Anchors Aweigh

Grand Rounds is up at NHS Blog Doc. Dr. Crippen includes lots of pictures in this edition, but has allowed me to run the one on the right -- it's his boat, the Borborygmi.

No, this did not influence his placement in the Grand Rounds hosting queue. Nor did this blog influence his naming of the boat. I suspect it's a reference to sea sickness?

Speaking of queasy stomachs, the demise of PaedsRN's GeekNurse blog is causing some well-justified fear, and anger at overzealous risk management censorship. This has touched off a few good posts and an interesting discussion at Random Acts of Reality.

I recall a medical student blog that was taken down last year, along with the potential for disciplinary action or expulsion... and a resident blog that was removed in 2004 -- again, with the threat of termination. I hope, at the very least, PaedsRN's employment is not in jeopardy, but I don't believe anyone has heard from him since his farewell post.

Through it all, I imagine there are some hospital administrators, somewhere, congratulating themselves on limiting their hospital's liability. At least they're sleeping easy.

We're poorer for the loss. Clinical Cases points to the Writely archive of GeekNurse's Grand Rounds.

"I always wanted to be a Tenenbaum"

It was pretty cool, passing by the crew and equipment for Matt Damon and Angelina Jolie's new movie, on my way to work one morning last fall (DeNiro's directing).

But it wasn't as great as seeing Willem Dafoe filming outside my hospital, a few months ago.

This rivalled the fact that, a few days ago, George Clooney's lastest project was filming just around the corner from my apartment.

But nothing fills me with more Manhattan movie magic than knowing I've been in the same elevator as Gene Hackman and Luke Wilson, the one featured in the Royal Tenenbaums. Yup. I was listening to the director's commentary on the DVD (you see, I was cleaning, and had run out of new music) when Wes Anderson revealed that it's hard to find large, elegant lifts requiring an operator. So he filmed the elevator scenes in the New York Academy of Medicine. This beautiful building is one I've visited several times, and actually mentioned in a post on Medgadget.com.

In the movie, Hackman and Kumar (Pagoda) play elevator operators inside the fictional Lindbergh Palace hotel (interior shots were filmed in the Waldorf-Astoria, Anderson says). After Hackman and Wilson ride to the top, they continued filming on the roof of NYAM. Sure enough, when Mordecai returns, you can glimpse one of the hospitals where I work.

Now all I have to do is become a member of the 375th Street Y. I guess it's pretty far north...

Samaritan Snare

It was a hot summer evening, and I had just completed an emergency department shift. I was exhausted, again. As I headed down the street toward the subway, I came across a man lying on the sidewalk.

He was disheveled, unshaved, dressed in dirty clothes, probably in his forties. He wasn't moving, but I could see he was breathing.

Everyone else was walking past him, but I... I'd been a doctor for several weeks, at this point. I was still in my scrubs. I looked around -- maybe a more senior resident would walk by? We were literally a few hundred yards from the hospital.

But there was no one I could consult. So I assessed the man. After a vigorous sternal rub, I learned the man's airway was intact, he could move all extremities, open eyes, and mumble. His pulse had a regular rate and rhythm. If there was a triage note for him it'd read, "EtOH-like smell on breath." There were no deformities, lacerations or abrasions on his face or hands. But I started to wonder -- sure, he was drunk, but what if he'd been assaulted, too? What if a car had hit him? There was no bottle lying around, no shopping card or cardboard box.

I looked around again, in vain. I had to make a decision. I picked up my cell and dialed 911.

As I waited for EMS to arrive, I thought about the Tipping Point. In Malcolm Gladwell's first book, he recounts a study of opportunity and conduct:

Seminarians were asked to give a sermon on a biblical story, across campus. Along their path, each student encountered an actor, playing a destitute man lying down, coughing and groaning. What factors influenced whether the seminarians would stop and help the man? The designers looked at three variables: 1) whether the student had expressed a desire to help others as a major reason for enrolling, 2) whether the assigned sermon was on "The Good Samaritan" or 3) how much time the seminarian was given to get across campus.

It turns out third variable was by far the most important -- hurried people don't stop to help strangers in their path, even if they're seminarians on their way to preach on the Good Samaritan.

Of course, in this instance, I was not exactly hurried. In fact, I was done for the day -- so I had the time and the means to help. My big reluctance in calling 911 had nothing to do with me, but rather, that I didn't want to make work for my colleagues -- the people in the ED I had just signed out to. Because the truth was, I suspected, that this guy would be ok -- he'd sleep it off, either under the warm summer sky or in the ED, and he'd be back at it the next day.

If that were the case, then I really wasn't helping the man at all -- I was just passing along a problem.

As it turns out, Gladwell had something to say about this problem of chronic homelessness and substance abuse, it just hadn't been published, yet.

Power-Laws and Redistribution

In a recent issue of the New Yorker, Malcolm Gladwell revealed some surprising statistics about chronic homelessness and healthcare. The costs were more expensive than I could have imagined. But the problem was not nearly as widespread -- and that gave cause for optimism. In an interview with an administrator in Nevada, Gladwell wrote:

"We came up with three names that were some of our chronic inebriates in the downtown area, that got arrested the most often," O’Bryan said. "We tracked those three individuals through just one of our two hospitals. One of the guys had been in jail previously, so he’d only been on the streets for six months. In those six months, he had accumulated a bill of a hundred thousand dollars—and that’s at the smaller of the two hospitals near downtown Reno. It’s pretty reasonable to assume that the other hospital had an even larger bill. Another individual came from Portland and had been in Reno for three months. In those three months, he had accumulated a bill for sixty-five thousand dollars. The third individual actually had some periods of being sober, and had accumulated a bill of fifty thousand."

Gladwell interviewed Dr. Culhane, who had written his graduate dissertation on homelessness and had slept in shelters, for research:

Homelessness doesn’t have a normal distribution, it turned out. It has a power-law distribution. "We found that eighty per cent of the homeless were in and out really quickly," he said. "In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back. Anyone who ever has to stay in a shelter involuntarily knows that all you think about is how to make sure you never come back."

The next ten per cent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. They were quite young, and they were often heavy drug users. It was the last ten per cent—the group at the farthest edge of the curve—that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. They were older. Many were mentally ill or physically disabled, and when we think about homelessness as a social problem—the people sleeping on the sidewalk, aggressively panhandling, lying drunk in doorways, huddled on subway grates and under bridges—it’s this group that we have in mind.

Culhane’s database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade —which was a surprisingly high number. But only about twenty-five hundred were chronically homeless.

It turns out, furthermore, that this group costs the health-care and social-services systems far more than anyone had ever anticipated.

The guy I saw on the sidewalk, that summer evening? He may well be one of the city's 2500. But New York's Bravest said they didn't recognize him as a regular, when they took him down the street to the hospital. Either way, as a first timer to the hospital, he would have had forms generated, labs drawn. Depending on the attending, maybe even a head CT. If his belly was tender on physical exam, maybe much more. It's easy to see how an indigent substance abuser can rack up millions of dollars of healthcare charges over the year. Faced with this tremendous expense from a relative small group, Gladwell found people proposing a revolutionary solution:

"I spoke with people doing services there. They had a very difficult group of people they couldn’t reach no matter what they offered. So I said, Take some of your money and rent some apartments and go out to those people, and literally go out there with the key and say to them, 'This is the key to an apartment. If you come with me right now I am going to give it to you, and you are going to have that apartment.' And so they did. And one by one those people were coming in. Our intent is to take homeless policy from the old idea of funding programs that serve homeless people endlessly and invest in results that actually end homelessness."

There's an obvious challenge to such generosity:

Post had just been on a conference call with some people in New York City who run a similar program, and they talked about whether giving clients so many chances simply encourages them to behave irresponsibly. For some people, it probably does. But what was the alternative? If this young man was put back on the streets, he would cost the system even more money. The current philosophy of welfare holds that government assistance should be temporary and conditional, to avoid creating dependency. But someone who blows .49 on a Breathalyzer and has cirrhosis of the liver at the age of twenty-seven doesn’t respond to incentives and sanctions in the usual way.

Power-law solutions have little appeal to the right, because they involve special treatment for people who do not deserve special treatment; and they have little appeal to the left, because their emphasis on efficiency over fairness suggests the cold number-crunching of Chicago-school cost-benefit analysis. Even the promise of millions of dollars in savings or cleaner air or better police departments cannot entirely compensate for such discomfort.

Yet, despite their lack of appeal to both ends of the political spectrum, these programs may just work.

Gladwell's piece ends on a sour note -- one of the more lovable alcoholics, who had been a regular to many healthcare workers, dies. When his caregivers grieved, it reminded me that homelessness isn't just a problem that needs a solution, a cost that needs to be controlled.

And it provided me with the proper perspective to answer a friend, who recently asked me, "Now that you're well into your internship, and have seen countless drunks and alcoholics -- many repeatedly -- would you call 911 again?"

Love and Support

In a curious convergence of two of my favorite writers, Malcolm Gladwell was interviewed by Bill Simmons, the former Boston Sports Guy and now ESPN.com columnist. Gladwell talked about the intersection of writing and sports, and the common drive for excellence:

I'm happy writing anywhere and under any circumstances and in fact I'm now to the point where I'm suspicious of people who don't love what they do in the same way. I was watching golf, before Christmas, and the announcer said of Phil Mickelson that the tournament was the first time he'd picked up a golf club in five weeks. Assuming that's true, isn't that profoundly weird? How can you be one of the top two or three golfers of your generation and go five weeks without doing the thing you love? Did Mickelson also not have sex with his wife for five weeks? Did he give up chocolate for five weeks? Is this some weird golfer's version of Lent that I'm unaware of?

And, from a conversation on individual athletes on supportive teams, Gladwell was able to generalize about his own situation at the New Yorker and the theme that runs through much of his work:

My point is its almost impossible to know where the person ends and their environment begins, and the longer someone is in a particular environment the blurrier that line gets. More specifically, you can't make definitive judgments about the personal characteristics of people who come from structured environments. What does it mean to say that a Marine is brave? It might mean that a Marine is an inherently brave person. It may also be that the culture of the Marine Corps is so powerful, and the training so intensive, and the supporting pressure of other Marines so empowering, that even a coward would behave bravely in that context. That's what I mean when I say I'm Plummer: I'm working in a such a supportive and structured environment that I no longer know where my own abilities end and where the beneficial effects of the environment begin. Just think if you were a New Yorker writer, Bill. Suddenly your editors would be asking you to make your stories longer. You spend the summers at a writer's colony in New England, working on an historical novel based loosely on Freud's famous falling-out with Adler. And girls would hit on you in bars because they would think of you as cute in that nerdy, bookish way. But you'd still be Simmons, wouldn't you?

Just a funny, interesting interview. It makes me thankful for my supportive environment(s) and hopeful that these two collaborate again (but if they should have a famous falling-out, Deadspin has predicted a winner).

I've also learned that Malcolm Gladwell now has a blog. If he keeps in up, and spends a little more time writing about healthcare, I may just have to ask him to host Grand Rounds.

Little Things

Nurses are on the mind these days -- for the first time in its 18 months, Grand Rounds has nurses as back-to-back hosts. Last week was Emergiblog, this week is GeekNurse.

It's got me thinking -- I'm pretty lucky to be working in hospitals offering some of the city's best nursing. Not being required to start my own IVs, or print labels, or push many meds, really frees up my time to see more patients, which is really what I ought to be doing.

I've written before about reporting respiratory rates -- how nurses (and EMS, I gather) often just report "20 breaths per minute" when a patient appears to be breathing comfortably.

There are a few cases where that's dangerous -- such as, for instance, when the respiratory rate is actually 20.

I've noticed that our ED's nurses, when they want to bring to my attention a patient's tachypnea, actually record "19" or "21" as the respiratory rate ... It's like they're sending me a secret code through the vitals that not all is well. Sometimes, when things are busy, this can be our only interaction -- so it's particularly sly and efficient.

Dry Wit Large

In the back page of The New Yorker, they now offer up cartoons for readers to caption. Not only have I worked with this week's caption contest winner, I've written about him before (during my residency interview, he coined the phrase 'cocktail party research' which I still use frequently... at cocktail parties).

He said his past research was guided so minimal efforts yielded maximum exposure.

With this caption I'd say that he's continued to follow that dictum -- but I've also learned he's written a fiction book about malpractice, surely a lot of effort for a smaller audience than the New Yorker. The book is narrated from the perspective of the defendant, one Dr. Charles (but not that one)...

If the book is as funny as his caption, I'll happily count myself as a member of this smaller audience.

Timeless

By 4:15 AM, the bakers at Hot & Crusty are putting their fresh-baked muffins and croissants on the shelves. If I'm awake and at all hungry, I make a point of stopping by and picking something up.

Which I just did (they're delicious). I thanked the man behind the counter and wished him a good night.

"Good night? It's a brand new day, boss!"

And so it is. I used to be one of those annoying kids in school -- so enamored with the idea of being up past midnight -- that I'd interject every chance I could something like, "technically, it's already tomorrow."

But after these last few rotations through emergency, night and day have lost their special distinctiveness. It doesn't faze me anymore when patients present at wee hours, asking for a "checkup" or inquiring about their monthlong knee pain.

In the city that never sleeps, every moment marks a brand new day, for someone.