Movin' Meat

Things that are not at all surprising, part 26

2012-01-30T10:06:00.000-08:00

I remember way back in the paleolithic era when the debate was actually going on over what health care reform would look like (before we settled on "greatest threat to liberty ever," that is) and my comment section was deluged with folks who railed against the very concept of universality in healthcare insurance. They, further, denied that such a thing as involuntary uninsurance existed, or that underinsurance was a problem at all. These commenters tended to be the rugged individualists of our great nation, and their testimonies were along the lines of: "I have type 1 diabetes and I've had three limbs amputated and I do just fine with my catastrophic health insurance plan" or "I have chosen not to buy health insurance and I'm just so badass that if I ever get sick I will go off onto an ice floe so as not to be a burden to society, so why should we hand out free healthcare to goddamned moochers?"

Or something like that.

So, it actually turns out that catastrophic/high deductible plans actually kinda suck. I'll take a moment to allow you to recover from the shock of that.

Now we already knew that being uninsured made you (that's the general you, not you in particular) more than four times as likely to skip or delay needed care. That makes sense. Healthcare is expensive, even if you're only paying charity rates, if you can find them. If you have to pay, and you don't have a lot of money, in many cases you just don't get it. And it turns out the same phenomenon is at play with high-deductible "catastrophic" plans. When you have to pay out of pocket (which is the central concept of these plans), you're more than twice as likely to skip or delay needed medical care.

Still, high-deductible plans are great if you never have to make a claim, but there you have it...

Fun factoid: if you have a high-deductible plan, and someone in your family is ill, then the effects on your own health trickle down, as you also tend to skimp on your own health care.

And back to the subject of the truly uninsured, the CDC came out with a report which found that (again, brace yourself for the shock) being unemployed makes you about 3 times as likely to be uninsured.

Aaron Carroll takes on directly the myth of the "uninsured by choice" cohort:

Many people like to think that being uninsured is a “choice”. And they’re correct, in the sense that you can “choose” not to buy insurance. I get that. But many people “choose” not to buy insurance for the sole reason that it’s crazy expensive. The average – not gold plated, but average – employer sponsored insurance plan for an individual plan in the United States last year was $5429. And that was just the premium. It didn’t include deductibles, co-pays, or co-insurance. The average family plan was $15,073. The median salary in the US, on the other hand, was less than $50,000 for households. For individuals, the median paycheck is $26,364. When you’re making that amount, and you lose your job, paying for that insurance plan is no longer possible. Paying for COBRA is even harder, as it’s usually more expensive.

I kind of wonder why I am wading back into this topic. Experience has shown me that it's become such an ideological shibboleth that the true believers are completely impervious to reason and data. I'm like a moth to the flame, I guess. I just can't leave it alone. Someone is wrong on the internet.

Selling the ACA, 2 years too late

2012-01-27T05:30:00.000-08:00

This is a cute and informative video about the health care reform act:

My favorite drawing is this, of economist Jon Gruber about to be crushed by the ogre of uncontrolled health care spending:

In fact, I think this will be my new twitter avatar.

Still, it would have been nice to have seen more of this sort of education and messaging two years ago when public opinion regarding the ACA was more malleable. Now people's ideas are pretty well set, hardened in part by their partisan stances. I was shocked to see that 55% of Americans now think that the individual mandate is unconstitutional. This is evidence, I think, of how effective the impassioned rhetoric from the opponents of the ACA has been in shifting the way the law is viewed. I don't think that many people have done a deep dive into Wickard v Filburn and come to this conclusion on their own; I suspect that more have been influenced by the persistent and angry denunciations of the mandate by its many opponents, with flaccid or nonexistent defenses of the law from its supporters. Consider, by the way, that when the court challenges were filed against the ACA's mandate, it was considered hopeless by legal observers; now we are truly a coin flip away from its invalidation. That's how far the frame has shifted, and it's entirely due to the effective case that has been made by conservatives and the failure of defenders of the law to respond.

Hopefully, this will be moot. If SCOTUS doesn't decide to overturn decades of precedent, and if Obama does manage to win re-election, the law will be completely implemented. In that case, I suspect it will becomes less of a partisan football, and we can maybe move beyond repeal to more productive arguments. I can dream, can't I?

Doctor Cat

2012-01-26T10:25:00.000-08:00

A friend alerted me to the existence of this:

Unfortunately, the Doctor Cat cartoon seems to be on a bit of a hiatus for health reasons (here's hoping the author gets better soon). It works for me on a number of levels:

1. Cats are cute (no explanation needed)
2. Cats are like doctors in that they are variably narcissistic, imperious and inscrutable.
3. Did I mention the cute factor?

Reminds me of this brilliant series from Medium Large:

The Myth of the Cost Sensitive Patient

2012-01-25T23:50:00.000-08:00

It simply will not go away, and the fact that anyone who has ever interacted with the health care system thinks this will ever be more than a pipe dream is simply delusional. The offender (this week) is former CBO and OMB director Peter Orszag. (Disclosure: I once had a man-crush on him as the uber-wonk of health care reform, until he left government and cashed in at Citigroup.)

Orszag writes in Bloomberg: To Shop Smart, Patients Need to Know Price of Care, in which he argues for greater price transparency "with the goal of helping people become smarter shoppers."

Sweet baby zombie Jeebus help me.

To his credit, Orszag notes that the extant experiments towards this goal "have not been overwhelmingly successful," in perhaps the same way that the captain of the Costa Concordia was "not entirely prudent" in his navigation. He also acknowledges that cost-conscious medical bargain hunters are "unlikely to play a dominant role in reducing health expenses." So he at least relatively connected to reality, unlike the free-market fanatics who continue to insist that if only patients were obligated to bear the costs of their medical care, they would magically demand only the most cost-effective care and our health care cost inflation crisis would be solved.

But it's just not so. I've made this point before over and over. But again, it bears repeating:
The patients who are the drivers of health care costs (you know, the sick ones) are neither equipped nor situated nor interested in pursuing the cheapest health care.

Bear in mind that we are talking about a relatively small slice of patients: half of all health care costs are concentrated in the sickest 5% of patients in the US, and 80% of costs are accounted for in the top quintile!

These folks are sick, which means in many cases they are not feeling good, what with being sick and all, and when you are not feeling good it's hard to be really rigorous in making sure that your procedure of the week is being performed by the cheapest possible surgeon. What's more, when you are sick, you often have a doctor, and that doctor has associates and affiliations which you may find yourself being steered towards. And you may even trust your doctor, and when he tells you that a certain consultant or hospital is a good one, then you might just take him at his word and go there without first creating a spreadsheet of all the local options and their variation in costs.

This is all assuming that you have a choice in the matter. The ambulance may take you to the closest ER, or the surgeon who offers the best price on your cardiac bypass might happen to practice at a hospital with the most expensive ICU (which you weren't expecting to need so you didn't put that line item in your spreadsheet).

This is assuming that you live in an area with more than one network of providers; many regions have evolved a near-monopolistic health care ecosystem.

Finally, it's all academic because the typical patient who is a real super-user of medical care is spending so much money that even an insurance policy which is designed to have a high level of cost sharing and encourage patients to be highly cost-conscious cannot have a hope of paying a reasonable fraction of the actual costs of their care.

For example (a not-entirely random example): when I got the bill for my wife's radiation therapy last year, it was the largest invoice I have ever seen that did not have a mortgage attached to it. If I recall correctly, it was about $80,000. Worth every penny, I might add. So what threshold would be effective in getting me to choose one provider over another when the treatment is so insanely beyond my means to pay? None. At least none that exist in the real world. If I were on the hook for 25% of that $80K, it would be a horrible burden (even for a rich doctor, yes). I would have been able to scrounge the money I am sure. But then, I'm in the 1%. Well, maybe the 2%. What about a median-income patient? Someone earning $60,000 a year (well above median, I might add) would find medical co-pays of $5, 10, 20,000 crippling and completely beyond their means. Which means that healthcare insurance either insulates the typical patient from the cost or forces them to defer needed care.

There's very little middle ground. Yes, it's theoretically possible to find the magic level that would motivate a patient to become a "smart shopper" without resorting to self-rationing, but that sweet spot is so small and so variable from person to person that I am skeptical it could ever be implemented on a large scale, and certainly will never ever "bend the curve" on health care costs.

None of this should be interpreted as an argument against transparency in health care costs. The system is so distorted that the typical gross charge is triple the actual cost, and just like airline fares, no two people pay the same price for the same service. It's an outrage, or it should be. Transparency might be a good thing in and of itself. There might even be merit in linking costs to quality, if it can be done rationally (of which I am not entirely convinced). But I wish to god that people would stop pretending that patients who are seriously ill and marginally informed about the economics of health care can ever be utilized as a tool for reducing the national cost of said care.

Because it's a fricking delusion.

Surgeons behaving badly: a rant

2012-01-17T04:30:00.000-08:00

I recently saw a patient who had had a major surgery at a downtown medical center. He had done fine initially, but at about 2 weeks out, the patient started having fevers and chills. He saw his surgeon in follow-up and was diagnosed, reasonably, with a UTI and started on antibiotics. Unfortunately, he got worse and presented by EMS to my ER quite ill indeed. It was clear that he needed to be admitted and possibly to have another surgery.

In this case, I was pleased that the patient and his family thought the world of their original surgeon. "Dr Smith was great, so thoughtful and kind and he knows all about my problem, you will call him, won't you?" "Oh, I have to be admitted and maybe another surgery? Can you send me to Dr Smith? He's the one I really trust."

No problem, I thought. So, on this holiday weekend, I call The Big Medical Center and get hold of Dr Jones, who is the partner of Dr Smith. I explained the situation and laid out the facts. Dr Jones surprised me by ignoring the fairly obvious clinical conclusion and asking, "Well, what do you think should be done?"

"I'm not a goddamn surgeon, which is why I'm asking you, you passive aggressive jerkwad," I didn't say. I did suggest that the patient needed to be admitted and perhaps explored versus observed. I waited for him to sigh and say "OK, why don't you send him down here. I'll arrange a bed."

"What do you want me to do about it?" he replied. It was becoming clear that he viewed the fact that the patient had landed in my ER, and not his, to be a stroke of luck, as the patient was my problem and not his. Oh well, I had given him the opportunity to be graceful and accept the responsibility.

"I think we should send him to The Big Medical Center and you should take a look at him. I honestly don't know whether you need to operate or not: that's going to have to be your decision."

"Why would you want to do that? You have [my specialty] at your little hospital. Have your surgeon look at him and I am sure they are competent enough to manage the issue." His voice was dripping scorn at this point.

"I don't think the family would be happy with that. They liked Dr Smith a lot and they really want to go back to The Big Medical Center, and for continuity of care it probably is in his benefit to do so."

He wasn't being put off so easily though. "Well, it's the holiday and Dr Smith is not going to be in the hospital and I don't know anything more about this patient than your surgeons do so he might as well stay there. Besides, his insurance probably won't pay for the ambulance transport -- does the family really want to be stuck with that sort of bill?"

Now I'm fuming. I'm pissed because this guy is doing everything he can to block this late-night admission, and moreso because his points are more or less correct. Still wrong on the global level, but accurate on the details.

I had no choice but to force the issue: "Look, I can keep him here, but if I do that, everybody is going to be unhappy. My surgeon is going to be unhappy that he's had somebody else's complication dropped in his lap. I'm going to be unhappy that I have to force him to take this case. The patient is going to be unhappy that they were not cared for at the institution and the medical team of their choice. And Dr Smith is not going to be happy that his patient was refused admission by his partner." I did not add that I was already unhappy that I was having to bully and threaten him into doing his bloody job.

He relented, getting in one last passive aggressive jab, "Fine. I'll accept him, since you're clearly incapable of caring for him up there."

I took a deep breath, swallowed some bile, and thanked him and set the phone down. I got what I wanted, the patient was getting the care he needed, and so I had won, at the expense of twenty-five points of elevated blood pressure and the need to work on the heavy bag for a while.

My experience is that there is nothing a surgeon hates more than having somebody else's trainwreck dropped in their lap. Many times I have had that conversation, where I call our specialty surgeon and he snarls at me, "Why is this patient here? Why didn't they go back to wherever the original case was done? Can't you send them back? I'm not fixing that guy's complication!" And frankly, I understand that perspective. The second surgeon is often offended that the primary surgeon is shirking - the ethos among surgeons is generally one of responsibility, though, and even mild territoriality. They usually want to be called about their patients and they usually want to have their patients sent to them when there is an issue down the road. I like that.

Which is why it was so maddening that this guy, who was partners with the original surgeon, was blocking the referral. It was his responsibility. He agreed in advance to cover his partner's cases, as they do for him. And here I am having to bully, badger and hector him into doing his bloody job. Gah.

I should point out here very clearly that this was an unusual event, which made it rant-worthy. My general experience with surgeons, en masse, is that they are very good about taking responsibility for their complications. The few who shirk this responsibility, though, give the rest of them a bad name.

Field guide to quackery

2012-01-16T12:09:00.000-08:00

From the inestimable folks at Sci-ence:

Worth clicking through for the full read.

Spirals and Fibonacci Series and Pine Cones

2012-01-13T21:00:00.000-08:00

This is so freaking cool:

And part two:

How is it that the world works like this? How awesome is it that the world works like this?

I remember once being criticized by a more touchy-feely friend who specialized in the humanities, for being a reductionist, too scientific. By wanting to break everything down into its component elements and understand how they work, he contended, we rob them of their mystery and their beauty. This video, I think, is a wonderful refutation of that contention. I get so much more satisfaction and joy out of understanding on a deeper level how the world works, and how deeply simple mathematics are embedded in the design of life. This is where the wonder and mystery reside, and this is why I will always love science and math, even when I'm not actively engaged in research myself any more.

Washington Medicaid vs Prudent Layperson

2012-01-13T13:24:00.000-08:00

Consider this scenario: You are driving down the road and your car is hit from behind. You car, being older, doesn't have the greatest safety features, and the seat back breaks, and your head is wrenched backwards by the force of impact. You feel a sudden sharp pain in your neck, and you are afraid to try to move because you don't know how bad the injury is. The next half hour is a blur. Bystanders and the police keep you in the car, the paramedics come and slap on a collar and strap you to all sorts of devices and next thing you know you are cold and naked under the bright lights of a trauma bay. You are examined, medicated, poked, prodded, scanned and rescanned. Finally, you are told that there doesn't seem to be any serious injury. Eventually, the collar is removed and you are taken off the backboard. You are allowed to go home and over time you recover. You were diagnosed with an acute cervical strain.

According to the State of Washington's Medicaid administrator, the Health Care Authority (HCA), the above scenario represents a non-emergent, inappropriate use of the ER. According to new guidelines they are putting in place, such care will no longer be compensated. Under Federal Law, providers may not attempt to recover monies from Medicaid beneficiaries (not that they have the ability to pay, typically, because they're on Medicaid). So the hospitals and other health care providers are mandated to perform this service for free.

The background here is that last session, the Washington state legislature tried to close the gaping budget deficit with all the subtlety and grace of a machete. They simply directed the HCA to reduce expense in "unnecessary" ER utilization by $72 million. Initially, the HCA tried to make a list of non-emergent diagnoses and issued a rule that if a certain client visited the ER more than three times for non-emergent diagnoses, subsequent visits would not be paid for. The WA healthcare community responded with a lawsuit that was successful in having the rule thrown out on procedural grounds — the HCA had not gone through the required public steps in issuing the rule.

We hoped that this had ended the matter, but the HCA has doubled down. They now intend to simply stop paying for any care in the ER which they determine, after the fact, to have been non-emergent or which could have been delivered in an office setting. This will be determined by a retrospective review of the coded diagnosis. Unlike the previous attempt, there will be no exceptions for children, wards of the state, those presenting via EMS or those referred to the ER by their PCP. The new policy will be effective on the first visit, not the third non-emergent visit. The HCA has decided not to go through the public rule-making process, nor will they apply for a State Plan Amendment with the Federal Center for Medicaid & Medicare Services. They simply decided they had the authority to not pay for things that are not, in their view, emergencies.

Why is this problematic? We all agree that Medicaid patients do overuse & abuse the ER, and for less acute complaints. Isn't it a good thing that the state is finally doing something about it?

The biggest problem is that this policy doesn't actually do anything to keep these patients out of the ER. They pay nothing now, they will pay nothing under the new policy. And it's not like there is a huge network of private docs waiting and eager to accept Medicaid patients in their offices. So they will continue to come, and emergency providers will simply be obligated to care for them without reimbursement. It's a forced cramdown on hospital and physician reimbursement, and other, more urgent, patients will still suffer longer waits because of the ER crowding driven (in some part) by overuse.

The next problem is that the health care community did come to the table with a variety of suggestions to reduce unnecessary ER use, including community care coordination, case management for ultra-high ER users, and better oversight and management of narcotic pain medications prescribed through the ER. Unfortunately, the HCA was not interested in any sort of meaningful collaboration and declined to pursue these suggestions, despite evidence that they would actually have reduced ER use and saved money.

Finally, the concept of retrospective denials is so patently unjust that I'm shocked that they have the gall to propose it. It was a common practice in the '90s for managed care auditors to deny payment for an ER visit for chest pain if the final diagnosis was heartburn. This sort of abusive behavior became so widespread that all 50 states and the federal government now have "Prudent Layperson" laws on the books which dictate that it is the presenting symptom, not the final diagnosis which determines whether it was appropriate for a patient to visit an Emergency Department. These apply to state- and federally-sponsored commercial health plans, but apparently not to Medicaid. The HCA flaunts that exemption in returning to the old days of abusive practices.

This is not over, by any stretch. The healthcare community in WA is fairly galvanized by this threat. It will surely return to the court system. Given the patent unfairness of the proposed policy, and the way in which the HCA simply arrogated themselves the right to make the non-payment decision, I think there's a good chance that it will also be struck down. There is, however, no guarantee.

Strikingly, the person behind this initiative is himself a physician. Jeff Thompson MD, MPH is the medical director and by all accounts has been the driving force behind this policy change. We have expressed our disagreement and concerns about the policy to him personally and in great detail, to no avail. His email address is published on the HCA web site. Perhaps you could contact him directly and let him know what you think of this policy. As always, I would encourage a polite and respectful tone, and bonus points if you live or work in Washington state.

Awesome CPR PSA Video

2012-01-05T12:46:00.000-08:00

Yeah, this is pretty great:

One thing that always bugs me about these videos is that the chest compressions look fake, well, because they are. If you've ever really seen CPR done right, pushing in 2 inches is a huge thing, in the videos, they're barely denting the skin. The consequence is that when someone does real CPR for the first time they NEVER push in deep enough.

I wish they would swap in a dummy or use some effects to make the compression depth more dramatic and obvious. Yes, it's a nitpick, but it matters.

The True Meaning of Christmas

2011-12-25T06:00:00.000-08:00

Well said, Linus.

From Calamities of Nature. For each of you that click through the link before the end of the year, the artist will donate $1 to Doctors without Borders.

A song for christmas

2011-12-24T06:00:00.000-08:00

The snowflake thingy makes it even cooler.

How did I miss this?

2011-12-20T15:40:00.000-08:00

Jon Stewart & Colbert singing a duet, "Can I interest you in Hannukah?"

The Colbert Report

Mon - Thurs 11:30pm / 10:30c

A Colbert Christmas: Jon Stewart

www.colbertnation.com

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The Field Where I Died

2011-12-17T10:48:00.000-08:00

The wife is watching an X-Files marathon while we make christmas cookies. This was one of my favorite bits from that series:

The text is from an old Victorian poem by Robert Browning:

“ At times I almost dream
I too have spent a life the sages’ way,
And tread once more familiar paths. Perchance
I perished in an arrogant self-reliance
Ages ago; and in that act a prayer
For one more chance went up so earnest, so
Instinct with better light let in by death,
That life was blotted out — not so completely
But scattered wrecks enough of it remain,
Dim memories, as now, when once more seems
The goal in sight again.”
Paracelsus, Robert Browning

One Year

2011-12-14T10:47:00.000-08:00

It's been a year since diagnosis. Sort of a weird anniversary to celebrate, but a milestone, hopefully the first of many. I don't have a lot of introspective thoughts here, so I'll leave all you ladies with the admonition to feel yourself up:

Wonder Woman

Catwoman

via @copyranter

Feeling Old-Timey

2011-12-12T21:00:00.000-08:00

From the Coen brothers' brilliant but underrated "O Brother Where Art Thou?"

Full of Win

2011-12-12T05:00:00.000-08:00

MODERN MEDICINE. on Twitpic

Via Gruntdoc, from @bungeechump on twitter. Based on some of his selected favorites, he's well worth following.

On a roll

2011-12-11T21:00:00.000-08:00

More Flogging Molly:

Don't like it? Feel free to start your own crummy blog. (please don't)

Saturday Night

2011-12-10T17:30:00.000-08:00

Rock on:

Flogging Molly, "Don't Shut 'em Down"

Nerd Rock Kings

2011-12-09T17:00:00.000-08:00

TMBG, of course:

Though I would also accept Tim Minchin as an alternative.

How Doctors Die

2011-12-09T00:16:00.000-08:00

A must-read piece from Ken Murray:

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

Worth the full read.

And so true. I've joked about getting the above tattoo when my times comes. (I would quibble that the modern CPR success rate is better than infinitesimal, especially with hypothermia, but it still ain't great.)

It may have to do with the time I spent on the onc ward as a med student, or it may be because my mother in law is a cancer counselor, but I have the dubious distinction in our shop for being the doc most likely to make a palliative care consult and/or make a patient "comfort care only" prior to admission.

Personally, I think it's because I am lazy, and like any other person I take the path of least resistance. Which isn't to say that I don't want to do the work of keeping someone alive -- not at all. It's that I find it so traumatic and horrible to subject a dying person to that sort of abuse that I'd rather face the family and have the "We need to talk" moment. It's not less work, but it's less awful.

I wish more ER docs took the time to do the same. I know what I want when my number is up, and I don't want a week in the ICU on triple pressors.

This is not my daughter or my dog

2011-12-08T18:30:00.000-08:00

But it could be:

I have a little girl just a few months older than this child, and two Bernese Mountain Dogs. We have scenes like this all the time, but I have never managed to capture one quite so well. I do offer you this old pic of son #2 who decided to nap on our late, lamented Berner #1:

The Oldest Profession

2011-12-08T05:01:00.000-08:00

Seriously NSFW anti-prostitution ad, and one that comes closer to any I have ever seen to convey to men a visceral sense of how awful it must be to be a woman in the sex trade:

Campaign against the prostitution english version from Black Moon prod on Vimeo.

I should say, as a point of order, that I'm not anti-sex. I'm sure there are out there many Julia-Roberts-eque hookers "with a heart of gold" -- call girls who are beautiful, sex-positive and in control of their bodies and their lives, able to choose their clients and making money and happy and good for them. They're not who this is about.

I see hookers all the time in my ER, and have for a long time. I see them up close and personal. They're not sexy. They're sad and miserable. They have abscesses from IV drug injections. They have missing teeth from meth use. They have sagging breasts and stretch marks on their bellies from the babies they had in their teens. They have psychological scars from the abuse they suffered at the hands of family members.

They don't usually think of themselves as hookers, and few of them fit the "streetwalker" image. They would be offended if they heard themselves described as prostitutes. But they are desperate and addicted and sometimes homeless and they have sex with men for money and drugs and shelter and protection. They don't think of it as turning tricks, typically, they just think of it as surviving.

I don't have any data, but I suspect that women (and some men) like this probably account for a huge majority of people in the sex trade. Add to that the illegal immigrants who are actually coerced into the profession and the more traditional streetwalking ladies of the evening and I am sure this is a large majority of the trade.

I don't know whether ads like the above do anything to help. I guess they increase awareness, so that's good. I actually don't think prostitution should be a crime. But I wish that the circumstances that led to prostitution could be eradicated.

Beyond the Mandate -- Why ObamaCare Matters

2011-12-07T05:15:00.000-08:00

There was an op-ed in the LA Times written by one Ms Ward, a woman with breast cancer. It's well worth reading, and I'll quote some of it here, but the whole thing is worth the read:

I want to apologize to President Obama. But first, some background.

I found out three weeks ago I have cancer. I'm 49 years old, have been married for almost 20 years and have two kids. My husband has his own small computer business, and I run a small nonprofit in the San Fernando Valley. ... With the recession, both of our businesses took a huge hit — my husband's income was cut in half, and the foundations that had supported my small nonprofit were going through their own tough times. We had to start using a home equity line of credit to pay for our health insurance premiums (which by that point cost as much as our monthly mortgage). When the bank capped our home equity line, we were forced to cash in my husband's IRA. The time finally came when we had to make a choice between paying our mortgage or paying for health insurance. We chose to keep our house. We made a nerve-racking gamble, and we lost.

... If you are fortunate enough to still be employed and have insurance through your employers, you may feel insulated from the sufferings of people like me right now. But things can change abruptly. If you still have a good job with insurance, that doesn't mean that you're better than me, more deserving than me or smarter than me. It just means that you are luckier. And access to healthcare shouldn't depend on luck.

Fortunately for me, I've been saved by the federal government's Pre-existing Condition Insurance Plan, something I had never heard of before needing it. It's part of President Obama's healthcare plan, one of the things that has already kicked in, and it guarantees access to insurance for U.S. citizens with preexisting conditions who have been uninsured for at least six months. The application was short, the premiums are affordable, and I have found the people who work in the administration office to be quite compassionate (nothing like the people I have dealt with over the years at other insurance companies.) It's not perfect, of course, and it still leaves many people in need out in the cold. But it's a start, and for me it's been a lifesaver — perhaps literally.

It hits home, for obvious reasons, but it's also important for another reason. So much of the battle over ObamaCare has focused on the Greatest Threat to Liberty Since Slavery, the individual mandate. It's utter, cynical, opportunistic bullshit, of course, since for years and years the mandate was the conservative counterproposal to further-reaching liberal plans. But after the PPACA passed, it was the only legal line of attack conservatives could find, and so here we sit, wondering what the most powerful man in America, Justice Anthony Kennedy, will do.

Will he strike down the entire law? Will he sever the mandate and leave the rest of the law? I have no clue. (I am assuming that the rest of the court will vote in their partisan blocs. Surprise me, guys!) But whenever this comes up in the media or in discussion, the flash point, the focus of the debate is the evil or awesome individual mandate.

What gets forgotten, though, is how much more is in the law than the mandate. While most of the attention during the drafting of the law rightly went to the plight of the uninsured and the near-universality of the coverage, much and more of the law was devoted to root-and-stem health insurance reform.

Reforms that help women like Ms Ward. Without the high-risk pool the PPACA established, she would be without any relief. State high-risk pools are unsubsidized and the premiums are unaffordable. The only reason this program is feasible is because it is temporary -- a bridge to 2014 when the insurance exchanges go into place, along with other critical insurance regulations.

Why does this matter? Because people like Ms Ward are in the individual market, and insurers individually underwrite each applicant -- and refuse those who are bad risks. Come 2014, every individual policy will have to go through each state's health insurance exchange, and they must conform to a number of new requirements. They cannot refuse any applicant. And they may no longer charge different premiums for patients with varying health histories, a feature called "Community Rating."

This is, it must be understood, how large insurers currently work. If you go work for Boeing, they don't ask you before you are hired whether your wife has breast cancer. All employees get charged the same, and the premiums for the entire pool adjust to cover the aggregate cost. All the PPACA does here is bring the same rules that the group market already works under to the individual market. And that's huge for so many people.

This is just one bit of the law that really matters to people, and that really will make the difference in the lives of so many Americans. And there is so much more. The requirement that insurers must spend 80% of premiums on actual healthcare. The prohibition on insurance "takebacks," or recissions. The expansion of coverage for kids. The requirement that premium increases must be reasonable and justified. Increased funding for primary care and community health clinics. And on and on.

So the next time you are inclined to go off on a spittle-flecked rant over the individual mandate (and I've emitted a few of my own), just pause and take a moment to remember that there is a lot more in this law than the mandate. I'm not going to persuade anybody who's already formed an opinion that the mandate really is good policy, but maybe I can remind them that a nuanced view of the law might be in order. It's not black and white. Regardless of the fate of the mandate, we should all be hoping that Justice Kennedy lets the rest of the law stand.

TimeScapes

2011-12-06T23:47:00.001-08:00

What a beautiful world we live in.

Holiday decorating tip

2011-12-02T07:45:00.001-08:00

It's that time of year when folks venture up ladders and out onto their roofs, putting up christmas lights and other holiday decorations. My own house is lit up such that it is probably not visible from space, but could serve as a beacon for passing aircraft. (Energy-efficient LEDs, of course.)

Anyhoo, it turns out that if you're not really accustomed to working on a ladder or walking on a roof, and if conditions are cold, wet and icy, or if the roof is mossy, the chances of suffering an acute and traumatic case of gravity are pretty decent.

Be careful out there.

Always been a sucker for models

2011-12-01T22:53:00.001-08:00

But this one takes the cake:

I wish I had many millions of dollars to make something like this.

The Physics of Angry Birds

2011-11-22T12:36:00.000-08:00

The Physics of Angry Birds | Wired Science | Wired.com:

Yes, OF COURSE somebody has taken the time to figure it out.

Turns out the slingshot is 4.9 meters tall (yikes!) and the red bird is about 70 cm tall. Yowza. The launch velocity is a constant 22m/s.

God, I love the internet.

Marijuana and Cyclic Vomiting Syndrome

2011-11-22T10:34:00.001-08:00

I have been working as an ER doctor for over a decade, and in that time I have come to recognize that there are certain complaints, and certain patients who bear these complaints, that are very challenging to take care of. I'm trying to be diplomatic here. What I really mean is that there are certain presentations that just make you cringe, drain the life force out of you, and make you wish you'd listened to mother and gone into investment banking instead. Among these, perhaps most prominently, is that of the patient with cyclic vomiting syndrome.

The diagnosis of cyclic vomiting syndrome, or CVS, is something which is only in recent years applied to adult patients. Previously, it was only described in the pediatric population. It has generally been defined as a disease in which patients will have intermittent severe and prolonged episodes of intractable vomiting separated by asymptomatic intervals, over a period of years, for which no other adequate medical explanation can be found, and for which other causes have been ruled out.

That is not seem to exist much in the way of good literature about this disease entity, which is surprising, because it is something that I see in the emergency department fairly regularly, and something with which nearly all emergency providers are quite familiar. These patients are familiar to us in part because we see them again and again, in part because they are memorable because they are so challenging to take care of.

Some things about the cyclic vomiting patient that pose particular challenges:

The intensity of their vomiting symptoms tends to be very severe, and refractory to most standard antiemetics.
The amount of affective distress the patient demonstrates is usually quite disproportionate to the severity of their symptoms, which is actually saying something, since they can at times be fairly ill. This often manifests itself as a patient who is ultra-dramatic, writhing on the gurney, or hyperventilating and sobbing in a knee to chest position, refusing to talk to the care providers. This can create the perception among care providers that the illness is psychogenic, a perception which is reinforced by the fact that there does seem to be significant association between CVS and mental health diagnoses.
Patients often will engage in behaviors which seem to be willfully making their symptoms worse, such as compulsively drinking water or being seen to induce vomiting by putting their fingers down their throat.
Coexisting with the vomiting is often a fairly severe complaint of abdominal pain, for which no clear diagnosis can be established, requiring in some cases high doses of intravenous narcotics. CVS patients are interesting in that sometimes the only agent that will stop the vomiting is hydromorphone. (For the nonmedical readers, it is worth noting that hydromorphone has no anti-vomiting properties, and in fact causes many people to vomit.) This requirement for narcotic medication supports a perception that the patient is drug addicted or drug seeking, itself reinforced by the fact that patients tend to come back to the emergency room several times in quick succession for recurrent vomiting. (For this reason, some have referred to CVS as an "Abdominal migraine.")

All of this makes management difficult in the setting where there is fairly little in the way of evidence-based guidelines, or even much in the way of expert recommendations or academic agreement on the definition of the syndrome. My observation, over the years, is that while Zofran and Reglan and Compazine can in some cases be helpful, in most cases they are not. I have however, had very good success with the use of benzodiazepines such as lorazepam or midazolam. Benzodiazepine seem to work in 2 ways: they are well known to have anti-emetic properties, but they are also quite sedating, and the patient does need to be awake to vomit. Interestingly, while use of normal vomiting medications seems to drive patient requests for narcotic medications, when I use the benzodiazepines, I almost never have to co-administer a narcotic. Since I have made these observations and implemented them in my personal standard treatment protocol, I found that CVS patients are much easier to care for, both in the sense that they're less emotionally draining for me and in the sense that they get better quicker and go home feeling better. It's not clear to me whether this treatment protocol results in fewer bounce-back presentations to the emergency room, but I would be very interested to find out if that is the case. (Interestingly, the use of hydromorphone seems to increase the likelihood of bounce-back presentations.)

I'm a little curious whether propofol could be used to manage the vomiting of CVS, since it is also known to have anti-emetic properties, but given the demise of poor Mr. Jackson, I suspect such off-label uses of that medication are not going to be encouraged.

One thing which I've recently become aware of, in part through our good Aussie friends at Life in the Fast Lane and in part from a journal club that I recently attended, is that there seems to be a fairly strong association with marijuana use and CVS. In fact, there has been proposed a disease entity called cannabinoid hyperemesis syndrome which may possibly represent the same clinical syndrome of CVS, or at least a significant overlap. This is particularly interesting because marijuana is in fact generally perceived to have antiemetic properties. Leon Gussow, a toxicologist who blogs at The Poison Review, has a nice write up over at Emergency Medicine News, where he speculates:

Because cannabinoids are lipophilic and have long half-lives, they may accumulate with chronic heavy use to the point where they start to exert a paradoxical effect. This may be related to their well-described ability to delay gastric emptying and decrease gastrointestinal motility.

However, I would temper that against the observation that in CVS patients gastric motility and gastric emptying is often increased.

Since I have become aware of this association between marijuana use and CVS type presentations it has been my “good fortune” to care for nearly a dozen patients in the emergency department who self-reported diagnosis of CVS. Curiously, of these patients about 10 admitted active marijuana use, and the 2 who denied it had positive urine screenings for marijuana. This does not exactly make a case series, but is certainly another interesting observation. Of course, since the prevalence of marijuana use in our Emergency Department seems to approach 100% sometimes, this also may not be a statistically significant association! Each of these patients was counseled about the possible causal relationship and advised to stop smoking the devil weed. Lord knows whether they will or not, but maybe it will actually do something to reduce their ER visit frequency.

I'd be interested to hear your observations on this matter, whether other ER folks have noticed the same thing.

YAQRIAS (Yet Another Quality Reporting Initiative Acronym Set)

2011-11-21T04:52:00.000-08:00

Okay, I am officially overwhelmed. I am about as well plugged in to the bureaucracy of medicine as any nonprofessional administrator can be. I am familiar with the joint commission audits, with the physician quality reporting program, with CMS core measures, with hospital compare, with HCAHPS, with meaningful use, with the hospital inpatient quality reporting program, with leapfrog and a variety of other patient safety and quality initiatives. Yet it seems that every time I turn around there is a new set of quality metrics being developed and implemented. I can't keep track of them anymore. It turns out, unsurprisingly, that our hospital is preparing for a new set of measures which will be tracked as of January 1, in addition to the measures that I was only vaguely aware of which they had already been tracking for the last 2 years.

This is, of course, the Hospital Outpatient Quality Reporting Program. You all knew about that one, right? Cause I didn't. So what this is, apparently, is yet another quality data reporting program. In these programs, the healthcare provider, in this case a hospital, is required to report their performance on certain quality performance metrics. If they comply with the reporting requirement, they receive the full payment update for their Medicare outpatient services, and if they do not report the measures, then they are penalized 2% of their Medicare outpatient dollars, a figure which can run into many millions of dollars for the typical hospital system.

It's important to understand, that at least at this time, hospitals are not being paid for how well they are performing these measures, simply for reporting them. It is not unreasonable to presume, based on experience with previous quality reporting initiatives, that ultimately payment will be linked with performance rather than just for reporting.

So what are the reported quality metrics which are relevant to emergency department care?
The existing metrics are:

Acute MI: median time to thrombolysis
Acute MI: thrombolysis within 30 min.
Acute MI: median time to transfer for PCI
Acute MI: aspirin on arrival
Acute MI: median time to ECG
Nontraumatic headache: Use of CT scan (medicare patients only)

New metrics being reported and tracked as of January 2012:

Troponin results within 60 min. for chest pain or MI patient.
CT head interpretation for acute stroke within 45 min. of arrival
Left without being seen rate
Door to Doctor time
Median time from arrival to departure for discharged patients.
Discharge instructions
Time from arrival to pain medication for long bone fractures

I have to say, somewhat reluctantly, compared to previous attempts to develop quality metrics for the emergency department, these are not terrible. I remember when we had a hard time in which we had to have given antibiotics to patients with pneumonia, which turned out to be not supported by evidence and drove overuse of antibiotics in the emergency department for patients who wound up not actually needing them. I knew one emergency department, not mentioning any names, where it became protocol to give an oral dose of antibiotics to anyone at triage who complained of a cough. These new metrics seem to focus more on ED throughput and efficiency, which is certainly a major factor given the ED overcrowding epidemic. And I don't think anybody would argue that getting a troponin back on a chest pain patient in less than 60 min. is an unreasonable expectation in this day and age.

The discharge instruction metric is interesting in and of itself. This is simply a prescriptive requirement that discharge instructions, which are curiously renamed "Transition records," contain the following data elements: major procedures and tests performed during ED visit; principal diagnosis at discharge; patient instructions; plan for follow-up care; list of new medications and changes to continued medications. Again, this does not strike me as unreasonable, and seems crafted in such a manner to compel EMR vendors to modify their standard discharge instructions to contain these fields by default.

So what is my take away from these new metrics and this program in general? Simply put, I think we are seeing the maturation of ED quality measurement and the nationalization of the concept of the emergency department dashboard. I also think that this is a continuation of the long planned trend of cost-cutting masquerading as quality management. Those hospitals that at this time are not reporting their data are already losing reimbursement from Medicare, which represents an overall savings to the program. By the time that all hospitals are on board and fully reporting the data, I anticipate that as we have seen on the inpatient side of things, payment will be linked to performance. In that setting, reimbursement will likely be withheld from those hospitals which are performing below the median or some other arbitrary percentile threshold. This moving target guarantees that at least half (or more) of the hospitals in the program will have a reduction in their reimbursement, even though they might be achieving a fairly high level of quality.

While I understand the overall crisis in healthcare costs in this country, and I understand the need to cut costs, and I also understand the need to improve standardization and quality of care, I do not like the fact that cost-cutting has essentially been piggybacked onto quality measurement. However, this appears to be an inexorable force that we are all just going to have to live with.

So, there you have it: enjoy! Another year, another set of quality metrics to measure and manage to.

This seems about right

2011-11-20T12:23:00.001-08:00

Though my personal graph would have the crossover point way earlier.

via SMBC

Frozen in Time

2011-11-18T10:31:00.001-08:00

We respond to certain "Code Blue" situations in our hospital. In the ED, of course, and in the outpatient areas and radiology, and if needed as back-up in the inpatient units. The hospital issues one of those overhead calls when there is a code blue -- a cardiac arrest or other collapse, person down, injury, etc, but we also carry a pager in the ER in case we don't hear the overhead call. The pager also signifies which doc is designated to respond to such a call, since we often have 8 docs working at once. It's a little ritual we have at change of shift, passing off the pager and the spectralink phone, like the passing of the torch to the oncoming doc.

So of course I took the pager home the other day and had to make an extra trip to the hospital to return it. Ugh.

As I was driving back in, I took a moment to really look at the thing, and it struck me that this pager is the exact same model I used in medical school and residency, way back in the mid nineties. The exact same one.

How bizarre is that, when you think about it? This device ought to be a relic in a museum of outmoded technology. This device was in use before the iPad and iPhone, before smartphones at all, before digital cell phones. When this device was first put to market, the internet barely existed, if it did at all, computers all had CRT monitors and the fastest computers out there was running a 200mHz Pentium Pro.

Yet it remains in widespread use, having never been updated, improved or (as far as I can tell) altered in any way whatsoever. Where else will you ever find a piece of technology still in use unchanged for a decade and a half? What industry is so ossified and hidebound that it would fail to adapt to the rapid improvements in communication technology?

Only in health care, my friends, only in health care.

Way Cool

2011-11-13T18:39:00.001-08:00

Bach's 1st suite of cello, visualized

(Apologies -- Blogger ate the link)

For those who served

2011-11-11T05:00:00.000-08:00

Work-life balance for physcians

2011-11-10T12:07:00.000-08:00

Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes.You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.

Yeah, Atari. Look it up, kids.

Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue -- that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life. These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.

But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on.Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.

For example, a study in Amednews, cited by @Skepticscalpel, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves -- stable and predictable practice environments -- and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.

This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. Skeptical Scalpel himself mused:

Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?

One commenter was rather more direct:

Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out.

Which, I think, aptly summarizes the position of the "old guard," the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated -- and thus, subject to change. Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is is worth the cost to my family and my personal life? Is it more important to me that I be a "good doctor" than it is that I be a good father and a good husband? I don't think so, and in fact, personally, I identify myself more as a father than a doctor.

Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.

So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of cohort replacement, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.

John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but poses the unsettled question of whether this is good or bad for patients.

To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.

The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it. You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.

However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.

The greater question of whether this is good for patients relates to the the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.

I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.

And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices, and it's very unlikely to change. So we had best recognize it and make plans to deal with it.

It's all a matter of perspective

2011-11-08T12:48:00.000-08:00

There's technically no difference between "I almost sent home that baby with bacterial meningitis" and "I made a tricky diagnosis of a life-threatening case of bacterial meningitis." The facts of the case are the same. One statement expresses justifiable pride in a job well done. The other emphasizes how close you can come to utter disaster without ever knowing it.

Apropos of nothing, I think I'll buy a lottery ticket today.

RIP Steve

2011-10-05T18:22:00.001-07:00

Living in the future

2011-10-03T04:30:00.000-07:00

My father in law, now deceased, was a nephrologist. I met him while I was in medical school. He was a reserved guy, not prone to butt into what he saw as others' business. So I still remember that while I was considering what sort of residency to pursue, he took a surprisingly strong stance that I should go into interventional radiology. His reasoning was simple: they have a great lifestyle, they make bags and bags and bags of money, and they get to play with all the coolest gadgets.

It was tempting, I admit. As anyone who knows me can attest, I am ALL about the gadgets. I'm not averse to bags of money either. But I never gave it much consideration, mostly because I am just not real good at radiology, though for an ER doc I do OK. (A low bar, it is true.)

I sometimes regret that decision. For example, I wrote the other day about a gentleman who presented with a ruptured abdominal aortic aneurysm. We had some heroic fun in the ER resuscitating him and getting him to the OR. After the fact, I had to wonder whether it was all in vain -- the mortality on ruptured AAAs used to be upwards of 75% even if they made it to the OR. It's a huge surgery with tons and tons of blood loss, and the only people with AAAs are old vasculopaths with bad hearts and bad brains and even if they survive the surgery they stroke out or die of kidney failure or ARDS or what have you. Bad juju.

So it was with pleasure that I logged into the computer the other day and checked on my "interesting patient" list to see that he was still alive and not even in the ICU. I'm not sure which fact was more surprising. I pulled up the dictations and read the op notes and was stunned to realize that when this guy's fricking aorta exploded, the vascular surgeons/interventionalists are such badasses they didn't even open his abdomen. They fixed it all through his groin. Through his groin.

I knew endovascular grafts were around -- they're not exactly new. But I did not know they could be used in the setting of acute aortic rupture. How cool is this? They get to the OR, access the femoral artery, then throw in a balloon catheter and occlude the aorta above the level of the aneurysm:

This stops the bleeding and increases perfusion to the brain, which is good. Then they do a nice leisurely series of angios to measure things and pick the right graft to apply, hook in the contralateral iliac limb, and you are good to go: one functional artificial aorta, estimated blood loss 50 cc. (Not counting the six units in the peritoneum.)

What an amazing thing these guys have accomplished with this technology. If we can get you to the OR alive, they can fix the gnarliest vascular catastrophe standing on their heads. I have got to say, I love living in the future. This sort of coolness almost -- almost, mind you, but not quite -- makes up for not having hovercars and personal jet packs. Which we were promised.

Had I known what sort of awesomeness the future held in the world of interventional radiology, this might well be a very different blog. And I would have bags of money. And the coolest fricking gadgets on earth. (Sigh.) If you'll excuse me now, there's a ninety-year-old dizzy patient I need to go see.

Still a sucker for slo-mo

2011-10-02T10:13:00.000-07:00

It doesn't pop, you see. That's why it's awesome. Though the fact that they calculated the resonant frequency of the nose does win bonus geek points.

Effing A

2011-10-01T22:54:00.000-07:00

The Aurora Borealis is effing gorgeous:

Aurora Borealis in Finnish Lapland 2011 from Flatlight Films on Vimeo.

Someday I will see it with my own eyes.

Absit Omen

2011-09-30T05:30:00.000-07:00

So it was just last week, that I bitched, and I quote, "Where's all the pathology? I haven't seen a AAA in years. That's just not fair."

Yeah, you all know EXACTLY where this is going now, don't you?

The very next day. The very next day. I know it's just confirmation bias, but this is why people have superstitions. Naming calls.

This wasn't the most challenging diagnosis I'll make this week. The paramedics called it in as a "probable ruptured AAA." Which, in retrospect, certainly saved his life. Because we were ready on arrival. He looked unwell, a typical pasty, sweaty, ashen obese middle-aged-to-older guy. I barely spoke to him beyond the necessary few words and threw the ultrasound probe on his belly. Too fat -- couldn't see squat. His vitals were OK, so across the hall to CT he went. I was there when the images came across and I saw this appear on the screen:

A lovely ten-ish centimeter aneurysm with lots of clot within it and lots of free blood/hematoma in the abdomen.

And the rest went as you might expect, except that it went beautifully. We had 8 units of blood standing by, large bore access, and the vascular surgeon on his way to the ER. When the patient suddenly said "I'm starting to feel lightheaded," the nurse reassured him that it was just the pain medicine, but I knew better. Moments later, he was pulseless and I was intubating him. He got six units of blood via the rapid infuser and as soon as the OR could be made ready he was out of the department. Door to door, 38 minutes. Alive and with a pulse.

Funny aside: I got back from CT before the patient and I briefed his wife on the situation and plan. I warned her, "Now, a lot of things are about to happen really fast. A lot of people are going to swarm over him and it's going to get loud and chaotic and I want you to know in advance that this is more or less normal in these situations. This is serious but we're going to take good care of him." How little did I know! As a result, while her husband crashed, the wife sat there smiling, assuming that this was just what I warned her about. (Fortunately the chaplain came by to take care of her.)

Anyway, it was thoroughly exciting and satisfying. After the patient rolled, the staff were all exchanging high-fives, the orienting nurses were standing around all wide-eyed, and the charge nurse drawled, "I feel like I need a cigarette."

The awesome thing was that I barely needed to give an order. EVERYBODY did their job perfectly:
The medics made the call (and got 2 16-gauge IVs)
One tech ran to get the blood
Somebody (I don't know who) called the OR
Someone (of their own initiative) got the rapid infuser ready
The trauma coordinator RN came over to run the infuser (she knows it better than anybody)
The HUC got me past medical records just in time to give them to anesthesia

As much as I'd like to take credit, all I did was tell them to give lots of blood and put in the tube. It was totally a team effort, and it was a thing of beauty to behold. But it probably is a good thing we don't have to do this every day.

Now, since it worked so well before, what should I wish for next? I know! "Man, I haven't had a good precipitous delivery in forever! Those are so much fun!"

Y'all can thank me on my next shift.

Flying above the Earth

2011-09-29T10:10:00.000-07:00

Courtesy of NASA:

According to the description, this begins over the Pacific Ocean and continues over North and South America before entering daylight near Antarctica. Visible cities, countries and landmarks include (in order) Vancouver Island, Victoria, Vancouver, Seattle, Portland, San Francisco, Los Angeles. Phoenix. Multiple cities in Texas, New Mexico and Mexico. Also visible is the earths ionosphere (thin yellow line).

If you squint pretty hard, I think you can see my house.

I am Han Solo

2011-09-28T12:16:00.000-07:00

Patient, to me: I was admitted last week at The Big Hospital downtown and they did a whole bunch of tests and couldn't figure anything out.

Me: Can you tell me what tests they did?

Patient: Oh, they did them all -- every test you can imagine.

Me: I don't know about that. I've got a pretty good imagination.

Don't let your imagination run wild

2011-09-26T22:00:00.000-07:00

Lest the students out there get disillusioned, it is probably a good idea to be upfront about the reality of being a doctor:

Maybe it's not always this bad, but in the ER there is a real ring of truth to this.

From the marvelous Saturday Morning Breakfast Cereal

Conversations from the back seat

2011-09-26T12:08:00.000-07:00

Dramatis personae:

6 Year-old Son

3 Year-old Daughter

Setting: The back seat of my car.

3YOD: (looking out the window) I like that park. It's pretty. I wish I could play there.

6YOS: (world-weary and wiser) That's not a park. It's a cemetery.

3YOD: What's a cemeberry?

6YOS: A graveyard.

3YOD: Oh.

3YOD: What's a graveyard?

6YOS: It's where they bury dead people.

3YOD: Why?

6YOS: Because they died.

3YOD: Why?

6YOS: When a person dies they put him in a grave in that yard.

3YOD: What's a grave?

6YOS: It's a hole in the ground. They put the dead person in a box and put it in the hole.

[long pause]

3YOD: (delighted comprehension) Oh! And that's where they turn into zombies!

6YOS: Yes.

Why I get paid the big bucks

2011-09-23T05:29:00.000-07:00

On the theme of knowing when and when not to follow the diktats of Emergency Medicine, one of the greatest challenges for a practicing ER doc is chest pain. Missed MI is still the biggest driver of malpractice costs, and last I hear, ER docs still send home something like 2% of patients who are having MI or unstable angina. Not good. So over the last decade we've gotten all these chest pain observation units and rapid rule-out protocols and early stress tests and all sorts of protocol-y goodness to fulfill every ER doctor's goal of never sending home an MI.

And it's good, and works. At least, for most cases. Consider if you will:

Mr Smith is 58 years old. He smokes, and was diagnosed with hypertension and high cholesterol several years ago. He is treated with medicines for these, but is not particularly compliant about taking them. He has a strong family history of accelerated cardiovascular disease, with a father who died of an MI in his 40s and a younger brother who has had a CABG. He presents with 24 hours of stuttering chest pain. It is episodic, lasting 2-10 minutes, dull, midsternal, without radiation or associated symptoms. It occurs sporadically both at rest and with exercise. On arrival, his ECG and troponin are normal, and he rates his pain as 5/10.

So this is a pretty straightforward case, isn't it? Slam dunk, admit to Card Tele, rule out & stress test. See? Protocol-driven medicine is fun and easy.

Oh, I forgot to mention something:

Mr Smith has previously had two MIs, has five stents in place, and says the pain he is having today is exactly the same as the last time he had an MI.

That gets your attention, doesn't it? I just ramped up my level of concern quite a bit. In this case, I am probably calling a cardiologist to see the patient in the ER and starting him on heparin and a nitro drip.

But I also forgot to mention a couple of other details:

Mr Smith had his last cardiac cath eight months ago, showing patent stents. His stents are three years old. He had a negative nuclear stress test three months ago. He also has a crippling anxiety disorder and has visited the ER for chest pain twelve times over the past year. He has been admitted seven times, ruling out each time.

Oh. Well, that does change things, doesn't it?

This is where protocol-driven medicine breaks down. Chest pain observation units are great for undifferentiated chest pain. but for someone with well-known, recently studied disease, they are less useful. Mr Smith is a real patient -- I changed nothing from the patient I saw yesterday. And I see a Mr Smith every single day I work.

The academic emergency physician will say, rightly, that I should treat the third Mr Smith exactly the same as the second one, because you cannot know when his noncardiac chest pain is noncardiac and when it is cardiac. A risk-averse doc will assert that he just admits any patient like this, because he does not want to run the risk of ever ever getting sued. But that is not practical or sustainable in the real world. I only have so many beds in the obs unit! There are only so many times you can admit someone for observation without objective evidence of active disease before you have to admit it's pointless. No matter where you personally set that threshold, there will be a patient who will visit you in the ER more than that.

I recall in residency a guy with known CAD who visited the ER for chest pain 550 times in a three-year span. We kept his ECG on the wall for easy comparison. After a while we stopped treating him with nitro and just gave him orange juice, which fixed his chest pain. But I digress.

If you work in an ER, someday you are going to send home a patient who presented with chest pain with a history of CAD. If you don't, then you are a crummy doctor with no clinical judgement. It's bad medicine and a poor stewardship of resources to admit every patient with chest pain. The difference between a good ER doc and a bad one, between an experienced physician and a robot, is acquiring the judgement to know where to draw the line, and how to do so safely.

I sent Mr Smith home, after talking to his cardiologist, observing him for six hours with serial ECGs and troponins, and arranging next day follow-up in the cardiology clinic. In this case, for this person, that seemed reasonable. For other patients, some of them do get admitted, depending on a million sometimes subjective variables -- how many ER visits, when they were last studied, how old the stents are, how the patients look, how bad their disease has been, how long the pain has been going on, etc etc etc. There's no good protocol for that.

Someday I am going to be wrong. In fact, I have been wrong, though with care there have been no bad outcomes. I can live with that -- you have to be able to live with that if you are going to survive long working in the ER.

This is the art of medicine. This ability to recognize patterns, to integrate a lof of variables and clinical data points and come out with an accurate, back-of-the-envelope estimate of risk, that is the hallmark of a true physician. It somes with time. We all start off as algorithm-driven neophytes and some never seem to progress beyond that point. But for the Mr Smith I see every day, who doesn't want to be admitted to the hospital again (he never does), but he also doesn't want to die, he really values having a "good doctor."

Violation of Dogma

2011-09-22T10:48:00.000-07:00

I've recently been studying a lot for my upcoming recertification exam for the Emergency Medicine boards. This actually may be why you have noticed me posing more than usual -- I have a clear and discrete task that I am supposed to be doing, which really encourages procrastination. But anyhoo, it has given me an opportunity to re-acquaint myself with all of the dogma we were taught in ER residency, and horrible amounts of mind-numbing trivia: deferoxamine is the antidote for iron overdoses, Brugada syndrome is a sodium channelopathy primarily affecting southeast Asian males, lymphogranuloma venerium is a rare STD caused by chlamydia.

Ugh. somebody please kill me. I hate this trivia SO MUCH that I'm half tempted just to show up and take the test cold. I'd probably pass. But it's a really high-stakes test and if I were to fail it would be expensive and embarrassing and would have unpleasant professional consequences. So I am going to make 100% certain that I will pass and that means reminding myself what the difference is between a Monteggia and Galeazzi fracture even though in the real world you just call ortho and tell them "Bone broke. Come fix."

It's not all bad, though, in that I have had the opportunity to refresh my memory about some uncommon stuff that you just DO NOT want to miss, because even though it's rare, if you miss it Something Bad will happen to a patient. Like, well, Brudaga syndrome, which is associated with unpleasant cases of sudden death. And since people not dying is kind of my raison d'etre, that's a fun and satisfying thing to review. In fact, it makes me kind of frustrated with my clinical practice. Where's all the pathology? I haven't seen a AAA in years. That's just not fair.

So I was particularly satisfied when I recently saw a kid with a classic You Do NOT Want To Miss This presentation. A 9-year old who presented 24 hours after a non-displaced midshaft tibia fracture from a bike accident. He had only mild pain at first, which is why the presentation was delayed. But over time the pain got worse and worse and finally the parents, perhaps a bit belatedly, decided to bring him into the little rural hospital where we sometimes work.

The fracture was spectacularly unimpressive. Sure, midshaft tibia is a bad place, but it was barely more than a hairline and it was completely non-displaced, in perfact anatomic position, and well-stabilized by the intact fibula. But the leg ... was a sight to behold. A skinny little fellow, his left leg was maybe three inches in diameter, but his right calf was about as big as my own. And tight as a drum. Bingo -- compartment syndrome.

That is when there is some swelling in an extremity which causes the pressure in the muscular compartments to be so high the muscle is deprived of blood and dies. And the patient is left with a non-functional limb. Don't miss this, and don't screw this up. Especially in an athletic nine-year-old. I wasn't sure this was compartment syndrome, mind you, but it was a really concerning presentation, with pain out of proportion to the fracture, progressively increasing pain, and severe pain with passive movement of the toes.

The management of compartment syndrome is clear: You stick a big Stryker needle in to measure the pressures, and if elevated, orthos fillets open the limb to restore blood flow. Ghastly, but it works. Only problem was that at this little hospital, there was only one ortho guy (since his partner got deployed to Afghanistan) and he does not like taking care of any pediatric stuff beyond the really simple cases. This is not simple. Also, I have never even seen let alone utilized a Stryker needle. So I called the local regional children's hospital and got their orthopedics resident on the phone.

The resident was a real piece of work who proceeded to abuse me because he thought my ortho guy was lazy and/or incompetent and was dumping work onto him, and he accepted the case in transfer only after reading me the riot act about how this was a surgical emergency and I needed to measure the pressures immediately and release the compartments immediately and I was endangering the child's leg by delaying care with an unnecessary transfer. I'm good at ignoring that sort of thing, thanked him for accepting the transfer, and got off the phone. In my heart, I felt that the kid would not need a fasciotomy, but I was not going to be the one to make that call. We had the kid downtown within the hour.

At the end of my shift I called the ER at the children's hospital and got the ER resident who was taking care of the kid. She was quite pleasant, and informed me that the kid had been splinted and would be admitted for observation. So, he didn't go to the OR, then, I thought. "What were his compartment pressures?" I asked. I was unsurprised to hear that ortho had not even checked the pressures. They just had examined the patient, somehow performed a visual/tactile/olfactory measurement of the pressures and decided it was fine. It must be wonderful to be a specialist and have that sort of godlike sensory powers.

I see this all the time, and it blows my mind. I was half-tempted to call the resident back and call him on the line of BS he had given me. I know that would have been pointless, but so tempting. The thing, though, is that this is what I mean when I talk about how real-world medicine differs from textbook medicine, like the case of the hangman's fracture the neurosurgeon wanted to send home.

I'm going to assume that the ortho guys at Children's were competent, and that they didn't just screw up. Possible, but they are specialists and pretty sharp. When I first spoke to the resident, he recited chapter and verse of the textbook at me, just as I would have to a medical student I was instructing (though I would have been nicer). But the real world is not black and white, and judgement is all about gauging the shades of gray and that involves instinct and experience.

See, I've never seen a true compartment syndrome, largely because I see the fractures on day one, before it has had time to develop. I palpated the kid's leg, and it was frighteningly tight, but there was some give there, just a bit. Maybe that was enough to tell an experienced ortho attending that it was not worth sticking the needle in. I don't know how it turned out, whether the kid went to the OR or not. The lesson, though, for budding ER residents out there is this: know the dogma, respect it, but don't be too insistent on it. There are cases where it needs to be followed and cases where it may not. The trick is to know the difference, or to get the patient to the right person to make the call.

F*ck the poor

2011-09-21T11:23:00.000-07:00

What the hell. I give up.

If you can't beat 'em join em.

Curious

2011-09-21T04:58:00.000-07:00

I just really wanted an excuse to post this video.

I had a few comments and private emails in the last post about the uninsured which I find really perplexing. They essentially say, "I'm charitable, I give to my church, I'm all in favor of voluntary charity. But when the government makes it compulsory and steals my money to give it away, that's not charity, that's fascism."

I'm paraphrasing, I admit. But not by much.

But it's one of those things that really make me scratch my head. These people have a fundamentally different understanding of the concept of charity than I do. Full disclosure: I was raised catholic and ~~enjoyed~~ endured 12 years of catholic education. While I have wound up not particularly religious (to say the least), it's fair to say that the core values of catholicism really have infected me, in a good way, at a very basic level. One of those values, one of the most important ones, is charity. Christ talked about it a lot. But what does "charity" mean? Or, maybe I should say, what does that mean to me, and how do I put it into action?

The definition of charity is:

1: benevolent goodwill toward or love of humanity
2 a : generosity and helpfulness especially toward the needy or suffering; also : aid given to those in need
b : an institution engaged in relief of the poor
c : public provision for the relief of the needy
3 a : a gift for public benevolent purposes
b : an institution (as a hospital) founded by such a gift
4: lenient judgment of others

Love of humanity -- that's where I draw my moral compass from. Not some niggling distinction over whether a particular cause rises to my discretionary level of "this is important and I personally want to support it," or whether the plight of a particular person inspires me to contribute. Those are important aspects of charity, to be sure, and certainly maybe ones I could be better about. Nor do I view charity as a mere personal virtue, which allows me to take pride in my personal munificence. The concept of charity I absorbed was the first one: the universal goodwill and love for fellow mankind -- the rich, the poor, the drunk, the irresponsible, and the moral imperative to care for them. All of them.

That understanding of charity encompasses it all. Personal charity, giving of yourself to support those in need. Institutional charity, where my (catholic, incidentally) hospital provides $30 million in indigent care annually. And yes, public charity, where society, as expressed in public policy, creates institutions and systems to take care of those in need.

That's why I favor universal insurance or whatever method of assuring that nobody would go without access to medical care. It's charity writ large. Policy goals are in some degree moral goals expressed and organized on a society-wide basis.

I don't want people to die unnecessarily.

I don't want people to suffer if it is preventable.

I don't want people's financial lives wiped out by illness.

This is why advocate for our country to create systems, be it individual mandates or medicaid or some other system, all too imperfect, to make sure that those who are needy can be cared for -- even if their need was created in part by their own irresponsibility. I pity them, and I hurt for them. We can do better for them -- indeed for all of us, since there but for the grace of god go we and those we care for.

So, anonymous commenters, I do not understand you. Your concept of charity is self-serving, narrow and harsh and not one I recognize. You give with one hand but turn a blind eye to those you deem undeserving. You place ideological purity in importance over real human suffering. You view charity as a personal virtue rather than as a force for good. Fair enough, I'm glad that you are so assured in your own moral rectitude. My vision is ... rather different.

And while I may understand your words, I don't think I'll ever really understand how you came to view charity that way.

I am aware of all internet traditions

2011-09-20T11:49:00.000-07:00

Your headline of the day, which I swear to god I am not making up:

Gordon Ramsay's dwarf porn double Percy Foster dies in badger den

And, Badgers are Awesome:

Yes, yes, more badgers! Very cute:

And some real kick-ass badgers:

You are welcome. You may now continue your regularly scheduled daytime activities.

Freedom to die

2011-09-20T04:36:00.000-07:00

I am always amazed at the viciousness that pops up in the comments when I post about the uninsured, and the human consequences of being uninsured. I've been running this blog for six years now, and it's been a reliable and persistent phenomenon. In my most recent post, about the guy who died of a dental infection, an anonymous commenter, no doubt a good christian, left this gem:

So I'm supposed to feel bad for this guy, pay more taxes to help fund a government program that will "help" this lazy person, all the while I have to provide free care to him in the ED, take money away from me that I earned through hard work, [...] What happened to this man is terrible, but I have no sympathy for him or his family. He refused to seek out ways to help himself. This is in no way my, or your responsibility.

To paraphrase, "Fuck him, the lazy mooching bastard got what he deserved. I got mine." I mean, wow. To describe this as callous indifference doesn't do it justice. Curiously, this sentiment is common and almost exclusively voiced from the political right. Christ talked quite a lot about universal charity and caring for one's fellow man, but for a non-trivial subset of conservatives, the gospel of "personal responsibility" trumps those other gospels, I guess.

You could see some of the same sentiment on display at the recent Republican presidential ~~goat rodeo~~ debate where Dr Ron Paul was asked whether society should allow those too poor or feckless to buy insurance to simply die. Dr Paul, to his credit, eventually said "no," though that is the general consequence of the policies he favors. What made news, however, was the cries of "Yes!" and loud cheers and applause that followed from the audience.

Based on the commentariat here, I don't think that's an aberrant example of the ethos of the libertarian right. I do not think that's representative of all conservatives -- at least I fervently hope not -- but it is representative of some of the most active and vocal republicans, and particularly those who are driving the policy bus these days. Aaron Carroll at TIE thinks it's a product of hyperpartisanship: "Many people wanted their side to “win” so badly that they began to delight in victory and the political game to a point they forgot that we were discussing very important issues with a human cost." Maybe he is right, but the consequence of championing this sort of policy is the mental gymnastics people need to go through to convince themselves that their favored policy would not result in people dying or suffering unnecessarily.

The same commenter above added:

Hypothetically, shadowfax, if you had no insurance and your wife was diagnosed with her breast cancer, would you just buy the vicodin and say, "nice knowing you honey?" I'm sure you would seek ways to help get her the treatment she needed.

Sure, I would seek help. But like too many others, I'm reasonably certain that either I would not find it, or even if we did, major compromises would have to be made in the quality of her care. That's a hard and fast rule of being indigent and sick. Things get delayed and some things you just don't get. As an additional bonus, even if we did get some limited charity care, our family would suffer financial ruin as a result. The cost of chemo alone is well over $100,000, not to mention surgeries, radiation, hospitalizations, imaging and many ancillary tests. It's pure fantasy to think that someone would give us that for free. Conservatives talk about communities banding together to help a member in need -- church bake sales and the like. But the ability of individual voluntary donations to raise the amount of funds needed to care for a serious illness is equally fantasy.

A case in point -- a sad and highly ironic one -- was that Dr Ron Paul's former campaign manager, a man who managed to raise $19 million in political donations -- became ill and died of pneumonia in 2008 at the very young age of 49. He was uninsured -- he wanted to purchase insurance but was denied due to a pre-existing condition -- and the medical bills totalled $400,000. His friends started a financial fund to offset the costs. It raised $35,000. This was a well-connected person whose whole life revolved around raising money, and private charity failed to cover his medical bills by an order of magnitude. Why would anybody think that this is a reasonable and sustainable strategy for others, especially those who are in lower-income communities? What about those who are socially isolated and don't have a church or a large group of friends?

Oh, there are charity clinics for folks like that, conservatives say. Which is equally a joke. This angry rant by a DKos diarist about her uninsured brother's experience with charity care for lung cancer tells a sadly typical story of what life is like for the indigent with a serious illness:

Steve worked 14 hours a day building beautiful guitars ... he barely eked out an existence with financial help from my husband and me. Money for health insurance? Don’t be ridiculous.

He was 63. He had to start Social Security early so he could afford to eat. He was too young for Medicare and too male for Medicaid. This nation does not recognize the years he spent working for others and making this economy grow, it only focused on the years he worked for himself, creating instruments of rare beauty.

When he had a pain in the butt, he had to wait until early in the morning of December 3rd to present himself at the ER of Highland Hospital, the Alameda County medical facility. There are guards at Highland, and a football field full of plastic chairs for the indigent to use while they wait treatment. He was sent home with a handful of Vicodin and a suggestion to follow up with a pulmonologist for the 3 cm spot the Xray showed on his lung. The soonest appointment was Feb 25.

He was in so much pain that he could not stand up for more than a few seconds at a time. He got Vicodin. And steroid suppositories. His buddies came up with the $2000 a proctologist wanted to do an outpatient surgery. But the hospital wanted $20,000 for use of the room for the brief procedure because he was uninsured.

Three months to see the specialist. When my wife was diagnosed, we got next-day appointments. I'm not asserting that her brother would have lived with better access to care -- sounds like he was palliative from the get-go -- but he probably would have suffered less, and statistically, some of the 50 million uninsured out there will die because of their limited access to care. And those who are lucky enough to get delayed, poor-quality charity care get it subsidized by the rest of us, as it is.

But the attempt to remedy the problem, initially proposed and embraced by conservatives, has disingenuously morphed into an un-American assault on liberty. The irony is pointed out by Danny Westneat of the Seattle Times:

So who should pay? Right now, we all do.

What was so provocative about the question is that the health-reform plan routinely denounced as socialist — so-called Obamacare — seeks to get the freeloading guy to pay his own way. He'd have to get insurance or be fined. He'd pay for it himself, unless he were very poor. The idea is then there'd be no need for the rest of us to pick up his huge charity-care bills.

It's true that coercing people to buy insurance is not "freedom." But what's so aggravating about the health-care debate is that neither is what we have today. It sure seems socialistic that all of us have to cover the uninsured guy's bills, as we do today. Yet an effort to stop doing that — to try to get him to pay for himself — is what gets derided as un-American.

Despite the existence of charity care and county hospitals, though, the human cost of uninsurance persists. The best estimate I am aware of is that 45,000 people die every year because of their lack of insurance.

But, fuck them, because I've got mine. Am I right? They're lazy, irresponsible, poor, probably black, certainly unwashed and they have nice cell phones, so they are subhuman pieces of shit who deserve what's coming to them. And an individual mandate is an unconscionable impingement on my personal liberty.

This is, as best I can tell, the libertarian take on the ongoing crisis of the uninsured. We are all free, and some lucky duckies are free to die.

I apologize in advance to those conservatives and libertarians who are offended. I'm angry and I am ranting. I know you are not like those bad libertarians. Please go ahead and explain in the comments how the free market and the personal responsibility fairy will fix the system, or just point to the Republican health care proposal which will replace Obamacare when it is repealed. I've been waiting for quite a while to see that one, but they seem stuck on "repeal" with no clear plan to "replace."

Happy Talk Like a Pirate Day!

2011-09-19T11:39:00.001-07:00

From the brilliant archives of Medium Large:

Instinct vs Expertise

2011-09-19T09:58:00.000-07:00

A hard thing about being an ER doctor is that I know a little, sometimes very little, about a lot of things. When I am faced with a particular condition, I often need to call the specialist for that organ, who knows way way more about it than I ever will, and they all think I'm an idiot because I don't know as much about their organ as they do. There's a huge asymmetry of knowledge, and it can create some tension and conflict.

I'm OK with it, because I can ignore their condescension and I am secure with what I do know, and its limits. But sometimes I get perplexing instructions from the specialists. The emergency medicine dogma can be overbroad and a little hidebound and what the specialists will do in the real world often radically diverges from what the Emergency Medicine textbooks say to do. It's often an interesting learning opportunity for me, especially when it's a condition I don't encounter that much. But I also have to work to maintain a flexible and open-minded attitude when I call a consultant and my side of the conversation consists of "Really? I didn't know you did that for this..." You need to know and trust your colleagues in other specialties, and know when to call BS on them and push to do something else, which is really hard to do when you are talking to someone who is so much more of an expert than you are.

So I saw this guy recently, a urban hipster who was perhaps a bit too old to be riding his longboard on the hilly streets of our fair town. He didn't seem to be too good at it, judging by the collection of crusted abrasions and aging ecchymoses he was sporting. He had been falling a lot recently -- we only get about a month of sun here, so I guess he was making the most of the summer weather practicing his new hobby. He had a variety of complaints from his recent falls, but it was a wound infection that had driven him to come in. A bit of road rash on his thigh was looking a bit cellulitic and I thought might benefit from some keflex.

I had to go through the motions of doing a more or less thorough exam, and he was pretty tender on his neck, I noticed. He said it had been hurting for about a week, since he had fallen backwards and hit his head on a car fender. He demonstrated how his neck was fully extended at the moment of impact, and the resolving goose egg on his scalp correlated. I wasn't terribly impressed by any of his orthopedic injuries, but I did order a few plain films, just to CYA, and I included a C-spine series as well, which is rare for me since if I really think someone might have a C-spine injury CT scanning is the imaging modality of choice.

I actually got a little short of breath when I scanned through his images and this jumped out at me:

For those not accustomed to reading these, this is a fracture through the posterior part of the second cervical vertebra, also known as a hangman's fracture. You might infer from the name that this is an unstable, bad injury, and you would be right. And our hipster friend had been walking around (hell, skating around and falling) for a full week with this injury! His neuro exam, I confirmed, was rock-solid normal. We popped a C-collar on him and I called the neurosurgeon at the local spine center to arrange transfer.

I had the opportunity to hold forth, as the nurses and techs gathered around the monitor to see the image, explaining that the "hangman's fracture" is a bit of a misnomer. Generally it is sustained from axial loading (as opposed to traction), which makes a ton of difference. The real-world mechanism is planting your forehead into a car windshield, that is, not hanging from a rope, and the spinal cord is typically uninjured in mechanisms of this sort. It's unstable and needs to be fixed, but there are many worse c-spine fractures you could have. My audience was very appreciative and I basked in their attention.

I was quite surprised, however, when I eventually spoke to the neurosurgeon. "It's a stable fracture," he told me, "he's had it for a week and his cord is fine. Put him in a hard collar and send him home. I'll see him in clinic next tuesday." It was one of those "What? Really?" moments I described above.

This surgeon, I should mention, was not some fly-by-night guy, nor was it the intern. He's a very respected professor at a university-affiliated trauma center. Not someone I am predisposed to argue with. I see hangman's fractures about, oh, once a decade, and he operates on them all the time. He clearly thought it was quite routine to send him home. And he did have a point -- it had been a week, after all. So with great discomfort, I acquiesced. For lay readers, it is important to understand that there are categories of stable spinal fractures that should go home, so it's not as crazy as it sounds. Not quite, anyway.

It seemed wrong, though, very wrong. I ran it by a couple of my partners and their eyes all got kind of big at the prospect, too. Without any clear plan, I decided to buy time and get the CT scan to better delineate the injury. After all, I reasoned, they will need it to plan the surgery when he goes to clinic next week. ("Next week? Am I really going to send a C2 fracture home for a week without even seeing the neurosurgeon? This is nuts! I just can't.") I chatted with the radiologist who read the CT, who described the hangman's fracture and blah blah blah, lots of technical details that meant nothing to me. I had radiology send the images electronically to the trauma center and sent a message to the surgeon that there was a scan available, in the hopes that might change his mind.

The surgeon called me back about ten minutes later, with a hint of anxiety in his voice. "Please tell me you didn't send that guy home, did you? This is a really bad, unstable injury. I need to operate on him today." To his credit, he had the grace to be embarrassed about his earlier advice and acknowledged that I was right to have stuck to my guns on this case.

I still don't claim to fully understand the intricacies of this injury or what about it changed the surgeon's mind. I'm not a neurosurgeon. I am very glad, though, that in this case I listened to my gut and that I didn't send him home. My malpractice carrier is, too. Knowing when to call BS, when to say "No" is one of the hardest things about my job, because it's pure instinct.

A Song for Dr Rob

2011-09-16T17:42:00.001-07:00

He knows why

Pretty picture from space

2011-09-15T22:41:00.000-07:00

Now that's just beautiful. According to the Bad Astronomer, you are looking at the aurora australis -- the southern lights -- and you can see orion to the left side of the pic, though apparently it's upside down, being seen from the southern hemisphere. I knew people walked on their heads down there, but I didn't know the stars did, too.

This is what health care rationing looks like

2011-09-15T12:57:00.000-07:00

The legislature in Washington State, like so many others, had a multi-billion dollar budget shortfall to fill this year due to the ongoing recession. Like others, it looked at the Medicaid program as a place where money needed to be cut from the budget. However, in what I believe to be a first in the nation (for now) approach, they directed the state Health Care Authority to find $72 million in savings specifically from Emergency Department utilization, and more specifically from those patients who over utilize the ED for non-emergent medical care.

The statutory language reads:

Emergency room visits in the Medicaid program will be limited to three non-emergent visits per year. The WSMA and the WSHA will be included in developing the criteria for defining non-emergent. [...] The department shall collaborate closely with the Washington state hospital and medical associations in identification of the diagnostic codes and retroactive review procedures that will be used to determine whether an emergency room visit is a nonemergency condition to assure that conditions that require emergency treatment continue to be covered.

That doesn't sound too unreasonable, does it? Anybody who has ever been in the ER knows well that Medicaid patients come back again and again, and often for trivial or routine complaints. So the plan was to generate a list of agreed-upon non-emergent diagnoses and simply not pay for them after the third such visit.

It's sadly predictable what happened next. The HCA had been set a hard target of cost savings -- $72 million -- that they were mandated to achieve. They looked at the universe of true frequent flyers and their complaints and realized that they were not going to get to their goal by denying payment for the runny noses and toothaches that comprise the majority of non-emergent medicaid visits. So they expanded their definition of non-emergent diagnoses, and recalculated the savings. It wasn't enough, so they expanded the list of "non-emergent" diagnoses further yet, and again and again until they got the dollar figure they wanted.

The list, as it currently exists, consists of about 750 so-called "non-emergent" diagnoses established in the ER, for which the state will not pay, including such trivial, routine, and non-emergent conditions as:

Viral infection NOS
Viral enteritis
Strep throat
Scabies
Migraine headache

OK, I can get behind those as non-emergency ER conditions. I'd quite like to see those folks re-routed to clinics or PCPs. But wait, there's more! Other "Non-emergent conditions" for which the state will not pay include:

Chest Pain
Abdominal Pain
Asthma Exacerbation (acute)
Acute Cholecystitis
Hypoglycemic Coma
Pneumococcal Pneumonia
Pseudonomal Pneumonia
Calculus of Ureter (i.e. kidney stone)
Syncope and collapse
Salmonella Enteritis
Streptococcal Septicemia

I shit you not. There are many others -- these are just the most ridiculous "non-emergency" conditions that jumped out at me. It's also manifestly arbitrary and haphazard what made it onto the list and what did not. The HCA considers "Cholelithiasis with acute Cholecystitis" an emergency condition worth paying for, but "Acute Cholecystitis" is not. The state will pay for hand cellulitis, but not for the more dangerous foot cellulitis. All diagnosis codes which are "Sprains" or "Contusions" are denied, across the board.

For the record, the HCA did collaborate with the health community in that they met with physician and hospital groups, listened politely, and produced the diagnosis list unilaterally. Though the physician groups had many ideas for saving money such as case management, generic prescription utilization, and other ideas, they were rejected as outside of the statutory language of the budget. No mechanism was identified by which patients could be redirected to clinics, nor was there any allowance for the fact that trauma patients do not know in advance whether their injuries are fractures or sprains.

The idea, should this go into effect as planned, was that patients would redirect their care back to clinics and primary care providers. It's not going to happen, of course. Primary care, and especially urgent care, for medicaid patients essentially does not exist, not in any meaningful way. Sure, there are charity clinics and community health centers, but they are grossly oversubscribed and the access is minimal for acute or otherwise unscheduled care. The ERs remain open 24/7, and thanks to EMTALA, we cannot send patients away unseen. Sure, it's possible to do a medical screening exam at triage and deny non-emergent cases, but that's a liability nightmare, and would probably be a de facto violation of EMTALA if that was only done for medicaid players. (Though I am not a lawyer.)

There is no way, actually, to even know in real time if a medicaid patient presenting with a non-urgent complaint is one of the few who have met their three-visit limit. (97% of medicaid patients in this state visit the ER less than or equal to two times annually.) The ER doc and hospital will only find out after the fact when the claim is denied. Technically, we can bill the patient but that is a fig leaf because of course a medicaid patient won't be able to (or care to) pay cash for their ER visit.

There are so many things wrong with this that it's hard to know where to start. Of course, it's primarily a cramdown for providers. The state just decided not to pay for a certain arbitrary list of things, and docs and hospitals have no idea which patients that will apply to and no choice but to provide the services anyway. Which is in a way, nothing new, since we've dealt with the unfunded mandate of EMTALA for three decades. What is new, and troublesome, is that the non-payment will be decided after the fact based on an arbitrary and wrong list of diagnosis codes. This is not entirely new -- it's what went on in the '90s and resulted in Congress passing the prudent layperson standard, which essentially ended such practices. However, it's new in that this is the first time a governmental payer has tried this particular stunt, and I have a feeling that a lot of DHSH directors in other states will be carefully watching this experiment so see if it takes. If it does, this may be our future once again.

So look closely, my friends. Rationing is here, not covert rationing, but open and unapologetic rationing. It may be blocked before it goes into effect; I hope it is. If not, look for it to be coming to a town near you real soon.

What happened to George Lucas?

2011-09-15T11:08:00.001-07:00

An exercise in wishful thinking. If only it were true.

Dr Seuss explains healthcare economics

2011-09-14T20:35:00.000-07:00

Oh The Jobs (Debt?) You'll Create! from Marketplace on Vimeo.

This certainly applies to the arms race going on in our neighborhood -- the proliferation of "Free-standing ERs," which provide high cost, luxury-themed care to wealthy communities which were previously well-served by existing facilities.

Nice places to get care, if you can access/afford them, but a short-sighted and improvident way to spend limited health care dollars.

Saturn Flyby

2011-09-12T16:00:00.001-07:00

Wow. Just Wow.
5.6k Saturn Cassini Photographic Animation from stephen v2 on Vimeo.

The looming doctor shortage

2011-09-09T11:01:00.000-07:00

Howard Dean wrote an op-ed defending the use of ~~foreign~~ international medical graduates:

Today, young physicians with degrees from international medical schools face skepticism from some in the American medical community. That strikes me as misinformed thinking, given the large number of international medical school graduates practicing in the United States, alongside American medical school graduates, and given that the American medical system depends on them to fill the growing doctor shortage.

The federal Health Resources and Services Administration predicts there will be a shortage of approximately 55,000 physicians in the United States by 2020. We simply can't build the capacity to meet our growing needs for skilled physicians -- especially given budgetary constraints on schools receiving government subsidies. Even if the new medical schools now in the planning stages all come to pass, they won't turn out enough primary care physicians to meet urgent needs in urban and rural communities.

I actually don't have a lot to say about the IMG thing, I have worked with and hired many IMG's and their skill and quality vary as much as US graduates. But this whole argument seems to miss the central point regarding the projected physician shortage. The supply of new medical graduates is not the choke point, under the current state of affairs. The choke point is the number of residency training slots.

The Balanced Budget Act of 1997 put a cap on the number of residency slots at 1996 levels. For those who don't know, pretty much all postgraduate medical education in the US is funded through medicare. That cap has remained in place ever since. Medical school enrollment has increased since that time, but the overall number of residencies has not (at least not by a meaningful measure).

There's a frustrating lack of information out there: a common misperception is that the AMA is somehow artificially restricting the number of doctors to keep reimbursement high. Nothing could be further from the truth. First of all, the AMA has essentially no say in the number of physicians trained -- that's largely the province of the AAMC, which has been warning of the physician shortage and calling for action for a long time. Furthermore, the AMA itself has been making the same call for years, too.

The problem is compounded by the fact that many residents, whose training is being paid for by the US taxpayer, are foreign-born and here on a type of student visas. When they are done training, they have to go home unless they can find an employer who is willing and able to sponsor them for a green card. I don't know how many US-trained foreign physicians actually do return to their country of origin -- not too many, I suspect -- but the wrongheadedness of the policy is maddening. If we are going to pay for their education, it should more or less automatically put them on a pathway to permanent residency.

Unfortunately, I don't see a solution in the works any time soon. In the current health care budget crisis, the likelihood that policymakers are going to increase funding for medical education is slim indeed. This means that physician extenders will continue to fill the gaps and provide more and more services. Some of this is just fine -- a PA or NP can be a great surgical assistant, fast track provider, or simple wellness care provider. But as medical students persist in their exodus from primary care, more and more complex disease management will fall on the shoulders of midlevel providers whose training is not intended to encompass it. Those patients who decompensate as a result, or who simply cannot access primary care services do to the shortage will be shunted to ... the ER, of course. The final dumping ground of American healthcare.

We are so screwed.

Top Ten Lies Told by Paramedics

2011-09-09T09:40:00.000-07:00

Apropos of nothing:

1. Its not my fault, he kept moving.

2. This might stick a little.

3. I did say clear first.

4. I know where I'm going.

5. It's OK, I'll cut along the seams.

6. The ambulance is clean.

7. It's the flu, not a hangover.

8. The gloves are for your protection.

9. The patient refused the treatment.

10. I am in it for the money

Uninsurance shouldn't be a lethal condition

2011-09-07T22:21:00.000-07:00

This is depressing:

A 24-year-old Cincinnati father died from a tooth infection this week because he couldn't afford his medication, offering a sobering reminder of the importance of oral health and the number of people without access to dental or health care.

According to NBC affiliate WLWT, Kyle Willis' wisdom tooth started hurting two weeks ago. When dentists told him it needed to be pulled, he decided to forgo the procedure, because he was unemployed and had no health insurance.

When his face started swelling and his head began to ache, Willis went to the emergency room, where he received prescriptions for antibiotics and pain medications. Willis couldn't afford both, so he chose the pain medications.

The tooth infection spread, causing his brain to swell. He died Tuesday.

It can't be denied that his poor decision-making was the proximate cause of this guy's death (and many times I've gotten the maddening call from the pharmacy, "Doctor, the patient only wants the narcotics"). The underlying cause, however, was the fact that he was uninsured. Sure, he should have sprung the $4 to buy the penicillin at the big box pharmacy (though clindamycin can be costly, if he was penn-allergic). But he shouldn't have been in the position to need it in the first place. He should have been able to get the tooth pulled -- or better yet, filled before it needed pulling -- before it became abscessed.

Sadly, this problem won't go away when the ACA goes into effect in 2014 (assuming it does). I'm going to speculate here, but if this guy was so poor that the antibiotics were too expensive, he probably will (would've been) covered by medicaid under the ACA, which means that though his prescription probably would be paid for by medicaid, he still would not have had meaningful access to dental care, because most dentists won't see welfare patients.

But hey, at least we don't live in some sort of socialist dystopia where sometimes people have to wait for hip replacements! Our Galtian paradise may be a bit rough, but it's got to be to keep the moochers from running over us.

Sigh.

It sucks that we are the only industrialized country not to have some sort of national insurance plan, it sucks that even the modest reform passed doesn't take effect for three years, if it ever does, and it sucks that people still die as a consequence of being uninsured.

Don't let the wingers tell you that there's no human cost to our crappy patchwork health care system. The children of Kyle Willis can tell you otherwise.

Chiropractic medicine, in comic form

2011-08-28T10:17:00.000-07:00

Darryl Cunningham has a lovely detailed explication of the state of chiropractic "medicine," in a multipanel cartoon format!

Worth clicking through to see the whole thing.

Bruce Lee vs Chuck Norris

2011-08-26T11:52:00.000-07:00

A martial arts classic, though perhaps a bit campy 40 years later:

And no, I have no idea what's up with the kitten.

Thank God for Japanese Pop Culture

2011-08-25T11:11:00.000-07:00

It's like a cotton candy-themed acid trip.

I can't look away. It's a weird fascination.

Time waste central

2011-08-18T22:56:00.000-07:00

Well, it's not exactly time wasted, because it's educational. But I just came across a fun and kind of addictive web site called One Night in the ED. It's not new -- looks like it's at least 6 years old, but I never saw it before.

It's just a collection of about 70 CT scans (and a few plain films) which you can view as unknown and try to guess the diagnosis. The CTs are fully represented and you can scroll up and down as you would on your PACS system. Then you click through to the diagnosis and an explanation.

It's great fun -- I just wasted half an hour there and I suspect I'll be back later.

Reversing the trend

2011-08-18T12:33:00.000-07:00

Well, this is satisfying. Over the years, in our ER we have mirrored the nationwide trend and have significantly increased the utilization of CT scans across the board. The reasons are manifold. Some cite malpractice risks, and indeed in our large group we have had one lawsuit for a pediatric head injury and another for a missed appendicitis which probably did contribute. But, in my opinion, there have been many other drivers of the increased use. For one, CTs have gotten way, way better over the last 15 years, which quite simply has made them a better diagnostic tool. They've also gotten way faster. As the facilities have invested in CT scanners, they have increased their capacity and increased their staffing, so the barriers to their use have rapidly diminished. I am so old that I remember when ordering a CT involved calling a radiologist and getting their approval! No more of that, I can tell you.

But a couple of years ago, we really started paying attention (perhaps belatedly) to the risks of increased exposure to radiation, especially for kids. And at that point, we began a concerted effort to reduce the use of CT scans in children. I pulled the numbers today, and here are the results:

(patients <14 y/o, all types of CT scans)

A 40% reduction from the peak utilization. Not too shabby. We were at about the national average at our peak -- studies show that CT scans were ordered about 6% of the time for pediatric ED visits. How did we make the change? Mostly by paying attention to it and talking about it a lot to our medical staff. We made it a journal club, we presented it multiple times at our department meetings. This is, by the way, a pretty significant commitment of limited resources, since we typically have only about 2 hours of clinical education time with our docs per month, and every time we brought it up, it was at the expense of some other topic. We also developed pediatric abdominal pain algorithms which utilized ultrasound and surgical consultation above CT scanning, and we emphasized the CT-sparing clinical decision-making rules for head injury.

Are we still "too high"? I don't know, because I don't know where it optimum rate of CT is. It's not zero, not at a trauma center, and sometimes there are belly pain cases that really do need imaging beyond ultrasound. I'm content with the relative reduction we have achieved so far, and hope we can improve on it as all the docs gain comfort with the radiation-minimizing technique. Some docs are always slow to change their ways, or persistently risk-averse (and test-happy). Maybe more data will come out to guide us in further reducing unnecessary scans.

Or, American medicine being what it is, maybe we'll just wind up ordering more MRIs.

Mad Skillz

2011-08-18T10:27:00.000-07:00

Just amazing

Breaking it in

2011-08-17T22:26:00.000-07:00

Well, our new ER has officially been "christened." Somehow a drunk guy got out of his room, came right up to the nursing station, took a poo on the floor right in front of the main nursing desk, and went back into his room -- all without being noticed.

Yup, it's a great night in the ER when there's human feces on the floor in the main hallway.

DYAC

2011-08-09T21:17:00.000-07:00

Stands for "Damn You Autocorrect!"

I'm sure half of these are fake, but even so they're fricking hilarious. Be sure to check out the "Best of DYAC" -- it's totally worth it.

Spot the Lesion

2011-08-09T10:02:00.000-07:00

Yesterday, I presented the case of a woman with double vision and ptosis and challenged you all to a game of "spot the lesion." To be honest, I found this stuff impenetrable as a medical student and it was only by sheer force of will that I was able to commit it to memory for exactly long enough to pass a test on it before immediately purging it from my memory. I did this several times for various board exams and such, but it never really "stuck." Hated neuro beyond words, I did.

As mind-numbing as I found it all in the abstract, I get excited about these cases in application. I may not remember where exactly the internal capsule is or what it does, but when I see someone with an interesting neuro deficit due to a lesion there, all of a sudden it makes so much more sense, and is, dare I say it, cool. I know, kinda sad.

This case is as classic (and cool) as you will ever see. It's a complete palsy of the Oculomotor Nerve (CN 3 for those keeping score at home).

So how do you approach figuring that out?

First of all, it's unilateral. Note the movements of the left eye are all normal. Some other things, systemic diseases, can cause ptosis (the droopy eyelid) or diplopia (double vision) -- think neuromuscular stuff like myasthenia gravis, botulism, etc. But those are usually bilateral. As an isolated right-sided finding, however, that should prompt you to think about either a central cause or a direct neuropathy. But central causes of this sort of thing are not likely, because the oculomotor nuclei are located deep in the midbrain, and are crossed, so a stroke or something bad there is not likely to give unilateral or isolated neurological findings. Therefore, we know it's a peripheral neuropathy. Yay! But which one?

The ptosis -- especially a complete paralysis of the levator palpebrae -- should be a huge red flag that the third nerve is involved. Even I remember this mnemonic from medical school:

The III is the pillar that holds the eye open; the 7 is the hook that closes it. Then you look at the pattern of movements that the eye has lost and note that it matches the oculomotor muscles which are innervated by the third nerve:

She can abduct it, so CN6 is intact, But up, down and adduction are shot, which are all CN3. The fact that with straight gaze and lateral gaze the right eye is a bit down compared to the left is due to the preserved function of CN4. Thus, the classic pattern of CN3 palsy -- "down and out."

Then you look at the pupil. It's big -- so you know this isn't a Horner's syndrome, though that wouldn't cause ophthalmoparesis either. And it's not reactive, either. The most common cause of acquired CN3 palsies is diabetic microvascular ischemia -- one of the many peripheral neuropathies that the sugar causes. But those are usually pupil-sparing. This involves the pupil, so something is compressing or otherwise pissing off the nerve directly.

The solution (as for just about everything in neurology, it seems) is to order your MRI, but in this case, you definitely want an MRA as well. Because the next most common cause of CN3 palsy is compression by an aneurysm (notoriously the PCA - posterior communicating artery). The deficit can apparently be intermittent with an aneurysm. But all sorts of things can do it, and the treatment will depend on the cause. It could be direct compression from a pituitary tumor, or a cavernous sinus thrombosis. If the patient presents with stiff neck and meningismus, either subarachnoid hemorrhage or meningitis should be considered, as they can do this. Demyelinating diseases can also do this, so if all else fails and if the demographic makes sense, consider MS. In older patients, consider arteritis, too. Herpes zoster can also rarely do this, though it's more classically the seventh nerve. These can occur post-traumatic, but be sure that the pattern of the deficit matches the nerve and that you're not going to miss an orbital wall fracture! I recently saw a patient with a port-traumatic transient internuclear ophthalmoplegia, which was also pretty cool. Sadly, I didn't have the presence of mind to get pics of that one.

In the incident case, the MR showed a suprasellar mass invading the cavernous sinus, most likely a pituitary macroadenoma:

Not something you can see commonly, but very classic, and a nice opportunity to review and relearn all the neuroanatomy we learned in medical school, but in the context of a real case.

xkcd again!

2011-08-08T23:19:00.001-07:00

Damn, this one hit close to home, since Liza's going through radiation right now:

But it makes it sound so BADASS.

Make sure to click through to see the rest of the comic. It's worth it. Make sure to mouse over the image to read the alt-text.

Randall Munroe is a genius.

Case of the day

2011-08-08T04:55:00.000-07:00

A 72-year old woman presents with a complaint of headache and that her right eye "just isn't working right." She is generally healthy, with only an idiopathic anemia, and no associated symptoms other than some fatigue and poor appetite. She characterizes the headache as being a sinus headache, and notes that it has been occurring on and off for a month or so, though she has never had any fever or nasal congestion/drainage. She has had "eye problems" related to this headache in the past, but today it is more severe than before.

When the patient looks at you, this is what you see:

She cannot voluntarily retract the right eyelid. It is nontender, and when you retract it for her, she complains of diplopia. You see this:

The right pupil is dilated and fixed; the left is 3 mm and reactive. Note that with level gaze the eyes do not seem quite conjugate. The right eye is deviated mildly down and out. When you ask the patient to look to her left:

There is no movement of the right eye at all. And when you ask her to look up:

Again the right eye does not move. Same with downwards gaze. On attempted right gaze you see this:

Uploaded with Skitch!

But on right gaze the patient still complains of diplopia. Vision in the right eye is grossly intact to confrontation. The right pupil reacts neither to light or attempted accommodation (on a very limited exam). Neurological exam is otherwise entirely normal, including as many cranial nerves as an ER doctor remembers how to test.

So -- what is the clinical finding here, and where is the lesion most likely to be based on the information you have?

Answer and discussion tomorrow.

(Photographs taken/published with patient permission.)

We are now the hostage

2011-08-01T13:40:00.000-07:00

News today is all over the debt ceiling deal which is brewing in Congress. I'm less interested in the horse-race element of who won, who lost than I am in the policy implications of the deal as it is currently taking shape. And there's one thing there that I really don't like, and anybody in healthcare should be pretty apprehensive about.

Here's the broad outline:

The debt ceiling gets raised and economic Armageddon is averted. Good enough.
A panel of mutually agreed spending cuts of about $900 Billion is enacted.
A commission is formed to negotiate another $1.5 trillion in deficit reduction over the next year or so.
A trigger is placed: if the commission fails to agree on the $1.5T in deficit reduction, certain deep cuts automatically go into effect.

The land mine here is the trigger. It's supposed to be a package of unacceptably painful spending cuts, so heinous that neither party would be willing to let them go into effect. It includes deep defense cuts which probably will be blocked, deal or no deal. But it also includes deep cuts into medicare and medicaid. To avoid any accusation that either party is willing to reduce benefits, though, there is no reduction in eligibility or benefits. All the reductions are in provider compensation.

I find this pretty scary. Details are not out there, so I don't know whether these cuts would be from hospitals, physicians or some combination. But I recall the ten-year cost of the SGR fix is supposed to be about $300 billion and sources indicate that is about the amount that is supposed to come out of medicare if the trigger goes into effect. I kind of doubt that the whole amount would come onto the shoulders of physicians, but it's a concerning possibility.

I'll be very interested to see the detail of the deal when they become available -- probably after passage. It seems to me that this is a terrible deal for health care providers -- the nation's economy was held hostage to the debt ceiling and deficit hawks. Now that has been defused, but the health care sector has replaced the overall economy as the hostage, and one I fear policymakers will be more willing to sacrifice in the name of expediency.

xkcd and Breast Cancer

2011-07-29T09:11:00.000-07:00

A wonderful exercise in visualization of statistics from the patient's perspective:

The comic's quite long -- click the link to read the whole thing.

The fiance of Randal Munroe, creator of the xkcd webcomic was diagnosed with breast cancer at about the same time my wife was. So this one really hits home.

Is this thing still on?

2011-07-25T12:38:00.000-07:00

Wow, it's been a long time since I updated. Definitely a record for me. So, what's been going on?
To start, my wife had her mastectomies at the beginning of June. The whole month was occupied with taking care of her and the kids while also trying to work enough to pay the mortgage (the bank can be quite unreasonable in their insistence on this point). We had family in-home for an entire month -- more, I think. All went well with the surgery and the healing process, though it was perhaps harder than we all expected. Now Liza is onto radiotherapy and doing OK. Her hair is growing back, she is getting her energy back (slowly) and feeling more like herself again. Feel free to stop by her blog and offer some support.

Somewhere in there we opened a new ER. It went very smoothly, as befitting the enormous amount of work that went into the planning for the transition. The volumes have been up just a bit, but it's been very strange. We are averaging 285 patients a day, up about 5%, but the variability has been huge. We will see 240 patients one day and 330 the next. Bizarre, and impossible to predict and staff for. We never had that sort of wild oscillations in the old place. Hopefully it will either settle out or become predictable over time. The operations part of moving in went very well indeed, and working in the new place is an unadulterated pleasure. There are some nursing kinks (the new greet/triage process is a bit hinky) but they are pretty minor. The time metrics have gotten absurdly low: 7 minutes from door to bed, on average, and 28 minutes from door to doc. Fewer than 1% leave without being seen. Patients seem really happy, and the staff is happier and less stressed than I can recall ever seeing. I can't wait to see our patient satisfaction scores when they start coming back.

Which is not to say things are perfect. We see to be having more late-day volume than we expected and may have to make some tweaks to the schedule. There is most definitely room for improvement. But overall, I'm enjoying going to work more than I ever have in the past. The only real problem is that the place is SO HUGE. if you have errands on different sides of the department the travel time is not inconsiderable. I should get a pedometer to see how far I am walking in a shift. I was thinking of getting those "heelie" shoes with hidden wheels, but one of my partners did me one better and tore his achilles tendon, so he got himself one of the kneeling wheel-carts. I get jealous watching him skate through the department at high speed on that thing. Wish I could tear my achilles tendon...

We've finished our hiring for the year, we think (and hope), and the new folks are starting to come on board, which is always really gratifying. I'm always incredibly impressed by the quality of people we are able to attract and it's very satisfying watching them step out into an independent role for the first time ever and watching them grow and their careers progress.

I'm getting old -- I'm up for my first board recertification this fall. So I have to study for that. The test is too damn expensive to show up and take it cold (don't think I wasn't tempted.)

Personally, the kids are off school and the house is crazy. They never stop moving, and are just exhausting to watch. My sister was out here to help and took to calling them the "noise beasts." We had one nice vacation to Crater Lake and through central/southern Oregon, and we will be hitting Lake Crescent in another couple of weeks. The baby is crawling all over the place, and getting ready to walk.
I hope to update a few more times in upcoming days -- I have a large number of posts kicking around in my head. Whether I have the time to sit down and put them into words is another question. For the moment, I will put up this picture of the baby, who REALLY likes herself some chocolate chip pancakes, and I will belatedly update the masthead to reflect the fact that I now have four children.

A visual argument in favor of healthcare insurance

2011-06-26T22:04:00.001-07:00

Mostly safe for work

Funny.

The day of reckoning

2011-06-14T00:17:00.001-07:00

Tomorrow we'll be far away
Tomorrow is the judgement day
Tomorrow we'll discover what our God in heaven has in store
One more dawn...

On an unrelated note, tomorrow morning at 5AM our new ER opens and the old one closes down. I'll be there working clinically. To the degree that it doesn't interfere with patient care, I'll live-tweet the experience.

For those not familiar with the institution or the project -- it's a 110,000 annual visit ER closing down and reopening next door in a new, state of the art 83 bed ER, with an entire new 10-story hospital opening directly above at the same time, more or less. The logistics of the transition are pretty staggering. The ER will be the first unit to open. The old ambulance bay will have a barrier put up at 5AM and the new department's ambulance bay and drop-off will be illuminated at that time and all new patients will go there. The staff closing out the old shop will dispo all the patients they can, and at a certain point, maybe by ten AM, any patients still in the old ER will roll across the skybridge to the new facility. We will open one cath lab and one OR in the new hospital while retaining capability at the old rooms. New patients admitted will go to the new tower and the old inpatient units will start discharging patients. By Friday, any patients still in the old tower will move across to the new inpatient units. They'll be bringing the other ORs and interventional labs online in a stepwise fashion during the week. Interestingly, a lot of expensive equipment is being "salvaged" from the old hospital. For example, the telemetry monitors in the ICU -- about half of the new ICU beds have monitors now. When a patient is discharged from the old ICU, they will take that monitor across to the new building and install it in a new ICU bed, which will only then become open for a new patient. Eventually, all the monitors will be re-installed in the new units. Elective surgeries are pretty much out this week. When everything is open we will have 16 ORs and 8 cath/vascular/EP labs with room for four more as need demands.

For the ER (and more importantly for ER patients) this will be a banner day. For too many years we have had many patients who received the entirety of their ER care in a hallway gurney. While the care has been good, it's a miserable experience to be in the hallway. Now all the rooms are private, both visually and acoustically.

And did I mention it's kinda big? A football field on each side, for perspective. 63 regular treatment rooms, 8 resuscitation rooms, 4 trauma rooms and 4 secure psych rooms. All the treatment rooms are identical in size and equipment. The "major" rooms are also identical to one another -- no hunting for gear. Major rooms also have built-in patient lifts mounted in the ceiling (as do all inpatient rooms). Subdivided into three autonomous sub-ERs with the NW zone being peds/fast track focused. One CT scanner in the ER with more CTs and MRI one floor up. Our processes are tight now in the old ER -- the average time from door to bed is 9 minutes and the time from bed to doctor is about another 20 minutes. We hope to improve that in the new ER. The idea is "no triage" -- patients come directly back to a bed and have their registration and nursing assessment performed there. This eliminates the latent period, wasted time in layman's terms, of triage and the waiting room.

I walked through the hospital today and watched folks on every single unit frantically preparing for the opening. They were stocking all the little last-minute items -- spectralink phones, toothbrushes, etc. It's amazing to see a hospital slowly come alive like this. Not all was quite right -- some workers in their wisdom decided to install the wall-mounted chart rack directly on the whiteboard the ED docs were to use for communication. Huh? Oh well, that will all get ironed out in time.

For my part I am terrified about the parts I had responsibility for -- how many docs will be there and when they are there and what rooms they are assigned to. If the patients don't show up (there is a new freestanding ER ten miles south) we could be horribly overstaffed and take a financial bath. If the "Field of Dreams" principle holds -- "If you build it, they will come" -- we could be understaffed with no way to rapidly hire more doctors. I have no clue. If our finely engineered complex processes break down, it could be chaos. As they say, the best battle plan lasts only until the first bullet flies. We will, I am sure, be rapidly re-engineering things.

This has been a huge project, in which I've played only a tiny peripheral role. I can honestly say that I am incredibly impressed by the foresight, the preseverance, the effort and the care that has been put into this undertaking from every level, from the CEO to the nurses to the housekeeping staff. Hundreds and hundred of people have dedicated years of their lives to planning for this. I can't take the least bit of credit for this accomplishment but I am incredibly proud to be part of this organization.

Wow oh wow oh wow

2011-06-07T10:17:00.001-07:00

Amazing photos of the volcanic eruption in Chile:

So so cool. Also amazing. More stunning pix at the Atlantic.

While I'm BLOWING YOUR MIND, here is a cool video of a huge explosion on the surface of the sun.

This sent over a billion tons of material into space, and the explosion was nearly the entire diameter of the sun itself. More video with a wider field of view here.

Both via the Bad Astronomer.

Further evidence of the death of journalistic standards

2011-06-02T13:01:00.000-07:00

The New York Times will let any idiot write for them.

Tort Reform does not end Defensive Medicine

2011-06-02T10:59:00.000-07:00

It's ever so satisfying to be proven right. Well, maybe "proven" is too strong a word to use, but there is a bit of strong evidence that, as I have said in the past, the practice of defensive medicine is driven by powerful multifactorial incentives and is very unlikely to change even if the most often-asserted motivator, liability, is controlled. Today, Aaron Carroll guest blogs at Ezra Klein's WaPo digs:

The argument goes that doctors, afraid of being sued, order lots of extra tests and procedures to protect themselves. This is known as defensive medicine. Tort reform assumes that if we put a cap on the damages plaintiffs can win, then filing cases will be less attractive, fewer claims will be made, insurance companies will save money, malpractice premiums will come down, doctors will feel safer and will practice less defensive medicine, and health-care spending will go way down.[...]

Health Affairs in December, estimated that medical liability system costs were about $55.6 billion in 2008 dollars, or about 2.4 percent of all U.S. health-care spending. Some of that was indemnity payments, and some of it was the cost of components like lawyers, judges, etc.; most of this, however, or about $47 billion, was defensive medicine. So yes, that is real money, and it theoretically could be reduced.

The question is, will tort reform do that?

That’s actually an answerable question. You could look at areas where tort reform has already happened and see how things have changed. For instance, we could look at Texas, where non-economic damages on malpractice lawsuits were capped at $250,000 about eight years ago. [...]
So what happened to costs of care after that law was put in place? Citizen Watch analyzed just that (pdf) using data from the Dartmouth Atlas of Health Care.

[Graph omitted] Texas is blue, the nation is red, and the law went into place at the dotted line. If anything, Texas’s Medicare spending seems to have gone up faster than the nation’s since 2003. Hardly a persuasive argument for tort reform = cost control.

You'll have to click to the piece for the graph, but it's as described. Now I can admit that there are confounding factors and alternative explanations for this finding. Maybe it just takes more than 8 years for doctors to adapt to a new liability climate. Maybe doctors didn't really trust the new liability protections and so continued their old ways. Maybe the national culture of defensive medicine is strong enough than a single state can't exert change. Maybe health care costs went up faster in TX for unrelated reasons unique to that state. All are possible.

However, my interpretation is that the fear of being sued is just one and not even the strongest driver of defensive medicine. As I have said before, there are many powerful reasons doctors practice in this fashion:

When we take risks, patients sometimes die. Doctors don't like that.
When bad outcomes happen, peer review can be very harsh in retrospect. Not only is this humiliating, it is as career-threatening as a malpractice lawsuit.
While you get sued only in a small fraction of bad outcomes, almost all unexpected bad outcomes are scrutinized in peer review/QI fora, making these very powerful disincentives for physicians to take risks.
We are educated to practice in a cautious fashion, and the experts in the fields commonly assert very conservative "standards of care." Cowboys and gunslingers are viewed very unfavorably.
Old habits die hard, and doctors are as conformist as any other profession, perhaps more. When the bulk of providers still proactive defensively, there's a real risk for an individual doctor to adopt a more permissive standard of care.

None of this is to imply that I am not in favor of tort reform. My reason, however, is not a belief that tort reform will end defensive medicine or save the health care system money. My reason is that the current system functions poorly and too slowly, injured patients frequently receive nothing, and meritless cases can impose huge financial and emotional costs on physicians. It's inefficient and horribly unfair. But when we look at the $2 trillion the nation spends on health care every year, tort reform should not be looked at as a potential game changer.

Memorial Day follow-up

2011-05-30T11:34:00.001-07:00

Iraq War veteran Don Gomez writes in the Daily Beast:

Like many Americans, I grew up without really understanding the meaning behind Memorial Day. I associated the holiday with barbecues, a day off from school, and sleepy Sunday afternoon movies about submarines and Generals. Even when I was fighting in Iraq, or jumping out of airplanes with the 82nd Airborne Division, it still seemed like an old holiday for old men. As a war veteran, I eventually came to understand the meaning, but I still figured it wouldn’t become my holiday until I was retired and gray.
Ten years of war has changed that. For the quiet few who have shouldered these wars, Memorial Day is no longer an abstract holiday honoring a faceless mass of heroes from a history textbook. It’s a list of names of people you know, reluctantly accumulated and growing ever longer. It’s a reminder of the awkward long-distance phone call to tell a friend that his old squad leader and mentor was killed in an IED blast in Afghanistan. It’s the swirl of emotions felt when informed that a friend was just killed in Iraq, leaving behind a young wife and children. It is the unavoidable sinking feeling, deep in the stomach, of "Why me? Why am I okay?"
When once I may have thought of Memorial Day veterans as old men in wheelchairs, I now think of the young blonde soldier at Walter Reed, painfully fixing her prosthetic leg to her knee for her morning physical training session.

This mirrors my own experience of Memorial Day (not counting the bit about jumping out of airplanes). When I was a kid/adolescent/young man it was about as remote and meaningful as Armistice Day or Colombus Day. Though I don't have the personal experiences that Mr Gomez does, it's fair to say that this has become, once again, a living holiday. Pity it took ten years of war for me and others of our generation to realize that.

Memorial Day

2011-05-30T05:01:00.000-07:00

Flogging Molly takes a moment to raise awareness of the epidemic of PTSD in our country's combat veterans.

It's killing me that they played in our state yesterday and I was unable to get there to see them.

Scenes from Tenerife

2011-05-27T21:53:00.001-07:00

I simply cannot get enough of these time-lapse videos.

El Cielo de Canarias / Canary sky - Tenerife from Daniel López on Vimeo.

Make sure you have HD set to on.

Watching the clouds surge and ebb like water is amazing. If you watch carefully there are a couple of cool bonuses: a "green flash" when the sun sets, a double rainbow, and a lenticular cloud.

Now I want to visit the Canaries.

Ethics of refusing informed consent

2011-05-26T11:18:00.000-07:00

In my Monday post, I posed a challenging real-life dilemma we recently faced in the ER. As always, I modified the posited case from the actual facts but the broad outlines were true to life: A young person of questionable capacity wants to refuse lifesaving treatment.

Short answer, for those not interested in the discussion: This case is a no-brainer. You intubate. In this case, sadly, the outcome was not good. As I hinted, early hypoxia in the setting of blunt chest trauma is a bad sign. The patient was intubated, but became progressively more difficult to ventilate over the next couple of days and subsequently died. The family was at the bedside and, from what I understand, they were very happy to be able to be with him in his final hours. On the other hand, due to his drug abuse, he proved extremely difficult to sedate (even on max propofol!) and was agitated and combative, in restraints, until hypoxia began to take its toll. While I am confident I did the "right" thing, the tally sheet is decidedly mixed as to whether was beneficent in its effect.

Discussion:

A key concept here is whether the patient has the capacity to make an informed consent or refusal to treatment. There is a lot of vague thinking and hand-waving that surrounds this issue. I was going to write up an extensive discussion of the requirements for capacity, but my work was done for me by inwhiteink, and much better than I could have. So go read it. Her conclusion:

From the available information, it is unclear if the case patient could manipulate information in a rational manner for this specific situation. We do not know the reasons why he did not want to be intubated. One reason could have been his stated desire to die. ... It may be unfair to assume that he cannot manipulate information in a rational manner simply because he could not state reasons for refusing intubation. However, it is also unfair to assume that he can manipulate information in a rational manner in the absence of data.

Exactly. Contrary to the popular misconceptions, the presense of alcohol or opiates or benzodiazepines does not prima facie render someone incapable. Capacity is demonstrated by the patient's actions/words, as interpreted by a trained physician or other professional. A mental health condition (such as depression/suicidality) can render a patient "not capable," but again, you must show how their condition relates specifically to the treatment the patient wishes to undergo or refuse.

A second consideration is the gravity of the decision in question. There is an important qualitative difference between refusing lifesaving treatment and, say, choosing an outpatient cardiac workup over an inpatient workup. An observer needs a much higher level of confidence in the patient's capacity to allow the former.

Context also matters. This is why I added the follow-on questions relating to the patient's age and the likelihood of death despite treatment. For example, a patient whose illness is likely to be lethal 98% of the time would not raise any eyebrows should he choose comfort care and refuse invasive curative therapy. Similarly, age naturally (for some) brings an acceptance of death. I have seen many a senior with a wonderful, serene acceptance of the approach of death. If a senior who was not evidently depressed said to me, "Doc, I've lived a great life and I'm with my family and I don't want to go through X," I can accept that as a reasoned decision to refuse care.

In this case, there were a variety of compelling reasons to over-ride the patient's refusal of care. First, this was a very serious, irrevocable decision. It was life-or-death, decide now, no takebacks. You can always withdraw care later, but you can't re-animate the dead if you change your mind. And, um, you can't change your mind if you're dead. The context argued for full treatment. He was young and not at the stage in life when most people view death with equanimity. He had a serious injury but with a reasonable expectation of cure. And I had a strong impression that his capacity was diminished. It wasn't clear-cut, but there was enough doubt that in this case I was not prepared to allow him to die. I would have allowed him to refuse, say, an x-ray of his knee. But not intubation.

So what are the legal and risk management implications here?

First of all, as pointed out, there are real risks of allowing him to refuse care. Whether or not you get sued, a case like this in which a young patient dies will evoke strong feelings within the care team and the case will be very closely examined in retrospect. Your hospital administrator and quality committees expect that in such cases that all appropriate processes are followed and rigorously documented. Maria suggests a "second opinion" in such cases, which would be a very good idea. This is not just to protect your own ass, but also to protect the patient. When you are literally making life-and-death decisions for someone else, the function of a second opinion/risk management/patient advocate is to double-check your judgement. In such cases, you would be well advised to involve whatever resources are available at your facility - ethics team, chaplain, whatever. If you do follow all the steps, and you get sued after all, your defense will be much stronger for having done all that extra work and having documented the process clearly.

On the other hand, should you decide to treat despite the patient's vigorous objections, you are on much firmer ground. From a simple malpractice point of view, there is a civil tort involving "wrongful death," but not "wrongful living," at least not in this context. You can be at risk for a bad outcome based on delayed diagnosis, etc, but generally not on the theory that you should have allowed him to die. (If there is precedent to the contrary, I'm unaware of it. Childbirth is a separate circumstance.) Though assault and battery charges have at times been levied against physicians who impose treatment on patients against their will, traditionally the courts have shown deference towards the judgment of a treating physician, and have especially given weight to the presumption that preserving life should be the default approach except in clearly defined cases.

So, basically, you are safe in treating and at high risk should you allow him to die. While I would not advocate choosing a course of action solely based on perceived liability risk, this is a case where the ethics and the legal issues point the same direction.

The final point I would address is that of process. What do you have to do to over-ride someone's wishes, or, conversely, to allow them to die, if appropriate? It's not as simple as just holding them down and pushing succinylcholine. The first thing I do, after formulating what I think should be the plan, is see if there is consensus among the care team (meaning the nurses and any other doctors involved). If there is a nurse who feels strongly that you should NOT do something, that conflict needs to be resolved before you move forward. Similary, the family needs to be engaged, if possible, to assess their feeling on what should be done. If the stars align and everybody is in agreement on the course of action, then you're good to go. (Again, I am assuming fairly exigent circumstances.) If there are irreconcilable conflicts, either within the care team or with member(s) of the family, then you are going to need to go up the chain of command. In my facility that generally involves a call to the risk manager or administrator on call; your institution may vary in its procedures.

I'm not surprised that the comments/emails I got on this case were about 9-1 in favor of treatment. It was a no-brainer, by and large. But it was an interesting case because it illustrated the difficulty in assessing decisional capacity and the elements required to over-ride a patient's wishes. And I enjoy taking a specific case and using it as an opportunity to drill down to the essential principles involved. Hope you enjoyed it, too.

Human factors and patient safety

2011-05-25T14:10:00.001-07:00

Every doctor or healthcare provider should watch this video.

Just A Routine Operation from thinkpublic on Vimeo.

It could never happen to me, right? Wrong. I'm as human and as fallible as those doctors who killed that poor lady, and as those pilots who flew perfectly good aircraft into smoking craters.

Take home points for me?

Situational awareness: never get so focused in on a single thing (like getting the intubation) that you lose sight of the big picture.

Teamwork: know who's in command, know your team, brief the team, and make sure that all team members feel comfortable speaking up if they see a problem.

Which goes back to what I've been saying for years about ER nurses. If you shit on them, if you belittle them or fail to respect them, they won't speak up and you will miss critical opportunities to prevent a mistake. Respect them and keep open channels of communication, and they will save your ass time and again.

My guidelines for blogging about clinical medicine

2011-05-25T01:50:00.001-07:00

There's been quite a kerfuffle over the "Unprofessional" post Dr V wrote. A lot of people have been very shrill in denouncing physicians who write about their experiences using social media -- blogs, twitter, facebook, etc -- with particular emphasis on those who do not use their real names.

So, while I won't tell someone how they should blog/tweet, or try to impose my vision of professional standards on a community that clearly is still coming to consensus with public conversations by healthcare workers, I will offer you my personal guidelines and values that I use in determining what I am willing to put into the public domain. These are just my opinions; your mileage may vary.

As a general principle: patients give physicians and nurses access to intimate details of their lives and they have a reasonable and valid expectations that we will respect their privacy and dignity. When using social media, that does need to be maintained. How you do that requires careful attention and may be controversial regardless of your approach.

Don't blog or tweet anything that you wouldn't want you boss/hospital administration to read. Stress test yourself by informing your employer or CEO about your blog and invite them to read it. That will keep you honest!

HIPPA -- it's the law, and it's a minimum standard for how much de-identified information you can publicly share. I would argue that how far you need to go beyond HIPPA depends on what you are writing, and the tone. If it's a straight-up medical science, such as an educational case report, I would contend that fairly little beyond the minimum information needs to be removed. If the case is unique, intimate or newsworthy, you may need to go a bit further.

Even though you may not have your name on your blog or twitter, do not think for a moment that you are anonymous. It would take creative hackers about ten minutes to figure out your real name and location (ask me how I know!). A lawyer would also be able to get that info easily. Don't put it out there unless you would be willing to stand by it with your real name there. That said, I think there are good reasons to maintain some degree of anonymity. Every patient I see in the ER gets my card, and I suspect that more than one has gone home and googled me. If one were to find this blog, he or she might be quite upset at the mere prospect that their privacy might be violated. Even the possibility of that I find unacceptable, so I keep my name off the blog. Yes, it's easy enough to find out who I am. But I think it's important to try to protect patients from even the fear that their privacy will be violated.

Which brings me to the next and maybe most important point: don't blog about real patients. This is tricky. When you have a blog (or live on twitter) and you see something noteworthy in the course of your professional life, the reflex is to share it, especially when the audience is a mostly professional one. It feels like you're chatting at the nursing station, but it's more like the hospital elevator or lobby -- a public place. So look carefully at the case, figure out what about it that is worth sharing, and distill it down to that. Then rebuild the case with completely bogus details. Your authenticity is what makes your stories interesting and valuable, so it's challenging to create a realistic fiction which conveys the central pont in a believable manner. I'm sorry to say this, but all of the stories I have ever told on this blog, at least since the very early days, have been made up out of whole cloth. Each story did illustrate a real point that arose out of a real case. But I generalize, fictionalize, and use archetypes to illustrate the concept. I've seen enough patients to be able to build a credible composite. Also, don't do it in real time. Write up a case and let it marinate for a while. The more unique the case, the more obfuscation and time are needed to ensure that your post is not traceable to the incident patient.

When you do write about an appropriately de-identified and fictionalized patient encounter, add some redeeming value. If the central point of your post is "people suck" or "Patients are stupid and I hate them," then just possibly you need to reconsider before you hit publish. As i said above, education is an excellent value-added element for a medical post. Some bloggers write beautiful stories about the human condition, uplifting and sad alike. But there are other stories to tell, about your life on the other side of the gurney, and those are good, too. Sometimes a patient makes you angry or afraid, and those are valid stories to tell. Avoid telling patient stories for their simple prurient interest. If the central point of your story is "can you believe this?" find a better point before you put it out there, or delete it.

Don't eschew humor. People are weird and wonderful and the things they do are hysterical. There's nothing wrong with acknowleding that fact. Many patients, in real life, will laugh at themselves. But don't laugh *at* patients; that is belittling and demeaning. Find the humor and celebrate it. Be positive and affirming. Be self-deprecating. Humor and respect are not incompatible, but it is oh-so-easy to cross the line to the "bad" humor.

This is something new, and it's going to take time for the world to adapt to it. In the old days (defined as prior to 2003) medical conversations were limited to private discussions in the doctors' lounge and the occasional book. Now they take place in the public sphere. I think that's a net positive. It's good for doctors and nurses to be able to easily express their emotions and their experiences. It's also good for patients to be able to see behind the veil of what really goes on in the health care arena. Is it perhaps disconcerting? Yes. Is it easy for frustrated or burnt-out docs to overstep the bounds of propriety? Sure. it is not, however, the medium which is the problem. It is what you say that counts, and how you say it.

I should also add, as a point of order, that if you go back through the nearly two thousand posts published here over the last six years, you will probably find some which do not live up to these principles. I have certainly learned, matured and evolved as a blogger in this time. In the spirit of intellectual honesty, I don't generally retro-edit or delete posts which turned out poorly. So feel free to play gotcha; it's easy. And I'll plead guilty in advance.

I hope these guidelines are useful to you, if only to understand where I am coming from. I'm a little disturbed by the prospect of a bunch of busybodies trying to regulate what physicians can share online, so my intent here is to show that an anonymous blogger can approach the task from a principled and positive perspective. Feel free to let me know in the comments how I can do better.

I don't buy your definition of Unprofessional

2011-05-24T15:23:00.001-07:00

So there's this Twitter machine, which you might have heard of. It's all the rage among the kids these days. Doctors have adopted it too, and as happened in the blogosphere there are no shortage of self-righteous, self-appointed internet scolds out there to police our conversations and make sure we all stay in line with their view of how doctors should comport themselves. The most recent is Dr Bryan Vartabedian, who blogs at 33charts and tweets at @Doctor_V. He chose yesterday to attack an anesthesiologist over a middle-of-the-night exchange about a patient with a priapism: Unprofessional Physician Behavior on Twitter

Now, I'm not averse to picking a fight or using strong language on the internet. Nor am I averse to calling someone out by name. You need to be able to handle criticism on the internet. But a couple of things struck me on this.

First, the tone: I have been attacked relentlessly on the internet and I've never hesitated to respond in kind. I took out a little frustration on DrRich the other day, and maybe that was a little over the top, but he's a guy who himself engages in hyperbolic language so I don't feel too bad about it. But It's, well, it's just rude to come out and lay into someone who is generally nice and inoffensive. Not only is it rude, it's self-defeating. You could initiate a conversation and have a teachable moment. But when your headline contains the word "Unprofessional" it takes the teachable moment and makes it an adversarial encounter.

Furthermore, Dr V high-handedly asserts in his comments, "Regarding outreach, I don’t engage anonymous people."

Isn't that convenient, as well as self-righteous? I understand that DrV has a principled issue with anonymity on the net among medicos. Fair enough. Don't link to them or endorse them. But are the anonymous health care provders some sort of unspeakable unpeople to be shunned? Especially when you are willing to call them out publically? Frankly, it's a jerk move to do so while maintaining that it's beneath you to correspond with him or her.

Then you have the actual substance of the complaint. DrV's central complaint was that there was a little giggle about the nature of the patient's medical condition. I take it that DrV has never read this blog, which at times has been a celebration of the strange mishaps, maladies and sexual proclivities of our fellow human beings. I'm sure his head would explode at these posts. For my part, I try to remain non-judgemental, educational when possible, and respectful, though it's impossible to ignore the very real humor in some cases. Some of my fellow bloggers, and I'll prove myself better than DrV by not pointing fingers, are real assholes with nothing but scorn, contempt, anger and disdain for their patients. They are truly a disgrace to the profession. So if you are looking for physician behavior on the internet which you want to shame and label as "unprofessional," DrV picked a fairly weak case, I think. And if you're going to pick a fight, you really need to have a clear, cut and dried example of behavior which crosses a bright line, which was most definitely not the case in the incident thread.

It's more arrogant, I think, for DrV to impose his personal value system on behavior for which there is not a consensus within the medical community. We all agree that HIPAA is a minimum standard, and that there is a moral obligation to be more protective towards patient privacy than the law's bare requirement. There's a lot of diversity of opinion, however, on where the line is. While DrV asserts that simply "disclosing the details of a case" is unprofessional, if you look at the actual conversation nothing more was disclosed beyond the diagnosis, lack of risk factors, and the duration of symptoms. That's hardly a lot of detail. I should also pont out that she expresses significant empathy for the patient which is to her credit.

The real issue here is that as a profession we are grappling with how to take the conversations that go on between healthcare providers and adapt to the internet. If this were a private exchange at the nursing station, or at a cocktail party, it would not raise an eyebrow. In the public arena, though, the boundaries are less clear. DrV is clearly an absolutist in his view of the amount of patient information that providers can discuss publicly - zero. He's entitled to his opinion, but clearly a large number of doctors and nurses disagree. I think it is OK to discuss patients so long as it is clearly anonymous, respectful and has some redeeming value. The value may be educational, or it may be in telling a human story. It may be to express a strong emotion that a healthcare provider feels, be it anger, shame, humor, satisfaction, etc. It may just be because the provider wants to tell his or her story. Just because we are doctors does not mean we cannot share our experiences. I took an oath of confidentiality, not silence. I would also point out that every single medical journal has sections in which doctors express their human feelings and experiences. The internet is no different, just self-regulated.

I think we all agree that the internet and social media is a new ecosystem for health care professionals, and that there are landmines which incautious physicians can step on. I think we agree that patients' identities and dignity must be protected. There's more common ground here than disagreement. To DrV, I would suggest that his version of appropriate physician behavior is not universally accepted, and he creates more heat than light by insulting well-meaning and inoffensive physicians.

Rational Tylenol Packaging

2011-05-23T12:46:00.001-07:00

This is interesting: from the Freakonomics blog:

Last time I was in London I had a headache, and went to the nearest Boots to buy something for it.
In U.S. drugstores, I’m accustomed to finding half an aisle devoted to headache pills, with bottles ranging from small to very large — at least 200 pills in them. So that’s what I went looking for in Boots, but no such bottle was to be found. The only options were cardboard packets containing maybe 20 pills, with each pill in its own blister packet. (The pills were also larger than U.S. pills.) Hmm, I thought. I guess Boots finds it can charge a lot for a small amount of headache medicine since most people, when they have a headache, aren’t very price-conscious.
[...] In England and Europe, Tylenol is sold under the name Paracetamol, and that’s used for huge numbers of overdoses, which on the whole aren’t lethal but leave the people with kidney damage and often of dialysis for the rest of their lives. They started doing that about five years ago, and they restrict the numbers, and they put them in plastic blisters so you have to tear them out. And again, you’d think all I have to do is go to six drugstores, you know, buy packets in each of them, all I have to do is just tear them out. But it has cut down the number of overdoses. It’s also cut down the number of serious overdoses that have led to kidney damage. Now, very few people died of an acetaminophen overdose. So it’s been hard to document that it cut the number of deaths, but certainly the number of attempts. The overdoses with it have been cut dramatically.

Hmm. Leaving aside the fact that APAP causes liver failure, not kidney failure, a factual error which makes this ER doctor cringe, this is actually kind of clever. They do something similar with kid's tylenol, which is deliberately sold in small bottles. Children's and Infant's Tylenol generally is sold in concentrations and quantities of 3g or so. The result is that if a curious 20-kg toddler decides to drink an entire bottle, they'll be getting a dose of 150 mg/kg, which is right at the threshold of serious toxicity -- and more importantly, is in an easily treatable range, even in a smaller child.

This makes sense to apply to the adult market. Tylenol is involved in at least 140,000 overdoses in the US annually (according to poison center databases (PDF); it may be much higher since many ER docs do not report tylenol overdoses, since many are non-toxic and we are very comfortable with treating them without poison center guidance). Of lethal overdoses, tylenol is in the top three, behind only opiates as a class, and cardiovascular drugs. So it's a non-trivial problem.

Would I, as a consumer, be annoyed at having to peel one of those damned blister packs to take a tylenol? Yes. It would be really irritating. But that's the point. The reason tylenol is so commonly implicated in overdoses is because it's convenient and readily accessible. Fairly few people who gulp half a bottle of tylenol are actually trying to die, few have any clue what the toxic OD is, and most are surprised when I tell them they took a potential lethal dose. It's perceived as a very safe drug. Some patients repetitively OD on tylenol precisely because they beleive from prior experience that it's safe. Putting tylenol in the blister packs woud not cut stop someone who is really determined and who does their homework, but those folks are hard to deter in any event. But it would certainyl cut down on the accidental/opportunistic overdoses.

It would be easy to do and it makes good sense. Which is why I'm quite sure that it'll never happen here in the US.

A case study in applied ethics

2011-05-23T04:49:00.000-07:00

In my professional life, one of the things I frequently have to do is tell someone that I am recommending a course of action that they may not be terribly keen on pursuing. And I know it when I am making the recommendation. "I'm sorry, sir, but I think we are going to need to admit you to the hospital/put this tube in your chest/cut off the remainder of your finger," etc. I am accustomed to getting resistance in these situations and having to convince the patient that there's a good reason to do what I recommend. Usually, patients exhibit good sense and comply. Sometimes they refuse. Generally, I am OK with that. It's the right of a patient to refuse treatment they don't want. I don't take it personally, but it can be a bit frustrating when you have to watch someone make a really bad decision.

But it does bring up an interesting and tricky issue: when is a patient NOT allowed to refuse care?

We had an illustrative and complex case recently along these lines. A young man, in his early 20s, was seen in the ER on three consecutive days for suicidal ideation and non-life-threatening suicidal gestures. In each case he was felt not to be eligible for detainment under our state's law (which sets a fairly high bar for involuntary treatment compared to many other states), and he was able to "contract for safety," for whatever that is worth, and so was released each time. A complicated overlying factor was his heavy dependence on opiates and benzodiazepines.

He returned to the ER following a motor vehicle accident. It was a single-vehicle accident where his car had left the road and hit a tree for no apparent reason. He appeared sleepy on the scene and roused with narcan pre-hospital; the medics assumed that he crashed because he was stoned. In the ER, he admitted taking some pills to get high, and admitted that he still felt somewhat suicidal, but denied that he was trying to kill himself by crashing his car. The urine toxicology test was positive for opiates and benzodiazepines, but a blood alcohol was negative.

He did have multiple injuries. Several broken ribs and pulmonary contusions and a small cerebral contusion. While he was in the ER, his oxygenation began to deteriorate and repeat chest x-ray showed increased opacification suggesting worsening pulmonary contusions/incipient ARDS.

I explained that he was going to require intubation and mechanical ventilation due to the severity of his lung injuries. He refused.

For those familiar with trauma, the early signs of hypoxia and worsening x-ray findings indicate a really bad lung injury which absolutely will require ventilatory support as a life-saving measure. There are not really any other compromise treatment options, at least none that offer reasonable expectations of making a difference.

At this time, the patient was alert and seemingly oriented. He was able to express that he understood that refusing intubation would lead to his death. He was unable to, or chose not to, articulate any reason that he did not want to be intubated. He stated to multiple people that he was comfortable with the idea of dying, and he felt at peace. He was adamant in his refusal of intubation.

At the time these discussions took place, he had received some pain medicine for the rib fractures. His oxygenation was borderline low at 89% on high-flow oxygen, but vital signs were otherwise more or less stable. No family was available. After some time in the ED, his oxygen levels began to decline further and the patient was no longer verbally responsive.

To summarize, this young man, with a long life ahead of him has a lethal injury for which he has clearly refused the only potential life-saving intervention. He has demonstrated the bare minimum elements of an informed refusal of care, and has done so consistently to multiple interviewers. However, his decision-making may have been compromised by his head injury, by low oxygen levels, or by the presence of intoxicants (both recreational and therapeutic). Other complicating factors include his latent suicidal ideation and speculation as to whether his injury may have been self-inflicted.

What would you do if you were the doctor in this situation (or the administrator/ethicist/judge called to offer guidance)? Would you provide supportive care and allow him to die, or would you violate his express wishes and intubate him?

Would it make a difference in your decision if you were told the survival rate for this injury was only 25% even with full treatment?

Would it make a difference if the patient were 75 instead of 25?

Does the possibility that he may have been suicidal invalidate his refusal of care?

Let me know what you think in the comments, and I'll fill in the outcome in a couple of days.

Walu Ngalindi

2011-05-14T11:31:00.001-07:00

WALU NGALINDI from GRANT WAKEFIELD on Vimeo.
Love the night sky, love timelapse.

I'm off on a well-deserved three-day break to Orcas Island. See y'all next week.

Too Awesome for Words

2011-05-12T10:31:00.000-07:00

The largest model airport in the world:

1:87 scale, with 40 autonomously moving airliners that taxi, take off and land at realistic scale speeds, 90 ground vehicles that also move autonomously.

I used to build models (WWII fighters, mostly) and this just blows my mind. It took $5 million and over half a million man-hours to build.

More here. The home page, with other miniature cityscapes is here.

Can we save costs by reducing ER usage? A counter-intuitive take.

2011-05-11T15:04:00.000-07:00

When we look at the $2,300 Billion that the US spends every year on health care, and the annual rate of increase of about 5% (inflation-adjusted), it's fairly clear that we need to get costs under control, or health care will bankrupt the country. One area of focus for possible cost savings has been the Emergency Department. The ER is viewed as a very expensive place to provide care, so that's not surprising. It's also viewed as overcrowded, which is true, and that it's used inappropriately by many patients, which is more debatable.

On that point, there are conflicting perspectives. I have criticized ACEP in the past for promoting misleading statistics, when they have claimed that only 7% of ER patients are "non-urgent." This was based on frank misuse of the triage categorization system and simply does not pass the sniff test for anyone who has ever worked in an ER. A better estimate might be 25-40% of ER cases as non-urgent, or representing conditions which could have been treated elsewhere. However, I'm not sure I'd call this "inappropriate use" since for many patients there is no alternative option. The barrier to this is multifactorial. Unfunded or underfunded patients have limited avenues to access for semi-urgent care because clinics simply turn them away unless they can pay cash. Even funded patients are challenged to find primary care physicians who are able to see them in a timely manner, a problem exacerbated by the shortage of primary care physicians. Furthermore, hospitals in many areas have been complicit in driving up ER utilization by agressively promoting the ER as a convenient place to receive low-wait or no-wait care.

Mostly.

So, it's a fair question -- are there potential savings to be realized in diverting low-acuity patients away from ERs? Legislators in MA, SC, and WA think there might be, and there have been suggestions that we should take measures to divert the less-urgent patients from the ER, perhaps using payment reforms or financial incentives/penalties to do so. Just yesterday there were hearings in the Senate HELP committee on whether non-urgent use of the ER can be reduced.

The question is whether this would save much money. ACEP says "no." They claim that the Emergency Department care accounts for only 2% of the nation's health care budget, and that reformers won't find much fat to cut here. To me, that 2% number also sounds implausibly low. The nation's ERs see 124 million patients annually. The average charge is about $5,000 for an ER visit (doctor and facility, source: PDF). Assuming a standard discount between charge and cost of about 70% (hard numbers on this are very hard to come by, but it's a good estimate) gives an average cost of an ER visit at $1,500. So that suggests that actual cost of ER care is $187,000,000,000. Given the total health expenditure of $2.3 trillion, we're more like 8% of the total health care budget. ACEP bases their claim on the respected AHRQ survey which found that the 124 million visits cost only $47 billion, or $376 per visit. While I greatly respect the AHRQ, this also, unfortunately, doesn't seem to pass the sniff test. I'd be interested to see a rigorous estimate of the actual cost of emergency medicine's services, and I suspect that it's somewhere between the two estimates. Which means that it's a non-trivial amount of money to be considered, somewhere in the tens to hundreds of billions, and a fair target for cost reductions, if there are any to be had.

Which brings us to the next question. Since there may be saving to be had, would reducing the number of non-urgent ER visits do much to realize said savings?

This is where I can get back on the ACEP party-line bus, and say, I don't think so. The general concept here is that the marginal cost of an extra ER visit is very low. The ER is already there and the lights are on, the doctor is already there, and the CT scanner is already there (and paid for in advance). Yes, you need to scale up a bit as the patient volume expands, but a study, admittedly a few years old, found that the marginal cost for a low-acuity ER visit was about 7% of the average ER charge, or about 20% of the actual cost of that low-acuity visit. This makes sense, in that the typical low-urgency visit is one that is low resource utilization. It takes fairly little time and almost no ancillary services to diagnose a UTI or a sprained ankle.

Myles Riner, who I know through the ACEP reimbursement committee, put some similarly provocative data over at ACEP's Central Line blog: Much Ado About Very Little – the Deferral of ED Care Boondoggle. He presented some data which he had reviewed from Anthem Blue Cross, which looked at costs attributed to a year's worth of non-admitted ER patients. This includes 637,000 patients, at an average cost of $1,500 per patient, which is much more in line with my real-world experience. His findings mirrored the data-clustering finding I posted last week, in that the most expensive patients are far, far more expensive than the least:

So, assuming (and it's a big assumption) that we could take the bottom 40% of ER patients with regard to their cost -- and I think it's reasonable to assume that cost, acuity and urgency are reasonably correlated -- and successfully redirect them elsewhere, we would save a grand total of 12% of ER costs. Depending which estimate of overall health care costs ERs represent, that would net the economy a savings of $5 billion to $20 billion. (If you could convince only the bottom 20% to go elsewhere, which might be more realistic, then you'd save between $2 and $7 billion.)

That's a drop in the bucket, folks. And it would require major, major restructuring of the health care system, because these people represent nearly 50 million patient encounters. Some of them would give up and not seek medical care if the ER was closed to them, and that would be OK. (I'm thinking of the sunburns and such, the truly trivial complaints). Some would fail to get medical care and get worse; a simple UTI would turn into a case of pyelonephritis, and then present to the ER sicker. Most, however, would need to go to their primary care office or to an urgent care clinic -- resources which at this time either do not exist or do not have capacity to care for this huge volume of patient encounters.

It would also be very difficult to accomplish. Many times it's impossible to predict in advance whether a given ER case will be easy or hard. That blood in the urine could be a simple UTI or it could be renal cell carcinoma. The baby with the rash could be a viral exanthem or it could be meningitis. The heartburn could be heartburn or it could be unstable angina, and you'll never know until you are seen by a provider with the experience and judgement to differentiate the two. So, prospectively, I have no idea how to sort out the 40% who could go somewhere else, even if they had somewhere to go, which they don't, and even if they could be easily deterred, which they can't.

Furthermore, I'd make the argument that, especially for low-resource-utilization patients, the ER provides an efficient, high-value service. In a well-functioning ER (sadly, not the majority of US ERs), a fast-track type patient can be in and out in 45-90 minutes. No appointment needed. Just show up, get seen & treated. For someone who is in pain, or has a challenging job schedule, or child-care responsibilities, there is real value to that sort of service. If you have to take a day off of work to get evaluated for a minor medical problem, that cost is substantial; an ER that can provide the needed care may wind up costing not just the patient but the economy less in the long run. Yes, it costs more than a doctor's office, but since the doctor's office is unavailable for this sort of care for many people, I don't see the validity to that comparison. The fact that a low-to-moderately complex medical problem can be addressed quickly and cheaply in an ER is a measure of the success we have in operating efficiently.

The best policy, of course, would be to have a network of primary care and urgent care offices which have excess capacity and are open for extended hours, if not 24/7. That would be a better and cheaper way to deliver acute care for a large minority of patients. That doesn't exist, unfortunately, and until it does, the ER remains not only the safety net, but a relatively low-cost alternative for patients who cannot access care elsewhere. Legislators and policymakers are misguided if they think they can achieve significant cost savings by reducing ER utilization.

The healthcare reform law's constitutionality

2011-05-11T11:56:00.000-07:00

A nice review of the law and precedents as it relates to the PPACA from the Yale Law Review, which concludes that the PPACA is "obviously" constitutional based on existing law. For those who don't feel like wading through the entire legal analysis, Kevin Drum at MoJo has summarized the case in a single powerpoint slide:

Though all the usualy caveats apply about the politicization of the Courts, as the 4th circuit court of appeals drew a 3-democrat panel of jurists, and the 6th circuit drew 2 republicans and 1 democrat, and it'll all come down to Anthony Kennedy in the end.

More paranoia about the IPAB -- a debunking of Dr Rich

2011-05-09T12:39:00.001-07:00

I shouldn't do this. It's madness to try to delve into the minds of conspiracy theorists and try to make sense of their ravings. But I can't help myself; I'm drawn like a moth to the flame. it never ends well. I only wind up with a horde of trolls in the comments telling me that I'm a glib supercilious idiot and should stick to medicine or go die in a fire or something.

Sometimes it's too hard to stay away. Maybe it was the personal affront I felt in the false imputation of ill motives onto progressives. Maybe it was the gross errors in fact, sitting there ripe for the plucking. I don't know, but I just can't resist a rebuttal to Dr Rich at Covert Rationing, who weaves a technocratic cost control body into a paranoid web of fantasy, concluding that:

Progressives are dedicated to “progressing” to a perfect society, and they know just how to achieve it. ... Specifically, the Progressive program requires individuals to subsume their own individual interests to the overriding interests of the collective – and human nature just doesn’t function that way. Thus, the Progressive program inevitably relies on a cadre of elites – those who have dedicated themselves to furthering the Progressive program – to set things up the right way for the rest of us, while manipulating we in the teeming masses to let them. And the rest of us, once the correct programs and systems are in place, will at last understand that it was all for our own good.

I suppose this paragraph tells you everything you need to know ... about Dr Rich. Any supposition that he was approaching the view of policy with a fair mind or that he is willing to attribute anything but the worst motivations to those on the other side of the aisle is completely shredded by this paragraph. As rhetoric goes, it's up there with "Conservatives want old people to die in pain." So we can scratch Dr Rich off the list of people who are willing to discuss health care policy with a neutral mindset. He's engaged in a holy war of ideology.

But how does he rank in honesty? Oh, that's not right of me. I shouldn't mirror his approach of automatically assuming the worst motives to someone I disagree with. His errors of fact could be deliberately dishonest, but they could equally result from laziness, ignorance, misinformation, or untreated paranoid psychosis. It's an open question! What is not really open for debate is that his theory is built upon several critical errors of fact.

Let me enumerate them. But first, a tiny bit of background.

You may have heard that healthcare costs are currently consuming something along the lines of 16% of the US Gross Domestic Product, and increasing at a rate well beyond inflation in general. Most people believe this is a really bad thing and that it is bankrupting the country. Most people believe that we need to do something to constrain the excess cost growth. The recently passed health care reform law -- the PPACA -- does make some modest steps towards this end. Many people believe that it does too little; I am one of them. One provision in the PPACA is the creation of the IPAB, the Independent Payment Advisory Board. I wrote about it a bit last month. If you'd like a summary, the Kaiser Family Foundation has a nice review (PDF). Basically, it will be composed of healthcare experts, doctors, nurses, patients and economists who, if health care costs continue to escalate, will create and institute reforms to control the spiraling costs.

This is where Dr Rich and I diverge in our opinion. I think it's a pragmatic fix to the political paralysis exhibited by Congress over the last two decades in actually cutting costs. He thinks it's a dictatorial body that progressives created to force humanity into a hive-like "collective." His evidence for that, however, lies on faulty understanding of (or slimy dishonesty about) the actual, you know, law.

For example:

1) It has dictatorial powers.
...The IPAB is actually all-powerful.
Once the Chief Actuary of CMS determines that the projected per capita growth rate for Medicare exceeds a certain target growth rate (which it inevitably will), the IPAB is required to submit a so-called “proposal” which will cut healthcare costs sufficiently to bring the growth rate back in line; which is to say, the IPAB will determine what will be paid for and what will not. Then, the Secretary of HHS is required to implement that “proposal” in its entirety, unless Congress acts to block implementation. However, Congress is hamstrung. The representatives of the people are forbidden from taking any action “that would repeal or otherwise change the recommendations of the Board,” unless it replaces those “recommendations” with its own legislation that would cut healthcare spending to the same target level.
For all practical purposes, then, the cost-cutting “recommendations” which the IPAB would “propose” for “consideration” will be implemented nearly automatically, with the full authority of the Federal government.
And, for all practical purposes, the IPAB will become a new agency of the executive branch, with near-dictatorial authority to cut healthcare spending where and when and for whom it sees fit.

Bold in original, and some rhetorical fluff omitted. So ... wow. This does sound bad. Congress is powerless. It cannot change any of the IPAB recommendations? That's awful. Why even have a Congress if it's going to legislate its authority away? Except, well, it doesn't. Dr Rich does acknowledge one countervailing fact -- Congress can substitute the recommendations of the IPAB with its own! Right there, that does seem to contradict the assertion of DICTATORSHIP that Dr Rich claims. But there's more! Not only can Congress choose to substitute its recommendations for controlling health care costs, Congress can WAIVE the requirement. That'd be Sec 3403 (d)(3)(D):

WAIVER.—This paragraph may be waived or suspended in the Senate only by the affirmative vote of three-fifths of the Members, duly chosen and sworn

So, to summarize, this infringement of LIBERTY by A DICTATORIAL UNELECTED BODY can have its recommendations swapped out by Congress or simply ignored. If you are a conspiracy theorist or a partisan hack, I guess that is dictatorship.

Now some may argue that Congress is too terribly screwed up to act in our interests and that they can never come together to overturn a bad recommendation by IPAB. (I'd also say that's a great illustration of why we need IPAB and an argument for congressional reform.) The argument is that the IPAB becomes a de facto dictatorial board, because the bar is set too high to override its recommendations. We will see, I suppose. Congress manages to get 60 votes together every year to over-ride the SGR, so I don't see why it's impossible that if some controversial rules were handed down by IPAB that Congress wouldn't waive the rules and scrap the recommendations. Is it hard? Yes, but it's supposed to be. But it's not impossible, and it's not dictatorial.

Another bit of epic wrongness Dr Rich engages in is a theory that the IPAB is FOREVER!

It is an immutable entity.
Section 3403, the section that creates the IPAB and spells out its functions, contains some remarkable language that, DrRich suspects, has never been seen before in American legislative history. To wit:
“It shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment, or conference report that would repeal or otherwise change this subsection.”
So, the astounding truth, dear reader, is that the IPAB and all its designated dictatorial functions are in force for perpetuity. Our Congress has passed legislation that purports to bind all future Congresses from altering it in any way.

Now in this, I have to give Dr Rich full credit for good faith argument. He's ignorant, but not being deceitful. I assume. The citation noted above is accurate, and it does sound bad. But in order to understand it you need to a) know a little bit about the arcana of the rules of order used in the Senate and b) know that Congress can NEVER pass a law that a future Congress can't undo. What the citation above means is that it is not "In Order" to modify or dissolve the IPAB. So, to do so, would require "Unanimous Consent" in the Senate, or a vote of 60 Senators to waive the rules for unanimous consent and vote on an "out of order" proposal to modify or repeal the IPAB. (Full disclosure: I may have the exact parliamentary details not quite right, but the gist is there and the conclusion is accurate.) So, just as with the recommendations of the IPAB, its structure and continued existence are completely contingent on Congressional action, though with a deliberately-high 60-vote threshold.

Dr Rich also waxes hysterical about the intrusion of the IPAB into the private health care market. He rants a bit about the way the bill was passed, but the gist of his point is this:

IPAB, at least every two years, [must] “submit to Congress and the President recommendations to slow the growth in national health expenditures” for private (non-Federal) healthcare programs. Furthermore, it designates that these “recommendations” may be implemented by the Secretary of HHS or other Federal agencies “administratively” (that is, without the interference of Congress).

First of all, again, this strikes me as a GOOD thing. My health care premiums are going up 15% a year, and I'd really like to see that slow down. So if (and it's a big if) IPAB has a good idea for a method in controlling private sector spending, then I'm very interested in hearing it. These are categorized "advisory" recommendations and are distinct from the "required" recommendations which pertain directly to the medicare program. And yes, The Secretary of HHS can implement such "advisory" recommendations administratively so long as they are within the existing statutory authority of the Secretary (Sec 3403, (e)(4)), and there are no explicit rules on how Congress may address such rules, which means that they can be over-ruled piecemeal or en bloc by a simple majority of both Houses of Congress, just as any other federal regulation can be: these advisory regulations would not require the 60-vote supermajority rule that the required recommendations would to overturn.

Conclusion:

The PPACA does create new board with some unique and unprecedented powers. I can see why this would make some people concerned. Power can be mis-used, and oversight is necessary. I would say that there are at this time many open questions about the IPAB -- remember that it does not yet have a single appointed member, let alone a track record. It may well be toothless or gridlocked by the time it comes into being. It may wind up as powerful as the Federal Reserve. It may achieve wonderful cost savings, or it may eviscerate the commercial underpinnings of American medicine. Lord alone knows. But it has more promise than ANY other federal cost-control proposal to date, and Congress seems to have retained enough power for itself that if the IPAB wind up doing something particularly bad or unpopular, they should not have trouble over-ruling it.

And if somebody tells you that the IPAB is the secret Democratic DEATH PANEL, they're either pushing a particular agenda dishonestly or grievously misinformed.

I can't add anything to this

2011-05-01T23:21:00.001-07:00

Except maybe, "Good Riddance."

Getting ready for the move

2011-04-29T23:14:00.000-07:00

The new facility will be open soon. I took a tour the other day and grabbed a few photos:

Woo hoo! It's going to be so great.

The Importance of a Good Left Hook

2011-04-26T10:51:00.001-07:00

Outside of work, I practice martial arts -- in particular, karate. We run a dojo which focuses on the traditional elements of the fighting system but also on real-world applications. By which I mean we do all the stereotypical karate "stuff" -- punching the air, conditioning, kata forms, that sort of thing -- but we also try to teach a more holistic self-defense approach including practical street fighting techniques, grappling, and personal safety and security. This differs a bit from many martial arts schools in that we are not sport oriented at all. Our students don't go to tournaments, and we don't teach techniques which are flashy but which would not be useful in a real fighting situation.

Don't get me wrong -- I love to watch the shotokan guys performing their kata with their incredibly athletic low stances, and I love to see the tae kwon do guys with their acrobatic spinning kicks. I mean no disrespect for their styles, and I know many practitioners of these arts are also excellent fighters. But the reality of a street fight is that they are fast, messy, frantic, and incredibly emotional. They do not have the elegant distance and measured timing that a tournament sparring match has, with the complex back and forth of feints, footwork and tactics. If you can pull off a leaping kick in the heat of a real altercation, well, that would be quite an accomplishment. But it would be difficult, since the distance for that sort of thing gets real close, real fast. They say any street fight that lasts more than ten seconds, you're probably losing.

So when I teach self-defense, I focus on close-in techniques: hooks and uppercuts, elbows and knees, wrist locks and arm bars. Simple, easy, high-yield stuff. Not as devastating as a lovely roundhouse kick, but lower risk and more likely to land.

As you close distance, the punches you can effectively use change. The long straight punch is great from middle distance, as is the back-fist punch. When you're really close, you want your punches to arc under or around your opponent's guard. If you can get your hip into it, a hook to the temple or the jaw can be devastating.

Case in point: I recently saw a young man from the local MMA (mixed martial arts) club. As an aside, I love MMA. It's still a sport, but it's pragmatic and authentic and intense. It's not what I do, but I can really appreciate its virtues. Anyway, this young fellow had taken a roundhouse to the right temple and had dropped like the proverbial sack of potatoes. His mates had not been alarmed by this, perhaps because knockouts are common in some dojos, but they really should have done something when he had a seizure. I guess it was a brief seizure, because they didn't call 911. They propped him up, gave him an ice pack and he started to come around after a while. (I swear, you can't make this stuff up.) In fairness, they were all pretty young, in their late teens and early twenties, and I guess they didn't know any better.

Our fellow went home and had a restless night's sleep. His headache kept him awake. The next afternoon he was still feeling poorly, with some nausea and a bit off balance. Finally he decided to come in and get checked out. His scan, as I am sure you have now guessed, showed a bleed:

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You can see the subtle enhancing rim of bright blood along the left side of the skull around the edge of the brain (remember, the CT image is reversed). More strikingly, the midline is shifted from the left to the right and the dark slits of the left ventricles are compressed. This indicates fairly severe swelling of the brain.

This patient, fortunately, did great. He did not require surgery -- the amount of bleeding was actually minimal. It was the swelling that was making him so sick. He did not have any more seizures, and neurologically made a complete recovery. (Whether he will have long term cognitive problems from the head injury is an open question.)

The teaching point here, applicable whether you are medical or martial in your interests, is that the vector, the direction, of applied force matters a lot to the brain. The skull is strongest in the forehead and the back of the head, and the brain is designed to rock back and forth in the front-back axis without too much damage. This is not surprising! Evolution is smart, and humans have been falling forward and backwards for eons, so there's a good survival advantage to being able to withstand the most common head injuries. But when the force is directed from the side, the risk of injury goes up dramatically. The brain is closer to the skull in the temporal area, and is tethered in a way that it gets rattled much more violently from an impact to the side. The skull is thinner and weaker there, and the major blood vessels run along the temple. One good whack along the ear can induce anything from a concussion to a lethal hemorrhage.

The take-home points are:

If you teach a dojo, I would not allow hooks to be used in practice, or perhaps only very cautiously with mandatory headgear.
If you are in fear for your life and wish to inflict injury, this is a great place to hit.
If someone in your dojo/ER does take a shot to the temple, you need to have a high suspicion for serious injury.

Also, I suppose I would add that if your buddy has a seizure after a head injury, you should go ahead and call an ambulance. But that's just common sense, right?

It should go without saying

2011-04-23T09:13:00.000-07:00

But, just for the record:

Do not stick your finger into the spinning blades of a lawnmower.

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This wound poses some interesting management issues. As you can see, it's a fairly clean amputation just beyond the distal interphalangeal (DIP) joint. The patient, optimistically, brought in the amputated portion nicely iced, but reimplantation at this level is not feasible. The blood vessels there are too small and distorted to anastomose. Such a relatively long section to re-install requires good blood flow or it will simply necrose and fall off. So I had to disappoint the patient and tell him it could not be made whole again.

However, the technical issue is that with this very clean amputation there was not enough soft tissue left to close around the stump. Ordinarily, I would take a bone rongeur to nibble away at the residual bony stump until there was enough slack in the skin to pull it across the stump and close it. But this guy had just a bit of intact distal phalanx. I would have had to remove the entire thing, which is not preferable since the flexor and extensor attachment points were still intact. Taking out the rest of the bone would have made the finger weaker and less mobile.

So, in the McGyver-like fashion that ER docs must emulate, I improvised. I took the devitalized fingertip and started harvesting. I excised the bone and the nailbed, leaving only the finger pad and a generous fat pad underneath. I thinnned the fat pad a bit, and trimmed the skin to fit the stump, then tacked it on like a cap. It looked pretty good, and I am optimistic that my little graft will survive. If it does, the fact that I left a fat pad will give him a little cushion over the bone and a relatively functional finger.

But still, the principle remains. Fingers and spinning blades of any sort should not mix.

Are End-of-Life costs avoidable?

2011-04-22T09:39:00.000-07:00

One interesting comment I have seen come up over and over is the idea that end-of-life costs are the thing that is spiralling out of control and that if we could somehow find a way to curb the costs of futile care, then that would somehow solve the health care inflation crisis. Andrew Sullivan endorsed such an idea the other day, a "Modest Proposal," which is not nearly as radical or amusing as Swift's. And indeed, there is a modicum of sense in the idea.Estimates are that spending in the last six months of a person's life account for 30-50% of their overall health care costs, and that the spending in the last year of a person's life accounts for 25% of overall medicare spending.So -- simple solution, right? cut down on the futile care, and we're good to go.

Only problem -- as a doctor, I sometimes have a hard time telling when someone is in their last DAY of life, let alone last year.

Just recently, I saw a guy with dead gut -- ischemic bowel -- a near-universally fatal diagnosis. we worked really hard on him in the ER, because saving lives is "what we do," but it was with a real sense of futility. It was depressing, actually. However, to my great surprise, the patient survived, after many thousands of dollars in expenses and will make a real recovery. He may never go back to work, but he will probably live many more years with good quality of life.

I have a friend whose mother, in her eighties, went in for a coronary bypass, and sadly suffered a stroke and died. Some might well criticize -- what were they thinking doing a bypass in an octogenarian? But consider, she was hale and active prior to the procedure and looked in advance to be a good candidate. And I have seen many nonagenarians who are ten years out from their CABG with good quality of life.

My point is that while some are lucky (?) enough to contract a terminal illness and expire in a planned manner with a clear line drawn on the extent of the interventions, or lucky (?) enough to die quickly and cheaply, many and perhaps most of us will not know in advance which of the several illness we incur as we age is going to be our terminal illness. If you think you can beat it, if your family and your doctor have reason to think you might be able to pull through, then it is difficult to give up. Even if you have an advanced directive, as Andrew suggested (and I wholly agree), in the absence of an established and accepted terminal diagnosis, most patients and families will be reluctant to invoke it and decline care.

So while we may have some ability to reduce costs in the end of life, the simple fact that we tend to get sick before we die, and nobody knows the hour of their death will make them difficult if not impossible to significantly reduce.

Where do I spend the bulk of my time?

2011-04-21T22:47:00.001-07:00

According to the iPhone tracker:

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Yeah, kinda creepy. Maybe not quite as accurate as I have heard -- when I break it down it looks like a grid pattern, not street by street, and some places appear I am pretty sure I have never been. That apparently has to do with the fact that the iPhone uses tower triangulation in logging its location. But the day-by-day log is much creepier:

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I hear there's a harmless explanation, and I actually believe it. All cell phones d this, and forensic cell phone specialists have been able to access this data for a long time. The Droid does the same thing (though it, sensibly, deletes data after a certain time). This is a technical nerd-level mistake and not Big Brother.

But still, man, creepy.