27 August 2006

Have you had enough?

the Squirrel Nut Zippers have their say . . .

It's worth the watch.

Background story here.

26 August 2006

Listen to your Gut (literally)

"Doctor, we need you in Room 15, right now!"

The call came from an experienced ER nurse and I knew better than to hesitate. It was near the end of my shift, but I put down the matter I was handling and hurried over to see the new patient. As I walked in the room, I could see that it was Something Bad [tm]. The patient was supine and rather grey-looking. The red numbers on the automatic blood pressure monitor read 54/30.

That's low. Really low. Low enough that you shouldn't be conscious, but as long as she laid flat, she said she felt OK.

It was an odd presentation. She really had no complaints -- just felt faint when she sat up. She had felt perfectly fine till a couple of hours ago -- no chest pain or fevers or trouble breathing or anything. Except maybe, she conceded, some mild abdominal pain, and maybe had diarrhea once. The list of Bad Things [tm] in the abdomen started subliminally cycling through my head as I pushed on her belly -- ruptured Aorta, dead gut, perforated bowel, etc -- but her belly was soft and essentially non-tender, which would *not* be the case with a perforation. A quick look at her Aorta with the ultrasound was normal. I felt like there was something I was missing, but I was side-tracked by the *huge* peaked T-Waves on the ECG the nurse handed me.

Peaked T-Waves are a sign of a very high blood potassium level, an imminently life-threatening condition. So at this point I stopped thinking and leaped into full-on ER doc mode. Two IVs. Lots of IV fluids. Insulin and calcium to lower the potassium. Antibiotics . . . just on general principles. Full lab panels -- she's in renal failure, which explains the potassium, though not the low blood pressure. Dopamine for the blood pressure. Get a ICU bed for her and call the ICU doc.

"Whatcha got?" she asked as she strolls in.
"I'm not sure, but it's bad. A 77 year old female with unexplained shock, I presume septic, acidotic with pH 7.05, new onset acute renal failure. She looks better on pressors but I still don't understand the primary cause. She had some abdominal pain but it's pretty mild. Otherwise, she has no symptoms at all."
"Righty-ho," says she, "Send her up when the bed is ready and we'll sort her out. If you can, call nephrology and get her set up for urgent dialysis, will you?"
"No troubles."

So I start back to work on my other patients, pleased that I have stabilized and dispositioned an incredibly sick person in such a short time. It took maybe an hour, probably less. I look at my list of patients for the day - 21 in 8 hours. Damn, I'm really hitting my stride. Given that almost half of them were admits, and three to the unit, I feel pretty good about the efficiency there. I may even get to go home within an hour of the end of my shift.

But I'm bothered. I still don't really have a diagnosis on this last lady. Ordinarily, that wouldn't bother me. I like to say: "The goal of the ER doctor is to keep the patient alive long enough for them to become someone else's problem." And that is just what I have done. Mission accomplished, and I can go home, right? But there's something I'm missing here. I can't put my finger on it, and it's bugging me.

Then the nurse comes to me and tells me that the patient just passed some stool, and it was bloody. Eureka! I literally smacked my forehead with my hand. She has dead gut, which is to say that a segment of her small bowel has lost its blood supply (most likely a blood clot) and has died. That would completely explain the sepsis, acidosis, and renal failure. A quick call to the surgeon -- patient to CT scan, and off to the OR for exploratory laparotomy. Her odds are poor -- dead bowel is a Very Bad Thing Indeed. But had I let a couple of hours go by till the busy ICU doc got to see her and figure it out, the odds of survival would have been fast approaching zero.

I now realize the thing that was bothering me was that I *knew* all along that it was dead gut -- it was the second thing I thought of -- but I had gotten so distracted by the other stuff that I had just lost track of it. All it took was one random piece of data from the nurse to trigger that connection and it came up from my subconscious to the front of the brain. I'm glad it did. And I walked out of the ER exactly one hour after the end of the shift.

24 August 2006

Now, that makes me feel old!

We have several new partners starting with us this summer, and have hired a few more for the winter. Most are striaght out of residency, but some of them are older than I am. But they all have a disturbing tendency to address me as "Doctor Shadowfax." Even in informal settings (e.g., Starbucks).

I suppose I can see why -- being the group's president, I have been involved in interviewing, hiring, and orienting the new physicians. So there's a status/respect/fear thing, I guess. I certainly haven't encouraged it, and as we get to know each other better the familiarity will come. But it stll makes me feel old.

18 August 2006

The Rightwing Times

"Socialist Workers' Daily"

What a right-winger sees when they look at the New York Times. Hysterical.

04 August 2006

Virtual Blue Angels

The Blue Angels are visiting Seattle, and I was telling First-born Son about them, and showing him photos in the local paper. He thought they looked "very very cool" so I hit Google Video to show him some live footage.

This is what I found:

Amazing. Just amazing. I love the inside-the-cockpit perspective. The level of obsessiveness it must have taken to make this is kind of astounding. The folks responsible are the Virtual Blue Angels, who apparently fly precision aerobatics on PC simulators.

I have totally missed my calling in life. I should have been a fighter pilot.

(NOTE: Video is 16 minutes in length)

Words to live by?

The Washington Post wrote an article about the Marines in Ramadi. There is a sign in their headquarters which reads:

Be Polite
Be Professional
Have a Plan to Kill Everyone you meet

Sometimes I think we should post a sign like that in our ER.

03 August 2006

The Arnold sides against the Doctors

I just found out that last week, California Gov. Schwarzenegger issued an executive order directing the Department of Managed Care to issue regulations prohibiting the practice of "Balance Billing."

This is a disastrous development in the ritualized detante between physicians and health plans, especially for Emergency Room doctors. When we go to negotiate with health plans to determine how much they will pay us for services provided to their patients, the doctors are already disadvantaged. The HMOs set the terms, and the only leverage we have is to threaten to not sign the contract and go "non-par." When a patient is seen by a non-par physician, the HMO gets the bill, and pays whatever sum they like (or just denies it), and the patient then is responsible for the balance. It's an ugly thing: patients don't like it (and complain to their HMO) and hospital administration doesn't like it (and pressure the ED docs to sign). But it is the only leverage that the ED docs have to get the HMO to offer terms which will fairly compensate the doctors for their services.

Our group has gone non-par in the past, and it is an effective and useful strategy in our negotiations with the health insurers. If that tool is taken away from us by executive fiat (or legislative, as happened in Maryland), there is no ability for doctors to effectively negotiate to recieve fair compensation for their services.

And just for a sense of perspective, I paid more for a plumber to unclog my toilet the other day than I will get paid for taking care of a three-day-old with a fever last night. The CEO of Aetna made $35 Million in 2005, and the CEO of United Healthcare made $333 Million in 2005.

02 August 2006

Tubes . . . A Series of Tubes

A Mash-up of Sen Stevens' infamous "Tubes" speech on Net Neutrality


01 August 2006

A Gap in Vocational Training

I've been interviewing a number of physicians in our summer hiring drive, and orienting the new crop of docs we have starting with us. It's really amazing. These are all highly accomplished, intelligent people who have trained for years and years to get to the point where they can finally enter the indsustry. On average, it's eleven years: 4 years of college, 4 of med school, and 3 of specialty training.

But they know nothing about the business of medicine. Not a thing. How charges are determined, how the documentation affects the coding, how the patient encounter turns into dollars of revenue, the differences between payers, contracting, etc.

How can it be that you can spend seven years of professional education and come out of it knowing nothing about the basic operations of the industry? It's not the students. They're bright and motivated, and usually pretty interested. And casting my mind back just a couple of years ago to when I came out of residency, I knew nothing about business either. It's the educators' fault, I think. During my seven years in acedemia, I was never exposed to any formal business training. Not once.

I don't know whether it arises from an ivory-tower academic disdain for mammon that the business side of the education is so neglected. Or whether it's because many of the instructors in medical schools have spent their entire careers in academics and actually know nothing about community-based medicine. Or whether the complexity and byzantine nature of the business just seems impossible to convey in the minimal time alloted so they don't even try. either way, it's a pity.

Hmm. If I were designing a curriculum for medical students (or better, residents) what subjects would it cover? It should be reasonable -- you don't need an MBA to practice medicine. Key topics might be:

  • Contracting (for individuals)
  • Malpractice (both Risk Management and Liability Insurance)
  • The basics of ICD-9 and CPT coding, and documentation
  • The RVU system and the mechanics of billing
  • Practice Finance
  • Contracting (third party payors & hospitals)
  • Health Policy (Macro)
It would be a start. It's pretty sad that it's possible to come out of what is essentially a vocational training program and know none of the above.