Overheard in a New York Comedy Club

The scene: a faded, half-filled comedy club, still clinging to its Seinfeld-era glory. A spotlight shines on a brick wall, a black painted wooden floor, and a lone microphone. A pathetic MC is trying to work the crowd.

MC: And how about these home defibrillators, huh?

The Crowd does not respond.

MC: I mean, do you really want Grandma shocking Grandpa? She can't even program a VCR!

Someone in the crowd chuckles softly, for a few seconds. Then, silence. A doctor, sitting amongst his fellow interns, raises his hand. The MC seizes upon the opportunity.

MC: You, sir?

Doctor: Yeah, so, those defibrillators detect whether it's okay to shock or not. The only thing people have to do is put the paddles on the chest and listen for instructions.

MC pauses for a moment, stunned. Thanks for interrupting my set!

Doctor: Just trying to help.

The MC introduces the next comic, and another teaching moment comes to a close.

Convergence

I have observed a striking correlation between blogging, interest in emergency medicine, and geocaching. First in myself, then Doc Shazam, and now Jaime Marks from the Differential went on a GPS hunt with her EM attending and a nurse.

OK, my n is 3. Still, it seems like these are naturally overlapping interests, and I can't offer an explanation why. It's worth noting, however, that none of these activities were possible until very recently.

Lightning in a Bottle

There is no better way to start your workweek than listening to "Bottle Rocket" by The Go! Team. It starts abruptly with a bright, heralding trumpets, crisp drums, a bouncy keyboard, and a fast-paced, almost indecipherable rap.

The first ninety seconds leave you breathless. Then, just when you think the song will start to get repetitive, the trumpets blare and give way to a most unexpected harmonica solo.

"This harmonica solo will not be topped," I thought, on first listen.

But then the cheerleaders started chanting, and I knew I was wrong.

I smiled all the way to work.

Reflecting Absence

Lately I've had the opportunity to spend some time in in northern New Jersey. Oddly enough, it's here where I've encountered the most raw emotion about 9-11. Maybe because it's the way the Manhattan skyline dominates the view here -- despite its own new construction, Jersey City and Hoboken are very much in New York's shadow. Or maybe it's because I'm working with EMT's, who have more than their share of stories from that terrible day.

Within a few minutes responding to a call near Liberty Park, or driving along the banks of the Hudson River, the tales come rushing forth: The paramedics they knew that died that day, the mutilated patients coming across the river on the ferry, the explosion in the WTC PATH station that nearly suffocated rescue workers across the tunnel.

While they're recounting these stories, their eyes invariably settle on a point above the southwest corner of lower Manhattan, where the twin towers once stood.

"As beautiful as the city looks tonight," one paramedic explains, "those towers, you have no idea how tall they were... They were bigger than everything."

In the late sixties and early seventies, Manhattan added 8-12 million cubic feet of office space to its skyline -- the equivalent of downtown Pittsburgh -- every year. Then, in 1973, the World Trade Center was dedicated, itself sporting over 13 million square feet.

So colossal, so incongruous with the genteel buildings around them, one could understand how some disapproved of the massive structures. Columnist George F. Will, calling the twin towers both hopeless and pointless, shared his objection to their aesthetic, in 1977:

"I have a recurring nightmare - if that is the word - in which two Concorde super-sonic airliners, one British and one French, slice the towers in half, a collision of modern achievements."

But the brash bulk of the buildings could also inspire. The WTC was a source of breathtaking photos and copycat architecture. A band even named itself "I am the World Trade Center" (their first album was released in July of 2001. Track 11 is called "September").

Stark, minimalist, utterly dwarfing everything around it, the twin towers were hard to get used to. But their absence is even harder to accept.

You can sense the loss when you look at the World Financial Center complex. The twin towers were originally at the edge of the island, but the dirt from the WTC excavation gave rise, in the mid-80's, to the World Financial Center buildings. Now those four buildings look like orphans, and in a sense, they are.

No view is as powerful to me, however, as the experience passing through the temporary WTC transit hub.

Making my way from the MTA to the PATH trains, along the vast concrete floor, I can see through the open air to Ground Zero to my left. The rebuilt WTC 7 is also visible to the west, and from this vantage point below, the protective metal plating along the base catches the sun, and doesn't look quite so repellent.

The bare station -- which will someday be home to one of Calatrava's sweeping white roofs -- is now decorated only with oversized arial photos of lower Manhattan, and large white banners featuring quotations about the city.

At first I thought the effect was Orwellian. But after a few trips among the energy and purpose of the commuters, the juxtaposition of the cheery signage with the bleak emptiness of Ground Zero, gives me a feeling of optimism I wouldn't have believed I could associate with this site.

My favorite banner bears an old quotation from journalist and author John Gunther. The banner ends before the third comma, but I find the complete quote to be entirely appropriate:

New York City, the incomparable, the brilliant star city of cities, the forty-ninth state, a law unto itself, the Cyclopean Paradox, the inferno with no-out-of bounds, the supreme expression of both the miseries and the splendors of contemporary civilization, the Macedonia of the United States. It meets the most severe test that may be applied to the definition of a metropolis: it stays up all night. But also it becomes a small town when it rains.

'Because the world is backward'

There's a masterful piece in today's New York Times about the Mini-Mental Status exam. Adapted from Bernard Cooper's book, it's the story of a doctor administering a battery of questions to an aging man, while his son looks on:

First she asked my father to tell her the date. I silently answered along. He got it right. I was off by a couple of days. I scooted my chair closer. Now I had something to prove. I felt as if my father and I were opponents on a quiz show.

"What state are we in?" "City?" "Hospital?" "Floor?"

Not until she whispered "Bernard" did I realize that I'd been muttering answers under my breath. But I was sure my father hadn't heard me. And anyway, I got them right. Dad, on the other hand, didn't know what floor we were on. But he probably would have known it was the third if he had been the one to push the elevator button instead of me. The mechanics of recall are delicate, so iffy and contingent.

My father lowered his head and laced his fingers together in his lap. He had the shamed, inward look of a man who knows he has blundered but doesn't know how.

"Mr. Cooper?" she asked. "Are you ready to continue?"

My father nodded. His head seemed heavy, as if with answers that would soon elude him.

"Spell 'world' backward," the doctor said.

"Why 'world'?" Dad asked, peering over his glasses.

Because the world is backward, I said to myself. Laws are repealed. Iron rusts. Logic unravels.

The trio continues processing the questions, only to get hung up by on a pen. Cooper captures the horror of forgetfulness, the absurdity of this test, and also its strange appeal.

These days I'm riding along with EMT's in ambulances. The crews are very efficient and well trained, and I've learned a lot about their jobs. To return the favor, I try to help out around the truck, or expand upon part of a patient's workup -- EKG interpretation, the differential for syncope, etc.

Just recently we were called for an assault on a young man, it turns out he was hit over the head by "some dude", at the bus station. He couldn't recall much about it, and had had a few drinks -- but there was something odd about his affect, on top of it. Aside from a small head laceration, his physical exam was unremarkable. But when the cops disclosed to us that the patient didn't know where he was, I launched into the Folstein (another name for the above-mentioned mini mental status exam).

The EMT's, and even the patient, were thrilled with the questions:

"Holy crap, doc!" one paramedic exclaimed. "I had the wrong date today."

"So I can say 'No ifs, ands, or buts', huh? Is grammar really that important?"

I sensed the test was not fulfilling its diagnostic usefulness. So I ditched the rest of the Folstein exam, and, egged on by my audience, went for broke:

"Okay, one last question. You know the expression, 'people in glass houses shouldn't throw stones' -- what does that mean to you?"

The group was stunned. Here was something not pondered in many bus stations. After a moment, the patient abstracted the meaning of the maxim.

The excitement faded, and the crew returned to their paperwork. Perhaps they had a new appreciation of how brain function can be assessed with a few simple questions. At the very least, they'd found a new diversion to challenge each other, and the patients they'd encounter that night.

A Bleat from The Bleat

Even Lileks gets the blues:

Well, I went off on a rant tonight; didn’t mean to, but it’s been building. I blame myself; I am feeling particularly small and useless these days. For God’s sake, my primary contribution to the world today was a 300-word piece on pretentious bath towels. Seventeen more years of this, then the gold watch? How exactly is it possible that I love my job, love my life, feel extraordinarily lucky and grateful, and still want to bang my head into the kitchen counter at night.

If you'd told me, a year ago, the size of our audience on Medgadget or Pre-Rounds, I wouldn't believe you. But sometimes, late at night, by the kitchen counter, it all seems like pretentious bath towels. Thank goodness for the privilege of my day job, for times like those and really for all times.

Completions and Connections

I'll always have a warm spot in my heart reserved for the Waitresses' Christmas Wrapping, the enduring tune that makes me smile every December (though it was inevitable that, this year, the Pogues' Fairytale of New York eclipsed Christmas Wrapping as my favorite holiday song.)

But I'm still impressed with what the Waitresses accomplished in their yuletide epic: they weave a complex tale of isolation and self-pity as a woman prepares her Christmas meal for one, interspersed with flashbacks to a yearlong, frustrated courtship. Yet the song is insanely upbeat, catchy, and singable -- remarkable qualities for any song, but more impressive when you consider it was one of the first mainstream proto-raps, written in 1981 (which makes the title a pun, always a plus in my book).

Christmas Wrapping also has the best sax part in any holiday song (except possibly Morphine's Sexy Christmas Baby Mine).

The finale involves a chance encounter that ties together multiple threads and leaves you optimistic for 1982 and beyond. The song takes on additional heft when you realize the singer, Patty Donahue, died of lung cancer just fifteen years later.

Perhaps because it's only played after Thanksgiving, the song never seems to get old. Or maybe it's beloved because it speaks to universal themes -- who among us hasn't endured a prolonged, punctuated courtship, only to have Christmas magic (or benevolent vacation scheduling) intervene?

Regardless, the lasting message of Christmas Wrapping is: this is no time to be alone. Here's hoping we can all be with friends and loved ones this season.

Escape from Manhattan

Last year I learned that, during the holidays, leaving New York's never easy. This year, it's downright difficult.

The significance of the strike was made clear to me today, while I, the intern, was griping about waiting in the cold for a hopsital shuttle that was running late.

A cardiology fellow was standing with me. He'd begun his commute well before me, and had budgeted the entire afternoon to get to the hospital.

"Why so much time? I think they'll understand if you're running late," I offered.

"If anyone has an ST-elevation MI tonight, and I'm not there..." His words trailed off.

We both stared down the avenue, searching for a sign of the approaching shuttle bus.

Conversion

It looked like it was going to be a bad call on pediatrics. Signout was full of new, borderline admissions -- asthma exacerbations that were already improved, a rule-out sepsis or two with the mildest of fevers. Plus, we got word that two more RSV's were heading up to the floor.

On rounds we learned that the patients slated for discharge didn't want to leave -- or at least, the parents didn't want them to. I caught a mom feeding her (supposedly NPO) baby, then complain of his vomiting, five minutes later.

I was quickly becoming as cranky as some of the infants.

As the day wore on, though, the work got done. The new admissions were straightforward, the language barriers were easily surmounted. I still felt like a cog in a vast, inefficient machine, but at least we were moving forward.

When an opportunity for sleep presented itself in the evening, I took it. As I drifted off, I recalled an episode from morning conference, earlier in the week:

One of the residents has presented a potentially interesting case of progressive lower extremity weakness in a twelve year old girl -- the differential included Guillian-Barre syndrome and cord compression. Workup had been negative, and when it came time to do electromyography, the kid fought off the needles -- vigorously. She had been faking it, for days.

We then discussed conversion disorder vs. factitious disorder, a psychiatry consult was decided upon, and it was my turn to present a case. I had a two month old with cough that just wouldn't quit. At the top of my differential, I jokingly put "malingering." Everyone laughed, but I remembered thinking that such a remark a few wouldn't have occurred to me, a few months ago. Floor medicine was jading me, far more than any experiences in the emergency room.

Sleep that night was fair enough -- just one call to the floor (the NPO baby had somehow managed to spit up milk again). At around midnight, my resident woke me.

"A new admission?" I asked.

"Actually," she replied, "kind of the opposite." The pediatric emergency department was swamped, and the attending was requesting another set of hands. My resident, like any good resident, was protective of her call intern, but knew I was in EM and might agree to it.

"Sure," I said.

And so I went down to the peds ED, which was indeed busy. I only saw a few patients; just enough for the attending to get a handle on the situation. But in that short time, I got away from those perfunctory floor exams and took real histories, real physicals, and made real decisions on the info I'd collected. I reassured some nervous parents, made a few kids smile, and generally felt like I was making a difference.

It's been months since I've been assigned to the emergency department, and it will be months until I'm formally back. But this little midnight ED stint was more refreshing to me than any sleep -- making my last call for 2005 my best.

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?