28 June 2006

A Mystery Solved

You may recall the gentleman who abused his rectum by inserting (or having inserted for him) various items not intended for anal placement. The one identifiable item ws a broken bar glass (note: it was not broken when it was inserted), but the other radio-opague item was more difficult to identify. At laparotomy, the surgeon discovered this:
And yes, that is a socket from a wrench set. It was, the surgeon reflected, the largest socket she had ever seen.

No, this is not a picture of the actual item -- it has been lost to posterity, down the biohazard bag, as it should be. The surgeon estimated the item to be at least 1.5-2 inches in diameter.

People are amazing.

27 June 2006

Rounding at 37,000 Feet - Update

You may recall the fun and excitement on my flight from Athens to New York.

Today I received all the thanks and recognition I was due from a grateful airline, for saving a man's life and saving the good people of Delta Airlines a million dollars.


Words fail me.

25 June 2006

Enough Boring Stuff

Sick of the Health Policy and finance stuff? Me too. Here's a nice freakshow case for your enjoyment.
You are looking at an x-ray of a man's abdomen. He refused to say what the items in his pelvis were or how they had come to be present there. You can see that the lower one appears to be a glass, perhaps a small tumbler, and that it is broken. He presented to the ER because he was passing blood. I do not know what the other item is -- it does not look like glass. I believe that the gentleman wound up with a diverting colostomy; I have not had a chance to talk to the surgeon who assumed care of this patient. I will post an update when the second item has been positively identified.

Yet another reminder that a rectum is a privilege, not a right.

Update: the Mystery has been solved.

23 June 2006

Aha -- there's the catch

I knew it was too good to be completely true. It turns out that in the fine print, CMS gives with one hand and takes away with the other.

In order to maintain budget neutrality, ALL CPT codes with a work RVU component will be decreased by about 10% in value. So the code we had which increased 30% will show only a 20% NET increase. The overall impact on Emergency Medicine (and most primary care specialties) is still positive, but more on the order of 7% rather than my previous estimate of 16%. The impact on procedural specialties is 0% to -8% in revenue. (Someone's gotta lose if it's to be a zero-sum game.)

Still, the increased revenue is welcome, and the equalizing of the playing field, while incomplete, is fair and long overdue.

More Good News

It would appear that the increased reimbursement rates applies not just to Emergency Medicine, but to the codes used in Primary Care offices as well. Their median code value has increased 37%. Great news for all the cognitive-based specialties (as opposed to procedure-based, like surgery). DB's Medical Rants has more. This may just go a little way to prevent the inpending collapse of primary care in the United States.

22 June 2006

BIG news for ER docs

The Center for Medicare Services (CMS) has just released the 2007 RVU values for the Emergency Department E/M codes. See here for the happy details, but the upshot is that the RVUs allocated to the ED codes have increased dramatically.

This is all thanks to the hard work of the guys in ACEP's Reimbursement Committee. They have been active advocates for Emergency Physicians in the house of medicine, and it is by their efforts that working ER docs will now get paid better for the hard work that they do. Specifically, much thanks to Mike Bishop, MD, and Dennis Beck, MD who represented us so ably on the Relative Value Update Committee (RUC), and to Dave McKenzie, the ACEP Reimbursement Guru.

How did they do it? The RUC is a committee which, under the aegis of CMS, brings together representatives of all the medical specialties to set the RVU value of each and every CPT code. Each set of CPT codes are updated at intervals of every 10 years (if I recall correctly). So it is not often that we have the opportunity to make our case that our RVUs should be more highly valued than they have been, and the audience to which we have to make this argument is . . . all the other specialties, who need to be convinced to give some of their RVUs to us. Not an easy task -- there is only a fixed pool of RVUs available.

The line of reasoning chosen was that the practice of Emergency Medicine has changed over the past decade. Patients are older and sicker and require more effort to work up. More workups are being done in the ED rather than upstairs or in the office. EDs are more overcrowded due to the contraction of the number of ED beds nationwide, resulting in longer ED stays and care delivered in the hallways. And EDs are used to board admitted patients, sometimes for days. In short, a complex ED patient requires more work now than ten years ago. (Note that this line of reasoning does not even touch upon malpractice, EMTALA, or charity care; these topics were verboten.)

This was a successful line of reasoning which resulted in the value of a level 4 evaluation increasing 31%, and a level 5 increasing 24%. Given that these are the two most common (and most valuable) codes, that's a massive increase. The level 3 increased modestly ~9%. Level 1 and 2 increased dramatically, 36% and 60%, but those codes were stragely undervalued before, and are pretty uncommon in any event, so the impact of that change is minimal.

So, what does this mean to your practice?

Well, it depends on your case mix. The higher the acuity at your facility, the bigger the impact. But it is likely to be big. For example, our facility sees a relatively high-acuity mix: Critical care - 5%; Level 5 - 17%; Level 4 - 34%; Level 3 - 40%; Level 1&2 - 4%. My prelimimary estimate is that this will result in an increase of 22% in total work RVUs billed -- or an increase of 16% for total RVUs, when you include the PLI and practice expense components. Since our contracts are all based upon RVUs, that should translate into a cool 16% increase in revenue. Same patients, same documentation, same contracts: 16% more money. Given that this is overhead-free money (except for collection costs), it probably will result in an even larger proportionate increase in provider compensation, maybe 20%.

It seems too good to be true. I'm so accustomed to getting screwed by the system again and again, getting squeezed from every which direction, that I can't quite believe that something this good would actually happen. I'm sure not banking on that extra revenue! I wonder if we'll get pushback from commercial payors. It's hard to imagine the Blues blithely shelling out an extra 16% for the same services. But unless they decide not to follow Medicare, I don't see how they could get around it. And an important caveat is that this is not final until CMS signs off on the committee's recommendation (though it would be pretty shocking if they did not). And in any event, it doesn't take effect till 2007.

And we won't get another "raise" for ten years. Sigh. Reality sets in.

Update -- more here.

[Obligatory disclaimer: I too believe that the RVU system is broken -- that it grossly underpays primary care providers, overcompensates procedures, and that this is a major cause of the dysfunctional nature of the US health care system. I further acknowledge that specialists, including ER doctors, are well compensated to begin with. It's not every day that a boy gets a 20% potential pay raise. Let me enjoy it.]

21 June 2006

Single Payor -- what might it mean for physicians?

Jim2 asked, in regard to the preceding post:

What does this mean for government sponsored single payer health care system? Right now, we pay less for the medicine provided to the needing than for the medicine provided to the fortunate. [...] If the government path is not getting enough money to doctors now, is there any hope that the government path would get enough money to doctors if it assumed the primary path now provided by private insurance companies?

First, some simple facts, for perspective:
Medical professional fees are determined by the RVU (Relative Value Unit, a somewhat arbitrary but useful index of physician work). For 2006, Medicare pays $39.90 per RVU. Medicaid pays rather less, on the order of $22 (may vary state to state; rough estimate). Uninsured patients in the ED, of course usually pay nothing, but in the aggregate maybe average $5/RVU. Commercial insurers may pay anywhere from $50-$100/RVU, depending on local markets, regulations, contracts, etc. Depending on its unique mix of payors and contracts, an average ER physician may collect, on average, $30-$50/RVU.

So, Jim, you are completely right, that the governmental payors are on the low end of the reimbursement scale. I would contend that they are grossly underfunded, Medicaid in particular. Medicare itself is so poorly funded that most doctors limit the number of Medicare patients in their practice, and many are no longer taking new Medicare patients. Many physicians actually lose money on an office visit for a Medicaid patient (not so much in the ER, as our overhead is lower).

The most common proposal I have heard for government-funded single payor health care is something along the lines of "Medicare for all." The clear implication from this, for physicians, is that all patients would be reimbursed at the same rate. While you would think this is a good thing, I expect that many doctors would fight it tooth and nail. For a ED group that is well-managed and has a good payor mix, they would face a potential 20% loss in gross revenue (an even larger loss of personal income). Most every group above the median would probably come off worse. Many inner-city groups with poor payor mixes would see an improvement in their incomes, but many of these groups already have governmental subsidies (i.e. for teaching resident physicians).

I think, on balance, the average ER group would come out ahead. There would be some decreased overhead - collections and contracting would be a lot simpler - and the problem of the uninsured would go away. But appprehensive of the possibility of losing income, I suspect that many if not most doctors would oppose. Worse, doctors have been living under the threat of cuts in medicare reimbursement for years, and have only managed to keep up (if at all) by cost-shifting to insured patients. A completely government-funded system would put physicians entirely at the mercy of the annual budgeting process, a prospect that instills terror into the hearts of all doctors. And I should add that I speak only as an ER doctor -- I honestly know little about how such a system would impact primary care physicians or other specialists.

I would probably support a system like this, but not out of self-interest, rather from the perspective of one who is outraged that the richest country in the world cannot provide even basic services to 20% of its citizens. As a physician, I think I might be viewed as something of a class traitor, supporting a plan inimical to the interests of working docs everywhere. I don't know.

Of course, it's all hypothetical, since no serious politician I am aware of is actually proposing such a plan, and were one on the table, the details would be critical to whether it would succeed or fail. And I have heard many other variations on the theme, which might invite more acceptance from physicians. Maybe once we take back Congress in November we might have something to talk about.

But I kind of doubt it.

The cost of ignorance

Today, for the nth time, I saw a child in the ED who had a viral illness characterized by fever, runny nose, and a nonspecific rash, who was not immunized. The parents informed me that they had concerns about autism and mercury in vaccines and had elected to pursue "natural immunity."

I gritted my teeth against the flood of invective that threatened to pour forth (the last thing I need is more complaints), muttered a vaguely contemptuous "That's an interesting strategy," and moved on. The kid was fine and went home. Ironically, the parents were irritated not to be prescribed antibiotics. It boggles the mind.

The concerns about Thimerosal and autism have been well-documented, most notably in an article by Robert F Kennedy, Jr. in a Salon/Rolling Stone article which has since been debunked and contradicted by numerous sources, including the CDC, the American Academy of Pediatrics, and the Institute of Medicine. Orac, of Respectful Insolence, has a nice line-by-line rebuttal. This hasn't stopped Kennedy or his fellow-travelers, who cry "conspiracy" and "cover-up," and continue to spread their misinformation and hysteria. As a result, immunity rates worldwide are declining. In Britain, it has been reported that immunization rates to measles, mumps, and rubella (the most commonly implicated jabs), have fallen as low as 77%, below the level required to sustain herd immunity. Prime Minister Tony Blair refused to publicly confirm whether his newborn child had recieved the vaccine. The consequences are now coming to pass, predictably, and tragically.

There have been confirmed outbreaks of Measles in the UK, as well as Germany, and most recently in Massachusetts. Thousands of cases have been reported. Complications such as pneumonia, encephalitis, and even some deaths have been reported. (In fairness, it seems that only the English, Irish, and German outbreaks are thought to be in large part due to inadequate immunization practices; the Boston outbreak is apparently due to faulty vaccines used in the 60's and worldwide travel.) This, from a disease that had been thought to be all-but-eradicated only a few years ago.

I have never seen a case of measles in clinical practice. I guess I am going to have to make sure I know what it looks like, because by all evidence, I will be seeing it in a few years.

Medicare cuts redux

It looks as if there is an early consensus to freeze the scheduled 5.4% cut in professional reimbursements for 2007. Nothing for sure yet -- no Senate bill, no "legislative vehicle," by which they mean another bill they can tack this on to as an amendment, but at least it's getting attention early this time. They will probably tack it onto the budget again, one would expect. Hopefully, things will move more expeditiously this time around.

Better yet, Ways & Means has started listening to the voices calling for re-thinking the Sustainable Growth Rate (SGR). The SGR is a formula which, based on GDP, determines the amount of money available for reimbursement for services to Medicare beneficiaries. This was initially intended to ensure that the total cost of the Medicare program did not exceed a certain fraction of the GDP, which, on the face of it, seems like a good idea. The unintended consequence, though, is that reimbursements fluctuate on the basis of larger macroeconomic factors, and that in an era of expanded services provided (i.e. more retirees who are sicker, with more chronic illnesses, requiring more services), the payment per service must necessarily go down.

And how. Physicians have already absorbed a 5.4% cut in reimbursement in 2002, and reimbursements are scheduled to decline a further 37% over the next nine years. That's not a typo -- thirty-seven percent. Bearing in mind that medicare already reimburses at pathetically low levels (thirty to forty cents on the dollar), is it any wonder that medicare patients have a hard time finding doctors who will take care of them? I wonder how long it will be before doctors start declining to take any medicare patients (as has already happened with medicaid)?

It's pretty obvious to all involved that the SGR is broken beyond repair and needs to be overhauled. I don't think that Congress has the ability to take it on now, in an election year. It's just too big a project (due to its size and complexity, some have likened a SGR fix to a complete overhaul of the US income tax code). So the best we can hope for is another temporizing measure -- a freeze in the cut, maybe a small increase (the AMA is pushing for a 2.8% increase -- good luck there, guys).

Further updates as events warrant.

20 June 2006

Thinking too hard about comics

From the brilliant but sadly obsessed Comics Curmudgeon:


So, just in case you were wondering, the Lockhorns’ marriage: still a nightmarish, soul-destroying prison from which there is no escape. As usual with this feature, once you start unpacking what’s going on, it’s hard to decide which aspect of this depressing vignette is the most heartbreaking:

  • Leroy has a porn dungeon.
  • The “porn” in Leroy’s porn dungeon consists of PG-13-rated pictures of girls in bikinis.
  • Loretta knows all about Leroy’s porn dungeon, possibly because he’s made no attempt to hide it.
  • Loretta casually points out Leroy’s porn dungeon to houseguests.
  • Loretta casually points out Leroy’s porn dungeon to houseguests with that stricken yet resigned look on her face that says, “Oh, God, if I had known what was in store for me, I would have drowned myself when I was a little girl!”
And I thought I could overthink Fred Bassett.

He's right, though.

Metapost

Cleaned up and expanded the blogroll and sidebar. Nothing major, but I highly recommend the blogs listed -- If you haven't yet, check them out.

15 June 2006

The Sky is Blue, Water is Wet, yadda yadda yadda

The Nation's ERs in Crisis, says the Institute of Medicine.

But we already knew that.

Less dense AP summary report here.

So what else is new?

The Hand of the Almighty

Whether or not you like old-timey music, you should take a moment to check this out.

Credits here.

14 June 2006

Bush and the Sunglasses

Via Crooks & Liars:

Today, at a presser, this exchange happened with Peter Wallsten of the Los Angeles Times:

Bush: You gonna ask your question with shades on?

Wallsten: Yes...

Bush: But there's no sun out here.

Wallsten: It depends on your perspective.

Bush: Touché.


Wallsten is blind...

08 June 2006

Perspectives

A commenter wrote:

Congrats on your transatlantic heroism! I did get a funny feeling reading the story though. I know it must be annoying to be singled out, especially amid the stresses of traveling. And as a non-doctor of course I can only imagine what it's like facing these situations. And I know that with a story like this where you practically need a triage center on the plane, grumbles about bad luck and inconvenience may be exaggerated for stylistic effect. Nevertheless, I can't help but be bothered by the cavalier tone. Put yourself in the shoes of the panicked woman, or the guy too short of breath to speak, and think about how you'd feel if possibly the only person on the plane who can help you is using iPod headphones to drown you out... Yeah, it must suck to be constantly "on call," but doesn't it kind of go with the territory? I always thought people wanted to become doctors because they were passionate about helping people.

Am I cavalier? Well, the title of this blog is "Movin' meat." so I guess the answer to that has got to be "yes." There are two sides of every medical interaction, and from the consumer side, it *always* sucks, whether you are seeing me in the ER or on an airplane or elsewhere. And from the professional side, it's always kind of routine (though less so over the Atlantic Ocean). But every day, I care for people who are afraid, in pain, etc. It's just not possible for me to give each of those people my full emotional empathy. I've got the compassionate mien down, so you could never tell, but inside my personal emotional state is (usually) a million miles away. Obviously, as any reader of this blog knows, some cases affect me more than others. An emotional distance between the doctor and the patient is almost necessary as a defense mechanism, a survival trait for the doctor.

To those who see behind the veil: the family member who stops and listens at the nurses' station, non-medical persons who read this blog, etc, it can be more than a little disconcerting to see the emotional disconnect. It's hard to understand how a doctor can walk out of a room with a dying patient and grieving family, and seamlessly switch gears into laughing and talking about baseball. Until you have done it, it's hard to really wrap your brain around the fact that, to us, "It's just a job." Not that we don't care about it, not that it isn't important, but you don't bring your work home with you. So to speak.

I'm reminded of one time I was sewing up a laceration on a teenage girl's arm. She was a bit weepy and anxious, and she *hated* the anesthetic injection. As I worked, we chatted, and she said that she had wanted to go into medicine, but she didn't think she could handle it. "I don't understand how you can do this," she said, "Isn't it hard?" I thought for a moment and said, "No, not really. It isn't my arm."

As to "Next time," well, last time I swore that I wouldn't answer the call, but I did. Maybe I will suck it up again. Maybe I'll follow the advice of a partner who confided that as soon as he gets on the plane he has a few drinks so he *can't* answer the call -- now that is cynical! Who knows?

06 June 2006

Grand Rounds 2:37

Grand Rounds is up over at The Medical Blog Network. Go Enjoy Yourself.

04 June 2006

Sea Urchins are not as warm and cuddly as you might think

And other useful lessons from Greece. I knew this in the theoretical, but now I know it in a very concrete, personal way. Whilst swimming in the Aegean Sea, I experienced an inadvertent encounter with a member of the class Echinoidea. To wit, I kicked one while treading water.


The above is a photo of my left big toe after a fellow traveler (who happened to be a nurse) had extracted about twenty spines from where they had embedded deep into the flesh. She used my own medical kit that I had brought along to use on other people. Not me. Oh, the irony. And the agony. The urchin encounter was painful but brief, and the resultant pain was but a dull ache. But there's nothing like half an hour of cold hard steel lancing into live tissue to carpe your diem. I should have used my lidocaine to perform a digital block, but I didn't anticipate the sublime intensity of the forthcoming pain, and I am a bit of a wuss, so I am not sure if I could have injected myself anyway.

Oh well, better half an hour of exquisite raw sensory torture than a suppurating infection and subsequent amputation, I always say!

Other than that (and the fact that the airline managed to lose our luggage both ways), the trip was lovely. We spent two lovely weeks sailing through the Dodecanese Islands off of the coast of Turkey, with a few days of stamping though various and sundry ruins in Athens and on the Peloponnese. Turns out they have rather a lot of those. I had fourteen blissful days of no email, pager, cell phone, TV, newspaper, and to my great surprise, I missed them not at all. I did miss The Boys, but only a bit (and The Wife missed them about as much as I missed my pager). I learned to speak enough Greek to get by, provided the Greek person to whom I was speaking also spoke excellent English. I managed to gain five pounds on my version of the Mediterranean diet (which contains rather more Fried Cheese than the other Med. diet), and have discovered a deep love for Greek food. I need to see if I can get decent dolmades anywhere herabouts. We drank a fair amount and laughed a lot. I got reacquainted with The Wife and discovered that I she is actually good company. I'll post some photos one I recover from the physiologic shock of re-entry into the real world.

That may be never.

Also, I should put in a plug for the sailing outfit we went with. They were terrific on every level. Wonderful, all-included, with a great knowledge of the islands, and a heck of a lot of fun. If you're ever inclined to go sail the mediterranean, check out the nice folks at Seascape.

02 June 2006

Rounding at 37,000 Feet


Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

"But Gee," I can hear you think, "Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory?" Well, yes. But. First of all, there is the performance anxiety thing. I'm used to working with a very small audience. In Economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room -- and I know they are very interested in what's going on. Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

So, on Olympic Air, somewhere over the mid-atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back. Great, I thought to myself, It's an Aortic Aneurysm. (see? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again . . . there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking somone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that. The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell.

As I stood up, I saw an elderly man about ten rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in. Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain.

I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane.

So I sat up in first class with him to keep an eye on him (The Wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be -- probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better.

And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.