27 February 2007

I'm a Lazy Man

So help me out, folks. I really ought to update my blogroll, but I bounce around too much in the blogosphere and follow interesting links without bothering to bookmark many worthy sites. So I know there are a ton of great sites I have perused from time to time and I would like you to help me get back to them.

So here's what I am asking: in the comments, give me the links for any Emergency Medicine-themed blog that you know of. I'm particularly interested in the ER Docs' blogs, because, you know, that's what I am. And I'm a self-absorbed jerk. No seriously, any EM-themed blog is what I am looking for, and when I get around to it (sometime around the time the ocean levels rise and swallow New York) I will get them all organized and in the blogroll.

Here's my starting list:

The A-Team
GruntDoc (aka the irascible Texan)
The inimitable Kim at Emergiblog

Blogs I have more recently come across
Gardner's Gate (ACEP Board Member)
Healthline's Straight Talk from the ER
March of the Platypi
Panda Bear, MD
Hallway Four
The KnifeMan

People who I wish posted more
Doc Around the Clock

Glorfindel of Gondolin (Great name)
The Budding Emergencist
DocShazam! (a name which really demands to be followed by an exclamation mark)
Is there a Doctor in the House?

OK, that's it for the docs (and Kim). Let's hear about the great Emergency-themed blogs you all read.


It's Funny 'Cuz It's True

Kind of funny, kind of not.

Credit: Tom Tomorrow

25 February 2007

St Baldrick's Day

My close personal friend Matt Dick (yes, that's his real name, and no jokes, please, he's heard them all, and they're really not all that funny) will be shaving his head on St Patrick's day as a fund-raiser for children's cancer research.

For Matt, as well as myself and all of our friends and family, this is a personally charged campaign. Our close friends have a very brave little boy, Nathan, age six, who has been fighting a deadly type of cancer, neuroblastoma, for almost four years.
The sad news is that Nathan has relapsed and is facing a tough fight. The good news is that he is feeling well and going to school and really enjoying life right now. Nathan has undergone a number of experimental treatments for his cancer, some of which may have helped slow the progression of his disease. Programs like St Baldrick's provide vital financial support to these experimental trials. So get yourself on over to Matt's page and cough up a couple of bucks to support kids' cancer research. Even small amounts like $10 or $20 are greatly appreciated. Also, you can see Matt's photo on his page. He's a funny-looking guy. Help make him even funnier-looking by paying to get him bald.

Also, pay a visit to Nathan's page and send him and his family some love.

23 February 2007

Back at the helm

Wowie. I leave you people without adult supervision for a couple of days and see what happens in the comments? (I was away, and unexpectedly without internet access -- oh the pain!)

Well, I'm back, and first of all I do want to thank all of those who shared their personal experiences, and also faithful commenter/blogger Scalpel, for his determined responses. Despite our contrasting viewpoints, I suspect we have more shared points of agreement than differences. That may be a by-product of working in the same trenches, and the same frustrations with the particular patient population that tends to show up in the ED. Specifically, I think we agree that the lack of personal responsibility demonstrated by (some of) the patients we see is maddening, and that a carte blanche system such as Medicaid encourages irresponsible utilization. Any policy solution which addresses the uninsured crisis should do so in a manner which ensures that patients do have a direct personal financial incentive to ensure that their health care dollars are spent in a rational manner.

Scalpel makes a couple of other points which I would like to address:

"Plenty of people with insurance don't take care of themselves either."
I have heard this many times from many sources, not just Scalpel. It's not totally off-topic, dovetailing with the "personal responsibility" theme, but it's also, well, irrelevant. There's a kind of implication that good health is a result of moral rectitude, and illness is somehow a deserved consequence of the patient's choices. It's a tempting conclusion to draw, given the self-destructive crap both Scalpel and I see every single day. But the counterpoint, a universally observed phenomenon among ER docs, is that the more upstanding a person is, the more likely they are to have some bizarre and lethal diagnosis (I recall the time the Chief of Police came in for a sore throat and I diagnosed him with metastatic laryngeal Ca -- a nonsmoker, of course). The other bizarre corollary is that the "scumbags" are just impossible to kill, it seems. They get drunk and fall off bridges and walk away.

But I digress, which should surprise nobody. The point, I think, is that how well one takes care of oneself should have no bearing on whether an individual is allowed to access the health care system.

"Health care is not a right."
This has been gnawed over to a great degree at Gruntdoc and KevinMD with no shortage of passion, and I will not even try to delve the complicated depths of this argument in an off-the-cuff post like this one. I repeat that there is a place for personal responsibility, and my preference as a physician and entrepreneur is to retain elements of the system which allow me to set/negotiate prices and retain a profit incentive. However, I am not willing to embrace any system which simply excludes 20% of the population with a shrug of the shoulders. I like the train of thought proposed by JimII -- the right to life is a fundamental right; therefore health care necessary to sustain life should be considered a fundamental need inseparable from the right to live. Whether you call it a right or an entitlement or just "universal" is a matter of semantics which means nothing to me. Consider it a moral imperative if you will -- design a system which will cover everybody. That is all I care about.

Scalpel does offer one common false choice: "if we try to provide healthcare for all, they may have to settle for "good" healthcare. Not super-excellent top -of-the-line healthcare." This is right up there with the whole "rationing" argument. Yes, it is possible that systems might be implemented which would ration or diminish the quality of care (see: Canada, UK/NHS). However, these are not obligatory consequences of universal coverage. Much of the ailments which plague the NHS and Canada's Medicare derive from underfunding. Since we're already paying top-dollar for our system, a system which simply preserves expenditures at current relative levels (with appropriate flexibility) should prevent the woes of rationing. As long as we are willing to pay for it -- through payroll, or taxes, or premiums -- there is no reason we cannot continue to enjoy the current quality of care that exists.

By the way, I am even open to a two-tiered system, in which the wealthy can purchase better or preferential access to care, if it is the cost of entry into universal coverage.

"Uninsured care can be handled at the state level with federal assistance. Further federalization of the healthcare system is not the only answer."
Certainly not the only answer. But if you buy the notion that there is some sort of compelling moral obligation to provide care to all Americans, it bothers me that in some places (like Scalpel's home, it would seem) there are no obstacles to care for the poor and there is comprehensive care for all, yet in other localities, like mine, the uninsured are SOL and on their own. The availability of such a fundamental need should not vary by location. I've no problem with using states as laboratories to come up with innovative solutions for intractable problems. But this doesn't require a whole lot of clever thinking -- we know the problem and the solution. I don't care who administers it, but there should be a national standard and national funding. Realistically, this means a federal program. Also, from my politically liberal point of view, I am suspicious of local control, since local programs are more easily subverted and nullified. Reminds me of when Newt tried to break up welfare into "block grants" for the states to disburse as they saw fit. But that is another topic.

Boy, that's a lot for now. More to come as I have time to think & digest. Thanks again to all who have read and contributed.

19 February 2007

The cost of losing your insurance

Promoted from the comments:

Surgeon in my Dreams wrote:

Shadow - many of us appreciate your looking at this side of this extremely "hot" issue.

I won't go into details, anyone who "knows" me knows already, but my husband will soon be uninsured.

We do not qualify for assistance with his medications because of our HUGE combined income. We attempted to purchase private insurance and they REFUSED - several companies not just one or two.

So, do we buy these medications, or do we pay to keep a roof over our heads? They come to about $1300 a month. Does not include doctor visits or lab tests or anything other than prescription medications.

We live very simply - not beyond our means at all. Drive two old, paid for cars, and have a simple small house with a payment that is no more than the average rent in our county.

The uninsured aspect is not his fault -nor can his illness' be chalked up to having "brought it all on himself" - nor am I sure it would matter if he had.

He worked his way through college from 18 until he was 23 or so while paying off his mom's home because his dad died young. Worked all his life and did everything right by the book (according to the commentors here)but still wound up in this predicament.

Some folks have no compassion - no empathy - and for whatever reason are just plain bitter. Whether it be because they have never had to struggle with adversity, or just simply because they have a 'big head' and think it could never happen to them, there is no reasoning with folk like that.

And in case anyone wonders - I am about as non-liberal as they come down here in my little southern world. I'm not even sure I am proud to say I have been a republican most of my life, because it seems to me now, that the very party I have supported is the very one willing to let us fall between those cracks some of you refuse to admit exist.
Is this a straw man?

17 February 2007

Challenge Accepted

Walter E. Williams, of the Laurel Leader-Call issues the following challenge:

"I challenge anyone to show me people dying on the streets because they don’t have health insurance."

(via Kevin, MD)

I accept your challenge, Mr Williams, and will run a series of real stories, anonymized of course, which will illustrate the real, undeniable, human tragedies which are the result of the crisis in access to health insurance and health care.

I will start with a recent case, because it was memorable and so aptly illustrates Mr Williams' utter disconnect from the reality of America's "Greatest Health Care in the World" [tm].

Mr Jones was an African-American in his mid-fifties. He worked as a framer, was married, and had three children in their early teens. African-Americans are statistically more likely to be without health insurance, and he was indeed uninsured. He made too much as a framer to qualify for Medicaid, and his employers did not offer insurance. In our state, individual policies are very expensive; almost prohibitively so, and Mr Jones had a history of high blood pressure, which would probably have drastically increased the cost or excluded him altogether. I do not know whether he "chose" to go without insurance or whether he tried and failed to obtain it, but it doesn't really matter. He had tried to be seen at the local charity clinic for blood pressure medications, but had given up because the clinic was overbooked and he could never get an appointment that didn't conflict with his work schedule.

I never found out what sort of person he was -- whether he was a pleasant, good hard-working family man, or whether he was a grumpy old cuss, whether he tried to take care of himself or whether he ignored his health and smoked and drank and ate fatty foods. I do know that his family thought the world of him and he was apparently dedicated to them, and that he collapsed in front of them on a Saturday morning.

When he was brought to me his blood pressure was 240/125, and he was deeply comatose. The paramedics had put in a breathing tube and he was not responding even to painful stimuli. I gave him medicine to bring down his blood pressure and obtained a CT scan of his brain. It looked something like this:This is not his scan -- I didn't happen to save the image, but it's pretty close. There is a large amount of blood in the brain tissue and the ventricles. This is typical of a hemorrhage caused by longstanding high blood pressure which weakens the arteries in the brain until one of them bursts.

I admitted him to the ICU under the care of a neurosurgeon, but there was really nothing anyone could do, and he died the next morning.

In one respect, the estimable Mr Williams is right -- this patient didn't die in the street. He died in the hospital. Maybe he would have died anyway, even had he been on medication. Maybe he had self-destructive tendencies and habits which contributed to his demise. We'll never know. But he had access to the health care system only for the last sixteen hours of his life. Had he been under the care of a doctor and prescribed even very inexpensive medicines, he might well be alive today.

And this is our national shame.

16 February 2007

An Ambitious Request

I saw a pleasant young lady this afternoon. She was requesting a refill on her pain medications. She reported that she was in a bad car accident about 5 months ago in Another City of a Far Away State. She spent four months in a rehab "nursing home," and upon release had come to Our Fair State to visit family. She, unfortunately, reported that all her pain medications and other possessions had been stolen. She asked for enough pain medicine to get her through the next two to three weeks until she got back to the Far Away State.

Her regimen was 20 mg Dilaudid four times daily. (note to non-medicos: that is an insanely high dose; a typical dose is 2-4 mg) That works out to about 1.7 GRAMS of Dilaudid.

I doubt I have ever written for that much Dilaudid in my career, let alone at one time.

I examined the patient and she did indeed have scars on both legs consistent with multiple surgical procedures and external fixators, and they looked like they were a few months old. So she wasn't lying. But that amount of pain meds, to be polite, stretches credulity. So I said that I would like to call her doctor back home and verify the meds and dose.

"I don't know the name of the doctor," she said.

Was it a surgeon or a rehab doc or primary care doc or a pain specialist?

"I don't know."

What hospital were you treated at?

"I don't know."

Which rehab facility were you at?

"I don't know."

Can I call your family -- husband, parents and find out from them where you were cared for so I can get supporting documents regarding this prescription?

"I don't know where they are."

Do they have cell phones?

"I don't know."

Um, you're not helping me out here.

Tough situation. My instinct is to believe her, and the evidence is on her side. And people hospitalized for months do get disoriented. But the sheer incredible amount of drugs was such that I just could not bring myself to write the prescription. Ultimately we negotiated that I would give her three day's worth and she would do the research to find out where she was treated and by whom, and then we could work better with her to control the pain. Just amazing.

Quote of the Day

"I hate freedom. And America."
-Congressman Don Young (R-AK), 2/16/07

(via Atrios)

I apologize. It's unfair to post this without explaining. What Don Young actually said was:

"Congressmen who willfully take action during wartime that damage morale and undermine the military are saboteurs, and should be arrested, exiled or hanged."

He attributed this "quote" to Abraham Lincoln. However, it was falsely attributed to Lincoln by a conservative pundit, Michael Waller in 2003. (He claims it was a typo and never issued a correction.) It has previously been publicly debunked. Yet Rep Young chose to use the false quote to demonize his political opponents, and whether the quote was used knowingly or through carelessness, he has thus far refused to retract the statement.

He has not at this point specified which of his congressional colleagues should be hung first.

Atrios' point was that apparently it's OK to make up quotes. At least OK if you are a Republican.

Seriously, can you imagine if a Democrat had said this? O'Reilly would be all over it like flies on shit. Some obscure bloggers for Edwards once said less than nice things about the catholic church and Bill Donohue and conservative pundits screamed outrage (and the media politely ignored Donohue's anti-semitism). Kerry screwed up a joke about Bush and was tarred as 'bashing the troops.' Yet Lou Dobbs can flog the lies about Pelosi's airplane for a week without anyone calling bullshit on him, FOX can claim Obama went to a Madrassa, and Young can call for the EXECUTION of opposition Representatives and it doesn't even get picked up by the AP. I just get frustrated by the double standard, and again I apologize for being unclear.

Your so-called "liberal media" at work.

13 February 2007

Update -- In which I am taken to school


Symtym, who is apparently a real, genuine law-talking-guy, explains in pretty clear and convincing language why I don't know my ass from a hole in the ground why my previous proposition is legally invalid. Money quote:

There is no taking under the 5th Amendment, nor is there an issue of due process under the 14th Amendment. Because participation in the Medicare program is optional (albeit, it is the rare physician or hospital that can survive without participation). [...edit...] EMTALA is a pre-condition for participation and payment by Medicare.
I think this is the fatal blow against my argument. It makes sense not only on the merits of the argument but also from a common sense perspective. If there were a valid constitutional claim against EMTALA, the first doc fined under it in 1986 (or whenever) would have made it, and since the law is still around, well, assume the conclusion. I don't agree with all of Symtym's assertions, but the point is moot so I won't belabor it.

OK, I will just a little. To be clear: I claimed that EMTALA might be an impermissible taking not just because it was a "taking" but because it is without just compensation. Were EMTALA funded (even to the pitiful Medicare level) it would be a lot more acceptable to the rank and file ER Docs.

Symtym derides this train of thought as "self-serving" but I will point out that my particular proposition was based on the premise that:
a) EMTALA is bad policy, and
b) overturning EMTALA might be a spur for action towards comprehensive health care reform.

Is it self-serving for my interests as a physician? Yes, but I do not think it is unreasonable to desire to be compensated for the services I provide -- all the services I provide. But this is also an unusual case in which my interests and those of the nation as a whole are aligned. If universal health care coverage is enacted, then the human tragedy of the uninsured being dropped in the ER in critical condition because of lack of access to routine care will cease. And if universal health coverage is enacted, then (presumably) I will be paid for taking care of those individuals whom I currently care for for free. And if universal health care is enacted, as a consumer, my premiums will no longer be inflated due to the fact that the ER doctors charge $350 per insured patient to subsidize the $0 per patient we collect from the uninsured patients.

[Ironic side note: our practice, a "small business" cannot find affordable health insurance. How funny is that -- the doctors can't afford health insurance! Kind of funny. Kind of not.]

But if that is "self-serving" well, I'll plead guilty.

12 February 2007

In which I shall make an unpopular argument

Mark Twain famously said that "Sacred cows make the best hamburgers." I reflect today upon one of the sacred cows of Emergency Medicine, EMTALA, and I wonder to myself:

Is EMTALA unconstitutional?

A little background for the non ER-docs in the audience. (hi mom!) In the Bad Old Days [tm], ERs did not always serve as the Ultimate Social Safety Net that they now are. When patients presented, a "wallet biopsy" was performed at the front door, and if the patient was indigent, they were turned away, or redirected to the local charity hospital, or sometimes they were evaluated and then dumped via ambulance on the charity hospital. Congress responded with the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd), commonly referred to as "EMTALA" (the "The Emergency Medical Treatment and Active Labor Act") or the "anti-dumping law."

This law required that all hospitals which participate in the Medicare program (effectively, all hospitals) provide a "medical screening examination" to all individuals who present to the ER to determine whether an emergency condition is present, and if such a condition is present, provide appropriate stabilization treatment within the capability of that facility. If a patient is to be transferred, the patient must consent to the transfer, the receiving facility must agree to accept the patient, and the risk and benefits of the transfer must be documented.

Given the demonstrated bad behaviors prior to EMTALA, most view it as an appropriate government response, and those involved in Emergency Medicine nationwide generally have incorporated its principles into their mission. Most ER docs that I personally know have a reflexive tendency to take responsibility for any patient that walks through the door, and given the national uninsured crisis, most ER docs think of it as a moral imperative to care for the needy and indigent.

But EMTALA contains no provisions for compensation of the providers who care for the indigent. It is, rather, a classic unfunded mandate. According to an AMA study, the typical ED physician will provide about $138,000 in uncompensated care annually. Hospitals accrue much larger costs, but do receive some small offsetting funds through Medicare.

It is true that EMTALA did accomplish its limited aims; the Emergency Departments of the nation are now effectively serving as a basic safety net for the most vulnerable members of society. Unfortunately, this has also created a perception that the nation's health care crisis is somehow resolved. I have, numerous times, encountered the argument that the uninsured do in fact, have access to health care through the nation's Emergency Departments. This reflects a limited understanding of the highly limited spectrum of services provided in the typical ED. This common misconception has diminished the sense of urgency required in reforming the funding of health care in America today.

From my limited experience, it seems that just about every health care provider I know agrees that while EMTALA does reflect a sense of moral rectitude, it is bad public policy. It shifts the failings of the healthcare "free market" onto the shoulders of private physicians by legislative fiat, rather than providing sustainable solutions. Worse, EMTALA provides a incomplete, "band-aid" solution to a critical deficiency of the national health-care policy -- the inability to provide full access to care for all citizens.

It is abundantly clear that comprehensive reforms are required, reforms which guarantee universal access to health care. Even republicans such as Mitt Romney and The Arnold have floated (tepid) proposals to accomplish this goal. However, I am suspicious that such an ambitious undertaking is be doomed to failure, as in 1993, by the many competing interests and advocacy groups, not least of which are the entrenched insurance companies. It may be that something dramatic may need to change in order to re-establish a sense of urgency for and momentum towards systemic health care reform.

One appropriately dramatic action would be for EMTALA to be overturned. Obviously, it is politically untouchable from a legislative point of view; it may, however, be vulnerable from a judicial approach.

The Fifth Amendment to the US Constitution states, in part, "... nor shall private property be taken for public use, without just compensation." The Fourteenth Amendment similarly reads, "nor shall any State deprive any person of life, liberty, or property, without due process of law." The argument to be made here is that EMTALA requires private citizens, largely physicians, to provide the fruits of their labor without compensation or due process, and as such represents an unconstitutional "taking" of private property.

The biggest question to which I am not truly competent to provide an answer is this:

Legally, is a person's labor considered property?

Absent some review in case law which I am unable to find, I cannot find a definitive answer on line. Most definitions of property do make a distinction between real property and intangible property, definitions which do not explicitly include, but which would seem to be expansible to labor. There is a historic precedent in the philosophy of law that all property is derived from labor. I do not know to what degree, f any, this has become incorporated into common, case or statutory law. If anybody reading this can provide me with a definitive answer, I would be very interested in reading it.

Assuming the preceding, the right to property is generally held to be a fundamental right, which the courts provide with a high degree of protection, or "strict scrutiny." This means that any restrictions or impositions upon that right must be: justified by a compelling state interest, narrowly tailored, and accomplished by the least restrictive means.

I think it is self-evident that the need to provide emergency health care to all citizens is a compelling need, and I can concede that the construction of EMTALA is indeed pretty narrow. Whether the least restrictive means are used is, however, open to question. EMTALA, were it linked to a funding method, some sort of standard fee schedule, would achieve the same goal with less restriction on the provider's autonomy. Thus, by my reading, EMTALA might be impermissible under the Fifth Amendment.

What would be the consequences of such a case being brought? I think the "house of medicine:" ACEP, the AMA, etc, would probably oppose any attempt to overturn EMTALA, simply for fear of the political backlash. They would not want to be perceived as wanting to put the poor and vulnerable at risk. Given the almost-certain filing of amicus briefs in opposition to a petition to overturn EMTALA, the odds of such an action succeeding seem low in the face of what may be a tenuous legal foundation for the case. A failed attempt to overturn EMTALA would indeed portray the plaintiffs -- and all physicians, by extension -- in a very negative light with no tangible benefit to show for it.

Conversely, if such a claim were successful, what would be the consequence? Again, I predict a highly negative public reaction, mostly directed against physicians. The perception would be that doctors don't want to take care of the uninsured (which is to some degree true); we as a profession would be viewed as acting to put the poor and vulnerable in jeopardy. The result, however, might ultimately be positive. The exposure of the "medical safety net" as being untenable would almost certainly spur lawmakers to action. Providing an impetus for legislative action to cover the uninsured would, indeed, be the only reason to make such a claim.

I think the dangers here are too great to justify trying these waters. Exactly what sort of legislative response Congress would come up with to replace EMTALA is uncertain, and punitive measures directed against physicians might well be part of the response. The AMA and other physician lobbying organizations would not face a sympathetic audience in trying to craft law or guide the legislative process, as they would lose a great deal of moral authority due to EMTALA's demise.

Furthermore, in the current political climate, where the health care crisis is getting a fair amount of national attention and just about every prominent democrat has a pet plan for universal coverage, there is some actual basis for hope that a solution may -- just may -- be on the horizon. In this environment, provocative moves like a challenge to EMTALA would probably work greatly against the interests of physicians, and are probably unnecessary.

Ultimately, I do not know whether the legal basis for this thought-experiment is sound. I suppose we will never know unless someone files a petition and makes the case. It would be interesting if some "rogue doc" out there did so. Coming from a private individual would help a bit to shield the house of medicine from the negative publicity, especially if those organizations were on record as opposing the action. Even a credible threat against EMTALA might be helpful in moving the debate forward.

Mmmm. . . great hamburger.

10 February 2007


Fun quiz. Somehow, I feel pretty good about my results...

Your results:
You are Dr. Doom

Dr. Doom
Lex Luthor
The Joker
Green Goblin
Poison Ivy
Mr. Freeze
Dark Phoenix
Blessed with smarts and power but burdened by vanity.

Click here to take the Supervillain Personality Quiz

05 February 2007

Comment Spam

Sigh. It's starting to get to be a nuisance.

I really don't like the word-recognition feature that blogger uses to prevent comment spam, but I suppose I could turn it on. Anybody out there know of any other methods to block the spam-bots?

In the Shadow of Saturn

Boy, this is cool.You can see the super-high-res image at NASA's web site. If you look carefully, just inside the outer G-ring, at about the 10 o'clock position, you can see the pale blue dot of Earth, at a range of about a billion miles. It's only visible on the high-res image.

With giant Saturn hanging in the blackness and sheltering Cassini from the sun's blinding glare, the spacecraft viewed the rings as never before, revealing previously unknown faint rings and even glimpsing its home world.

This marvelous panoramic view was created by combining a total of 165 images taken by the Cassini wide-angle camera over nearly three hours on Sept. 15, 2006. The full mosaic consists of three rows of nine wide-angle camera footprints; only a portion of the full mosaic is shown here. Color in the view was created by digitally compositing ultraviolet, infrared and clear filter images and was then adjusted to resemble natural color.

The mosaic images were acquired as the spacecraft drifted in the darkness of Saturn's shadow for about 12 hours, allowing a multitude of unique observations of the microscopic particles that compose Saturn's faint rings.

Ring structures containing these tiny particles brighten substantially at high phase angles: i.e., viewing angles where the sun is almost directly behind the objects being imaged.

03 February 2007


My neighbor's kid constructed this ramp:
I am not sure what use he intends to put it to. He skates and rides a dirt bike on the streets around here, though not with any great skill, it must be said. But I kind of admire his chutzpah -- by my eye, that thing takes off at about a 45-degree angle. Unfortunately, I've got to go to work soon, so I won't be around to witness the excitement.

That's okay; I can ask him about it when he gets to the ER later.