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.

Completions and Connections Left from Last Year

Ah, New Year's. Resolutions are being made, abstract deadlines are pending. The senior residents are interviewing for jobs, medical students are touring through our ED. Yes, there's ambition in the air, and I'm certainly doing my part -- committing to new projects at a dizzying rate.

But that's not to say old projects will wither! In fact, I've been meaning to point out two entries to my recent Grand Rounds edition that somehow ended up on the cutting room floor (I blame the egg nog).

The first is actually a trio of posts from my closest blogging consigliere (at least, geographically). New York nephrologist Dr. Joshua Schwimmer compiles KidneyNotes, his helpful collection of useful links and news clippings, punctuated by some striking photos. He has an extensive list of medical podcasts, for those of us who got iPods for the holidays.

But what he really wants to draw our attention to is a new tool he developed for Dissect Medicine, the medical version of the Digg popularity aggregator. Though still small (and in beta), Dissent Medicine could easily become a huge destination for medical news and opinions. Kinda like Grand Rounds, without the soul.

Another entry came from Dr. Ves Dimov at the Clinical Cases & Images Blog -- the leading blog for highlighting web practice resources. He sent in his impressions from the American Society of Nephrology (ASN) Renal Week 2006 -- which will go down in history as the first medical conference where data on medical blogging was presented. Unless we missed one already.

For the record: Pubmed now lists one article with the word "weblog" in the abstract, and 32 articles with the word "blog" (though four papers predate the Web 2.0 era, and include an author named "Blog" -- is that Swedish?)

If you're interested on the emerging impact of blogs in medicine (and who isn't?) here are a few noteworthy references: A blog for residents' dermatology education, PACS IT guys using a blog to good effect, and a neurologist in Japan using a blog to teach the public about epilepsy surgery.

Some people are already drawing conclusions and making recommendations:

Therefore, research should be conducted to determine the best ways to integrate these tools into existing e-Learning programmes for students, health professionals and patients, taking into account the different, but also overlapping, needs of these three audience classes and the opportunities of virtual collaboration between them. Of particular importance is research into novel integrative applications, to serve as the "glue" to bind the different forms of Web-based collaborationware synergistically in order to provide a coherent wholesome learning experience.

The wheels, they are turning.

Grand Rounds 3.14

Welcome to Grand Rounds, the collection of the best posts in medical blogging!

Grand Rounds has come a long way since the last time it was hosted here. By my count, eighty-nine unique bloggers have hosted 118 editions. This includes doctors, nurses, students, patients, administrators, analysts, entrepreneurs... with the occasional doula or transplant coordinator or epidemiologist thrown in, for good measure.

Many bloggers have changed over this period – I've lost track of all the births and graduations, but can't forget some of the trials and disasters some fellow bloggers have endured. Others slowly changed focus of their writing – from medicine to political commentary, or from work musings to home life. Some have merely changed their web address (eleven, by my count, with the lion's share jumping to SEED's scienceblogs family).

Twenty-nine bloggers have hosted Grand Rounds more than once, including ten of the first twelve hosts. But, in this time of year-end reflection, I'm thinking about the nine bloggers that seem to have stopped writing online altogether –- Galen, Shrinkette, Code Blue Blog, 'Doctor' from Chronicles of a Medical Madhouse, Mudfud, Iatremia, Red State Moron, Dr. Andy, and Geeknurse. Some have archives available for your perusal and fond recollection. Some, sadly, are gone. A few appear to be overwritten (does typepad recycle?).

Hopefully, our missing colleagues all doing ok. Bloggers talk to each other enough, reading and commenting on posts so frequently, that when one of them disappears, it feels like we're losing a friend.

But, with internet anonymity being what it is, it's conceivable these writers have surfaced on other sites, and we just don't know it. Or, they're just waiting for a time where their schedule permits more public reflection.

It's like they say: Great blogs don't die, they just... go on hiatus, and re-emerge with newfound resolve and a burst of creativity. This year, we witnessed the comebacks of Medpundit, The Blog That Ate Manhattan, Dr. Dork, Doc Around The Clock, and Intueri. They had their reasons for taking a break, but we're delighted to have them back -- even as the medical blogging world continues to grow...

This week, the final edition of 2006, I asked bloggers to submit their best work of the year. Some have undoubtedly been improving their writing week by week, so their best post is simply their latest. Others looked to posts that were the most fun to write, or generated the most comments. Some bloggers let me decide! Now, it's your turn -- see what you think. I've loosely organized the posts into the following categories:

Medical News and Commentary

Bloggers are renowned for their abilities to comment on the news (often, in pajamas) but on a few memorable occasions, bloggers can report news, too. Such is the case with Dr. Steven Palter of Doc in the Machine, who announced his award-winning endometrial diagnosis technology on his blog. It's part of a series Dr. Palter has written, on the radical transformation of surgery.

Mighty GruntDoc, probably the most consistent contributor to Grand Rounds and current favorite to reach Four-Time Host status first, submits this analysis of a case where law and medicine collided in the ED.

The blogger On The Wards digs deeper into an intriguing new finding on obesity -- are certain bacteria responsible for making you fat?

A new blogger on the scene, Sandy Szwarc, whose blog Junk Food Science argues from the perpective of enjoying food and accepting body shapes, pokes holes in recent reporting on the obesity epidemic.

It's getting cold outside -- and outdoor enthusiasts are paying the price. Healthline writer Dr. P.S. Auerbach provides a timely primer on hypothermia.

What if our insurance companies could provide us with "Nutrition Facts"-style info on basic surgeries and diseases? Henry Stern of InsureBlog interviewed the Chief Innovation Officer at Blue Cross Minenesota, to learn about this new initiative in health care transparency.

Reflections on the Job

Frustrated in dealing with the radiology department? The Not Dead Dinosaur coins the term Rad Rage after weeks of trying to get an x-ray properly interpreted.

Old-school blogger Dr. Anjali Taneja of To The Teeth wrote me a nice note, promoting the work of her colleague Andru Ziwasimon, who asks a simple question: Why do we cut the cord immediately after birth?

Faithful GR contributor (and two-time 2006 host) Kim, from Emergiblog, recalls giving a needy patient shelter from the storm.

Dr. G.C. George, of Odysseys of George, once wrote that being included in a recent Grand Rounds made his day. That's high praise, because shortly afterward he described this day, which captures the sheer joy this surgeon feels at work.

Speaking of a surgeon on a strange trip, Dr. Jon-Mikel Inarritu-Castro of Unbounded Medicine wrote about his most memorable patient this year: The guy who woke up with an arm... somewhere else.

Integrating what we learn in the classroom to what we see with patients is one of the trickiest parts of medicine. Dr. Signout notes that it's even trickier when the patients aren't in the hospital, but rather, encountered along the side of the road.

Geena from CodeBlog, who provided us with a memorable singalong before getting distracted this year, relates the tale of a patient with a rapidly expanding bust size.

A young resident physician, Dr. Couz, ponders a taboo subject, and precisely why patients and physicians choose to ignore it in their encounters.

Influences

Who doesn't love a year-end Top Ten list? At one point, I was thinking about compiling a few such lists here, like Dr. Charles once did... But Yan Minis has submitted such an audacious Top Ten, it may put to rest all future medical lists: The Top Ten Health Practitioners of All Time.

Medical Student Jeffrey Leow over in Melbourne writes about a role model that he hopes will influence his future practice of medicine.

The Other Side

One of the best parts of Grand Rounds, I think, is hearing the patient perspective (in fact, before my time, hospital Grand Rounds used to actually involve patients.) In that spirit, the award-winning blogger at DiabetesMine opened up the floodgates with her post, the Diabetic Partner Follies, which has "become host to hundreds of responses and astonishing emotional catharsis."

What if your medication changed size, shape and color, but everyone pretended it was the same? Rachel of Tales of My Thirties writes on one of the few times generic switches are risky with her thyroid pill switch.

Ever think about what it's like to wear a Holter monitor? Find out, when Dr. Dork becomes a patient (but remains, thankfully, a lovable dork).

Just in time for the New Year (okay, a week early) -- one of the contributors to Chronic Babe shares some tips on finding the right doctor for your individual needs.

When life gave her lemons, she wrote Lemonade Life. Allison Blass shares her frustrations on being a role model and poster child for diabetes, all while struggling with its physical demands.

A pastoral care volunteer writing at Barefoot in the Snow warns that doctors need more counseling than they're getting. She should know -- she stirringly describes of what it's like to be the frightened patient.

Urostream's blogging urologist, KeaGirl, sends in a fascinating post about the Jehovah's Witness dilemma before elective surgery -- it gets more enlightening in the comment section, when a Jehovah's Witness writes to clarify the specifics of their beliefs.

The Persistence of Memory

Most bloggers are writing from a safe distance from the Iraq warzone. But as the psychiatrist Maria from Intueri.org vividly demonstrates, the front lines are everywhere when soldiers come home.

Rita, the credentialer of the medical blogosphere, shared the value of compassion in her interactions with PTSD patients. Writing at MSSP Nexus, she learned Sometimes people act irrationally for very rational reasons.

At a funeral, a parent asks Neonatal Doc about advances in NICU care. It's a conversation prompted by an unforgettable loss.

Poet's Corner

Susan Palwick is a poet and novelist writing at Rickety Contrivances of Doing Good. She's started a series of poems based on her work as a volunteer chaplain in an emergency department. (check the sidebar for more).

A beloved blogger from down under offers a harrowing depiction of psychotic depression.

Levity

Maybe it's the season, but two blogging surgeons known for their cutting remarks and dour temperment submitted some funny stories this week:

Sidney Schwab was called into the OR for a obese patient in a curious predicament...

... and Aggravated DocSurg, waxing nostalgic, tries to explain that chemotherapy is a lot like a TV show or method of mass transit.

A senior cardiologist and colleague of Dr. Wes reflects on end-of-life issues. It actually makes a lot of sense.

Dr. Anonymous is upset about me being named Time magazine's Person of the Year (and here I was, thinking you were the choice). He proposes something else -- something that can be part of us, and yet, is distinctly not us...

Well, this was a busy week... but it's been a thrill hosting again, and reconnecting with this far-flung community for the end of the year. If you have any memories of these bloggers or others I may have missed, please share them in the comments!

Next week, Musings of a Distractible Mind will ring in the first Grand Rounds of 2007!

Grand Rounds Comes to Blogborygmi 12/26/06

Hey, everyone -- I'll be hosting Grand Rounds next week!

Some of you are probably asking, "Why?" Or more pointedly, "Are you still blogging?"

Yeah, I've got some explaining to do: I wanted to give my editors at Medscape a break -- Christine Weibe and Susan Yox have brought coherence to my disjointed interviewing style, every week for the last thirteen months, without reprieve. Their ideas and enthusiasm have helped Grand Rounds in innumerable ways -- and they deserve recognition and relaxation.

Plus, I've gathered data from several years, several sites, and it's pretty clear that fewer people read medical blogs around the holidays.

So, no Pre-Rounds spotlight next week -- no eager new blogger or grizzled, esteemed vet to take the center stage. It just wouldn't be fair.

And yet, canceling Grand Rounds seems unnecessarily drastic -- especially at the end of the year, a time for reflection and "best-of" lists. Plus, it would totally ruin the numbering scheme.

So I'll host! Yay. Send me an email -- with the url and description -- of your best posts of the year to nick /at/ blogborygmi.com . Submissions are due Christmas morning (Eastern Daylight Time).

I'm also looking for links, posts or remembrances from blogs and bloggers that 'retired' in 2006.

Thanks!

Flattened

It's some combination of sound and sensation. It starts in the middle of the workday, and lurks in the back of my mind as I make my way through the ED. My pace isn't quite the same; my balance is ever-so-slightly off.

The unsettling feeling gains traction on the commute home -- spilling into conscious thought the moment I walk through the door, into the quiet, familiar apartment.

Yes, there is definitely something stuck to the bottom of my shoe.

Before I even look, I'm performing damage assessment: how bad can it be? I've only taken a few steps in my kitchen...

Fear and loathing give way to surprise and recognition -- I've never expected to find something pleasant under my shoe, but today I saw a sticky pad from an EKG lead, nestled near the heel of sole.

I pulled it off and speculated on when we first came together. Was it at the bedside of the bradycardic woman? Maybe during the central line? The lead pad reminded me of some interesting patients, some memorable rhythms.

I threw it out. And then I washed my hands.

Selection Bias

The bulletin boards of every major hospital I've worked in are bombarded by signs of variable quality, soliciting research subjects or volunteers. Passers-by are asked to call a phone number if they fit within a certain demographic, take a certain drug, or engage in a certain behavior.

Where I went to medical school, the research solicitations were amateurish and fun. For whatever reason, investigators at that hospital were performing a lot of research with alcohol (on, with, and for)... Signs were frequently up, in bright neon colors, asking for young men and women to drink alcohol and give blood (for an immunoassay), drink alcohol and enter a driving simulator, drink alcohol and take a quiz. I have many fond memories of being paid to drink -- doing my part for science.

Now, I notice in some hospitals where I work, the ads are a little more slickly produced, but the 'image' conveyed to me is not exactly upbeat. Investigators are looking for patients with refractory depression, or active genital herpes, or WTC responders with respiratory problems.

When I see that many of the contact-stubs have been torn off of these solicitations, it prompts a different reaction than when the "drinking quiz" was recruiting.

Of course, I'm glad research on these diseases is being conducted. It gives hope, for both the volunteers and all patients.

Maybe the ED is warping my perspective on illness. Since I don't spend much time in clinics anymore, it's hard to remember what patients look like when they're not having an acute infection, or flareup of some chronic condition.

When all the tabs are ripped off the posters, it hits home that there are sick people everywhere, making their way, just walking around me in the lobby, by the bulletin boards.

And that's when I really wish for another alcohol study...

Champagne for Saline

Via Grahamazon (and yes, it makes me nostalgic when I start a post like that) comes this rich tale of a doctor who subbed saline for spinal fluid:

A former emergency room doctor fired for sending saline rather than spinal fluid to a laboratory was reprimanded for that incident Tuesday by the Maine Board of Licensure in Medicine.

Dr. Cesar O. Garcia, who had lived in Hampden while working at MaineGeneral Medical Center in Waterville and Augusta, was fired by the hospital in July 2004, shortly after the mistake was discovered.

I'm intrigued by this story -- because I think this subterfuge has crossed every ED doc's mind at some point. When you're confronted with tapping a morbidly obese patient, with poor landmarks and a low threshold for pain, for instance -- or an insanely busy shift where a patients' "worst headache ever" got better with one tylenol...

Fortunately, no harm was done to the patient. But really, I don't understand how this doc thought he could get away with this, to begin with. Sure, sending saline could reassure the patient that there's no excess of blood cells in the CSF, no bacteria... but can anyone get around ordering glucose and protein, things that saline might lack? Wouldn't the chloride level be off?

Answers To...

Names that patients, nurses, colleagues and superiors have used to get my attention in recent days:

Doctor

Doc

Doc-torrr (en espanol)

Doctor Nick

Doctor Genes

Doctor Gens

Doctor Gee-nes (hard g, one syllable or two)

Doctor G

Genes

Jean

Nick

Nicky

Nick-o

Papi

And maybe a few others I'm forgetting now. Now that I think about it, that last one seems to work the best.

Time Out of Mind

The last couple of months have featured some difficult work scheduling, bookended by some ambitious travel plans. Occasionally, usually on a bus or train or plane, I would jot down what I figured was a blogworthy observation or two. Many of these made little sense upon review, but I've transcribed a few disjointed thoughts below for your perusal.

Cabin pressurization is seemingly balanced by passenger decompression. This was made clear to me upon boarding a recent flight to Europe -- after an endless ED shift, frantic packing, and stressful journey to the gate. I settled into my seat and fussed with my carry-on as the pilot began to speak to the crew, in his crisp, proud, and utterly unintelligible German:

"Begrüßen Sie an Bord, ist dieses Füllermaterial, weil es dieser Verfasser könnte verstehen was ich sagte, und zweifellos nahm nicht Anmerkungen unmöglich ist. Mindestens, nicht bis später. Der Film auf dieser Reise ist ... Akeelah..."

Wait, what was that last thing he said?

"...And the Bee."

Of course. I had a chuckle at this, and a few of my fellow passengers were amused, as well. There would be more hurdles to cross after landing, but for now we could relax a little.

People who have been fated to sit next to me in recent weeks include: a former navy pilot-turned-Hitachi VP; a dancer; a preternaturally aged schoolteacher who coldly graded essays with a red, red pen; and the obese, hairy, loudmouth lawyer who turned out to be a pro wrestler, on the side (he played the heel, naturally).

My decidedly undemocratic survey of our conversations suggests the vast majority of travelers are leading rich lives. And we did't even fly first class.

I'm editing a pre-rounds in transit, and marveling at just how much some people care about their blogs. They speak of addictions, of loving maintenance. Meanwhile, I contemplate my bimonthly posting regimen, and cast a wary eye at blogborygmi's ghost-town blogroll -- a tumbleweed-strewn replica of the medblogosphere circa fall '04.

I do love blogborygmi, of course, but in the same way I'm fond of that old buddy from school, who taught me how to approach girls. He was really valuable to me at one time, helped me out a lot, but circumstances intervened and new we're just not so close. Every now and then I think of him, and give him a call, but if we stay on the phone too long it just reminds me of all the new priorities and obligations that occupy my time.

No matter where you go these days, you may encounter someone asking for money for martial arts lessons, because ninjas killed his father. Either there's an underreported patricidal ninja epidemic, or the nation's panhandlers are cribbing Overheard in New York.

Forgive me, seasoned poker players, but isn't emergency medicine a little bit like no-limit hold 'em? The way doctors and patients size each other up, try to read each others' hands. Even so, most hands are straightforward -- you know how it'll unfold from the flop. Other times, you have to wait for labs to come back, there are raises and calls. But no matter how benign the situation might start out, you never really know which patient is going to take you "all in."

On my flight to the ACEP conference in New Orleans: I counted six residents and five attendings -- and that was just from the few programs in the city I'm familiar with. Should a passenger experience a medical emergency en route, he or she could do worse than to pick a flight packed with emergency physicians.

Transitioning from a high-acuity shift in a New York City ED to a tourist in New Orleans -- in the space of twelve hours -- is pretty much the most profound change of pace I've experienced. I recall being miffed that the folks on escalators in New Orleans don't spontaneously organize into standing and walking lanes, like they do in New York. But I knew I was having trouble adjusting to the laid-back lifestyle when I consumed a po' boy in less time than it took to make it.

Many friends asked me for some reportage on how New Orleans has changed. Well, before this week, my last trip there was for the millennium (coincidentally, my fellow resident and current hotel roommate was also present for that party). On the shuttle ride from the airport into the city, I kept pointing to caved-in roofs, derelict poles and transmission lines, and asking if it was unrepaired storm damage. "No," a local would correct me, with a sigh. "That building was like that, before..."

The best recent commentary I've read on the city actually comes from today's Grand Rounds host, Dr. Michael Hebert, who writes:

And finally, from Douglas McCollam of Slate, we have this: "It's fair to ask why, in a city where vast swaths remain uninhabitable, all this money is being spent to fix a stadium. You won't hear that question in New Orleans . . . If they can fix the Dome up after all it endured, then perhaps other things can be fixed as well. Perhaps, after all, the city need not die."

This angst is real, the conflict between tragedy and frivolity. New Orleanians feel it too, just as they felt it before as they celebrated the first Mardi Gras after Katrina. But in this town, tragedy and frivolity have always walked hand in hand. Name another city where cemeteries are promoted as a major tourist attraction. Where its most famous holiday (Mardi Gras), a celebration devoted to excess and debauchery, is counter-levered against the most solemn religious period on the calendar, Lent, and on purpose. In New Orleans, the jazz funeral starts with a dirge and ends with a riotous party at the gravesite. We don’t sweat it here. Maybe because we ignore tragedy. Or maybe because we are so used to it that we understand that if you don’t dance at somebody’s grave there is nowhere to dance at all.

A town where tragedy and frivolity walk hand in hand... No wonder so many emergency medicine conferences are scheduled here -- it's a natural fit for our practice environment.

And, speaking of dancing at the gravesite, I've got a parade to get to...

Kicking Down the Cobblestones

In a city of fast walkers, I take some pride in being among the fastest. But lately, thanks to an adjustment in my train-hopping commute, I've come across some speedwalking that's startling to behold.

If you get on a Brooklyn-bound 6 train, about 2/3 of the way back, and get off at 59th street, you're let off onto a broad, dimly-lit platform that extends about a hundred feet. At the edge, there's a short staircase descending to the ancient N, R, and W trains.

Every weekday morning, between 6:30 and around 9, you'll see the 6 train's doors open, and dozens of snappily-dressed, well-coiffed men and women emerge. The smart ones will just break into a sprint, right there. The majority will speedwalk with a vigor and determination bordering on maniacal. A few pitiable souls will leisurely stroll out the train doors, only to be brutally elbowed aside by those determined not to miss the next ride to midtown.

The thundering of the speedwalkers' footfalls could easily be mistaken for the rumble of another train. The few children that witness this procession invariably begin to cry. I, too, was horrified and awestruck when I first took this route. But so often in this ambitious town, the transformation from surprised bystander to competitive participant is brief.

Interference pattern

I remember working in a lab during the summer of 1999, the summer between first and second year of med school. I was building a cDNA library and would occasionally have to show up in the middle of the night to check my colonies or adjust the broth.

Every time I went in, no matter how late, the lights were always on in the adjacent lab. The Mello Lab. The techs were always there, 'round the clock.

"What are those techs working on, over there?" I'd ask my labmates, at a more reasonable hour.

"RNA-i," they'd reply.

When the concept of RNAi was first explained to me, I remember feeling impressed and vaguely irritated. I had taken many bio courses in college (Mello's college, no less) and again in med school, and had learned nothing of this powerful, simple mechanism cells had developed for silencing specific genes.

I had already spent several years working on viral transduction, and had become jaded to the whole field of gene therapy, for research and for treatment.

RNAi sounded too good to be true. And the fact that it was discovered and fleshed out just fifty feet away from my humble cDNA library lent an air of unreality to the enterprise.

But Mello and his techs knew they were onto something, and they had the fortitude to see it through. Now the college textbooks have been rewritten, and Craig Mello has won the Nobel Prize for Medicine.

Let the Sun Shine In

Movies I have thoroughly enjoyed, featuring the word "Sunshine" in the title, in descending order:

1. Eternal Sunshine of the Spotless Mind
2. Little Miss Sunshine
3. Sunshine State

This is New York

I'd long ago concluded, mistakenly, that the emotional power of 9/11 lay in its capacity to make people relive the awful fear, confusion and loss in the days following the destruction.

At least, that's what had affected me most, in reading about the World Trade Center, or talking with responders. But five years out, the real impact and pain may not come from looking back, but in looking at us now. That was the resounding message of this week's New Yorker (the cover recounts Phillipe Petit's famous tightrope act between the towers -- now, he's literally walking on thin air) .

Roger Angell, who usually writes about baseball and boat trips, absolutely floored me with this brief piece, the end of which is excerpted below:

Those of us in our eighties or late seventies can still remember when this was called a young country (it was said all the time in school) and, if we lived in New York, retain the vision of earlier iconic towers—the Empire State, the Chanin Building, the George Washington Bridge—going up, week by week, to prove the point. The Depression and Pearl Harbor and Guadalcanal and Dachau and Hiroshima aged and toughened us, to be sure, but perhaps not as much as the History Channel would have it. In the early sixties — in our forties, that is — we suddenly cheered up when some historian noticed that the late, Massachusetts-born, white-mustachioed Supreme Court Justice Oliver Wendell Holmes, Jr., who had served on the bench into the nineteen-thirties, had in his long lifetime shaken hands with John Quincy Adams and also our new incumbent, John F. Kennedy. How young we were, after all!

None of us, no one in the world, holds such a notion today. Our United States feels as old as Tyre. Also anxious and bloodied; also short of sleep. What’s a shock, as this special September comes along, is that 9/11 is only five years back. Boys and girls born that spring and summer are entering kindergarten this year, and before they leave elementary school will have learned and tucked away the date in about the same place as Antietam and the typewriter and the Great Plague—that is, if they’re paying any attention at all. We worry about them, as elders do, but what we know about them that they don’t is that they are the older generation. Even while this ancient, inescapable irony dawns, we think back more often to a deceased parent or to a friend gone too early, to a favorite teacher or poet or departed doubles partner—anyone who died before September 11th—and wish ourselves that free again, and that young.

The New Yorker's architecture critic, Paul Goldberger, nails home the point with a little less poetry:

Amid all the squabbles and revisions, it’s unsurprising that so many people who once cared passionately about Ground Zero have simply lost track of the developments there and have stopped caring. This summer, the success of the first movies about 9/11, and acclaim for a clutch of important novels dealing with the subject, showed that the public is still hungry to make sense of the tragedy and what it means for America. But they are no longer looking to architects, contractors, and developers for answers. By the end of the day on September 11, 2001, it was clear that the terrorists’ act had enormous symbolic power in the eyes of the world, and, in the months that followed, a consensus arose that whatever happened at Ground Zero should make a powerful symbolic statement of our own—of the values that America, and New York, stand for. Five years after the terrorist attacks, the saddest thing about all the many absurdities surrounding the rebuilding—the personal wrangles and group rivalries that have obscured any sense of commonality, the pious statements masking an utter lack of conviction, the maxed-out budgets and cut corners — is that they may say a lot more about us than we’d like to think.

Indeed, browsing through the criticism and disappointment over the Freedom Tower, from the architects, students and fanboys over at Wired New York, has been instructive. The appeal of the original World Trade Center was not simply its boxy bulk, but the fact that this mass was duplicated. It commanded attention, even as you searched for an facet to focus on. The new 1WTC shirks that, instead seeming to superimpose the twins into one slightly taller but thinner building.

But today, the designs for World Trade Center Towers 2, 3, and 4 were unveiled. We already knew the site would feature the western hemisphere's tallest building -- now it looks like the site will have two additional towers to rival the height of the Empire State Building, and another tower as tall as the Citicorp. There are no twins, but rather, a very well-nourished set of siblings.

It's dizzying to think what downtown will look like in a few years, with four neighboring skyscrapers under construction. Comparing the scene to images from the twin towers' rise, it should be enough, I think, to make anyone feel young again.

Can You Hear Me Now?

I used to wonder why Gizmodo et al are always taking jabs at Verizon. To me, they've always been friendly, with good plans and coverage. Sure, Verizon disables some cool features thge manufacturers put on their phones, but that just makes hacking them more rewarding, right?

Then I got a text message from the company, noting that I hadn't visited my "Pix Place" (online repository of my camera phone pictures) in 150 days, and if I didn't log in within 30 days, all my pictures (approximately fifteen, in total) would be deleted.

Cheerful, huh? Because these blurry photos must be taking up about 200 kb on Verizon's servers, and clearly, a competitive company in a cutthroat industry can't afford to give out free memory...

Then, when checking my voicemail a few days later, I heard a disturbing new automated message. Instead of informing me I had my regular three saved messages, I learned I had "three saved messages, whose retention time is about to expire."

A confession: I saved some messages for a long time. One, for instance, dates back to when the Sox beat the Yankees in the 2004 ALCS, and a friend called me up and made some kind of drunken hooting noise that I thought was worthy of repeated listens. Every 21 days, Verizon would play the message to me and ask if I wanted to delete it, and I'd always smile and press no.

Well, I guess they'd had enough, or maybe Verizon is run by a Steinbrenner acolyte, because in a few days those treasured messages were erased.

I think someone at the Onion is also frustrated with this company:

Verizon Introduces New Charge-You-At-Whim Plan
August 21, 2006 | Issue 42•34

NEW YORK—Verizon Communications, Inc. announced a new service package for its wireless and residential customers that would charge them widely varying, but always high, fees every month depending how the communications giant feels at the time. "Our Charge-At-Whim packages offer the same mediocre quality and insufferable level of customer service you’ve come to expect," a Verizon spokesman said Tuesday. "But it adds an unjustified, arbitrary and, if you’ll allow us to boast, frankly unjustifiable method of determining just how much you’ll pay for them." Packages start at "oh, $69.99 a month, let’s say?" and went into effect about three or four months ago.

Feels about right.

Lost my Driving Wheel

I just concluded the best, hardest month of my residency thus far.

I've taken call many, many times before this, but never with the same potential for frenzied activity, 27 hours straight (24, for my readers on the Bell Commission). After the first few calls for the medicine ICU, I grew efficient enough to get in an hour or two of sleep. But, unlike floor medicine, where the overnight intern is awoken a dozen times for generally trivial concerns, all my pages in the ICU were genuine problems.

I performed more emergent intubations, more lines, more spinal taps, and about a thousandfold more ABG's than in any single rotation before this. Running a code no longer paralyzes me with fear. Most incredibly, from my perspective, was that I was making so many of these critical decisions.

Because of the crazed sleep schedule, in which I'd be unconscious for about 15 of my 21 free hours post-call, life outside the hospital became filled with malaise and dysphoria. My apartment has never been messier. So many obligations got punted to September -- relationships, phone calls, emails, workouts, blogging.

Nothing was getting done -- nothing was worth doing. I didn't get out much, and when I did, things seemed unbearably slow or purposeless. I never felt really alive until I was on call again. Isn't that a lark? Maybe I was so conscious of my agency because most of the people around me were heavily sedated.

I did call my parents a lot, often to thank them for happy childhood memories that would surface at odd times. This was likely prompted by the wrenching conversations I would have with families about their sick loved ones. Until now, too often, talking with families in the ED was been a chance to gather history and transcribe medication lists, or explain why someone is going to be admitted / discharged (when all the family wants is for them to be discharged / admitted). But this month had more than its share of conveying painful news, of asking families to make difficult decisions.

It's remarkable, how thoroughly and abruptly lives can be disrupted, how strong people are forced to be, at their most vulnerable.

I can see clearly now

If you want to simulate the development of visual cognition in newborns, take a course in ultrasonography. I remember when I was a med student, and a resident showed me my first blurry, shaky FAST images (focused assessment of sonography for trauma).

Resident: See that? That's Morrison's pouch, showing no free fluid between the kidney and liver.

Me: I think that's just static, and you're playing a trick on me. Can we adjust the image?

Resident: No, actually, see, this echogenic area is the renal pelvis...

Me: Really, just stop, you're not fooling anyone.

A few years later, and here I am, identifying venous thrombi and peri-pancreatic stranding, the common bile duct and the superior mesenteric artery. It's unbelievable what you can see in that static-y window. I especially like how, the better I get with ultrasound, the more it seems to help (compare that with sub-subspecialties like toxicology, where the effort of accumulating greater expertise finds diminishing returns for patient aid...)

Other observations:

In my surveys, whenever I apply the ultrasound probe over the male bladder, the men always crack a smile and ask me if they're pregnant. It never gets old. (The women, they don't ask out loud).

There is a striking correlation with EM ultrasound expertise and a past life as a disc jockey. In fact, it turns out I used to listen to one of my U/S mentors, on the radio. Different frequencies now, but same catchy appeal.