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

From 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.

Backlog

I've got a pile of old unpublished posts in various stages, and just promised a regular reader I'd be finishing them up soon. Until then, here's Lileks, on his new book Mommy Knows Worst:

It’s a compendium of archaic child-rearing advice, going back to the 1920s, when parents were urged to give their kids sunburns and linseed enemas. It’s perhaps the only book I will ever write that devotes a substantial chapter to the greatest problem of the 1940s: CONSTIPATION. You have no idea how slow the bowels of American children moved in the forties. Dads will enjoy how stupid and useless they were made to look in the 50s; Moms will enjoy the detailed how-to-give-birth-at-home section from the WW1 era, and everyone will love the 1960s pamphlet on dealing with home stresses via industrial tranquilizers. It’s the usual retro-fest with many ads, laden with unfair commentary, and attractively priced; perfect for everyone who’s ever had a kid or a mother. I think that covers it all.

I think Lileks is downplaying the size of the constipation crisis among infants of the 40's, and even today. If there's one thing I remember from medical school pediatrics, it's that constipation causes a surprising number of hospital visits (a second fact springs to mind: parents aren't often satisfied with the diagnosis of constipation).

Now that I think about it, I should buy this book in preparation for my peds month in December. One or two of those chapters may come in handy on the floors.

Decay

She came in with their teenage son to see him. She was about forty-five or fifty, with makeup and earrings and a nice blouse. I didn't recognize her at first -- she wasn't what I expected.

When my patient told me his ex-wife would be coming to visit, I simply imagined someone like him. I tried to picture his home; the squalor and decay that I associated with a pathology like his.

I overheard her at the front desk, asking, "Why can't anyone tell me where he is?"

I looked up from my charting and saw her. "I'm sorry," I answered. "I'm taking care of him. I spoke with your son on the phone. We just moved him to isolation -- it's right this way."

I led them to him and opened the door. Her face contorted and her posture stiffened, then she went inside. Their son followed.

I stayed outside, by the desk, writing my chart. I had a lot of questions I wanted to ask her, about his medical history, his alcoholism -- but it could wait until they were outside again.

I didn't want to go back in there.

She emerged a few minutes later, and took a moment to adjust her outfit and take a few deep breaths. She briskly walked toward me.

"When is he going to surgery?" she asked.

"Hopefully within the hour."

She thought carefully for a moment about her next question, and asked slowly, "What is that godawful smell in there?"

In a moment, I tried to imagine their divorce, maybe a few years ago, as his drinking got worse. Was there an ultimatum? A custody battle? In the end, maybe she felt she there was nothing more she could do -- so she took their son, and hoped that somehow her husband would turn it around, by himself.

He didn't, and now it had come to this: asking the emergency department intern about the smell.

I pursed my lips and looked into her eyes. "It's the foot," I said. "His right foot is just dead tissue."

Celebrity Skin

It's October, 2005, and I'm continuing to coast on all the writing I did last year.

A few days ago, the Wall Street Journal mentioned blogborygmi in a piece on medical blogs (reprinted here). It looks like the reporter read though some of my archives, which is really nice. But she listed me as anonymous -- maybe because I requested that my hospital affiliation not be disclosed. Or maybe she thought "Dr. Genes" was a pseudonym (though the last time I was quoted in the WSJ, my name was the topic).

I also was interviewed by Dr. Kent Bottles of SoundPractice.net, as part of his series on medical bloggers. It's really a wonderful thing he's doing, recording the thoughts of early medblogging pioneers like MedPundit and Dr. Centor -- I'm really honored to be listed among them.

A few hours after doing the interview, I sauntered into work, my head still a little big from the attention. Internship can be a long slog, and sometimes it gives me a warm fuzzy to know this medical blogging scene is taking off, and I'm a part of it.

One of the seniors greeted me excitedly.

Resident: "Nick! You just missed all the cameras! The network was here. Our attending is going to be on that makeover show! They just swooped in and took her away."

Me: "Really? Dr. B? But she's so..."

Resident: "Pretty? Yeah, but she felt she had kind of lapsed a little bit since she started here. Anyway, they filmed in the ED, they got a shot of all of us, I'm going to be on national TV!"

Me, smiling to myself: "That's really... great..."

I guess, despite all the progress, medblogging still has a ways to go.

Diamond in the Roughage

I often wondered which medical blogger would first make it onto Blogger.com's "Blogs of Note" first... would it be the news and views from mighty Medpundit? The rich examining-room tales of Dr. Charles? The heartbreak and introspection from The Cheerful Oncologist (you know, before he moved off blogspot).

As far as I can tell, none of these fine, erudite blogs have been featured. But this one is: Ah Yes, Medical School. Ah yes, they've chosen to spotlight the bawdy writing from a still-adolescent twentysomething male, preoccupied with breasts, poop jokes, and whining about work.

It's really funny.

It looks like he's labored without much recognition for years, before finally getting some attention this month. I wonder how many others are out there like him. Maybe now with google's blog search, it'll be possible to find more of these hidden sites.

Year Two is underway

First things first: Next week's Grand Rounds is being hosted by a medical student and Katrina evacuee, Neils Olson. The Tulane medical students are in the process of moving again -- from Texas A & M to Baylor for the rest of the semester. So do him a favor and get your submissions in early. His blog is called the Haversian Canal (a coincidence, I'm certain) and his email is haversian.canal -at- gmail.com

I must point out, one of Dr. Reider's major contributions to medblogging, besides practically strarting it, is the medlogs.com site. For the medbloggers who were peeved that GR was late this week, or they weren't included in the carnival -- try thinking of it this way: Jacob Reider has been linking to all of your posts, every day, for years.

Having said that, I expect Mr. Olson to be on time next week, hurricanes notwithstanding. (There are few things more certain than freshly-minted MDs demanding promptness and preparedness from medical students -- it's far more natural to us than, say, giving orders to nurses who've been working for a decade or two).

The City That Never Sleeps

There's nothing quite like the intense mood swings experienced during a night on call. The stress and fatigue, coupled with arbitrary setbacks and lucky breaks, can take me from dread to euphoria and back in a matter of minutes. And, as the night goes on, the likelihood of such swings rises...

And so I found myself on one call night last month, admitting patients and cross-covering the medical floors. Things finally quieted down at around 4 AM. My co-intern and I took the opportunity to follow-up on some radiology reports from earlier in the evening.

"Hey -- did the radiologist comment on Richardson's chest X-ray?" I asked, staring at the patient census, seated at the Team Room desk.

Jane, who was sitting at the computer, called up the report. "Yep, it's in here:"

"Portable chest X-ray, good inspiratory effort, the lungs are unremarkable with no infiltrates, effusion, or evidence of pneumothorax. The heart is within normal limits. New York is prominent and calcified."

I looked up from the lists. "What was that last part?"

"New York is prominent and calcified."

After we shared a few quizzical looks, we realized what had happened and started to smile, then giggle. Then came the full laughter, reserved for when the the absurdity of hospital work can't be denied any longer.

After about a minute, when our laughter subsided, Jane reasoned it out loud: "I guess the dictation machine interpreted 'aorta' as 'New York'..."

"Yeah, but..." The pendulum had swung, and I was getting serious again, maybe a little paranoid: "What if the dictation is right? What if this city really is..."

My words trailed off in the new, somber mood of the team room.

"It could be worse," Jane offered. "A lot of aortas are described as 'tortuous.'"

Snelgrove, Apres Mort

The Boston Globe is reporting the release of autopsy files and police documents surrounding the death of Victoria Snelgrove, a fan killed by a pepper-ball gun after the Red Sox beat the Yankees in the 2004 ALCS.

It's been nearly a year since this event, but we're finally moving closer to understanding how Snelgrove died -- and answering the questions incisively posed by Code Blue Blog immediately following the shooting.

In today's Globe:

...video evidence included with the transcript shows that Milien was the only officer in the vicinity with a pellet gun and that he fired two shots in quick succession in her direction, according to investigators.

Milien also said he had no idea that the FN303 pepper-pellet gun could kill someone. "Not in a million years," he said.

But the pepper-spray pellet pierced Snelgrove's left eye, opened a three-quarter-inch hole in the bone behind it, broke into nine pieces, and damaged the right side of her brain, according to an autopsy report. The 21-year-old Emerson College student was pronounced dead at 12:50 p.m. on Oct. 21, nearly 12 hours after she was shot.

The mainstream media is focusing on the police's judgment and use of force:

Conley announced last week that none of the officers will face criminal charges. On Friday, Police Commissioner Kathleen M. O'Toole demoted the overall commander that night, James M. Claiborne, from superintendent to captain; suspended two officers who shot fans; and issued written reprimands to two other officers who did not secure evidence after the shootings. Milien accepted a 45-day suspension without pay for using poor judgment and excessive force.

The Washington Post says the suspension is 90 days. The Boston Phoenix wonders why there isn't an inquiry into the coverup.

But I haven't seen an analysis of the mechanism of death. It's just facile for the Globe to say Snelgrove's skull had a hole, brain tissue was damaged, and she died twelve hours later -- there should be more, especially given the "nonlethal" billing of the pepperball gun, the literature on the these weapons, and what we know about traumatic brain injury.

CBB and I shared a spirited exchange on this subject last fall. His drew on his experience and knowledge of physiology. And some literature. I countered with my own lit review and some math.

We were the only ones asking these questions, let alone proposing answers.

Perhaps, from the public policy standpoint, the mechanism of death is now just an academic exercise. These "nonlethal" guns kill, and that ought to be the end of their use.

But the way Snelgrove died will undoubtedly come up in the Snelgrove's lawsuit against the makers of the FN-303 pepperball gun:

The letter sent to Falk by the Snelgroves' attorney, Patrick T. Jones, disputes that contention, saying that in its marketing material, FN Herstal suggested that the projectiles would break apart when they hit someone, which Jones argued led Boston police to believe the "projectiles are safe and contributed to an attitude by the shooters . . . that they could not cause any serious injury."

...After Snelgrove's death, the department pulled the weapons from service. Police Commissioner Kathleen M. O'Toole announced yesterday that the department will not use the guns again.

In his letter to FN Herstal, Jones alleges that the fact that pepper pellets fired from the guns penetrated the head of Snelgrove and two other victims proves that "fragmentation either does not always occur on impact or that the penetration of the skin can occur in some cases even with fragmentation."

..."As marketed, designed and sold, the product actually increased the likelihood of injury to innocent bystanders," Jones wrote. "As a result of these breaches, Victoria Snelgrove suffered severe injuries and death.

If the autopsy is, in fact, available, there might be some qualified medical reportage later week. We'll see -- in the meantime, eleven months have passed. Since Snelgrove's death, the FN303 has been barred from use by the Boston Police, and its future in US crowd control is very much in doubt.

Code Blue Blog's author, radiologist Thomas Boyle, MD, hasn't posted in five months. After the Snelgrove death, he went on to make increasingly bold but well-researched claims -- like that Ukrainian PM Yuschenko wasn't poisoned, or that Bill Clinton was sick. During the Terri Schiavo controversy, he criticized neurologists for over-interpreting individual head CT slices. Code Blue Blog became, briefly, the most heavily trafficked medical blog, and Boyle explained his views on TV and radio.

His conclusions and presentation style rubbed many the wrong way, but you had to do your homework before you disagreed with Code Blue Blog. And if reporters and interviewers took a cue from his pointed, reasonable questions, we'd enjoy a higher level of journalism in this country. Of all the voices in the media and blogosphere, his is one I'd like to listen to, again.