Photo by Hannah Loewenberg

We welcome you back to our final submission of Dr. Hannah Loewenberg’s two-part series on her alternative pathway through medical education and lessons learned from Psychological First Aid (PFA). In her last submission of Into the Wild She Goes, we explored the important guiding PFA principles of Safety, Self-Efficacy, and Calm, following Dr. Loewenberg from the mountains of North Carolina to the clouds atop the Himalayas. We will close here with final guiding PFA principles, Connection and Hope, and Dr. Loewenberg’s perspective of a hopeful future in Emergency and Wilderness Medicine. 

Connection

My arrival in Kathmandu coincided with the beginning of Tihar, the Nepalese Festival of Lights. The Hindu celebration reveres animals of the earth, notably the crow, the dog and the cow.  A magical and vibrant celebration, Tihar blankets the entire nation with a rainbow of electric neon. You notice the lights before your plane even touches the ground.  Arriving at the airport in Kathmandu, you experience epic, awesome chaos. As you take your first breaths of the hazy, arid air thick from dust of the dry season and shuffle amongst the dense crowds through airport security, you notice that everyone is being herded through metal detectors just like almost any airport around the world. Then if you pay close enough attention, you notice those same metal detectors don tails of electrical wiring that just happen to not be plugged into any electrical socket whatsoever. 

Dr. Luanne Freer found me amidst the chaos. Dr. Freer, or Lulu as her friends know her, is an incredible emergency physician and passionate friend of the Nepali people. She has also served as the Medical Director for Yellowstone National Park and is the founder of Everest ER, the first formal emergency clinic at the Basecamp of Mount Everest that provides aid to all tourists of the mountain and to the remarkable Sherpa who guide them. She embraced me with a hug and then guided me through the complex labyrinth of the airport. Shortly after my arrival, Dr. Paul Auerbach joined us. Dr. Auerbach was essentially the father of wilderness medicine (he passed away June 23, 2021). Of his many accomplishments, Dr. Auerbach co-founded the Wilderness Medical Society, the world's leading wilderness medicine organization, and authored the largest volume of wilderness medicine text to date.

Photo by Hannah Loewenberg

For the next two weeks, Dr. Lulu and Dr. Paul trekked with us through the Himalayas raising money for a hospital they were building in memory of their late friend, Wongchhu Sherpa. As we hiked, I was entertained by stories from Paul and Lulu about their friendship with Wongchhu. Lulu told of how Wongchhu was instrumental in helping her build Everest ER. Paul described their mountain biking adventures and Wongchhu’s magical ability to get things done. From the sounds of it, Wongchhu was a force of nature. His spirit lives on through his daughter Lakpa Sherpa. After his story telling, Dr. Paul would regularly remind me to look up at the scenery we were immersed in. Through blue skies, bright sunlight glittered the dusty trail and illuminated the distant, snow-peaked mountains we trekked toward. We passed brilliantly colored teahouses and prayer wheels as we crossed paths with Nepalese porters carrying towering loads that nearly matched their own bodyweight. Often we would hear the pleasant and utterly peaceful clanking of bells donned by the horned, long-haired Himalayan yaks. As we stepped aside to make space for the lumbering, ox-like creatures, I noticed that all of the aircraft passing through the valley flew not above us, but below. Within a matter of days, we were walking in the clouds. 

Photo by Hannah Loewenberg

What stands out most vividly in my memory of this journey is the genuine connection Dr. Paul and Dr. Lulu shared with their Nepali friends. After dinner, Luanne loved to instigate her favorite card game among our whole crew of Americans and Sherpa, one in which the winner proudly displays undergarments on their head as a crown of accomplishment. On the very special occasion that we were served cake to celebrate our journey, Dr. Paul exhibited his miraculous skill I can only describe as frosting-throwing, where he forced a dollop of cake frosting into the air from the back of his hand aiming for it to either arc back into his mouth or end up stuck on the ceiling of the tea house! One night, he attempted to pass on his skill of frosting-throwing by teaching Lakpa. It always seemed like the goal of the day was shared laughter. Although I never had the honor of meeting Wongchhu Sherpa, I imagine his goals in life were likely aligned with similar purpose. Perhaps the most valuable lesson Nepal gave me was a newfound appreciation for connection and the shared joy and healing that results from laughter and friendship. As our trek came to a close, and I journeyed home to Tennessee for Thanksgiving with my family, I prepared to embark on the next chapter of my scholar’s year. A seventeen-day river expedition through the heart of the Grand Canyon.

Hope

Among the adventurous individuals who are granted the opportunity to embark on an extended voyage through one of the oldest and deepest crevices on the planet, virtually none will emerge at the end of their journey unchanged in some way or another, and those who travel by way of boat will undoubtedly form an intimate and everlasting connection with the immensely powerful river that carved it. As all Colorado River journeys begin, our trip launched at Lee’s Ferry, the Martian-red ingress in the crag that marks accessibility prior to the walls’ dramatic ascension. After many days of travel, gear acquisition, gathering of provisions, and other important logistics and planning, we were finally there. The vociferous excitement among our crew was tangible, yet I couldn’t help but feel a sense of hesitation. Something about this journey was different than any other journey I had ever embarked on. Perhaps the deepest motivation for me stepping away from medical academia was to rediscover my reason for being there in the first place. Rivers had ignited the fire in my soul and sparked my passion for rescue and austere medicine, but in pursuing that path, I had lost touch with the very experience that got me there in the first place. I found myself apprehensive of boating and no longer felt like the paddler I once was. If you ask any oarsperson, rowing through the Grand Canyon is probably the epitome of any paddling expedition. The stars had aligned and I somehow managed to find myself thrust into what was probably going to be the most significant whitewater journey of my life. I spent the entire first night by the river in a frenzy. I could hardly sleep and my thoughts and heart raced for hours. 

Photo by Hannah Loewenberg

Throughout my time listening to patients as a physician, I have found that fear is a common theme in life. In the medical field, people come to you for help, and more often than not they are afraid. Our job as physicians is to educate our patients and help facilitate their journey through their concerns and anxieties, often on the absolute worst day of their entire life. Acquiring communication skills and empathy requires time to reflect. How could I possibly take on the emotions of others without first addressing my own? Earlier this year, I was told a story of fear. 

As humans, most of us fear storms. Weather surges with danger. When you spend most of your time outside, you learn to fear and respect the power of exposure. Most living creatures have learned to recognize the danger inherent in storms and seek shelter to ride them out. The American Bison is one exception. When faced against a storm, other animals will attempt to run away and seek refuge. When bison sense a storm, mechanisms enhanced and nurtured by evolutionary biology take place, and their bodies and intuition instinctively propel them towards it. Bison have figured out that by running into the storm, they inevitably pass through it faster and spend far less time suffering. Even before I knew of this counter intuition, I strongly felt the need to step away from the rigid constructs of medical training in order to explore my own fears. I needed to learn to face the storms for myself. 

So into the Canyon I went. Our crew of 14 individuals was comprised of mostly strangers, folks who met through friends of friends. Some of us worked in healthcare and others were seasoned river guides, biologists or mathematicians. Some of us had immense knowledge and experience on water and others were just embarking on the very first overnight river journey of their lives. We spent our mornings waking to the titanic red walls, drinking coffee while we packed up camp and rigged our rafts. As we began downriver, sometimes we encountered a lulling stretch of flatwater to read our guidebooks and adjust plans for lunch spots and day hikes. Other times we camped just above major rapids where we slept to the hum and roar of the challenge that awaited us below. 

Photo by Nathan Lucas

The time would come where we would spot the entrance to one of the significant rapids of the day and gather by the riverside to go hike and scout the water ahead. As we investigated the most suitable route to launch through the rapid, I noticed the landscape had a way of creating quite a disproportionate illusion of exactly how large the water was below. No matter how much you dissected the features of the river, when you entered the current, the water was bigger than anything you had ever imagined. You had no choice but to work as a team to get through it. This experience can be illustrated by our run through Hance rapid. Hance is a stout, class 8 rapid (Grand Canyon rapids are classified differently; this would correspond to a Class IV on the traditional whitewater scale) that drops about thirty feet in elevation. The crux move is to miss the massive top hole of recirculating water at the entrance. But when we managed to slide into it sideways with no speed, one of our oars was ripped from the tower only to be rescued by another crew member who made the split second decision to dive into the whitewater mid-rapid to grab it. I, then, had to make the split second decision to grab the ankles of said crew member so that he wouldn’t be swallowed by the raging waters below.  We celebrated our narrow success with beer and cider as soon as the waters calmed.

Photo by Rev. A.Z. Andis Arietta

Before the sun would set and darkness would fall, we would settle into camp for the evening. As we built our evening fire and cooked our dinner, we would gather around to enjoy each other’s company and get to know our new family of friends. What I found throughout our days and nights by the river is that you receive from the Canyon what you bring in to it. By entering the canyon with courage and preparedness, knowledge of yourself, your strengths and limitations, respect and love and willingness to help, give to and receive from those who are similarly finding their own way, then you will leave the canyon with abundant lessons and gifts and friends.

As I sit here now, I find myself asking what it was that I received from my weeks living in the Grand Canyon. We are living in a time of great suffering for all healthcare providers. Throughout this year, I have been searching for what exactly is missing in our education and practice that is fueling this epidemic. For me, medical school felt like a marathon of sacrifice and the winner gets to be whoever sacrifices the most. According to Fedarko, this is a defining characteristic of life in the entire world above the canyon rim. “Of the many attractions that draw people to the bottom of the canyon, perhaps the most potent and beguiling is the realization that the experience is the opposite of a race – the antithesis of rushing from where you are toward someplace you think you would rather be, only to discover, once you arrive, that your true goal lies somewhere else.”

 Photo by Colleen Hickey

What I received from the Canyon was a newfound sensation of hope. Hope can be defined as many things. For some, it is described as the feeling of expectation and desire for a certain thing to happen. For others, maybe it is simply the faith that circumstances have the power to improve. However, as individuals, we all have incredibly different ideas and personal definitions of hope. While in the canyon, I had time to linger and suspend myself in a blue-and-amber haze of in-between-ness. As I floated and drifted, savoring the pulse of the river on my own odyssey through the canyon, I had time and space to reflect and integrate meaning into my life. I realized that hope, for me, is the perspective you gain when you allow your circumstances, whatever they may be, to be viewed in a way that fills your heart with love. After I left the Canyon, I found my heart full. 

It is my hope that this essay encourages others to have an open mind and rethink how we train and practice medicine. I hope that it shares an understanding that we don’t need to compete with each other to prove ourselves competent. Rather, as we continue to strive to learn and grow, I hope we begin to appreciate the value that we, ourselves, are already enough. As care providers, I hope we come to understand that our presence, itself, is healing. When you trust your good intentions and sincerely respect both your patients’ autonomy as well as your own, I hope that you find the pressure lifts. I hope that one day we can move toward a more holistic healing philosophy, for peace of mind and heart are vital dimensions of healing that we must not forget. We are all human. We all suffer injuries to our hearts and our souls. There are times where we all feel overwhelmed and helpless and alone. It is during these times of stress that we suffer the most pain and despair and are most vulnerable to hopelessness. However, I hope we come to realize that this place of vulnerability is also the place where we discover our greatest potential. When we claim responsibility for our own actions and learn from the education and training practices that allow us to be self-efficacious, we no longer feel helpless. When we learn to practice authentic mindfulness and exercise calm, we cease feeling overwhelmed. When we take time to appreciate and value others in our lives, we are no longer alone. When we pause to reflect on our own safety and move through fears that make us feel unsafe, we are able to create safety and love for both ourselves and those around us. When we emulate safety and love, we, ourselves, build hope. 

These endeavors might sound simple, but we know these tasks are not easy feats or we would have already figured out a solution to our struggles. These are very personal and difficult, even brutal vulnerabilities that must be addressed authentically and intentionally – like muscles that need strengthening, they require repetition and care. It is an endeavor of the spirit. Through listening to our values and honoring them as a daily practice, we get to explore the very root of our anxieties and stressors. The challenge lies with manifesting the same authenticity within our leadership, communities and workplaces. We must engage our own talents and passion and demand that our leadership honor the same creativity. Through vulnerability, we find the courage that we are exceedingly capable of creating greatness. Rather than bandaging and masking symptoms that allow us to escape our pain, it is my hope that we are able to create lives and careers that we no longer need to escape from. After all, this is your life. Go savor it. 

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This piece is dedicated to my former classmate, Julian Richardson, to Dr. Paul Auerbach, to Megan Rand, and to my Uncle, Dr. Robert Shankerman - my lifelong mentor, fellow physician and outdoor enthusiast who passed away from complications associated with Covid-19. To all who have faced or are facing times of despair, your strength is admired and your journey is celebrated.