on Fodor’s. Finally, locals can probably offer tips that make your day-to-day life on elective easier. You know, stuff like helping figure out transit routes, good places for groceries, and what you might need to bring before heading to the city.

In essence, utilize those interviewing skills you picked up in clinical sessions and strike up a conversation with a local.

 3) There are a million “absolute right way” to do a simple procedure

From suturing, approaches to presenting a case, to even taping people’s eyes, you’re never doing it right. On day one you might get a nice lesson on how to approach intubating a patient. Great, you think, I’ll just do it like this with the next few docs here and I’m set. Day two, your doc looks thoroughly unimpressed with your “technique”, even though you did the exact same thing as the other attending.

Great, don’t tell me this is your first time intubating. You’re doing it all wrong! and you get another lesson, which will only be corrected by the next guy.

Repeat ad nauseum to every elective and every physician you encounter along the way. It’s like facing Tyson for the first time on Punch-Out: you cannot win. I feel like you simply got to go with it, and take solace in the fact that you’ll likely do it yourself once you got medical students of your own to “teach”.

4) Find a good coffee shop

Quick quiz, what’s some of the signs that you’re a #BasicMedStudent?

a) You need caffeine to operate.

b) You need wifi to either work on applications or go on social media (or blogs) to procrastinate from working on applications.

c) You consume a large amount of sugar/carb dense snacks to compensate for the lack of sleep you get.

d) All of the above.

The coffee shop provides all of these amenities, making it the natural stronghold of the traveling medical student. The trick is finding a good one to bunker down in when you’re in a new city. A good coffee shop will cover the basic necessities of survival: protection from the elements whether it’s rain, snow, or the cold; a means of communicating with others via a strong wifi connection, hydration in terms of coffee/tea/beverages; and food in terms of an assortment of baked goods.These are the basics, and everyone has their own personal preference on what they value more. For me, it’s the wifi. Sometimes I can’t count on the connection at the accommodations I’m staying at and I need to get online to work on CaRMS. But that’s just me. 

And, when in doubt, find a Starbucks: they’re everywhere (especially in Vancouver)

5) Wade, don’t jump, in.

Every hospital will run slightly differently. There’s a lot of desire, especially at first to try to jump right in and look like a star off the bat. I would recommend against that. Seriously.

There’s no rush and it’s better to be a fly on the wall and watch what happens, ask the right question, and ease into it. People like to welcome the rookie and it’s pretty favorable to appear as the person who fits in well seemlessly and remembers all the veterans’ advice.

Don’t worry if you don’t try to jump in. It’s just too confusing and stressful trying to figure out a hospital’s way of doing things before you really even have been there. Each are it’s own beast. And it doesn’t matter if you might look bad in front of someone stumbling around lost the first few days. Sorry to burst that bubble but you’re pretty forgettable.

6) When it comes to accommodations – location, location, location!

Electives can be pretty expensive, from application fees, gas fees, air fare, and costs of living. And even though you’re expected to be in the hospital and clinic for most of the day, you actually won’t be allowed to live in one while you’re visiting.

Bottom line: you need to find a place to live.

Now generally the options are: rent/sublet from someone (usually another medical student or resident), find a friend, or stay with family. A lot of people go with the options of staying with friends and family to save cost or to have a good time. But I feel the most important aspect of choosing your lodging is location.

The key number is 15 – that is minutes or less from your main hospital/clinic/centre. The main reason for that is it’s close enough you can escape the clutches of the hospital quickly, but that also means you can get to the hospital quickly when you need to. This is beneficial when you want to come in early in the morning, if you want to get a few more minutes of rest or have a long morning routine, or (if you’re close enough) even having a place to retreat to on a night of call that isn’t a stuffy room with a molded plast mattress.

Having paid for a place right next to the hospital and having saved money by staying at home and commuting, I still say the location is worth missing out on the free meals and cheaper save. Over time, the earlier mornings due to the commute and having to still spend up to an hour getting home after work is done just adds up and cuts into your productivity.

7) Never turn down offers from physicians

While they may be strangers to you, you shouldn’t turn down offers from any of the physicians you meet while on electives, especially if it’s candy.  Often these offers come up innocuously, and have a very short time period to respond.  So are you in? And while that answer yes might not always be crazy, memorable, the hospital turning into a bumping club, adventures, there is often some benefit awaiting, even if there might seem to be some work involved in it.

Help out with a report? Sure that’s a bit of work, but you can get published and it makes a good impression with the residents.

Why not stay later for a case, who knows what you might learn.

Volunteer a weekend to go on an organ retrieval? Always answer yes. It’s a magical, humbling experience.

In the end the electives are not only a chance for you to demonstrate that you’re a great potential resident to each program, but it’s an amazing opportunity for you do tailor your education independently. While it can be a lot of fun to play tourist, go out and eat fun meals, and travel, it ultimately comes back to have the freedom of 16 weeks for you to pick up additional skills for your future as a ______this spot left intentionally blank________ physician.

Happy trails.

48 hours in Halifax

Much like this article, my weekend away had a hard time taking form at the start. The Family Day Weekend was looming and I was informed I’d have Monday off. Perfect, I thought, I could go on a quick trip and have some fun. But where?

I won’t bore you with the details of how I settled on Halifax, except a big factor was that I had never been to the Atlantic time zone before. With that determined, a last minute (but not last second) round trip ticket was purchased and I was off to Nova Scotia. Thanks to a long layover , it wasn’t until 5pm on the Saturday night that I touched the tarmac in YHZ. Noting that my return flight was 8pm on the Monday night, I realized that I had about 48 hours before I needed to be back in the airport to enjoy Halifax.

This is the log of those 48 hours.

Hour 1) Pick up rental car. Stupidly agree to prepurchase gas refill to whatever level the car currently is at. Realize too late that the car is filled up. Grab a quick coffee, and drive into the city. At the MacDonald Bridge discovered that I had no change to pay the toll. Fortunately the bridgekeeper let me through (didn’t even ask me these questions three), remarking that I “must not be from around here.”

Hour 2) Uneventfully got to the hotel, parked the car, and settled in. Got a few tips about what to do in the city. Discovered that I didn’t pack socks or underwear for the weekend (d’oh!) and rushed over to a Walmart and get a few pairs. Decided to grab a few energy drinks as well, because I wanted to have gratuitous amounts of energy.

Hour 3) Went to explore Barrington, one of the main streets of the city. A storm was moving in so I ducked into the Freak Lunchbox, which fortunately was also one of the spots I was advised to check out. This place was like a compact version of Willy Wonka’s chocolate factory, with a nerdy twist! It was a little bit retro, a little bit psychedelic, and a little bit geeky, all in the right amounts. There’s no way I can fully describe how awesome the place is (and, disappointingly, neither does its website), so you’ll just have to check it out.

Hour 4) Popped into the Economy Shoe Shop, a pub recommended by my preceptor who did medical school back in Dalhousie (so who was I to argue). Fortunately, it was a good tip (unlike cool guy tips, which are just awful), as the food was great, the atmosphere was friendly, there were Calvin & Hobbes comics in the washroom, and there were ample beers on tap (Harrison, the bartender, is a particularly good guy).

Hours 5 – 10) Embarked on some good ol’fashionded Haligonian pub hopping (and yes it did involve an Old Fashioned). Checked out some classics like the Durty Nelly’s as well as some of the new places, like the Stubborn Goat. The reputation of Maritime hospitality was on full display as people were always up for striking up a conversation, splitting some pizza, or including a visiting stranger into their celebration.

At some point in the night, I had been invited to join a fellow on his birthday evening out (No I didn’t come out of the cake).

By the end of it, a new acquaintance offered to drive me back to hotel as a hail storm decided to pop up in the middle of the night.

Hours 11-14) Sleep.

Hour 15) Worked to update the OMSA website quickly (go check it out, a ton of services, opportunities, and discounts offered there). Afterwards, went to have breakfast with an old friend from UBC. She decided Cora’s which I have never been to before. For years I’ve had Cora’s hyped up from brunch loving friends everywhere. It was okay (no Marionberry pancakes). Essentially an overpriced and over-esteemed Denny’s. Actually a Grand Slam would have been amazing.

But I digress, it was a nice meet up, a couple West Coasters catching up on the other side of the continent. She’s finishing up her MHA and in the application cycle for medical school this year. Hopefully it goes well for her.

Hour 16-17) Lots of wandering around the city, taking pics from view points around the citadel and from the harbour. Very icy, very windy, and oh so very, very, very cold. Surprised I didn’t end up with some form of frost bite as a result.

Hour 18) Wandered into the Halifax Seaport Market, kind of a larger and more open version of the Covent Garden Market. A mix of local produce, craft vendors, food stalls, and artists, it was pretty lively considering it was a Sunday morning.

What caught my eye the most, was a small shop class in the very back, it was a weekly group that met every Sunday to learn a specific type of carpentry: bow and arrow making. The students were bent over decrepitly old work benches whittling down staves of maple. Their instructor, an old man sporting thick white whiskers and a weather worn face and belonged in a Hemingway, would rotate through and inspect the students work, offering guidance and tips as well.

Hour 19) Went back to the hotel. Read a couple cases. Took a quick power nap.

Hour 20 – 23) Went to watch the Canada – Finland Olympic Mens Hockey game. After asking everyone last night about the best sports bar in town, I ended up trekking to HFX Sports, which is supposedly modeled off Real Sports in Toronto. After snagging the LAST seat in the whole bar (score!) and getting a round bought from my neighbours for being in Halifax the first time (double score!), I partook in one of the time honoured and sacred rites in this country: celebrating a big hockey win with a crowd a strangers.

Hour 24-26) A few random snippets of things” toured the Maritime Museum right before closing, working out at the hotel, reading more cases, sitting down to write an article for In-Training Magazine (THE agora for the medical student community).

Hours 27-31) Met with another former UBC-er for some delicious seafood and a few apres dinner drinks.

If Saturday was all about meeting new people in the city, Sunday was about re-establishing some old relationships. I hadn’t seen Jenn for about 5 years, as she left Vancouver to go work on her Masters’ and now a PhD out at St. Mary’s University. It’s nice to re-connect after a while, and reminded me that these relationships do need to be tended or risk falling apart.

Hours 32 – 40) Sleep, working out, packing up the hotel room and signing out. Nothing to see here.

Hours 41) Hiked around Point Pleasant Park. It was pretty bare, like Old Mother Hubbards pantry. The recent hailstorm and subsequent warmer weather and rain led to a thick layer of ice cover the whole trail as well. This created an interesting walking sensation, almost as if I was walking over a frozen lake.

Hours 42-43) Drove out of the city, south and east, towards a “classic touristy” spot, as Harrison the bartender described it.

“It” being Peggy’s Cove, which had one of those classic “let’s have it on a postcard or feature it in a romantic sitcom scenelighthouses. The road out to Peggy’s Cove was gorgeous, with immaculately iced over bays, serpentine roads wedged between rolling shoreline, and tiny colourful towns dotting the way.When I arrived at the cove, I left like suddenly I was part of a #WeAreWinter commercial or on set in a real-life re-enactment of Frozen (I’m assuming, I haven’t seen the movie).

The lighthouse did look like it belonged in post card, but no post card picture ever correctly depicts the cold wind that whips around the outcropping rocks. As the sea spray had frozen over the path as well as many of the rocks that led to the lighthouse, I was a bit leery about wandering too close to the furious Atlantic rim. I did wander into the nearby restaurant and had a delicious lunch of various seafood delights.

Passed on the pickled herring, however.

Hours 44-46) Decided to take the scenic route back and drive along the coast some more. While it did take a bit longer to end up back in the city, and the route had some harrowing moments (like nearly running into a herd of deer after coming up a hilly segment), it was well worth it to appreciate the Nova Scotian country side. The clouds had blown past, the sky was clear, the vistas were exceptional.

Hours 46-47) Got back in the city. Went to the Paper Chase, a great little newsstand and café. You see, I had a few paragraphs left for my In-Training article (again, the agora for the medical student community), and I was determined to finish it before I left. One invigorating cup of tea, and one astounding piece of carrot cake later, I got that checked off my “To-Do” list.

Hour 48) I rode that feeling of accomplishment out of Halifax, down the 118 (because I didn’t want any more awkward encounters on toll bridges), and back to YHZ. A little while later, as I drifted off for a nap while the plane was taking off the runway, I had half a thought that I’d wake up and it’d still be Friday and the last 48 hours were all just a dream (just a dream). Awoken by the Thundersnow landing at Pearson, it was reassuring to know it wasn’t.

Halifax truly is a city that belongs to the elements. Water, that one’s easy, as it lies on the edge of the Atlantic. Earth, the jutting rocks and hills that shape its roads and stones that form its buildings reminds us of its history. Wind, takes the form of the storms that batter its citizens on a whim. Fire, from roaring ovens and grills come hearty epicurean delights. And, of course, who can forget about Heart (because no quasi-Captain Planet allusion is complete without Heart), especially in the company of Haligonians.

Yes, Halifax was definitely displaying it elements this past weekend. Fortunately, I, too, was in my elements then – my elements being eating food, sampling local craft beverages, and having a new experience. And that’s what happened in my 48 hours in Halifax.

The cyclist’s survival guide to clerkship commuting

So congratulations, you decided to forego the car for clerkship and adopt the lean, green, quad strengthening machine that is the bicycle as your main mode of transportation for the 3rd year rotations. Take a moment and let that all sink in for a moment.

First of all, you got a bike. So get ready for a lot of questions of whether you are either a) stupid, b) insane, or c) Hipster. At least, that’s what the “regular” people will say about you. Get used to that. A lot.

But never mind that, because getting a bike to get around during clerkship is a GREAT idea. There are a ton of reasons that make it quite a sensible thing to do.

First of all, London isn’t that big. The distance between Victoria Hospital and University Hospital is around 10km along the bike trails, which translates to about 30mins at a moderate cycling pace. That’s about the same time it takes buses to get between the two, and that is WITHOUT traffic.

Secondly, it’s guaranteed exercise. Clerkship gets stressful, and that can through a real monkey wrench into one’s workout routine. However, by biking, you’re getting a section of dedicated cardio everyday (and it forces you  to do a leg day). That’s going to come in big when you feel guilty about indulging in those on-call and post-call meals.

Third, London is flat. While it’s not Prairie flat, it’s still horizontally-inclined enough that it’s not super daunting to a newbie cyclist. This was definitely one of the reasons I kept cycling up. The routes never seemed too arduous that they weren’t worth the effort.

That said, there is a huge valid reason against trying to cycle the whole year in London. That reason is Winter. Yes, winter sucks. It’s cold, makes the roads slippery and bumpy, and snow in the eyes sucks. Not only is this uncomfortable to bike though, it’s getting pretty unsafe. However, for the craziest (aka the honeybadger-ist) clerkship cyclists, there are ways to handle for winter.  What follows is a list of tips lifehacks on how to  make winter cycling much more enjoyable (and you don’t even need to get one of these to do it). 

1) Be prepared

Whenever I’m faced with solving any problem, I like to start with simple approach – ask myself “what would Batman do“. Usually this comes down to a two word statement: prep time. While you don’t need to go extreme as creating an alternate personality as the Cyclist of Zur-En-Arrh to be psychologically ready to handle winter cycling, be ready ahead of time to deal with the cold commute. This can be done simply through checking out weather reports, knowing which routes you plan to use ahead of time, and getting the right equipment ready.

2) Earlier the better

While most cycling commuters will already be used to leaving a bit earlier than drivers to make the trip, when the snow and ice hits, one has to be ready to take a bit more extra time on the journey. Riding through the snow is harder and slower than any other time of the year, as you can’t just power up hills, rip around corners, or zip down slopes. Plan in some extra time so you aren’t late and won’t feel rushed along the ride. The more time the better, as the worst thing that could happen is that you arrive early and can do some pre-rounding before morning report.

3) Suit Up! 

As both Barney Stinson and Japanese Macaques living in Russia know, being out in the snow requires a whole different set of gear. An important part of winter riding is keeping the core warm, yet managing sweat during the excursion. And like any good superbowl dip, the key is layering.  A base, moisture wicking layer, then an insulating mid-layer, topped by windstopping and waterproof outer shell is a classic trio (another classic trio: salt, pepper, and cumin). Protecting your feet and legs from soak and cold is equally important, because unlike Magikarp, the splash of slush from your wheels and cars is supereffective at getting you cold. Thermal long johns, insulating socks, snow pants, and waterproof boot covers are all good options.

Finally, pay special attention to your hands and your head, as they are both very vulnerable to the freezing temperature. Insulated leather gloves, mittens, or lobster claw styled gloves are all good options for keeping the hands warm and dry. As for your head, ear covers, neckwarmers, and toques make up the essentials of my winter kit. The key is to keep exposed skin to a minimum.

Oh, and if this sounds like a lot of extra gear to be bringing, a spare change of clothes (including dress shoes) can easily fit into a medium-sized pannier.

4) Eat breakfast

Breakfast is the most important meal of the day, especially so if you’re going to be pedalling hard through the powder. You’ll be burning off more calories in these trips, after all. Being hungry while making the commute will just lead to an unenjoyable bike ride, and an irritated mood before you even before your shift begins. So start the day right by being properly fueled for the road.


5) Get your tires snow ready. 

Like cars, bikes have winter tires.They are pretty much like a normal tire, only bigger and awesomer. Oh, and they often have embedded studs to help grip into snow and ice. This can prevent you slipping on a patch of black ice, which can be really dangerous. If you want to forgo winter tires, getting chains for your normal tires is the next piece of advice. Additionally, letting out some of the air pressure in the tires helps increase the gripping surface area. Cycling without studs or chains is a risky move, even riskier than hitting on a hard 17.

6) Cars will try to kill you

Okay, so this might be a bit of a broad overstatement. While there are dangerous drivers who wish nothing but malice towards cyclists, the danger posed from an average motorist is that they simply aren’t expecting cyclists to be on the roads when the weather gets snowy. Adding to the problem is that cars won’t be able to stop as quickly in the snow and slush either, they can slip and spin out too, and drivers also will have worse visibility in the snow. On top of all that, the road shoulders are often more clogged than an artherosclerotic artery with packs of plowed ice/snow, forcing you to cycle closer to the middle of the lane, which is a real zone of danger for cyclists in busy traffic. In the winter you need to ride defensively (make eye contact with drivers), assert lane control (which are part of a biker’s rights), be on the look out for cars, and do whatever they can to improve being visible (adding reflective gear and using high lumen lights).

7) Clean and cold

As the snow and ice pile on, so does the salt. This salt, along with a bunch of debris, gets tracked into your gears and chains with all the slush. Without proper care, these can damage and wear down your ride. Make sure to wash off the salt daily by running some hot water along the chain and gears when you get back home. Additionally, storing your bicycle in a cold and dry location is advisable as a warm bike in snow can lead to ice forming on the gears and brakes. Finally, frequent lubing of your chain and gear will help keep the ride operating smoothly.

8) Know when to call it in

Somedays you’re James “Bucky” Barnes, aka the Winter Soldier, and some days you’re Napoleon after Russia, aka Winter’s Bitch. Because that’s what being in the middle of the “Snow Belt” means, and there’s nothing you can do except this. So when it’s like Jötunheimr  outside and the mercury’s lower than Kramer’s sperm count, it’s advisable to look for other options, such as carpooling or taking public transit. To prepare for the scenario where you’re already on the road and a polar vortex hits, it’s advisable to plan for “bail out” zones, such as bus stops. LTC buses come equipped with racks that can accommodate bikes should the commute prove too long/laborious/treacherous.

Well there you have it. Winter cycling is a bit of a challenge, but nothing that should dissaude an adventurous heart. Keep at it and soon you’ll be reaching cycling in the snow like Calvin’s dad.

Holiday Reading


Please consider two manoeuvres which I have developed in my brief clinical training. It is felt that they have significant potential utilities:

1)      Behind the curtain test – The clinician is to observe the patient with minimal disturbance of the system in accordance with Heisenberg’s uncertainty principals. The clinician will approach the patient with minimal sound production via footsteps. The clinician then shall slowly create an opening orifice in the side curtain of the bed, which is only enough such that the patient can be observed in his/her entirety. The clinician shall be in such a standstill position for sufficient amount of time such that any behaviour, which would otherwise not be observed had the patient been aware of the observer’s presence, come to surface. For those technologically advanced, a flexible colonoscopy can be applied for medium to long distance observation, should it be impractical to approach the patient without been detected. For those on call, in infrared night goggle may be helpful. While the specificity and sensitivity of this test have not been elucidated, its theoretical basis is so solid, such that funding should be allocated to explore the usefulness of this procedure.

2)       Apparition manoeuvre (scientifically named Grande Exorcistic Detoxification Mystique & Specifick)  – deliriums patients present significant challenges at night for those clinicians on call. I have hereby developed a manoeuvre intended to examine the sanity of such patients. Given the fact that this procedure is strictly protected by copyright and should only be performed by the most seasoned Physician, I have here provided an alla breve equivalent for the general practitioner: the clinician is to drape his/her whitecoat over the head, not allowing for the recognition of the facial features, and slowly walk into the patient’s room and then exit without pronouncing any utterances. This manoeuvre works on the Chemical principal of alikes repel: if the patient is delirious, this manoeuvre will make them more delirious such that the deliriums cancel each other out. So far, this manoeuvre have proven to be completely useless, but it’s without doubt that with aggressive marketing under the guise of its scientific name, this manoeuvre will nonetheless gain popularity and become the standard of care in quackery.

SIR, I hereby beseech you to consider these two discoveries for dissemination in the clinical setting, for the sole purpose of relieving boredom for those on-call.

The winter blues

So let’s take a look at where we are at in the year now, hmmm?

Days getting shorter, check.

Temperature dropping, check.

Clerkship dragging on, check.

CaRMS application milestones, and interview anxiety, check.

Perpetual tide of exams rolling out, check.

Between all that, and having to deal with things like always waking up in the dark, constantly trudging on boots to deal with the biting cold, and the continual all-nighters, it’s pretty understandable to have a case of the “winter blues” . However, often overlooked or disregarded is the more serious condition of Seasonal Affective Disorder, or SAD.

Despite the silly (albeit fitting) acronym, SAD can be quite the serious. It is a recurrent major depressive disorder that follows the pattern of the seasons. According to the Canadian Centre of Addiction and Mental Health (CAMH), SAD is linked to shortened hours of daylight and lessen exposure to sunlight, which do play a role in the brain’s release of melatonin and serotonin, although the exact pathophysiology is not quite clear.

What is more apparent is the symptoms of SAD. These include: lethargy, feelings of hopelessness, increased appetite and weight gain, social avoidance, anxiety, and oversleeping. This can resemble bipolar disorder or hypothyroidism, as well as clinical major depressive disorder. However, the latter is more likely to have insomnia and anorexia.  It is believed that SAD affects women more than men, with 60 – 90% of those affected being female.

But what can be done for those afflicted? The treatment options, listed by CAMH, include antidepressant medication, trytophan supplementation, and light therapy. Antidepressant medication has shown to be effective in treating SAD, fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) being listed as effective in management, and bupropion (Wellbutrin) being used prophylatically. Tryptophan supplementation is believed to increase stores of this amino acid, which is an essential component in serotonin and melatonin biosynthesis. Again these two neurotransmitters are strongly linked in the pathophysiological mechanism for SAD.

Light therapy is quite an interesting treatment option for those with SAD. Light therapy ‘lightbox’ bulbs are upwards of 100x more ‘luminous’ than a normal incandescent lightbulb. Individuals with SAD are to receive daily dosages of 30 min to 2 hrs to help increase the body’s level of sunlight exposure.

Additionally, exercise has been recommended by the CAMH as a means to help prevent SAD, as well as showing a role in boosting therapy and preventing further recurrence. While the physical aspects of being active are at the basis of these recommendations, I suspect that the associated social aspects of being active, such as increased interaction and making personal connections are also an added boon. So if it’s too icy to run on the road, strap on some skates and hit the rink instead!

One important thing to note is that while this article has given a basic overview of SAD, it is not meant to be a be-all-end-all summary to be used in (self) diagnosing the condition. Yes, it’s pretty obvious, but still needs to be mentioned. If there is ever the case where symptoms emerge, do not improve, or worsen, consult a physician immediately.

While the depths of winter, especially when coupled with a harsh academic season, can be difficult to get through, it is incredibly important to maintain our mental well-being while undergoing the trek through the cold season. How many days until spring now?

A glimpse of the future

Today I was a medical student observer at the PARO General Council. PARO stands for the “Professional Association of Residents of Ontario”, sort of a student union but for the medical residents throughout the party. It was quite an experience sitting in this 5 hour meeting in a swanky business suite on the 19th floor of a massive bank building. Seemed more like the setting for a corporate take-over rather than the meeting place for a group of young physicians with a passion for advocacy.

The point was addressed fairly early on, “Residents have come a long way.” In the past the resident was seen still as more student than anything else, forced to sleep in the hospitals, barely compensated for their long hours of work, and kept voiceless on any of the matters happening in their workplace. They have the chance to start a family, they are paid for the long hours they put in (how fair renumeration is will always be a heated topic), and they are finally regarded as professionals when working with their colleagues and attendings.

Yet it was not a simple path to reach the guaranteed rights and benefits residents now possess. It took years of fighting, the insight to realize groups like PARO would become necessary, and incredible amounts of advocacy. Often this was done by residents for their fellow colleagues, even more so it was done so that future residents would end up with better conditions than before. It was a tremendous sacrifice of their time and effort, because they still had to keep up their duties to the hospital and their patients. Humbled was the only word that came to mind.

Actually, grateful would work as well.

And as the story of PARO’s early history and how it transitioned to some of the current day issues unfolded, I saw how the achievements were not just simple static events of the past. Everything continues to flow from one stage to the next. Some issues have been addressed and settled already, and some still require work. Efforts in trying to establish fair duty hours and manage fatigue while on service is becoming a hot topic, as is advocacy to ensure residents can be informed on what they can expect for a future job market when they emerge from their training.

As each generation of residents pass, new issues relevent to that cohort emerge and need to be handled.

I guess my point is that one day (sooner or later), my classmates and I will become a new generation of residents. We’ll be enjoying a lot of the benefits that hundreds before us worked so hard (maybe as hard as their clinical training), to achieve. But we need to keep up the fight. It won’t be enough to simply take these benefits like some sort of professional hand-me-down.

We need to pay it forward when the time comes.

At the brink

In a few short hours, clerkship will have started for me. I realize that this past week was the official start of 3rd year, but as it was largely an instructional week about some of the “how-tos” regarding clerk duties (“how to access powerchart”, “how to do a sign off”, “how to dictate”…) – a clerkship bootcamp – it really did not register with me.

Now, I cannot stop pondering over what tomorrow, the next week, and the upcoming year is going to bring. What will call be like? How different is this going to be from the past two years? How long will I be able to keep biking to my shifts? How difficult are the end of rotation exams going to be?

Ultimately my mind circles back to one question: “am I ready?”

Honestly, I want to tell myself yes. Reason it out – that hundreds, if not thousands, of students have been on this path before me and have been just fine. Normalize the process in order to soothe it over, get a hold on the anxiety, and move forward.

Yet the question returns, like a demented boomerang. It ceases to just go away. Each time it reappears it brings a friend: another question, a hypothetical situation, a hidden doubt.

Somtimes, I welcome these thoughts, as in the past, I’ve relied on the fear and worry to motivate me onward. But the stakes seem higher now, and especially with the fact that I’ll be working with real people who are sick, I don’t want to be the one needing to make mistakes in order to do it right.

If getting through medical school is a journey, I liken it to one across a mountain path. The first two years are along hilly trails: winding around, rising steady, rough at times, but generally you can see the route and it’s something you’ve been on before. Clerkship then rises out of that like a sudden and steep peak, and I now stand at its brink. Personally I haven’t experienced this yet, but I’m assured that my skills and knowledge should be adequate for the ascent. With it looming over me, I cannot be sure.

It doesn’t help that I’ve always had a fear of heights as well.

I guess in the end, I’ve made it this far, there’s nothing else to do but climb.

See you all at the next plateau.