Master of the House

Emergency Medicine programs have the most "off-service" rotations of any specialty, and emergency departments feature the most rotators from other specialties.

So it was not unusual for me, an EM resident rotating through Surgery, to receive a emergency consult from a medicine resident, rotating in the ED:

"An elderly man fell and broke his hip. Pain's under control, vitals stable, ortho will see him -- but what concerns me is his giant inguinal hernia. His scrotum is the size of a volleyball."

I came down to the ED to evaluate the hernia. It was indeed large, but nontender. The patient was too demented to tell me much about it, but a family member showed up and informed me he'd had the hernia for many years. Furthermore, he had no trouble eating, voiding, or ambulating.

As I presented the case to the surgery chief, he interrupted me and said, "This seems like an inappropriate consult. Who called it in? One of your colleagues?"

"Well, actually, a medicine resident."

The surgeon shook his head and said, "Loss of domain."

"Excuse me?" I asked.

"When that much bowel has relocated outside the abdomen, for so long, it'll never go back. It's called loss of domain."

"Oh, ok" I said. "I thought you were referring to the difficulty emergency programs have ensuring consistency, with so many rotators coming and going."

"Well, that too."

The Noise Made By People

My first thought upon reading this New York Times piece was, "Thank goodness Dan didn't film me in Mr. Palumbo's study hall."

Schoolyard scraps, spectacular skateboard spills, puppy-love quarrels, goofy antics like placing a slice of American cheese over the face of a snoring buddy, and bruising stunts like hurling one's body through a neighbor's wooden fence — these and other staples of suburban teenage life have taken on a new dimension as online cinéma vérité. Instead of being whispered about among friends and then fading away, such rites of ridiculousness are now routinely captured on video and posted on the Internet for worldwide perusal, and posterity.

"Teens have been doing inappropriate things for a long time, but now they think they can become celebrities by doing it," said Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Schneider Children’s Hospital at Long Island Jewish Medical Center.

"In the past, you’d brag to your friends in the locker room about doing something stupid or crazy or daring," Dr. Adesman said. "Now the Internet provides additional motivation. But these things can just as easily lead to criminal prosecution as broad celebrity."

Then I had another thought: Someday, a mangled teen will roll into my ED, we'll ask ourselves, "How did this happen?" ...

...and then EMS will give me a URL.