25 February 2006

Well, that's just not fair

His parents brought him in, limp in their arms and unresponsive. He was seven and small for his age. Oddly, they didn't seem particularly concerned. I don't know what they were thinking, but the triage nurse took one look at him and brought him straight back and came and got me from my morning coffee. He was a funny-looking kid, pale with a large forehead, but cute in his way. But the way he lay on the gurney with his eyes closed and snoring respirations while the nurse put an IV in told me something was amiss, seriously so.

A quick interview yielded no clues -- he just collapsed while walking to the potty. No illness, no ingestion, no trauma, previously healthy kid. He had been talking when mom came to get him, though he couldn't walk on his right leg, but then got sleepier and sleepier on his way in. I thought perhaps he had had a seizure with a prolonged post-ictal state. But obviously, this kid was going to need a huge work-up -- CT scan, spinal tap, blood tests, toxicology tests, etc.

The Head CT obviated the need for the rest of the work-up:


The bright white stuff is blood, most likely from an aneurysm or vascular malformation, and there's a lot of it. You can see from the lines drawn that the left side of his brain is being pushed over to the right. Not good, not good at all.

As I mentioned, the parents were oddly clueless about the gravity of the situation. So when I sat down and explained the results of the scan, it hit them like a blow from a hammer. They crumpled before my eyes and it was all I could do to keep from going down with them. Somehow I preserved my professional mien, and managed to convey the essential information they needed to know. Then I left them to pick up the shattered pieces of their life while I went to work getting this kid to the care he was going to need. Helicopter to the regional neurosurgical center. Intubate him for airway protection. Mannitol (sure, why not?). Lots of sedation, probably unnecessary, as his GCS was probably 8 or less.

I broke off his two front teeth intubating him. They were baby teeth and getting ready to fall out on their own. A silly little thing, but somehow made me feel so much worse. Not that he will ever know. I don't know if he will live. He may, but even if he does, life as his family knew it is over, or at least fundamantally changed forever. It's just not fair.

I made sure to give both my kids an extra hug before bed tonight.

24 February 2006

23 February 2006

Self-insuring?

Carlos asked:
"What is involved in having a group self-insure?"

We looked pretty seriously into this in 2002 and 2003. The short answer is that you generally need a bigger practice than ours to make the economics work out. The consultants we used opined that a 100-physician base would be the "critical mass" at which it would make sense. We are one of the larger ED groups, at 35 docs, so it would have been tough to find enough other docs to form an alliance with to create our own risk retention group.

The advantages of your own insurance are huge:

  • Direct access to the reinsurance market
  • Strong incentive for internal risk management
  • Capital growth opportunities*
  • Premium reduction in the future*
* Assumes that you do manage your risk well and that your loss experience outperforms the actuarial analysis. The risk, of course, is that if you have a bad loss experience, well, you're playing with your own dollars.

The financial cost of starting up a self-insurance program is substantial, and generally is the largest obstacle. There is the need to capitalize the reserves, which can be substantial, and of course the need to pay lawyers and actuaries and consultants . And the administrative hassle is also significant -- you need to go to somewhere where the insurance laws are favorable -- Bermuda and Hawaii are popular -- and incorporate there, and find the folks to set up and manage the structure, and go there to oversee the operations on a regular basis.

So for us, the financial obstacle was the main reason we did not, but we are also pretty stretched thin on the administrative side. In retrospect, we have had a very very good loss experience, so I wish we had done it. We would be sitting on a huge pile of cash with much lower premiums now. Oh well. Maybe in the future this is something we can create.

22 February 2006

Emergency Physicians and Radiology

GruntDoc ranted:

[Our] hospital where the radiology department has the 'exclusive billing' clause for radiologic services. Right now they don't care if we use our US machine in the ED, but they do care if we bill (even though the ED uses different codes) because it interferes with their exclusivity.

As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn't important so I could do it when it's convenient for me.

I won't claim to be the most experienced voice in this field, but from what experience I have, this seems to be a common problem: radiologist groups who will or can not deliver real-time interpretation of plain films, due to high workload and staffing difficulty. Most do give readings of CTs and Ultrasounds, and deliver over-reads of plain x-rays, usually within 24 hours. But from our side of the fence, this creates huge operational problems in the ED -- the massive amount of time spent reconciling the discrepancies between the ED docs' original reads and the final radiologist's report, the potential harm to patients, the pissed-off patients who had to be notified that an "error" had been made, the increased liability from even trivial discrepancies, etc.

As you might expect, it can prove difficult to convince the radiologists to give real-time reads on plain films, especially at night, since they are getting paid either way and it is hard to find docs to work between the hours of 11PM and 7AM. Hospital administration, though sympathetic, may claim they have have little power to compel the radiologists to come around. So many times the ED physicians suggest that since they are, for whatever reason, obligated to deliver care solely on the basis of their own interpretation of the X-rays, that they have provided the service to the patient, assumed the risk, and deserve the compensation.

Beware that when you raise this point, you are igniting a turf war. It's one you can win, though, if you have the will and an adequate political base of support within the hospital. It is important to have defined your goals in advance: some ED groups see this as an important business opportunity and a significant source of revenue worth fighting for. Our philosophy, when we addressed this a few years back, was that we did not want to be reading the X-rays, that we wanted contemporaneous interpretations. So we play the role of "patient advocates," arguing that the best care is a real-time reading of all radiographs by a radiologist. This is a nice tactic to take because it clearly puts you in the white hat, and I think is probably where most ED groups find themselves trending. But it is backed by a real threat that we could bill for the interpretations ourselves if this service is unavailable.

This threat has teeth because, on a routine basis, most payors, most notably Medicare, will only pay once for an X-ray interpretation. If only one bill is received, they pay it without question. If more than one provider attempts to bill for an ER study, the CMS policy is that the provider who performed the interpretation at the time care was delivered to the beneficiary is the individual who will be compensated. Though I have not heard of any OIG investigations on this matter, the implication is very clear that if the radiologists also attempt to submit a bill for payment, that practice would be at the least noncompliant and at the worst, fraudulent.

Similarly, I might suggest to GruntDoc's hospital administrator that the radiology group's "exclusive" contract for interpretive services is also noncompliant and possibly illegal since it would seem to prevent other physicians from billing for services legitimately rendered to beneficiaries.

The other major objection to ED physicians performing the primary reads of ED X-rays is QA, which is required under Medicare part A. The response to this is that it is simply not our problem -- that is a hospital function. If the hospital has to pay the staff radiologists for QA over-reads on X-rays that the ED physicians have already billed out, the hospital may suddenly find that it has a dog in this fight and the pressure on the radiologists to provide timely interpretations may suddenly increase.

Either way, I view this as a win-win for the ED and well worth the effort to fight it out. Either you have the option of billing your own X-rays and the (modest) revenue that would accompany it, or you get real-time radiology reports on all your X-rays and the higher level of quality and security that comes with that service.

And by the way, every word I have written on this subject can be as easily applied to ECGs as well as to X-rays, except that real-time interpretations from cardiologists are much less useful or likely to occur.

21 February 2006

Quick note on Malpractice deal in WA State

Back from skiing Mt Hood. Had fun and managed -- barely -- to avoid injuring myself. I'm too tired today to really blog in detail but I can't help commenting on a major development in my own back yard -- Washington doctors and lawyers have reached a negotiated agreement on some elements of malpractice reform. Read more here or here.

A quick review of the proposal is encouraging, though not overwhelming. No caps, nor much in the way of innovative alternative dispute resolution. Doctors would have the ability to apologize to the patient without fear of that being used against them in court. That does have some potential to reduce needless liability. It also requires pretrial mediation and establishes a voluntary binding arbitration system. Nice, but kind of toothless. It allows juries to hear whether a victim has already been compensated for their injury from another source. It does not allow partial payment of judgments or limit the use of expert testimony. It does require more comprehensive data collection on the part of the OIC, about five years too late.

I'm a little discouraged that this may foster the mistaken impression that the crisis is over, but any progess is better than none, I guess. I am pleased that Washington Governor Gregoire has shown some leadership in brokering this compromise. It leaves me wondering what the next step is in this fight. I don't think anybody expects this to be the final word on this matter.

Oh, and by the way, we just got our 2006 malpractice renewal. It's down about 15% from last year, leaving us up only 400% since 2002. Progress.

17 February 2006

Pity me

We're off to Portland -- somone is having his FIRST birthday and we are celebrating at Granny K's.



While we're there, I just may get in a couple days of skiing on Mount Hood.


My suffering knows no bounds. See you next Tuesday.

15 February 2006

32, 33, 34, 35

Oh vanity, what a burden it can be.

I went to the men's clothing store to get some big-boy clothes, as I am getting more of an administrative role at work, and it turns out that I may have to wear a shirt and tie more often, and a careful review of my closet revealed several articles of clothing which dated back to the Reagan administration.

Really.

So I found an Unctious Saleperson who measured me and pulled tasteful clothes for me to wear from wherever they hide them, and the first thing I noticed was that she had pulled pants in the 35-36 inch waistline size. I told her that it was a mistake and that I usually take a 33-34. She smiled unctiously and offered me a 34 with the 35 and suggested that I try both. Well dammit if the 35 didn't fit a lot better. So I assumed that this particular store just cuts their clothes a bit small. I came home and went through the closet, generating five sacks of recycled clothes for goodwill. And I checked to see what fit before chucking anything.

None of the 33s fit, and the all 34s were uncomfortably snug.

Okay, so maybe it wasn't the store. I weighed myself for the first time in I don't know how long and I am up about 8 pounds from my baseline weight, which is not a lot but my weight has been rock-stable for about 8 years so it is a significant deviation. Damn. It is finally happening. I have hit the mid-thirties and my metabolism is finally slowing down. You know what that means. No more eating whatever the hell I want without caring what the fat content is, knowing that I couldn't gain weight no matter what I ate. I'm officially entering middle age (or at least knocking on the door). This sucks.

Well, I am not going down without a fight. I've been less active lately, mostly due to work, and I am committing to getting back to my fighting weight within a couple of months. More exercise is the key to my plan, though I will try to eat a little more sensibly. Starting tomorrow. Right now I am getting a bowl of Ice Cream and going to bed.

14 February 2006

The Laws of Emergency Medicine

There are a number of indisputable tenets of Life in the ED. Some are inherently obvious, such as "Unspeakable evil will befall us should anyone utter the "Q" word." (That would be "Quiet" for the non-medical folks.) There are, however, a number of other fundamental principles which any experienced emergency provider can attest to. I have assembled some here for your education and edification.

  1. The Patient will always lie.
  2. (Corollary to #1) If the Patient is unable to lie, the family will do so for them.
  3. If you allow them to, the Patient will likely hurt you.
  4. Never, ever, under any circumstances, take off the shoes.
  5. Never start a shift with an empty stomach or a procedure with a full bladder.
  6. Multiply the stated amount of alcohol consumed by two (by three on weekends).
  7. The room where you perform a rectal exam will never have hemoccult developer.
  8. The word "stool sample" cure diarrhea.
  9. Never stand when you can sit.
  10. If it looks like a donut, eat it.
  11. Don't fuck with the pancreas.
  12. The likelihood the pregnancy test will be positive is directly proportionate to the intensity of the patient's protestation that she cannot possibly be pregnant.
  13. The probability of *any* patient having an acute medical problem varies inversely with the number of patients checking in together.
  14. The most dangerous diagnosis an ED patient can have is "Just Drunk."
  15. Every patient who comes to the ED has this common goal: to find a way to die on you and make you look bad.
And I hate looking bad.

Feel free to propose additional Laws in the comments.

Meta-Med-blogging

Maria over at intueri has this week's highly creative Grand Rounds up. You should check it out for the sheer loveliness of the prose if not for the links.

Doc Around the Clock has a Drug-Seekers Word Finder which I wish I had been creative enough to make up.

13 February 2006

Rice Krispies

It's 7:30 AM, and I have just come on shift. The ED is empty and I am just sitting down with a cup of coffee and going through my mail. Nice to start off slow for once. But the nurses inform me that I have a "sick one, probably an allergic reaction." The story is that he woke up suddenly short of breath, eyes and throat swelling shut, with pain in the left upper chest area.

I head into the room to see the fellow, and the nurses were right. He is very sick indeed. The numbers look bad (HR 135, BP 95/60, SpO2 84%) but he looks worse. Obviously he is in distress, sweaty and working hard to breathe, splinting on the left, voice muffled in that "hot potato" tone that will set every ER doc's hair on end. The left eye is swollen shut, and his face looks a little puffy, but there's no redness, which would be expected with an allergy, and a quick peek in his throat shows no obvious swelling, though that can be deceptive. Lungs clear with good breath sounds bilaterally. Hmm.

Okay, let's get some basic things going: oxygen, IV access and fluid bolus, get respiratory therapy for some breathing treatments, call for a portable chest x-ray, ECG. This looks odd. It doesn't look like an allergy -- no wheezing, too much pain. Probably a PE (blood clot in lungs) but why is his face swollen? Has he occluded his superior vena cava? No, that's silly, SVC syndrome doesn't happen acutely. But his neck looks kind of swollen, doesn't it? Moreso than it did only five minutes ago. The circumference of his neck now exceeds that of his head, giving him a comical appearance not unlike that of the Mayor in Nightmare Before Christmas. Weird. I reach out to touch it and the skin crackles under my fingertips: Rice Krispies. Subcutaneous emphysema: like the popping of the air cells in fine bubble wrap, the tissues of the neck and (I now realize) the face and the chest have been infiltrated with air, and they crackle and snap under the pressure of my touch.

"Don't worry, sir," I reassure the patient, who is visibly freaked out by the stranges noises, "I know what this is and we can take care of it."

There's really only one place that air in the neck can come from -- the mediastinum, the potential space in the middle of the chest between the lungs. Typically, it comes from a punctured lung, though occasionally it may come from a ruptured esophagus. The patient is started on broad-spectrum antibiotics and undergoes a CT scan, which confirms the diagnosis:


Further images and some annotated images for our non-medical folks can be found here.

Other images showed a very small left anterior pneumothorax -- a ruptured lung -- which was the likely source of the air. Since I was working at our rural site, I arranged for transfer to the main hospital, where there is cardiothoracic surgery and pulmonary medicine. The patient looked much better with some IV fluids, oxygen, and pain medicine. While we awaited transfer, he continued to puff up more and more. It really was amazing: if you look at the CT scans, you can see free air all through the neck, chest, and back; his face continued to swell till both eyes were swollen shut. Each breath was like a stroke of the bellows, forcing more air into the tissues. I worried a little that there might be a tension pneumomediastinum, but his blood pressure remained stable. Given how small his pnemothorax was, we elected not to put in a chest tube.

At this point, the patient remains in ICU (day 3). He has had no decompression of any kind and is showing improvement. His espohagus was intact. As best we can figure, it was a spontaneous event, most likely due to underlying subclinical COPD. A rare and dramatic presentation -- only the second or third such one I have seen in eight years at this job.

Nope, this job is never dull.

10 February 2006

Defensive Medicine -- what is the cost?

An issue that raised its head briefly in the last presidential campaign was defensive medicine, in relation to the malpractice crisis and tort reform. The president's argument was that the US could save ~$100 Billion per year in defensive medicine expenses if tort reform were passed. I don't know about that -- I think he may have misplaced a decimal there. The culture of defensive medicine is so engrained that I suspect even sweeping malpractice reform might not change practice very much, and the data from states that have passed tort reform seem to back that up.

But it's a little maddening to see otherwise excellent health policy boggers such as Ezra Klein and Kate Steadman claim that defensive medicine does not exist. Hard to measure? Damn straight. But every day of my working life, every patient I see, every diagnostic/therapeutic decision I make, the specter of "what if" haunts me. The decision-making for every single patient encounter is driven by three factors:

  1. What does my gut tell me this person likely has wrong with them?
  2. What do I need to do to reasonably establish the diagnostic impression?
  3. What do I need to do to cover my ass in case I am wrong?
Number one is by far the most important factor. A good ER doc will know the diagnosis five minutes after meeting the patient, most of the time. Number three probably accounts for 2/3 of the CTs and Ultrasounds ordered in the ER. Defensive medicine is endemic -- especially in the ER, where the standard of care seems to be that any missed diagnosis, no matter how obscure or unlikely, constitutes negligence.

For example, the "Standard of care" in ruling out an aneurysm in someone with the worst headache of their life is a CT scan and a lumbar puncture (spinal tap). This is something every ER doctor will agree on to near-unanimity. However, with modern high-resolution CT scans, the negative predictive value of a CT scan is something like 99.8% -- yet every single ER doctor will still do that LP, because if you don't and you are unlucky enough to have that one person in 500 who had the false-negative CT any ER doc will testify that you fucked up. That's defensive medicine. What's the cost? Well, a spinal tap costs maybe $300-$500, and you are doing 499 unnecessary spinal taps for each aneurysm you diagnose by the tap -- that adds up (in dollars as well as pain inflicted on patients who didn't need the LP).

There are examples of this kind of defensive practice for most any presenting complaint in the ER. Like chest pain. Good lord, how many people with atypical pain and no risk factors wind up staying in the ER six to eight hours (or admitted) for cardiac enzymes and a rule out? And it's because the acceptable percent of patients discharged with myocardial infarction is zero.

Don't just take my word for it; there was a lovely study recently published in AEM:

Emergency Physicians' Fear of Malpractice in Evaluating Patients With Possible Acute Cardiac Ischemia, Annals of Emergency Medicine, 46,6, 525-533 (abstract only)

Which documents that the more fearful a doc is of malpractice the more likely s/he is to admit a patient with chest pain, and the more likely s/he is to order extra tests or admit the patient to the ICU. And, as imporantly the diagnostic yield of the extra admissions/tests was nil. So this is not "better medicine" being practiced, it is CYA medicine.

Those of us who work in the pits call this "proving the inherently obvious."

So it makes me a little crazy when it's claimed that doctors aren't motivated by fear of lawsuits -- we are. Now if you want to claim that the overall fraction of healthcare dollars spent on defensive practice is low -- 1-2% of all spending -- I might agree with that. But bear in mind that the healthcare expenses in the US are in the trillions of dollars, so we are talking many billions spent on unnecessary care. If you want to argue that tort reform won't change doctor's practice patterns, I would be open to the possibility -- doctors don't want to be in the NPDB whether it's for a million dollars or for fifty thousand. But don't tell me that defensive medicine doesn't exist.

09 February 2006

ACEP Director Testifies Before Congress

Finally. I wonder if anyone was listening.

Washington, DC - David C. Seaberg, MD, a member of the Board of Directors of the American College of Emergency Physicians (ACEP), today testified before a joint hearing of subcommittees of the U.S. House Committee on Homeland Security.

It was a little off-topic, as he was supposed to be talking about Bird Flu, but he managed to paint the picture of a nation's health system which is in crisis. Money quote:

The latest figures from the CDC found emergency department visits have risen 26 percent over the past decade - from 89.8 million in 1992 to 114 million in 2003. At the same time, the number of emergency departments decreased by 14 percent. In addition, between 1990 and 1999, hospitals lost 103,000 staffed, inpatient medical/surgical beds and 7,800 Intensive Care Unit (ICU) beds. As a result, fewer beds are available for admissions from the emergency department. Once the emergency departments have filled all of their beds, there is no reasonable way to expect that these stressed systems will be able to suddenly create the surge capacity necessary to effectively manage a pandemic, natural disaster, terrorist attack or other mass-casualty event. [...]

Dr. Seaberg proposed the following 10-Point Plan to increase capacity, alleviate overcrowding and improve surge capacity in the nation's emergency departments:

  • We must increase the surge capacity of our nation's emergency departments by ending the practice of "boarding" admitted patients in emergency departments because no inpatient beds are available. This will require changing the way hospitals are funded to allow for inpatient and intensive-care unit surge capacity to manage this burden [...]
  • Homeland Security agencies on the federal, state, and local levels need to understand that hospitals and emergency departments are part of the community's critical infrastructure. We cannot have response and recovery in a disaster without fully functioning, protected, and connected health resources.[...]
  • We must provide federal and state funding to compensate hospitals and emergency departments for the unreimbursed cost of meeting their critical public health and safety-net roles to ensure these emergency departments remain open and available to provide care in their communities.[...]
  • Congress should pass H.R. 3875, the "Access to Emergency Medical Services Act," which provides incentives to hospitals to reduce overcrowding and provides reimbursement and liability protection for EMTALA-related care.
How many times do we have to say "it's a crisis" before something gets done?

08 February 2006

Never mind examining the patient . . . just get the CT

I'm not one for hyping the scary malpractice stories, but this is really amazing. Three separate doctors came to the same conclusion, independently, the child suffers an unrelated injury weeks later, and the doctors are held liable.

This is why malpractice judgements need to be taken out of the hands of juries.

07 February 2006

Scary Dude

I am generally pretty conscious of security/safety issues in the ED. I work in a place which is pretty high acuity: we have a strong security presence in the ED, and though I have met many a person who was creepy and unsettling, I have never been attacked and never truly been in real fear for my personal safety.

Yesterday, I was working at a small rural place we also staff. There is no security except 911, but we rarely need it and with the lower acuity, security is less in the forefront of my mind. In the afternoon, a homeless guy showed up at triage and told the nurse that he had HIV and was really sick. He was pretty vague about the specifics and only wanted to talk to the doctor.

Okay.

I went into a small exam room with him, and he indicated that it was kind of sensitive, and gestured to me to close the door, for privacy, which I did without really thinking. He stood near the door, and I leaned casually against the gurney. I immediately realized that I had made a serious, serious error. This poor fellow's brain was not working right at all. He was just a little jumpy, moved a little too abruptly, and stared with a manic ferocity at an invisible point about six inches to the left of my head while he spoke to me with an intense voice which gradually got louder and louder. He had many delusions about HIV -- his ex-wife had infected him with thought powers, he was infecting people on the street by looking at them, he could see the virus on his clothes, and he wanted to be sealed up in an airproof chamber to keep him from killing again.

This last bit delivered in a shout.

So, I reflected, I am in a very small closed room with a deranged, agitiated nutcase between me and the door. I slowly put down the chart and quietly assumed a "ready" stance, considering which blocks and joint locks would work best in the space available. I was a little bit bigger than the patient, which I hoped would help. And I started talking. I spent a while calming him down. It was really hard to redirect him from these delusions, but he had just enough insight to realize that they were an aspect of his mental illness, and finally, I asked him if he would be willing to come in to the hospital for treatment, and he agreed.

Greatly relieved, I asked him if he would pee in a cup for a drug test, and he agreed to this as well. I turned to look in the cabinet to see if we had cups, and a bolt of terror went through me:

Ohmygod, I just turned my back on him!

I spun around, but he was being good just then. Practically shaking with the adrenaline, I gave him the cup and slipped out the door.

An anticlimactic ending to the story, I'll admit. Or at least to that bit. Later, the guy did escalate, barricaded himself in the room, and the police were summoned to restore order. They discovered he had outstanding warrants and he left in their custody, with a directive for a psych eval in jail. And I went in to see the next patient with abdominal pain.

My job is never boring, but fortunately, rarely is it exciting in quite this manner. And I am going to be a lot more careful about closing the door in the future.

06 February 2006

Does anybody watch the news anymore?

Seriously. I was reading an article about the declining viewership of the network's evening news, and it occurred to me that I did not know who was anchoring any of the major networks. I haven't watched one moment of the network news since the Great Anchor Purge of 2004/5. That is pure coincidence, of course. I watched a bit leading up to the election, then stopped cold afterwards. Now I can't remember the last time I watched.

It's because the TV news sucks. It's superficial, sensationalized, and aften biased, or at the minimum omits important details. How can that be the major source of information for people in the US? Is it still? I can get more information from ten minutes and a newspaper (or five minutes and the internet) than I can from a half-hour broadcast.

I'll watch CNN occasionally, idly, to get the headlines, or maybe channel hop between CNN, Headline News, and MSNBC for a few minutes. But that's pretty rare. I'll very seldom turn them on for the purpose of getting news, and that's only for big events like a pope dying. I never ever watch Fox.

And don't even get me started on the local news.

So what do you watch? Where do you get your information?

04 February 2006

It's time for a special prosecutor


MoveOn.org is rainsing funds for an ad campaign calling for a special prosecutor to investigate Bush's domestic spying program. Watch the ad (best morph ever) and donate here.

Weatherblogging

We're having an amazing wind storm here right now. We get these a handful of times each winter, but this one is pretty remarkable. The wind speeds are sustained in the 40s with gusts to the 60s. (The coastal area has hurricane-force winds, sustained in the 60s with gusts to 75.) Our house is situated on a bluff overlooking the Sound, so we get the full force of the wind off the water, and the whole structure shudders and groans with each gust. I look out the window and see all the whitecaps on the water and these enormous trees flexing back and forth.

I kind of like it. It's one of those awesome reminders of Nature's incredible power. Liza hates it, largely because it makes it really hard to sleep, which is true.

Now we're just hoping that we don't lose power for the big game tomorrow.

01 February 2006

A Failed Presidency

1. In the latest Gallup poll, a majority (52 percent) now describe the Bush presidency as a failure. Contrast this to ratings of Clinton, who, from September, 1996 onward, never had less than 64 percent describing his presidency as a success and was usually at 70 percent and above.

2. Remember that classic question of presidential debates, are you better off today than you were [insert number] years ago? In the same poll, Gallup asked whether “things have gotten better or worse in this country in the last five years”. By 64-28, the public said that things have gotten worse, including a 70-21 margin among independents.

3. In the new LA Times poll, by 2:1 (62-31), the public says that the country is not better off because of Bush’s policies and needs to move in a new direction (67-25 among independents and 71-21 among moderates).

4. In the same poll, by 60-32, the public says Bush has not fulfilled his promise to “restore honesty and integrity to the White House”.

5. In the new Washington Post/ABC News poll, the Democrats in Congress are favored by 16 points (51-35) over Bush on the direction for the country, Democrats are favored over Republicans by 16 points (51-35) on having better ideas and Democrats are favored over the Republicans by 14 points (51-37) on which party can best handle the main problems facing the nation in the next few years. The latter measure is the first time since 1992 that the Democrats have broken 50 percent on this measure and had a lead over the Republicans of this magnitude.

6. In the same poll, an astonishing 50 percent–half the country!–strongly disapproves of Bush’s handling of the situation in Iraq.

Posted by the good folks over at Emerging Democratic Majority.

Yikes. Agreed that we shouldn't put too much faith in polls (as we learned to our regret in November 2004), but these are pretty grim numbers.