16 November 2006

Now this is what responsible, competent government looks like

Wow. The last twelve years of corrupt, ineffective republican governance has so accustomed me to hackery and rhetoric instead of decisive, responsible action that I actually got a chill (the good kind) reading this Salon article:

Remember those abusive Republican robo-calls and the sample ballots that suggested -- falsely -- that Michael Steele is a Democrat? The soon-to-be Senate majority leader does, and he's prepared to do something about them.
In a breakfast meeting sponsored by the American Prospect, Harry Reid told reporters today that the calls and the phony campaign literature were "absolutely wrong," and that one of the first 10 bills he introduces in the next Senate will deal with such abuses. "We need to make these criminal penalties," Reid said, saying that civil liability was apparently not enough to deter what happened in the run-up to last week's election.
And this bit from Atrios:
Washington- Senator Chris Dodd (D-CT), an outspoken opponent of the Military Commission Act of 2006, today introduced legislation which would amend existing law in order to have an effective process for bringing terrorists to justice. This is currently not the case under the Military Commission Act, which will be the subject of endless legal challenges. As important, the bill would also seek to ensure that U.S. servicemen and women are afforded the maximum protection of a strong international legal framework guaranteed by respect for such provisions
as the Geneva Conventions and other international standards, and to restore America’s moral authority as the leader in the world in advancing the rule of law. [...]
The Effective Terrorists Prosecution Act:
  • Restores Habeas Corpus protections to detainees
  • Narrows the definition of unlawful enemy combatant to individuals who directly participate in hostilities against the United States who are not lawful combatants
  • Bars information gained through coercion from being introduced as evidence in trials
  • Empowers military judges to exclude hearsay evidence the deem to be unreliable
  • Authorizes the US Court of Appeals for the Armed Forces to review decisions by the Military commissions
  • Limits the authority of the President to interpret the meaning and application of the Geneva Conventions and makes that authority subject to congressional and judicial oversight
  • Provides for expedited judicial review of the Military Commissions Act of 2006 to determine the constitutionally of its provisions.
Oh, it's going to be fun to be in the majority!

15 November 2006

Election Analysis

This is a cool graphic from the NYTimes today. I am a sucker for this sort of gee-whiz animation, but it's worth noting for one other reason. There has been some carping from the right side of the aisle that there really isn't a "mandate" for the new Democratic Majority, that the margin of victory was only a couple thousand votes here and there. (Though, oddly, I recall hearing that there was a mandate after a similarly narrow win for the GOP in 2004. But I digress.)

The interesting point of this graphic is that, truly, the bulk of the Democratic pick-ups were quite narrow -- they are largely stacked up in that band with a <10% margin of victory -- but the swings were huge. The average change from 2004 to 2006 was 20-25%. This was not an election where the Democrats picked up the marginal GOP seats; they reached deep into the "safe" seats and took them away. My personal favorite was PA-10, where Don "Choke-em" Sherwood was the victim of a 92 point swing! (In fairness, he did run unoppsed in 2004.) This illustrates two things. First, the size of the Democratic wave was huge. The number of seats taken was huge, and the seismic shift in two years was massive. It could have been even bigger - there are another nine seats not yet decided, all of which look to be GOP holds by less than one percentage point. Second, this strongly validates Howard Dean's fifty-state strategy, in which every seat was challenged, even the hopeless ones. It turns out that some of our pick-ups came from those seats that nobody in their right mind would have picked as competitive. Events threw them into contention (FL-16 Foley, TX-22 - Delay) and the fact that the Democrats had a viable, well-funded candidate in those seats allowed the Democrats to be opportunistic and take them.

The other question raised by this analysis is the durability of the new Democratic majority. How many of these deep red seats are tenable past 2008? TX-22 is going to be a tough hold. Incumbency and (hopefully) a record of success in Congress will provide some edge in 2008, but you know the GOP is going to target each and every one of these races with highly-financed challengers. But many of the pick-ups were in blue or deep purple districts (PA, NH, CT) and should be hold-able. The Dems have a bunch of vulnerable republican targets of their own. So perhaps the size of the majority night shrink, but it's way too early to tell. Lord alone knows what will be happening in Iraq in 2008. And the presidential election.

14 November 2006

Universal healthcare?

Kevin Drum has an amusing take on the insurance industry's proposal for Universal Healthcare. Money quote:

Let me get this straight. The private insurance industry favors a government program that would purchase more private insurance for people, but is opposed to anything that would drive down the cost of insurance or guarantee coverage for people the insurance industry doesn't want to cover. That's quite a plan. Why not just ask for grocery sacks full of unmarked bills instead?
As an ER doc, I'm willing to go along with most anything that would get those 46 million Americans covered. As a taxpayer, I am reasonably sure there is a better, cheaper way to do it.

13 November 2006

Door to Dilation

There was an AP Report today on a major initiative to reduce the time from the moment a patient hits the door with a heart attack, more precisely known as an acute coronary thrombosis, to the inflation of a balloon in the blocked coronary artery which restores blood flow to the affected heart muscle.

The full text of the report can be found here.

I do know that we are already doing the most important things listed as recommendations:

  • We call in the cath lab based on a reliable EMS report of a STEMI
  • We call in the cath lab based on the ER doc's interpretation of the EKG
  • The call-in is a single phone call
We don't have a cardiologist in-house 24/7 (yet?), and I have no clue how long the team has to arrive.

The results? Based on the current data, our facility, in 2006, has a median door-to-dilation time of 69 minutes, with the national median being 90 minutes, and the 90th percentile being about 75 minutes. Our total number of cases is about 140 for the year, which I perceive as being reasonably high, and certainly statistically significant.

I can't take too much credit on this one. We have great leadership, great administration, and great cardiologists. They have identified this as a major goal for the hospital, and put systems in place to generate this type of success. It is satisfying to see that it can be done, and that it makes a difference.

(Side note: I have been at this facility for six years and have never once given thrombolytics. Amazing.)

08 November 2006

Political Capital

Jan 18,2005:
"I earned capital in the campaign, political capital, and now I intend to spend it."

Nov 7, 2006:
The American people requested a refund.

What a great day

The following things have happened in the last 24 hours:

I ordered a new computer
The Democrats took the House
The Democrats took six State Houses
The Democrats took the Senate (apparently)
The Democrats took ten state legislatures and over 275 seats nationwide
The Republicans won not a single pick-up
I found my car keys that had been missing for three weeks
I no longer have to hear the names Santorum, Rumsfeld, Romney, Frist, Harris, or Burns (excepting C Montgomery Burns)

Rumsfeld getting shit-canned is literally icing on the cake.

What a great day. One for the books.

Update: Hysterical Mac Geek joke re: Rummy

07 November 2006

Morning in America

As of my bedtime, we have 24 seats in the House for Speaker Pelosi.
The Senate is shockingly close. At this point, Tester is leading in MT, McCaskill is projected to win in MO, and Webb has declared victory by a fingernail's breadth in VA. If (and that's a big if) these results hold, we take the Senate, also. Amazing. I would never have predicted it, but boy am I happy. We'll see if it holds.

[Picture of a beautiful sunrise in Montana (fittingly) credited to Sarpy Sam]

Pre-School Attack Ad

I'm voting for Jimmy.

Game Day

It's on.

Let's predict -- Just for fun. Pollster predicts 234 seats for the Dems, which would be a pick-up of 32 seats. Charlie Cook predicts 20-35 seats for the Dems. Over at Hotline they see a consensus of 25 seats. Stu Rothenberg sees 30-36 seats going blue.

After 2004, I am incapable of this sort of rational exuberance. The numbers do look that good, but I am going to take the "under" and predict that the Speaker Pelosi will take the gavel with a 5 seat majority -- total pick-up of 20.

Why? Dunno. Cynicism, the proven GOP GOTV game, expecting some republicans to get in the booth and find they just can't pull that "D" lever. Also, I'm a Cubs fan at heart. I expect, on a fundamental, genetic level, for my team to blow it in the ninth. And the GOP has been the Yankees of politics for the last decade or two.

For completeness, I will predict four seats in the Senate. Pennslyvania, Rhode Island, Ohio, and Missouri. Maybe Virginia, also. I think Montana and Tennessee will slip away from us. We'd need six of the seven to take control (and all seven to build a Lieberman-proof majority).

I will predict that Lieberman will win a squeaker, caucus with the GOP, and be indicted in 2007.

I do see one historic possibility -- I think this will be the first election in forever in which one party (the Democrats, in this case) does not lose a single seat it currently holds.

Game on.

06 November 2006

A Matter of Perspective

I took a continuing education class, PALS -- Pediatric Advanced Life Support -- this weekend. A nice refresher, since I don't get to take care of critically ill kids too often (fortunately). We were split into small groups for simulated cases on SimKids. In my group were about 3 pediatricians and 4 peds nurses. I was the only provider who sees more adults than kids.

When it was my turn to run the "mega-code," my preceptor took me through a simulated cardiac arrest that involved just about every nasty twist he could think of. In the end, he concluded by saying, "Good job. You saved his life."

Without thinking, I responded, "We don't really save lives. We just prolong them."

Laughing, he instructed the rest of the class "Oh, don't pay any attention to the cynical old ER doctor!"

Who, me?

One Day More!

Feel good about it:

05 November 2006

Frivolous Lawsuits and the need for malpractice reform

We settled two lawsuits this quarter. In neither had there been medical negligence. It's pretty galling to settle cases like these, but it's smart. The deck is stacked against us, and you have to make the good decisions, even when it is bitter.

Both cases were quite straightforward. In one, there was a DVT diagnosed and treated according to hospital protocol -- low molecular weight heparin and transition to warfarin. The patient went on to have a pulmonary embolus and recovered uneventfully with no adverse sequelae. We only settled because it was cheaper than going to trial. As galling as it was to pay, we did have the satisfaction of knowing that the plaintiff's attorney took a loss on the case. (It was a very small payout, and his preparatory expenses were considerable.)

The other case is more maddening. A very young child was dropped on his head, suffered an epidural hematoma, which was diagnosed on CT, and the child was transferred to a regional trauma center. He recovered, though with some degree of neurologic disability. The plaintiffs waited ten years to file (!) and alleged that some minor delays in CT and transfer were the cause of the bad outcome. This is obviously bogus. But we knew they were going to wheel a brain-damaged kid in front of the jury. The likelihood of losing this case was significant for that reason alone, and the risk of a big payout was significant. So we settled in the mid six figures. I hated to settle, and struggled with the decision, but with juries making decisions, it's a crap shoot, and they consistently rule in favor of sympathetic plaintiffs.

What can we do? When you are at Yellowstone, they tell you not to feed the bears because it just encourages them. But that metaphor doesn't work when the alternative is to let the bear maul you and hope that he won't get all of your food.

The real problem isn't that these suits were frivolous. I don't really know what that word means. I do know they were baseless. The problem is that the newspapers are replete with cases where there is a huge jury award in cases where there was no malpractice. This is what induces us, and lord knows how many other medical groups, to settle cases which were well-handled. When there is no correlation between whether negligence occurred and whether you win or lose, the only viable strategy is to pick your fights very very carefully.

Simply: Lay juries are not qualified to make determination of causation.

What typically happens is that the two sides present dueling expert witnesses who assert fundamentally incompatible standards. The jury is then left to decide which was more credible. How the hell are they supposed to decide which of two eminent, respected academicians is right? When medical experts disagree, how on earth can uneducated laypersons decide accurately what constitutes negligent behavior? If the plaintiff died or was severly imparied as an outcome, that inarguably biases a jury to assume that "something must have gone wrong," and their verdicts do tend to correlate.

I am also aware that the defense prevails in many or most malpractice actions. To me, this is not an indication that the system works. Quite the opposite. There have been cases of which I was personally aware in which the care was clearly substandard but the defense experts were more convincing and the jury went along. The problem is not that doctors win 87% of the time, nor that awards are out of control. The problem is that juries are unpredictable and commonly make very wrong decisions. The result of this is that in many cases patients who were injured go uncompensated (especially if they are not sympathetic victims), and that doctors who were not culpable wind up losing.

When there is not good correlation between causation and verdicts, the system falls apart. I think that tort reform is essential. But I do not particularly favor caps. Caps are clumsy and heavy-handed. Moreover, caps on awards do not get at the heart of the problem, which is the arbitrary and capricious decision-making patterns of juries. It's just as well, because caps are as dead as a doornail, politically speaking. I would like to see an alternative solution. I would prefer special health care courts or some other system which attempts to improve the accuracy of judgements.

Because it's clear that the current system is a miserable failure.

04 November 2006

True Dat

Courtesy of PZ Myers

True Dat.