23 December 2006

Holidays in the ER

I am lucky enough this year to be more or less off on the holiday. I work tonight, the 24th, from midnight to 8AM (technically the shift starts on the 23rd at 11:59PM, for clarity in scheduling). So while I am theoretically working christmas eve, I am actually off for the real eve of christmas. I am also off on christmas day.

The holidays are different in the ER. There's usually plenty of good cheer and decent food. The staff traditionally flagrantly violates JCAHO standards and brings in a sort of spontaneous potluck which gets set up at the nursing station or in the break room if there is space. There is a sense of camaraderie, in that all of us who are there are kind of pissed off that we have to be at work and not home with our families, but since it is a shared burden we don't get too openly bitter, but sort of refocus on trying to make the best of it and have a marginally festive time where we are. And there is a weird feeling of insularity (especially on the night shift), that we are set apart from the other 99% of the population, being at work when the rest of the real world is on hiatus. More than a little pride in that fact.

The holiday clientele is also a bit different from the usual mix. Fair to say that alcohol related presentations increase, though not so much for christmas as New Year's or the Fourth of July. The nursing home patients come in regardless of the day. Old folks overindulge and go into CHF, young men get kidney stones, young women get gall stones, and plenty of people develop acute illnesses. Many (or most) of the trivial or recreational visitors simply don't come in -- it's the one time of the year when everybody has something else they would rather be doing. But there seems to be a corresponding uptick in the psychiatric visits, and the chronic pain exacerbations seem to increase. Last night I saw six migraineurs -- triple or more what I would average. I wonder how much of this is due to the stress of the holiday season and how much is due to the fact that all the doctor's offices are closed. And since all the clinics are closed, the ED volume is about 30% more than on an average day. The acuity is higher than average, and the waiting room becomes an ugly place indeed.

Aftercare is a huge problem. There is a five day gap when all the clinics are closed and you cannot get anybody in for an urgent recheck or consultation. But (for once) patients are incredibly resistant to being admitted to the hospital -- as I said, they all have something else they would rather be doing. The worst thing is the relatively rare holiday tragedy -- be it a fatal MI or motor vehicle accident. Knowing that someone's holidays have just been ruined forever casts a pall over the entire ED. Fortunately, in the dozen or so christmases I have worked in the ED, I have seen only a few of those. Maybe I am just lucky.

Well, off to work. Happy holidays all.

19 December 2006

Just go to the ER

Surgeon in my dreams commented:

I have migraine headaches and asked my doctor just last month during a visit what should I do if I have another like the one I had just gotten over. I mean I was hurting so bad I just knew I was about to die and welcomed it. I was throwing up with barely any time to come up for air in between.

I asked him if I come to his office would he give me something or just what should I do. He TOLD me to to go the ER. He said he did not keep anything strong in his office so it would do me no good to go there.
[sigh] This is so emblematic of much that is wrong with health care (especially primary care) in this country. No criticism to you, SIMD, you and many many other patients do what they are told and "just go to the ER." And we are there to see you, because we have to be. But the point is that people like you shouldn't come to the ER. I should be clear on this point -- there are times when, say, a headache or abdominal pain do warrant an ER visit. New onset symptoms which are not well understood do require an emergent evaluation. But for chronic conditions which have been appropriately diagnosed, we are all better off if you are treated by your personal doctor. And let's be honest: doctor's offices do have IVs, medicines, fluids, etc., and if they do not it is a matter of choice on the part of the office practitioner.

I am not trying to criticize my office-based colleagues. I suspect many of them would love to provide comprehensive care, from routine and preventative visits to more urgent, acute problem-based care. Flea gets insanely pissed off anytime someone is diverted away from his care. He may be an outlier, but I suspect he is representative of many clinic docs' desires. Most clinic docs will not or cannot manage to provide these services because primary care compensation is so low that their financial viability is dependent on through-put, and the reimbursement given under ambulatory care codes is woefully inadequate compared to disruption to the office flow and the time investment required to provide the care. Change the site, though, to the ER and I can collect three or four times the amount (far more including facility fees) for the exact same service. Even with the recent RVU updates, the system remains broken, and one of the consequence is the shuffling off of much primary care to the ER.

Symtym covered this pretty well last month. A couple of key points that bear emphasizing:
  • Emergency Medicine has been a willing victim of its own success.
  • Emergency Medicine has been all too willing to cover for the deficiencies in the availability of primary care (in terms of numbers and time).
  • Emergency Medicine is not an essential service, but a convenient service.
  • "Just go to the ER" is not a national health policy.
I particularly like the last point.

To respond more usefully to you , SIMD, we must acknowledge that we go to war with the health system we have, not the one we would wish (to paraphrase the departed but not lamented Sec Rumsfeld). Let's also acknowledge that the ER is expensive, overcrowded, inconvenient, and the care there is in many cases suboptimal. So what else can you do? If I had migraine headaches, and on an occasional basis they became uncontrollable, and if I had a PCP who knew and trusted me, I would ask for the following "Emergency Kit":
  • Two tablets of orally-disintegrating Zofran
  • Five tablets of 10 mg Toradol
  • Four tablets of 2mg Dilaudid
This is in addition to any other migraine headache medications which had proved useful in the past (Imitrex, Zomig, etc). As long as the crises which require the above meds are relatively infrequent, I suspect that most clinic docs would not balk at the above, especially when presented in the context of "I want to stay out of the ER." I do not know you, SIMD, and I am not giving you medical advice, because this plan would not be appropriate for everybody. But I suspect that for many people, such advanced planning (or even prescribed acutely) would manage their illnesses better than the ER does.

16 December 2006

Expectations

KevinMD linked to an unfortunate guy named Dave who is fighting a tough disease and had a really tough day at the ER. It struck a nerve with me, since I see the same thing every single day of my working life, though not so much from the patient's perspective. I flatter myself that I am better at handling it than the ER doc Dave had to deal with, but I have enough insight to know that I have good days and bad days.
Dave was understandably upset about a whole bunch of things: he wasn't seen in a timely manner, his pain was untreated for a long time, the staff seemed to lack compassion, the ER doc listened poorly, the doctor's office was unresponsive and poorly communicative, etc. Pretty frustrating. Part of the frustration was, I think, due to unrealistic expectations of what happens in the ER. Some of the problems may be avoided and/or mitigated in the future with different strategies. Here were my thoughts for Dave and others like him.

----------------------
I have a close family member with IBD, so I have some sympathy for your situation, but as an ER doc, sadly, I have to say that your experience is typical, and future expectations should be tempered by the reality of our "wonderful" health system.

Several reasons:
1. ERs are terribly overcrowded. in 1992 there were 6000 ERs nationally seeing 80 million patients. In 2004 there were 4000 ERs seeing 110 million patients. Our ER has not been significantly expanded in over a decade and we see nearly double the volume we used to. So private rooms are a thing of the past, and hallway beds and long wait times are all too common. A three-hour wait is actually on the short end of the spectrum in many ERs, if you have a non-life-threatening complaint. Sadly, a crohn's exacerbation is not dangerous, so you will be at the bottom of the priority list, but requires a lot of resources (bed, IV, labs, X-ray), which will keep you out of the Fast Track.
2. Private MDs rarely ever see "their" patients in the ER. It has become the standard for the ER docs to primarily see every patient and only consult the specialists as needed.
3. "Chronic condition with painful exacerbation" is, sadly, not best treated in the ER. The docs don't know you, may not trust you (due to the high prevalence of drug seekers), and pain perception is so variable that pain of 10/10 is not a priority for the ER staff. It's a grim joke for us that every patient rates their pain as a "ten." Makes it hard to sort the wheat from the chaff.
4. The fact that you were acting as if you were in pain doesn't mean much to us either, since we see so many hysterical people and fakers that all overt demonstrations of pain are taken with a grain of salt. In fact, the general rule in the ER might be that the more vocal a patient is about their pain, the less likely it is than an objective diagnosis will be determined. We are human and have our biases, and tend to respect stoicism. This ironically means that the less you complain, the more sympathetic and responsive the staff tends to be.
5. A better strategy for you is to have a plan with your GI doc of what to do at home when the pain spikes. Have a limited supply of some really strong pain meds which is to be used in case of emergency, and use it only very rarely. And honestly, IV pain medicine is no stronger than oral. So as long as you are not vomiting, oral medicines are preferred. Also, IV pain medicine can be more addictive and seems to decrease the pain threshold for the next episode, and are best avoided for that reason.
6. When home management fails, if it's during working hours, it's better to coordinate with the clinic than brave the ER. Get a same-day appointment if possible, or walk in. Coordinate a direct admission to the hospital, if it's probably going to be necessary. To be sure, some private practices are resistant to this, but the ER (as you learned) is generally not the best place for treatment of non-emergency conditions and should be the option of last resort.
7. Complaining, criticizing, demanding, and threatening the staff (i.e. asking for an administrator) will not endear you to the staff at either the ER or your doctor's office. The staff are human, and their reaction to perceived manipulative behavior will be to get defensive or passive-aggressive. The squeaky wheel does not get the grease. You will get labeled as a drug seeker or fired from the practice or undertreated or treated last. You *are* dependent on the good will of the staff (at both sites), and alienating them is not in your best interests. I do not defend bad behavior on the part of the medical folks, but you have to live in the real world.

Sorry you had a crappy day, and sorry the ER doc was a dud. Good luck to you in the future.

Shadowfax

15 December 2006

Tagged!

Scalpel-man tagged me with this meme. I don't usually go for this sort of thing, being fiercely opposed to chain letters and just vaguely curmudgeonly in general. But what the heck, I suppose it'll help prove to The Wife that I am not completely Scrooge-like. It's fun.

1. Hot Chocolate or Egg Nog?
Oh, Hot Chocolate by a mile. Nog is yucky horrible stuff, cocoa is the staff of life. Even better if it's a Mocha (I am in Seattle, after all).

2. Does Santa wrap presents or just sit them under the tree? It depends on whether Santa forgot to buy enough wrapping paper and runs out at 11PM Christmas eve. Generally, presents get wrapped. However, Santa doesn't learn well from past mistakes and so they are frequently unwrapped.

3. Colored lights on tree/house or white? Tree gets multicolored lights. The house used to get white lights until Number One Son insisted they be blue (no idea why), so we have white lights in the bushes and blue lights along the eaves of the house.

4. Do you hang mistletoe? No.

5. When do you put your decorations up? The outdoor lights generally go up the first nice (read: dry) day after thanksgiving. The tree and interior decorations follow shortly after since The Wife gets irritated by the crates lying around.

6. What is your favorite holiday dish? I am not sure it really counts, but I'll say Sierra Nevada's Celebration Ale. I scored a whole case of it this year -- I got to the store just as the distributor was unloading the truck.

7. Favorite Holiday memory? HUGE family parties on Christmas at the houses of various aunts and uncles, with me and my gazillion cousins running around like crazy and making much noise and getting into lots of trouble.

8. When and how did you learn the truth about Santa? I actually can't recall ever believing in Santa. So I must have been pretty young.

9. Do you open a gift on Christmas Eve? Like all right-thinking Americans, no. Christmas Day is the proper and correct time to open gifts. The Wife has expressed another opinion on occasion, but I think she had been huffing paint or something.

10. How do you decorate your Christmas Tree? I drink beer (see No. 6) and wrangle the kids while The Wife obsesses over the selection, set-up, and decoration of the tree. It is a laborious and painstaking process. She will carefully examine every single tree on the lot. The trunk must be exactly plumb once it is in the stand (she uses a laser level for this measurement). This year there are 1500 lights on the tree, each exactly evenly spaced from its neighbor. The outcome, however, is always exceptionally beautiful.

11. Snow! Love it or Dread it? Snow on a flat surface: amusing but a sad waste. Good for the occasional snowman, angel, or fight. Snow on an inclined surface: Nirvana.

12. Can you ice skate?
Haven't in years, but yes. However, a new ice rink and hockey center opened up not far from us recently, and has been a wonderful source of business, from concussions to epidural hematomas. So I'm in favor of skating.

13. Do you remember your favorite gift?
Given: engagement ring.
Received: Millennium Falcon and Han Solo/Chewbacca action figures.

14. What’s the most important thing?
42

15. What is your favorite Holiday Dessert?
I kind of avoid them. I grew up with Plum Puddings and Trifles and (so sorry, mom) never really liked them. I'm good with Pumpkin Pie and Ice cream.

16. What is your favorite holiday tradition?
Roast Goose with the good Irish-style potato stuffing. To die for. (thank you, mom.)

17. What tops your tree?
An angel (I had to go look).

18. Which do you prefer giving or receiving?
Let's be honest. I'm a bad bad person, and I acknowledge it, and I have come to terms with it. Receiving.

19. What is your favorite Christmas Song?
"A Christmas Song" by Jethro Tull

20. Candy canes, Yuck or Yum?
Eh. Truly indifferent. Non-peppermint ones preferred.

As befits my status as Resident Curmudgeon, I hereby refuse to throw out any more tags. The meme dies here.

13 December 2006

Reading the Tea Leaves

The Senate is controlled by a single vote. A democratic senator, Tim Johnson, D-SD, is stricken ill and rushed to the hospital. Reports conflict. He's having a stroke. It's not a stroke. Will he survive? Will he serve out his term? Will a Republican governor appoint a replacement, flipping control of the Senate to the GOP?

This is always a maddening part of being a medical professional. Give me 30 seconds with the chart and I can tell you in exact detail what the situation (or at least the differential diagnosis) is. But the vague and contradictory reports, frequently written by media writers not familiar with medicine can be tough to interpret in the best of cases.

Here's my attempt at reading between the lines:

1. Senator Johnson had an episode of difficulty speaking, evidenced by stuttering and apparent word-finding difficulty. Audible here via CNN. This does clearly point to an acute central nervous system process such as an ischemic stroke causing expressive aphasia.

2. His condition "appeared to recover" to the extent that he was able to ask if there were any additional questions before ending the call. The neurologic deficit was mild and short-lived. This argues against a persistent structural lesion such as hemorrhagic stroke or tumor. The absence of complaint of headache further argues against such diagnoses.

3. However, after initial improvement, another problem developed: "[He] was able to walk back to his office in the Hart Senate Office Building, then began having problems with his right arm. He thought he was all right, she said, and went to his desk, but came out a few minutes later and it was apparent he needed help." The language symptoms having resolved, he developed new symptoms of a motor nature. The language centers (often called "Broca's area") are typically in the left brain, in the same vascular distribution as the left motor cortex, which controls movement of the right arm. Again, this is consistent with cerebral ischemia, though the intermittent nature of the symptoms and variable type of symptomology suggest transient ischemia (often called TIA or mini-stroke) versus true cerebral infarction, aka stroke.

4. His "spokeswoman Julianne Fisher said the senator did not suffer a stroke or heart attack." That helps a bit. Clearly she is repeating what a medical professional told her. "No stroke" implies a more or less clean CT scan -- if there was a hemorrhage, most folks would call it a stroke or aneurysm, and it's an affirmative enough finding that I do not expect that we would be told "no stroke." Also, "no stroke" might imply that his neurologic exam in the ER was not suggestive of a stroke, meaning no persistent neurologic deficit. And based on what I have heard, heart attack would not generally be high in the differential anyway.

5. But he went to surgery. What surgery? Don't know as of this moment. But if he had a TIA, that would generally involve a Carotid Ultrasound as part of the ER work-up. If that revealed a critical stenosis of the carotid artery, it is possible that he would proceed emergently to the operating room to open the offending artery via a procedure called carotid endarterectomy. Less likely, he could undergo some sort of interventional radiology procedure such as intra-vascular thrombolysis, thrombectomy, or angio-embolization of an aneurysm. These procedures, however, are less common and would generally be performed in the context of a true stroke, and given #4 above, would be less likely, in my estimation. Generally, carotid endarterectomies are not performed emergently, but in the case of a senator, VIP medicine might well motivate a vascular surgeon to do so. I would be surprised, but it is possible that carotid angioplasty/stenting might be possibly performed but it would be much less likely.

No further updates are expected tonight. Given the information at hand, I suspect that the Senator had either a TIA or possibly a mild stroke, and underwent carotid endarterectomy. This would imply that his illness might be mild enough to allow him to serve out his term, at the least, and make a full recovery, at the best. It is always possible, and alas, too common, that early media report are inaccurate or incomplete, so I would not hold this estimate out as definitive. Certainly, tomorrow is promised to nobody, and this is a serious condition for the senator, who is, after all, a young man. Regardless of the political implications, our thoughts go out to him and his family, and hopes for a speedy recovery.

------------------------
Update:

Sounds like it was an AVM -- Arterio-venous malformation. AVMs can cause bleeding inside the brain which are essentially indistinguishable from a stroke, though as we are seeing with Senator Johnson, the treatment is quite different. It is interesting that he was never described as having a headache, which is typically the hallmark of a ruptured or bleeding AVM. Oh well, that's the risk one takes trying to read between the lines of the incomplete or inaccurate media reports.

Presuming that the senator underwent craniotomy to repair the damage, it is a big surgery, and a serious condition, but the outlook for survival and a functional recovery are good. The recuperation period, however, can be prolonged.

Oh Brave New World

Every day I get down on my knees and gratefully thank my Creator for the blessing of the Internets, which give forth such wonders:

11 December 2006

Good News, for Once

So it looks as if Congress (for better or worse) has passed the bill which would prevent the 5% cut in Medicare reimbursement to physicians. No action on fixing the SGR formula, but another band-aid. So, fine.

Where does this leave Emergency Medicine?

If you remember back a few months ago, ACEP won a major victory at the RVU Update Committee, in which the RVU values for ER docs (and many so-called 'cognitive' specialists) were increased, at the detriment of the procedure-based specialties. Of course, CMS giveth and CMS taketh away, and what with the fact that the budget neutrality clause required a 10% reduction in all RVU values and the proposed 5% medicare cut on top of that, nobody really knew what it meant. But now it's safe to say that we do. CMS did release its final rule not long ago, so we have the final RVU values for Emergency Medicine (if you follow the link, look on page 1021). Here are the updated RVU values:Let's look at a hypothetical busy practice in the Pacific Northwest. The case mix is as follows:

  • Level 1 -- 0.5%
  • Level 2 -- 5%
  • Level 3 -- 40%
  • Level 4 -- 34%
  • Level 5 -- 16%
  • Critical Care -- 4.5%
Based on the 2006 fee schedule this would yield a weighted average RVU value of 2.45 RVUs per "average patient." Based on the 2007 fee schedule this would yield an "average patient" worth 2.84 RVUs. That's a 16% increase. Since these six CPT codes account for 85-90% of EM revenue, that translates to about a 15% increase in total RVU production. If your contracts are based on the Medicare fee schedule, as all of ours are, that should result in an increase in revenue of that same 15%.

One of the tough things about Emergency Medicine, from a business perspective, is that it is not a growth industry. Your business is limited to what walks (rolls) through the front door. You can bill and code as well as you like, but you just can't really *grow* your business, and hence your revenue is pretty fixed. And you're always getting squeezed, by payors, by the government, by malpractice insurers, by the hospitals, and on and on. So to get a "raise," to get "free money," to get at least some tiny token to offset the huge burden we shoulder by seeing all society's castoffs and most vulnerable citizens, well, it's a huge pleasure. And I am going to savor it.

Don't say ACEP never does anything for you.

08 December 2006

Why are we ruled by these miscreants?

I apologize for my extended absence -- I think I went on blogging overload after the election, and frankly, have had writer's block the last couple of weeks. Also, I have not been working clinically too much, which limits the "bizarro" stuff I get to see and write about.

But it was with a thrill of excitement that I got an email last night telling me that

"House and Senate negotiators just reached a compromise bill that would eliminate a scheduled 5% Medicare rate cut for physicians in 2007 and establish a 1.5% incentive increase for doctors who report on quality measures."
Wow! Great news! This scheduled rate cute (the first of an estimated 30% cut in physician reimbursement) has been hanging over our heads and causing great anxiety in the medical community. So I was thrilled to see that it looks like it would be canceled.

Then today I read this Washington Post summary. The bill, if it passes some serious obstacles, would also:
  • Allow unlimited tax-free deposits in HSA (creating a billion-dollar tax loophole for the wealthy)
  • Cut health care for low-income children
  • Open 8 million acres of the Gulf for oil exploration
  • Allows oil companies to continue extraction in the Gulf without paying royalties
  • Give business $7.5 Billion in tax breaks for R&D
  • Allow clothing importation from Haiti without tariffs
Among many, many other unrelated line item tax breaks and carve-outs, some reasonable and many heinous. Why are all these unrelated items in one bill? Why is this bill the very last thing Congress is acting on before adjourning? Why, every year, is the freeze on physician reimbursement cuts linked to some unholy compromise.

I wish I could say with confidence that things would be different or better under the incoming Democratic Congress. I suspect that the objectionable content of these smorgasbord bills will be lessened. On the other hand, I suspect (wrongly, I hope) that the Democrats may be less friendly to a freeze on the Medicare cuts, which will already have gone into effect. At any rate, it certainly won't be one of their legislative priorities.

[sigh]

And over at The Health Care Blog, they complain that "the AMA still has Congress where it wants it." Weird.

16 November 2006

Now this is what responsible, competent government looks like

Wow. The last twelve years of corrupt, ineffective republican governance has so accustomed me to hackery and rhetoric instead of decisive, responsible action that I actually got a chill (the good kind) reading this Salon article:

Remember those abusive Republican robo-calls and the sample ballots that suggested -- falsely -- that Michael Steele is a Democrat? The soon-to-be Senate majority leader does, and he's prepared to do something about them.
In a breakfast meeting sponsored by the American Prospect, Harry Reid told reporters today that the calls and the phony campaign literature were "absolutely wrong," and that one of the first 10 bills he introduces in the next Senate will deal with such abuses. "We need to make these criminal penalties," Reid said, saying that civil liability was apparently not enough to deter what happened in the run-up to last week's election.
And this bit from Atrios:
Washington- Senator Chris Dodd (D-CT), an outspoken opponent of the Military Commission Act of 2006, today introduced legislation which would amend existing law in order to have an effective process for bringing terrorists to justice. This is currently not the case under the Military Commission Act, which will be the subject of endless legal challenges. As important, the bill would also seek to ensure that U.S. servicemen and women are afforded the maximum protection of a strong international legal framework guaranteed by respect for such provisions
as the Geneva Conventions and other international standards, and to restore America’s moral authority as the leader in the world in advancing the rule of law. [...]
The Effective Terrorists Prosecution Act:
  • Restores Habeas Corpus protections to detainees
  • Narrows the definition of unlawful enemy combatant to individuals who directly participate in hostilities against the United States who are not lawful combatants
  • Bars information gained through coercion from being introduced as evidence in trials
  • Empowers military judges to exclude hearsay evidence the deem to be unreliable
  • Authorizes the US Court of Appeals for the Armed Forces to review decisions by the Military commissions
  • Limits the authority of the President to interpret the meaning and application of the Geneva Conventions and makes that authority subject to congressional and judicial oversight
  • Provides for expedited judicial review of the Military Commissions Act of 2006 to determine the constitutionally of its provisions.
Oh, it's going to be fun to be in the majority!

15 November 2006

Election Analysis

This is a cool graphic from the NYTimes today. I am a sucker for this sort of gee-whiz animation, but it's worth noting for one other reason. There has been some carping from the right side of the aisle that there really isn't a "mandate" for the new Democratic Majority, that the margin of victory was only a couple thousand votes here and there. (Though, oddly, I recall hearing that there was a mandate after a similarly narrow win for the GOP in 2004. But I digress.)

The interesting point of this graphic is that, truly, the bulk of the Democratic pick-ups were quite narrow -- they are largely stacked up in that band with a <10% margin of victory -- but the swings were huge. The average change from 2004 to 2006 was 20-25%. This was not an election where the Democrats picked up the marginal GOP seats; they reached deep into the "safe" seats and took them away. My personal favorite was PA-10, where Don "Choke-em" Sherwood was the victim of a 92 point swing! (In fairness, he did run unoppsed in 2004.) This illustrates two things. First, the size of the Democratic wave was huge. The number of seats taken was huge, and the seismic shift in two years was massive. It could have been even bigger - there are another nine seats not yet decided, all of which look to be GOP holds by less than one percentage point. Second, this strongly validates Howard Dean's fifty-state strategy, in which every seat was challenged, even the hopeless ones. It turns out that some of our pick-ups came from those seats that nobody in their right mind would have picked as competitive. Events threw them into contention (FL-16 Foley, TX-22 - Delay) and the fact that the Democrats had a viable, well-funded candidate in those seats allowed the Democrats to be opportunistic and take them.

The other question raised by this analysis is the durability of the new Democratic majority. How many of these deep red seats are tenable past 2008? TX-22 is going to be a tough hold. Incumbency and (hopefully) a record of success in Congress will provide some edge in 2008, but you know the GOP is going to target each and every one of these races with highly-financed challengers. But many of the pick-ups were in blue or deep purple districts (PA, NH, CT) and should be hold-able. The Dems have a bunch of vulnerable republican targets of their own. So perhaps the size of the majority night shrink, but it's way too early to tell. Lord alone knows what will be happening in Iraq in 2008. And the presidential election.

14 November 2006

Universal healthcare?

Kevin Drum has an amusing take on the insurance industry's proposal for Universal Healthcare. Money quote:

Let me get this straight. The private insurance industry favors a government program that would purchase more private insurance for people, but is opposed to anything that would drive down the cost of insurance or guarantee coverage for people the insurance industry doesn't want to cover. That's quite a plan. Why not just ask for grocery sacks full of unmarked bills instead?
As an ER doc, I'm willing to go along with most anything that would get those 46 million Americans covered. As a taxpayer, I am reasonably sure there is a better, cheaper way to do it.

13 November 2006

Door to Dilation

There was an AP Report today on a major initiative to reduce the time from the moment a patient hits the door with a heart attack, more precisely known as an acute coronary thrombosis, to the inflation of a balloon in the blocked coronary artery which restores blood flow to the affected heart muscle.

The full text of the report can be found here.

I do know that we are already doing the most important things listed as recommendations:

  • We call in the cath lab based on a reliable EMS report of a STEMI
  • We call in the cath lab based on the ER doc's interpretation of the EKG
  • The call-in is a single phone call
We don't have a cardiologist in-house 24/7 (yet?), and I have no clue how long the team has to arrive.

The results? Based on the current data, our facility, in 2006, has a median door-to-dilation time of 69 minutes, with the national median being 90 minutes, and the 90th percentile being about 75 minutes. Our total number of cases is about 140 for the year, which I perceive as being reasonably high, and certainly statistically significant.

I can't take too much credit on this one. We have great leadership, great administration, and great cardiologists. They have identified this as a major goal for the hospital, and put systems in place to generate this type of success. It is satisfying to see that it can be done, and that it makes a difference.

(Side note: I have been at this facility for six years and have never once given thrombolytics. Amazing.)

08 November 2006

Political Capital

Jan 18,2005:
"I earned capital in the campaign, political capital, and now I intend to spend it."

Nov 7, 2006:
The American people requested a refund.

What a great day

The following things have happened in the last 24 hours:

I ordered a new computer
The Democrats took the House
The Democrats took six State Houses
The Democrats took the Senate (apparently)
The Democrats took ten state legislatures and over 275 seats nationwide
The Republicans won not a single pick-up
I found my car keys that had been missing for three weeks
I no longer have to hear the names Santorum, Rumsfeld, Romney, Frist, Harris, or Burns (excepting C Montgomery Burns)

Rumsfeld getting shit-canned is literally icing on the cake.

What a great day. One for the books.

Update: Hysterical Mac Geek joke re: Rummy

07 November 2006

Morning in America


As of my bedtime, we have 24 seats in the House for Speaker Pelosi.
The Senate is shockingly close. At this point, Tester is leading in MT, McCaskill is projected to win in MO, and Webb has declared victory by a fingernail's breadth in VA. If (and that's a big if) these results hold, we take the Senate, also. Amazing. I would never have predicted it, but boy am I happy. We'll see if it holds.

[Picture of a beautiful sunrise in Montana (fittingly) credited to Sarpy Sam]

Pre-School Attack Ad



I'm voting for Jimmy.

Game Day

It's on.

Let's predict -- Just for fun. Pollster predicts 234 seats for the Dems, which would be a pick-up of 32 seats. Charlie Cook predicts 20-35 seats for the Dems. Over at Hotline they see a consensus of 25 seats. Stu Rothenberg sees 30-36 seats going blue.

After 2004, I am incapable of this sort of rational exuberance. The numbers do look that good, but I am going to take the "under" and predict that the Speaker Pelosi will take the gavel with a 5 seat majority -- total pick-up of 20.

Why? Dunno. Cynicism, the proven GOP GOTV game, expecting some republicans to get in the booth and find they just can't pull that "D" lever. Also, I'm a Cubs fan at heart. I expect, on a fundamental, genetic level, for my team to blow it in the ninth. And the GOP has been the Yankees of politics for the last decade or two.

For completeness, I will predict four seats in the Senate. Pennslyvania, Rhode Island, Ohio, and Missouri. Maybe Virginia, also. I think Montana and Tennessee will slip away from us. We'd need six of the seven to take control (and all seven to build a Lieberman-proof majority).

I will predict that Lieberman will win a squeaker, caucus with the GOP, and be indicted in 2007.

I do see one historic possibility -- I think this will be the first election in forever in which one party (the Democrats, in this case) does not lose a single seat it currently holds.

Game on.

06 November 2006

A Matter of Perspective

I took a continuing education class, PALS -- Pediatric Advanced Life Support -- this weekend. A nice refresher, since I don't get to take care of critically ill kids too often (fortunately). We were split into small groups for simulated cases on SimKids. In my group were about 3 pediatricians and 4 peds nurses. I was the only provider who sees more adults than kids.

When it was my turn to run the "mega-code," my preceptor took me through a simulated cardiac arrest that involved just about every nasty twist he could think of. In the end, he concluded by saying, "Good job. You saved his life."

Without thinking, I responded, "We don't really save lives. We just prolong them."

Laughing, he instructed the rest of the class "Oh, don't pay any attention to the cynical old ER doctor!"

Who, me?

One Day More!

Feel good about it:

05 November 2006

Frivolous Lawsuits and the need for malpractice reform

We settled two lawsuits this quarter. In neither had there been medical negligence. It's pretty galling to settle cases like these, but it's smart. The deck is stacked against us, and you have to make the good decisions, even when it is bitter.

Both cases were quite straightforward. In one, there was a DVT diagnosed and treated according to hospital protocol -- low molecular weight heparin and transition to warfarin. The patient went on to have a pulmonary embolus and recovered uneventfully with no adverse sequelae. We only settled because it was cheaper than going to trial. As galling as it was to pay, we did have the satisfaction of knowing that the plaintiff's attorney took a loss on the case. (It was a very small payout, and his preparatory expenses were considerable.)

The other case is more maddening. A very young child was dropped on his head, suffered an epidural hematoma, which was diagnosed on CT, and the child was transferred to a regional trauma center. He recovered, though with some degree of neurologic disability. The plaintiffs waited ten years to file (!) and alleged that some minor delays in CT and transfer were the cause of the bad outcome. This is obviously bogus. But we knew they were going to wheel a brain-damaged kid in front of the jury. The likelihood of losing this case was significant for that reason alone, and the risk of a big payout was significant. So we settled in the mid six figures. I hated to settle, and struggled with the decision, but with juries making decisions, it's a crap shoot, and they consistently rule in favor of sympathetic plaintiffs.

What can we do? When you are at Yellowstone, they tell you not to feed the bears because it just encourages them. But that metaphor doesn't work when the alternative is to let the bear maul you and hope that he won't get all of your food.

The real problem isn't that these suits were frivolous. I don't really know what that word means. I do know they were baseless. The problem is that the newspapers are replete with cases where there is a huge jury award in cases where there was no malpractice. This is what induces us, and lord knows how many other medical groups, to settle cases which were well-handled. When there is no correlation between whether negligence occurred and whether you win or lose, the only viable strategy is to pick your fights very very carefully.

Simply: Lay juries are not qualified to make determination of causation.

What typically happens is that the two sides present dueling expert witnesses who assert fundamentally incompatible standards. The jury is then left to decide which was more credible. How the hell are they supposed to decide which of two eminent, respected academicians is right? When medical experts disagree, how on earth can uneducated laypersons decide accurately what constitutes negligent behavior? If the plaintiff died or was severly imparied as an outcome, that inarguably biases a jury to assume that "something must have gone wrong," and their verdicts do tend to correlate.

I am also aware that the defense prevails in many or most malpractice actions. To me, this is not an indication that the system works. Quite the opposite. There have been cases of which I was personally aware in which the care was clearly substandard but the defense experts were more convincing and the jury went along. The problem is not that doctors win 87% of the time, nor that awards are out of control. The problem is that juries are unpredictable and commonly make very wrong decisions. The result of this is that in many cases patients who were injured go uncompensated (especially if they are not sympathetic victims), and that doctors who were not culpable wind up losing.

When there is not good correlation between causation and verdicts, the system falls apart. I think that tort reform is essential. But I do not particularly favor caps. Caps are clumsy and heavy-handed. Moreover, caps on awards do not get at the heart of the problem, which is the arbitrary and capricious decision-making patterns of juries. It's just as well, because caps are as dead as a doornail, politically speaking. I would like to see an alternative solution. I would prefer special health care courts or some other system which attempts to improve the accuracy of judgements.

Because it's clear that the current system is a miserable failure.

04 November 2006

True Dat

Courtesy of PZ Myers

True Dat.

29 October 2006

Follow-up

One of the frustrating things about working in the ER is that you so rarely get follow-up on a patient you have seen. They leave the ER and it is as if they cease to exist. And when you do get follow-up, it's usually a bad thing -- "Remember that chest pain you sent home yesterday?" So today I was pleased to get follow-up on one of my patients from yesterday's post. It was Patient Number 5, Chronic Abdominal Pain Lady.

Now I didn't realize that it was her at first. For one, the name on the chart was different. Also, the details of the presentation were slightly different. When I walked into the room, though, I noticed that she looked very familiar. Then I saw the external jugular vein on her neck, a very distinct large and bifurcated vessel that I had had to cannulate to get blood off her the day before. (BTW, how sad is it that I didn't recognize her face but did recognize a vein?) At first, I played dumb and got some details from her. She recognized me and tried to give me a close approximation of the previous day's story, getting a little flustered when I pointed out that she had told the triage nurse something very different. I made an excuse and left. The admitting clerk approached me and told me of not the one but three other names they recognized her as having used. They all had social security numbers, dates of birth, phone numbers, and addresses which were identical, except for an occasional flopped digit.

I went back in and explained to her that I was happy to screen her for an emergency condition, and treat one if it were present. I also pointed out the . . . irregularities in her registrations. I did not accuse her of anything, but I said that I was concerned about her dishonesty. (Even when you have someone busted, it's wise not to overcommit oneself.) Predictably, she escalated and became angry and threatened to sue me and stormed out.

Ah, victory. I hate (really hate) having an adversarial relationship with patients. But it's hard not to savor a clean win when one comes along.

28 October 2006

Oh, the pain of it all! Oh, the pain!

With Apologies to Dr Zachary Smith. . .

The first seven patients I saw today were in the ED for:

  • Dental Pain (ongoing for three years)
  • Back Pain (third visit in one month, 18 in 2006)
  • Migraine Headache (six visits in a month, and second ED visit in 18 hours)
  • Back Pain (this one was legit)
  • Chronic Recurrent Abdominal Pain (ran out of Oxycontin and doctor "out of town")
  • "Cyclic Vomiting Syndrome" (in which only narcotics stop the vomiting)
  • Oxycontin withdrawal
Sometimes I wonder why I bother. I occasionally wish my job demanded something more than a valid DEA license, and decision-making skills beyond "yes narcs" and "no narcs." It just drains the carpe right out of your diem to start the day off in a series of ugly little dogfights over drugs with people whom, to put it charitably, you have concerns about the validity of their reported pain.

Now please don't jump to conclusions here. Pain sucks, and in the common event that I know to a reasonable certainty that someone is suffering, I am quite free with the narcotics. That's a big part of my raison d'etre. The problem is that increasingly, it seems that the chronic pain complaints far outnumber the acute pain complaints, and treating chronic (or recurrent) pain in the ED is fraught with difficulty to say the least. You don't know the patient, they come to the ED over and over for the same thing, they are demanding (both in terms of time expended and emotional energy), some are dishonest, there always seems to be some barrier to treatment which requires ED therapy ("Doctor out of town," "Lost prescription," "Only a shot works," "Threw up my pills," etc), and there is never objective evidence of physical disease.

These folks are colloquially referred to as "drug seekers." I wasn't trained in how to deal with them, and haven't seen any good educational/research on the topic. That which I have seen seems to have been infected by the Pain Thought Police, whose first law is that "Only the patient can tell you if the pain is real," and whose second law is "All pain is real." (You can see the problem there, at least from my point of view.) So of necessity, my approach to these folks is sort of ad hoc.

Off the top of my head, I would describe most of the "problem patients" as falling into a few distinct groups:
  • Malingerers: Want drugs for diversion or recreational use
  • Organic pain superimposed on narcotic addiction
  • Organic pain superimposed on psychiatric condition
  • Minor injuries in individuals with poor pain tolerance
  • Primary psychogenic ailments
These probably comprise 80% of the repeat visitors we see for narcotics. I commit heresy -- The Pain Thought Police would have us believe that organic pain and narcotic addiction can never co-exist. Any ED doc will tell you the truth. The real problem for me is that there are a couple of other categories:
  • True organic pain of long duration
  • Acute pain in a narcotic-habituated individual
And my job is to sort out the wheat from the chaff, so to speak. I try to find a way to say "no" to the first group of "seekers" in a manner that is therapeutic, honest, defensible, and not too much of a pain in my ass, while acurately sorting out the occasional individual who looks like a "seeker" but in fact is "legit."

It sucks. You wind up feeling judgemental and mean, you have to make people cry, and when you are wrong, you feel absolutely horrible -- and you always have that nagging doubt in your head, "Was I too harsh?" This is honestly the most emotionally challenging thing I have dealt with as an ER doctor -- not as hard as having a child die on you, but more of an every-day sort of low-level emotional parasite. Some ER docs say "Why bother?" Give 'em what they want -- it's easier and everybody's happy." No complaints to administration that way, either. We euphemistically call these docs the "candy men," but in truth I feel like a more honest appellation would be "pushers."

When I came home, my wife cheerfully greeted me and asked brightly, "So how many lives did you save today?"

Oh, the pain of it all. . .

[PS -- Don't miss the Follow-up to this post.]

25 October 2006

Obamarama!

So Barack Obama is going to run for president? Or maybe not. He's too young, too inexperienced. He should stay in the Senate. Or, he's charming and visionary and the perfect anti-Hillary and a wonderful communicator who just happens to be black. He should run.

I don't have a firm opinion. Though when I saw his DNC speech I turned to my wife and said "That man is going to be our next president." So maybe I'm a prophet.

Hilzoy over at Obsidian Wings has a fascinating rundown of what Obama has actually accomplished in two years as a freshman senator in the minority party. I am a little surprised, and if anything it increases my sense that Barack is a guy with real future as a politician, and that I am glad he's on our side. Whether his future is in the Senate or White House I don't know, but based on what we've seen, he seems likely to do a great job wherever he is.

Oh, you should go check out the link, if only to see the little picture in the upper-left of the screen. Hysterical.

Stay the Course

When your policy has failed, you can either change the policy, or change the name of the policy. Anybody care to guess which the Bush team chose to do?

24 October 2006

Terrorized by a small child

I was at the YMCA locker room changing before Karate, and a little boy was there, naked, maybe six years old. I couldn't see anyone else around, though there might have been someone lurking in the rows of lockers. The little boy came up to me and said, "Is it a bad thing if somebody touches my privates?"

Alarm bells started going off in my head. "Um, yes. Yes, that is a bad thing. Nobody gets to touch there." I looked around nervously. Still nobody there. But I was terrified that someone would come in and overhear part of the conversation that I, a strange adult male, was having with a naked child, mistake me for a pedophile, and call the cops. The kid followed me around the locker room, strangely insistent on the topic. Mostly he asked the same question over and over in slightly different phraseology.

The ER doctor in me did wonder if there was a reason the kid was asking this question. Should I ask him? Should I tell someone? Who would I tell? How does one go about that? I decided not to, mostly based on the tone the kid was using -- the same sort of fantasy tone my son uses when he torments me with hundreds of random questions. There was no affective hint of anything other than a little kid rambling on.

So I hid. I bravely went back to the bathroom and locked myself in a stall. In fairness, I did need to use it, so it wasn't an act of pure cowardice. When I came out, I saw the kid had attached himself to some other guy and was tormenting him with repetitive questions, mercifully on a different topic.

Borat

Funniest movie ever made or reprehensible piece of crap?

You decide.

23 October 2006

4 AM Ramblings

It's a little strange how your perspective changes when you are a parent. Something about the power of visualizing your child in the position of any other child who meets with an accident or untimely demise makes the emotional impact of images and thoughts of that type an order of magnitude more potent. The interesting thing is that I find it is not just limited to cases where there is a simple parallel between my kids and the victims. For example, I've been literally sickened by the carnage in Iraq and in Lebanon for quite a while. But I find that my empathy has extended even to the adults. Particularly the adults who are being kidnapped, tortured and murdered in massive numbers. I can rationalize the death of a soldier in a firefight -- the act of kidnapping an unarmed, helpless civilian and toruring him to death seems inhuman to an incomprehensible degree. I feel sick when I think about it, and it's because I am empathizing with the victims. I don't think I would have viewed it the same way before I had kids. I was a lot more dispassionate in my outlook then.

21 October 2006

Obesity is a malignant disease

Dr "Bard Parker" over at A Chance to Cut has an interesting abstract of the recent literature surrounding obesity in trauma. It may be from the Journal of Proving the Intuituvely Obvious, but is worth a look. Nobody in health care would even shrug at the notion that really heavy people are a nightmare to care for, simply on a practical basis. This is the first time I have seen severe obesity linked to short-term mortality.

In short, the heavyweights were 7 times more likely to die in hospital than similar non-obese patients with comparable injuries. They had more infections, spent more time in the ICU, had more central lines, more episodes of organ failure, and spent longer on a ventilator. (To which anyone who has spent time in an ICU responds "duh.") Intubations and tracheostomies are more difficult, and central line placements are more challenging in the obese.

I can vouch for that personally. I am pleased to report that I have three succesful, first-pass intubations in 500+ pounders in the last two years. (One survivor.) Last year we had a young man in his early twenties who weighed over five hundred pounds who expired after a motor vehicle accident. To this day I do not know what his injuries were. He did not fit in the CT scanner, so we had no real way of assessing him. He died of respiratory failure right in front of our eyes. It was terrible; he came in awake, talking and very afraid. He could only breathe sitting up, and even then his respirations were ineffectual. He slowly became somnolent. After great deate and with great trepidation, we intubated him, successfully (no simple matter). But we were unable to ventilate him effectively, and he coded and expired. I would presume there were internal injuries which contributed, but we were never able to ascertain that. It was a bad thing.

It seems like we see more and more of these cases as time goes on. Sad.

16 October 2006

Distorted Beauty

Dove (yes, the soap/cosmetics company) has an amazing video here, at their "Campaign for real beauty." It's worth thirty seconds of your time. I might add that it's a really nice thing for a cosmetics company to focus on. Good for them.

15 October 2006

The risks of notoriety

I am at the national convention for ACEP, the American College of Emergency Physicians. I enjoy coming because it's always full of engaging lectures and really lets me reconnect with the reason I am an ER doctor, lets me refocus my thinking and develop my vision for where I and my practice are going.

It's also a lot of fun, and I get to reconnect with old friends from residency.

So today one of my partners and I were walking into the hotel, and ran into the director of my residency program, who was talking to a half-dozen of the current residents. He waves me over, greets me enthusiastically, and introduces me to the residents. "This is Shadowfax," he says, "He graduated from the program in 2000."

One of the residents blurted out "The Shadowfax?" Another follws it up with "Oh man, I've heard about you!"

Uh-oh.

"Er, what exactly did you hear?" I managed to weakly croak.

"I was talking to Dr Jones, and he told me about the time you walked into a room for 30 seconds, walked out and said, 'This kid has Kawasaki's and needs to be admitted for IVIG. This is the most interesting thing I am going to see all day. I'm going home.'"

"I heard about you used to do spinal taps with your eyes closed," chimes in another. "They said you preferred to do it by Zen."

I had some very vague memories of the incidents. They sounded familiar (though somewhat inflated in the telling). The stories, to my great discomfiture (and the poorly suppressed amusement of my partner) went on for a while. I was more than a little surprised that I had been remembered at all, let alone in such detail. It's a big academic program, and I didn't cultivate any close relationships with the faculty, so I kind of expected to be forgotten. I guess I did make an impression.

That's a good thing, right?

How to frame the debate

Make it personal.


From Majority Action. Powerful and effective. I have lived for so long in dread of the "wedge issues." The wedges have been used so powerfully and brutally, almost exclusively by conservatives, that I have developed an almost-reflexive aversion to them. The pathetic inability of the progressive movement to counter them made me pull my hair out. I know there are moral complexities to this issue which by far exceed what can be conveyed in a 30-second commercial. It's sad that american discourse has come to this. But it's nice to see the progressive side finally get into the game.

12 October 2006

September Fund makes a funny



From Harold Ickes' September Fund.

Impending Democratic Landslide?

I remember too well the late October polls which showed that Kerry was sure to beat Bush and I have vowed to never put so much of my hopes into polls again. But this is certainly encouraging. Constituent Dynamics has put out a huge slew of polls today -- 48 districts. The results do not look good for the GOP. (Cool interactive poll -- check it out.)

If you look at only the races where the Democrats lead is outside of the margin of error, the Dems are already at 218 seats, which is the magic number needed for Speaker Pelosi (TX-22 is considered a certain pick-up and was not polled). There are another 20-25 races which are toss-ups. If there is no "Democratic breeze" blowing and we only split the remaining seats, the Democrats will control the House 228-207. If we do better than predicted, the margin could be even larger.

Now there is only one poll that matters, and that's in 25 days. Whether this is a huge win, a win, or a loss will depend on the ground game -- and the Republicans have the best ground game. They've beaten us with it before, and I have seen them close the deal too many times for me to take anything other than transitory pleasure from this sort of polling data. But it is encouraging.

04 October 2006

Meanwhile . . .

Sex scandals that bring down bloated, corrupt, corpulent Speakers of the House are fun and all but let's not forget. . .

23 US Servicepersons have died in Iraq since Sunday.

George Bush has blood on his hands and this is why we stand against him.

The Republican Assault on Charge Nurses

So here's an increasingly rare comment on an actual health care related topic.

The NLRB, heavily dominated by Bush Appointees, voted along party lines yesterday to reclassify millions of US employees as "supervisors" who are by that definition, ineligible to join unions, organize, or engage in collective bargaining. This case revolved around a Michigan hospital's attempt to break their nurses union, and the result is that somewhere around 800,000 nurses (and about 7 million workers in other industries) are stripped of the protections offered by a union without truly being members of management.

It's no suprise, coming from the most virulently anti-union, anti-worker administration in living memory. These are the same folks who opportunistically used the passage of the Department of Homeland Security bill to engage in a little union busting.

35 days till daylight.

01 October 2006

Strange Ironies

Noted civil rights lawyer Glen Greenwald points out an odd distinction with regard to Republican Congressperv Foley's cybersex:

[I]n-person, actual sex between Foley and a 16-year-old page would be perfectly legal in D.C. and in most places in the U.S. . . . Despite all the irritatingly righteous (and overheated) "pedophile" language being tossed around, in the overwhelming majority of states, and in Washington DC, the legal age of consent for sex is 16 years old. That means that actual, in-person sex between Foley and a 16-year-old page in D.C. would not be criminal at all (though it likely could have other legal implications).
Interesting but not too significant, since they are not alleged to have done anything more than talk dirty. This is where the felony potential kicks in:
[U]nder the so-called "Adam Walsh Child Protection and Safety Act of 2006" . . . along with 18 U.S.C. 2251, discussion or solicitation of sexual acts between Foley and any "minor" under the age of 18 would appear to be a criminal offense (see Adam Walsh Act, Sec. 111(14) ("MINOR.--The term 'minor' means an individual who has not attained the age of 18 years") and 18 U.S.C. Sec. 2256 (1) (“'minor' means any person under the age of eighteen years").
And who, you might ask, was a co-sponsor and author of some of the language of the "Adam Walsh Child Protection and Safety Act of 2006"?

None other than the honorable representative from Florida's 16th district, Mark Foley.

Hoisted by his own petard.

Your Government at Work

Via Ezra:

With little public attention or even notice, the House of Representatives has passed a bill that undermines enforcement of the First Amendment's separation of church and state. The Public Expression of Religion Act - H.R. 2679 - provides that attorneys who successfully challenge government actions as violating the Establishment Clause of the First Amendment shall not be entitled to recover attorneys fees. The bill has only one purpose: to prevent suits challenging unconstitutional government actions advancing religion.
Original citation.

I hadn't heard about this. I wish I could say I was surprised, but I'm not. Sometimes I think I have lost the capacity to be surprised by these people.

37 days to daylight.

30 September 2006

Signing Statement: Runnymeade, 1215 AD

Funny. Sort of.

Bride of Acheron wonders, "What if Bush had signed the Magna Carta"?

Trial By Jury
In regard to Section 39's suggestion that "No free man shall be seized or imprisoned, or stripped of his rights or possessions, or outlawed or exiled, or deprived of his standing in any other way, nor will we proceed with force against him, or send others to do so, except by the lawful judgement of his equals or by the law of the land", we shall construe the provision in a manner which is consistent with our nation's traditional constitutional commitment to us of responsibility for conducting and protecting the security of our beloved homeland against all foes, foreign and domestic, and shall consider these provisions only advisory in cases of those determined to be enemy combatants or supporters thereof or apologists therefor, especially rumor-mongering free-lance town criers or wandering scribes.

There's more.

29 September 2006

Republican Culture of Corruption

Well, we knew they were corrupt, but quite frankly we did not know that they were this sort of corrupt. I was thinking more the "bribes for government contracts" sort of corrupt, not the "covering up sexual indiscretions with minors" sort.

Let's recap, cause it's fun:

Today, creepy-ass Representative Mark Foley (R-FL) resigned after emails and text messages revealed the squirm-inducingly gross cyber-sex he was having with a 16-year-old male House Page.

The AP reports that this came to light 10 or 11 months ago. The page worked for Rep. Rodney Alexander (R-La). Rep Alexander notified the House leadership. Speaker Hastert (R-IL) and Rep Shimkus (R-IL) did nothing for almost a year. They report that the child's parents did not want to pursue the matter. So they buried the matter and allowed this pedophile to continue working with teenagers until ABC news publicly revealed the emails today.

It would be easy to view this as a personal and private failure of one sick man. But this goes deeper. The GOP leadership knew. They did nothing.

Why did Republican House Speaker Denny Hastert permit Foley to remain in the House GOP leadership (Deputy whip) for almost a year after they knew he was having sex talk with minors online, minors he met on the job?

Why did Republican House Speaker Denny Hastert leave Foley as the co-chair of the House Caucus on Missing and Exploited Children for a year after they knew?

Oh, yeah. Because they are all irredeemably corrupt. They would rather support a pedophile and retain a republican seat than get him out of Congress and risk losing the seat. Power is more important to them than justice, than honor, and more important than the continued safety of the teenagers working in our nation's capitol.

I almost forgot.

Senate passes McCain Torture Act

So the new, updated litany of "Low points in American Democracy" reads as:

  1. Dred Scott: Supreme Court held that blacks are property and not citizens of the United States.
  2. Alien and Sedition Act: Made it illegal to criticize the president.
  3. Plessy v Ferguson: Supreme Court institutionalized racial segregation.
  4. Japanese Internment camps: Imprisoned 100,000 innocent Japanese-Americans.
  5. McCain Torture Act of 2006: Authorizes torture and rescinds Habeus Corpus as US policy.
So much for the Magna carta and 230 years of American moral authority.

Ave atque vale.

28 September 2006

What the GOP doesn't get

President Thumbscrews and his rubber stamps in congress just don't get it. They don't understand that whether the US engages in torture says more about us than about our enemies.

As John Aravios so elegantly illustrates:


And when George W Bush stands up in front of the world and says "The United States does not toture," the rest of the world will know it is a lie, because they have been watching the open assault on the Geneva Conventions, and heard Bush say:

Common Article III of the Geneva Convention . . . says that there will be no outrages upon human dignity. It's very vague. What does that mean, "outrages upon human dignity"?
George, if you have to ask that is a sure sign that you are a true moral cripple. And your attempts to lawyer up the Geneva Convention make the US a moral cripple in the eyes of the world. And history will damn you for that.

Democrats in Congress plea for Habeas Corpus

Has it really come to this?

Feingold speaks.

Dodd speaks.

Obama speaks.

Where are the rest of the democrats? Where is the filibuster?

Sigh.

27 September 2006

Things which have irritated me today:

  • I arrived at work to find that we are short three nurses, leaving me two nurses to cover an 18-bed ED.
  • We are out of patient chart templates and nobody knows how to order them, so I have to take notes on blank paper.
  • Despite being short-staffed, a steady stream of ambulance traffic arrives. (Didn't they get the memo?)
  • The computers are on the fritz.
  • I got chewed out by an irascible consultant.
I have been at work one hour.

Sigh.

24 September 2006

That doesn't sound right

What? A Democrat speaking plainly and courageously from a point of personal conviction? Are we in Bizarro World?

From Saturday's debate between Republican Senator Burns and his Democratic challenger, Tester, in Montana:

When it came to the USA Patriot Act, Burns called it a useful tool, saying it lets law enforcement fight terrorism with the same tactics used against organized crime. He said that people "need to be able to go to the movies or football games without worrying about being blown up. I don't think Mr. Tester understands the enemy," he said.
Burns said he also supported programs monitoring international telephone calls against those suspected of terrorism.

"He wants to weaken the Patriot Act," he said of Tester.

Tester sought to clarify:

"I don't want to weaken the Patriot Act, I want to repeal it. What it does, it takes away your freedom ... and when you take away our freedoms, the terrorists have won," Tester said.

He came back to the subject near the end of the debate, when Burns tried to link him to New York Democratic Sen. Chuck Schumer, who is, Burns said, pro-gun-control.

"With things like the Patriot Act," Tester said, "We'd damn well better keep our guns."
Nice.

20 September 2006

Not Dead Yet

Oh, good times. The NYT's tech guru, David Pogue, writes:

Ten years ago

* Fortune, 2/19/1996: “By the time you read this story, the quirky cult company…will end its wild ride as an independent enterprise.”

* Time Magazine, 2/5/96: “One day Apple was a major technology company with assets to make any self respecting techno-conglomerate salivate. The next day Apple was a chaotic mess without a strategic vision and certainly no future.”

* BusinessWeek, 10/16/95: “Having underforecast demand, the company has a $1 billion-plus order backlog….The only alternative: to merge with a company with the marketing and financial clout to help Apple survive the switch to a software-based company. The most likely candidate, many think, is IBM Corp.”

* A Forrester Research analyst, 1/25/96 (The New York Times): “Whether they stand alone or are acquired, Apple as we know it is cooked. It’s so classic. It’s so sad.”

* Nathan Myhrvold (Microsoft’s chief technology officer, 6/97: “The NeXT purchase is too little too late. Apple is already dead.”

And the stock price:

The Daily Show meets the Senate

Senator Harry Reid and Dick Durbin play Q&A on the Senate floor. This occurred immediately after Majority Leader Frist cast the blame for the "Do Nothing Congress" on the Democrats (you know, the minority party). Rarely can anything that occurs on the Senate floor be described as "hilarious" but this is one of those cases.

A partial transcript:
Mr. REID. Mr. President, for more than 3 years, this Congress, which has been given the name of the ``do-nothing Congress,'' has turned a blind eye to the intractable war in Iraq, ignoring the administration's many mistakes and allowing it to stay on a failed course.

Here we are, with 6 days left in the 109th Congress, and the Republicans, who control the House and Senate and the White House, have not held one hearing--not one--into the President's wartime failures. During the Civil War, President Lincoln was faced continually with oversight hearings by his Congress. Of course, we know during World War II, there were a number of commissions. The most famous was that conducted by Senator Harry Truman of Missouri, which led to his becoming Vice President. Some say, but for that he would not have been chosen as Vice President. What was the Truman Commission? It was to determine what was going on with World War II. Was money being wasted? Were troop levels right? Korean war hearings were also held, and the same for the Vietnam war. But for this war, none--even though this war has taken longer than it took to settle the differences in the European theater in World War II. Soon it will be the same amount of time that we were able to beat Japan.

This Republican Congress has wasted 20 months on horse slaughtering; the Schiavo case, dealing with someone's personal relationship, which should not even have been before this body; gay marriage; the nuclear option; flag burning; repealing the estate tax. But they could not find a day for some time to look at the President's mistakes, missteps, and misconduct, which have hurt American security and plunged Iraq into a civil war--not a day.

Yesterday's Washington Post newspaper brought the latest indictment of the Bush incompetence in Iraq, in a front-page story entitled ``Ties to GOP Trumped Know-How Among Staff Sent to Rebuild Iraq.'' [. . ]
..... applicants didn't need to be experts in the Middle East or in post-conflict reconstruction. What seemed most important was loyalty to the Bush administration.

Here are some of the questions that were asked of the applicants: ``Did you vote for George W. Bush in 2000?'' They even asked questions about how the applicant felt about Roe v. Wade. People being interviewed for purposes of helping rebuild war-damaged Iraq were asked questions on Roe v. Wade. The questions had nothing to do with one's competence, their educational background, or their experience.

A 24-year-old who had never worked in finance--but had applied for a White House job--was sent to reopen Baghdad's stock exchange. The daughter of a prominent neoconservative commentator and a recent graduate from an evangelical university for home-schooled children were tapped to manage Iraq's $13 billion budget, even though they didn't have a background in accounting.

Mr. President, this picture says it all. Here is Paul Bremmer. [...] on his throne--on his throne. He is on a throne surrounded by Iraqis.

Mr. DURBIN. Will the Senator yield for a question?

Mr. REID. I will be happy to yield for a question.

Mr. DURBIN. Can the Senator refresh my memory? Was Mr. Bremmer the recipient of a gold medal or something from the President? Didn't he receive some high decoration or medal for his performance in Iraq?

Mr. REID. The answer is, yes, he received that. I assume one would expect that from somebody who had a throne while he was over there.

Mr. DURBIN. Isn't it also true that George Tenet, who was responsible for the intelligence that was so bad that led us into the war in Iraq, got a medal from the President the same day?

Mr. REID. That is true.

Mr. DURBIN. Did Michael Brown with FEMA receive a gold medal from the White House before he was dismissed?

Mr. REID. I don't think he did. Even though he was doing a heck of a job, I don't think he obtained a medal from the White House.

Mr. DURBIN. Apparently, these gold medals were being awarded for incompetence. They missed Mr. Brown, but they did give one to Mr. Bremmer.

Mr. DURBIN. Will the Senator yield for another question?

Video here.

15 September 2006

Anonymous Comment

From Nathan's Guest Book:

Nathan has changed my life forever.
I take a million pictures of my kids.
I read them “just one more” bedtime story when they ask.
I put off watching my favorite show to snuggle them in their beds a little longer.
I take them everywhere so they can experience everything.
I apologize when I have been short with them.
I tell them I still love them even though I’m angry at the moment.
I’ve taught them about death, heaven and God. They are not afraid.
Nathan has taught me that life is too short and too many bad things happen.
He also has taught me to just accept the bad things when they do happen.
There is no time to sulk or think “why me?”
Nathan has taught that I should make the best of every single moment I have on this earth
He has also taught me that good health is nothing to take for granted.
Children are the greatest teachers.

As much as I have learned from Nathan and as much as he has changed my life for the better, I would give it all back if it meant he could stay here on earth with his family.

Stay strong Gentry Family. You are an inspiration to us all.

I couldn't have said it better. You may recall that Nathan is a young boy with Neuroblastoma. He and his parents are in New York looking for new treatments. Send them some love.

This is why we move the meat

Our waiting room is always full, or at least it seems like it. Sometimes the nurses and hospital docs get a little miffed at me when I am pushing hard to get patients out of the ED as fast as possible. I don't look for a diagnosis quite so much as a disposition, and once there, I try to move the patient and get the next one back.

And this is why. Bad things happen in the waiting room. Apparently a runaway jury has decided to upgrade it from malpractice to homicide. Great. It won't stand, but it does usefully reinforce the point that I like to make: Quality ER care is of necessity Timely ER care.

Patient's Heart Attack In Hospital Waiting Room Is a Homicide
Coroner's Inquest Followed Death Afer 2-Hour Wait in ER
September 14, 2006

The official ruling by a coroner's jury in Lake County, Illinois that the cause of death for a 49 year-old patient who died in a nearby medical center was the "result of gross deviations from the standard of care that a reasonable person would have exercised in this situation." The jury determined that the patient's 2-hour wait in the hospital's emergency room was a homicide.

A Radical Regime

I've always loved the writings of Sid Blumenthal, the journalist and former advisor to President Clinton. His memoir, The Clinton Wars, is probably the best restrospective on the Starr witch hunt that I have read (Lord but it seems like ancient history now). I still read him from time to time on Salon, the Huffington Post, and TPM Cafe. He's recently been mounting something of a crusade regarding the radicalism of the Bush presidency (here and here and of course his new book), and today has a great bit out today on Bush's character and how it has in many ways defined his presidency. I like it because it really rings true with my own perceptions. Money quote:

But Bush’s temperament is an essential part of the dynamics. His stubbornness, lack of curiosity, shallow reservoir of knowledge, Manichean division of the world, and contempt for “nuance” are parts of a personality that key members of his administration play upon to get their ways. They carefully restrict the flow of information to him and flatter him as a great historical figure misunderstood by the mere mortals of his age. Their constant manipulation of Bush is an important part of the decision-making within the White House.
I don't think I will buy his book, though. I think I would find it depressing and not particularly helpful, and I would rather look forward (optimistically?) to a new congress and a not-too-distant new administration.

14 September 2006

Body Armor II

Faithful commenter Matt writes regarding the body armor ad:

It's also absurd. Let's go over what this argument supposes:

A) That Donald Rumsfeld would not take more budget if you gave it to him.

B) That you know more about the effective distribution of resources for battlefield safety than staff at the Pentagon.

Seriously, the body armor thing is a horrendously stupid argument. Could it make a great campaign? Sure, but it just fails on its merits.

You may have noticed that the narratives that define political campaigns occasionaly deviate from slavish devotion to "facts" and "truth." What this ad is is brilliant political theatre. There are a million legitimate ways to criticise the administration's execution ot the Iraq occupation. The problem is this: they're complicated, boring, and impossible to explain in a 30-second ad.

This is exactly the same thing as the "John Kerry voted against $80 Billion for the troops" that was so effective against him. It is a minor out-of-context vote (maybe even a procedural vote?) that is used to illustrate the broader point.

In Kerry's case, the point was: Kerry is soft on terror.

In this case the point is: The Republicans have screwed up the war.

Both points are debatably true, but more importantly, both fit well in the narrative that the parties want to use in the respective campaigns.

13 September 2006

Body Armor

This is awesome:



Atrios calls it the best ad of the cycle so far, and I'd have to agree. It's like Swiftboating in reverse -- it's true, and against a republican!

04 September 2006

Crikey

Well, this is a bummer. Sounds like it was a stingray spike to the chest. Funny, I would have thought it would be something more venomous that would get him.

Is a stingray venomous? I don't know.

Even the crocodiles may shed a tear. Rest in Peace, Steve Irwin.

03 September 2006

Reading


Wind, Sand, and Stars, by Antoine de Saint-Exupery

Yes, the same writer who wrote The Little Prince. He was also a pilot for the Aeropostale (now Air France) in the nineteen-twenties, and wrote three books about his experiences. I had always kind of wondered why there were so few works of literature about flying, since I have found it to be one of the most beautiful and spiritual experiences, and would have expected it to lend itself to literary expression. But most of the books on aviation I have seen have been pretty dry, technical treatments which utterly fail to evoke the wonder and majesty of flight.

Saint-Exupery brings a beautiful, elegant prose along with a unrestrained love for the craft and art of flying together with sensitive insights and philosophy together in a work which almost reads as poetry. Add to it that he writes about a time when aviation was a dangerous trade, which lends a bit of a swashbuckling air, and it truly is a masterpiece. He even (mostly) manages to avoid that lethal trap for pilot-authors by eschewing the jargon and technical minutia of flying, depicting his aircraft more as an organism and partner, and narrating his flying as more a matter of instinct than science. But he does so without demeaning the reader or himself, and gives enough detail to let he aviation junky like myself take pleasure in understanding the inside story.

Saint-Exupery was shot down by the Luftwaffe in 1944 while flying a reconnaissance mission over the Med.