Gupta out at Surgeon General?

So hints the WaPo's Al Kamen:

PROGNOSIS QUESTIONABLE

It's been seven weeks since we noted that neurosurgeon and CNN medical reporter Sanjay Gupta, one of People Magazine's Sexiest Men for 2003, was in line to be nominated as surgeon general. But then time passed and former Senate majority leader Thomas A. Daschle's nomination to run the Department of Health and Human Services blew up, much to Gupta's dismay. Buzz is that he's now rethinking whether the job is as attractive as it had appeared. The answer may be linked to the future of the proposed White House Office of Health Reform, which Daschle was also to head, and what part Gupta will play on the new team.

Interesting.  Many have commented that Gupta was an unconventional choice for Surgeon General, having no public health experience.  The theory was that he would function as the administration's media front-man on health care reform.   If that role is not in the offing after all, then it stands to reason that his enthusiasm for the job might wane.

The Hard Part

So Obama has proposed a national health insurance plan which would be, ostensibly, more or less universal.   Great!   Let's declare victory and go home!

What? 

We have to pay for it?

I thought it was supposed to be free.

Crap.

Tomorrow, the Washington Post and Wall Street Journal report, Obama will release the blueprint for a budget with will make a "down payment" on financing his health care package.   Key details:

• Estimates vary, but universal health insurance is expected to cost about $100 billion annually, or a Trillion dollars over the ten-year time horizon they use in BudgetLand.  His finance plan covers about $634 billlion of that amount, leaving Congress to find the other $35 billion annual allocation.
• New taxes are in the mix, and they are targeted at the wealthy.   Deductions would be limited or eliminated for taxpayers with incomes over $250K.  This provision would raise $318 billion.
• Medicare Advantage programs, in which private insurers are paid an average of 14% extra to cover Medicare beneficiaries, would be subject to competitive bidding.  This would save $175 billion, and, this author suspects, would essentially phase Medicare Advantage plans out of existence.
• Medicare would no longer pay for re-admissions within 30 days of a hospital stay, and will penalize hospitals with a lot of bounce-backs, at savings of $25 billion.
• Expanding the Hospital Quality Improvement Program (saving, according to the Obama administration $12 billion over 10 years);
• Wealthy medicare patients would have higher premiums for the Part D drug plans.
• Drug makers will have to increase the rebate on drugs for Medicaid patients from 15% to 21%
• Reducing drug prices by allowing more generic drugs on the market
• Improving Medicare and Medicaid payment accuracy

More details will come out of the health summit next week.   At this point, the principles outlined by the administration regarding the health plan itself are sparse: all will Americans have their choice of health plans, will have the option of keeping their employer-provided health plans, there will be subsidies for some, and an expanded role for medicaid for the indigent.   The working assumption at this time is that the universality of the plan will require mandates, but to my knowledge the administration has not clearly articulated that point, and may be taking an incremental approach.

A couple of thoughts:

• Expanding Medicaid is a bad idea.   It can cover drugs and hospital-based acute care, but it a huge drain on inelastic state budgets, and the reimbursement rates on medicaid are unsustainably low.   Most private physicians simply will not take Medicaid patients -- in this case, the government may be providing health insurance, but is not providing meaningful access to health care.   (Further, I've always found it morally offensive that the life of a poor person is worth less than that of a retiree.)  Ideally, Medicaid should be ended; if impossible, its reimbursement should be brought into line with Medicare's.
  
• Medicare Advantage is an expensive boondoggle; if its costs are brought in line with standard medicare, that will be a good thing.  If it cannot survive on its own, then the market will ensure its extinction.
• Taxes.  Obama just signed the biggest tax cut in history into law -- and it's aimed squarely at the middle class.  The obligatory tax increases are being aimed at people like me, who can afford them.   It's like I've died and gone to progressive heaven.
• Hospitals will feel the pinch, but it may help improve quality if they respond -- lower costs and higher quality?   Where's the catch?  
  
• I suppose it's a bit too inside-baseball for a blueprint like this, but I'm still waiting to see if they are going to take on the contentious and necessary physician payment reform as part of this package.   I'm suspecting not.
• Though Obama has acknowledged the necessity of cost containment in health care as an integral element of health care reform, I do not see anything here which will do much to truly rein in costs.   We'll see if that is addressed in the health care summit next week, or if they kick that can down the field a bit (which is more likely).
• "More accurate" Medicare payments is probably a euphemism for the expansion of the RAC program.   Bear in mind it's mostly aimed at hospitals, but is beginning to turn its attention to physicians.
  

Exciting times.   Gotta give the man credit for having the balls to stick to his guns and put health care out there in the middle of a recession, but then, this is a perhaps one-time opportiunity to get it through.   This was a tough first step -- acknowledging the costs (partly).   There are a lot more difficult decisions to make, and we'll see if his team confronts them as well as they have this one.

[Updated: more details via Jake Tapper]

Cancer sucks

Just sayin'.

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Another Loss

Henry Scheck passed away this morning with his family at his side.   I grieve for their loss.

ACEP Re-introduces its bill

Today, Reps. Bart Gordon (D-TN) and Pete Sessions (R-TX) in the U.S. House of Representatives, and Sens. Debbie Stabenow (D-MI) and Sen. Arlen Specter (R-PA) in the U.S. Senate introduced the "Access to Emergency Medical Services Act of 2009."  This bipartisan bill has 50 co-sponsors in the House and 4 in the Senate, and is essentially unchanged from the bill of the same name introduced in the last Congress.

The intention of this bill is to address the crisis in ER overcrowding, patient boarding in the ER, and unfunded care mandated under EMTALA.   As readers of this blog probably know, the number of ED visits annually has increased from 90 million to over 120 million, while the number of EDs has decreased by 10%.   This has resulted in skyrocketing volumes at the remaining departments.   The patient boarding epidemic shows no sign of decelerating, as the number of hospital beds nationwide continues to shrink.   And the obligation to provide uncompensated care imposed by EMTALA continues to discourage specialists from taking ED call, jeapordizing patient care.

The bill would require:

(1) Bipartisan Commission on Access to Emergency Medical Services:  Following the recommendation of the
IOM, the bill creates a commission that will examine factors, such as emergency department crowding, the
availability of on-call specialists and medical liability issues, which affect delivery of emergency medical
services.
 
(2) Emergency/Trauma Physician Payments:  Authorizes an additional payment through Medicare to all
physicians who provide EMTALA-related care, including on-call specialists whose services are needed to
stabilize the patient. The additional funding would help ensure emergency and other physician specialists are able
to continue providing care to the growing Medicare population.  These payments would neither increase Medicare
beneficiaries' co-payments nor negatively impact any other physicians' Medicare payments.
 
(3) Emergency Department Boarding/Diversion:  CMS would develop hospital boarding and diversion
standards, working through consensus-based organizations such as the National Quality Forum (NQF) and
Hospital Quality Alliance (HQA).

This is a common-sense, non-partisan bill which did not ignite any controversy in the last legislative session.  Unfortunately, it got crowded out by the Presidential race and the economic crisis.   Generally, for a bill like this to get out of committee, it needs about a hundred co-sponsors in the House and ten or twenty in the Senate.   ACEP has a tool on their web site for you to contact your legislators and ask them to review the bill and consider signing on as co-sponsors.  You may get more leverage by calling their DC office in the House or Senate and asking to speak to the LA (Legislative Aide) responsible for Health Care issues.  Often the LAs are more in tune with the details of individual bills and are very influential in shaping the Members' policy positions.

Full text of the proposed bill, as well as fact sheets and other resources may be viewed here.

Kevin Makes the New York Times

Well Done.

Key graf:

Universal coverage must go hand in hand with the training of more primary care providers — not only doctors, but also nurse practitioners and physician assistants who can provide excellent primary care. According to the Association of American Medical Colleges, there will be a shortage of 46,000 generalist physicians by 2025, a deficit that not only will balloon under any universal care measure, but cannot be made up as both doctors and mid-level providers gravitate towards more lucrative specialty practices.

And the flight of generalists will not be halted until reimbursement reform takes place to change the financial incentives away from specialization and back towards office-based practice.

Will the RUC take this lesson to heart?

XKCD

What can I possibly add to this?  Nothing.

Two more tidbits

Obama said in his non-SOTU today that health care reform cannot wait another year, and "must" be enacted this year.   Interestingly, Elana Schor wrote today at Talking Points Memo:

"There is an acknowledgment on both sides that something has to be done" on health care, Senate GOP Conference Vice Chairman John Thune (SD) told me, adding openly that more than three members of his party "are gettable" for a health reform bill this year. ... "You could get a lot more than three Republicans" to back the coming health reform bill, another Senate GOP leader, Policy Committee Chairman John Ensign (NV), told me. The key, as he described it, is the process Democrats use for consideration of the measure.

Interesting.   I had assumed that the stimulus bill was a precursor and warm-up for a scorched-earth battle over health care.  That senior republicans are making conciliatory noises this early is encouraging indeed.   It could be a ruse, of course, and the process is only filled with a million potential pitfalls, but it would be an amazing political feat to see a national health care plan pass with more than one (let alone more than three) GOP votes.

On a slightly more wonky note, Joe Paduda over at Managed Care Matters delves into different political battle field and writes:

It looks like reimbursement for cognitive services - the 99xxx codes ... will be increased while payments for surgeries, imaging, and other 'procedures' will be reduced.

This just makes sense. Primary care physicians have seen their total compensation slide year after year, while those doctors specializing in 'specialties' have seen slight increases. There is a shortage of primary care docs - newly minted physicians can't afford their debts on $125k a year, so they have to specialize in one of the more lucrative areas if they are to have any hope of a decent income. ... Reducing compensation for specialists is going to ignite a political firefight - one that will be loud, violent, and ugly. It is also long overdue. There are going to be winners and losers in health reform, and one group that looks likely to lose is specialists.

It's not clear to me whether Joe has a source for this or if it's just a reading of the tea leaves by one with experience in the system.

Health Wonk News of the Day

This is a fun time to be a health policy nerd.   (This is an especially fun time to be a progressive health policy nerd.)   There's just so much going on, and much of it is good.   Things which caught my attention today:

Ezra Klein reports that Obama's speech tonight will include a proposal for a universal health care plan.   This is significant in that it is a shift from candidate Obama's mandate-free plan, or at least signals that he is willing to follow Congress' lead in developing a universal health insurance program.

The Wonk Room reports that polls indicate that Americans strongly support health reform as a top domestic priority; 72% favor a program that would increase the involvement of the federal government to provide heath insurance to more Americans; and 66% agree that it is the "responsibility of the government" to "make sure" that all Americans have health care.

In more ominous news, Obama has insisted that entitlement reform is inextricable from health care reform, and a HHS study out today shows that health care continues to grow as a share of GDP (exacerbated by the contraction in GDP) from 16.6% to 17.6%, with costs rising to $8,000 per person, and the ranks of the uninsured swelling to 48 million.   The rise in costs will result in the Medicare Hospital trust fund running out of cash as soon as 2016, earlier than previously anticipated.   Ezra reminds us, however, that this is not a "medicare" problem, but a problem of the overall excess growth in health care spending from all sources:
The CBO notes that over the past 30 years the cost of heath care has increased about 2% more than the increase in income, each and every year.  The compounding effect of this excess growth has led to the tripling of the fraction of GDP dedicated to health care from 5% to the current 17+%.

So, if Obama and the congress are intent on tackling the cost of health care in tandem with the expansion of health insurance to all Americans, they have their work cut out for them, don't they?

Univ of Chicago vs ACEP

This one just won't go away.

So, to summarize for those keeping score at home:

• U of C starts a program to redirect non-emergent patients away from the ER to community health centers and other hospitals.
• The Chicago Tribune and community activists suggest that U of C is engaging in patient dumping.
• A case is published by the Trib in which a child with a dog bite to the face is discharged from the UCMC ER with instructions to "follow up at Cook County."
• ACEP releases a press release strongly condemning the UCMC program.

New development: University of Chicago fires back.

I have received (from multiple sources) documents in which UCMC strongly defends itself, the care provided to the child with the dog bite, and criticizes ACEP president Nick Jouriles for the "reckless and uninformed" press release sent out by ACEP. Their key points include a complaint that ACEP did not contact UCMC prior to releasing its statement, which essentially accuses UCMC of patient dumping, and a contention that delayed primary closure is within the standard of care for this sort of injury.

As far as the ACEP release, I admit to ambivalence. Standard journalistic practice is to contact the subject of an article for comment prior to press, but ACEP is an advocacy organization, and not subject to the same constraints that bind media organizations. I suppose it would have been polite to call the UCMC ED chair for insight prior to jumping on the bandwagon. On the other hand, I note that the ACEP release called for congressional hearings, which without doubt would have been used not to condemn UCMC but as a platform to advocate for strengthening the safety net that is the nation's emergency departments. So I would say that the ACEP release, while perhaps rude, fits neatly within the general mission of the college, of improving access to emergency care.

The contention that the care provided to the child, Dontae Adams, was "appropriate" is in my mind highly suspect, despite the joint statement (PDF) from the Chairs of Plastic Surgery at both UCMC and County, and the citation of the ACEP "policy" on wound management. Again, I qualify this in that I did not see the child or review the record. But the statement from the plastic surgeons "we believe Dontae would have been well served either with delayed surgery, as the University of
Chicago team recommended, or with the immediate surgery performed by the physicians at Stroger Hospital. Both options are acceptable..." is weak tea, my friends. Similarly, a commenter cites an "ACEP recommendation" that "Delayed primary closure is ... best used for wounds at high risk of infection, such as heavily contaminated wounds, wounds from animal or human bites."

First of all, note that a seven year old opinion in a non-peer-reviewed publication (PDF) is not a clinical policy. ACEP has plenty of clinical policies which reflect consensus opinion on important topics as informed by the current evidence. None address this injury. Secondly, note that the cited opinion is actually contradictory to the incident case. I and the evidence agree that infected wounds and wounds at risk for suppuration should not be closed at the initial presentation. However, dog bites to the face, presenting promptly, are not at particularly high risk for infection when washed out and debrided appropriately. The excellent blood flow to the facial structures make it a very low risk area for infections, even for dog bites. Given the importance of cosmesis in this area of the body, unless there is a high degree of devitalized tissue present, there is no good reason to delay closure of the wound.

The real test here is "what would you want for your child?" Or, since parental preference clearly did not drive care at UCMC, what would be the common practice for an insured patient in a "normal" hospital for a disfiguring facial dog bite? Primary closure, that's what. This is what makes University of Chicago look so bad -- the deviation from the common practice, and the diversion of an indigent patient elsewhere.

The University of Chicago team could make a good case to a jury in a malpractice trial that their care was within the standards of care. I'll buy that. Delayed primary closure is, technically, a persmissible option. I'd vote to acquit. But the real-world question here in the court of public opinion is not malpractice, but patient dumping. And on that front, UCMC is guilty, guilty, guilty! Had they referred Dontae to their own plastic surgery clinic, I would be much more charitable in my conclusions here. You take care of your own, right? But that is not what happened. They turned the child away with the instruction to "go somewhere else," on the thin pretext that it's (barely) within the standard of care.

And make no mistake, the Cook County plastics guys signed on to the extremely tepid defense of Dontae's care out of courtesy alone. You may note that they did the right thing: they repaired the child's injuries on initial presentation. Because it's the right thing to do medically, and it's the right thing to do as a humanitarian. They were not about to throw University of Chicago under the bus, but in this case their actions speak much louder than their words. They knew bad care and an unavoidable patient dump when they saw it, and the County guys stepped up and took care of the patient.

Ultimately, I have sympathy for UCMC: they are overwhelmed, and they are looking for creative solutions to decompress their ER. They took a risk with this program, and I respect creative thinking in trying to make scarce resources stretch farther than they are capable of. My advice (had they asked me which of course nobody ever does) would have been to admit that in this case an error was made and that policies would be improved and it would not happen again. By persisting in a futile defense of bad care, they just wind up making themselves look worse and inviting tighter scrutiny of a policy which is controversial even in the best of circumstances.

Pharyngula Nails it

"We consider ourselves atheists and scientists."

Skiing Mt Hood

Be warned: take your meclizine before watching! It turns out that skiing whilst holding a camera at arms' length pointed down hill is pretty difficult, and the resultant video is a bit, um, jerky.

Skiing at Mt Hood, Oregon from Shadowfax MD on Vimeo.

This is only a blue run. I tried to film a couple of black diamonds, but simply couldn't keep the hill in the frame. (In fact, I kept dropping the camera -- thank god for wrist straps!) I need a helmet cam, I think.

Mount Hood is such a pretty mountain.

The Workhorse Group

Another note from today's New York Times:

Since last fall, many of the leading figures in the nation’s long-running health care debate have been meeting secretly in a Senate hearing room. Now, with the blessing of the Senate’s leading proponent of universal health insurance, Edward M. Kennedy, they appear to be inching toward a consensus that could reshape the debate.

So, who's represented at the so-called "Workhorse group"?

The 20 people who regularly attend the meetings on Capitol Hill include lobbyists for AARP, Aetna, the A.F.L.-C.I.O., the American Cancer Society, the American Medical Association, America’s Health Insurance Plans, the Business Roundtable, Easter Seals, the National Federation of Independent Business, the Pharmaceutical Research and Manufacturers of America, and the United States Chamber of Commerce.

Dr Wes is annoyed at the representation of so many interest groups. I would counter, however, that a big part of the reason health care reform failed in 1993 was the failure of the Clinton administration to get all the stakeholders together and to come to consensus prior to the introduction of legislation. If the Chamber of Commerce is not on board, they will be on the outside throwing hand grenades and disrupting the process. They may never sign on -- I don't know. But AHIP and NFIB were active opponents of health care reform the last go-round, and if they are on board, that may go a great way towards removing massive obstacles to the legislation.

The key points of the emerging "fragile consensus" seem to be:

• A mandate for all persons who can afford it to purchase health insurance;
• Means-tested subsidies of the cost of purchase, for those who qualify;
  
• Enforcement of the mandate via a tax penalty;
• Community rating for private health plans;
• A "Floor," or minimum standards for benefits provided by heath plans;
  
• Expansion of Medicaid eligibility.

Still up for debate:

• Pay or Play, or a requirement for large employers to provide health benefits or pay a supplemental tax;
• A public plan, such as opening the FEHBP to any citizen, to compete against private insurance plans.

This is pretty good progress, if it can be believed -- and were I a cynical man, I might suspect that this memo was leaked to the Times to cement the compromises made thus far as "done deals." The insurers' lobby has apparently accepted the bitter pill of community rating (requiring them to charge all comers the same rate) in return for the universal mandate (which will bring many more customers to their business, expanding their revenue base to offset the expense of community rating). Fair enough. If the negotiations don't blow up, this is an excellent starting point. If the strongest opponents of reform can be co-opted into support, albeit tacit, or at least non-opposition, that will give Obama a huge leg up, and the ability to use the bully pulpit to argue for the few remaining progressive priorities.

Also interesting is the fact that the republicans have chosen to absent themselves from the process. One can infer from this that they will take the same tactic on health care reform that they did for the stimulus. Namely, whine about the lack of "bipartisanship" and reflexively oppose. Of course, if right-wing organizations like the Chamber of Commerce are in support, it will be hard to make any credible claim that this is ideologically-driven left-wing partisanship. This legislation is also more likely to attract support from GOP moderates like Snowe, Collins and Specter, making the obstructionists in the rest of the dead-end caucus that much more irrelevant. Just as well, since they still don't seem to have any new ideas.

One more note: apparently Obama is going to use his big Budget speech on Tuesday to open the debate about health care reform, and as I mentioned previously, Baucus is beginning Senate hearings on reform the very next day. And so it begins.

No More Magic Asterisks

From today's NYT:

For his first annual budget next week, President Obama has banned four accounting gimmicks that President George W. Bush used to make deficit projections look smaller. The price of more honest bookkeeping: A budget that is $2.7 trillion deeper in the red over the next decade than it would otherwise appear, according to administration officials. The new accounting involves spending on the wars in Iraq and Afghanistan, Medicare reimbursements to physicians and the cost of disaster responses. [...]
Even with bigger deficit projections, the Obama administration will put the country on “a sustainable fiscal course” by the end of Mr. Obama’s term, Peter R. Orszag, the director of the Office of Management and Budget, said Thursday.  “The president prefers to tell the truth,” he said, “rather than make the numbers look better by pretending.”

Now that's refreshing -- honest accounting?   Telling the truth to the American people about exactly how deep the hole we are in actually is?  

It's weird to have a president who talks to us like we are grown-ups, and thinks we have a right to know the truth about the status of the federal government's finances.

Now as for their plan to balance the budget this term while also enacting universal health care at the same time . . . well, even I'm skeptical of that one.

ACEP Piles on Univ of Chicago

Executives at the University of Chicago Medical Center had hoped their initiative to divert some patients from its emergency room would spark a healthy national debate.

Now they've got one.

The nation's largest group of emergency physicians on Thursday condemned U. of C.'s plans, saying it comes "dangerously close" to violating federal law and calling for a congressional investigation. U. of C.'s initiative is aimed at clearing its ER of patients with non-urgent injuries and illnesses by redirecting them to community hospitals and clinics.

Surprised?  Not me.


Via Symtym

Number of uninsured skyrocketing

Yikes.   According to this report from ThinkProgress, the ranks of the uninsured are swelling at a staggering rate of 14,000 a day.

Granted, it's not exactly surprising, given the 627,000 new jobless week after week, as the newly unemployed tend to rapidly turn into the newly uninsured.  This may improve a bit as the stimulus provision subsidizing COBRA coverage becomes operational.  Admittedly, that's only a stop-gap solution.   Apparently, Max Baucus has scheduled his first hearing on comprehensive health care reform for the 25th (the day after Obama's budget speech).

The impact of the newly uninsured is already being felt in our ER.   Volumes continue to rise, and we are seeing a small but significant increase in the number of "private pay" patients ("private pay" being a euphemism for "no pay.") and also a decrease in the number of commercially insured patients.   I only wonder how bad this will get before a recovery begins or a national health care plan is in place.  I'm not exactly going to hold my breath for either possibility -- it looks like we are probably in for a long, lean year at the very least.

Darwin Funny

Via Crazy Andy; T-shirts and posters are available from the creator with proceeds to go to the National Center for Science Education.   I think I will be sporting one of these soon!

An email from an old friend

I have an old buddy -- we go back a few years, are from the same home town, and we used to be real tight.   He spent a lot of time on the road, and used to email me several times a week, sometimes on a daily basis.   We had a whole posse, actually, and though we didn't live in the same city any more, the whole crew was really good about keeping in close touch, mostly via email, but calling my home pretty frequently, too.  

But a few months back, he got a new job -- a big promotion.   He doesn't have to spend nearly as much time traveling any more, and I figured we'd be able to hook up, maybe get a beer or hang out.   But no.  As soon as he got this new job, it was like he vanished off the face of the goddamn earth.  No more emails.  No phone calls.  Nothing.   I mean, I get it, he was busy, but is that any excuse for not keeping up with your friends?  You get a new job and all of a sudden you're too good for me?  He dropped me like a warm turd.  Yeah, I got the occasional message from the crew, a sort of desultory "He hasn't forgotten about you -- he still cares," email, but whatever.  I got over it.  It's not like I haven't been dumped before.

So I was a little surprised to see an email from him in my inbox today.  What does he want?  An apology?   It was with a mixture of suspicion and curiosity that I opened it to read:

Shadow --

Today, I signed the American Recovery and Reinvestment Act into law.

This is a historic step -- the first of many as we work together to climb out of this crisis -- and I want to thank you for your resolve and your support....

Figures.  It's always work with him, isn't it?  

Mount Hood

Ski day today.

An important note to Twitterer-Bloggers

IF:     You are a blogger,
AND IF:     I have bothered to sign up as a follower on Twitter,
THEN:     You may conclude that I already read your blog.

IF:     I am savvy enough to follow you on Twitter,
THEN:     I am probably also savvy enough to be aware of RSS feeds for blogs.

THEREFORE:   You do not need to tweet every time you have a new blog post up,
BECAUSE:    My RSS reader will let me know.

CONCLUSION:   Please make your tweets more interesting.

QED

Late Night

Rock on.

Best Avatar Ever

Must belong to MIA, a nursing student in the Midwest who apparently just passed her first round of exams!   Congratulations to her for her academic prowess and for the insufferable pop culture coolness to remember the Animaniacs!

The day of the shaving approacheth!

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Just under a month to go before I will be shaving my head to cure pediatric cancer. So far, through your generosity, I have raised almost $4,000, which is almost 40% of my goal of $10,000! You guys rock!

Once again I would like to thank those of you who have already made a gift, and ask those who have not yet to consider a donation. Even small sums of $50 or so are valuable and necessary. St Baldrick's is the largest private foundation dedicated to the cancers which strike down children, and raised over $18 million last year. Of that, over 75% went directly to research towards cancer therapies. With the current economic climate and the general dearth of governmental funds for pediatric malignancies, organizations like Baldrick's are essential in keeping the research moving forward.

Research like that performed by my friend BethV, who is working on a nasty cancer called medulloblastoma. She is working on the signal transduction pathway that is responsible for the activation of the "cancer gene." This pathway was whimsically named "Sonic the Hedgehog," by an anonymous grad student in the lab late one night. A funny name for a serious disease. Beth's task now is to find compounds that can shut off this pathway, and she is screening some very promising candidates. This work is funded in large part by a grant from the St Baldrick's foundation.

Unfortunately, useful clinical therapies from this work may come too late for Henry, whose medulloblastoma was diagnosed only in October 2007, but has proven resistant to treatment, and Henry is transitioning to hospice care; my heart goes out to him and his family. Medulloblastoma is the most common brain tumor in children, and no effective treatment is available for recurrent disease.

And a cure, when it comes, will be too late for Nathan, who lost his battle against neuroblastoma in July 2007.

So, if you can, please take a moment and visit the St Baldrick's web site and make a donation; whatever you can afford. Together, we are doing our part to support scientists like Beth on their work towards cures for these terrible diseases. And remember, all donors will receive a free, high-quality digital image of me, freshly shaven and goofy-looking for your viewing enjoyment. Print it out and draw a mustache on it! Put it on your dartboard -- next to the picture of Barack Obama! Frame it and build a small shrine in my honor! The option is yours, and there's no wrong choice. So what are you waiting for? Click the link and make a gift!

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I must have missed this

Joe Paduda reports that last week, the FDA announced that they are "considering" a requirement for additional training for physicians to prescribe certain "high risk" opioid medications.  The list is pretty much exclusively the long-acting narcotics like oxycontin and fentanyl patches.

Hmmm.

I don't know quite what to think about this.   On the one hand, my "Physician Deity Syndrome" instinct is to bristle at the suggestion that I need more training, some sort of merit badge, in order to continue doing what I already do.   On the other hand, I know a number of doctors who merit the appellation "candyman" and a little refresher (and reminder of stricter oversight) might not be a bad thing.   It's challenging when you see their patients come to the ER over and over with their chronic fibromyalgia and they are already stoned on narcotics and insisting they need more.

From my very provincial perspective, it has the potential to make life easier.  I pretty much never prescribe long-acting narcotics from the ER, of course, so I would likely not seek out the merit badge.   We get a number of patients who present seeking prescriptions for these meds -- "I lost them," "Doctor out of town," and similar tales of woe.   Solution!   "I'm sorry, but I'm not licensed to prescribe that."   The only problem is on those rare occasions when I do have a legitimate indication to prescribe it, say a cancer patient with uncontrolled pain, or a new pathologic fracture, then my hands are tied.

It will be interesting to see if this goes through.  It's not unprecendented -- Suboxone was released with a restriction on the providers who could prescribe it.   I am not sure if Suboxone is still subject to that restriction, but it's another drug that I'm just as happy not to prescribe through the ER.   But that's a small niche drug, whereas the long-acting narcotics have a much larger market presence.

(As an aside, given the presence of certain key words in this post, I fully expect this post to have ten times the traffic of a usual post, and some annoying spam in the comments.  We'll see if that turns out to be the case.)

The Time is Right

Via Yglesias and Atrios, there is an interesting new CBS/NYT poll out today which shows that the american public is much more prepared to accept a primary role for government in the provision of health insurance.

HEALTH INSURANCE
 
Americans are more likely today to embrace the idea of the government providing health insurance than they were 30 years ago. 59% say the government should provide national health insurance, including 49% who say such insurance should cover all medical problems.
 
In January 1979, four in 10 thought the federal government should provide national insurance. Back then, more Americans thought health insurance should be left to private enterprise. 
 
HEALTH INSURANCE:  PRIVATE ENTERPRISE VS. GOVERNMENT?
                                            Now       1/1979
Private enterprise                    32%        48%
Government – all problems      49            28
Government – emergencies      10           12
Don’t know                              9            12

I don't think that the public is inclined to trust the government more now than they were 30 years ago -- quite the opposite.   But the experience of a private enterprise system has persuaded people that the government couldn't possibly be worse.   Never mind the 46 million left uninsured by private enterprise, it's the incessant hassles -- pre-authorizations, referrals, denial of claims, and retroactive cancelling of claims that has led a plurality of americans to conclude that they's be better off being done with private insurers and letting the government taking care of them.

Single-payer is not even on the table (Max Baucus, asked directly, said "I'm not going to waste my time on that.") but it's pretty clear that people are ready for an expansion of the public sector's role in health insurance.  It's serendipitous that this comes at a time when the planets are aligning in favor of the same -- a president committed to a national health plan, large democratic majorities in both houses of congress, and a rare consensus between labor and industry that health insurance should be guaranteed to all.  Now is the time.

Big City

Sorta weird to see Obama hanging out in Chicago for the holiday weekend.


I've gotten very accustomed to presidents who go to secluded spots for their R&R: Crawford, Martha's Vineyard, Kennebunkport, some fake ranch in California.   I wonder if, after some time, the Secret Service, or the neighbors, or both, will get so fed up with the hassle of having POTUS in Hyde Park that they will gently redirect his presidential ass back to Camp David...

Do not pray for easy lives

So said President Obama, quoting JFK, as he spoke yesterday on the passage of the economic stimulus bill.  

The politics are interesting: Obama got exactly what he asked for, and passed the largest tax cut, and largest spending bill in history within three weeks of his inauguration; progressives are unhappy with what they view as an insufficient stimulus; and the GOP casting itself as the Grand Obstructionist Party.   How's that working out?  Not too well: the approval of the congressional republicans is tanking. 

It's hard not to view this as a big win for the new administration; I guess they meant it when they said they wanted to hit the ground running.   But, politics aside, massive bills like this always boil down to the WIIFM principle: What's in it for me?

For health care, "our" fraction of the $787 million is substantial.   I have rounded up what I think to be all of the health-care related provisions:

• $87 billion in additional federal Medicaid funds for states; under the provision, states will receive the funds over 27 months, during which time they cannot change their eligibility requirements for the program;
• $24.7 billion for federal subsidies to cover 65% of the cost of health insurance premiums under COBRA for as long as nine months; the provision would apply to workers who were "involuntarily terminated" between Sept. 1, 2008, and Dec. 31, 2009, and whose annual incomes do not exceed $125,000 for individuals or $250,000 for families;
• $10 billion in additional funds for NIH, with $8.5 billion allocated for research grants and $1.5 billion allocated to renovate research facilities;
• $1 billion for prevention and wellness programs;
• $1.1 billion for Comparative Effectiveness Research (CER) to generate data on the relative efficacy of various medications and medical devices. (Funds divided between the Agency for Healthcare Research and Quality, NIH and the HHS secretary);
• $19 billion for Healthcare Information Technology (HIT), with $17 billion for investments and incentives through Medicare and Medicaid and $2 billion for a discretionary fund for grants and loans;
• $191 million to eliminate proposed reductions in Medicare reimbursements to teaching hospitals;
• $13 million in adjustments to Medicare reimbursements for long-term care hospitals;
• $460 million temporary increase in Medicaid payments to hospitals that treat large numbers of uninsured or underinsured patients;
• $680 million to accelerate Medicaid reimbursements to nursing homes and hospitals;
• $1.3 billion to extend a program that provides Medicaid coverage to individuals who make the transition from welfare to work;
• $550 million to extend the program that helps low-income Medicare beneficiaries cover the cost of Part B
  premiums.

The sum total works out to about $145 billion, or about 18% of the total cost of the bill (or an even higher fraction of the expenditure part of the bill).  A couple of notes:

Incentive payments are provided to Section 1861(r) providers (physicians) who adopt and utilize EHR technology that is certified as meeting appropriate standards for interoperability, security and clinical functionality.  To receive the incentives, providers must demonstrate that they are engaging in meaningful use of the EHR technology, including electronically exchanging clinical information with other providers and reporting on clinical quality measures.  Unfortunately, Hospital-based providers are not eligible for the program.

The HIT provision also requires the federal government "to take a leadership role" to develop interoperability standards for health care IT by 2010.

Some right-wing media outlets have claimed that the CER and HIT provisions represent a "new bureaucracy, [... to] monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective."  This is false; a product of the hyperbolic imaginations of those opposed to the bill in general, and by those makers of expensive yet marginally effective drugs and devices who stand to lose if data comes to light showing that existing/cheaper therapies are as effective.  The bill does not create any reporting or monitoring authority, and certainly no restrictions on how care may be provided, and, in fact, the office of the National Coordinator for HIT was established five years ago by George W Bush.

Overall, this is not a bad end-sum for health care, especially coming on the heels of the expansion for CHIP a couple of weeks ago.   We are already seeing an uptick in volumes and a decline in payor mix, as more people lose insurance and lose access to their primary care providers -- bolstering public assistance for health care and COBRA seems like a smart move as we dive into this recession, and the majority of the money goes to just this purpose.  The HIT and CER provisions are mostly icing on the cake.

More importantly, this bill showed that Obama has the capability to overcome the heels-in-the-dirt obstructionism of the rump republican caucus.   The dead-enders in the House are completely irrelevant, and with just a few collaborators in the Senate, the administration is going to be able to move major legislation.   This is significant, given that all signs remain that Obama will pursue more sweeping health care insurance reform this year.   The lessons learned from this fight will serve him well.   He has learned that the GOP has no good faith willingness to engage in any sort of bipartisan negotiations, and he has learned how to go outside the beltway and sell his agenda to the people who put him in office last November.  

"May you live in interesting times" is an old Chinese proverb -- both a curse and blessing.   It's going to be an interesting year in politics.

This is Awful

And I am ashamed of myself for linking to it:

Doctors' Opinion of Financial Bail Out Package

The Allergists voted to scratch it, and the Dermatologists advised not to make any rash moves.

The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve, and the Obstetricians felt they were all laboring under a misconception.

The Ophthalmologists considered the idea shortsighted; the Pathologists yelled, 'Over my dead body!' while the Pediatricians said, 'Oh, Grow up!'

The Psychiatrists thought the whole idea was madness...

Go over to Happy's to read the rest.

Happy Valentine's Day

Courtesy of the geniuses over at Street Anatomy.    Don't buy any flowers, but be sure to give your loved one a hug and kiss.  I know I will.

That didn't take long

I wrote the other day about an interesting, innovative, and risky plan the University of Chicago is undertaking to decompress their overwhelmed ER. They are screening patients at triage and refusing some; sending patients to local community health centers or other local ERs.

As I wrote, three days ago, "it's a big gamble -- the first time a patient is inappropriately redirected away, or has a bad outcome, the media, the regulators, the lawyers, and Chuck Grassley will be all over them like flies on stink. So they had better be very careful in developing and adhering to their triage protocols, I think, to survive the extra scrutiny that this move will engender."

Well.

Via Symtym, the first bad case has already happened, and it simply couldn't be worse from a PR point of view:

University of Chicago ER sends kid mauled by pit bull home

Oh. My. God.

I mean, really? A child? Mauled by a dog? What karmic crime has U of C committed that the first bad case was this one? (Oh, yeah, they're sending patients away from the ER.) I suppose the article could have been worse if it had featured a photo of the child's mangled face, but that would just have been icing on the cake.

But it gets worse. (yes, worse!)

The child's mother alleges that she was pressured for insurance information, and the implication is that her medicaid status contributed to their decision not to perform surgery.

And when she was discharged, she was told to follow up "at Cook County."

I obviously cannot comment on whether it was a justifiable decision not to undertake a primary repair of this injury, having not seen it. But it sounds like bullshit to me, and the hospital's defense is unbelievably lame, "that sending Dontae into surgery too quickly would have created a risk for infection." WTF? A dog bite on the face? Folks, you just don't leave those open. On the arm, maybe, because scarring doesn't matter so much there, and infections are more common on the extremities. But facial wounds are less likely to get infected, due to the excellent blood supply, and due to their cosmetic importance, wounds there are generally better treated with a washout, primary closure, and antibiotics.

When she did (promptly) present at County, the child was operated on. This implies to me (though not conclusively) that this truly was a patient dump, that the University chose not to or did not have the resources to care for the child and just sent them away, hoping that they would become somebody else's problem.

It's arguable (and will be argued) whether this was a true EMTALA violation. The kid was screened, and there is an argument, albeit weak, that it is acceptable to pursue secondary closure in dog wounds. So the University may not be on the hook for a statutory violation. My experience with the CMS Quality Improvement Organizations, however, is that they will use this as an opening to delve into the records of U of C and find every single transfer and redirect and crucify the organization for this and possibly other transgressions. (I've been through the same experience for far far less, and no, the incident patient does not need to be a Medicare beneficiary to precipitate such an investigation.)

One other point, more relating to the Chicago Tribune than to U of C. I notice that the date of the injury was cited as "august." I wonder how long the Trib has known about this case, and whether they were sitting on it to maximize the political impact. Just sayin'.

May you live in interesting times

Nouriel Roubini, the Cassandra who was nicknamed "Dr Doom" and "permabear" in 2006 and 2007 as he accurately predicted the sub-prime and liquidity implosions, has more recently acquired a high degree of respect and infleunce in financial and political circles.  

So it's worthy of note that today he penned an op-ed in the Washington Post recommending that Geithner go ahead and nationalize the insolvent banks (aka, "the Swedish Plan"):

Nationalization -- call it "receivership" if that sounds more palatable -- won't be easy, but here is a set of principles for the government to go by:

First -- and this is by far the toughest step -- determine which banks are insolvent. Geithner's stress test would be helpful here. The government should start with the big banks that have outside debt, and it must determine which are solvent and which aren't in one fell swoop to avoid panic. Otherwise, bringing down one big bank will start an immediate run on the equity and long-term debt of the others. It will be a rough ride, but the regulators must stay strong.

Second, immediately nationalize insolvent institutions. The equity-holders will be wiped out, and long-term debt-holders will have claims only after the depositors and other short-term creditors are paid off.

Third, once an institution is taken over, separate its assets into good and bad ones. The bad assets would be valued at current (albeit depressed) values. Again, as in Geithner's plan, private capital could purchase a fraction of those bad assets. As for the good assets, they would go private again, either through an IPO or a sale to a strategic buyer.

So, to be clear, he's not talking about permanent nationalization of the banks, nor of the entire financial sector, but just the insolvent banks, and just long enough to spin them back off in a viable format.

I can see why the financial sector (and Goldman Sachs alum Paulson) resisted this so long: it will wipe out the existing shareholders, and that's a big big hit to the captains of the universe set on Wall Street.   But, as Atrios (who, BTW has a PhD in economics) says, it's time to stop pretending that all these banks with negative equity are actually solvent.

Ammunition and canned goods, I say!

A Good Day

February 12, 1809.

Charles Darwin and Abraham Lincoln were born.   Stephen Jay Gould could have (and probably did) use this interesting coincidental connection as the basis for a wonderful allegorical essay about setting minds free or something poetic like that.   Aware of my own lack of talent in that vein, I'll content myself with making note of the bicentennial of two of the greatest men to walk this earth, and leave it at that.

Court Rules: Sky Blue, Water Still Wet

Also, Vaccines Don't Cause Autism, Chocolate Pudding is a tasty treat, and Mr Rogers is a beloved children's entertainer.

I don't think for a moment that this will cause the poor, deluded anti-vaxxers to see the light.  But another brick in the wall against their misguided cause is a good thing. 

A Conversation with a Three-year-old

Walking the pipeline trail yesterday, Second-Born-Son says to me:
"Dad, I don't really like myself."

This was a pretty alarming thing to hear from such a young kid, and he said it in sort of a despondent tone that heightened my sense of worry. I gently probed:

"That's too bad, buddy? Why don't you like yourself?"
"I don't like my body."

Okay, I thought. That's a little strange. A bit young for body image issues.

"Why don't you like your body?"
"I wish it was different."
"Well, what do you wish was different about it?"
"I wish I had a car body. Or a truck."
"A car? You mean . . . like a robot?"
"Yeah. With rocket boots. That's what I wish I had."

I have to admit, that there have been times when I would have appreciated a pair of rocket boots.

Oh those crazy Canadians

This is what happens when it rains in Winnipeg this time of year.

(h/t @ShawnKing)

How's your Irish?

Mine's not so great, either. But the music doesn't need words.

Quoth Krugman

Ignorance is Bliss

The drug and medical-device industries are mobilizing to gut a provision in the stimulus bill that would spend $1.1 billion on research comparing medical treatments, portraying it as the first step to government rationing.

Because freedom is all about laying out vast sums on medical treatments without knowing whether they’re actually doing any good.

Remember this the next time someone talks about “entitlement reform” (which will probably happen in the next three seconds or so.) Health care costs are the main reason long-term fiscal projections look so scary — and here we have corporate interest trying to prevent us, not from trying to spend our health dollar more wisely, but from even trying to find out what we get for the health care dollar.

Yeah. What he said.

Going on Diversion

Via Chicago Tribune

U. of C. emergency room to get more selective
New version of patient triage aims to cope with spiraling costs and long waits for treatment

Key Points:

UC's ED sees 80,000 patients annually -- they estimate 40% of those do not need ED level care. That sounds consistent with my experience in an urban facility.

UC has had to lay off 5% of its workforce as their financial situation worsens, and IL Medicaid payment rates are among the lowest -- and slowest -- in the nation.

"The emergency department will be reorganized to provide more evaluations from doctors and nurses before care is provided." This sounds like a nurse and doc (resident?) in triage performing the MSE right there, and then deciding whether to allow the patient back to the ER or redirect them elsewhere.

"In some cases, patients will be referred to any of about two dozen community health centers throughout the South Side or to either of two community hospitals, Mercy Hospital and Medical Center and Holy Cross Hospital, which have agreed to be partners in the initiative. For some patients, The U. of C. will provide transportation or schedule appointments."

I've got to wonder why on earth Holy Cross and Mercy would agree to be part of this. I'm assuming that the patients redirected there would not represent great revenue, and I don't know of any urban hospital that is operating at under peak capacity these days. It sounds like those are representing inpatient transfers, from the example case cited in the article. But what's their incentive to be UC's dumping ground?

As for sending patients out to community health clinics -- it looks like a great plan on paper, especially when the hospital goes the extra mile by assisting with scheduling and transportation. But it's a big gamble -- the first time a patient is inappropriately redirected away, or has a bad outcome, the media, the regulators, the lawyers, and Chuck Grassley will be all over them like flies on stink. So they had better be very careful in developing and adhering to their triage protocols, I think, to survive the extra scrutiny that this move will engender.

Ultimately, this is a desperation move for an overwhelmed ER. Hospitals don't pull this sort of stunt lightly, especially hospitals with such a high profile and reputation. I expect to see more of this in comping years, if current trends continue -- hospital and ER closures in the face of increasing utilization of the ER. But with the slow death of primary care and the dearth of community health centers, it's an open question whether other institutions will have receiving facilities to offload these non-urgent ED patients to.

Melena (an unusual cause)

I went to change the baby's diaper, because she was smelling a little funky.   I was perturbed to see that her poop was this jet black and viscous stuff, looking for all the world like melena.  Melena, for the non-medicos, is the black tarry stools that occur when someone is bleeding into their intestines, and is a pretty serious finding.

I wasn't too worried, because it would be bizarre for a baby to have a GI bleed, and because her poop lacked the distinctive acrid stench of melena. (How sad is it that I recognize it?)   I mentioned it in passing to my wife, who responded casually, "Of course her poop is black.   She ate her body's weight worth of blueberries yesterday."

Ah.  There you have it.   Add that to the list of things that turn your stool black! (Iron and pepto-bismol being the others.)

I'm still not an economist

But this is interesting, and perhaps a better bit of perspective than my previous post had. See Calculated Risk for an in-depth explanation.


The difference is that the jobs lost are expressed in a percentage basis rather than in absolute magnitude of number of jobs lost, which can be misleading in a growing nation. Upshot seems to be that this looks like it may be as bad as 1981-2 in terms of jobs, but not as bad as the recessions of the '40s and '50s. Downside there, it seems like the more recent recessions take longer to fully recover the lost jobs.

Update: kudos to Peter at Medical Pastiche for the reference!

Substitutions

Yesterday afternoon in my ER:

Me: Well, sir, I have some good news for you. The CT scan of your abdomen looked perfectly fine.

Patient: That's a relief.

Me: So, were you perhaps wondering why you got a CT abdomen, given that you are here for a fainting spell?

Patient: Yeah, that had me kind of worried -- I figured there must have been something really wrong.

Me: Well, there's a funny story to be told, and I'd like to offer you an apology. I was looking at your lab results and I was very surprised to see a CT scan result in there. See, the CT scan was ordered on the patient in the bed next to you, who has a kidney stone. And it appears that nobody noticed until you had already undergone the study.

Patient: Wow. How did that happen?

Me: It looks like it was my fault. I entered the order in our computerized system, and apparently I just clicked on the wrong patient name. I have no idea how I could have done that, but there it is.

Patient: But the scan was OK?

Me: Yes.

Patient: And no harm done?

Me: No, other than the fact that you got a dose of radiation you didn't need.

Patient: Okay, then. Good thing you were just ordering a scan, and not an enema!

Me: True dat.

The same thing happened again later the same shift. This time, I caught the error immediately, since I was double-checking. I'm still unsure if it was a computer glitch or user error.

So when President Obama said in yesterday evening's presser, "Why wouldn't we want ... an electronic medical record that will reduce error rates, reduce our long-term cost of health care, and create jobs right now?"

Well, I began to wonder.

It's taken as axiomatic that an EMR and E-prescribing reduce error rates. That has not been my experience. In the four years we have used one, I have found that we have simply substituted one type of error for another. In the old days, I would get calls from pharmacists who were unable to decipher a hand-written prescription from one of my partners. Now I get calls from pharmacists about prescriptions written incorrectly -- the wrong formulation selected from the drop-down menu, or the dispense and frequency fields filled out nonsensically. I got in a real pissing match with a pharmacist the other day about a prescription for Tylox (oxycodone with 500 mg tylenol) when they only carry Percoset (oxycodone with 325 mg tylenol). Apparently the computer had substituted the less-common Tylox in automatically, and these cannot be altered over the phone, so the patient was unable to fill his prescription and had to come back to the ER.

Don't get me wrong. I think we need an EMR, for a variety of reasons. I can manage my physicians with the data culled from it, we can view operational "dashboard" parameters of the ED, it does simplify and expedite order entry. On the whole, it is a strong positive for the ED. It may reduce costs by allowing us to do more with less resources.

But what it does not appear to do is reduce errors, not in and of itself. When politicians and policy-makers hold an EMR out there as a panacea for medical errors, it is a false hope and a false promise.

Worth a note

Steve Benen points out the end of the Bush "Bubble Boy" staged "Town Halls":

At an event in Elkhart, Indiana, today, an audience member asked President Obama, "You have come to our county and asked us to trust you, but those that you have appointed to your cabinet are not trustworthy and cannot handle their own budget and tax issues. I'm one of those who thinks you need to have a beer with Sean Hannity, so tell me why, from my side..."

As my friend Alex Koppelman noted, when the questioner elicited boos, the president intervened, silenced the crowd, and said the woman raised a legitimate question. After addressing the substance, Obama joked:

"Now, with respect to Sean Hannity, I didn't know that he had invited me for a beer. But I will take that under advisement. Generally, his opinion of me does not seem to be very high. But, uh, but I'm always good for a beer."

Now, it's always good when a public official can defuse tension with a little humor, and I'm very glad Obama defended the woman's right to ask a confrontational question. But reading about this, another angle comes to mind: since when can critics of the president attend public events and ask unscreened questions?

Apparently, as of about 20 days ago.

You can like or dislike his policies, disagree with his governing philosophy, but it's damn refreshing to have a president who is unafraid to allow someone who disagrees with him to ask a question at a public forum, and who has the quickness of wit to respond with humor and grace. I hope it lasts.

This is cool

How to glide an F-16 to a dead-stick landing.


Note the airspeed on the left stays at 220-250 the whole time. Man, how high *is* the stall speed on a Falcon? If I recall correctly, the best glide is usually something like stall + 25%, so that would put stall at somewhere in the vicinity of 175kts.

I'm so sick from the drink

Rock on.

Oh Noes!

I always knew it...

Guidelines for Twitter

Twitter is a fun and occasionally useful social networking app.   You're basically supposed to give frequent updates on what you are doing and pithy observations on life, in short 140-character clips, or "tweets."   It's sort of like text-messaging the entire world, as they are public feeds.   You can see my twitter feed over there to the right. 

For people new to Twitter, there are all sorts of unspoken "rules" that can be confusing at first -- how many people should I follow, do I have to reply to every tweet @me, what sort of things should I be tweeting, etc.  

One imporant bit of Twitter etiquette is knowing when not to Tweet.   One good example might be, "When you have having a private briefing with the President."  Another example might be, "When you are taking a secret trip to a war zone."  Things like "Just landed in Baghdad" are the sorts of things that get your security detail kind of annoyed with you.   And you might be expected to know better, especially if you happen to be the ranking member of the House Intelligence Committee.  Seriously.

Gotta be careful, because Osama bin Laden is on Twitter, too.

(via Swampland)

For the Junkies

Political and Aviation junkies, that is:


A photojournal of President Obama's first flight in Marine One and Air Force One.

Question: the dorky "Air Force One" flight jacket that POTUS wears -- is that a relatively new affectation? Bush wore it all the time, but I don't remember Clinton wearing it. But maybe he did and it just never got as much press.

Update: I guess not. Here's a US News & World Report photoessay showing Reagan and Carter with what look like the same flight jackets (though not being worn at the moment).

A Little Alarming

I've kept my yap pretty well shut about the economic apocalypse unfolding in slow motion and the politics of the federal governments' response.  (Yes, you're welcome.)   But this kind of caught my eye.

The blue line shows job losses in the 1990 recession; the red line is job losses in the 2001 recession, and the green line is the job losses in the current recession, so far.  This looks very bad, to me.   I wonder how it would compare to previous recessions.   Still, not good.  not good indeed.

If you need me, I'll be at the store stocking up on ammo and canned goods.

Headache WIN

Chronic Headache patient in the ER with her typical, frequent, severe migraine headache:

"Doctor, the only thing that ever works for me is Toradol and Reglan!  Can you give me that, please?"

Yes! (Victorious fist pump)

Forty minutes later, the patient leaves, comfortable and happy.

Symtym's on fire today

Makin' me laugh out loud...

This makes me sick to my stomach

The FAA has released the transcript and the audio of the ATC communications from the flight which landed in the Hudson.  

"Tower stop your departures we got an emergency returning."

"Who is it?"

"It's 1529. He ah bird strike. He lost all engines. He lost the thrust in the engines. He is returning immediately.

"Cactus 1529 which engines."

"He lost thrust in both engines, he said."

"Got it."

"Cactus 1529 if we can get it to you, do you want to try to land on runway one three?"

"We're unable. We may end up in the Hudson."

The good bit starts about eight minutes in.  The thing that just blows me away is putting myself in the seat of that controller.   He just lost one of his planes.  He knows that 200 people just fell out of the sky, and the massive loss of life that usually goes with that.   And he just keeps doing his job without a hiccup, sequencing and vectoring the other planes without betraying how much he absolutely must be freaking out inside.   That's professionalism.    I know how to handle stress and keep doing your job -- have someone die on you and then go to see the next hangnail.   I do it all the time, and I am practiced at it.    The difference is that I only have one patient at at time die.  Also, most controllers will go their entire career without losing a plane, let alone a commercial jet.

There were a lot of heroes that day, and not all of them were on flight 1529.

More on Kitzhaber

Seen a bit of buzz surrounding former Oregon Governor Kitzhaber as a potential candidate for HHS Secretary. One other thing in has favor: he's a blogger. Maybe not a real prolific one, but it's got to count for something, right?

UPDATE: As Lyle notes in the comments, Kitzhaber has essentially ruled himself out for the job. Bummer.

Supreme Court Justice Ginsberg diagnosed with Pancreatic Cancer

Aw Crap:

Supreme Court Justice Ruth Bader Ginsburg had surgery Thursday after being diagnosed with pancreatic cancer, the court said.

Ginsburg, 75, had the surgery at the Memorial Sloan-Kettering Cancer
Center in New York. She will remain in the hospital for seven to 10
days, said her surgeon, Dr. Murray Brennan, according to a release
issued by the court.

The court announcement said the cancer is apparently in the early stages.

In 1999, Ginsburg, had surgery for colon cancer and had chemotherapy and radiation treatment. She has been a justice since 1993.

The pancreatic cancer was discovered during a routine, annual exam
late last month at the National Institutes of Health in Bethesda, Md.

I suspect she must have had a Whipple, but who really knows. It's encouraging to know that the cancer was "early," but once again, I don't know what they mean by that, and the diagnosis of pancreatic cancer is a grave one in all events. One also wonders what signs of "early" pancreatic cancer are evident on physical exam.

I'll be wishing her well, and hoping for a rapid recovery and return to the Court. I've said it before, and I'll say it again. Cancer sucks.

UPDATE: Buckeye Surgeon points out that the tumor was discovered on a routine surveillance CT Scan, indicated by her history of Colon Cancer. That makes more sense, and in my optimistic opinion, improves her prognosis substantially, since pancreatic cancer is rarely discovered prior to local extension. This may be the exception to the rule.

More on Kitzhaber

Seen a bit of buzz surrounding former Oregon Governor Kitzhaber as a potential candidate for HHS Secretary.   One other thing in has favor: he's a blogger.   Maybe not a real prolific one, but it's got to count for something, right?

Things that won't win me any friends

At least not in the Bay area.

So Barry was doped.   No surprise.  It was the worst-kept secret in baseball for the better part of the decade. There was never any "proof" other than the ridiculous growth spurt he enjoyed in his late thirties and the testimony of a few not-exactly-trustworthy former associates.  But he had never tested positive, at least not that I can recall.

But the NYT reports today that samples from Bonds collected between 2000-2004 have tested positive for nandrolone, THG, and clomid, among other things.   So there we have it.   The elusive positive tests.   He's guilty and we all know it, and now there is evidence to support it.

It's a pity that he's retired now, since it would be nice to ban him from baseball, end his career in shame, and throw the cheating bum out on his hypermuscular ass.   I wish the Commissioner of Baseball would give him the old Pete Rose treatment, and retroactively ban him (thereby excluding him from the Hall of Fame).   I'm quite confident that Bonds did more damage to the game than Rose ever did.    Full disclosure: I'm a huge Cubs fan, and Sosa was probably also juiced.   If proof could be found of that, I'd support kicking his ass out as well.

The harm that Bonds (and the other members of the steroid generation) has done to the game probably pales next to that suffered by a generation of high school and college athletes who followed in their heroes' footsteps.  Steroid use was (is) epidemic in the locker rooms around our nation, and I can't hold the successful professional athletes blameless for that.  It's very frustrating to me that neither Bonds or McGwire nor any other the others will ever face accountability for their behavior, either in the courts or within their sporting body's judgment.

A jolt of adrenaline

I had a weird shift, with a strange predominance of chest pain patients.   Nothing unusual about that per se, but they were strange chest pain patients.  The median age was 28, and all of them had very atypical symptoms -- sharp pain, pleuritic pain, burning pain, pain associated with itching, pain associated with half the body going numb, pain associated with a sudden urge to go shopping, you get the drift.

So, what can you do?  I did the drill and worked them all up appropriately.  Every once in a while I would shake my head at the 28-year-old who had a (negative) troponin on the chart. (But doctor, the protocols say everybody above 25 gets a troponin and coags and...)   So I thanked the nurses for following the protocols and sent all the chest painers home, except for a couple who had enough risk factors to buy themselves a rule-out.

One of the last chest painers I saw was a middle-aged guy, totally healthy, with atypical pain and a lot of anxiety.   His pain was sternal, and worse when I touched it, and he was hyperventilating.   I probably was going to admit him for a rule-out based on age alone, but I had no expectation that he would have real pathology as the cause for his pain.   Just one more pointless expenditure of time and money to reassure the perfectly healthy.  So he got the full battery of tests and some morphine (which did nothing) and some ativan (thank you very much, doctor, I feel better now).

I pride myself on reading all my own x-rays and ct scans, even though we have excellent local teleradiologists.  I enjoy it, it's a bit faster in most cases than waiting for the read, and it's good practice.   So as I was getting the admitting packet together, I took a look at the patient's chest x-ray.

Uploaded with plasq's Skitch!

The radiologist had commented on a tortuous aorta, but to me it just didn't look right.   My (overactive?) imagination thought the whole aorta looked plump.   The red arrows make it look more obvious, since the right heart border and the aortic margin are sort of superimposed.  It wasn't a particularly striking CXR without the "hey dummy" arrows in place.  I asked the rad what he thought, and got the standard "well, could be, but it's hard to say, if you are concerned, get a CT."   I double checked the blood pressures -- symmetric, and re-interviewed the patient to verify that the pain was not tearing or radiating to his back.  Well, I thought, why not?  I've chased wild geese for less in the past, so I ordered the CT.  The study was done gratifyingly quickly for so late in the shift, and I lazily scrolled through the images before the patient was even back in the department.  this is what I saw:

Uploaded with plasq's Skitch!

At the level of the aortic arch.

Uploaded with plasq's Skitch!

A bit below that level.

This is where I got my jolt of adrenaline.   No way was I expecting this to be the real deal.   It went all the way down to the iliac arteries.  For the non-medical types reading, this is an Aortic Dissection, in which a small tear in the lining of the aorta allows the blood to separate the layers of the aorta and create a "false lumen" or a separate compartment within the aorta.   The shearing forces of the pulse cause the separation to propagate on down the aorta.   This can cause all sorts of complications, from clotting off important arteries (coronary, carotid, renal, vertebral) to simply rupturing and causing death (which is what killed John Ritter).   The red arrows on the CT scan show (so clearly and beautifully) the initimal flap and false lumen, and the aorta in the lower image is quite distended indeed -- probably not far from the rupture point.

The classic presentation in this case was simply absent -- the characteristic pain and physical findings were not present.  The CXR is notoriously non-specific: in most cases of dissections, the CXR is abnormal, but rarely in a specific way to point a practicioner toward a dissection.   It was pure luck that I had taken a look at the x-ray myself and given it some thought.   I wiped my brow as the cardiothoracic surgeon and her team wheeled the patient off to the OR, as this would have been an easy diagnosis to miss (at least initially) and the consequences would have been lethal.

The only take-home point that I can think of here (other than to read your own films and be suspicious) is that I have now diagnosed about a half-dozen dissections in my career, and the one thing they have all had in common is that they were all very anxious.  Some were pretty classic, some were not, but all of them had that "something's not right" fear written on their faces.   It's a pity that anxiety is sensitive but not specific for dissection, as all of my chest painers were anxious that night.

Another bullet dodged.   I love this job.

Who's Next for HHS?

So Tom Daschle is out for HHS secretary.   I'm a little surprised, since he was a real political heavyweight, and he had the White House team in a full-court press to save the nomination.   But the optics of the thing were pretty terrible (over $100K in unpaid taxes?  Yikes.) so it's probably just as well.

Once again, my vote for the HHS secretary (and de facto point man for universal health care) is former Oregon Governor John Kitzhaber.  Kitzhaber has experience in health care, being the architech of the Oregon Health Plan, and has remained active in health policy circles since leaving office.  The major down side is that he is not well connected in DC, and will not be able to shepherd a bill through Congress like Daschle would have.  

You majesty is like...

A stream of bat's piss...



Classic.

Have a nice night.

Sponsor my scalp, please

I wrote recently about a young child I saw with a new renal tumor. I followed up, and it turns out it was not a Wilm's tumor, as we had hoped, but a neuroblastoma.

I still kind of shudder when I hear that name; it was neuroblastoma which killed Nathan, and now there is one more child out there suffering from that disease. The technical details regarding her tumor imply that she has a serious challenge ahead of her.

It's just under six weeks now until I'll be going bald once again, to raise funds for pediatric cancer research. If you can, please consider clicking on the image above and making a donation towards a cure for these terrible diseases. Providing funding through organizations like St Baldrick's is a critical means to expedite the maturation of these treatments and bring them from the lab bench to the bedside. Last year, St Baldrick's Foundation raised almost $18 million, a new high for this organization, the largest dedicated to pediatric cancer research. Over 85% of the money raised went directly to research on these malignant diseases. One recipient was my friend Beth V, a pediatric oncologist at the local university center. She is working on exciting new therapies for medulloblastoma, and the support from St Baldrick's provided her the ability to continue her work on a very promising pathway.

I know that with the economic crisis, money is tight and we all are carefully examining our charitiable activities. Unfortunately, cancer research is not immune to these economic forces, and as corporate giving dries up, it is even more important for people like you, the private individual donors, to continue or even increase your support for this cause. If the research funds diminish, scientists like Beth will be obligated to scale back their work, and fewer therapies will become available for very sick children.

I will be shaving my head in honor of Nathan Gentry, who died of neuroblastoma on July 29,2007 at the age of seven, and for Henry, who is fighting recurrent medulloblastoma, and for the child I recently cared for with neuroblastoma. I hope that you will be willing to support our team with a donation of whatever you can afford -- gifts as small as $25 or $50 are welcome. If you can give as much as $100, $250, or more, that would be even better. The top donor, should they be able to be in Chicago on March 13, will be awarded the first pass with a razor on my head! All donors will receive the warm fuzzy satisfaction of participating in a great cause, and a free digital picture of my glistening scalp.

Thanks for all of your well wishes, and for your generosity -- both past and future. And yes, I will post some post-shaving pics here for your voyeuristic pleasure.

What I'm drinking tonight

Arrogant Bastard Ale.

Motto: "You're not worthy."

Congratulations to the Steelers.   Man, what a game.  I was rooting for the Cardinals (marginally) but can't take anything away from Pittsburgh -- they earned that win the hard way.   Whatever happened to the days of boring Super Bowls characterized by lopsided scores and blow-outs?   Two lead changes in the last three minutes?  Crazy!

Enjoy yourselves!  

The Good Old Days

Obama gets nostalgic, Biden is nuts, and SNL nails it again.