30 January 2008

Movin' Meat: Door to Doc

A comment I made drew some disbelieving attention over at Crayzee Central. I didn't give it much thought initially, but it's probably worth a post. What I said was that Door-to-doc time at our facility is down around twenty-five minutes. It's true, and not because we are some "cushy" palace of a private hospital with lots of empty beds and nurses sitting down with nothing to do. It's been a long, hard slog for us to get where we are, and it might be informative to write about how this came about, and why.

First of all, a disclaimer. I am the administrator for our professional corporation. I am not involved directly in ED operations or hospital administration. So while I have a place and a voice at the table where the decisions are made, I am not a decision-maker, nor am I responsible for implementation. I will use the phrase "we" in describing our accomplishments, and I feel a great sense of pride at the progress, but I cannot take credit and do not want to be seen as doing so. We have a great team -- the CEO, the ED Medical Director, the Nursing leadership, etc. If our hospital's ED management were a baseball team, I would not be the star pitcher or slugger. Maybe a good utility infielder. So I will take the opportunity to brag, but don't label me as too egotistical.

In order for this journey to make any sense, context and perspective are needed. In order to see how far we've come, you need to know where we started.

Our facility is a very large, private charity-based hospital in an economically depressed urban/suburban community. We see over 100,000 patients annually, which is as about a big as ER as I have ever heard of without a major academic affiliation. Our hospital's physical plant is very old and the ED has not had anything but cosmetic renovations in two decades. It is very small, with fewer than 50 beds in the ER, though the hospital does have several hundred inpatient beds. The hospital administration has some financial resources, but due to a very marginal payer mix departmental budgets are quite restricted. (Part of the reason budgets are restricted is the hospital is running a profit margin necessary to assure the bond markets we are credit-worthy in order to build this.)

A necessary element of success is the leadership. Our hospital C's - the CEO, CFO, COO, and CFO - are excellent. Reasonable, visionary, and exacting. They are somewhat new to this institution, and bring with them a commitment to the mission of being the premier medical center in the region. They understand that when our performance in the ED fails to meet standards that it is often due to factors not under our control, and they do not personally blame us. Neither do they give us a free pass. Every identified "improvement opportunity" must have an action plan. Sometimes it seems a Sisyphean challenge -- we are tasked to do the impossible with inadequate resources -- but the result when we fail is that we just have to begin anew. The consequence, after several years' relationship with this administrative team, is that we know they will hold our feet to the fire, and we know expectations are high, but we also know that as long as we share their vision, as long as we keep working towards the shared goal and making incremental progress, we don't need to fear them.

A few years ago, our ER was truly in crisis. The wait times were in measured in hours. The walk-away rate approached 9% at its worst. The nurses were burnt out -- understaffed and overwhelmed, they routinely called in sick, taking "mental health days," leaving the ER even more short-staffed. Patient care suffered. There were, I believe, a number of preventable adverse outcomes due to the chaos in the ED. Physicians resigned, citing an unsafe environment and excessive stress. It didn't all happen at once. Like the story of the frog boiled alive in a gradually heated pot of water, life in a busy and inefficient ER slowly got worse over a period of years, with a variety of causes. We rushed about, putting out fires here and there, and rarely paused to look at the big picture. The wake-up call came when Press-ganey changed its methodology of ranking patient satisfaction scores. We had always had low-ish scores, but under the new method, we ranked at the 1st percentile.

That got some attention. It's hard to be told that you are the worst ER in the nation and not respond with denial, disbelief, with excuses -- especially when it is due to a change in the "scorecard." But there it was, staring us in the face: 99% of American ERs had patients who were happier with their care. This put us down with inner-city hell-holes like King-Harbor in LA. The message was heard loud and clear up and down the organization: improving the performance of the ER is of the highest priority, and every department, every service line that impacted the ER would be expected to contribute.

This is going to be a long story, so I'll break off here for today, with the observation that the last sentence is the most critical component of our organizational turnaround. Hospitals that view ER performance as an ER problem routinely fail to solve their problems. The ER is largely dependent on the institution for its success or failure, and without an institution-wide performance improvement plan, the prospects for meaningful reform are bleak.

I get letters

Why St. Baldrick's matters:

One recent letter I got was from faithful reader and longtime lurker, Tara. She writes:

I wanted to say thank-you for your St. Baldrick's efforts. I know that you have a personal reason to be involved in pediatric cancer research. I unfortunately do as well - my 3 year old son was diagnosed with metastatic medulloblastoma 3 months ago. So on Henry's behalf, thank you.

I have read a lot of Nathan's site. I remember crying over Nathan's passing, which was of course before Henry was diagnosed. How life has turned into before and after 10/13/07 for me.

We corresponded back and forth for a while and after she discussed it with her family, I have added her son Henry as an "Honored Child" on my St Baldrick's page. I am glad and proud to be able to sponsor Henry; while too many children have fought and lost their battles with cancer, there are as many who are still waging their fights, and more diagnosed every day.

You can read about "Henry's Challenge" at their family blog. He sounds like a great kid, with a devoted and loving family. They don't deserve what they are going through, but then, with cancer, who does? Maybe through the funds we raise at St. Baldrick's, we can hasten the day when these cancers are curable, and where the treatments are not so difficult.

I am amazed at my little perspective into this world of pediatric cancer. I have known folks on both sides of the gurney, so to speak, and both sides of the fundraising. A close friend of mine is a Pediatric Oncologist; her research is on medulloblastoma. She is currently applying for a grant from St. Baldrick's to further her research. So from my perspective, I get to help raise the funds, and get to see how the money is put into action towards curing these diseases. St. Baldrick's puts about 85% of all its funds raised into research -- the other 15% goes towards administration and marketing, which is low-to-average for an organization of this size. This year, St Baldrick's is on pace to raise $16 milion.

So help us out -- make me shave my head, and do your bit to help kids like Nathan and Henry. Click on the link below, and toss us a couple of bucks!


Giants vs Patriots

From the Onion:
Giants: 'We Almost Beat The Patriots Once, We Can Almost Beat Them Again'

"We stood up to them once, hit 'em in the mouth, and made them beat us," Coughlin said, noting that in the previous meeting, the Giants defense put the Patriots in the challenging position of having to score three times over the last 20 minutes of the game, which the Patriots naturally did with time to spare and without apparent effort. "And mark my words, that's what we're going to do in the Super Bowl—meet their strengths with ours, play as hard and as fast as we can, and force them to eventually beat us."

28 January 2008


Not to be confused with tagalog.

My thoughts at MedPage Today.

27 January 2008

Identity Leak

I blog anonymously. By which I mean that nowhere on this site do my name or my likeness appear. But I'm not really anonymous. In the early days of the blog, my name appeared on it, and Google's memory is forever. I have been quoted in the media under my real name, with my blog referenced. Once, an enterprising, and fortunately benign, commenter used the limited info I provide, some very good inductive reasoning and Google to figure out my real identity.

All of which is to say that anonymity is a thin veil, too easily pierced. As was learned, with serious consequences, by superb (and much missed) med bloggers such as Barbados Butterfly, Flea, and Trenchdoc. The list of medblogs to abruptly vanish for this or similar reasons is a very long one - too long to properly credit them all. I only highlight the above ones because they were among my favorites and went down more or less simultaneously.

I post this to remind myself and all the other medbloggers out there that you need to be conscious that what you post is no different from what you write in a medical record -- unlikely to come back to haunt you, but as dangerous as a loaded gun should you write the wrong thing and get unlucky. Anonymous or not, there's no escaping responsibility for what you write.

I have had a couple of aspiring medbloggers ask me about this topic, and my advice is this:
Do not count on your pseudonym to shield your real identity. Know that getting outed is a likely probability, increasingly so the longer you keep up the hobby. Never post anything under cover of anonymity that you would not be comfortable putting your name to, or that you wouldn't want your boss or a malpractice attorney reading back to you as you sit on the witness stand. Have a plan for how you will handle it should the question ever arise, and consider immunizing yourself against that contingency by informing your employer in advance of any negative press.

On the plus side, I recently interviewed a resident for a position in our group, and while we were chatting idly, talking shop and telling stories as doctors do, he referred to a post I had written. He didn't know I was the author, and he didn't reference my blog by name. But, damn! He reads my blog!

Ah, fame, you are a harsh taskmistress that we take such risks for you...

25 January 2008

Distraught Cowboys fan

Every day I get down on my knees and thank the Flying Spaghetti Monster for the internets and the glorious things it brings me. Is there anything else in life that can rival this in its absurdity?

Forgot to self-link

Don't miss a word of my brilliant* prose!

We're from the Government, and we're here to help is over at MedPage Today. Um, Medpage Yesterday?

*Your mileage may vary

Practical tips for new parents

Apparently the parents of this unfortunate baby didn't read this helpful parenting book.

More hysterical images can be seen here.

23 January 2008

AAPL: Great News! (Stock Tanks)

I'll never understand the market. Apple posted their results for the fourth quarter of 2007, their best quarter ever, it announced today.

Revenue was uo 35% over 4Q 2006
Earnings were up 58% over 4Q 2006; net margin was 22%
Earnings crushed Wall Street estimates of $1.61/share, coming in at $1.76/share
2.3 million iPhones were sold, for a total over 4 million in 200 days
22 million iPods were sold, bringing the total number of iPod sales over 100 million
Apple computer sales overall up 44%
Apple desktop computer sales were up 53%; laptops up 38%
Apple projected sales for 1Q 2008 at $6.8 B, up 29% from 1Q 2007

The results?

AAPL dropped 10.6% on the day, to close at 139, its lowest close in 6 months, 30% off the 2007 high-water mark of 199.

I know the market's tanking and all, but is it too much to ask that it make a little sense?

A Real-Life ER Doc

Lots of folks think working in the ER is exciting, and sometimes it is. But many if not most days are like running on a treadmill -- working hard but not really accomplishing anything. There are days I joke my job could have been performed by a trained monkey with a DEA number and a stack of preprinted Vicodin prescriptions.

Over at Ten out of Ten, read a marvelous post in which the writer describes a typical shift, keeping score on the well-known "Useful/Not So Much" scale. Very well-done. And, I might add, a more interesting/satisfying shift than many.

"Screw it, I'm In!"

Bill Clinton for President!

22 January 2008

A New Champion!

Anyone who has ever worked in the ER has at some point participated in a "Guess the Blood Alcohol Level" pool. We're a jaded bunch in the ER, and a level usually needs to be over 400 to be considered truly high, and not till it's over 500 are we generally impressed.

Bear in mind the legal limit in most states is 80.

But I read about a new champion this afternoon. His Blood Alcohol Level was 118, which would not be so remarkable except that he was 11 months old! So for his age bracket, I think he wins the gold medal. I wonder how they got him to blow in the breathalyzer? Maybe there's pacifier adapter...

[ed note. I joke with the gallows humor of an ER doc. This is of course terribly sad and obviously criminal.]

Health wonkery

Over at TAP, Ezra Klein has an excellent revisionist history of the Clinton Health Plan debacle of 1994, with an insightful lesson on why it failed: the Clinton team, inexperienced and distracted, did not adequately prioritize the issue, spent their political capital elsewhere, and put the policy before the politics.

He also reviews the current situation and makes the case for why and how 2009 might be different.

Key stat that I did not know:
[a key index of the cost of health care is] the ratio of family premiums to median family income. In 1987, it was 7 percent. Today it's 17 percent.

Well worth a read. And maybe a little cause for hope.

20 January 2008

I'm a Beautiful Man

I say this as a simple statement of fact, without pride or vanity. Central to my good looks is my hair. I have a full head of, thick, lustrous, straight auburn-brown hair with full body. I have the sort of hair that John Edwards has to pay $400 to get. But my hair is so naturally appealing that I do not to spend an excessive amount of time primping it; it just naturally falls into place. My wife reports that she initially intended to give me the brush-off on our first date, a blind date, but my hair looked so nice she hung on, and the rest is history. I am not obsessed with it, nor do I make a big deal of it, but it cannot be denied that I simply have great hair.

You may wonder why I am perseverating on about my hair, and there is in fact a reason. I am going to shave it off, and I want you to help me in this quest.

Long-time readers of this blog may recall my posts about Nathan. Nathan was a great little boy who had the misfortune to develop neuroblastoma, and despite waging a long and determined fight against this dreadful disease, he died this summer at the age of seven, one of the far too many children to become angels due to neuroblastoma.

I've known Nathan's parents for years and they are among my closest friends. Nathan's death has affected me deeply. My oldest son is now the same age Nathan was when he relapsed, and I think about Nathan almost daily when I tuck my children into bed. It's a terrible thing when things like this happen to children, and in Nathan's memory and honor I want to do what I can to help speed the day when diseases like this are curable.

This is why I joined my friend Matt in participating in this year's St. Baldrick's Day event.

Here's how it works: You click the link and pony up a couple of bucks. I shave my head and post the pictures here for all the world to see. Children's cancer research gets the money. You get the warm satisfying feeling of positive karma spreading through your body. We all win.

So go ahead and click the link below. Give what you can, and I thank you in advance for your generosity. Children's cancers are shamefully underfunded -- less than 1% of all cancer research funds donated through the American Cancer Society are directed towards research on pediatric cancers. Your dollars will fill a critical need, and will make a real difference.

What are you waiting for? Click the link!


Need some ideas

I have a "Ski Mix" on my iPod, and it hasn't changed much at all in the last couple of years.   Honestly, I'm getting bored to tears with the music, and I'd like to make a new playlist for skiing, maybe with some new tunes that I've not heard before.

Any ideas?

Generally, I'm looking for some energetic songs with a nice beat.   I'm not generally a fan of acid metal.   I like 'classic' music from the '80s and '90s but am fairly ignorant of all music produced in this decade century millennium.   Bonus points for anything celtic -- I'm a big fan of the Pogues.   

I'd love to hear your recommendations in the comments...

No Snark, just Interesting

I try, I really try, not to get sucked into the horse-race element of the electoral process. But I can't help it. The Nevada results had been in for hours, and the South Carolina Republican results were still pending, and there I was, clicking "refresh" on the CNN page like a rat with an electrode implanted in its nucleus accumbens. It's just too exciting; I can't help myself.

And I'm not even a freaking Republican!

My humble observations:

  • The Press is all over itself anointing St McCain after his Big Win, yet it is little mentioned that prior to today, Romney had more delegates than McCain, and after today, his lead has grown even larger.
  • Oddly, though Hillary beat Obama in Nevada, Obama apparently won more delegates.
  • Has any front-runner in the national polls ever crashed and burned as spectacularly as Giuliani? Just a month ago, he led in the national polls by a significant margin. After five states, he has received barely half the popular votes of fringe candidate Ron Paul.
  • The degree to which the press loves McCain is matched only by the passion with which major elements of the GOP establishment hate McCain. Rush said that if McCain gets the nomination, it will "destroy the Republican party." Tom DeLay had a similar sentiment and added that McCain is unprincipled and refused to endorse McCain should he be the eventual nominee. I don't get it. McCain seems plenty conservative -- way too much for my tastes. Why the animus? (Bonus points for irony: DeLay called someone else unprincipled!)
  • Strangely, this makes me more open to McCain, maybe on the theory of "the enemy of my enemy is my friend..."
  • Rush has been openly supporting Romney, which is strange, given Romney's not-exactly-spotless conservative credentials. Julia at FireDogLake has an insightful and amusing explanation of why this might be the case.
  • Duncan Hunter drops out of the race, and Grandpa Fred does not, surprising the 99% of the electorate who were unaware they were still running.
  • So if I understand the current dynamic correctly: neo-cons hate Huckabee, evangelicals and movement conservatives hate McCain, corporate conservatives support Romney, tolerate McCain, and fear Huckabee. There's an old saw in politics, "When your opponent is drowning, you throw the sumbitch an anchor." In that spirit, I offer the timeless words of the philosopher Nelson:

18 January 2008

Ten Years

Good lord, has it been a decade already since that fateful day in 1998?

Jon Stewart helps us remember...

Gosh, remember when a blowjob was a scandal? A simple heterosexual blowjob, that didn't involve underage boys, cost money, involve crystal meth, or occur in the airport bathroom? How quaint.

17 January 2008

Advice from CNN

In response to the Glenn Beck incident, CNN posted an article today on "What not to do in the ER." (h/t gobiidae) After some context about long waiting times, the bullet points are below (with my responses):

1. Don't forget to call your doctor on the way to the ER. When ER doctors hear from a fellow physician, they listen.

Better advice might be to call your doctor *before* you decide to go in. If you are not so sick that you need 911, then you probably have time to call your doctor. You may not need to go to the ER at all. Maybe they can advise/reassure you over the phone, call in a prescription, make arrangements for an office visit, a specialty referral, or even a direct admission. However, don't expect that a "call-in" is going to have much of an impact on your ED visit. We won't have a bed waiting for you, you won't be seen any sooner than your complaint would otherwise require, the doctor who took the call may not even be on duty any more, and unless your doctor has important background/technical information about you, the call is just wasted time for both of us.

2. Don't use an ambulance unless you really need it.

Amen. What more can I say?

3. Don't be quiet. If the triage nurse -- that's who makes the decisions about who needs care first -- isn't helping you, don't stop there . . . Speak up. Say, 'I need to see the person in charge.'

Great advice. Wonderful. All we need is for every patient in the waiting room aggressively advocating to be bumped to the front of the line. Disruptive behavior by patients and families is a huge time suck and slows the process down for everybody else. The truth is that if you are in the waiting room, it is for one (or more) of these four reasons: your condition is such that you can safely wait; there are sicker patients who need to be seen first; the ER does not have the resources to care for you now; or the triage nurse has made an error in his/her evaluation of your condition. Complaining to the charge nurse or administrator on call will not change the first three, far more common, situations. If you really think that the triage nurse didn't understand the situation, or if something changes while you are waiting, then, yes, do speak up. But otherwise, frustrating as it is, accept that your spot in the queue is what it is and deal with it. I've been there. It sucks. But until the ER crisis abates, wait times will be a fact of life for most, and complaining won't change that.

4. Don't get angry, and don't lie.

Oh god yes. Disruptive, complaining patients are hard enough to manage. Once emotions are unleashed, things grind to a halt. The staffer(s) who have to de-escalate the angry person get nothing else done till things settle down, and then those staff (be it a doctor, nurse, tech, or administrator) are always themselves upset -- it's a natural reaction -- and need to take a break of their own to reset their attitudes before they get back to work. So getting angry just pulls people off their real jobs and slows everything else down. And lying -- don't go there. If you get busted, and you probably will, you will almost certainly get labeled as a malingerer and whatever real reason you came for will be lost. And you may get subjected to unnecessary medical procedures and risks -- "chest pain" becomes a CT scan with lots of radiation, or "worst headache" becomes a spinal tap, etc. Don't ever lie to your doctor.

5. Don't forget the phone. If things get really bad, and no one is helping you, look for a house phone, dial zero, and ask for the hospital administrator on call.

See #3 above. Also remember that ER staff are people, and when you precipitate confrontations such as this, there is a natural reaction that damages the therapeutic alliance we want to have with patients. The staff won't like you. They will label you as a complainer. They may passively-aggressively sabotage your care in small but unpleasant ways. I don't condone it, and I try to be professional as do we all. But it occurs. Furthermore, excessive complaining and escalation of complaints is a common manipulative behavior, and will raise a legitimate suspicion that the complainer has "an agenda." Most commonly, it's narcotics. Sadly, we also see a lot of folks with various mental health and personality disorders, and these people are more likely to generate complaints. I realize this is advice with a "chilling effect." But it's truth: there are down sides to being too much of an advocate in health care settings. Know this, and make sure that if you do decide to complain, the potential benefit exceeds the likely cost.

Advice they should have given, but did not:

6. Pick the right time to go to the ER

Some may say that if you can choose when to go in, it's not an emergency and you shouldn't go at all. Realistically, there are times/conditions when there is no viable alternative. Holidays and after hours. Those with no doctor or insurance. Certain things many primary care docs just don't do, like setting a fracture, draining an abscess, IV fluids, etc. So, if you can wait and pick your time to go in, you will be much better off. Early mornings -- 6 to 10AM are reliably quiet and you may well be seen promptly. Early evenings 5 to 9PM are by far the worst. After midnight can be good, but between 3-6AM staffers are tired and more prone to making mistakes.

7. Pain is your priority, not ours.

That sounds bad, doesn't it? But my job is first and foremost to make sure you are not going to die or suffer a serious complication, and to make sure the other 40 patients in the ER are not going to die or suffer a complication. For us, it's all about risk, and despite the propaganda, pain is not a vital sign. Severe pain might bump you up a triage category, but it's not going to put you ahead of someone with heart symptoms, difficulty breathing, a serious infection, or stroke symptoms. Yes, we will do our very best to get your pain managed to an acceptable degree, and it is part of our mission to do so. But patients need to understand that if pain management is your main problem, there will be a disconnect between your sense of urgency and ours. If your pain is very acute -- a kidney stone, a long bone fracture, urinary retention, it will garner faster attention than long-standing pain. When things are going well and nobody has to wait (see #6), then we can and do make pain control the priority. But when demand exceeds capacity, the life threats come first.

8. Pay no attention to the man behind the curtain.

Chances are, you will hear the ER staff chatting about non-work related things. It may sound like they are slacking off, or not paying attention to work that needs to be done. Remember, that this is a job for us, and the same social/personal milieu that exists in any other workplace also exists here. I know patients don't like to be an audience for these interactions, and I tell our staff to try to keep the chatter down and out of sight because of the negative perception it generates. But the concept of "acoustic privacy" is new in ER design and in most ERs the patients can hear the conversations from the nursing stations. The fact that we are having conversations does not mean we are not working hard -- often we talk as we chart, review labs, and perform other patient care activities, and in most cases there are rate-limiting steps in patient care that leave us with non-productive time to interact with our co-workers. Maybe I'm waiting for the specialist to return my page. Or the nurse is waiting for the pharmacy to tube down your meds. Or there is no bed to take you back to. So please don't take offense at the fact that not every second of our time is consumed by direct patient care. However, if you do overhear someone say something inappropriate or derogatory, don't be afraid to call them on it. A reminder that patients can hear and are listening is often helpful.

9. Be realistic, and be understanding

We are on the same team, we share the same goals, and we really are working hard for you. Our job is not easy, there are obstacles to care, and outcomes are not always perfect. Everything takes longer than we (and you) would like. The average ER stay in the US is something like three hours. Work with us, be pleasant, express gratitude when it is earned, and be forgiving of our failures. If you can make a positive personal connection with your caregivers, chances are we will work even harder for you. If you are hostile or express a sense of undue entitlement, it will make it harder for us to empathize with you and your care will be adversely affected.

10. Ask a lot of questions.

We are often in a hurry and talk quickly using medical jargon. If you don't understand your diagnosis, the treatment, the alternatives, or the follow-up plan, PLEASE ASK for clarification. If you go home and do badly because we failed to explain things such that you could understand, that is our fault and our liability. So you do us a favor, as well as yourself, when you take a moment to make sure you really understand the plan. Most health care professionals enjoy educating patients, so it's not burdensome to ask. Sometimes your questions are revealing and very helpful.

15 January 2008

From the Journal of Proving the Intiutively Obvious

Blogging on Peer-Reviewed ResearchI don't know why it is, but for some reason, a large proportion of Emergency Medicine research makes me roll my eyes and mutter, "well, duh!" under my breath. Like the paper I read a number of years ago which demonstrated, with ample citations, that being on a backboard hurts. "Well, duh!" Ever been on one? Ever seen poor trauma patients strapped to the board begging to be let off? We needed a peer-reviewed paper to establish that fact? (Using the Visual Analog Scale (VAS) for pain.) Geez.

Well, another one hit the press today. Not as inane, but every little bit as obvious, IMHO, to anybody who has set foot in an ER over the last decade. Apparently, the average waiting times in ERs can sometimes get a bit long, and are increasing. Given the fact that since 1994 the number of ER's in the US has decreased from 5000 to 4500 and the number of ER visits has gone up 25% (from 90 Million to 115 Million), what else would any rational person expect?

Sarcasm aside, this is important research. Add it to the pile, on top of the IOM report and the rest of the data showing that the nation's ERs are in crisis.

This study resembles one I blogged on last week, in that it represents some interesting data mining of the NAMCS database (did this just become available or something?), again to good effect. The results showed that the average wait time in the ER increased about 4% per year over the seven-year study period, and, interestingly, that patients with heart attacks had wait times that increased 12% per year (despite a huge increase in awareness of the "time is muscle" concept and Medicare's focus on the door-to-dilation time for heart attack patients). The overall wait time increase was more than a third: 36%, This was consistent with the wait time increase for patients triaged "Emergent" -- 40%, and heart attack (AMI) patients' waits increased a staggering 150%. No explanation is given as to why AMI patients had a larger proportionate increase in wait times... an odd omission given the importance of the topic, but then, data-mining is good for finding problems, not so great for pinpointing the causes.

Whitecoat will probably be annoyed to find that the study noted another example of racial disparity in the longer wait times for minorities. In this case, this may be accounted for by the fact that wait times were longer at urban and academic EDs, though the authors do not draw that exact conclusion. And unlike the other study I blogged, apparently, payor status had a large effect on quality of care -- wait times increased by 50%. The authors are not entirely clear whether that may be due to the urban hospital effect, though one would hope a decent multivariate regression analysis would sort that out. The crosstabs are missing, also, and uninsured patients are more likely to show up with less-urgent complaints, so that may account for the longer wait times by the uninsured.

Nonprofit hospitals, unsuprisingly, fared worse than for-profit hospitals. This is by no means a validation of the profit motive in providing health care, but, I suspect, more due to the fact the nonprofits tend to care for underserved populations and have less resources to expand their service capacity to meet demand.

Also interestingly, the average urgency of ER visits declined. This is consistent with the general impression that more people are using the ER for their primary care. While not exactly desirable, this is indeed consistent with our Dear Leader's idea of Universal Health Care.

Don't be deceived by the relatively "short" wait times cited -- many in the 15-30 minute range. These are average times, and remember that for one patient seen on arrival (say, a patient arriving by ambulance, a detail not referenced in the paper), there's another who waited an hour or more. Our ED has an average door-to-doctor time of about 25 minutes, and we are rather proud of that fact, but there are still days when the waiting time is three hours. So averaging can make the ER look better than it really is.

Ultimately, there's no real take-home point beyond that encapsulated in the headline. The nation's ERs are in crisis -- over-burdened, under-funded, beset by the collapse of primary care, and hamstrung by the scarcity of inpatient hospital beds. How much longer will it take before the policy-makers wake up and do something to avert the impending catastrophe? I first heard about this via a diary on Daily Kos, and the author took exception to the fact that a mass-casualty incident such as a terrorist attack was cited as a potential threat. But when you look at the the ED, and its role in disaster preparedness for unlikely events such as terrorist attacks, pandemic influenza, SARS, etc, you realize how thin the line is separating a "shitty but functioning system" from "complete and total collapse." And being a paranoid ER doc, my job is to assume the worst-case scenario and proceed as if it is the case.

Kevin and some others like to scream about CanadaCare and other bogeymen of the healthcare wonk set, but, really which is more emblematic of a broken health care system: the system which requires long waits for elective surgery, or that which progressively fails to care for heart attacks in a timely fashion?

citation: Health Affairs, Waits To See An Emergency Department Physician: U.S. Trends And Predictors, 1997-2004;
DOI: 10.1377/hlthaff.27.2.w84

13 January 2008

An Act of Defiance

We had a new baby girl eleven days ago. The First- and Second-born sons seem to be adapting very well to her arrival, but we have been on the lookout for some pushback, some sign that they are not entirely pleased about arrival of the little one. But so far, there has been no overt signs of resistance to the new regime.

Until last night. We were watching a movie, and around 11:00 PM I heard Second-born son rustling about, playing quietly. I went upstairs to tuck him back into bed and found him, only too proud to show me his handiwork:

11 January 2008


I hadn't followed the "Iranian Speedboats Harass US Navy Ships in Persian Gulf" incident too much. My cursory review of the incident didn't strike me as being particularly portentious or significant.

But maybe it is more important. Historian Walter Russell Mead writes in the Wall Street Journal:

From the 18th century to the present day, threats to American ships and maritime commerce have been the way most U.S. wars start. The pattern began early. Attacks by the Barbary pirates in the Mediterranean led President Thomas Jefferson to send the U.S. Navy thousands of miles on a risky expedition to suppress the threat to American merchant ships in 1801. During the Napoleonic Wars, British and French interference with U.S. commerce led to a series of crises and undeclared "quasi-wars" that culminated in the War of 1812.

Sumatran attacks on U.S. ships in the 1830s led President Andrew Jackson to dispatch naval forces on a retaliatory mission. The widespread (though probably erroneous) U.S. belief that the USS Maine had been destroyed by a Spanish mine in the harbor of Havana, Cuba, forced a reluctant President William McKinley to launch the Spanish-American War in 1898.

The 20th century was no different. German attacks on U.S. ships in World War I brought America into that war; the Japanese attack on the fleet at Pearl Harbor brought the U.S. into World War II. The Tonkin Gulf incident in 1964 (alleged attacks on U.S. ships by North Vietnamese boats) led Congress to authorize President Lyndon Johnson's use of force in Indochina. The North Korean seizure of the USS Pueblo in 1968 touched off a near-war crisis at the height of the Vietnam conflict, and the Cambodian seizure of the Mayaguez, a container ship, led President Gerald Ford to dispatch combat forces back to Indochina less than one month after the U.S. withdrawal from Saigon in 1975. [...]

Last weekend, the Iranians fled before shots were fired. Good for them. If Iran wants a large-scale military conflict with a U.S. that is angry, aroused and united, endangering American naval vessels in the Straits of Hormuz is the right way to get one.

Well, when you put it that way, and with an administration eager for war with Iran, it's a little chilling, isn't it?

10 January 2008

Couldn't Happen to a Nicer Guy

I read on KevinMD about the angry tirade CNN's resident demagogue, racist, homophobe and all-around scumbag Glenn Beck posted on YouTube, in which he detailed what sounded like a truly horrible post-op experience. He wrote about horrible uncontrolled pain, an unanticipated trip to the ER (complete with obligatory false expectations of "Your doctor called in and your room is waiting"), and an admission for pain control.

Let's be frank. I have a keen Bullshit Detector. It comes with working for a decade in the ER. Beck's behavior sounded, to me, like the classic behavior of a drug-seeking patient. Complete with dramatic description of the pain, hysterical behavior, unrealistic expectations, and requirement for massive doses of opioid medications. But I read Beck's narrative with a grain of salt. I didn't know what surgery he had had, and I imagined that it might have been a lumbar laminectomy or fusion or something like that, and those can indeed result in very severe post-op pain. His behavior, while a little over the top, would not be inconsistent with a dramatic personality and severe pain. So I cut him some slack and moved on.

But then I found out what he had had done: hemorrhoid surgery.

I shit you not.

It's hard to imagine something more trivial. Uncomfortable? Surely. Desirable? No. But ohmygod did this guy make a mountain out of a proverbial molehill (no pun intended).

Let's go through this in detail:

"The anesthesiologist told me later [...] I've never had anybody wake up on the table before. He said, as soon as I turned you off, as soon as I turned all the juice off because we were done, he said, you woke up and turned around and said, I'm in pain. He said, so I turned everything back on. It took three hours to stabilize me on pain. [...] When I was in the recovery room, the nurse who was watching me, I would hear alarm bells and she would say, "Mr. Beck, breathe, Mr. Beck, just take a deep breath." I was not breathing. "

So this would imply to me that he was not under general, but maybe MAC (moderate sedation), in which the goal was to make the patient sleepy but not "fully out." Many hemorrhoid cases are done under local only. It's ridiculously uncommon to wake up from general anesthesia via an inhaled anesthetic or propofol. Apparently he had a very high medication tolerance (consistent with his prior history of substance abuse) and complained of persistent pain even when he had received so much medication that he was experiencing respiratory depression.

The exact timeline after that gets fuzzy, understandably. He was seen in the ER for urinary retention (not uncommon after getting high doses of narcotics). He was apparently admitted and recounts being on a PCA, "Morphine, fentanyl, Toradol, percocet every two hours and a morphine pump," and discharged on a fentanyl patch! Inpatient for five days! Wowie. For a hemorrhoid.

I can understand and sympathize with Mr. Beck if there was indeed a delay in getting the catheter in. In our ER those cases usually get brought more or less right back, because retention is so uncomfortable and it's such a quick fix. He was annoyed with the staff's apparent lack of empathy. I wonder if his histrionic behavior at triage contributed to the lack of urgency the nursing staff felt in addressing his complaints (in general, the more dramatic the behavior, the less acute the problem). It's hard to say whether the staff was truly indifferent and callous, or whether Beck's self-absorbed perspective just made them seem so. Either is perfectly possible, but Beck's credibility isn't running real high in this self-aggrandizing narrative.

Some of KevinMD's commenters thought that it was dumping on the ER that he was sent there for admission. In fact, I disagree. I go nuts with frustration when people show up saying "my husband's doctor called, they're expecting him, he needs to have a catheter put in and he needs pain medication right away; he needs to be admitted." But given that he had urinary retention, the ER was in fact an appropriate place to go, and the evidence would suggest that his doctor did the right thing and admitted him himself. So, not truly a dump.

I'm still amazed that the surgeon admitted him for hemorrhoid pain. I wonder, had he not been a TV personality and VIP, would he have been? In my experience, these cases wind up with the surgeon (or his on-call partner who doesn't know the patient) not seeing the patient and telling the ER doc over the phone "just send him home." In most cases, this puts me in the position of being the "bad guy," but on the other hand, I'm used to being the bad guy, and there is little justifiable indication to admit people for pain which in any reasonable person would be managed with NSAIDS and mild to moderately potent opioids.

Patients like Beck are a terrible challenge. With prior histories of drug abuse, they often have poor response to standard treatments for pain, and concomitantly, a very heightened perception of pain. Throw in poor coping skills, a sense of entitlement, maybe narcissistic personality disorder, and it's a management nightmare. No amount of medicine is ever enough. You can, as demonstrated, put them into a drug-induced coma and they still complain of unbearable pain, and the pain does not resolve even as the physiologic insult heals. So as a doctor, you either wind up over-medicating them to little effect (and feeling like you are contributing to the problem), or sending them out, still complaining of pain, and feeling like a heartless bastard.

One might hope that this experience might teach Beck some empathy and compassion, traits notably absent from his media personality. The tone of his blog post makes me expect that he will instead mount a crusade against the evil and indifferent medical community and their inability to treat hemorrhoid pain. Great; just what we need. Just as well nobody is watching.

09 January 2008

Best Care Anywhere?

Not in the US.

In France. Or Japan. Or Australia.

In fact, any one of the 18 other industrialized nations ranked by the journal Health Affairs (subscription required) in a recent study, as cited by Reuters.

The study looked at what they called "preventable deaths," defined as "deaths before age 75 from numerous causes, including heart disease, stroke, certain cancers, diabetes, certain bacterial infections and complications of common surgical procedures." By this metric, France had the highest quality care with 64.8 preventable deaths per 100,000 people. Japan and Australia lagged with 71.2 and 71.3.

The United States came in dead last with 109.7 "preventable" deaths per 100,000 people. By this measure, somewhere north of 100,000 Americans die prematurely every year.

The study's lead author was quoted as saying "I wouldn't say it (the last-place ranking) is a condemnation, because I think health care in the U.S. is pretty good if you have access. But if you don't, I think that's the main problem, isn't it?"

You can quibble with the details of this study -- the definition of "preventable deaths" is always controversial and open to debate. And there are differences between the populations in terms of general health and the incidence of certain diseases. But the findings provide a reasonable comparison between countries, and it's not unreasonable to conclude that this provides at least a partial index of the overall quality of the health care system. Further, since this reproduces the results from multiple other studies showing that the US has, on aggregate, the worst health outcomes in the industrialized world, further credibility would be added to this result.

And for this, we pay $7000 per capita. Again, we pay the most, and get the least.


Blogorygmi riffs on the Presidential race via the extended metaphor of
"If it were the ER..."

08 January 2008

More milestones

From Today's NYT:
Health care spending exceeds $2 Trillion

Up to 16% of the GDP. How long is this sustainable?

Grady Hospital in danger
(again, or, more properly, still):

Once admired for its skill in treating a population afflicted by both social and physical ills, Grady, a teaching hospital, now faces the prospect of losing its accreditation. Only short-term financial transfusions have kept it from closing its doors, as Martin Luther King Jr.-Harbor Hospital in Los Angeles County did last year. That scenario would flood the region’s other hospitals with uninsured patients and eliminate the training ground for one of every four Georgia doctors.
There are now almost 20% fewer public "safety net" hospitals than there were 15 years ago. But rather than Grady's well-known financial troubles, it may well be the Joint Commission that deals the killing blow:
Last month, the Joint Commission, the country’s leading health care accrediting agency, raised serious concerns about Grady’s status after observing numerous significant shortcomings during a five-day inspection. Although the commission has not yet released a public report, hospital officials, speaking anonymously, said the commission’s concerns included broken equipment, sanitation and the adequacy of staff supervision.
Will Grady join MLK-Harbor as an anchor safety-net hospital closing its doors? And it's not just in Georgia that the county hospitals are crumbling. ABC reports on Parkland Hospital in Texas:
"I've brought people back that have been in the waiting room 24 hours," says nurse Bunni Mayfield as she scans the hallway for precious bed space. "It's pretty sad. People who come to county know it's going to happen."

06 January 2008

Security, please!

Man brings a hand grenade to the ER.

Yikes. I knew Detroit was a rough town, but...

"Demerol? Certainly sir. How much would you like? Just don't pull the pin."

We work in one site where there is no security presence (small hospital). It can be a little scary sometimes. Glad we don't have to deal with that sort of thing, though.

Sunday Morning Snark

From an open thread over at the Great Orange Satan, a comprehensive list of the various (non-obscene) nicknames applied to the current occupant of the Oval Office:

The Decider
The Boy King
Smirky McStumbletounge
Worst. President. Ever.
Moron in Chief
That Man
King George
Clown Prince
Miserable failure
Bush the lesser
Commander Codpiece
(and his little Weapon of Mass Destruction)
Reverse Midas
Bubble Boy
The Texecutioner
Dr Zeaus
Commander Cuckoo-Bananas
Chimpy McFlightsuit
Dear Leader
The Uniter
Mission Accomplisher
Incurious George
The village idiot
The Turdmaster (c. ref. "Turdblossom" Rove)
C+ Augustus
Mr. Misunderestimated
Mr 24 percent
Commander in thief
Pretzel boy
Dick Cheney's hand puppet
President* Bush (*disputed)
President Rainman
Mr Malaprop
The Lame Duck
Little Lord Pissy Pants
Mayberry Machiavelli

[photo: Northrop SM-62 Snark Guided Missile]

04 January 2008


My little blog cracked 200,000 visits today. Small potatoes in the world of the blogosphere, but still noteworthy. (I'm up to a "Flappy bird" in the TTLB Ecosystem.) I don't know how sitemeter calculates the traffic, and wonder how many of those visits are indexing bots. But I'm happy to take it as it appears to be, since that's the conclusion that is most gratifying...

I'd like to extend a real thanks to all the folks who have dropped by to read this blog, both those who enjoy my writing and opinions, as well as those who come by to disagree. I really appreciate your feedback and your opinions. As Ezra Klein frequently says, "My commenters are smarter than me." Thanks for taking the time and effort to come here.

Race and Pain

Blogging at MedPage while the baby naps....

02 January 2008

An Introduction

First-born son and Second-born son were very excited to meet First-born daughter today.

All is well.

Sporadic blogging may be expected for the next couple of months, with many a terse three-AM post. I hate one-handed typing...

2008's Worst Pun of the Year

That was quick. Took me a few minutes to comprehend, followed by laughter and self-loathing for finding it funny.

Bad Astronomy

01 January 2008

What the hell is that?

I've now been working in the ER for long enough that I feel like I've seen it all. It's not true, not by a long shot, but I am hard to impress. I've removed so many mundane and sexual foreign objects from so many orifices that it generally doesn't rate on the interest meter any more. Sure, it's not an everyday occurrence, but I actually take more pleasure and interest in treating a little girl who swallowed a dime than some deviant who crammed unknown objects up his butt.

So I had entirely forgotten about the most recent sexual device removal until I got a phone call from a very confused urologist today. A few weeks ago, a fellow presented requesting removal of a "male chastity device" which was, um, stuck. I didn't even know such things existed. Apparently, the penis is inserted into a restrictive container and secured in place using a retaining ring locked around the base of the scrotum. It prevents erections, and I gather is a part of submissive roleplay. A quick google search (which I do not recommend for the faint of heart) turned up a surprising number and variety of such devices, but the one this gentleman had on resembled this:
It was made of steel and the lock was jammed. It was damned difficult to remove. Ring cutters are no good on steel, being made for soft metals. I have used rotating cutting tools before but they tend to heat up the metal too much. Bolt cutters are ... imprecise and thus difficult to use in the genital region. Ultimately, though, it took our largest and strongest bolt cutters and a fair amount of lubricant to remove the offending device. The patient did not wish the device returned to him, and so after the entire staff had gazed at it in wonderment it was placed in the dirty utility room for disposal.

Or so we thought.

I am not sure exactly in which bin it was deposited, but evidently, a well-intentioned cleaning crew picked it up with the rest of the used surgical instruments, and took it back to central sterile supply, where it was washed and sterilized. I can see why -- being stainless steel, it does look like something that ought to be re-used, and the cleaning guys would be afraid to throw it out, not knowing what it was for. I can only imagine their puzzlement as the techs contemplated this unfamiliar object, and in the end they drew a reasonable conclusion from its shape and included it with one of the urologists' surgical trays, with an explanatory note. I happened to be in the ER when the urologist happened to open up this operative tray to find one unexpected instrument, and called down for an explanation. After a great deal of laughter, the mystery was cleared up and I can only presume the device will finally be disposed of.

Unless the cleaning crew finds it again...