In one of the emergency departments I work in, the clerk's desk is located near the exit and, shall we say, safely the front-lines of patient care. I sometimes remark to the clerks when they missed a really good case or interesting trauma, but they seem to be happy with their location.
Late one night, I was finishing some charting near the clerk's desk when a family of three came up to say goodbye. Their son had been in a car accident, in which he had lost consciousness. After a negative head CT, a benign exam and some pain medication, he was feeling fine and good to go.
As I wished them a farewell, I remembered an abrasion on the young man's left hand.
"Wait -- I've got just the thing for that," I said, reaching for my bacitracin, gauze and tape (the interns have well-stocked cargo pants).
I put the patient's hand on the clerk's desk and squirted some bacitracin onto the gauze. "Now you're finally getting a front-row seat" I told the clerk.
As I applied the dressing, the patient wobbled a little, and I noticed he seemed a little pale. "Everything ok?"
"uh......."
"Hey, ah, are you alright?"
The patient was staring off beyond my shoulder, with wide, wide pupils. He replied, in a monotone: "I can't see."
He stumbled a little bit and I caught him. "Why don't we get you back to your stretcher," I offered, with a cheeriness that rang utterly false. My mind was racing -- I haven't seen a fainting spell like this, could we have missed an epidural?
At that point, the father slumped to the floor. "My son... My son is blind."
Oh my God, they're dropping like flies.
My attending rushed over to catch him. The man was cold and clammy, similarly pale.
"No, sir, he's ok!" I was insistent. "We scanned his head. He's just... doing what you're doing."
We got the father-and-son team back to the stretchers, had them lie down for a bit, and gave them something to drink. They perked up in short order -- no hematomas, just... relational syncope.
When they felt ready to try again, I walked the family to the door, passing the clerk's desk. She (quietly) warned, "Dr. Genes, I've seen enough tonight."
As we passed through the waiting room, a question occurred to me: "Hey, who's driving?"
The father shot a glance at his son, who was shaking his head slowly. The mom chuckled to herself, as the family made their way out of the hospital.
Respirar Profundo
Songs with the word "breathe" in the title that I have enjoyed, listed in order of when I first heard them:
The newest addition to the list is Anna Nalick's Breathe (2 AM), which played during the climax of Grey's Anatomy tonight. The lyrics should appeal to bloggers, or at least, MySpace users.
Pink Floyd: Breathe in the Air
Prodigy: Breathe
Telepopmusik: Just Breathe
Sixpence None the Richer: Breathe Your Name (hey, cut me some slack, I'm omitting the entries from Maroon 5 and Faith Hill)
Science Dept (featuring Erire): Breathe
Sia: Breathe Me
The newest addition to the list is Anna Nalick's Breathe (2 AM), which played during the climax of Grey's Anatomy tonight. The lyrics should appeal to bloggers, or at least, MySpace users.
Prototypical
I found myself blathering at Medgadget the other day about the inefficiencies of chest pain admissions. It made me nostalgic for my first patient I saw as a newly-minted physician, one Saturday morning back in July.
After days of orientation, and then a half-hour shadowing a senior in the Emergency Room, learning about the translator phone, computerized order-entry, and the nurse's names, I was eager to begin.
There was one chart in the to-be-seen rack. I picked it up. The triage note declared CHEST PAIN as the chief complaint.
I put the chart back down. "Probably not a good teaching case," I thought, recalling my medical school ER rotations. "And the attending will want to make the decision to rule him out for MI, herself."
I was ready to wait for another chart when it struck me: I'm not a student anymore. And today was a good day to get re-acquainted with a symptom I'll be encountering daily, for the rest of my career.
And so, I saw my first patient. He was in his early 50's, was mildly hypertensive on no meds, quit smoking, with no other risk factors. He reported a vague pressure pain around his sternum for the past few days, on and off, unrelated to exertion or meals. Pretty normal EKG, with no older ones on file.
I poked, I prodded, I tried to get his story and exam to lean one way or another. But his diagnosis remained ambivalent.
So, with a deep breath to acknowledge this momentous occasion, I wrote my first order as a physician:
The rest of the cardiac workup followed. It seemed a little dramatic to me, ordering all this bloodwork and monitoring for what would likely be reflux or costochondritis.
I was knee-deep in other patients, an hour or so later, when the attending pulled me aside.
As I recall, the patient got cathed and did okay. And I haven't had much hesitation to rule out MI in the many, many ambiguous chest pain cases I've seen since.
After days of orientation, and then a half-hour shadowing a senior in the Emergency Room, learning about the translator phone, computerized order-entry, and the nurse's names, I was eager to begin.
There was one chart in the to-be-seen rack. I picked it up. The triage note declared CHEST PAIN as the chief complaint.
I put the chart back down. "Probably not a good teaching case," I thought, recalling my medical school ER rotations. "And the attending will want to make the decision to rule him out for MI, herself."
I was ready to wait for another chart when it struck me: I'm not a student anymore. And today was a good day to get re-acquainted with a symptom I'll be encountering daily, for the rest of my career.
And so, I saw my first patient. He was in his early 50's, was mildly hypertensive on no meds, quit smoking, with no other risk factors. He reported a vague pressure pain around his sternum for the past few days, on and off, unrelated to exertion or meals. Pretty normal EKG, with no older ones on file.
I poked, I prodded, I tried to get his story and exam to lean one way or another. But his diagnosis remained ambivalent.
So, with a deep breath to acknowledge this momentous occasion, I wrote my first order as a physician:
Aspirin 325 mg PO x1.
The rest of the cardiac workup followed. It seemed a little dramatic to me, ordering all this bloodwork and monitoring for what would likely be reflux or costochondritis.
I was knee-deep in other patients, an hour or so later, when the attending pulled me aside.
"That first patient you saw, the rule-out MI?"
"Yeah?"
"He's ruling in."
"Really?"
She smiled. "Good pickup. I guess this bodes well for your career."
As I recall, the patient got cathed and did okay. And I haven't had much hesitation to rule out MI in the many, many ambiguous chest pain cases I've seen since.
Blanketed
Yesterday, more snow fell in New York City than at any other time since record-keeping began. And I was working in the ER during the storm's peak hours.
Patient volume was down for a Sunday, but only a little. And, while we had some shoveling-induced chest pain toward the end of the day, the majority of patients I saw had the same routine complaints as any other day: Headache for a month, cough and sore throat for a week, and so on. Pretty remarkable, really. The only difference in my practice was my standard opener, which changed from:
to
New Yorkers are clearly resilient to external influences, but perhaps not as tough when their troubles arise from within.
Patient volume was down for a Sunday, but only a little. And, while we had some shoveling-induced chest pain toward the end of the day, the majority of patients I saw had the same routine complaints as any other day: Headache for a month, cough and sore throat for a week, and so on. Pretty remarkable, really. The only difference in my practice was my standard opener, which changed from:
What brings you in today?
to
What, in the name of all that is good and decent, brings you in today?
New Yorkers are clearly resilient to external influences, but perhaps not as tough when their troubles arise from within.
Acting Out
I've always considered rounding on the hospital floors to be one of the most unnatural of human interactions. The emergency medicine version -- signout -- is a far more efficient and humane process, where the new doctors coming on shift meet the patients, get a blurb about their history and workup, and learn what's pending before discharge or admission.
But, just like rounds can be a source of occasional amusement, so too can signout. The other day, a colleague was signing out a patient as follows:
"This 31 year old man was ped-struck at last night. Positive LOC according to EMS, EtOH on board, good vitals, A and O times three since arrival here. His head CT and C-Spine were negative."
"How about pain? wounds?" the receiving resident asked.
"Pain's under control, no lacs. He's got abrasions on his right ear and temple." Then she tapped her temple, for emphasis. Her expression was one of concentration -- she was recalling the man's initial presentation in the trauma room.
"His right elbow, too." As was said this, she clasped her right elbow. I looked over at my senior, who was starting to smile.
"Also a big abrasion across his abdomen," she continued, as she rubbed her belly. "And bilateral knees" -- at which point she bent down and grapsed her knees.
When the resident straightened herself up, she saw our team stiffling the giggles.
"Hey!" she offered, in good-natured protest. "It helps me remember..."
The attending started singing, Head, Shoulders, Knees and Toes, and we merrily made our way to the next patient...
But, just like rounds can be a source of occasional amusement, so too can signout. The other day, a colleague was signing out a patient as follows:
"This 31 year old man was ped-struck at last night. Positive LOC according to EMS, EtOH on board, good vitals, A and O times three since arrival here. His head CT and C-Spine were negative."
"How about pain? wounds?" the receiving resident asked.
"Pain's under control, no lacs. He's got abrasions on his right ear and temple." Then she tapped her temple, for emphasis. Her expression was one of concentration -- she was recalling the man's initial presentation in the trauma room.
"His right elbow, too." As was said this, she clasped her right elbow. I looked over at my senior, who was starting to smile.
"Also a big abrasion across his abdomen," she continued, as she rubbed her belly. "And bilateral knees" -- at which point she bent down and grapsed her knees.
When the resident straightened herself up, she saw our team stiffling the giggles.
"Hey!" she offered, in good-natured protest. "It helps me remember..."
The attending started singing, Head, Shoulders, Knees and Toes, and we merrily made our way to the next patient...
Unexpected Report
Recently, there's been a lot of traffic in the Emergency Department, and a lot of traffic in social departments, as well. So many new faces and challenging interactions -- much of it is very gratifying, but some of it stings and prompts second-guessing.
All that, combined with a bone-deep fatigue, unseasonable weather, and looming deadlines has led to a kind of constant, low-level paranoia I'm not accustomed to.
Maybe this is part of developing into a vigilant attending, or being a considerate person. Maybe I should lay off the coffee and get some sleep.
Either way, Haloscan informed me, just now, that a comment was made to this post from 2004. A few weeks ago I'd brush it off as a tasteless hoax or misguided plea. But considering my mindset these days, coming at the end of a long night (not to mention the subject matter), I must say: I'm a little creeped out.
(The comment counter says 0 for older posts, but trust me, there are comments. And the commenter's handle suggests he's got a sick sense of humor, or was actually there).
All that, combined with a bone-deep fatigue, unseasonable weather, and looming deadlines has led to a kind of constant, low-level paranoia I'm not accustomed to.
Maybe this is part of developing into a vigilant attending, or being a considerate person. Maybe I should lay off the coffee and get some sleep.
Either way, Haloscan informed me, just now, that a comment was made to this post from 2004. A few weeks ago I'd brush it off as a tasteless hoax or misguided plea. But considering my mindset these days, coming at the end of a long night (not to mention the subject matter), I must say: I'm a little creeped out.
(The comment counter says 0 for older posts, but trust me, there are comments. And the commenter's handle suggests he's got a sick sense of humor, or was actually there).
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.
The MC introduces the next comic, and another teaching moment comes to a close.
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.
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.
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.
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:
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:
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:
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:
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:
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.
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:
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.
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.
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.
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.
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:
This year? We're in a position to make at least some of this happen. More details in the coming weeks...
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.
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.
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