30 January 2007

Tale of Two Patients

It all happened in Room 14, bed 2. The two of them came in a few hours apart and were like carbon copies of one another. Both middle-aged men in their late forties, somewhat overweight, blue-collar machinists. Both fully insured but had not seen a doctor in ages because "I just hate doctors." Both with large, dedicated, anxious families at their bedsides, certain that if Dad went in to see the doctor -- in the ER no less -- it had to be serious!

Both felt foolish for being there and apologized for "wasting my time."

I could have just photocopied the first medical record and used it for both of them.

Chest Pain
- feels like gas bubbles in the chest, non-radiating
- comes and goes for a week, worse today
- not worse with exertion nor relieved by rest
- not associated with nausea or shortness of breath

Past History
Told he had high blood pressure but was never treated.
Thinks the last time it was checked, his cholesterol was "a little high"
Father had early-onset heart problems

Both were symptom-free in the ER and had normal ECGs and a normal troponin.

I had identical, almost verbatim, conversations with both of them. "The good news is that the tests here look good and I can say that you are not having a heart attack." A quick look of relief flickered across both faces at this point as both wives exhaled deeply and said "Oh thank God." A pregnant pause follows. "The bad news is that the pain you describe is in some ways like heart pain, and you have risk factors for heart disease. I can't tell for sure whether there might be an impending heart attack, and we need to interpret these symptoms as a warning sign that further testing is needed. I want to admit you to the hospital for observation."

At this point, relieved and embarrassed, both wanted to just go home. Both tried to bargain -- promised to take meds and follow up with a doctor. Both wives demonstrated irritation and told their husbands not to be stupid. Both husbands irritably told their wives that "I knew it was nothing."

"Here's the thing, Mr _____," I respond, "I think the chance that this is your heart is low -- probably 5% or less. You like those odds, don't you?" Two nods with a subtle see, I told you so glance to to the wife. "But that's one in twenty," I continue, "and I am going to see twenty patients today. Do you want to be the one? Are you feelin' lucky, punk?" (The last bit delivered in my best Dirty Harry voice.) Both slumped back in defeat and their wives thanked me with immense satisfaction.

You never know. Both described symptoms much more suggestive of acid reflux than heart disease. I probably admit ten or twenty patients for observation for chest pain for each one that rules in. It's hard to do, because people hate to be admitted, the hospitalists don't want to do the admit, and it's a lot of work to admit someone. But you do it, because you don't want to fall into the "fallacy of knowing" and thinking you can predict in advance who will and who will not turn out to have "real disease." It is not very rewarding, and you feel like an idiot calling up the admitting doc twice in a row with a "low risk rule out that sounds more like GI disease than angina."

Patient number one was discharged from the hospital after eighteen hours of observation and a negative stress test. Patient number two had a triple bypass today, after ruling in and have three-vessel coronary artery disease showing up on angiogram.

22 January 2007

The Healthy Americans Act - Analysis

Well, since I have jumped off the cliff with the "Medicare for all" explication, I might as well continue the theme and talk about my fave-of-the-day policy fix for the American Health Care Debacle. If you're bored by the whole discussion and want me to get back to posting freak-show medical tales, check back in later this week -- I'm working a couple of shifts and may have something interesting to talk about.

I am comfortable admitting that I am a relative neophyte in the field of health policy analysis. And maybe it is typical of newbies in any field to fall in love too quickly with the first Big Idea which comes across their field of vision, and maybe I have fallen victim to this tendency. So take the forthcoming enthusiasm with a grain of salt.

Senator Wyden of Oregon recently proposed the "Healthy Americans Act." (HAA) (snark: I thought all major bills were required to have either a catchy title or an acronym that spells something cool. "Healthy Americans Act" sounds like a joint resolution that all Americans should eat more vegetables. Geez, you'd think for such an ambitious proposal, they could have found a better title.) I have not read the entire text of the Act. It's quite long (166 pages) and written in dense legal-ese and I was more interested in watching the Bears crush New Orleans. But like any good upper-level executive, I did browse through an Executive Summary generated by the Lewin Group. It turned out to also be long and complicated. But I will attempt to summarize the executive summary for your benefit, only without taking 30 pages and using colorful graphs.

This is a sweeping proposal which would dissolve the employer-based health insurance system and replace it with a system of universal coverage, at lesser expense, which includes cost containment mechanisms, increased reimbursement for providers, eliminates Medicaid, preserves patients' rights to choose a plan and doctor, and reserves a role for the private insurance industry. Modest, eh? But I like the "vision thing."


  • All employers are obligated to terminate their current health plan, if they offer one, and redirect their current health care costs into payroll.
  • Statewide agencies called "Health Help Agencies" (HHAs) are established, which administer the enrollment of beneficiaries into plans, disbursement of premiums, and certification of participating health insurance plans.
  • Insurance companies are invited to develop plans which are community rated (i.e. no underwriting or adverse selection of those with health conditions) and have benefits at least as good as the Federal Employees Health Benefits Program(FEHBP) (the plan used by members of Congress), or better if desired.
  • Consumers may choose among the plans offered in their states. If no plan is chosen, they are randomly enrolled in a low-cost plan.
  • Premiums are collected by the IRS at the time consumers file their federal income tax. New and increased deductions offset any increase in taxable income due to increased payroll (bullet #1). New withholdings are created to spread out the collection of premiums over the course of the year.
  • Premiums are subsidized on a sliding scale for those with incomes below 400% of the federal poverty level. Medicaid is eliminated due to redundancy.
  • Medicare and VA/CHAMPUS programs remain unchanged.

Unlike some compromises which leave nobody satisfied and have something for everybody to hate (see: ArnoldCare ), HAA takes the opposite approach and tries to include a sweetener for every stakeholder in the current system:
The big winners. Universal health coverage, guaranteed insurance that is not employer-dependent and can never be taken away. No pre-existing conditions screening. Flexibility and Security. Automatic enrollment and collection of premiums. Discounts for participating in wellness programs.
Also big winners. The risk of rising health care costs is taken from their shoulders and, in essence, all the extant health insurance plans are changed from defined-benefit to defined-contribution.
Doctors and Hospitals.
Ostensibly reimbursement will increase due to the elimination in care provided to the uninsured and the elimination of low-reimbursed Medicaid patients, all of whom will now be reimbursed at higher commercially insured rates. The multitude of payers ensures competition for providers to joins networks, which should keep reimbursement levels reasonably high (compared to the monopsony power of a single-payer system). Also promises increased reimbursement to Primary Care Providers. Also includes some weak incentives for malpractice reform.
Realize cost savings from elimination of underwriting and premium collection. Profit margins will be built in to the system to encourage plans to participate, and well-managed plans will prosper.
State Governments
Benefit from the elimination of Medicaid, a large and escalating drain on most state budgets. Contributions from the states are still required, however, though to a lesser degree.
The actuarial analysis promises that this plan will reduce overall health care expenditures by almost $1.5 Trillion over a decade. This is done through competition and engaging consumers in the decision-making process. According to the analysis of the non-partisan Lewin Group, this plan achieves near-universal enrollment at no additional cost.

There are some bitter pills to swallow, though most are not deal-breakers.
For consumers -- The FEHBP is something of a high deductible, plan, and is still expensive, so consumers are exposed to the full cost of health care. The theory is that this will sensitize consumers to price, inducing them to reduce unnecessary spending and carefully choose the cheapest plan that works for their needs. This is one of the key elements in the cost containment strategy. Also, if your current employer doesn't offer you health insurance, and you earn more than 400% the federal poverty line, you will have to cover the full cost out of pocket with no increase in pay to offset. If you want to choose a plan which has more generous benefits, the excess cost (above the average plan's cost) will be paid for with post-tax dollars.
For taxpayers -- The health insurance market remains highly fragmented, though some functions are taken over by HHAs, and this plan will not reach the level of efficiency and cost savings associated with a single-payer system.
For insurers -- They will probably fight this more than any other group. They are forced to accept a much higher degree of governmental regulation, community rating of enrollees, and lower profit margins. We'll see Harry and Louise again.

Will it work?
It seems to have a good chance. There are some enviable efficiencies in the plan -- I personally like the idea of dovetailing the premium collection with filing for taxes, and nobody will mourn the death of Medicaid. The claim of universal (or near-universal) coverage seems pretty likely to be fulfilled. Forcing insurers to provide community-rated plans should guarantee the availability of affordable plans. There is portability of plans, and the entry-level plans are still decent coverage. The means-tested subsidies make good sense. The funding appears adequate. The big question is whether the promises of cost savings are exaggerated or unrealistic. I don't have the analytical chops to make a judgment on that one, though the Lewin actuaries make the case that the cost savings are real.

I do not know whether this bill has a chance of becoming law -- certainly the odds are stacked against it. But it is the first proposal for health care reform I am familiar with, which does not seem to contain any lethal flaws. It achieves much of the goals of a single payer system without threatening to impose a socialized healthcare system. It is not perfect, but, more importantly, it is attainable. It has attracted much positive attention from health policy wonks out there. It is more comprehensive, more generous, and less divisive than Arnold's California Health Reform proposal. You can learn more by visiting Wyden's advocacy site, Stand Tall for America. (What is it with this guy and the lame names?) I think it is worthy of qualified support, absent alternative plans. Write your senators today and urge them to support S 334; I already have.

21 January 2007

In Defense of Single Payer

I promised myself that I wouldn't do this, but GruntDoc threw the bait out there and I just can't help myself.

Before I launch into this, a couple of quick comments: First, I am not necessarily endorsing single payer as a national health plan. I do think it is probably one of, if not the, best systems possible for a nation-wide health funding system, but it does have drawbacks, as I will make clear, and is not itself a panacea. More importantly, it is a politically moribund proposal and I prefer to focus my thoughts on the possible rather than the ideal. Second, in more direct response to the irascible texan, a single-payer system such as the proposed "Medicare for All" National Health Insurance (NHI), is not at all equivalent to the UK's National Health System, which is a true socialized system in which the government owns/employs the hospitals and health care providers, nor is it comparable to any fully-governmentally-operated public institution such as the public schools. What it is, is essentially the same health care delivery system we have today, but publicly financed by expanding the federal Medicare program to cover all Americans.

In the United States, in 2005, health care cost $2.0 Trillion dollars, or about 16% of GDP. About 45% of health care dollars come directly from the government, and the balance comes from the private sector, mostly from employer-financed insurance plans. This is itself anomalous, as most other industrialized countries' governments contribute 70% or more to the cost of health care; the US is unique as the only OEDC country without some sort of nationalized health system. Hospitals, doctors and insurance companies are independent and often for-profit. The result is a highly commercialized, highly fragmented delivery system. The governmental payers (Medicare and Medicaid, mostly) are quite efficient; Medicare has been reported to have administrative costs as low as 3%, a number which has been disputed, but is in any case much lower than the 15-25% of private health care dollars which go to administrative costs. That is an enormous amount of money coming out of citizen's premiums, somewhere from $110-250 Billion, which goes towards non-productive purposes such as corporate profits, exorbitant CEO compensation, marketing, brokers and other middlemen, attempts to deny payments, etc. Recapturing even a small fraction of this administrative waste would provide enough savings to cover all 46 million uninsured Americans, at no increase in cost to consumers. Additional savings to the system would result from the streamlining of processes from the providers' side: no longer would doctors and hospital administrators have to waste valuable time negotiating reimbursement with the myriad health plans in their areas, complying with the arcane rules of dozens of different health plans, appealing denials of care, and billing and trying to collect from hundreds of different payers. The coding and billing requirements for an expanded Medicare are no more difficult to comply with than the current system, and greatly simplified in that it would be the only plan providers would have to interface with.

It is critical to understand that a single-payer expansion of Medicare would retain the status of doctors and hospitals as private, institutions with an intact profit incentive. While the medical market would be publicly funded, it would remain a private health care delivery system. All players would still be motivated to continue to seek efficiencies, reduce costs and increase profits, to innovate and find new ways to deliver care. This plan does not change at all how medical research would be conducted or funded, nor would the innovators in medical technology be impacted -- you get a new drug or medical device approved, then it will get paid for, just as it is today. Patients would still be free to choose their doctors and government would not intrude into the medical decision-making process, as it does not today.

National Health Insurance would improve America's competitiveness in the global market. It is paid for by a modest tax (or premium, if you prefer the term), and no longer represents an increasingly unsustainable burden on employers. GM annually is responsible for over $7 Billion in health care costs for its employees, compared to Toyota, which has been reported as paying, per car built, about 10% the amount that GM pays. It makes no sense for a car maker to run a health plan on the side; Medicare for all would allow America's businesses to cut their costs and focus their efforts on the core competencies of their businesses. It is true that if a national health insurance plan were enacted, some of the money currently contributed by employers to their private health plans would need to be redirected into payroll, to prevent the change from representing a huge pay cut for American workers. However, employers would likely be only too happy to make this change if it takes the risk and uncertainty of future cost increases off of their backs. NHI would also increase the flexibility of the work force, as individuals would be less reluctant to change jobs or start their own businesses, knowing that their health care was secure and no longer dependent on their employers. The Medicaid program, which is woefully underfunded, byzantine in its various forms, difficult to access, and a huge burden on states' budgets, would be eliminated and folded into the NHI.

The drawbacks of a change to a National Health Insurance plan are real, and significant. Most immediately, the hundreds of thousands of jobs extant in the private health insurance industry would be eliminated. Some of these could be assimilated into the administration of the National Health Insurance, but there would be significant upheaval and human cost associated with the transition. Additionally, billions of dollars in market capitalization in the for-profit insurance sector would evaporate, potentially causing disruption in the financial markets. These would, however, be short-term challenges, and more than compensated for in the longer run by the increased efficiency of the NHI. The displaced workers would, unlike displaced workers today, still have health care coverage!

From a physician's perspective, I am less than thrilled by the prospect of Medicare being my only payer. Medicare Part B is not well-funded and under continuous pressure in Congress for further cuts. If all my patients reimbursed at Medicare rates, it would represent a significant reduction in revenue which would not be adequately offset by the reduction in administrative costs. The likelihood of future cuts is very concerning and absent some reworking of the mechanism for physician compensation which appears to provide some guarantee that NHI would maintain provider compensation at its current levels, neither I nor the physicians' lobby would ever get fully behind a NHI.

There are a number of other crises in American health care which are not addressed by an expansion of Medicare. This should not be taken as a defect on the part of the NHI, but simply beyond the scope of the proposal. For example, the progressively escalating costs of health care: increasing amounts of services provided, expensive new technologies, inflated pharmaceutical prices, etc, do not have any mechanism for control in the proposed NHI. However, neither the current system nor any other proposed system include mechanisms to address this problem. Similarly, the alleged undersupply of physicians, the inarguable shortage of primary care physicians, and the relative overcompensation of specialists compared to primary care doctors remain as pressing problems under the proposed NHI.

There are a number of myths about a single-payer system which should be addressed:

Single Payer is equivalent to Socialized Medicine (which is bad).
Untrue. As noted above, the fact that all current players in the health care delivery system -- Doctors, hospitals, industry -- remain private and for-profit differentiates this proposal from other, true, socialized health care systems. It is also worth noting that just about every OEDC country with a socialized health system has lower infant mortality and longer life expectancies than the US. I won't delve into the argument whether socialized medicine is better or worse than our system; however, it is to some degree an open question at this time. However, this plan only creates a National Health Insurance, as opposed to a National Health System.

A National Health Insurance would result in rationing of health care.

Some would argue that in the US now we already have rationing of health care. If you have money, you get care; if not, you don't. Additionally, access to critical health services such as mental health and substance abuse treatment, long-term care, and preventative care are extremely restricted under the current privately-funded system. However, nothing about the NHI proposal requires or implies rationing as a mechanism for controlling costs. Given that the policy-makers in Washington DC would be answerable to angry voters, the viability of any sort of rationing as a political answer is limited, to say the least.

Canada has a similar system and has prolonged wait times for elective care.
True, however this exists for unrelated reasons. For one, physicians in Canada are paid far less than in the US; this has resulted in a large-scale emigration of Canadian-trained physicians to the US. Canada has about 25% fewer doctors per capita than the US, and historically has invested far less in medical technologies, such as CT scanners and MRIs, and Canadians admitted to the hospital stay significantly longer, resulting in limitations on inpatient capacity. Moreover, in the US today, if you do not have insurance, the wait time for elective care is forever. Given the existing medical infrastructure in the US, and absence of any disincentive for further investment, it appears that the ability to deliver care to all comers would be preserved at least as well as it currently exists.

Single Payer would create a huge, complex, government bureaucracy.
As opposed to the simple and user-friendly relationship Americans currently enjoy with their insurance companies? A NHI plan would expand the existing Medicare administration, which is incredibly lean compared to its private-sector rivals, and simpler, since questions of eligibility and enrollment are eliminated under NHI. The massive private bureaucracies that currently exist would cease to be, and administration would become simpler for health care providers and employers.

The Free Market can solve the problems of the health system better than the government.
If a free market existed, that might be correct. However, the current system creates such huge asymmetries in information that no free market can be said to exist. Consumers are unable to compare prices between different health care providers, and are reluctant to price-shop for medical services in any case. Consumers and employers have limited ability to compare and choose health care plans, especially small businesses and private individuals. Insurers use their size and superior financial resources to coerce hospitals and doctors to accept lower reimbursement. Insurers go to great lengths to identify and discriminate against consumers who may be sicker and less profitable. Pharmaceutical companies abuse patent protections and market forces to inflate the cost of prescription drugs. In a market with so many skewing factors and perverse incentives, free market forces are severely constrained at best.

I'm running out of steam, and have, I suspect, lost the interest of most of my readers. Health policy is so exciting! It's exhausting to think about, let alone try to organize your thoughts and back up your arguments with facts. I hope I have provided plenty of fodder for discussion/argument, so feel free to open fire in the comments. Tomorrow, I will compare this single-payer plan to my preferred solution. And by tomorrow, I mean "the next time I have the energy to undertake such a herculean effort."

Winning Ugly

Grossman had a passer rating of 73, but threw no interceptions and made the big plays when it counted. I think the MVP for the Bears might just be Reggie Bush, who taunted linebacker Brian Urlacher before back-flipping into the end zone on an 88-yard reception.

The Saints never scored again.

20 January 2007

Needs no explanation

I came back from vacation today and flipped open the comics page and was greeted with this opening panel from Get Fuzzy:

I do not know and do not care what, if any, rational explanation exists to explain this panel. And I don't want to know it if there is one. It is, in my humble opinion, the strangest and funniest image to ever grace the comics pages.

Freedom is Slavery

Sometimes these guys just defy parody. When Bush signed the Military Commission Act, there was much furor over the fact that it appears to limit habeas corpus appeals for those accused under this Act. But yesterday's testimony from Alberto Gonzalez takes it a step further with the double-think regarding habeas:

Gonzales: "There is no express grant of habeas in the Constitution."

He is of course referring to Article I, Section 9, Clause 2 of the US Constitution: “The Privilege of the Writ of Habeas Corpus shall not be suspended, unless when in Cases of Rebellion or Invasion the public Safety may require it.”

This exchange with Senator Arlen Specter is priceless:

GONZALES: [...] Again, there is no express grant of habeas in the Constitution. There is a prohibition against taking it away. But it’s never been the case, and I’m not a Supreme —

SPECTER: Now, wait a minute. Wait a minute. The constitution says you can’t take it away, except in the case of rebellion or invasion. Doesn’t that mean you have the right of habeas corpus, unless there is an invasion or rebellion?

GONZALES: I meant by that comment, the Constitution doesn’t say, “Every individual in the United States or every citizen is hereby granted or assured the right to habeas.” It doesn’t say that. It simply says the right of habeas corpus shall not be suspended except by —

SPECTER: You may be treading on your interdiction and violating common sense, Mr. Attorney General.

And to think that Gonzalez was short-listed for the Supreme Court, and rejected as "too moderate!" (shudder)

19 January 2007

Home (sigh)

You may not be able to tell, but the above picture is of fresh powder hissing over the tips of my skis. I nearly killed myself getting this picture. Do you have any idea how hard it is to take a picture of your own skis while powder skiing? And it doesn't really even look like anything interesting. Not that I am bitter. Oh, conditions were great:
Yes, perhaps a little gray, but you can see how much snow there was (that is The Darling Wife in the distant center of this photo, by the way.)

We also learned an important lesson at the US border. You do NOT admit that you have any fruits or vegetables unless you wish to have your car searched (really) and your contraband confiscated -- in our case, some illicit Chilean grapes and the leftover, frozen hamburger helper. Never mind that both the grapes and the beef had been purchased in the US initially. They were going to confiscate our apples as well, but they had "Product of WA, USA" stickers on them which was enough to convince the Customs agent that they were permissible. Actually, I have to compliment the nice folks at the Lynden Customs office; they were pleasant and quick, nice to my kids, and seemed to appreciate the absurdity of the situation. They also didn't cite me for violating the law on importing Canadian Mad Cow Beef, which was nice of them.

Next time the groceries will be well hidden and I will deny their very existence.

16 January 2007

Thoughts from Big White

The Big White ski resort is located in British Columbia, near Lake Okanogan, about 20 miles from Kelowna.

Canada, some of the readers of this blog may be aware, is located directly to the north of the United States.

In this part of the world, the further north you are, the lower the ambient temperatures tend to be.

Today's skiing was as cold as I can recall ever being (and I grew up in Chicago and rural Illinois). The temperature was in the single digits and the modest wind made it feel substantially colder. Add in the relative wind from the motion of skiing or riding the lift and, despite several layers, glove liners and hand warmers, I was perilously close to frostbite.

Do not think I complain, gentle readers, for I do not. Because this wintry chill was accompanied by a gentle yet persistent fall of feathery-light powdery snow, with several inches accumulating over the course of the afternoon, and more falling outside my window as I type this. I have said it before, and I will say it again -- Happiness is the sound of fresh powder hissing over the front of your skis.

15 January 2007

Gone Fishin' Skiin'

No, that's not me in the photo. I'm off to Big White, in British Columbia. See you in a week!

14 January 2007

Divided Loyalties

I am a huge Bears fan. I have been a Bears fan since growing up in Chicago in the early eighties (a good time to be a Bears fan). I was fortunate enough to marry a woman who shares my passion for the Bears. Since moving to the Pacific Northwest, we have also become boosters of the hometown team, the Seahawks.

So watching the Bears and Hawks play today is a painful experience. Not that I have any doubt over who I am rooting for -- the Bears all the way. But it is torture. I want to be glad when the Seahawks do well, when Alexander rips off a great second effort for a first down, when they score to take the lead in the third quarter. And I feel bad when things go poorly for them. But I want the Bears to win so badly.

And of course, I share the premonition of doom that all longtime Chicago fans suffer from.


13 January 2007

Universal Health

Wowie. Since the Democrats came back into the majority, it seems like the intertubes are suddenly choked with competing plans for universal healthcare coverage.

Senator Wyden of Oregon led out of the gate with an ambitious plan to dissolve the nation's employer-based health financing system in favor of individual mandates and community-rated plans. I like this idea, though it has enough unanswered questions to raise doubts whether it would work if enacted. It has sweeteners to bring employers, doctors, and insurers on board, and more importantly, it has the vision thing -- a big, bold plan which is simpler and much more palatable than HillaryCare. I suspect it will go nowhere.

In California, the Governator has followed in the footsteps of Mitt Romney by proposing a plan which would essentially force employers to pay for health insurance, either directly, or indirectly into a state-run health plan. It also inlcudes subsidies for the poor and community rating of plans to prevent insurers from trying to select out the sickest patients. However, the benefits are rather stingy, and for some reason they chose to ensure the health-care industry's opposition by taxing the income of doctors and hospitals to fund the state plan. There are rumors of price controls in the plan which sound ominous, but I have no direct evidence of. In the end, as Ezra points out, it is a great proposal from a Republican, moves the discussion left, and is unusual in that it is likely to be enacted in some form.

Representative Pete Stark and the folks at the Economic Policy Institute have a fascinating proposal of a hybrid national public-private system. It's simple and elegant. To crib from Ezra: "The government will create a new, Medicare-style health plan that's open for enrollment to any and all individuals interested . . . all employers will be required to offer insurance as good or better than the new government plan. If they don't want to contract out with the private sector, they'll pay 6% of payroll to enter their workers into the government plan. The unemployed and self-employed will have to buy coverage, and there'll be heavy subsidies tied to income." I suspect the insurance industry would fight this tooth and nail, but there's a lot here to like. This plan would essentially compete the private insurance industry out of business, I think. The net effect would be a gradual transition to a single-payer system, or one in which the private insurance industry is either much smaller or much less inefficient. As a doctor, I am not sure I like it, because Medicare is a terrible payer and there is a clear implication of cost controls, but from a national health policy perspective, it is pretty appealing.

And then there is the old favorite, "Medicare for all." A true single-payer system. It would be the cheapest and most efficient way to fund healthcare, would preserve the dynamism and vitality of the American health care industrial complex, and would ensure that every American had equal access to health care, without rationing. However, it would require taxes, and would essentially dissolve the insurance industry at a stroke, and would certianly draw fierce opposition from the physician's lobby, as Medicare is such a lousy payer. It would be easily tarred by opponents as big and scary and wasteful and requiring Canadian-style waiting lists, and too expensive. So it's dead, alas, because single-payer is definitely the best way to go, if only in theory.

I feel like I'm in a strange time warp to 1993. Heady times. I hope someone can muster the political courage to get soemthing on the table passed, if only as an experiment

12 January 2007

My First Migraine

Oh how the mighty can be brought low . . .

I worked several nights in a row until yesterday, my first day off. So I pretty much just stayed up Thursday with only a short nap, to get back on a daytime schedule. As usual, I went to Karate on Thursday night, and got myself nice and dehydrated. Foolishly, I decided the best product with which to rehydrate was an otherwise excellent IPA from the Hood Canal Brewery.

I woke up at 4AM with a mild-to-moderate headache, and could not get back to sleep. Over the ensuing four hours, the pain gradually increased until I had a full-blown migraine. (note to medical types -- no, not a true vascular headache, since it wasn't unilateral and throbbing, but with all the accoutrements of the migraine, including photophobia, phonophobia, vomiting, etc.) The pain was exquisite, rippling across my skull in little flurries and surges, like a cold fire. By a large margin, it was the worst pain I have ever felt. I have been generally healthy, with only occasional back pains and minor surgical procedures, so I admit that I am rather naive when it comes to serious pain. I would rate it as an "8 or 9" on the infamous pain scale. I am tempted to call it a "10" except that I can imagine the pain being worse. And being a rather central pain, there was no escaping it. When I hurt my back, if I lie still, it eases. The pain in my head was one of those that you can't ease and wind up sort of writing around continuously trying to get away from it.

My Darling Wife, being one of the perhaps three faithful readers of this blog, was entirely convinced this was an extension of "My Bad Week" and that I was experiencing an extremely ironic head bleed. That thought had crossed my mind also. She adamantly wanted me to go to the ER. I couldn't bear that prospect -- I felt the car ride alone was likely to be lethal, but also the horrible idea of being seen by my partners and colleagues in that wretched state was deeply offensive to whatever shreds of dignity were left to me at that time. Also, I knew to a certainty that this was not meningitis or a hemorrhage, and didn't want to argue with one of my partners about a spinal tap. In my pain addled-state, I had difficulty explaining this to The Darling Wife, who harumphed in annoyance and left to take the kids to school, leaving me with a grumpy threat that I would be in trouble if she came home and found me dead.

In the end, ibuprofen and Gatorade turned the tide and I started to improve. I'm twelve hours out and have only a dull ache which hurts but is no longer incapacitating. Fortunately, today was my day off. Unfortunately, I had hoped to get some stuff done, but oh well. Lord, I hope this was an isolated phenomenon. I will firmly resolve that I will no longer drink beer after Karate (and I only had one, by the way, so I would not call this a hangover). For now, I will rejoice that it was brief and self-limited and accept this and my recent back troubles as fate's attempt to give me some sympathy if not empathy for the migraneurs and back pain folks that pass under my hands.

11 January 2007

Olberman Erupts

What he said.

Whole Lotta Death

Been a downer week here in the ED. Seen a lot of sick people with devastating neurologic injuries, several of whom have died, and none of the survivors will have any sort of a happy outcome.

This was a young-ish lady with thin blood due to liver problems. She was watching TV on the couch with her husband and cried out suddenly and went limp, as her extremely caring husband cradled her. She came in intubated with a GCS of three (deeply comatose). The white stuff on the left side of the brain is a whole lotta blood. This is a non-survivable event. After family congregated and had a change to talk it over, they decided to withdraw care and she died within six hours of admission. He husband was greatly consoled by the fact that he had been with her in her last waking moments.

This elderly man went onto the roof to clear off some tree branches from a windstorm. We think he fell trying to get back on the ladder. He has blood on the right in the subarachnoid space, and a small hematoma on the left in the subdural space; a classic coup-coutrecoup pattern of injury. This is a rather small bleed, actually, but there is diffuse injury to the entire brain, and though it has now been several days, he has not regained consciousness and probably never will.

This is a gentleman who had been transferred into our county jail from a distant facility. Less than 24 hours after arrival he was found unresponsive. Again, the white stuff is blood from an intracerebral hemorrhage, likely due to elevated blood pressure (possibly cocaine-related). In this case, the blood poured into the ventricles in the central portion of the brain, which caused sudden increase in the intracranial pressure as the normal drainage of the brain was blocked. A catheter was inserted to relieve the obstruction. He too, is deeply comatose and unlikely to survive. Sadly, nobody knows whether he has any family or friends who should be notified. As of this writing he is alive in the ICU.

This is another older man who fell down several stairs, leading with his head. This is a lateral view of the upper cervical spine, and you can see that the top portion of the second vertebra -- the odontoid -- has been knocked off and pushed backwards. What you can't see is the spinal cord which is getting compressed by the fracture fragment. (The spinal cord doesn't always show up on CT scans.) He did have family at the bedside, and he too passed away shortly after arrival.

The kicker is that it was the same neurosurgeon on call for each and every one of these cases. They all came in after midnight (except the fall off the roof). After a while the poor neurosurgeon cringed at the mere sound of my voice, just knowing that I had something awful for him. But all the badness certainly casts a pall over the department and sucks the carpe right out of your diem. Sheesh. I hope this isn't an omen for how the rest of the year is going to go.

10 January 2007


At our ER, we have a pretty huge geriatric population. We are the only hospital in the county of any reasonable size, so we get most of the nursing home traffic, and I guess that there are a lot of old people out there living in our catchment area. It's a mixed blessing -- lots of interesting pathology, but often challenging and not always in a good way. One happy consequence, however, is that I see a lot of World War II vets.

I am not unusual among males of my age group in that I am a huge WWII buff. I have avidly consumed histories of the "Last Good War," watched "Band of Brothers" and made countless models of Spitfires and Mustangs. But I have never had the pleasure of personally knowing anyone who actually served in the war.

So, when I note that I am interviewing someone who is of an age that they might have seen service, I make it a point to inquire whether they served. It's a little off topic, so I slip the question into the social history. Usually, the patient will let me know whether it is a topic they feel comfortable discussing. With surprising frequency, they seem almost eager to talk about it. I've been lucky enough to hear some pretty cool stories. This is one of the few things I'm willing to sit down and "waste time" on when the ED is going to hell around me. Frankly, the vets seem pretty gratified that I thought of it and cared enough to ask and listen.

There was one guy the other day whose knee was swollen and bothering him. He told me how he was on a destroyer in the Leyte Gulf, and he was up on the observation mast and saw a Japanese sub surface and fire a torpedo at them. He sounded the alert, and his skipper executed a hard turn away from the torpedo, causing it to miss. But the evasive maneuver caused them to run hard onto a reef, and the shock threw my patient off the mast, and he wrenched his knee badly landing on the deck. The destroyer was undamaged, the submarine got away, and my patient was evacuated for medical care. His ship went down in a hurricane while he was in the hospital and his knee bothered him off and on for the rest of his life.

Amazing stuff.

There was another guy recently who answered in the affirmative when I asked whether he had served in WWII. I asked which branch of the service he had been in and there was a pause before he replied almost apologetically, "Well, you see, I was in the Wehrmacht."

I didn't ask him any more questions.

06 January 2007


Clinical Pre-op diagnosis : Acute right lower quadrant pain.
Post-op diagnosis : None given.
Specimen : Appendix.
Macroscopic The specimen is submitted in a formalin-filled container having a label with the patient's printed identification data, including her name "xxxxx, xxxxx". The label also has the penned inscription "appendix" and the container holds a 9 cm-long vermiform appendix with a very small amount of attached adipose tissue. The appendix ranges from 0.8 cm to 1.1 cm in diameter and generally has an erythematous serosa. The proximal end of the appendix is closed by surgical staples. The serosa of the middle to the appendix contains a sizeable plaque of yellow-tan, fibrinous exudate. The appendiceal lumen ranges from 0.1 cm to 0.4 cm in diameter and is filled with a mixture of red, viscous exudate and fecal material. Beneath the zone of serosal exudate, the appendiceal mucosa, submucosa, and wall exhibits much red discoloration. However, no perforation is evident. The remainder of the appendix exhibits focal red discoloration. One longitudinal section of the appendiceal tip and two representative cross-sections are submitted for histologic processing in one cassette.

Remember what I said about 90% of the diagnostics in EM being reflex? This one wasn't. It was a 13 year old girl with nausea and vomiting, high fevers, and a bit of diarrhea. She had some vague cramping pain which was epigastric. We've seen tons and tons of gastroenteritis recently and this seemed like more of the same. She looked a bit dry, so I started an IV for hydration and got some labs. Her WBC was elevated at 18,000, which is quite high. Initially, I wrote this off as being due to dehydration, which can make the WBC count go up. It's actually a little too high for appendicitis, classically. She seemed pretty uncomfortable, though, so I decided to play it safe and image her abdomen. I got an ultrasound since she was skinny as a rail (better to avoid the radiation of a CT scan, as well), and to my surprise it showed a "tubular noncompressible structure in the RLQ suggestive of possible appendicitis."

The language the radiologist used was not really definitive, so I went back and re-examined the patient (no, really!), and she did now have some discrete tenderness in the right lower quadrant which she had not had before, though there was no guarding or rebound tenderness. So with an evolving exam and suggestive ultrasound, it was time to call a surgical consult. To be frank, I did have some misgivings about the diagnosis, as it was not exactly a classic presentation, and I rather doubted she would go to the OR. The conversation went like this:

Me: Hi, Dr Grim, I've got a young girl with a fever, evolving RLQ pain, elevated WBC, and an ultrasound suggesting appendicitis.
Dr Grim: (cheerful, but distracted) Sounds like she needs an operation. Send her up.
Me: OK, but I should let you know her presentation is more like a little GE, and . . .
Dr Grim: (still cheerful) Yeah, that's great. Go ahead and send her.
Me: Sure, but the ultrasound was not quite. . .
Dr Grim: (a little less cheerful) Sure, sure. That's fine. Send her up.
Me: Okaaaay.

So up she went, and I felt a little guilty that she didn't really have an iron-clad diagnosis, and a little worried that the surgeon hadn't wanted to hear about all the data. Was he going to be pissed when he met her and her exam wasn't great? Would he send her home? Or would he take her to the OR without even examining her? I was going to feel pretty bad if she had a negative laparotomy. Oh well, I did try, and Dr Grim is the one who is going to bear responsibility. . . right?

So I was pretty pleased to get the above-noted path report in my box today. Score one for the home team.

04 January 2007

Kicking ass and taking names

I did something to my back at Karate the other day. Nothing serious, but a painful lumbar muscle strain. I took enough ibuprofen to kill the proverbial horse, but it was still really hurting when I went in to the swing shift, 7pm-3am, and it was with the grumpy thought that "nobody gets narcotics tonight unless they're in more pain than the doctor," that I began my shift.

The department was absolutely out of control on my arrival. The PAs were doing well keeping the "Greens" taken care of, but there were probably 20 "Yellow" and "Orange" patients
in beds and in the hallways waiting to be seen, some of whom had been waiting four hours or more.* And that's not even to mention the waiting room. Ugly.

So I put my head down and got to work. What else can you do? The nice thing was that according to the day's assignment, I had my own eight-bed area, which for once was fully staffed with nurses and a tech, and I had some of the best nurses on my team. And it was amazing. Things just happened like they are supposed to -- meds were given, beds were emptied, every patient I touched just got dispositioned as soon as I walked out of the room. Truly, I was in The Zone. And some of the folks were sick. One dude with a hemoglobin of 2.5 (which is about 15% of the normal red blood cell count), another with a severe pneumonia, a couple of septic octogenerians, a ruptured ectopic (diagnosed, I might add, on bedside ultrasound), etc. My partners in their areas were doing the Lord's work, as well. Six hours into the shift, I finally looked up. All patients had been seen, and the waiting room was empty. At that point, I had seen twenty-four patients, of which eight were admitted.

Now, I don't mean to brag. Well, yes, I do mean to brag a bit, but I should supply a little perspective. At our facility, the acuity is high, operations are not too efficient, and if you can see two patients an hour, you are doing well. I had seen four patients an hour. It was, as far I can recall, my all-time personal best. And even better, all my patients were done, the documentation was done, and I walked out the door an hour early. Unheard of -- all the stars aligned for me. I had also been able to do this without short-changing the patients in terms of face time. I got to sit down and talk to each at the beginning, and check in once or twice each. I can't credit the nurses enough. I ran them hard, to be sure, but they rose to the challenge. I wish I could work with that group every night.

And as I got into the car to drive home, it occurred to me that I had not thought about my back in hours.

You know, one of the interesting thing about my job is that it is always challenging. The medicine is challenging -- sometimes. But honestly, after a while, you can tell the diagnosis even before you walk into the room. You just know, somehow. The mental gymnastics in figuring out the diagnosis on 90% of the patients becomes reflex. But the real challenge -- to be efficient, to Move the Meat, to manage the limited resources in your department in the most effective manner -- that is always different and never gets old and, strangely, sometimes offers more satisfaction than does the actual patient care.

I can't wait to see what tomorrow is like.

*We use a "Five Tier Triage System"
Red -- About to die
Orange -- Very serious complaint/problem; should not wait
Yellow -- Potentially serious problem; wait should be short
Green -- Stable, minor problem; not urgent
Blue -- Not urgent at all (med refill, etc)