29 October 2007

MRSA Hysteria

The media continues to annoy the long-suffering Dr Shadowfax.
You can read the particulars over here.

28 October 2007

Leopard bugs

Lots of them out there, apparently. Including the dreaded "Blue screen of Death" finally making an appearance in the Mac world.

I got lucky. Only one, and that easily enough resolved with five minutes research at the Apple Support page.

But it was a scary one. My administrator password got lost, and the fix involved booting into unix mode and typing things like:

dscl . -delete /Users/[username] AuthenticationAuthority
and ever since I learned about rm -r (deletes all files on the machine) I have been leery of mucking with the command-line interface.

But now TimeMachine is steadily plugging away backing up my irreplacables and I am enjoying my flip-view finder and all is good in the world.

27 October 2007

Sleepy ... so sleepy

One of the things I love about this blog, is that a lot of my readers, like me, work odd hours. I enjoy seeing the timestamps on the emails and comments; a surprising number of them originate between 0100 and 0400 hours. I guess a lot of ER types get bored and read blogs on the night shift.

One of the things I don't like about my job is that I have to work nights. Don't get me wrong -- I worked nights exclusively for a few years before I had kids, by choice. I like the pace of night shifts, I like the occasional down time, I like the camaraderie that the night staffs always seem to enjoy, and I even learned to like the traditional post-night shift team meal of pancakes and beer. That was when I was working all nights. Now I just work the same fraction of nights as the other docs in our group, a handful per month, and I find them much harder. It's easier to flip the sleep/wake cycle when you're going to work five nights in a row. One or two stand-alone night shifts are a lot more disruptive to my biological rhythms. And it's well known that as you get older, your ability to handle the sleep deprivation gets less and less.

This is why I was interested to hear a lot of buzz recently about a medication called Provigil (Modafinil). It apparently is FDA approved for the treatment of "Shift Work Sleep Disorder," a disease which I am pretty sure did not exist before the good folks at Cephalon decided to market the drug to shift workers. It is basically a stimulant which is more effective than caffeine, milder than amphetamines, and with a lower side effect and dependence profile than other stimulants. I attended a few lectures at ACEP's Scientific Assembly which addressed this issue -- both from a quality of life perspective as well as a physician performance and patient safety perspective -- and I was surprised to hear an almost evangelistic level of enthusiasm for this drug from the speakers. I have personally known a few ER docs who have tried it and they also rave about its virtues. They say that you are just blissfully awake for that awful first night up, without the jitters from caffeine, without feeling edgy or off-kilter, and you are able to sleep the next day -- there's no hangover.

It's got me wondering. I have never self-medicated (other than with coffee or booze or the occasional antibiotic), and I am not about to start. If nothing else, it is a schedule IV med. (It's also on the FAA's list of forbidden drugs for a pilot to take, which is ironic since apparently the Air Force uses it to improve pilot alertness on long missions.) But I am tempted to take the commercial's advice and "ask my doctor about a free trial..."

I'd be interested to hear any experiences any of my readers might have with this medicine -- especially any of the under-reported down sides. It sounds too good to be true, which means it probably is.


I wrote this post in a slow moment of an overnight shift. I hadn't thought I was particularly tired, but once I was on my way home a wave of fatigue broke over me and really took me by surprise. I almost fell asleep at the wheel and drove off the road several times. Scary -- thank God for rumble strips on shoulders! Fatigue impairs your judgment; I should have gotten the hell off the road but I was afflicted with a severe case of get-there-itis. I managed to focus myself after the second or third time it happened and made it home without incident.

I don't think it makes a compelling point for or against Provigil, but it's a disturbing irony to occur three hours after writing a post on sleep issues...

26 October 2007


The good folks over at MedPage Today thought it would be a great idea to have medical bloggers-in-residence at their site, providing original content and insight into medical issues of the day. And they turned, of course, to the most renowned and admired medical blogger out there, Kevin Pho, to set up the program. Really, it's a perfect idea -- what better way to attract traffic to their informational site than to bring on board the unique and provocative opinions of several well-regarded bloggers like Kevin, MD, Dr Wes, electrophysiologist, and the Highly Distractable Dr Rob?

Kevin, however, after one of his well-publicized laudanum binges, also invited me, of all people, to be part of this project. At least I assume he was blotto -- I can't think of any other explanation for including me in this otherwise serious endeavor. Being the Accomplished Writer and Savvy Negotiator that I am, I held out for the same deal that Herman Melville got when he wrote Moby-Dick: $5 per page. It turns out that was a lot more money in 1851 than it is today. Damn.

But I am now, for better or worse, inarguably and indisputably, a PROFESSIONAL BLOGGER.

Head on over to the MedPage Blogger page. Bookmark it. Or wait a few days till we have the RSS feed up and bookmark that. I'll still post here as I currently do. There may be a bit of cross-posting, but I'll try to keep the topics separate. For those who like my medical blogging but hate my politics, your wish is granted: except for some health policy stuff, I'll try to keep the politics over here.


25 October 2007

Apple Rocks

Leopard comes out tomorrow. I haven't had this much anticipation for a new operating system since OS X itself. It looks phenomenal. Time Machine itself is worth the $129 price. The NY Times inestimable David Pogue (author of the Missing Manual series) has a two-part rundown on some of the new features here and here. And the eye-candy is, as always, spectacular. For example:And:(Just to be complete, Google Finance also rocks.)

Things that make me sad

James Watson resigns over "racist" comments.

Obligatory disclaimer: Watson's remarks (and some past remarks, apparently) were offensive and ignorant at best.

But I can't help feel sorry for the man. I have some lingering affection for him. I grew up with a fascination for biological sciences, and Watson and Crick were demigods in the textbooks; the mythic account of their discovery of the double helix was like Prometheus bring fire to the primitives. I read Watson's memoir, The Double Helix, and came away feeling as if I knew the young scientist in the '50s, like I was there during the exciting time of discovery. It was a key part of my inspiration to go into the life sciences. Sure, I knew there was much that was fictionalized and much that was omitted (Rosalind Franklin's contribution, for example). But still, it was a great story and great science.

It's sad indeed to see a great man end his career diminished in such a way. I don't blame him per se for having anachronistic views: he is quite old and I have known many elderly individuals to have embarrassingly unreconstructed views on race, sexuality, society, etc. It is a pity that he spoke out so prominently that it couldn't be ignored and that an institutional repudiation was required, and that he must thus end his long and distinguished career in ignominy.

24 October 2007

Reason Number 23

Why it's a good idea to wear a full-face helmet:

Poor focus due to the cell phone camera ... you can't really tell, but those are some really deep gouges where the patient's chin would have been. He might not have a jaw left if it weren't for the helmet. As it is he walked away with only a minor ankle fracture.

Well, he didn't "walk" away. More like hobbled away. You get the idea.

Things that make me unhappy

It's 9:30 AM and I have already driven 85 miles today.

22 October 2007


Not long ago I was working out at the local gym. Nothing too intense -- half an hour on the elliptical trainer and some weight-lifting. I sat down at the chest press machine and settled in, when a friend of mine, Ron, who happens to be an critical care doctor walked past and sat down next to me at the military press machine. We each took the iPod earbuds out of our ears and chatted a bit, since it had been a few weeks since we had seen each other. After exhausting all the casual avenues of conversation, we donned our iPods once more and went to work.

The two of us spent a while there, doing several sets each. The weight equipment was located in the center of the room, facing the entryway, with the aerobic equipment -- treadmills, cycles, etc -- behind us. I tend to get a bit of tunnel vision when I am working out pretty hard, and it was only in my peripheral vision that I noticed a couple of familiar-looking guys hurry past me. In my semi-hypoxic state I wondered how I knew them.

Oh, that's Bill, from Medic 16, I suddenly recalled. Satisfied at having figured out that mystery, I went back to work. I didn't know he was a member here. But there was still something that didn't quite fit. Why was he wearing his work clothes?

And, I suddenly realized, the other guy I had noticed was his partner. And he had been carrying a tackle box. What the hell are they doing here?

I put down the weights and turned around. Behind us, at the foot of a treadmill, there was an old man on the floor and the paramedics appeared to be intubating him, as best I could see through the small knot of people clustered around them. I tugged at the sleeve of the ICU doc who was still doing his set, "Hey Ron, check this out..."

The two of us stood there with the rest of the slack-jawed gawkers and watched the medics finish their resuscitation and load the fellow on the gurney. They were quick and efficient and were out of there in less than five minutes. We pulled the iPods out of our ears once more.

"We probably should have helped out," he offered sheepishly.
"I never heard anything. Did you?"
"Not a thing."
"Well, we couldn't have done too much anyways, right? No airway equipment, no defibrillator..."
"At least our CPR is better than average."
"Don't give me that. I've seen you do CPR."
"Okay, okay."

We went back to our workouts and finished in silence.

16 October 2007

Important CPT changes affecting ER Docs

The 2008 CPT book is out. For the past few years, there has been some controversy about ER docs using IV infusion codes in the ER. The language did not expressly prohibit it, and some payers would actually reimburse for it (though not all), so many ER doctors added these codes into their charge master.

For our part, we did not. There were several reasons. First of all, the documentation requirements are, not exactly onerous, but detailed enough to represent a significant obstacle to compliantly billing for that service. It would require a fair amount of attention and education of our doctors to ensure that the charting matched the charges, but doctors these days are absolutely overwhelmed with "educational mandates" like patient satisfaction, joint commission, quality and "pay for performance", and even some actual medicine, too. People only have so many incoming information channels, and doctors are saturated. So I preferred to focus on maximizing the documentation of the more "legitimate" and common services like critical care and fracture care, which in the end are far more valuable.

Also, I rather suspected that IV infusion was never intended to be a code for ER doctors to use, and that it was an oversight which would be corrected. For a doc in an office or a chemotherapy infusion center, there are costs to be covered and in the absence of a separate E/M charge, the infusion code represents the entirety of the physician work, which should be reimbursed. But in the ER, the facility bears the overhead of the infusion, and the infusion is really just accessory to the diagnosis and management work, so it doesn't make sense to reimburse for it as a separate line item.

And I have been proven right (yes, it does happen on rare occasion). The new language of the "Hydration , Injection and Infusion" codes does appear to preclude further use in the ED setting. Page 383 reads:

“Physician work related to hydration, injection, and infusion services predominately involves affirmation of treatment plan and direct supervision of staff. These codes are not intended to be reported by the physician in the facility setting.

When these codes are reported by the facility, the following instructions apply. The initial code should be selected using a hierarchy whereby the chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. This hierarchy does not apply to physician coding.”
Emphasis added. Well, that settles that.

The Circular Firing Squad

This used to be a patented Democratic specialty, but it appears the Republicans are encroaching on our intellectual property:

The Republicans’ circular firing squad is now assembled. All that’s left is for someone — President Bush, House Minority Leader John Boehner (Ohio) or Senate Minority Leader Mitch McConnell (Ky.) — to yell the appropriate command: "Fire!"...

So what advice would this Republican give his party’s Members of Congress? "If I were in a swing district, I’d vote to override. There’s no way I’d take a bullet on this. But if I were in a good Republican district, I’d vote to sustain the veto."

Those comments are not atypical of what many Republicans are saying.

One Republican Member of Congress I spoke with was just as explicit. "It’s stupid politics. The leadership is putting pressure on Members [to sustain the veto], promising to rebuild the brand. I don’t know why our guys are following [Bush] into the sea like lemmings." (from Roll Call)
For my part, I hope the Republicans do sustain the veto. Not because I don't support SCHIP; I do, as does the vast majority of the American people. But because if the SCHIP expansion goes down, the likely democratic response will be to re-authorize the plan as it exists for a year, and bring it up again in October 2008.

Right. Before. The. Election.

In that case, either the Republicans and Bush roll over and hand the Democrats a major legislative victory immediately prior to the voting, or Bush repeats his petulant veto and the Republican circular firing squad sustains again, handing Democrats the perfect icon for branding conservative callousness in the election season.

Now if the Democrats can remember the old adage: When your opponent is drowning, throw the son of a bitch an anvil.

Get cancer, lose your job.

George Bush's America. Via Washington Post.

A firefighter and an EMS dispatcher in Manassas, VA were terminated after being diagnosed with colorectal and breast cancer, respectively, and going out on disability. Each was in discussions with supervisors regarding alternative job duties which they would be able to carry out when a notice of termination came in the mail. With their jobs went their health and life insurance benefits.

Appalling doesn't begin to describe this sort of behavior on the part of the employers, but apparently "legal" does. The legal details are beyond me, but it really doesn't matter. As an employer, I have had employees get sick, and cost our small business a lot of money. Even if we could get away with it legally, it would have been absolutely reprehensible to cut our valued co-workers and friends off in such a time of need.

For their sake, I hope these EMS workers belong to unions with retirement plans that do include health insurance; the article wasn't clear on that point. Because otherwise, they are screwed. Unable to work, uninsurable -- I guess once they've spent down their assets they can get on Medicaid. But there's going to be an obligatory time frame in which their medical funding, and probably their care, is compromised. Hopefully it won't cost them their lives.

This is why we need some sort of Universal Health Care now.

(h/t Americablog)

15 October 2007

Called Out

Scalpel (and many of his commenters) doesn't believe in climate change, and in his faux dialogue on the topic uses me as an example, implied anyway, of hypocrisy.

You just know I can't let that go unanswered.

It is kind of wasted effort, though, since it's already been defined as a matter of belief and not of evidence. The vast majority of the evidence, and the vast majority of the world's experts have achieved a consensus that climate change is real, and climate change is to a large degree caused by human activity. I'm not going to indulge in a link-war on this point, because there are, I am quite sure, hundreds of "climate change is a myth" links, and the simple engaging in that sort of tit-for-tat implies a false equivalence. So I'm going to accept that climate change is one of those concepts that attract a population of adherents who just cannot be dissuaded by evidence, along with:

Evolution is unproven.
The moon landings were faked.
Mercury and vaccines cause autism.
Chronic Lyme disease/Morgellon's/etc exist as separate disease entities.
The income tax is unconstitutional.
The earth is flat.

There's an old saying that "there's no point in trying to teach a pig to sing, because it just wastes your time and annoys the pig." In the same spirit, I'll not argue the evidence that man-made climate change is real, but rather accept it as a given. If you disagree, feel free to say so in the comments, but I won't follow your links or engage any further on the point.

Scalpel did make one interesting point, though, that is worth discussion. To what degree is it possible for individuals to make a difference by changing their lifestyles? Am I indeed a hypocrite for driving a fast car, for not living in a geodesic dome powered by wind and solar, mulching my waste, and eating only organically grown food from my own garden?

It pains me to say it (really), but I agree with Dick Cheney on this point. He famously said, "Conservation may be a sign of personal virtue, but it is not a sufficient basis for a sound, comprehensive energy policy." As Scalpel also pointed out, jet emissions as well as industrial activities so overwhelm the individual's ability to make a difference that it is all-but-pointless to try. The solution to this problem will not come from a grass-roots people-powered change, especially one that involves personal sacrifice. It would be nice, but human nature and the limits of technology make that unlikely.

The solution must be government-based, with sensible measures like raised CAFE standards and increased use of nuclear (yes, nuclear) energy in concert with investment in alternative technologies, and market-based incentives to reduce emissions, and regulatory penalties with real enforcement for violators. We're not going to get any of that under a Republican government, as the last seven years have shown. So my personal investment is to some degree (not completely) defined by my support of Democratic candidates for federal office.

And my car gets 25 mpg, which is no LEV, to be sure, but better mileage than a SUV. So my liberal conscience is OK with that.

One other point of agreement might be that the Cassandras of climate change do, I think, tend to overstate the catastrophic consequences. I am deeply ambivalent about that. It's an effective tool to motivate people and stimulate necessary change, but it does tend to undercut the credibility of the movement when subjected to close and unfriendly analysis.

I'm Left Brained

Or at least I am according to one of the freakiest optical illusions I have ever come across.

I wouldn't have believed it if my wife hadn't stood over my shoulder and seen the exact opposite thing I did.

Nobel in Economics

According to the NY Times, today's Nobel in Economics went to the founders of "Mechanism Design Theory," of which I had never previously heard. According to the article, this theory:

[A]ddresses situations in which markets work imperfectly, such as when competition is not completely free, consumers are not fully informed or people hold back private information. In such cases — for example, when people refuse to divulge how much they are willing to pay for a good — trade can break down.

Their work also addresses cases where transactions do not take place openly in public markets, but within companies, in private bargaining between individuals or between interest groups.
Wow. Sounds just like the economics of the US Health Care system.

Someone should look into that.

10 October 2007

Ezra Channels Malkin


"If a conservative is a liberal who's been mugged, then a progressive is a Republican who's gotten sick."


It is bizarre but doctors who make six figures will eagerly line up for free pens, cheap nylon tote bags, and plastic novelties emblazoned with the name of a drug or biotech company.

I guess it's better from an integrity punt of view to accept amusing but worthless trinkets than the expensive wining and dining which used to be so common. (it still goes on but more sub rosa.)

Liveblogging ACEP

I had fully intended to give a detailed running account of this year's Scientific Assembly. Unfortunately, this has been the busiest and most hectic SA ever for me. I have been running from lecture to committee meetings to interviews to meetings with insurers, billing agencies, ED Information system vendors and more. And socializing, of course. Even though we are basically in my home town, I haven't seen my kids in three days.

Probably the most fun has been the recruiting. I have met maybe a dozen senior residents from exceptional training programs, all lured to the balmy Pacific Northwest. Fun to meet and get to know these guys (and girls), and also fun to pitch our group to them, since I am really proud of the organization we have built.

Now I am tired. I have come across a lot of interesting info which I hope to reflect on more in the coming days. For now I offer the following insight:

The Coding and Nomenclature committee is the most boring thing I have ever endured.

05 October 2007

Compassionate Conservatives

Bill Kristol:

"Whenever I hear anything described as a heartless assault on our children, I tend to think it’s a good idea. I’m happy that the president’s willing to do something bad for the kids.”

As usual, Krugman gets it right:

All of the famous Bush malapropisms — “I know how hard it is for you to put food on your family,” and so on — have involved occasions when Mr. Bush was trying to sound caring and compassionate.

By contrast, Mr. Bush is articulate and even grammatical when he talks about punishing people; that’s when he’s speaking from the heart. The only animation Mr. Bush showed during the flooding of New Orleans was when he declared “zero tolerance of people breaking the law,” even those breaking into abandoned stores in search of the food and water they weren’t getting from his administration.

What’s happening, presumably, is that modern movement conservatism attracts a certain personality type. If you identify with the downtrodden, even a little, you don’t belong. If you think ridicule is an appropriate response to other peoples’ woes, you fit right in.

So once again, if you’re poor or you’re sick or you don’t have health insurance, remember this: these people think your problems are funny.

The other side of the gurney

The Darling Wife was waiting outside the Y last night when I finished with Karate. I was surprised to see her, since there was no reason for her to be there (with the kids) at 9:30 pm. I figured something was up. It turned out that First-Born Son had fallen off the bed and hurt his wrist. He insisted that Second-Born Son had pushed him off the bed, but SBS dutifully reported that they had both been jumping on the bed and FBS "just fell."

One glance at the wrist told me that we were heading back in to the ER.A torus fracture of the distal radius. So now FBS is sporting a cool fiberglass splint which we'll have converted to a cast next week. He was pretty good with the pain and is feeling fine now, running around and back at school.

So, I have two boys and each has been to the ER once. Let's see, that is seven and a half years of parenting with one ED visit every 3.25 years. If that trend holds steady (if), then by the time they head off to college we'll have a total of eleven ER visits.

04 October 2007

The Panacea of HSAs

Kevin approvingly links to an op-ed by 20/20's nutcase-in-residence John Stossel. Key graf:

We’d each be better off if we paid all but the biggest medical bills out of
pocket and saved insurance for catastrophic events. Truly needy people would
rely on charity, not government, because once government gets involved,
unintended bad consequences abound. If people paid their own bills, they would
likely buy high-deductible insurance (roughly $1,000 for individuals, $2,100 for
families) because on average, the premium is $1,300 cheaper. But people are so
conditioned to expect others to pay their medical bills that they hate high
deductibles: They feel ripped off if they must pay a thousand dollars before the
insurance company starts paying. But high deductibles may be the key to lowering
costs and putting you in charge of your health care.

Stossel's explanation for the escalating cost of American healthcare is the typical conservative mantra that Americans consume too much health care. If we could only somehow make consumers directly bear the cost, they would start making smart, rational cost-sensitive decisions and stop consuming so damn much unnecessary health care

Which is stupid on so many levels. American health care is insanely expensive for numerous reasons, but lack of price transparency/sensitivity is not one of them.

The biggest waste of healthcare dollars by far are the structural inefficiencies inherent in the modern health care industry: the fact that doctors & hospitals spend 15% of revenue trying to get paid; that insurers waste 10-20% of premiums on administration; wasted spending on defensive medicine and malpractice; the lack of access to preventive healthcare, etc.

Beyond that, there may be a role of overutilization, but it is just silly to think that by shifting the cost onto consumers, that consumers will cut back on the right items or make more rational decisions. For example, higher deductibles will create a negative incentive for patients to access routine preventative services, which may lead to later detection of disease or poorer control of chronic diseases like diabetes. This would also likely fall heaviest on the economically disadvantaged who are most price sensitive and most likely to skimp on 'elective' doctor visits and tests.

On the other hand, the largest amount of "wasted" dollars is in fact physician-driven, and consumers in general do not have the education or resources to second-guess the advice given to them by their doctors. For example, if you have chest pain, and an abnormal angiogram, and you find yourself in the recovery room talking to a cardiac surgeon who is recommending a bypass, most people are going to be terrified and happy to accept the advice of the intelligent, trusted expert at their bedside. You are probably not going to go home and research the benefits of CABG vs stenting, nor are you likely to look around for the best price, were that information available. Or if you have been suffering from chronic knee and back pain and your orthopedic surgeon recommends an arthroscopy or laminectomy, most patients are unaware of the data showing that many of these procedures are no better than placebo, and even if the surgeon discloses that fact, but says "I think you are likely to benefit because ..." the natural tendency is to trust the doctor and go with his/her recommendations.

Ditto in the ER -- you come in with heartburn, and I see you and wonder if it might be a heart attack or an Aortic Aneurysm (and I hate getting sued) so I recommend a CT scan and and admission for a rule-out MI work-up. People rarely if ever inquire as to the costs, and when they do, I point out the risk to their life, and that tends to end the debate. And when you are 80 and demented but your family it too squeamish to sign a DNR, you can get a week in the ICU for the pneumonia which should have naturally ended your life.

Now, I am not claiming to have an answer for the spiraling costs of healthcare. It seems like a particularly intractable problem. My point, however, is that none of these drivers of health care spending will be affected by HSAs and higher deductibles. HSAs are a scam to let the wealthy (like me) shelter money pre-tax, and to shift some of the cost and risk of health care from Bushco's corporate masters onto consumers.

And, not to beat the dead horse once more, it does nothing to cover the uninsured.

03 October 2007

Suffer the Little Children

Bush vetoes expansion of health insurance for children.

Umm ... George, I think that's not what He meant.

Seriously, this is so emblematic of the Bush administration it's almost a self-parody. The guy can't find his veto pen for five years of binge and purge spending, then objects to a $7 Billion a year expansion of health care for the poorest children. The guy pushes through a $40 Billion government-funded prescription program but claims that a modest expansion of children's coverage is "socialized medicine." Best of all, he throws another log onto the electoral self-immolation of the Republican Party by forcing them to vote (and again and again) against a popular and humane program supported by 63-86% of the Americal populace.

Angry moonbat Orrin Hatch said:
"It's unfortunate that the president has chosen to be on what, to me, is clearly the wrong side of this issue... If we're truly compassionate, it seems to me we'd want to endorse this program."

Well, the other 65% of the country figured out years ago that Bush's "Compassionate Conservatism" was a campaign lie. Don't worry about the kids, though, Orrin, as Dubya himself said, "They can always go to the ER."


01 October 2007

Baby trapped in PowerBook

Freaky.The hand reaching "out" of the keyboard really makes it work for me.

Rudy ... Rudy ... Rudy

Christian Conservatives Consider Third-Party Effort

Alarmed at the chance that the Republican party might pick Rudolph Giuliani as its presidential nominee despite his support for abortion rights, a coalition of influential Christian conservatives is threatening to back a third-party candidate in an attempt to stop him.

(from Caucus, the NYT political blog)

For fifteen years I've heard dire predictions that the GOP would split as a result of the uneasy alliance between the the corporate and social conservatives. Never happened. I kind of doubt it will happen this time, either. But we can hope.

If nothing else, the Dobsons are sending a clear message to the kingmakers in the GOP, and at the same time hamstringing their most electable candidate. Pass the popcorn.