Time Out of Mind

The last couple of months have featured some difficult work scheduling, bookended by some ambitious travel plans. Occasionally, usually on a bus or train or plane, I would jot down what I figured was a blogworthy observation or two. Many of these made little sense upon review, but I've transcribed a few disjointed thoughts below for your perusal.

Cabin pressurization is seemingly balanced by passenger decompression. This was made clear to me upon boarding a recent flight to Europe -- after an endless ED shift, frantic packing, and stressful journey to the gate. I settled into my seat and fussed with my carry-on as the pilot began to speak to the crew, in his crisp, proud, and utterly unintelligible German:

"Begrüßen Sie an Bord, ist dieses Füllermaterial, weil es dieser Verfasser könnte verstehen was ich sagte, und zweifellos nahm nicht Anmerkungen unmöglich ist. Mindestens, nicht bis später. Der Film auf dieser Reise ist ... Akeelah..."

Wait, what was that last thing he said?

"...And the Bee."

Of course. I had a chuckle at this, and a few of my fellow passengers were amused, as well. There would be more hurdles to cross after landing, but for now we could relax a little.

People who have been fated to sit next to me in recent weeks include: a former navy pilot-turned-Hitachi VP; a dancer; a preternaturally aged schoolteacher who coldly graded essays with a red, red pen; and the obese, hairy, loudmouth lawyer who turned out to be a pro wrestler, on the side (he played the heel, naturally).

My decidedly undemocratic survey of our conversations suggests the vast majority of travelers are leading rich lives. And we did't even fly first class.

I'm editing a pre-rounds in transit, and marveling at just how much some people care about their blogs. They speak of addictions, of loving maintenance. Meanwhile, I contemplate my bimonthly posting regimen, and cast a wary eye at blogborygmi's ghost-town blogroll -- a tumbleweed-strewn replica of the medblogosphere circa fall '04.

I do love blogborygmi, of course, but in the same way I'm fond of that old buddy from school, who taught me how to approach girls. He was really valuable to me at one time, helped me out a lot, but circumstances intervened and new we're just not so close. Every now and then I think of him, and give him a call, but if we stay on the phone too long it just reminds me of all the new priorities and obligations that occupy my time.

No matter where you go these days, you may encounter someone asking for money for martial arts lessons, because ninjas killed his father. Either there's an underreported patricidal ninja epidemic, or the nation's panhandlers are cribbing Overheard in New York.

Forgive me, seasoned poker players, but isn't emergency medicine a little bit like no-limit hold 'em? The way doctors and patients size each other up, try to read each others' hands. Even so, most hands are straightforward -- you know how it'll unfold from the flop. Other times, you have to wait for labs to come back, there are raises and calls. But no matter how benign the situation might start out, you never really know which patient is going to take you "all in."

On my flight to the ACEP conference in New Orleans: I counted six residents and five attendings -- and that was just from the few programs in the city I'm familiar with. Should a passenger experience a medical emergency en route, he or she could do worse than to pick a flight packed with emergency physicians.

Transitioning from a high-acuity shift in a New York City ED to a tourist in New Orleans -- in the space of twelve hours -- is pretty much the most profound change of pace I've experienced. I recall being miffed that the folks on escalators in New Orleans don't spontaneously organize into standing and walking lanes, like they do in New York. But I knew I was having trouble adjusting to the laid-back lifestyle when I consumed a po' boy in less time than it took to make it.

Many friends asked me for some reportage on how New Orleans has changed. Well, before this week, my last trip there was for the millennium (coincidentally, my fellow resident and current hotel roommate was also present for that party). On the shuttle ride from the airport into the city, I kept pointing to caved-in roofs, derelict poles and transmission lines, and asking if it was unrepaired storm damage. "No," a local would correct me, with a sigh. "That building was like that, before..."

The best recent commentary I've read on the city actually comes from today's Grand Rounds host, Dr. Michael Hebert, who writes:

And finally, from Douglas McCollam of Slate, we have this: "It's fair to ask why, in a city where vast swaths remain uninhabitable, all this money is being spent to fix a stadium. You won't hear that question in New Orleans . . . If they can fix the Dome up after all it endured, then perhaps other things can be fixed as well. Perhaps, after all, the city need not die."

This angst is real, the conflict between tragedy and frivolity. New Orleanians feel it too, just as they felt it before as they celebrated the first Mardi Gras after Katrina. But in this town, tragedy and frivolity have always walked hand in hand. Name another city where cemeteries are promoted as a major tourist attraction. Where its most famous holiday (Mardi Gras), a celebration devoted to excess and debauchery, is counter-levered against the most solemn religious period on the calendar, Lent, and on purpose. In New Orleans, the jazz funeral starts with a dirge and ends with a riotous party at the gravesite. We don’t sweat it here. Maybe because we ignore tragedy. Or maybe because we are so used to it that we understand that if you don’t dance at somebody’s grave there is nowhere to dance at all.

A town where tragedy and frivolity walk hand in hand... No wonder so many emergency medicine conferences are scheduled here -- it's a natural fit for our practice environment.

And, speaking of dancing at the gravesite, I've got a parade to get to...

Kicking Down the Cobblestones

In a city of fast walkers, I take some pride in being among the fastest. But lately, thanks to an adjustment in my train-hopping commute, I've come across some speedwalking that's startling to behold.

If you get on a Brooklyn-bound 6 train, about 2/3 of the way back, and get off at 59th street, you're let off onto a broad, dimly-lit platform that extends about a hundred feet. At the edge, there's a short staircase descending to the ancient N, R, and W trains.

Every weekday morning, between 6:30 and around 9, you'll see the 6 train's doors open, and dozens of snappily-dressed, well-coiffed men and women emerge. The smart ones will just break into a sprint, right there. The majority will speedwalk with a vigor and determination bordering on maniacal. A few pitiable souls will leisurely stroll out the train doors, only to be brutally elbowed aside by those determined not to miss the next ride to midtown.

The thundering of the speedwalkers' footfalls could easily be mistaken for the rumble of another train. The few children that witness this procession invariably begin to cry. I, too, was horrified and awestruck when I first took this route. But so often in this ambitious town, the transformation from surprised bystander to competitive participant is brief.

Interference pattern

I remember working in a lab during the summer of 1999, the summer between first and second year of med school. I was building a cDNA library and would occasionally have to show up in the middle of the night to check my colonies or adjust the broth.

Every time I went in, no matter how late, the lights were always on in the adjacent lab. The Mello Lab. The techs were always there, 'round the clock.

"What are those techs working on, over there?" I'd ask my labmates, at a more reasonable hour.

"RNA-i," they'd reply.

When the concept of RNAi was first explained to me, I remember feeling impressed and vaguely irritated. I had taken many bio courses in college (Mello's college, no less) and again in med school, and had learned nothing of this powerful, simple mechanism cells had developed for silencing specific genes.

I had already spent several years working on viral transduction, and had become jaded to the whole field of gene therapy, for research and for treatment.

RNAi sounded too good to be true. And the fact that it was discovered and fleshed out just fifty feet away from my humble cDNA library lent an air of unreality to the enterprise.

But Mello and his techs knew they were onto something, and they had the fortitude to see it through. Now the college textbooks have been rewritten, and Craig Mello has won the Nobel Prize for Medicine.