http://www.codeblog.com tales of a nurse (homepage) Thu, 01 Jul 2010 03:33:06 +0000 http://backend.userland.com/rss092 en Not so very long ago, I took care of a rather young patient in her 30's.  She had a respiratory illness that quite frankly baffled us.  We couldn't figure out exactly why someone so young and healthy was being completely knocked on her butt by a pneumonia. The illness progressed to the point where she required bipap to help her breathe.  This is a conforming mask that goes over the mouth and nose and gently (?) pushes oxygen into the patient's lungs.  It's considered non-invasive and is something we typically try before intubating patients.  Although most patients tolerate it fairly well, I know it's uncomfortable.  It can be difficult to put the mask on the patient and achieve a good seal so that no air escapes around the mask.  For this reason, we don't take it off very often - just to do mouth care, give meds, sometimes give a meal if the patient is up to eating.  Some patients can't even tolerate coming off the mask to eat more than a few bites of dinner. So my rather young patient was experiencing what it was like to have a bipap mask on to help her breathe.  I know in some ways it was giving her a break since she didn't have to work so hard to breathe, but in other ways it was pretty bothersome.  When I was getting report, the nurse told me that the last time they'd tried to take the mask off to give her a break she only lasted a few minutes before becoming short of breath again and dropping her oxygen sats. So it was with an inward sigh that I explained how breakfast would go.  I told her we could take the bipap mask off for her to eat, but that I wanted her to hold an oxygen mask over her nose and mouth between bites.  She readily agreed; I think she would have done almost anything to get the bipap off. Breakfast came and I got her all set up.  The respiratory therapist (RT) got the bipap machine off, and we gave her a regular oxygen mask.  I didn't have high hopes that she would last very long off the bipap and watched her very carefully from my desk across from her room. She was very good about using the plain oxygen mask between bites.  She lasted 5 minutes, then 10, then 15.... a half hour later she was still doing great just using the oxygen mask.  I was thrilled!   I went in and told her that she could just keep using the plain mask but to let me know immediately if she became short of breath.  I told her I'd be watching her oxygen sats and if they started falling, she would go back on the bipap immediately. To my complete and utter surprise, she lasted through lunch!  After lunch I could tell she was pooping out some, even though her sats were holding just above where I wanted them.  I told her I thought she should go back on bipap and rest over the afternoon.  She somewhat reluctantly agreed.  I was personally delighted with how long she lasted and told her and her parents that it was very encouraging that she did so well for so long. About 20 minutes later, I was sitting out at the desk when I saw the patient's mother come out looking a bit dejected.  I wondered if my patient was okay so as she walked by I asked if she needed anything.  She replied that she was just a little sad and I was genuinely curious as to why.  So I asked, of course. She replied that she had been so encouraged throughout the day while her daughter was off bipap, and now that she was back on it, it seemed like a step backwards.  It was her 30 year old baby sitting in that bed and she was very understandably worried about her. So while I was inwardly (and a bit outwardly!) cheering that my patient lasted a good part of the day without bipap, my patient's mother was very dismayed about the same event.  I tried to tell her that her daughter was doing great, better than I could have even hoped, and that seemed to mollify her a little.  It just never would have crossed my mind to be sad about the whole thing.  I'm glad she came to talk about it.  It definitely provided a different perspective. http://www.codeblog.com/archives/tales_from_the_ccu/perspectives.html My patient's daughter had been up all night in the ED with her mother and by now it was just after noon.  She was very tired.  Nonetheless, I needed to find her to ask an important question. I got to the waiting room and found approximately 10 family members, but not the daughter.  I asked where she was. "We aren't really sure." I thought this was a strange response.  Not only was she a nurse, but the person I wanted to speak with knew the patient best out of everyone there.  She just wasn't the kind of person who took off without telling anyone where she was going. "Ok... ?"  Then I just stared at them all, because sometimes that will elicit more of a response.  People don't like being stared at blankly. "The doctor told us that he took her somewhere to rest, but he said that we had to leave her alone, and he wouldn't tell us where he took her." Hearing "we think she ran off to join the circus" would have been only slightly more surprising. I went back to the nurse's station and related my story to some other nurses working with me that day.  We were all quite puzzled and just a tiny bit amused. As it happened, the doctor in question showed up at the desk and I told him that I had something important to discuss with the patient's daughter and would he mind, please, letting me know where he stashed her? He said he would not do that.  He said she was tired and stressed by her mother's condition and needed rest. Well, yeah, but I really needed to know if the patient had had the flu shot this season, lest I be reprimanded over not providing a complete admission record.  (Not really, but I did need to know something rather important.) He said she'd be there in a little while.  About half an hour later she appeared in her mother's room. Her family thanked me profusely for "finding her." http://www.codeblog.com/archives/tales_from_the_ccu/the-kidnapped-napper.html I received this email from a dear friend of mine recently: Hey everyone! So,  for the last 2 1/2 weeks my husband and I have been seranaded with alarm tones every day.  We thought it was the new alarm system we had installed (it does a lot of automatic things we have since disabled), then we thought it was the smoke detectors...a new ringtone on our iPhone?... the battery charger on his new bike...his computer when his e-mail was hijacked?...the battery on my bike mileage computer?...my new alarm clock?...the refrigerator ice maker?...the clothes dryer? ...everyday we checked everything, and everyday we thought we had found and fixed the culprit, until the next morning when we would hear it again! It was not until yesterday morning when we figured it out... can you guess? It was coming from my husband's chest!  The battery on his pacemaker/AICD was alarming to let us know that he was just about out of juice!  Four years ago they told us we would hear that when the battery got low, but that was a very long time ago...and it just didn't sound like it was coming from him!  We sent a modem transmission, and the doctor called back to say, "come on in!" After talking with my friend later, I found out that her husband had his pacemaker replaced and all is well.  It took about 2 weeks to figure out where the alarm was coming from, since it only sounded once a day and only for about 20 seconds at that.  My friend expressed disbelief that it was so hard to determine that it was coming from her husband but surmised that going through body tissues helped the sound disperse enough to make it a mystery! This left me wondering if any of Dr. Wes' patients have had similar trouble with figuring out that their chests were alarming! http://www.codeblog.com/archives/story_submission/the-case-of-the-mysterious-alarm.html My son accidentally ingested peanut butter yesterday.  He's allergic. He's done this once before, which is when we found out about the allergy.  He had some really awful hives 3 hours after he ate that small bite of peanut butter sandwich but that was all.  His allergist told me that it would most likely never get worse than that. He managed to eat some more yesterday.  I braced myself for the hives to come, and we dosed him with Benadryl.  An hour later he vomited.  The pediatrician's advice nurse advised me to take him to the ER.  At the time I thought it was overkill.  He wasn't having any breathing difficulties beyond the cough he already had (he has a cold).  He definitely wasn't acting quite right, though, so off we went. I barely made it down the street before he started having very long coughing fits.  He was breathing okay in between, but he just kept coughing so much.  He couldn't go more than 10 seconds without coughing.  About a mile from the hospital (this is probably 1 1/2 hours after ingestion) he started putting his fingers in his mouth but wouldn't tell me why.  Itchy tongue? It was the longest ride of my life.  Traffic, red lights.  Imagine being the 13th car at a red light when you have an emergency!  Of course there was no parking when I got to our nearest ER.  I hastily parked in a "reserved" space (sorry, director of geriatric services) and ran in.  Although the waiting room appeared to be full, there was no line at registration.  When I put him on the counter, I noticed that his lips were bluish.  I told the lady at registration and he was in triage within about 30 seconds. I was a little hesitant to come to this hospital.  About a year ago I had a panic attack, which I had never had before.   I had been hyperventilating for a couple of hours (due to a reason not related to the panic attack) and then it occurred to my CCU trained brain that hyperventilating for a few hours might be Very Bad for my serum pH level.  This made everything exponentially worse and I was immediately convinced that I was going to die.  Convinced. It didn't occur to me that debating whether my pH was above or below 7.1 might be indicative of the fact that I was most likely just fine.  I think if one's pH is really 7.1 they aren't debating much at all! So we went to the nearest ER late at night.  I was doubtful that I'd make it there alive, visions of ABG's being drawn and intubations happening... I was really scared and really quite irrational.  But my CCU brain was still there, feeding into it all, convincing me of all the bad things that could happen. When I got to triage, they could not have been less impressed with me.  A ho and a hum and a normal pulse ox later, I was thrown to the waiting room.  I'll admit that the normal oxygen level calmed me a bit but I was still hyperventilating for some reason and could not stop.  Already long story short:  Panic attack caused by hyperventilating caused by a probable reaction between two commonly prescribed drugs that I'd taken earlier for The Worst Headache Ever.  Whatever it was wore off, I calmed down, we went home. So I wasn't sure, running into that same ER with my son, how responsive they'd be.  I had nothing to worry about.  The triage nurse exuded a level of calm that blanketed over everything.  It wasn't an unconcerned or disinterested calm.  It was a "I've seen this before and know exactly what to do" calm. She handled my son (and me!) perfectly.  She wanted to put the pulse ox probe on his finger and told him that Elmo had been there the day before and had had the same sticker put on.  My son doesn't know very many cartoon characters, but he knows Elmo very well.  If she'd said Dora or Mickey Mouse or Barney, he wouldn't have had a clue what she was talking about.  But because Elmo had had it the day before, he finally reluctantly let me put his finger out. His pulse ox was 90, which is not very good.  Normal is about 95-100 on room air for a reasonably healthy person.  I told them it was an allergic reaction to peanuts and they got us back to a room so fast our heads spun.  When his oxygen level dropped to 85, once again my CCU trained brain had visions of Horrible Things happening, but it never came to that.  After some oxygen, Benadryl and IV steroids, he was back to almost normal.  The hives did show up 3 hours after ingestion on the dot, and they were uncomfortable but not as severe due to the meds he'd received. So being a highly trained RN is a bit of a double-edged sword when healthcare becomes personal.  On one hand I never needed to ask for clarification about what anyone was saying, and I had no trouble understanding the conversation between the doctor and nurse.  I knew the reason for and possible side effects of every medication they talked about giving him.  I knew what all the equipment was for and what the normal numbers were supposed to be. On the other hand, I knew exactly what they were talking about, I knew what everything was for and what normal numbers were supposed to be.  When I realized they weren't normal, I was pretty freaked out. I intuitively knew why we had to put an IV in, but couldn't help thinking about possible infection of the site and infiltration.  I wasn't worried about giving the Benadryl as he's had that several times in his life for various reasons, but the Solumedrol he needed?  That's a drug I've probably given a thousand times, and never have I seen a reaction from it.  But this was my son, and how was it going to affect him?  Did they know how to calcuate the dosage based on his weight?  Would there be a miscalculation while drawing it up? Everything turned out fine.  Everyone was professional and competent and knew just how to deal with a sick kid and his anxious mother.  Kiddo is completely back to normal today and is no worse for the wear from the whole experience. But now my complacency about peanut butter is gone.  The hives were certainly awful but not life threatening, so I hadn't really been overly concerned.  I've been careful, of course, as have those who watch him, but 3 year olds are 3 year olds and they are amazingly fast.  Now that I know it can affect his airway, I'm even more concerned about the times that he won't be in my direct control, especially when he starts to go to school.  I feel like I'm going to need to tattoo it on his forehead.  I think the public in general (and schools in particular) are more aware of allergies, which is a tiny bit comforting. He's also allergic to eggs, which I used to think was the bigger pain in the butt.  There's a lot more that he can't eat due to eggs than peanut butter, but his reaction to eggs is very minor comparatively.  I used to even think that if I had a choice, I'd rather he not be allergic to eggs. I've changed my mind. http://www.codeblog.com/archives/uncategorized/a-double-edged-sword.html When Beth found out that her husband had cancer, a friend suggested that she look into creating a page on CaringBridge.org.  As she puts it, "CaringBridge became a tool to help us communicate with others." I spoke with Sona Mehring last week, who is the owner of CaringBridge.  The site started as a simple webpage for a friend of Sona's who was going through a difficult pregnancy.  Sona and her friends used the site to keep friends and family informed of updates, keeping everyone in the loop without having to make several phone calls each day. Thus, CaringBridge was born.  Anyone with an illness or those who are taking care of someone with an illness can create their own webpage through the site to keep friends and family informed of the patient's progress.   It's free, there are no ads, and Beth states, "I appreciate its ease of use. It is an intuitive interface, so it didn't take much time at all to set up and use. I've never been frustrated using it!" Sona pointed out that using the site is beneficial to 3 different groups of people.  The patient stays connected to family and friends through updates.  Those who get updates can then sign a guestbook with questions or words of encouragement. The patient's main caregiver can also benefit from messages of support.  Being a primary caregiver can become very isolating as they become more and more involved with the patient's day to day care - traveling to appointments, trying to procure test results or helping out in the hospital.  The caregiver might also find comfort in being able to journal their feelings on the site. And the site can aid the community's ability to rally around the patient and caregiver.  Sona mentioned a study showing that contact with family and friends can decrease significantly when someone is diagnosed with a major illness.  One of the biggest reasons was that the patient's community did not want to "bother" the patient or caregiver.  This concept was not lost on Beth, who said, "I sense that some are eager to keep in the know, but do not want to feel like they are bothering me." CaringBridge not only connects patients with community; it also connects patients with other patients.  Sona explained that patients and families often meet others going through the same thing in waiting rooms or treatment rooms and swap CaringBridge websites, thereby forming a support group of sorts amongst themselves. Sona says that people come to use the site mainly through word of mouth from current and previous users.  Hospital employees also refer patients and families, and CaringBridge is active in trade conferences as well. Personally, as a nurse, I think this site is a fantastic idea.  I certainly have days at work when I'm getting call after call inquiring about the status of a patient from different family members.   We always encourage families to designate one person to call the unit for an update and then disseminate that information to everyone else.  Rather than making numerous phone calls, that designee can update the website.  People visiting the site can enter an email address to be updated automatically every time an entry is made. Beth did say that it's sometimes difficult to know how to say things: "One of the challenges has been knowing what to share and how to share it, as the information is broadcasted."  She went to on explain that when both caregiver and patient are contributing to the site, the needs of both need to be taken into account.  One person may have the desire to share a lot of information when the other person might want to show a little more restraint. The last feature about the site I want to mention is the ability to easily turn a journal/pictures/guestbook into a real book.  Sona mentioned that some of these books are even used at memorial services. If you've been reading codeblog for awhile, you know that I don't regularly endorse websites.  I find CaringBridge.org to be exceedingly useful to patients and families and wanted to help spread the word. You can also find them on Twitter and Facebook. http://www.codeblog.com/archives/the_scoop/caringbridge.html I took care of an elderly man recently.  He'd been dealing with multiple medical problems for almost 30 years.  Despite being in some very significant pain, he still made eye contact, still said "please" and "thank you." He wasn't faking the pain.  He was very stoic, but I could tell he was hurting.  That tight-lipped grimace, the tachycardia, not moving a muscle unless it was absolutely necessary.  Still, manners prevailed. My colleagues and I went above and beyond for him and his family.  There's just something about being polite to others that makes those others want to help you and help you and help you some more. I'm not saying that we don't want to help those that aren't overly polite.  It was just nice to be treated, well, so nicely.  I wouldn't expect everyone in severe pain to maintain such decorum.  Every once in awhile you just click with a patient and it makes being a nurse so enjoyable. So!  News #1.  Another of my posts has made it into a book.  It's called "Lives in the Balance" and was edited by Tilda Shalof, who has written quite a number of books about ICU nursing.  I have read some of those books, so when she personally asked for one of my posts to be included I was quite flattered! I've read the whole book, which is full of very compelling stories written by nurses who work in ICU.  I highly recommend giving it a read, and not just because one of my little posts made it in! News #2 will only be news if you don't follow me on Twitter or Facebook.  I am just over 10 weeks pregnant!  We are over the moon about this and can't wait to meet him or her in late July. And I guess the bonus news is that this blog is 7 years old this month :-) http://www.codeblog.com/archives/tales_from_the_ccu/a-rambling-and-some-news-and-some-other-news.html First of all, hightail it over to Reality Rounds for the latest edition of Change of Shift!  She did a splendid job of making it very spooky by renaming our blogs.  (I am Corpseblog!) And tune in tonight at 6pm PST to the Dr. Anonymous show, where he will be interviewing me.  Talk about scary :-)  I am excited to finally be asked (I've waited years!) but also nervous because I am not exactly well-practiced in live interviews! http://www.codeblog.com/archives/the_scoop/change-of-shift-the-doctor-anonymous-show.html Welcome to Grand Rounds!  This is volume 6, number 6.... and the 6th time I am hosting... during the week of Halloween.  Does anyone else find that creepy coincidentally satanic fascinating?! (Incidentally, if you are reading this through RSS, I am aware that the formatting is less than optimal.  Very sorry about that and we are trying to fix it!) For this edition, I thought we could go out Trick or Treating on Medblogger Lane.  I'm sure we will find some colorful stories along the way... The first house we come to seems amiable enough.  The porch light is on and when the door is answered, some good old fashioned chocolate is put into my Trick or Treat bag!  Even though she is diabetic, apparently Amy at Diabetes Mine prefers to give out the real stuff instead of the sugar-free kind.  The reason may surprise you. The next house also has the porch light on, but no one answers the door when I ring the bell.  Finally I notice a note that says I should just take some candy from the bowl.  Not Nurse Ratched is horribly sick with H1N1 and doesn't want to spread any germs.  Read her first-hand account of what it's like to be knocked out by this flu. Dr. Bates from Suture for a Living is at the next house.  She has some great candy but it was kind of a pain to get.  She said that the candy was password-protected and that I had to prove that I had a professional responsibility to eat the candy, and would not eat it out of mere curiosity.  Take a gander at what happens when HIPAA is peering over your shoulder when you go looking around where you shouldn't. If I thought that was hard, I was not prepared at all for what I'd have to do to get the sweets from Barbara at Florence dot com.  First, I had to document that we did a time-out so that the correct candy would be given.  After that I had to document that the candy was received.  She actually made me eat some in her presence so I could document that the candy had no adverse effects on me.  Then she had me stick around to report off to the next trick-or-treater about everything that had just transpired.  You might be tempted to skip this house, but you can't.  She shares her perspective about a recent study that claims nurses spend 35% of their time documenting documenting documenting. The next house was just crazy.  When I arrived, they would only open the gate to let me in if I was wearing a face mask.  Laika from MedLibLog wasn't taking any chances after watching this very descriptive video that shows how the flu virus is transmitted and starts taking over the cells in your body.  When I finally got past the gate, Dr. Val from Better Health informed me that she would love to give me some candy, but unfortunately the Big Candy Store down the block ordered it all up and now there wasn't any left.  So I wouldn't feel as though I wasted a trip (and a mask!), Dr. Anonymous sat me down and told me all about the candy H1N1 flu, including busting some myths about the vaccine and informing me of when it might be available. On my way to the next place, I passed someone dressed up as a shark.  That reminded me of Dr. Auerbach's post at Healthline.com about shark attacks - why they attack and steps we can take to avoid being attacked.  I was especially amused at reading this: "...it is important to note that any shark, including the seemingly docile nurse shark, will bite a human if sufficiently provoked."  I'm sure there are a few doctors out there who learned that the hard way. I finally arrived at the Medblogger Lane Haunted House.  It was with much trepidation that I walked through the front door... ...and had to stifle a scream as I entered the room!  A mad scientist was performing various experiments on poor unsuspecting subjects.  You would think that a little playful squirt of lime would result in no harm, but Dr. Charles explains how it could end up badly.  The adjacent hallway was dark and a little spongy.  It seemed strangely reminiscent of a certain screening exam.  The Clinical Cases & Images Blog gives us the quick and easy Cliff Notes version of colorectal screening guidelines.  Allergy Notes describes the scary effects of sulfite hypersensitivity.  In another room Sharp Brains had specimens in jars and was performing tests to find out if caffeine had a sustained lifetime benefit or harm. The last room had people who have had very scary things happen to them.  Trauma Junkie described a typical day in the life for a patient with Cystic Fibrosis and shares his newfound wisdom about how sometimes the patient teaches the practitioner.  Chris at Life in the Fast Lane relates a story with a very important lesson: sometimes we need to dig a little deeper and ask a few more questions before the medical mystery can be solved.  And Robin at Survive the Journey describes what it's like to parent a child who has Cushing's Disease, from diagnosis and management to terrifying flare-ups and hospitalizations. After all that, I was ready to get back to some more trick or treating!  The next house I came upon was giving out gift certificates to iTunes!  I thought that was perfect because I could use it to check out some of the Anatomy software apps on Dr. Penna's list.  As I was leaving, I overheard a conversation about a laptop being stolen from Blue Cross Blue Shield and the potential damage that could result.  Dr. Joseph Kim from Non-Clinical Jobs lets us know what to do in case we find ourselves in this predicament. I finally arrived at a huge scary house... you know, the kind that is decked to the nines in Halloween decorations... the one that makes your heart go just a little faster as you're walking up to the porch.  I rang the bell, said "Trick or Treat!" and waited.  And waited some more.  Surely a house as big and fancy as this would have great candy, right?!  Finally a piece of paper was slipped under the door.  It asked if I had any conditions that would be exacerbated by procuring and ingesting sweet edibles.  It further stipulated that I needed to meet a minimum threshold of candy before they would provide me with any more!  What was this?  Some kind of confectionery deductible?  I concluded that I had unwittingly arrived at the House of Insurance. Instead of filling out the forms that had piled up outside, I decided to sneak in the back door to see if I could find out anything interesting, and boy did I ever... Insure Blog was trying to figure out how Washington would handle 14 million new patients finding themselves on Medicaid if the Baucus health care bill is enacted.  Louise at the Colorado Health Insurance Insider was pondering the composition of hospital boards of directors - are they comprised of objective participants, or is there some significant conflict of interest going on?  And in the corner was a group led by Leslie at Getting Closer to Myself discussing the merits of marrying for love... or insurance coverage. By this time it was getting late and I decided to head home.  I spotted a big bonfire along the way and decided to stop by to see what was going on.  Several people were gathered around the fire sharing experiences and information.  Jolie Bookspan at the Fitness Fixer described several ways to treat knee pain that do not involve scalpels. Jenni at ChronicBabe informed us about fibromyalgia and contributed a list of resources that provided education on how to live and even thrive with the disease.  Jeffrey at Nuts for Healthcare explained that fibromyalgia remains controversial in the medical community; however, while drug companies have been accused of fear-mongering to a desperate population for a handsome profit, recent neurological research has begun to unravel the biological manifestations of the disease in the hope to pinpoint a cause. Novel Patient proudly described how she painstakingly stood up against her chronic illness and disappointing new diagnosis.  Rachel at talesofmy30's divulged her secret for learning to love her body after enduring disordered eating patterns and a type 2 diabetes diagnosis.  Stacey at ACP Internist spoke about a possible reason as to why medical students are not going into primary care.  David Harlow at HealthBlawg gave a detailed account of his experience at the Connected Health Symposium 2009 conference held last week in Boston.  To finish the evening, Barbara at In Sickness and In Health shared with us a story she told her father while he was ill in the hospital. That's all for this edition of Grand Rounds.  Next week, Grand Rounds will be held at nonclinicaljobs.com. Have a safe and happy Halloween everyone! http://www.codeblog.com/archives/carnivals/grand-rounds-volume-6-number-6.html Last week I attended the Blog World Expo conference in Las Vegas.  This is the first year that medbloggers had a track all to ourselves!  The sessions I attended were interesting, and as part of the audience I was delighted to watch my fellow medbloggers on the panels.  There were lots of thoughtful questions & answers, and many silly antics (how many times DID Doctor Rob get onto the big live Twitter feed anyway?? blogworld blogworld blogworld!) Unfortunately, due to a splitting headache, I was not able to attend the last session, but I had plenty of chances to meet and spend some time with medical bloggers that I have been reading for years.  It was truly great meeting each and every one of you and I'm looking forward to seeing everyone again! Meeting Terri from Nurse Ratched's Place was a real treat, as was meeting Kim at Emergiblog.  Kim posted quite a bit about the conference - you can read her post here, which contains LOTS of pictures!  Kim and I shared a lovely (albeit sugary!) lunch together AND managed also to do a joint interview, which can be seen here. (The MJ Propofol anecdote?  True story.) Here are some other thoughts from the bloggers that attended, namely Doctor Rob (one of these days I will earn a golden llama for my blog.  It is a blog goal of mine), Dr. Wes, Dr. V, Kerri (congratulations!), Kevin MD, Doctor Anonymous,  Nick MD, and Dr. Ramona Bates.  Ramona made a beautiful quilt that we all signed.  It was given away as a door prize to one very lucky person, who did not happen to be me.  I was really thrilled to meet one of my favorite bloggers who is also the medical blogger I've known for the longest time (7 years in December!) GruntDoc. A big thanks goes to Dr. Val (also fantastic meeting her finally!) who helped arrange the whole darn thing, and Johnson & Johnson and Medpage Today, who sponsored us. 2010, anyone??  :) http://www.codeblog.com/archives/the_scoop/blog-world-expo-2009.html Grand Rounds is up at Sharp Brains today! Next week, Grand Rounds will be held here at codeblog for the 6th time (Yes, GruntDoc, I counted!)  Use the submit your story/contact form at the top of the page, or email to codeblogrn gmail.  There is no theme, but it will be very close to Halloween, so if you want to submit something super-scary, I'm all for it! http://www.codeblog.com/archives/carnivals/847.html