30 December 2010

Five Years. Huh.

In all the recent hubbub around here I seem to have forgotten my fifth blogiversary. Five years. Wow. That's like seventy in blog-years. I'm not super sentimental about milestones like that, but it's not trivial either.

I've long wondered why I continue to blog, what I'm going to "do" with it. I still don't have an answer. My enthusiasm for blogging has waxed and waned over the years. I've seen many great bloggers come and go, including, regrettably, Dr Rob, at least for the moment. For a while, the pressure of having to keep creating content, to get something out there made blogging a chore. Not so much any more. Sven notwithstanding the recent life issues I have found a place of peace with it: I'll write when I have something to say and when I have the time and energy to say it. When not, then I don't force it. That seems to be a good balance for me, and as I don't seem to be in danger of running out of opinions any time soon, it looks like I'll keep putting stuff out there. Whether that's a good thing is for you to judge.

Anyway, it's been a good run so far, and lots of fun. Thanks for dropping by to read, thanks for your support, and wishing all of you a happy new year.

21 December 2010

Science! It Works, Bitches

Randall Monroe, the author of the acclaimed xkcd webcomic is apparently suffering from a serious illness in the family, and I have linked to his posts on it before. I didn't really expect we'd be part of the same club so soon, but there it is. He continues to draw, and this one really hit me home: 

 

Sickness

 

I was thinking the same thing the other day. I am so profoundly grateful that we live in the time we do. Ten years ago, the HER2 receptor was associated with poor outcomes. Now, with the advent of Herceptin, that is much better. The data suggests that Herceptin reduces the risk of relapse by as much as 50% compared to traditional treatment. I spent a lot of time working on monoclonal antibodies during my lab days in the early nineties, and it is painstaking work. (My own lab career was cut short by a couple on incidents, one involving a broken hose and a flood in the lab and another when somehow half the lab became radioactive.)  But the hard work and the science continue to bear dividends, and in this case, we are the beneficiaries.

Yay Science!

 

(also, the tag line is an inside joke for long-time fans of xkcd. The phrase is available at the xkcd store on a t-shirt.)

20 December 2010

Cancer Sucks

This year has been a weird one for me and cancer. In the ER, we see cancer patients pretty infrequently. The occasional chemotherapy with fever, but that's about it. I think the oncologists try hard to keep the patients out of the ER -- to everybody's benefit. But this year, I've had a weird rash of cases where I've made primary diagnoses of cancer in the ER -- several times over and over and over again. In ten years I don't think I've made as many cancer diagnoses as I have this year alone. Just very strange.

Unfortunately, it came home to roost. My wife was diagnosed with breast cancer last week. 

This is an unusual case, in that my wife is quite young, and that the cancer was diagnosed shortly after our fourth child was born. Likely the pregnancy/nursing changes in the breast masked the lump; when she first noticed it, she thought it was perhaps a clogged milk duct. She showed it to her OB, who recommended watching it for a couple of months. When it did not go away, the OB ordered an ultrasound and mammogram (and thank the FSM that she was so meticulous), which showed a pretty obvious, relatively large cancer.

So it's moderately aggressive and locally advanced infiltrating ductal carcinoma. We are expecting it to be Stage 2b or 3, depending on the number of lymph nodes involved (they are palpable and appear enlarged on US). Curiously, the one node they biopsied was clean, so we are holding out hopes they might not be involved. Most importantly, the receptor status is encouraging: ER/PR negative (as one would expect in such a young woman) but HER2 positive. This is good because it opens up some treatment options, notably Herceptin, and avoids the poor prognosis involved in what they call "triple negative" breast tumors.

Having said that, this is going to be a rough road for our family. We anticipate, after staging is complete, a mastectomy followed by chemo and radiation. The chemo will be adriamycin and cytoxan, which I understand to be pretty brutal, for 12 weeks, followed by Herceptin and Taxol for another 12 weeks or so. Having said that, with what we know right now, we believe that there is good reason to expect a cure. 

Obviously, this has been a pretty huge shock to our system. It's scary and maddening. We've been shuttling back and forth to tests and doctors' appointments all week.  We have also been suffering from emotional whiplash as we veer from despair to determination and back again. But so far we are holding it together very well. The kids took the news well and seemed to process it at an age-appropriate level. We have been overwhelmed by the outpouring of support from our friends and family. Absolutely everybody seems to want to do something to help. It's humbling, since my wife and I are the sort of people with a mortal dread of imposing on others, but the reality is that we are going to need it. I'll be pretty focused on taking care of my wife, and I'll have to go back to work, and the kids are going to need to get to school, laundry, dinner and the usual stuff will need to be done. So we are going to have to learn to graciously accept some help; the biggest challenge will be coordinating all the volunteers to match our needs.

It could go without saying that blogging will be light to irregular as my priorities have been completely turned upside down. Don't list me as a dead blog -- I hope to come back to my regular, industrial-strength blogging once the treatment is complete, which is probably six months or so.

For those who wish to follow her progress and know what's going on, we have created a journal at the Caringbridge website which you can read.  A lot of our friends -- both real and online -- have asked what they can do to help. We thank you for all your support and warm thoughts. We don't really have a lot of needs beyond those which are local, but we would love to have your notes of support and encouragement for Liza over at Caringbridge. For those who wish to do something more tangible, I would encourage you to donate to a cancer charity. Longtime readers will know that my charity of choice is St Baldrick's Foundation, which raises money for pediatric cancer research, and I do intend to shave again this year. So if you feel the urge to take action, you can click here and donate to St Baldrick's online. And if you have breasts, or know someone who does, remind them to take a moment and do a breast self exam.

Again, thanks in advance for all your kind thoughts.

14 December 2010

Cool

If you read Bad Astronomy you've probably already seen this, but in this NPR article, a writer discussing scale shows a few cool relative maps, and also muses over the tiny area of the Moon which was covered by Armstrong and Aldrin.

 

Map of lunar excursion plotted on a baseball diamond

 

Neil Armstrong read the article, took issue, and responded.

08 December 2010

An Anticipated Relaunch

One of my favorite writers has returned to the blogosphere!  Intueri has relaunched as In White Ink -- The Unwritten Details!  The early posts are promising, as one would expect of a long-time medblogger, and the site design is lovely, as one would expect from the beautiful, minimalist design of the old site.

If you don't recall her, Intueri was the blog of a psychiatrist in training, and contained some of the most beautiful, compassionate writing on the human condition of any of the medbloggers out there. She's done with training now and hopefully back on the beat.

I've added it to my feed reader, and I'd recommend you do as well.

07 December 2010

Instructional Tattoo

From the KIROTV slideshow of The Ugliest Tattoos

I don't endorse, obviously, but it did make me laugh.

Well *that's* a vivid demonstration

In martial arts, there's a lot of talk about the "nerve clusters" as preferred striking points.  People refer to spots in the neck and the shoulders (most typically) as places where you can hit someone and temporarily paralyze them. I've always thought it was a bit of a crock: something dreamed up by people who have spent too much time watching Star Trek and convinced themselves that the Vulcan Death Grip was real. As a physician, I found the anatomy dubious -- sure, there are the brachial plexus and cervical plexus -- but the idea that you could strike them and paralyze someone, to me, seemed like so much magical thinking.

Which isn't to say that the neck isn't a great target. It is. It hurts like crazy when you strike it, it's a vital place where you can really injure someone, and if you control the neck you control the body. So I have tended to accept the nonsense talk about nerve clusters as just meaning "a good place to hit" while quietly not believing the hand-waving superstitious belief in "nerve clusters."

Then I saw this video off of the "Fail Blog:"

 

It's hard to watch that and not conclude that something funny neurologically just happened. The guy has an almost instantaneous total body spasm or convulsion, and drops as if poleaxed. It's not a centrally mediated reflex (like a vagal response); it's too fast. I'm not sure I can really explain it, medically, but damn.

I guess the old masters may have actually known a thing or two after all.

One thing about karate -- it does have a way of keeping you humble.

02 December 2010

On Drug Policy

A commenter posted the following question on the last post, about the economics of drug abuse:

Based on your experience as an ER doctor, I was wondering what your thoughts are on the drug use, specifically the drug war. Do you see legalization as an option for some drugs? What do you think of the Portuguese model of decriminalization and treatment? 

Will drug users just always be drug users? 

Far be it from me to opine on something that's not really my field of expertise. Wait, no, never mind, that's pretty much my stock in trade around here: wildly unsupported opinions about whatever occurs to me at any given moment.  So here goes!

First of all, the easy one: Pot. That should be decriminalized. It's not exactly benign, but it's probably less dangerous than alcohol, and it is inarguable that the black market for pot funnels a LOT of money into dangerous drug cartels. More to the point, it's just not the case that marijuana addiction necessarily harms people any more than alcohol, and I think that for consistency if you're gonna prohibit something it should be worse than the things you leave legal. I favor pot because it's largely harmless and my inner libertarian thinks the government shouldn't prohibit an activity absent compelling proof it is in the public interest. Pot fails that standard. Legalizing pot has practical policy benefits that we've all heard hashed to death in the wake of Prop 19, so I won't belabor the point. 

 

But I think that is not what the reader was asking about, and that the real question revolves around the harder drugs: should they be legalized?  In this case, my answer is no, I think they should remain illegal. This is a case where my inner libertarian yields to my inner paternalist. The hard stuff: meth, cocaine and heroin are potent. Really potent. These drugs have such a powerful effect on the brain that they drive behaviors that are all but impossible for people to control. Not all, but a predictable and significant number of people. It robs them of their agency, because the desire to obtain more drugs is so overwhelming that addicts cannot control it. They say meth is so great that all it takes is one time to hook someone for life.  They're too dangerous, and too unpredictable. Nobody who uses them for the first time can predict in advance whether they will be able to use them responsibly and occasionally (which is possible for some) or whether they will become enslaved to a lifelong addiction. Nobody makes an informed decision to become an addict: they make a mistake and get trapped.  And the life-wrecking power of these drugs is so obvious that I don't need to expand on the point, but meth in particular seems to do something to the frontal lobes that fries them; chronic meth users are functionally lobotomized. It's terrible.

So these drugs are so dangerous that I think it is essential that the government continue to make them illegal. But, as I said, the interdiction strategy has completely and utterly failed.  I'm not saying that we should give up on stopping the drug traffickers, but that a lot of resources spent on that effort could be redirected elsewhere with a lot of benefit. Economics dictates that where there is sufficient demand, supply will develop to meet it. Ignoring the demand problem while trying to kill the suppliers is like fighting entropy: it's a futile effort. 

So how do we stop demand? Sure, sure education in schools and "just say no" and all that is good stuff, but it's clearly ineffective. If we cannot prevent the drugs from getting to market, and we can't, then we also can't stop people from experimenting with them. What we need to do is identify the addicts who can be rehabilitated early and dedicate the resources to getting them off -- and keeping them off.

There's loads of evidence that drug treatment works. Not for everybody and maybe not permanently. No cure is perfect. But it massively mitigates the problem, and the return on the investment in drug treatment is equally massive, from the savings in incarceration costs, to less violent crime, to the economic benefits of returning people to the workforce.  So we should be redirecting resources from enforcement/punishment to treatment and rehabilitation.  There are all sorts of smart, proven strategies, from drug courts to needle exchanges to brief interventions in the ER. Unfortunately, it turns out that in times of recession, the first thing that gets cut is social services. Take this recession, in our liberal state: We lost our state-funded in-ER chemical dependency counselors, we lost at least three local detox centers, and we lost the state-run secure detox facility. The police budget is sacrosanct: that's "Public Safety" and woe to the politician who cuts it. But drug treatment? Ah, fuck 'em. Addicts don't vote.

Which is maddening because it's dumb. Why would you cut the cheapest and most effective tool in your arsenal? 

I am obviously frustrated with the current situation, but I should point out that I think a lot of progress has been made in the drug war since the panicky days of the 1980s. Things like needle exchanges were politically controversial -- even radioactive. Now they're accepted and unremarkable (so long as the money is there). Drug courts have gained widespread acceptance. Cocaine, heroin and meth use are all well off their historical peaks. Prescription drug abuse is on the rise, but otherwise, things are steady-to-improving.   It's not all doom and gloom

01 December 2010

The Refugee

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This is the song that made me fall in love with U2, back in 1983. I had all their albums until they lost their way with Achtung Baby, and drifted away after that. But damn, their early music was great.

Market Economics in Action

I've discovered over the years that I really like economics. I never took an econ class in my entire life, since I was pretty focused on the life sciences, but I've picked up a fair amount informally over the years.  Fortunately I have a strong background in statistics and math, and I've done a lot of reading on economics. I wouldn't say that I have any special level of understanding or credibility on the topic. Perhaps it should be noted that my wife took away the checkbook for good reason. But I enjoy it as a topic, as something to read about and a powerful tool for understanding how the world works.

On another note, one consequence of being an ER doc is that you are pretty close to "the street," and I don't mean Wall Street. I mean the folks living and scrounging on the streets. As a matter of functioning in the job, you learn the street jargon, you learn what drugs people are using and why and what the effects of those drugs look like. The other day I saw a middle aged guy brought in for acting really weird. Though everything in his social history argued against it, he just looked like he was on meth. I checked a tox, and sure enough, it came back positive. He strenuously denied any drugs, but eventually gave in and admitted the meth use. I remember in residency walking through downtown Baltimore with a fellow resident and our spouses and we amazed them by serially identifying the likely drug of choice of the various street people we passed, based on casual observation of their behavior. It's just what we do.

Now Baltimore was a heroin town. I remember a statistic that of the population of 700,000, 70,000 were actively using heroin, though I am not sure if that was true. It seemed an underestimate based on the folks we saw at our inner-city hospital. There was a bit of coke and the ever-present alcohol, but heroin was the epidemic. (Ever see The Wire? That show used to send shivers down my back it was so accurate; The Corner is maybe even better.)  Chicago, where I did med school, was more of a cocaine town. But when I moved to the Pac NW, the whole matrix shifted. There was no heroin -- literally none. We had a meth epidemic, and if I am not mistaken, the Pac NW was the first region where meth was really big. Cocaine was also unheard of in our town. A bit of prescription drug abuse, oxycontin and xanax rounded out the stable of abused substances (in addition to the ever-present alcohol). 

So it went for the better part of a decade. We saw an occasional heroin addict, the meth population waxed and waned, and the oxycontin abuse really became frightening in its dramatic increase.  The heroin addicts were a tough bunch -- the only heroin available in our state was "Black tar," which is thick and sludgy and very sclerotic to the veins. Basically it destroys the veins quickly and users have to switch to IM administration, and they got these terrifying deep facial plane abscesses that needed to be drained in the OR. No wonder it was unpopular!  So these users were hard-core, long-time addicts, really committed to their drug. In Baltimore, they had the highly refined "China White" which was practically pharmaceutical-grade and could be used IV for 30+ years. I didn't miss dealing with heroin addicts, but the oxycontin addicts were nearly as challenging to treat.

So it went -- unti recently. Over the last eight months, something changed.  All of a sudden, we started seeing large numbers of herion users, many of them "novice" injectors, still using their veins. Most of them were pretty frank that they had only recently started using heroin, and few of them had any record of ER visits for drugs in the past.  So, amateur economist that I am, I started systematically asking the heroin users how long they had been using, whether and what they had used before, and why they changed. I was surprised how consistent the answers were: they were nearly all former oxycontin users. Until this year, Oxycontin was easily available and cheap in our area. The users knew their doses and were able to carefully calibrate their intake to avoid accidental ODs or other misadventures. Few injected -- most chewed, smoked or simply swallowed the drug. For most, it was safe and simple and they stayed out of trouble (and out of my ER).  Then recently, Oxys became nearly unavailable, and scarcity drove the price way up. Previously, our community had a going rate of about a dollar a milligram for oxycodone, and at the epidemic's peak, the price was half that. Now, I was informed, it was triple, if you could find them at all.  "So we all switched to heroin," one pretty eighteen-year-old with track marks up both her arms glumly informed me.  Heroin was much cheaper, and apparently the local suppliers were more than able to accommodate the sudden spike in demand.

Of course, the dosing of heroin is harder to titrate, being of variable purity and quality, so people started OD'ing more regularly. And injecting causes all sorts of complications like abscesses. And while pill popping (or smoking) can for some be easily hidden from family, track marks are harder to explain away.  So they started appearing in the ER.

There you have it: economics in action. If I were a clever, real economist, I might neatly package the conclusion along the lines of the demand for opiates being relatively inelastic, but the brand (?) sensitivity is low, and once the incidental costs of heroin (inconvenience, lower quality, abscesses, disease, visibility) became lower than the absolute cost of oxycontin, the market suddenly tilted. (That's probably mostly gibberish, but it sounds economish.) As it is, I just shake my head at the sadness of it all and the seeming futility of interdiction as a strategy for dealing with drug abuse. Cut off one drug, and people switch to another, more harmful one. A funny sort of progress.

30 November 2010

xkcd

xkcd: Positive Attitude

This made me sad, but also kinda cheerful. Click through for the rest of the comic. Apparently, Randall Munroe, the author of the brilliant nerd comic xkcd is dealing with a serious family illness. I've been reading his stuff for years. Weird that you can worry about someone you don't know and will never meet. Hoping that things work out OK for them, whatever it is that is going on.

This is my favorite xkcd strip ever: it involves velociraptors!

SGR Fixed! Now we never have to worry about that again, right?

Maybe not:

The House passed a one-month, $1 billion “fix” to the Medicare physician payment formula Monday afternoon, two days before doctors were scheduled to take a 23 percent hit in Medicare payments. 

The House approved by voice vote the Senate’s plan to fund the fix through cuts to payments for certain therapy services. The bill, which had passed the Senate on Nov. 18, now awaits the president’s signature.

If signed into law, a 2.2 percent update in physician payments will be put in place through the end of the year. This will be funded by expected savings from a 20 percent reduction in payments for therapy services. 

I admit to being a little baffled as to why they enacted a ONE month fix -- this just kicks the ball further down within the lame duck session, as the new Congress does not take office until, what, Jan 5? So something further will be needed this session to prevent the 25% cuts from taking effect.

Background (for those new to the game): The SGR was a formula inserted by Republicans into the 1997 Medicare Modernization Act which was intended to provide a modest restraint on the growth in Medicare Part B payment to physicians: the original estimate was that it would save $12 billion over ten years. But they got the formula wrong -- badly wrong, and it soon began requiring deeper and deeper cuts in physician reimbursement, far beyond those intended by those who wrote the law. Congress never acted to fix the formula, only applying one- and two-year patches which allowed the mandated cuts to compound without ever letting them go into effect. But the cost of not fixing the SGR goes up with every time Congress punts, making it harder and harder to find new dollars to offset the ever-more-expensive "Doc fix." Apparently we are up to $1 Billion per month, now, which is more than I last heard. During the health care reform debate, when Congress again punted on this issue, the ten-year costs were estimated at something like $300 Billion. 

It's taken a political given that these cuts cannot ever be allowed to go into effect, as the result on the program would be catastrophic: Since Medicare is in most localities already a low-payment insurer, a 25% cut in reimbursement would cause a lot of docs to simply drop out of the program, or more likely to severely curtail the number of slots in their practice available for medicare patients. In our community, I know that it is extremely difficult for a new medicare patient to find a physician that will accept him or her as a patient. That will only get worse. This problem wasn't created by the SGR, but it has certainly be exacerbated by it: as Aaron Carroll at The Incidental Economist wroteThere’s nothing like the threat of a double-digit percentage payment cut to make a one or two percent increase look large. The SGR has in fact enabled Congress to slowly defund Medicare payments to physicians in this manner, with the effect that, according to the Center for Budget and Policy Priorities

The reimbursement rate for physicians next year will still be 17 percent below the rate paid in 2001, adjusted for subsequent increases in the costs that physicians incur in providing services as measured by the [Medicare Economic Index].

If Congress were to allow the cut to take effect in January, which it clearly will not do, the reimbursement rate would be 35 percent below its real 2001 level, an outcome that cannot be justified on policy grounds and one that would risk inducing large numbers of doctors to stop accepting Medicare patients.

While there is a sort of "cost containment" good news element to this -- some parts of Medicare expense can in fact be regulated -- it's been done in an accidental, jury-rigged fashion, under constant threat of catastrophe, and without a lot of benefit for patients for the amount of pain exacted from both patients and physicians. 

Put it another way: if physicians were forced to give up 17% of their inflation-adjusted revenue in a reform, I would expect this to come with some sort of sweetener, something which would improve the quality or efficiency or convenience of care. Because it will have consequences: currently, docs simply limit access and increase volume to make up the loss. What could policymakers have gotten in exchange for that 17% if it had been part of a carefully designed plan? But we (as patients and as physicians) got nothing of value for that concession.

Now, physicians will probably be asked to give up more, whether as part of bundling, P4P, or by being forced into vertically integrated ACOs. You can see from surfing around on the medical blogs how well that is going to be accepted on top of the previous decade's worth of cuts. It may be that the bunker mentality created among physicians by the SGR will play a significant role in inducing docs to reject further participation in payment reform.

Aaron Carroll summed it up well:

The part that makes me despair is the complete disconnect between what groups say they want, and their displeasure when they get it.  People seem to be upset that Medicare costs so much; but any attempt – even successful ones – to slow those cost increases is met with howls of rage and screams of rationing.  People don’t seem to realize that the money we spend in Medicare isn’t going into a pile somewhere.  It goes to doctors and nurses and hospitals and companies.  When you spend less, those people make less.  All of them.

You simply can’t have it both ways.  You either choose to spend less and piss people off or spend more and piss different people off.  Either way, you’re going to piss someone off.  A good system would try to make that decision rationally.  But at least it would make a decision.

Congress, as a body, doesn't seem very effective at making decisions these days.

29 November 2010

Fearful Symmetry

tiger

 

TIGER, tiger, burning bright

 
In the forests of the night, 
What immortal hand or eye 
Could frame thy fearful symmetry?

She was a strange lady: the triage nurse visibly rolled her eyes as she gave me report. "Seizures" 20 times a day for weeks. Strange auras. A poor and unreliable historian. She was a a heavy drinker with unspecified mental health problems. She'd had one of her "episodes" at triage and it had looked pretty fake -- certainly not an epileptic-type seizure.  It did not sound like a promising case, at least not in the sense of finding a "real" diagnosis or a productive treatment plan. 

Until the patient arrested, of course. That got our attention pretty quick!  She had just been put on the monitor, and the nurse happened to be in the room and saw her go out. We called the code, and hooked up the machines and gave her the good juice, which fixed her.  For the moment.

This is what the monitor showed:

Torsades
Uploaded with Skitch!

Is that not beautiful? This is Torsades de Pointes, an arrhythmia which is a sub-type of ventricular tachycardia in which the QRS axis twists around the myocardium. It's linked to long QT syndrome and low magnesium.  You can see in the above image how symmetric and regular the pattern is as the electrical focus moves around the heart.

There's not much more to the story: This lady, once we converted her back into sinus, has a corrected QT interval somewhere around 600ms! It was likely related to a medication she was taking. She wound up going back into torsades about three times, requiring recurrent cardioversion, before the Mag and lido kicked in and stabilized her rhythm.

If there's a point to the story, I suppose it's that even weird/crazy patients have bad things happen to them and you can never assume someone is just nuts. But mostly I wanted to share a lovely picture.

 

25 November 2010

Hazy Shade of Winter


I'm off to the beach for a few days. Enjoy yourselves and have a great holiday!

24 November 2010

Fricking Amazing

This blows me away:

Is this for real? It seems actually not possible, but then I don't know much about rugby. I do know the All-Blacks are supposed to be pretty good, though.

71%

On nonpartisan politics:

I've always been kind of bummed at the general low rate of participation in American democracy. During my lifetime, the voter turnout rate has been something along the lines of 50%-ish in presidential years and 35% in midterm years.  What does that say about the American electorate? That they are to passive/uninformed/disinterested to bother exercising a fundamental right that people in other places and times have fought and died for? Or is an indictment of our system -- that the government is so dysfunctional that people have written it off and given up?

However, here in my home state in the upper-left corner of the US, we have recently gone to an all-mail-in vote. (I think there's one county that still has traditional voting.) I was listening to the news yesterday and heard that the Secretary of State announced that, this year, 71% of all voters cast their ballots!  71%! That's just stunning.  Oregon, also vote by mail, is about the same, and pushes the 90% threshold in Presidential years.

Why doesn't every state do this?

It's so convenient: you fill out the ballot and send it in whenever you like. You can take the time to research the gajillion voter initiatives (when in doubt, vote no), carefully consider the down-ballot and judicial races, and talk it over with your family as you fill out your ballot. You don't need to stand in line, it doesn't matter if the weather sucks. There are no worries about voter intimidation or minority neighborhoods with inadequate numbers of voting machines/ballots. You don't need to worry about electronic voting machines miscounting your vote. You don't need to juggle work and/or childcare to make it to the polls during the specified hours.  

I admit that I kind of miss the civic ritual of going to the poll, but we've invented a new ritual in our family: I involve my kids and have them help me fill out my ballot, and talk about what we are voting for and why. I'm not sure they really understand it yet, but they will in time.

I suppose there are hypothetical concerns about fraud with mail-in ballots, but those have never really been substantiated as actually happening, and quite honestly even if they did occur, would be marginal in their effects compared to the fact that DOUBLE the number of voters actually cast their ballots in such systems.  How can such increased participation NOT strengthen our democracy?

I've noticed that republicans generally oppose measures that would tend to increase access to the ballot and favor those that would restrict it (voter ID laws, motor voter, etc). The thinking is that making it easier for poor/elderly/minority voters to vote will disproportionately help democrats. But that doesn't seem to be the case here. Despite being a "deep blue" state, we have had the last three major statewide elections (Gov x2, senate) be decided by a few thousand votes. There's real parity here, and while it's impossible to know what the state would look like under traditional voting, it certainly doesn't seem to have disadvantaged republicans too much.

Things change slowly, but more and more states are adding "early voting" and I wonder if ultimately most states will go towards voting by mail.  I really hope they do.

23 November 2010

Health Care reform law gaining public support

GOP hardliners soon to be in control of the House have made repeal of the detested healthcare reform law a cornerstone of their agenda, despite the impossibility of actually being able to repeal it, politically, at least until an election or two has passed, and despite the fact that their ascent to power had more to do with the terrible economy and high unemployment than any mandate to repeal the law. It seems that, finally, there may be movement towards increased public support for the law.  A new McClatchy poll shows a majority of Americans now in favor of the law:

A majority of Americans want the Congress to keep the new health care law or actually expand it, despite Republican claims that they have a mandate from the people to kill it, according to a new McClatchy-Marist poll.
The post-election survey showed that 51 percent of registered voters want to keep the law or change it to do more, while 44 percent want to change it to do less or repeal it altogether.
Driving support for the law: Voters by margins of 2-1 or greater want to keep some of its best-known benefits, such as barring insurers from denying coverage for pre-existing conditions. One thing they don't like: the mandate that everyone must buy insurance.

Of course it is the mandate that makes the whole thing hang together. And it's hardly news that people like the individual provisions and protections found within the law. From a recent Kaiser Family Foundation poll:


 
I suspect, depressingly, that the GOP will continue to grandstand on repeal, and that they will run on repeal again in 2012, especially if the courts uphold the consitutionality of the mandate. But when push comes to shove, given the unacceptability of the status quo and the popularity of the patient protections, they will blink when it comes to actual repeal.

17 November 2010

The Healthcare is Too Damn High

While we're on the topic of deficits:

Not to belabor the point, but if we really want to cut the deficit, neither Social Security nor Defense nor other discretionary spending is the real budget killer. It's Medicare, and more precisely, the excess growth in Medicare (and health care in general) above the rate of inflation that will bankrupt us in the long term:

(Source: CBO, 2008)

Also, for those who are confused about the "too damn high" meme, I offer this flashback to one of the more glorious parts of the 2010 election season:

The rent is too damn high:

On the Bush Tax Cuts and the Deficit

From the Center on Budget and Policy Priorities:

Note that by 2050, the debt from the Bush tax cuts alone will equal 100% of GDP.  100% of GDP. Say that to yourself slowly a few times and savor it.

Two take-homes from this:

Any Republican who claims to be worried about the deficit but wants to extend the tax cuts (which is basically all of them) is a liar or an idiot or both.

It's profoundly depressing and irresponsible that Obama is willing to even consider making the middle class tax cuts permanent. IIRC, the ten year cost of the tax cuts is about $4 Trillion (with a T), of the which the cost of the upper-class tax cuts are $700Bn. So Obama making the correct argument that we can't afford the tax cuts for the rich, but ignoring the much more pressing fact that we can't afford the rest of the cuts either. Not that it matters, since Dems have so backed themselves into a corner that they'll all be made permanent anyway.

We are governed by idiots, truly.

16 November 2010

Where's my government-run health care?

Freshman Republican Congressman Andy Harris, who was elected on a promise to repeal the Affordable Care Act, is outraged that he's going to go a whole month before his government-provided health insurance kicks in:

A conservative Maryland physician elected to Congress on an anti-Obamacare platform surprised fellow freshmen at a Monday orientation session by demanding to know why his government-subsidized health care plan takes a month to kick in.

Republican Andy Harris, an anesthesiologist who defeated freshman Democrat Frank Kratovil on Maryland’s Eastern Shore, reacted incredulously when informed that federal law mandated that his government-subsidized health care policy would take effect on Feb. 1 – 28 days after his Jan. 3rd swearing-in.

“He stood up and asked the two ladies who were answering questions why it had to take so long, what he would do without 28 days of health care,” said a congressional staffer who saw the exchange. The benefits session, held behind closed doors, drew about 250 freshman members, staffers and family members to the Capitol Visitors Center auditorium late Monday morning.”

All the more embarassing because he's a doctor, for Pete's sake. You'd think he'd have a better idea of how insurance works. Guess the dude's never heard of COBRA.  Also, it's pretty standard that this is how enrollment happens.  And it's idiots like this that want to repeal the PPACA.  Jon Chait provides the best commentary:

I think we finally have a working definition of a health insurance crisis--when a member of Congress has to go a whole month without coverage. Of course nothing's stopping him from using his own money and purchasing private health insurance in the individual market. Those onerous Obamacare regulations haven't taken effect yet so he can explore the wonders of a still-functioning private insurance market as God and Adam Smith intended.

05 November 2010

Friday Flashback - A New Threat


I wish I could say that every patient encounter worked out well, that all my patients went home happy and satisfied.   It would be nice, but unfortunately that is not true at all.   There are many patients who present with unrealistic expectations or an agenda which is non-therapeutic and I am relatively straightforward and unapologetic about correcting patient's misconceptions about the care that is or is not appropriate in the ED.  Unsurprisingly, this often, though not always, involves narcotic medications.

Which is not to say that I am a jerk.   I try to be compassionate, and I try to find alternative solutions, and I have been told that I can turn away a drug-seeker more nicely than any other doctor in the department.   But when it is time to say "no," I say "no," firmly and without evasions or excuses.

People don't like to hear that.  All the more so in this "the consumer is king" environment of customer-service culture we foster in the medical industry these days.   So, when I do say no, as nice as I try to be, some people get upset.  Sometimes they escalate.  They hurl insults, spit, throw themselves on the floor and throw a fit, or feign unconsciousness.  I have been threatened with complaints to administration, with lawsuits, with actions against my license, and even with physical harm.  I pride myself in being determinedly polite and non-responsive to behaviors like these, since, if I engage, it only further escalates the situation, and the threats are usually empty (though I am rather security-conscious both in and out of the hospital).

I thought I had heard it all, but I got a new threat recently.  The context was one in which I felt a little bad about having to say no.  The patient was a grandmotherly sort of lady in her middle years.  She presented a sad and pathetic figure as she told me her tale of ongoing diffuse body pain which was poorly controlled even on high doses of methadone.   Alas, she was out of her meds and wanted a refill (actually, her initial request was to be admitted to the hospital).   She was unable to explain how she had come to be out of her pain medications.  A quick record biopsy showed that she had many, many previous ER visits for pain medicine refills, and had been on a pain contract with her doctor, who had terminated it because of her repeated violations of their agreement.

In light of this, I felt it would not have been appropriate to provide further narcotic medicines through the ER.  She had been out of her meds long enough that she was not in symptomatic withdrawal.  She had already been referred to a pain management clinic for future care, so there was not much more for me to do.

She escalated; I explained my thought process.  She yelled, she wept, and she begged.  I held firm, and she was discharged.  On her way out she stopped by the charting station and said, with a vicious spite in her voice, "I hate you.   You are a terrible, terrible person, and I hope you suffer, and I hope your children suffer.  In fact, I am going to make sure of it.   I am going to go home and make a voodoo doll of you and all of your children and I am going to stick pins in all of them!"

What does one say to that?  Suddenly I didn't feel so bad about saying no any more.  Bemused, I encouraged her to "have a nice day" as she stormed off.

This job is never dull.

Originally Posted 6 November 2007


02 November 2010

31 October 2010

This is Halloween


In the soundtrack the prologue is voiced by Patrick Stewart. Much better; I have no idea why they changed it to the other guy in the movie itself.

 

Now if you'll excuse me, I'm going to go raid my kids' candy stash...

29 October 2010

Friday Flashback - Showmanship

I have been practicing a style of Okinawan Karate for a number of years now.  It's a simple, practical fighting style -- nothing showy or acrobatic, which is good for me since flexibility is not one of my strong points.  One of the key features of this style is a heavy emphasis on joint locks and grappling techniques, called tuite.  Frankly, this is my favorite part of training.  When someone has grabbed you and thinks he is controlling the situation, you can easily and simply use his own grip against him to turn the tables and put him on the floor.  I am continually amazed at the inventiveness of the old masters: how they understood body mechanics and topology and applied that to develop techniques in which one can place leverage on a joint in an unusual and powerful manner with only a simple and subtle movement.

You may think I'm a little off-topic, that I have become confused and think I am on the KaratePage Today site.  Not at all, my friends.  You see, I have had occasion from time to time to put my karate skills into more ... direct application ... in the ER.  Mostly it has been intoxicated or psychotic patients who needed a little focused pain to restrain them until an intramuscular injection of Haldol could take effect.  Once, a belligerent drunk attacked a nurse and I took him to the floor until security could get there and put on four-point restraints (followed by the local police applying handcuffs).  But, frankly, most of these have been psychosocial, not medical, applications of karate.  But not always.
 


I was working not terribly long ago at a site where we have double-coverage, and my partner asked me to help out with a dislocated shoulder.  We generally tag-team these procedures.  One of us plays anesthesiologist while the other does the procedure.  That way one doc can focus on the procedure without worrying about the patient's depth of sedation, ventilatory status, airway status, etc., and the other doc can focus on performing sedation safely.   

When you are doing the sedation, though, it's really not too engrossing, and like any good short-attention-span ER doc, I tend to watch the "main show" with interest.  This particular patient happened to be a rather obese woman, who unfortunately was so plump that we couldn't even palpate any bony anatomical landmarks.  After an uneventful induction of deep sedation with Diprivan, I watched "John" go through the standard maneuvers to reduce the offending joint.  He applied traction, external and internal rotation, extension and elevation with traction, and even some futile attempts at humeral/scapular manipulation.  He pulled and pulled until his face was red and his scrubs were stained with sweat.  He never got that satisfying "clunk" that indicates a positive reduction, but we both wondered if it might be in anyway.  The post-manipulation range of motion seemed normal, and sometimes if the shoulder is loose enough, you really don't feel the joint reduce.

The "post-reduction" film dashed our hopes.  Still out, despite all John's close-to-heroic efforts.

With a hint of malice in his voice, he said, "This time I'll push the drugs, and you can pull on the arm."

Fair enough.  I like a good reduction.   I stood by the bedside, while the various choreographed motions went on to re-induce sedation, and pondered the procedure.  John is more muscular and likely stronger than I am.  I had just watched him do every usual technique that I would have tried.  How was I going to reduce this one where he had not?  My mind wandered and entered one of those lateral drifts.  I thought about some tuite I had recently worked upon in karate class.  There was one nasty technique, involving a wrist-elbow-shoulder lock.  Not too useful in a fight, I had thought at the time, but it put a lot of very uncomfortable pressure on the shoulder if you could get it.

In the interim, a small crowd had gathered at the bedside.  (The ED was near empty, and a difficult reduction is always a popular diversion.)   A nurse nudged me, interrupting my reverie, "She's ready.  Let's see what you've got."   Still thinking about that joint lock, I picked up her right hand with my right hand, threaded my left beneath her forearm, up through the crook in her elbow, then over and behind her humerus.   I pressed down on her hand, levering against my left arm, while lifting and pulling a bit on her humerus with my left.  Immediately, without any hesitation, the shoulder popped in with a satisfyingly audible clunk.

Mildly surprised, I said, "There, that seems to have done it."   The crowd dispersed, murmuring appreciatively.  John was staring at me.  "What the hell did you just do?"   I explained that it was just a trick with leverage and showed him how to do it.  I elected not to tell him where I had come up with it and that I had never tried it before.  It would have ruined the moment.  

Now he thinks I'm some sort of genius.

I can live with that.

Originally Posted 2 November 2007

I'm a sucker for time lapse

And these are Freaking Amazing!

 

Landscapes: Volume One from dustin farrell on Vimeo.

It's totally worth it to watch in HD

28 October 2010

Rapping about condoms


Clap your hands but don't get clap on your glans!

I love it.

27 October 2010

Some sunlight on the corruption of the RUC

Interesting article (front page!) in the WSJ today about the RUC:

Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement. [...]

The RUC, as it is known, has stoked a debate over whether doctors have too much control over the flow of taxpayer dollars in the $500 billion Medicare program. Its critics fault the committee for contributing to a system that spends too much money on sophisticated procedures, while shorting the type of nuts-and-bolts primary care that could keep patients healthier from the start—and save money.

I'm glad to see the RUC getting some much-needed scrutiny, and skeptical scrutiny at that. But they miss the point with the "fox watching the henhouse" angle, or at least they paint with too broad a brush. "Doctors" are not a monolithic group, and it is those subdivisions that make the RUC such a dangerous agency.  The author manages to touch on the critical dysfunction here:

"This system pitted specialty against specialty, surgeons against primary care," says Frank Opelka, a surgeon and former RUC alternate member who is vice chancellor at Louisiana State University Health Sciences Center in New Orleans.

Primary-care groups have pushed for more representation on the committee, and their leaders have argued its results are weighted against their interests. 

Dr. Levy says the committee is an expert panel, not meant to be representative, adding: "The outcomes are independent of who's sitting at the table from one specialty or another."

I believe is where one would feign a coughing spell and blurt "bullshit!" into your hand. While the theory is that the members are there as RUC members, the reality is that every specialty lucky enough to have a seat on the RUC leverages that seat as an opportunity to advocate for the economic interests of their specialty.  The general surgeons are famous for sending a team of lobbyists, lawyers and (really) healthcare economists to make sure the RUC does not make any changes that would undermine the income of surgeons. (And yes, ER docs also have representation, though they bring a less impressive posse, and they do advocate for EM-related services to be up-valued.) This is referenced in the (oddly unlinked) accompanying article, where primary care physicians recounted an epic battle from a few years ago:

At one point, the debate reached such an impasse that J. Leonard Lichtenfeld, who represented the American College of Physicians, and at least one other RUC member, Tom Felger, who represented family physicians, actually came close to ending their involvement in the talks, and asked for a break in the meeting, according to both men. They felt a surgical faction was blocking their push, they say.

"I was willing to leave the negotiations," Dr. Lichtenfeld says. "I felt that we were being stonewalled for economic reasons."

On the other side, surgical groups had argued there wasn't strong evidence that visits with patients had gotten more difficult. "There were some bitter feelings," says John O. Gage, who represents the American College of Surgeons on the panel.

This touches on an arcane point of procedure the RUC utilizes: a code is assumed to be correctly valued unless it can be shown the amount of work involved in that service has changed. So you are not allowed to claim that the codes are fundamentally imbalanced or misvalued or that the effects of the current valuation are undesirable as a matter of policy. You have to contort yourself to make the case that somehow what you do has gotten harder, that it is different from what it was five years ago. At least that's what you have to do to increase a code's value. They rarely go down in value, despite the (nicely documented in the article) fact that surgical procedures reliably require less work as time goes on and technology/practice make them easier to perform. So the effect is that surgical procedures are even more overvalued than they were to begin with. It's also telling that the RUC relies on self-reporting surveys of doctors to determine the work that goes into a particular code. I frequently get these surveys that tell me that how I answer this survey may impact how much I get paid for this service in the future, so how much work is this service: a little, a lot, or a super-lot? The validity of these surveys which are reported by people who have an interest in their results and *know* that their responses will translate into dollars gained or lost is pretty much nil.

But this is a less biasing factor than the non-representative make-up of the RUC itself. Check out the WSJ's awesome interactive graphic about the RUC. When you view it on their site, you can mouse over the RUC members and see their specialty affiliation:

RUC

You will note that the relative specialty vs primary care representation on the committee is striking. Not only are primary care (and other so-called "cognitive" specialties) far outnumbered by their surgical/procedural colleagues, consider that these few primary care docs represent a cohort of physicians far larger than the specialists in actual practice.  One neurosurgeon has as much representation as 150 internists in this body.

Now I would agree that this does not need to be a strictly democratic process as a matter of principle. While we Americans are kind of ingrained with the idea that equal representation is the ideal, there's no reason that it has to be the case with this sort of body.  However, as a matter of policy, in terms of creating economic outcomes and incentives that would tilt the balance towards higher quality, lower cost health care, a more representative or weighted composition of the RUC would be preferable. 

I should also add that while I rail against the corruption of the RUC, it's not meant as an indictment of the people on the RUC, but the process and the system. I know the EM representatives of the RUC (past and current) and they are absolutely awesome people of high integrity. But it is also fair to say that they understand the game they are playing, on a very pragmatic level, and they work within the framework they are given to produce the best results for Emergency Medicine. Good people, bad system.

If I were king (I can't count all the times I have said or thought that) I would remove the fig leaf of objectivity and allow RUC members to openly advocate for their interests (which they are already doing sub rosa), coupled with a rebalancing of the RUC to provide more proportionate representation. Then I would hire a couple dozen Jonathan Grubers to crunch the numbers and make recommendations to the committee, based both on physician work as well as on the macroeconomic impact of the RVU valuations.  Of course, if I were king I'd also probably disband CPT entirely and also the New York Yankees, so maybe it's just as well nobody has seen fit to entrust me with that much power. 

Yet.

The Democratic Electoral Strategy

As usual, the Onion nails it. What could possibly go wrong?

 

Democrats: 'If We're Gonna Lose, Let's Go Down Running Away From Every Legislative Accomplishment We've Made'

 

WASHINGTON—Conceding almost certain Republican gains in next month's crucial midterm elections, Democratic lawmakers vowed Tuesday not to give up without making one final push to ensure their party runs away from every major legislative victory of the past two years.

 

Party leaders told reporters that regardless of the ultimate outcome, they would do everything in their power from now until the polls closed to distance themselves from their hard-won passage of a historic health care overhaul, the toughest financial regulations since the 1930s, and a stimulus package most economists now credit with preventing a second Great Depression.

 

"There's a great deal on the line, and we know it isn't going to be easy for us," said Senate Majority Leader Harry Reid (D-NV), speaking from the steps of the Capitol. "But if we suffer defeat, we will do so knowing we cowered away from absolutely anything we produced that was even remotely progressive or valuable in any way."

 

"And we will keep cowering right up until Election Day," Reid continued. "From Maine to Hawaii, in big cities and small towns, we will collapse into a fetal position and refuse to take credit for our successes anywhere voters could conceivably be swayed by learning what we have achieved on their behalf."

 

[...] According to party leaders, the Democrats are putting their sweeping new health care law at the top of the list of accomplishments to back away from, mainly by allowing its most popular provisions—federal subsidies to make health care more affordable; allowing children to stay on their parents' insurance until age 26; and rules that prevent sick people from being denied coverage—to be summarily dismissed as "Obamacare."

 

"Thanks to our efforts, a lot of people don't even realize they may already be benefiting from these reforms," Rep. Melissa Bean (D-IL) said. "They certainly don't realize they might be one of the 30 million currently uninsured people who will be provided coverage by the time the law is fully enacted."

 

"You can be certain we'll keep that information a deep, dark secret until we're thrown out of power," Bean added.

 

26 October 2010

Japan's supreme contribution to human culture

I really don't know what to say about this, except that it's the GREATEST THING EVER MADE BY HUMAN BEINGS!

 

Srsly. Wow.

 

Make sure you check out what happens to the cat.

23 October 2010

Death of a Gummi Bear


Awesomeness enhanced by the soundtrack (apparently a cover of DKM's "Shipping up to Boston")

22 October 2010

Great Ideas that won't work (part 27)

Peter Orzag is a super smart guy.  He's a wonk's wonk. Serious, articulate and innovative, he possesses some serious nerd-fu powers, and I'm a huge fan of this former OMB director. (We all have a favorite, don't we?)  

But he doesn't know jack about medical malpractice, it seems.

Ezra pointed out a clever idea the Orzag wrote about in his NY Times column regarding medical malpractice reform:

As President Obama noted in his speech to the American Medical Association in June 2009, too many doctors order unnecessary tests and treatments only because they believe it will protect them from a lawsuit. Instead, he said, “We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines.” [...] What’s needed is a much more aggressive national effort to protect doctors who follow evidence-based guidelines. That’s the only way that malpractice reform could broadly promote the adoption of best practices.

Well, it sounds great, especially from a policy nerd's point of view: you kill two birds with one stone. Encourage adoption of evidence-based medicine, and also provide doctors with much-needed protection from baseless accusations of malpractice.  What's not to love?

Nothing, except the fact that it wouldn't work.

Seriously, I have reviewed lots of med mal cases, and, sadly, "failure to follow evidence-based standards" isn't a common allegation of professional negligence.  It's "failure to diagnose" and technical errors that tend to be the big money-losers in the legal arena. Evidence-based standards don't help.

Consider the biggest money-loser in Emergency Medicine: missed MI.  I'm not sure there are formal evidence-based standards for the diagnosis of myocardial infarction, but if there were they would probably be pretty straightforward, along the lines of get an ECG and order serum troponin, maybe with some subrecommendations about serial troponins if the first tests were negative; most of the existing guidelines focus on the most efficacious proven treatments of MI once it has been identified.  But if I may slightly fictionalize a case I recently reviewed, there was a guy who presented in the ER with a toothache. He thought he lost a filling and was triaged to fast track. He never complained of chest pain, though he did have nausea and vomiting (attributed to the tooth pain) and a triage nurse had recorded a complaint of left arm numbness.  He was discharged with penicillin and pain medicine and a referral to a dentist. He came back with a V-Fib arrest  about 8 hours later and subsequently died.

In retrospect, it's pretty apparent what happened here. The treating doctor simply never considered "chest pain" and cardiac issues as an avenue he should work up. An ECG was never ordered, because why would you?  I think this case was not malpractice (that was my opinion) in that this was a very atypical presentation of the disease and most reasonably prudent physicians would not have been able to correctly diagnose this particular MI, based on the information that was available at the time the patient presented. Evidence-based standards really only apply when the diagnosis is already made, or when the presentation is typical enough that standardized work-ups are appropriate.  Orzag's clever idea would not provide much of a line of defense for the physician who simply misses the diagnosis (whether it was his fault or not).

Similarly, if you do follow evidence-based standards, that won't shield you from allegations that you did so incorrectly. Another case I recall was a baby whose mother dropped it on its head and suffered an epidural hematoma. The ER doc did follow what would likely be the evidence-based guidelines and ordered a head CT. The bleed was diagnosed and treated appropriately. The child had a poor neurological outcome, and the plaintiffs later claimed that some trivial delays in the ordering of the CT scan were the cause of the bad outcome.  While in this case, the delay did not cause the bad outcome, it's hard to imagine that the "I followed the guidelines" defense would quash the lawsuit, and in some cases a delay really could cause harm and perhaps should be considered as grounds for negligence.

Then, finally, there are the claims that rely on faulty technical performance. Consider a patient in whom the ER doc follows the guidelines in securing an endotracheal airway, but cannot do so and as a result the patient suffers an anoxic brain injury. Evidence-based treatment is not at all relevant to the question of the physician's competence in adequately intubating the patient.

So what I am saying is that Orzag's proposal, attractive as it is, would not be particularly effective in changing the overall culture of defensive medicine or the jackpot mentality that pervades the medicolegal culture. It would provide physician defendants with an attractive line of defense in some occasional cases, which is welcome.  But as a panacea, or even as a driver of improvement in either of the desired policy arenas, it would be completely ineffective.

Friday Flashback - The Sh*t Hits the Fan

I posted the other day about a satisfying evening in which I was fortunate enough to see a number of acute cases in a row. Frankly, none of them took a ton of diagnostic acumen -- bread and butter stuff for emergency medicine, really. It was, though, a nice day.

One thing that struck me about a particular case was how quickly it went bad -- very very bad.

It was a woman in her child-bearing years who suddenly collapsed (i.e. syncope) while watching a football game. She came in looking ill but with stable vital signs, complaining of severe abdominal pain which had come on at the moment she fainted. Her hematocrit on arrival was 27 -- indicating either chronic anemia or acute blood loss.

So I'm no dummy -- the first thing I thought of was a ruptured ectopic pregnancy. But her pregnancy test came back negative. I am an experienced ultrasonographer -- don't ask me to find the common bile duct, but I can see blood very reliably if it is there. So I dropped the ultrasound probe on her abdomen, and the results were perplexing. There was definitively no blood in Morrison's pouch, or in the spleno-renal recess, or in the pelvis. There was an odd hypoechoic stripe across the body of the liver. It looked like a blood vessel, but was too linear. In retrospect it was probably blood in the falciform fissure, or some anomalous similar structure. But again, there was clearly no free blood in the peritoneum at that time. But based on that odd finding, I called in the ultrasound tech for a formal study.

A very short time later (it was chaotic -- fifteen minutes?), she crashed. She became unresponsive and profoundly hypotensive, with a heart rate around 150 (from the 80's). Annoyingly, in her throes as she passed out, she managed to pull out both her IVs. A repeat hematocrit came back at 21 -- she was clearly losing blood rapidly; the ultrasound tech arrived while we were re-establishing IV access and beginning aggressive volume and blood resuscitation. He dropped the probe on the abdomen and I uttered a four-letter word, because the DRY abdomen I had seen shortly before was now FULL of fluid.

Fortunately, it was not difficult to persuade the on-call surgeon to come in and take this young lady directly to the operating room. The surgeon did a superb job to stanch the bleeding (from her ruptured Splenic Artery Aneurysm) and perform an emergency splenectomy. The patient survived (thanks in no small part to the Cell Saver) and did very well.

What was striking was how very quickly she went from "ill-but-stable" with an empty belly to "moribund-with-belly-full-of-blood." Amazing.

Originally Posted 10 November 2007


19 October 2010

Times Change

GruntDoc posted about the classic ER doctor's nightmare: “You know that patient you saw yesterday?” was how the conversation started.

I've been there.  I know the bolt of adrenaline, the cautious, "Yeah, why do you ask?" that you always respond with.   But one thing that our Brave New Technological World has brought to us is this: the email of doom.

Your institution may vary, but for us, the adrenaline-producing email comes with the subject line of "SECURE Email for Dr. Shadowfax" and it links to the hospital's (damned) HIPAA compliant encrypted webmail interface. Nobody ever uses it because it's a hideous pain in the ass, except the official hospital quality officer who is responsible for reviewing all "Unusual Occurrences," which is the euphemism for unexpected deaths, bad outcomes, 24 hour returns, patient complaints, nursing complaints, etc.  Nothing good.  So when you see the awful subject line, you just know that whatever is waiting in there for you is an unpleasant little Christmas present, the sort you don't really want to unwrap but you have to.  Just as an extra bit of pain they make sure the login process is as slow and cumbersome as possible. Two entries of your password (which has to be changed every ninety days, natch, and you can't re-use passwords). 

The awful, truly awful thing about these emails is that they are only generated by BAD things. There's no possibility that this will be a patient compliment, or a "well done." So as soon as you see the header you are bracing yourself for whatever bit of awfulness lies within. It's not necessarily anything your fault. People get worse. Subtle presentations become more clear over time. Nurses mess things up and patients complain about the dirty guy in the waiting room (these also go to the secure email, for your comment). But as soon as you see the "SECURE Email" header, you are sure that it was that dizzy guy from yesterday, and you're cursing yourself for sending him home until you finish the login process and find out that it was really some dude unhappy that you only gave him ten vicodin.

I think that sometimes our medical director sends out trivial emails on the secure email system just to screw with our heads.

Of course it goes both ways.  As the "boss" for our group I have found that people dread seeing my name on the caller ID, and the meanest thing I can do is leave someone a voice mail saying that I need to meet with them. It's like when you were a kid and you got called to the principal's office, that sense of "What did I do?" (or in my case, "What did I do that you found out about and can you pin it on me?"). So I try to be really clear when I'm calling about a minor thing so people don't freak out, but the power of intimidation is amazing, even when I don't want to be intimidating, which is pretty much all of the time. Worse, sometimes I do have to call someone in for a "real meeting," and that's just hateful all around. 

I also remember the old medical director, a close friend, used to call from the office just to chat, and when I saw the caller ID I also had the panicked sense of "Crap, what did I do?" until I answered and found out he just wanted to talk about the Chicago Bears.

Which in my mind ranks right up there with sending out trivial emails on the SECURE system as the hallmark of an absolute bastard.

18 October 2010

Squee

Just Another Drunk

The guy in room 8 was a drunk, "just another drunk." It sounded like he was pretty hardcore -- homeless, been living on the street for a while, refused at the mission.  The story sounded benign: he had been sleeping in a bush somewhere, and some Good Samaritan had called the ambulance, but he denied trauma or any other problem.  Just had so much to drink that he wasn't able to get back to his regular spot under the bridge. Alcohol level somewhere north of 300.

I was a little curious, though, because a quick review of the records showed that he hadn't been in our ER before.  Most of the resident homeless alcoholics in our community stop in the ER every so often, if only for a laceration or a sammich once in a while.  And I also noted that his age was 75 years old.  That's a remarkable feat of longevity for someone living on the street.  So when I saw him, I was a little more inquisitive than usual, just to be sure I had constructed the narrative correctly.

I had.  He was not exactly new to our community; he had been staying in the local jail for six months.  Prior to that he had been living on the street in a town a bit further south.  But once released, he hadn't bothered to go back "home" since one bridge is much like another.  So he stayed in our fair city instead. He was surprisingly cheerful in spite of it all.

He looked wiry and weather-beaten, someone who knows how to survive on the street, but also frail and vulnerable due to his age.  While he was clearly expecting to be discharged back out, I was a little apprehensive about letting him go on his own.  I probed -- "Do you have any family?  Anyone local that you could stay with for a while?"

He considered for a moment.  His face darkened, just briefly, and he responded, "No. No family."

That made me sad.  We discharged him once he was ready -- there weren't any other good options. He had no acute medical needs to justify an admission.  We used to have some detox beds but once the recession hit, social services were slashed to the bone, so that's not available any more. There are some local charities, but quite frankly they are not equipped to handle someone like him, and I'm not actually sure that he was interested in any "treatment" at this point.

But I reflected, as I completed his chart, after he left, on that moment of hesitation before he said he had no family, no friends, nobody on this earth that he could look to for help.  He had considered the question.  Clearly he was going through a mental checklist of his own, remembering all the people that he once had relations with before he decided all of those doors were closed to him. Seventy-five years alive and all alone.  What a tragic legacy.  What were the stories to be told there?  Estranged spouses and girlfriends?  Children, now grown, who longer wanted anything to do with him?  Or had he somehow, improbably, outlived them all? Was he the survivor in his small social circle?  That's a kind of isolation, a kind of loneliness that I'm not sure I can really understand. What frailties, what demons drove him to such lengths? His story would have been long, fascinating and sorrowful to hear, I am sure. But he wasn't inclined to share it.

Seventy-five years and not a single person who gives a shit about you. What a legacy of failure for a lifetime's efforts. No wonder he wanted to lose himself in drink. But really, he wasn't so different from many of the others who pass through our doors for a few hours. He just had lived longer. Most of the 40- and 50-year old homeless alcoholics are the same, they just meet their ends sooner due to the elements or the drink or violence or accident. They don't make it to a diamond anniversary.

I have a couple of uncles who succumbed to alcoholism, lost their careers and families and everything, winding up on the street. I've watched my cousins go through the cycles of anger and regret and forgiveness. They wanted to badly to save their dads, and they couldn't save them from themselves no matter how they tried. And so it was with the guy in room 8.  He got his sammich, some vitamins and juice, and he was off to fend for himself, and there was nothing we could do for him except be here for him when he needs it.

Of all the sad things we see in the ER -- and there are plenty -- this seem to me to be one of the saddest and least appreciated, and by far among the most common.

17 October 2010

15 October 2010

Difficult

Friday Flashback - Small Victories Part Two

I work from time to time at a rural hospital up in the mountains. It's a pleasant change of pace from the high-intensity trauma center where I do the majority of my shifts. The acuity, volume, and patient population vary dramatically, as you might expect. The Big Hospital sees over 100,000 ED patients annually, whereas the rural shop sees less than 20,000.

One interesting consequence is that the nurses in the little hospital seem to know all the patients, either socially or from previous ED visits or both. Depending on the circumstances, it can be very helpful or very awkward (or both). One recent night, a woman came staggering into triage clutching at her lower back. The charge nurse groaned upon seeing her, and took me aside: "We know her from before. She's a big-time drug seeker, and has been caught on more than one occasion altering and forging prescriptions from this ER." She pulled out a binder where we keep "care plans" for patients with chronic pain and narcotic issues. The patient's history was laid out there in its sordid detail, and supported the Medical Director's recommendation that this individual not be prescribed narcotics. "Just kick her out of here, will you," the nurse suggested.

As helpful as this kind of advance knowledge is, I kind of hate it. I still have to go in and see the patient, and it's very hard not to be prejudiced about the encounter and give the patient a fair evaluation. Especially when the vast majority of time the prejudice would have been accurate. So I try to push the "drug-seeker" conclusion out of my mind until after spending some time with the patient. But it's not easy.

This encounter, however, did not seem likely to diverge from my preconceived expectations. She informed me that this was her standard back pain for which she was on a staggering dose of narcotics (OxyContin, 80 mg TID plus oral Dilaudid!) but the pain had just become intolerable. It was with a sense of despair that I went through the formulaic questions necessary to differentiate chronic back pain from an acute emergency, and her answers were bland and unrevealing. I noticed, though, that she was sort of writhing on the bed, and when I asked her directly, she said that, yes, in fact, the pain was coming in waves. Hmmmm. Might there be something more than myofascial back pain?

So I got a simple test: a urinalysis. It showed a microscopic amount of blood in her urine. The nurses rolled their eyes at me when I ordered a CT scan of her abdomen, but to my mild surprise and infinite satisfaction, the scan showed a large obstructing kidney stone!

It just goes to reinforce the old adage that even drug-seekers get sick, too. But then I found myself with a conundrum: how on earth was I going to control her pain. When you are on high doses of pain medicines, they lose their potency, and I estimated that I could use all the morphine in the hospital without making a dent in her pain. Worse, she had deteriorated somewhat in the time it took to get the scan, and when I saw her again, she was pale and covered in a sheen of sweat.

Predictably, she was "allergic" to Toradol, as many drug-seekers claim to be (it doesn't provide the euphoria that narcotics do) but when I questioned her carefully she said it just "upset her stomach" and "doesn't work for me." So I explained that I thought narcotics would not help her pain, but I thought Toradol might, and she agreed to give it a try.

Forty minutes later I checked on her again and she was resting comfortably. With gratitude, she said, "I can't believe how well that stuff worked! I never would have thought it." A little while later, she went home, feeling "100% better," and I faxed some prescriptions over to the pharmacy for her. By god, it is satisfying when things works like they are supposed to, and in this case, it perfectly split the Gordian knot of pain management in the opiate-addicted patient.

Originally Posted 28 November 2007


14 October 2010

Sunshine Highway

In a DKM sorta mood lately:



Cheers.

Life's little and not so little victories

I groaned when I read the chart.  It didn't look promising, and in fact it looked downright painful.  A flog -- might take a ton of work and involve a difficult disposition.  And worse, I had picked it up with only a little more than an hour to go in my shift.  These are the "witching hours," when there's not really enough time left to perform a work-up and dispo a patient, but when there's a long enough time left before your relief arrives that you can't in good conscience let the patient wait.  I toyed with the idea of saying "hi" to the patient and getting labs ordered and seeing if I could sign it out to the next guy.  Not too unreasonable if it was going to require some time-consuming test, which it looked like it might.  I braced myself for the worst, squared my shoulders and walked into the room.

To my surprise, I found myself calling the admitting doctor fifteen minutes later, diagnosis in hand.

There were red flags all over the chart to begin with:
  • 75-year old woman, speaks only Ukranian: Great. I'm going to have no capacity to communicate with this lady. Not to stereotype, but in my experience there's a strong cultural reticence among elderly eastern european women.  Translators help only a little bit.
  • One month of fever, temp at triage 38.5: She's old and febrile, so it's going to be something real. This is not a worried well person I can blow off, reassure, and send away.
  • Headache: Oh shit, am I going to have to do a spinal tap on this little old lady? Jebus, let it not be so.
  • Seen in ER three times this week, and in clinic twice: What possible reason is there to think that I am going to figure this out when five previous doctors have not?
babushkaYeah, there are times when ritual suicide seems a more attractive option than sticking your head into the morass, but this is the life I have chosen.  I threw myself into it. The scene in the room was verging on the comical.  This stout, wizened old woman could have been the embodiment of Mother Russia herself, so classic was her broad, deeply lined face.  She lay back on the gurney, her head wrapped in a white babushka and a floral scarf around her shoulders. She was wearing a pair of oversized wrap-around sunglasses similar to the cheesy old Blu-blockers. For some reason her family had carefully wrapped a couble of ER blankets around her head and her lower body, so she looked as if she were partially mummified.  She was attended by two very concerned, ridiculously attractive younger Russian women.

As I had anticipated, the old lady said not a word for herself. Her daughter and granddaughter did all the talking, and when I tried to address questions directly to the patient, the old lady gave monosyllabic replies, which her family amplified on translation to full paragraphs.  The story was both reassuring and alarming.  She had already had CT scans, spinal tap and blood work on more than one occasion, with no diagnosis. So at least I was unlikely to have to repeat the tap, I reflected.  But she also had now lost the vision in her left eye, and the right eye was very blurry.  The daughters were also concerned about the new swelling of her eyelids and face.

Indeed, I noticed that there was a significant amount of periorbital edema, bilaterally, and also some faint erythema.  I wondered whether the vision loss was from the eyelids being swollen shut, maybe a facial cellulitis, or possibly even a retrobulbar cellulitis could cause fever and vision loss.  I mused on these possibilities as I went to examine her.

She flinched violently away from me as I touched her face to remove the sunglasses.  So it was very tender.  I wanted to examine a bit more thoroughly, so I moved to push her babushka back. This provoked quite a reaction!  She slapped my hands away and unleashed a rapid diatribe in Ukranian.  I didn't understand a word of it, but the meaning was quite clear: she did not want me to touch her babushka!

I was firm, however, and she submitted to my requests (with some coaxing from her daughters), and when I peeled off the head-blankets and afore-mentioned babushka, I was struck by these two large, bright red swollen lines running up the sides of her temples.  Right ... along ... the course ... of the ... (wait for it) ... temporal artery!  It was the most amazing thing I have ever seen, and quite tender, as well. I immediately went back to the computer and checked her previous labs -- sure enough, her sed rate was 75.  Somehow, one of the previous five docs had ordered the right test and managed not to put two and two together.  Maybe the patient didn't let him touch her babushka!

Not to be critical, of course. This was not an easy history or exam, and it was probably way more obvious by the time I saw it. (Her sed rate was over 140 by that time, so there really had been progression of disease.)  And Temporal Arteritis is ridiculously rare -- I've been doing this for well over a decade and I have never actually seen it before. I can't vouch for the fact I would have figured it out on the first visit. But it wound up being enormously satisfying: I got this "red flag case" admitted and started on IV steroids, with an optho consult, all in a little over half an hour.  And I got to feel, perhaps undeservedly, terrifically clever for being the guy that figured it out, or at least being the guy who removed the babushka.  Sadly, this may not make much of a difference for this lady -- the visual loss is often permanent.  It's also the exception that proves the rule: I wrote recently about the general uselessness of the physical exam. This is one of those cases where exam was everything, and why you still have to do it.

Also, I just love saying "babushka."  That word has got such a lovely round feel to it: baBOOOshka.  Babuska. Babushka.  I'm really a simple man with simple pleasures.


(Also, I know that Ukranians and Russians are not the same thing, just like Irish and Scots aren't, and they hate being conflated together. Permit me my rhetorical flourishes.)