The Envelope, Please...

MedGadget has announced the 2005 Medical Weblog Awards, to considerable interest. There's even been some speculation as to how the awards ceremony will unfold.

Last year, I wondered if the show would run the show like other award telecasts:
I hope Dr. O goes all-out with this, Oscar-style: Excerpts from each nominee, Joan Rivers-style interviews, Lifetime Achievement awards, In Memoriam for defunct blogs... If he really wanted to, he could announce one winner every twenty minutes, dragging the proceedings well into the wee hours...

This year? We're in a position to make at least some of this happen. More details in the coming weeks...

"And the present is trivia, which I scribble down as notes."

There's a great scene in Memento where our afflicted protagonist, with only a short-term memory at his disposal, is trying to jot down a crucial clue revealed to him by the duplicitous Carrie-Anne Moss. He's looking around, frantically, for a pen and paper.

She knows his condition, walks out of the room and patiently waits. A few moments later, she abruptly returns to shatter his train of thought.

He forgets the important note and returns to baseline -- a mildly confused but otherwise blank slate.

I have moments like that, every night on call. Except, instead of Carrie-Anne Moss, the nemesis is a pager.

And instead of a single murder mystery clue, it's a half-dozen lab values or vital signs or abnormal physical exam findings.

And instead of just needing a pen and paper, it's also needing to find the right signout note, and a computer, and the getting the orders in, and the signout updated, before the pager goes off again.

But the frantic part? And the short-term memory? And the use of body parts? That's pretty much the same.

Grand Rounds: A New Partnership

This week's Grand Rounds is being hosted by Geena at Code Blog: Tales of a Nurse.

This week's collection of the best of the medical blogging is is notable for several reasons. Geena's now the first person to host three times, making her an odds-on favorite for the Five Timer's Club.

But, more importantly, this is the first edition of Grand Rounds to be promoted by Medscape.

That's right: the web's leading medical news corporation is getting involved with blogs, becoming the first major media site to sponsor a rotating carnival.

That they've chosen to do this speaks volumes of the high quality of writing on medical blogs, the efforts and creativity of each week's host, and the sophistication of our audience.

Medscape is performing a service to their readers, in linking to Grand Rounds each week. They're also doing a favor to the hosts of Grand Rounds, by sending them a new source of traffic: medical students, nurses, and doctors who are online, but haven't ventured into the world of blogs.

So, do Medscape a favor and check out their medicine resources, news alerts, and CME credit opportunities. It's a perfect match.

And, tune in next week when medical student Graham Walker hosts Grand Rounds, at his blog, Over My Med Body.

Sickness and Health

It was a Sunday morning shift, one of my first as an intern. I'd been out a little too late the night before, and hadn't had time to pick up coffee before the train to work. In other words, I was still a little bleary-eyed when I walked into the Emergency room.

And that's when I saw them.

Gracefully moving in long, flowing red satin gowns. They were ministering to the overflow patients lined up in the hallway. Beautiful women, four or five of them, with their hair done up and jewelry sparkling. The contrast between them and the bloodied, disheveled men in the stretchers could not be more striking.

One of the seniors noticed me, transfixed at the entrance.

I tried to address a question to him: "Did we hire... church volunteers... Sundays?"

"Nope," he replied. "Knife fight at a wedding last night. Those are the bridesmaids. The groom's in the trauma room -- hey, do you want to take a look at the best man's chin laceration?"

I considered the scene for another moment and said, "I do."

Genes for "Jeans for Genes"

I first learned about the Jeans-for-Genes charity when in London a few years ago. After the initial rush of long-supressed childhood taunts subsided, I thought it was a great idea. Now it's come stateside, in the form of a celebrity auction.

The idea is: celebrities sign a pair of jeans. You buy them. Proceeds go to the National Hemophilia Foundation -- "for all bleeding and clotting disorders."

I'm not sure if the celebrities have worn these jeans, or simply signed them. For that matter, I'm not sure how their wearing them would affect the jeans' value -- that's for the market to decide (my guess: used Tyra jeans would be worth more than, say, Jay Mohr's.) Bid on a pair and see for yourself.

I would stand in line for this

There is no doubt in my mind that the sharp siren sound the opens and loops through Moby's "Extreme Ways" is intended to evoke the charging and acceleration of an IRT train.

These trains have inspired other artists, in the past.

It's not a bad way to head off to work each morning.

A Tale of Two Calls

It was the best of calls, it was the worst of calls. It was a time of wisdom, it was a time of foolishness. It was a season of belief, it was a season of incredulity. It was the spring of hope, it was the winter of despair. We had straightforward admissions, we had lousy cross-coverage. In short, the resident slept soundly for six hours, the intern was busy with paperwork, hypotension, and desaturations all night.

When it was over, the next morning, the intern had prepped discharge paperwork for more than half of the admissions, with two more leaving against medical advice. The census would stay managable. And the cross-coverage patients had all survived.

They said of the intern, after the call that night, that it was the peacefullest man's face ever beheld there. Many added that he looked sublime and prophetic.

Some of the most remarkable sufferers of this same process have been allowed to write down the toughts that inspire them. If he had given any utterance to his thoughts that morning, they would have been these:

"It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to, than I have ever known."

-- Loosely adapted from Charles Dickens, A Tale of Two Cities.

Harmony in the ED

Look at the rightmost columnFrom the November 2005 issue of Annals of Emergency Medicine, by Goyal, Hollander and Gaieski at Penn:
"The Figure displays an underrecognized clinical phenomenon for which we are proposing the term 'synypnea.' Synypnea is seen across the country and is defined as when emergency department waiting room patients have the same respiratory rate. We think it is pathophysiologically linked to menstrual synchrony. There is little scientific exploration on this topic, however, which represents fertile grounds for original research."

This is too funny -- it exposes one of the more absurd aspects of a job full of unacknowledged absurdities.

Now, I'm too new at this to speak authoritatively on the historical perspective of respiratory vital sign reportage. My understanding is that, for decades, nurses would faithfully collect the blood pressure, heart rate, temperature, and would simply jot down "RR = 20" on patients that seemed to be breathing comfortably -- even though twenty inpsirations per minute qualifies as mild respiratory distress.

By the time I was a medical student on surgery, we was told to never present a patient "breathing comfortably at 20 respirations per minute" -- and that if we did, we'd be holding retraction for the rest of the month.

But since most patients had "20" listed on the vitals, and since actually collecting the vitals on our own was out of the question, the students had an internal debate: Normal was about 10-12. Some of the patients in pain were breathing at 16. What should we settle on?

It seems our compromise -- 14 respirations per minute -- has become the standard at teaching hospitals across the nation.

As for Hollander's interpretation of the phenomenon, I would drop the second "y", and call it synpnea (it's more true to the Greek roots). And I wonder if his linking this to menstrual synchrony was a subtle jibe at the nurses who collect the vitals?

Station to Station

It's November, and the interns are entrenched. The novelty of writing prescriptions and ordering tests has faded. It's dark when we go into the hospital, dark when we emerge.

And by now, interns have become fiercely loyal to our chosen specialties. Most of us have done a rotation or two in our fields, as well as a few off-service months. Hence, I'm hearing unsolicited comments like, "You're in emergency medicine? Here? That is so not for me. I can't understand how anyone could choose that."

I'm doing floor medicine this month, and while it's a tolerable experience, let me state for the record: It's not for me. The phone calls, the forms, the follow-up with consultants, the incessant paging... All for patients that I rarely even see. No thanks, I'll take my chaotic ED over that, any day of the week, two shifts on Sunday.

But I'm starting to understand how some people could enjoy floor medicine. I keep thinking back to a revealing experience during internship orientation, back in late June.

The hospital-wide orientation itself was a glimpse into the mind of Internal Medicine, since their residents dominate the incoming class. Granted, I wasn't expecting the bonding, team-building, and river-rafting experience of my medical school orientation, but I thought there would be an opportunity to make some friends and learn something useful.

And, sure enough, when I looked at the orientation schedule, I saw several fifteen-minute coffee breaks between lectures on "Filling out Death Certificates" and "How to Spot Suicidal Tendencies and Drug Abuse in Your Colleagues." (Oddly enough, I don't recall meeting anyone during those coffee breaks. I think we all stood quietly, by ourselves.)

At the end of orientation, there was the issue of certification. Hundreds of newly-minted doctors had to prove they were properly vaccinated, properly insured, properly credentialed, that they fit snugly into their white coats and N95 masks, and more. We had to observe up-close demonstrations of blood draws and line placement.

The process was set up in an alley off our hospital's vast lobby, in stations. After lectures got out, we'd visit each station, do whatever was required, and collect a sticker. When our sticker-sheet was complete, we could sign out and begin healing the sick.

Each station was a mob scene. No one's documentation was quite right, no one could understand how the butterfly needle retracted, and everyone could smell through the masks. Most stations were staffed by, shall we say, unsympathetic hospital administrators. At every juncture, there were barriers. The process seemed like it could stretch for hours.

Waiting in line at one station, I noticed a fellow intern's sticker sheet. She already had eight stickers, while I was still on number three or four. She would be done soon -- free to go home and unpack, or enjoy the city. I'd be cooped up in line on a sunny summer day for a good while longer.

We introduced ourselves. It turns out she was a Harvard grad, going into Internal Medicine. "How did you get all those stickers so fast?"

"I cut out of the last lecture early," she said. "Some of the stations were already set up."

"Oh, well," I remarked, "you missed an uplifting talk on persuading families to donate organs."

"That talk wasn't mandatory. This is."

And that orientation experience, to me, was appropriately representative of floor medicine: Obstacles everywhere. A long list of things to check off before you could go home. The patient, a distant abstraction.

I haven't seen that intern again, but I have no doubt that medicine is for her.

Post-call Postings

If I had the time or energy for another web-publishing venture, I think I'd organize a collection of all the post-call ramblings of interns and residents across the web.

I was talking about this recently with a prolific blogger. The moments after a call day represent a great opportunity for writing: the authors are either giddy or grouchy. They've spent the past 30-odd hours on the front lines of the human condition. Their judgement and motor coordination are equivalent to a BAC of 0.05.

It sounds like it'd be intriguing to read. But my own post-call rought drafts never seem as profound or emotionally charged, upon well-rested review. Maybe the readers would have to be post-call, as well.