Papers, please

Just in time for the summer – and the new identification rules to get into the United States – picked up my new Special passport yesterday. Green cover, and it’s a bit thicker and heavier than the regular blue passport: not just the gravitas of being On Her Majesty’s Service , but it’s got double the pages (48), and hidden somewhere in the cover, one of those high-tech new radio-frequency electronic chips!

The info guide says it’s only detectable within 10cm of a properly-encoded reader, and for extra protection some of the data can only be picked up if the passport is open, and the machine-readable area (the bits at the bottom with the “>>>” characters) is scanned by a regular optical reader. The guide also says not only to safeguard it like a regular passport, but also clean, dry and unbent, like an “electronic device”.

There’s also a special note on the observation page that, even though the passport’s valid for five years, if you’re not actually on duty anymore you shouldn’t be using it, and have to return it to the Passport Office forthwith. So you can’t just use it instead of coughing up 87$ for a regular blue one to use for international trekking and backpacking that’s not at Her Majesty’s pleasure – sorry, no freebies here.

Despite all the high-tech measures, it’s still got all the classic essentials of a passport: on the front cover, the Canadian coat of arms, and on the reverse, a scripted request from the Minister for Foreign Affairs (and perhaps International Trade, depending on what the department wants to call itself at the time) in the name of Her Majesty for free passage “without let or hindrance” and “such protection and assistance as may be necessary”

And, most classic of all: an actual embossed stamp! You can just feel the official-ness with your fingertips

Passports are pretty neat. Last time I was at the Foreign Affairs and International Trade headquarters – “Fort Pearson” – there was a display of passports through the ages. The first one ever was just a regular letter-sized slip of paper with a note to the effect of what’s still on the inside-front cover today. English Royal seal at the top – the Canadian-ness only indicated by the “Passport, Canada”. (“Passport – by the way, Canadian.”) No photo of the bearer – just a name, their job, where they live, and a signature

Official Canadian Bilingualism (at least for the fields, not necessarily for the entries) and descriptors beyond job came along by 1922. Photos too, though it doesn’t look like there was a designated spot on the page for it, it was kind of just glued on in a convenient space on page 3. A bit more secure, but not quite the same standard expressionless mugshots you have to use now though

By the ’30s, things were looking a bit more official. Still had employment as the number-one descriptor, the language of entries were still at the whim of the passport clerk, and the separate “Wife-Femme” column suggests only men would be allowed to hold passports (unless there was a women’s edition they just didn’t have on display I didn’t see). But now there’s at least a proper space for the photo

Foreign Affairs and International Trade (or whatever it is calling itself nowadays) saves the most convenient documents for themselves though: simple credit card-sized IDs you can keep in your wallet, no booklets to forget or misplace

Who knows, maybe booklet passports will go the same way too. Visas and stamps replaced with electronic “permission” tags added to your chip as you cross the border. You won’t even have to show your card anymore – you’d just walk up, and as you approach the radio-frequency reader it would “stamp” the chip, and you’re set! No more lines to queue through, no more cold sweats standing in the immigration line as you hear your flight being called for boarding

Yet there is still something irreplaceable about the passport. It’s the tangible, legal expression of nationality; anyone can tack a flag on their backpack, but a passport – you need at least two years of permanent residence, a guarantor to vouch for your identity, and 87$ for that. People move, marry, invest in other countries just to get one; it’s what you wave at the embassy gates when you need help in a foreign land. At the airport you can’t help but peek at what documents people have in hand – colours of almost 200 nations distilled into blue, red, green or black with gold-embossed coats of arms

And, of course, the stamps. You can Photoshop yourself onto the Eiffel Tower or the Great Wall, and mail-order Andean sweaters and handfuls of Sahara sand – but you haven’t really been anywhere unless you’ve got a stamp to prove it

Looking forward to stamping the crap out of the new passport this summer!

If it looks like a pilot and flies like a pilot…

Interesting question about “aircrew” today – what about the people who fly UAVs? “Unmanned aerial vehicles”, or drones: they’re all over battlefields nowadays, an extra set of eyes and ears spying on the enemy – and kitted out with bombs and missiles, an extra set of fists too.

Undoubtedly they save lives. They can pick out freshly-turned ground (suggesting IED placement), map out enemy territory and detect ambushes ahead, and warn of civilians and non-combatants in the area. There’s even a American Navy ad featuring them: “Working every day to unman the front lines…”.

But are they still “aircrew”? Whilst “flying” the machines, do the operators need to be “A1″ status like other pilots: near-perfect uncorrected vision, free of alcohol and certain medications, G-LOC resistant, and subject to the exhaustive medical oversight?

As it stands, not always. Some UAVs are owned and operated by the Army, others by the Air Force, so the standards vary. The drones themselves vary immensely, from kit-assembled hand-launched model aircraft, to jet-powered fighter-sized equipment that need real runways to take off and land from.

The most interesting medical tidbit about UAVs is actually psychiatric. Pilots (of manned aerial vehicles, that is) have some well-defined mental stresses that come with their job, that doctors know to watch out for: the aviation industry’s obsession with protocol, regulation and safety the attendant risk of injury and death when humans deign to break the law of gravity; and of course, the disconnect of killing others beyond visual range, at the push of a button. Out of sight, out of mind? Not at all.

Part of the pilot’s coping mechanism is the close-knit, closed-door culture that develops around flyers. At an airbase, pilots have the benefit of wingmen and aircrew barracked together: we’re taught the spinning of stories, competition between comrades and, yes, copious consumption of alcohol aren’t just out of tradition, but survival.

But UAV operators? For many, it’s a shift job, no deployment overseas necessary: get up in the morning, kiss the spouse and kids good day, drive out to the operations centre, plug in to the UAV console, take off, scan the battlefield with your cameras and infrared, observe the real-time streaming video of unknown good guys and bad guys fight and die on the other side of the world, fire your missiles and drop your bombs, kill a few yourself and watch them die.

At the end of the shift, shut off the console, drive home, back to the spouse and kids. “How was your day?”

Apparently some UAV operators get “attached” to the people they observe. Whilst providing reconnaissance for Army units, they can actually start to recognise individual soldiers as missions progress. You never learn their names, of course; but you can pick out the “tall guy”, the “short guy”, the “guy with glasses”, the “guy who walks like Charlie Chaplin”. When you see them hit and fall, it’s not at all like being a pilot – you’re anything but disconnected.

I don’t know if UAV training includes the same sort of combat discipline instruction they give to people at the pointy end on the front line (eg infantry, etc), but I do hope UAVers know what they’re getting into when they sign up, and I hope that everyone who watches those UAV feeds really grasp what they’re seeing. You don’t even have to be military (or an unlucky civilian) anymore to see real-life combat close-up: just tune in on YouTube and watch the action live at your laptop.

Kind of a misnomer, “unmanned aerial vehicle” – the front line is now more “manned” than ever.

Here’s looking at you

Never thought I would see the day – since I was here last the police have set up surveillance cameras in Downtown Toronto

It’s only a pilot project ’til the end of the year, and the cameras aren’t actually being monitored live: “Recorded images will be viewed by police only in the event of a reported incident. Images recorded by the camera will be retained for a period of up to 31 days, and then recorded over unless viewed in relation to an incident.” So Big Brother’s not really watching, unless you ask him to, after the fact. The reassurance/deterrent value’s not so much that a cop is actually watching you and will jump in if someone robs or rapes or kills you, but rather that if you get robbed or raped or killed, they’ll have a picture to print around and try to track down your attacker. Naturally, when they first came out Torontoners weren’t so sold on them, and for good reason.

It looks like it might be working though – they don’t say anything about increased arrests or convictions with the cameras, but according to the police stats crime in the area is down 12,2% over the past year (“crime” = murder, sexual assault, assault, robbery, break and enter, auto theft and theft over $5K), so maybe it’s helping. Then again, crime in the city overall is down 11%, so maybe it’s just part of a general safe-ing trend. British police – they’re the world leaders in setting up cameras on every corner – haven’t really noticed a big impact in crime solving or evidence collection despite billions worth of equipment; though cameras did make some good terrorist pickups, and of course if you ask any victim of crime who gets justice thanks to those grainy photographs, it’s worth it. Plus, the more and more you use cameras, the faster and better technology gets as suppliers come up with better kit to sell to police.

The area’s pretty empty until nightfall when the clubs start up and the city’s hedonists descend to the area – some presumably armed and angry and ready to snap to rage, road or otherwise – I wonder how well the cameras work at night? I wonder if the cameras also have deterrent value for traffic violations – red-light running and pedestrian/cyclist hits/kills, that sort of thing. Answers to that and more (maybe) when the pilot project wraps up at the end of the year.

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Speaking of security – lucky hospital security here isn’t so strict: tried out my old med school student ID from 3 years ago (almost a lifetime!) to get into the computer lab

Sure enough – open sesame!

The only thing sneakier than sneaking onto the Internet on someone else’s network with your computer, is sneaking onto the Internet on someone else’s network, with someone else’s computer lab.

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And speaking of hospital security, and the police, there’s a neat FAQ in Emerg now about what to say to the police when suspects end up becoming your patients – not an uncommon occurrence in a busy Downtown hospital. As much as we always look out for our patients’ “best interests” and protect their privacy and confidentiality, it’s nice to see that the powers-that-be have some reassuringly common-sense takes on what can be messy situations

The police call the Emergency Department and ask: “Do you have a GUNSHOT victim at your site/in your Emergency Department?”
Once you determine that it is the police enquiring, respond to their question. Information disclosed to the police is restricted to that required by the Mandatory Gunshot Wounds Reporting Act, 2005: the fact that a person is being treated for a gunshot wound, the person’s name, if known, name of our facility/site and location of our facility/site.

The police call the Emergency Department and ask: “Do you have a STABBING victim at your site/in your Emergency Department?”
Once you determine that it is the police enquiring, respond to their question with the following standard responses:

- If the individual police is describing is NOT in the emergency department, tell the police that they are not. You are not violating anyone’s confidentiality by responding ‘no’ to the police if the individual described is not in or has not been in the Emergency Department.

- If the individual IS in the Emergency Department respond to police by stating – “I am not authorised to disclose that information.” There is no law requiring the hospital to report stab wounds to the police. Hence patient confidentiality is paramount unless safety is a concern or the patient consents to the disclosure.

The police call the Emergency Department and ask: “There was a break and entry several blocks from the hospital. During the suspects escape he/she may have cut their arm and may be requiring stitches. Has someone that meets this description presented in your Emergency Department?”
Firstly, as indicated in the question above, you would ask for the officer’s name and badge number etc to verify that the caller is in fact the police. Secondly, in this situation you should advise the police that they should obtain a warrant if they require information.

You must balance this against the fact that you would not want the police to waste time in getting a warrant if there is/was no one in the Emergency Department that meets/met this description. If there is/was no one matching the description in the Emergency Department (and of course you have verified that it is the police inquiring) you may inform the police that no, we do not have anyone in our Emergency Department matching that description, or no it would not be worthwhile to obtain a warrant.

Back when I was here, it turned out there was pretty much always a cop around Emerg, either bringing in a suspect for medical clearance or taking one to jail once I’d signed off, so police never had to call us to check; they’d just radio their buddy already here to take a look around. Maybe another sign of crime rates going down: cops don’t come to Emerg so often anymore, hence the need for policies when they call us on the phone?

Come fly with me

A dose of civil aviation at the Air Canada Flight Operations Training centre. Though military aviation has to contend with high-Gs, low oxygen, and the operational stresses of killing and avoiding getting killed, pilots and aircrew are generally healthy, fit people, and there’s only a few thousand of them in the country – the medicine should be relatively straightforward.

On the other hand, commercial aviation: you have to think about 75 thousand people flying every day (that’s just Air Canada), many of whom are in less good shape than the ideal aviator. Of course when people start to see air travel as a “right”, like public transit, instead of the private service it really is, people just assume they can fly whenever they want, no matter how sick they might be.

I had no idea before, and wouldn’t've thought to tell any of my patients, but there’s a whole list of things that you actually have to call the airlines in advance if you have them

Air Canada requires 48 hours’ advance notice (72 hours for certain destinations) to process your boarding in the following cases:

- You have an unstable medical condition (physical or psychological).

- You have suffered from a recent major medical incident (e.g. heart attack, heart failure, stroke, respiratory failure)

- You have chronic obstructive lung disease and/or a chronic heart condition.

- You have undergone surgery in the last 2 weeks on your brain, eyes, ears, sinuses, chest or abdomen.

- You have anaemia or leukaemia.

- You require oxygen or need to use your personal oxygen concentrator (POC).

- You require the use of a battery-operated medical device during the flight.

- You have an infectious or contagious disease such as the chicken pox, tuberculosis, etc.

- You require an attendant to travel with you (attendant must be 16 years of age or older and capable of assisting you with your personal and physical needs).

- You have thrombophlebitis.

- You have had an incident on board a previous flight or at the airport and may require medical attention.

- You have caused a flight diversion on a previous flight you have taken.

- You are an Unaccompanied Minor and have a medical problem.

- You have an intellectual disability (eg Down syndrome, Alzheimer’s disease).

- You suffer from epilepsy.

- You are travelling with an infant aged 7 days or less or a premature infant or an infant with a medical condition.

- You have a cast that was placed on a part of your body less than 72 hours ago.

- You require an extra seat for medical reasons (eg leg cannot bend or flex or must remain extended at all times, back problems, full-leg cast, etc)

The airlines can, for medical reasons, ban someone from flying. (Obesity, and free seats for obese persons came up – though obviously obesity is a medical problem, it’s not any more risky for them to fly.) But, don’t relax just yet: if I remember the stats right, there’s over a thousand medical incidents on Air Canada a year; about 20-30 medical-related flight diversions; and – it happens – 5-10 inflight deaths.

Fortunately most airlines (including AC) have some sort of insurance programme where if you’re a doctor and you try to help, you’re covered if something goes wrong. And you get a thank-you letter from the Air Canada medical officer too – I can’t remember if you get some cash or points or a free ticket as well. One of the guys on the course came up afterwards and said he didn’t get anything – his lucky day, now that AC top doc can fix that!

I actually did once get the clichéd call on the intercom, last time I was flying back from Singapore: “Good evening ladies and gentlemen, there is a passenger with a medical emergency. If there is a doctor on board, would you kindly identify yourself to any crew member.” I guess that’s me now!

48-year-old woman, Russian, sudden onset shortness of breath, lightheadedness, nausea, vomiting and shaking. Couldn’t get much of a history from the language barrier except she has “minor” diabetes, no heart disease, no high blood pressure and no medications. Doesn’t smoke or drink, and is normally “healthy, healthy” according to her husband. Digging a bit more, maybe she’s been a bit “sick” the past week with the “flu” in Seoul – “muscular aching”, but no fever or cough. She didn’t look good: fully conscious but pale even in the dark cabin light, arms shaking, breathing fast.

Thought about blood clots in the lungs or the legs, a heart attack, low blood sugar, and plain old anxiety. Gave her oxygen by mask and two aspirin to chew in the mouth. I also asked her to take a glass of orange juice (for the sugar) but she was really against it: “no sugar, water only.” As we talked she actually started to get better, which made me lean more towards anxiety, though it must be pretty severe if it was making her throw up. The patient and her husband seemed to agree “this is probably psychological, yes”.

Talked to a doctor on the satellite phone (“satellite phone” – sounds so cool) who seemed satisfied with the patient improving, and said thanks for coming out. So even though I was the only one who got up, I wasn’t without backup. Phew! Plus the plane was quite well-stocked: stethoscope, oxygen, pulse oximeter, glucometer (too bad I couldn’t get a sample) and a whole pharmacy of medications. Looks like you could do most everything except labs. Interestingly I didn’t see a defibrillator, but then again I didn’t ask for one.

Eventually I did persuade her to take some orange juice. She was really worried about throwing her blood sugar high and needing to take drugs when she gets home, but after a quick talk about blood sugar and how high sugar for a little while doesn’t really matter, while low for even a short time can be pretty unhealthy, she came around. Whether it was blood sugar or anxiety, things settled down, I left her with a jotted-down SOAP-note to give her family physician when she gets home, and the flight attendant came by and gave me a card, and a $100 voucher for Singapore Airlines

Not all medicine tonight: got to hang around the hangar and check out some planes and plane accessories

If you look at some aircraft engines there’ll be a “swirl” on the hub of the turbines

It’s actually there to scare birds away: when spinning, the moving shape apparently looks like an eye (a predatory eye?) so the birds get scared and know to not fly into it.

Humans need to watch out for it too.

All the maintenance on planes happens overnight, so the hangar is a buzzing place after-hours. The mechanics pore over all the defects noted during the course of the day

remove and replace any damaged parts needing repair: this is the inner edge of an engine intake, when the turbine blades went off-kilter and reamed out the inside wall of the engine

but being a fairly new aircraft fleet, most things are still under warranty – which is key, when a plane is worth a few dozen million and an engine costs as much as a house

Airplanes are kind of spooky when they’re all quiet and you’re all alone in them – when does that ever happen? When you’re sneaking aboard on a flight course, I guess. You can take any seat you want

put the coffee on

no queue for the toilet – you have it all to yourself

and dig around for stuff people leave behind – it can be like a gold mine in there

On the larger planes, there’s a hidden upper deck – not just the double-decker 747, but the wide-bodies too – for a crew rest area

but even then, the first class loungers look more comfy – the only time I’ll ever be in one

The only thing more spooky than being alone in an aircraft cabin

is being in the hotseat!

Hmm, what does this button do?

Just like in the passenger seats, the seats in the cockpit have safety cards you have to read when you fly

But before pilots get anywhere near to the controls, they qualify first on the simulator. Once done on the simulator though, they go straight to flying service flights, passengers and everything – no “road test” or “graduated licensing” here.

The simulator is so life-like real-steel (well, real-aluminium) that they can go right to work. It’s raised off the ground on pneumatic struts, so it can simulate the essential rolls, banks and dives – and the dreaded weather anomalies along the way

Like the real thing it’s got all the displays and controls

all the buttons press and levers move, everything generates the appropriate feedback. CP taking off from LaGuardia airport in New York – full speed ahead!

The simulator really does feel real, and it does have sick bags nearby just in case. Even the graphics are complete – the New York set has all the terrain, bridges and the familiar touristy landmarks. I wanted to try flying under the Verrazano bridge and skim the Hudson River, but we ran out of time. (Someone else managed to do it though – altitude = 26 feet!) Pictures of the Statue of Liberty didn’t turn out, but I did dip my wings whilst flying by in salute (note the horizon)

Almost forgot to mention the most essential part of Air Canada’s training centre: the Zamboni!

(More pictures on the flickr Basic Aviation Medicine set.)

Adrift

Public service announcement: stop reading this, and back-up your hard drive. Now.

My laptop crashed last week. I guess I should’ve seen it coming – six years (I just realised it now – I thought it was just five, but it’s been six years!) of trouble-free, relatively-fast performance, when computers usually go obsolete every four years (I’m sure they design a crash around university students and their four-year degrees) was pushing it. So when I heard the grind-grind-grind-GRRRRRIND coming out just under and left of the trackpad I shouldn’t've been too surprised. Instead I just rolled my eyes in frustration, having to reboot and losing the photos I was resizing to make email-friendly.

And then I saw the Black Screen of Death – haven’t seen one of those in years, I thought it was just a MS-DOS thing. But there it was, on my PowerBook G4 screen: black screen, with a prompt, “localhost:/ i have no name!” This can’t be right, so I rebooted again. No luck. Even then I still wasn’t too worried though; I even thought about taking a picture of it, but of course if the computer wasn’t working, I wouldn’t have a hard drive to upload it to. Plus my camera was still full of graduation photos I (thankfully!) hadn’t deleted yet. (Yes, I just graduated – but that’s neither here nor there right now.)

It wasn’t until the third or fourth time I tried it that it hit me. The sickening feeling of losing six years worth of research, writing, photos – six years of memories, lessons, ideas… What a way to graduate, by losing everything that got you there in the first place. How do you describe losing that? If memories, lessons and ideas are what make your identity, who you are… who am I now without them? That error message isn’t far off the mark, I guess: “localhost:/ i have no name!”

Ugh… Just writing about it, it’s visceral, nauseating, crushing, suffocating, unreal… and writing about it here at a hospital workstation, on an unfamiliar keyboard, facing an unfamiliar screen… adrift without a computer, and memories stored thereon, to call my own. That’s the best word I can come up with right now, “adrift”.

I’m really trying not to overdramatise, and choose my words carefully here – I mean, I’ve had to tell people they have cancer, or they’re going to die, or going to lose a limb or an eye, or their child, so I think I have a sense of perspective about bad news – but still, it’s a feeling I’d never wish on anyone.

Panicking thoughts that run through your head: Do I have anything backed up? Anywhere? Stuff on email? Photos I sent around? I really should’ve uploaded more on flickr. Or maybe even stayed on facebook, I had some albums there. Would the School still have copies of my research? (Of course not – you know how many students they go through each year?) What else am I missing? I knew going with paperless banking was going to bite me in the end. I’d better start writing stuff down before I forget…

I guess I liked to think I was the kind of person who didn’t need souvenirs or photos around me to remind me of the things I care about – if it’s something/someone important worth remembering, you don’t need crutches like that to prop up the images and feelings you take with you as memories. Maybe I was just saying that because moving around from school to school and city to city the past 10 years I never could hold on to too much… the one thing I could hold on to was my laptop, but now that that’s been taken from me… ugh.

I told BML the story… maybe there’s a up-side to it:

the good that can come out of your situation is those memories that mattered most to you most will grow ever more lucid in your mind… since you won’t be relying on pictures. you will hold on to them more dearly than you would have before. you’ll also grow to trust yourself with your memories.

I’m trying to remember as many things and people as I can right now – if at the physiological level, memories are electrical circuits within the brain that develop when something’s experienced, and become ingrained as the circuit is triggered again and again (through recollection), maybe I can hold on them. As long as I don’t remember too many things at once and muddle the circuits and short them out. What was my ICU case report write up about? Heart failure after crush injuries. What was it about crush injuries? Heart… crush… ICU… did I have a crush on someone in ICU? Dammit – must keep memories straight!

Anyway, don’t let this happen to you. Back-up your hard drive. Now.