29 September 2008


Wheee! Can't remember ever seeing a week like this before! Oh me oh my.

I don't even know what to think anymore. Krugman says a bad deal's better than no deal. DeLong says we should just nationalize them all. Roubini says we all need to find a nice cave to live in. McCain said he only he could save the nation by getting the house republicans to vote for the bill, but in the end, Boehner said the house GOP killed it because Pelosi hurt their feelings. (Just for the record: I admire the courage of all the reps of both parties who voted no. This bill was railroaded through with little consideration and huge pressure, promises of doom if it did not pass, and it took a lot of balls to withstand that pressure and say "no." Whether that'll make things worse, I dunno, but I admire the balls.)

Wowie. I don't think anybody knows what's going on anymore.

And in the midst of the carnage, AAPL was downgraded today (nice timing, Morgan Stanley) and plunged 20% on the day:

Well, just for the record, I bought AAPL today, and also bought into the indices. I'm bullish, long-term, though for sure the short term looks bleak. But values like these don't come around too often.

Buckle up, kids! It's gonna be a wild ride!

Why I love the Huffington Post

Check out that headline and the graphic. Oh, the pathos! Yes,this is a big deal, but the banner headlines on the site are pretty much always in the apocalyptic "Next Coming" font, even for more mundane stuff. And that pic! I'm sure it's photoshopped -- the Capitol is in full sunlight despite the ominous black clouds. But it's a beautiful effect; finely crafted on pretty short notice.

It's basically the New York Post of the left. News, but full of drama, hyperbole, opinion (and some questionable veracity). Take it for what it's worth, but it does bring a smile to my face.

Patients say the damndest things

He was 93 years old, and had come to the ER for what turned out to be CHF: tired, weak, short of breath on exertion, and a rapid pulse. Not too challenging, and I was practically filling out the admission orders before I even went into the room to see him.

He was a charming elderly gentleman, gravely dignified, and entirely cognitively intact. I interviewed and examined him and explained the plan.

"There's one more thing I'd like to talk to you about, doctor," he said, when I was done. "And I don't know what it is all about, but it has me quite concerned, I can tell you."

He took a deep breath, and continued, "I lost my penis yesterday."

It took a great deal of self-control on my part to keep my face straight and my voice even. "Really? Tell me about it."

"It was there the other day, but yesterday, it was just gone." Lowering his voice, in a conspiratorial whisper he added, "I think my body just swallowed it up."

The medical mystery was not a mystery at all: though he was a thin gentleman, he had been sitting in his chair a lot, and his pubic region was edematous. The swelling had caused his penis to involute, and it was entirely retracted. I explained gently to him that once we got the fluid off, it would be better, and his relief was palpable.

But still, I wager never again in my life will I hear someone say these words to me:
I lost my penis yesterday.

I love my job.

28 September 2008

If six year olds could vote

Cracked Magazine had a contest for readers to imagine with what political ads would look like if the voting age was lowered to six.

Some of the "ads" are pretty funny.

27 September 2008


I did not know this, but September is Childhood Cancer Month.

If you have a moment, spend some time viewing this photoblog at the online Boston Globe. Powerful. Don't miss the beautiful picture of Nathan Gentry at #6.

I still think about Nathan every single day.

And there are still so many kids out there fighting their own battles. If you are so inclined, it's never a bad time to toss a few bucks to research for childhood cancer. I'm a big fan of the St Baldrick's foundation, and you can donate on line here.

26 September 2008

You don't call in sick...

You call in dead.

That's what we joked, darkly, when I was in residency. The workload is so huge and the disruption so severe when someone was out, that there was tremendous pressure not to call in sick. In fact, I don't think I was ever directly discouraged from calling in sick, but there was just this understanding, that you had better really be sick if you missed a day.

I absorbed that ethic well, and in the twelve years of my career have taken fewer than twelve days off, I am sure. Most ER docs of my acquaintance share the same approach. I have been administering sick call for our group for a while, and I simply cannot recall anyone ever calling in for what seemed to be a frivolous reason.

But some are more Hard Core than others. I remember one morning, a few years back, when I came on shift. I was surprised to see that the partner who I was supposed to replace was on "the board" as a patient. This guy, I'll call him Bill, was famous in our group. He worked eighteen shifts a month and moonlighted as well. He always came in and got started thirty minutes early. He was an absolute shit magnet and always wound up with the knottiest, most difficult cases and always pulled it off with a smile. We joked that if we got sick, we would never let him care for us, not because he wasn't awesome, but because he would surely find some horrible diagnosis! (In fact, he was responsible for these two of my favorite cases.)

Apparently Bill had fallen ill while on shift. Fever, RLQ abdominal pain, a surgical consult and on the schedule for the OR for an appendectomy. He had a fairly large number of patients to sign out to me -- it had been a busy night. (We double cover at night, so the other doc helped as best he could till I got there.) I got the briefing and went to work, while Bill went upstairs to the OR.

The ER was swamped and I sort of forgot about Bill for a while. Eventually I got the labs and scans all back on one of my "inherited" patients, and I went to the room to let her know she was going to be admitted. Who should come out of the room, but Bill! He was wearing a hospital gown and robe, holding his IV pole, and laughing as he told the patient she was going to be admitted. He wisecracked, "Maybe we'll share a room!"

"What are you doing down here?" I asked, confused. He airily replied, "Oh, you know, I hadn't finished my dictations, and so I was looking in the computer and saw the results on this lady, so I thought I'd come down and dispo her for you, cause I know the story and the exam better. I'll just call the admitting doc and then I'll finish up my charts and go back upstairs."

At that moment, the surgeon rounded the corner. She stood all of five foot three, but her eyes were blazing with fury and she seemed to tower over us both. "What the hell do you think you are doing?!" She spat the words through gritted teeth, and I backed slowly away, lest she view me as an accomplice. "The nurses told me you had 'escaped' from post-op, and I didn't believe them, but this! This! I. Will. Not. Have. It." I think Bill tried, feebly, to explain himself, but she rode right over him in her rage. "You will stop what you are doing right now. You will lie down on this gurney," she gestured at an empty hallway bed, "and you will come back upstairs with me now. And if you so much as think of getting out of bed," she continued, "I will have you put in four-point restraints."

I endured a withering look from her as I helped Bill onto the gurney. He winced a bit, less from the pain than from the tongue-lashing that continued without pause as we got him situated. By this time a curious crowd of sober-looking nurses had gathered around, and watched impassively as the surgeon drafted a couple of idle hands to take her patient back upstairs. Only after they were safely out of sight did we, as one, erupt in hysterical laughter.

Wiping a tear from her eye, the charge nurse observed that only Bill would have pulled a stunt like that. She confessed that the post-op nurses had called down looking for Bill, and it was she that had ratted him out. I heard later that the surgeon had kept him in the hospital an extra day as punishment.

Only Bill.

24 September 2008

Just one more!

Credit where it's due: for the first time, well, since 9/11, I listened to Bush speak and found myself nodding in agreement with much of what he had to say. Not too much credit to the man: he was reading words someone else wrote about a deal he was obligated to make, but for the first time he had the maturity or wisdom to make the compromise and get the job done, rather than stamp his feet and insist on "my way or the highway."

I know what I said earlier, but there are in fact a few redeeming qualities about this $700 billion deal, as far as available details can be understood:

  • The Treasury will essentially receive stock options (sort of) in companies they bail out, so that if taxpayers may receive a return on the investment in these companies.
  • The distressed assets will be purchased at their current fair market value -- a deep discount from their nominal value, as initially suggested.
  • With no need to leverage these assets further, the Treasury has the ability to wait and see if their actual value improves, which may be the case.
  • There's some fluff about executive compensation and bankruptcy protections for consumers which is irrelevant but nice symbolism, and the oversight requirement is apparently satisfied.
So, as I understand this, this package is not a simple giveaway to the investment firms, comes at some cost to these firms (and their execs), and has potential to return value to the taxpayers -- conceivably to turn a profit, though few expect that. Though the cash outlay may be in the high 12 figures (!) the actual cost after returns should be much much lower.

By the way, I may be fiercely liberal, but it may surprise you to learn that I am what used to be called a fiscal conservative (before that phrase was retired due to excessive irony), now I guess I would be called a deficit hawk.

On a snarkier note: did anyone catch the Palin trainwreck tonight? I had to feel bad for her, sent out there to claim that McCain was not a deregulation fanatic. She got crucified by Couric on that point, which made her look bad, but that wasn't entirely her fault: her marching orders were to claim something patently false. It's hard to put lipstick on that, er, um, never mind. But it was pretty inexcusable that she had no clue what their stance is on a foreclosure moratorium. That was pathetic.

It's no wonder that the McCain camp is trying to scuttle the VP debate. They must be terrified at the prospect of Palin having to face tough, unscripted questions. I was a little freaked about about Palin for a while, but it's becoming more clear every day that this choice was a gift for the Obama/Biden ticket.

OK, I swear, back to the medical stuff tomorrow!


John McCain is going back to the Senate! He will probably need to bring his Senatorial ID with him, as he's been gone so long that nobody will recognize him. Just for the record, McCain has not actually cast a ballot in the Senate since April 8th, and has been the most absent senator, missing 412 of the 643 votes since January 2007. Cancel the debate -- the economy needs me now!!

Letterman is devastating:

"You don't suspend your campaign. This doesn't smell right. This isn't the way a tested hero behaves." And he joked: "I think someone's putting something in his metamucil."

"He can't run the campaign because the economy is cratering? Fine, put in your second string quarterback, Sara Palin. Where is she?"

"What are you going to do if you're elected and things get tough? Suspend being president? We've got a guy like that now!"
Obama snarks that as President, sometimes you have to be able to do two things at once. Like walk and chew gum. (my words)

According to TPM, the deal is 98% done, and it looks pretty good -- the Treasury capitulated on all the major points. Taxpayers may well get value for their dollars in a buy-out, rather than a bailout. McCain, I infer, is just jetting in to grandstand and try to claim the credit.

Desperate, and sad.

Right meets left

A provocative piece over at the Great Orange Satan (that would be Daily Kos) titled "A Conservative Case for Universal Health Care."

Some key points:

  • Government already controls about half of the health care market and it will get larger. Any hope of creating an efficient "free market" here is fantasy.
  • Liberals need to hold their nose and concede a "relief valve" like there is in Great Britain, where people and companies can purchase insurance for health care "above the basics" and jump the queue to a private health care facility. Focus on getting the basics into a universal plan, and let the rich still get some benefit from being rich.
  • ALL health care systems ration. The European systems ration the "middle procedures," those that are "important but not urgent," like knee replacements, and are also forced to look at cost-benefit on speculative treatments. The U.S. instead rations based on who your employer is. My conservatism says we need to look at cost-benefit on some rational basis.
  • Most health care lawsuits are not about "malpractice." They are about fear of loss of future access to health care.
There's more. It's worth a read.

Don't know how Kevin missed this

It's old -- almost two weeks old, which makes it paleolithic by blogosphere standards, but Dean Ornish had a great article in Newsweek titled "The Collapse of Primary Care."

While nothing in the article is new or surprising to readers of this blog (or Kevin's), it's cogent and well-written, and I think of significance because it shows how the, well, the impending collapse of primary care in the US is percolating up to the forefront of the public consciousness. A groundswell of consensus opinion that the system is broken and needs to be fixed is a necessary precondition for fundamental reform.

More like this please.

Politics (Meta)

I used to notice that when I put up a purely political piece, that the comment section was usually over-run with biting responses from conservatives. I attributed this to the fact that the med-blogosphere has an undeniable right-wing, reactionary slant. And I don't mind, truly. There is something satisfying about being a gadfly to those who see things differently. Sometimes it got a little depressing, though, when the comments section would devolve into a shouting match between the trolls and me.

Lately, I've noticed a shift. A lot more people are commenting on the political posts from a progressive point of view. Maybe it's the generally increasing traffic here, or maybe it's due to the increased energy and attention on the left, as the political cycle heats up. I don't know, but it's a welcome change. There are still plenty of dissenters, but I enjoy seeing that there are readers out there who share my viewpoint on politics and health policy.

So to all of you who venture into the sandbox in support: thanks. It's good to know you've got my back.

I have a better idea

So the Treasury has a trillion dollars that's burning a hole in its pocket. Hank Paulson wants to give it all to his golfing buddies, no strings attached.

A trillion bucks, huh? That's a whole lotta scratch.

Keeping the financial markets stable is a nice idea. I'm no economist, but as someone who is vested in the markets and who would like to retire someday, I can see the value in that. I'm just not sure that it's the best way to spend that cash, ot that it's even really necessary. I thought the beauty of free markets was how resiliant they are supposed to be, right?

It's a funny statement on the political discourse in this country that if anyone proposed taking a trillion dollars and doing anything other than giving it to really rich people (or spending it on an awesome war), they would be ridiculed as non-serious people. But there are a lot of other priorities that might be better served by that sort of expenditure. For example, if we chose to dedicate that trillion dollars not towards the health of our markets, but towards the health of the American people, we could:

But that's just crazy talk.

Speak out now

In their continuing war against women's reproductive rights, HHS Secretary Leavitt has proposed a new federal regulation which would allow healthcare providers to refuse to provide any service they deem would violate their personal values.

Now let's be clear: this is not about abortion. There already exist in many other statutes -- federal and state -- ample protections for OB/GYNs who do not wish to perform terminations. That's not at issue here, the Secretary's claims to the contrary notwithstanding. This is entirely intended to reinforce the Christian right's effort to redefine contraception as abortion, specifically post coital contraception, also known as "Plan B" or the "morning after pill." Under this rule, which applies essentially to all hospitals nationwide (as recipients of CMS funds), the ER doctor could deny rape victims access to emergency contraception, and in fact could even withhold the information that Plan B is an option to a woman who is unaware it exists! This rule would also allow hospitals to declare it their policy that Plan B will not be prescribed from their facility, and HHS would accept this as an "institutional health care provider's" conscientious objection.

While in many settings this would not impact women's access to this service, in areas where there are no alternative facilities to refer patients to, or in conservative regions where all the facilities might adopt this conscience clause, then this rule may allow a de facto abolition of a woman's right to choose post-coital contraception.

The Department will be accepting comments for the next two days on their web site. Take a moment to express your objections.

Some general principles I would endorse:

  • The welfare of the patient must be at the center of medical decision-making and treatment.
  • The religious/moral beliefs of a caregiver or religious doctrine of a health care institution cannot be allowed to obstruct a patient's access to care.
  • Patients must be able to make treatment decisions based on accurate medical information and their own ethical or religious beliefs. No information may be withheld.
  • Health care institutions must provide emergency care immediately, without exception.
  • For non-emergency care, referrals must be made if treatment is refused.
  • The ability of non-objecting health practitioners to serve their patients must be safeguarded. No physician "gag rules" should be allowed.
The anti-choice zealots out there like to say that " health care providers shouldn’t have to check their conscience at the hospital door." With respect, they are wrong. As a physician caring for the vulnerable, when options are limited, I must subordinate my personal opinions to the values and welfare of the patient. I often do not approve of my patients or their choices. That is immaterial; it is not my role to be their pastor or for me to impose my moral code onto them.

To put it more simply, while I may have my opinions (and I certainly do), patients come first.



Dear Mr. American,

Good day and compliments.

I am HENRI PAULSON, the Ministry of the Treasury of the Republic of America, and the personal financial adviser to GEORGE W. BUSH (the eldest son of the former dictator of America, GENERAL GEORGE HUSSEIN WALKER BUSH).

This letter will definitely come to you as a huge surprise, but I implore you to take the time to go through it carefully as the decision you make will go off a long way to determine the future and continued existence of the entire members of my country.

It is with deep sense of purpose and utmost sincerity that I have the privilege to write you this letter knowing full well how you will feel as regards to receiving a mail from somebody you have not met or seen before. There is no need to fear, I got your address from a Wall Street business directory which lends credence to my humble belief. I also assure you of my honesty and trustworthiness. I need to ask you to support an urgent secret business relationship with a transfer of funds of great magnitude.

During the last Military Regime here in America, the Government officials set up companies and awarded themselves contracts which were grossly over-invoiced in various ministries. My country has had great crisis that has caused the need for large transfer of funds of US$800,000,000,000.00 (eight hundred billion US dollars) in cash for safe-keeping. If you would assist me in this transfer, it would be of most profitable for you.

I am working with the honourable MR. PHIL GRAMM, lobbyist for UBS, who will be my replacement as Ministry of the Treasury in January. As Senator, you may know him as leader of the American banking deregulation movement in the 1990s.

This is a matter of great urgence. We need a immediate blank cheque. We need the funds as quickly as possible. We cannot directly transfer these funds in the names of our close friends because as civil servants we are constantly under surveillance by Democratic members of Congress, the media, and the American public. My family lawyer, MR. RICK DAVIS, advised me that I should look for a reliable and trustworthy person who will act as a next of kin so the funds can be transferred.

Please note that this transaction is 100% safe and we hope to commence the transfer latest seven (7) banking days from the date of the receipt of the following information: all of your bank account, IRA and college fund account numbers and those of your children and grandchildren to wallstreetbailout@treasury.gov so that we may transfer your commission for this transaction. This way we will use your country's name to apply for payment in your name. After I receive that information, I will respond with detailed information about safeguards that will be used to protect the funds. That's all. Let me know what you think about this.

We are looking forward to doing this business with you and solicit your confidentiality in this transaction.

May Allah show you mercy as you do so?

Your faithfully,

Dr. Minister of Treasury Paulson

(h/t Americablog)

23 September 2008

Real world iPhone experience

This pretty much mirrors my experience with the iPhone 3G. Don't get me wrong -- I love it! What other phone -- a fracking phone, for the love of Jeebus -- can play a flight simulator like X-Plane? The web browsing, contact management, and interface are amazing.

But it isn't fast in most of the basic operations. The GPS, in particular, is accurate but so slow that Garmin doesn't need to worry just yet. Web pages load tolerably but not fast. Opening emails is frustratingly slow.

Still, I'll never go back to my Blackberry.

Pet Causes

Those of you whose memories stretch all the way back to March may recall that I shaved my head for St Baldrick's, an organization dedicated to raising funds for research towards pediatric cancers. We raised just shy of $40,000. My close personal friend, Beth Villavicencio was awarded a grant from the St Baldrick's Foundation, which has now been officially announced:

St. Baldrick's Foundation awards $50,000 for preclinical trial on new drug
September 22, 2008
Children who survive medulloblastoma, a type of brain tumor, often have lifelong side effects from traditional treatments. But a new medication study by Dr. Elisabeth Villavicencio holds hope for better results. Her preclinical trial to determine the efficacy of IPI-926 will be supported by a $50,000 research grant from St. Baldrick's Foundation, a nonprofit organization dedicated to raising money for childhood cancer research.

Preliminary studies have shown that IPI-926 is more effective and less toxic than older drugs in its class. If her research shows the drug does prolong life, Villavicencio and her colleagues will work to move it toward clinical trials in children with medulloblastoma.

The St. Baldrick's Foundation makes grants to research institutions to find new cures for childhood cancer and to find treatments to ensure a better quality of life for patients and survivors. The foundation funds research projects conducted by established pediatric cancer experts, as well as younger professionals who will be the experts of tomorrow. For more information, visit www.StBaldricks.org.
Very exciting, and congratulations to Beth!

Also, faithful reader litbrit points out that American Express is running a promotion in which they will give a total of $2.5 million to a variety of charitable causes -- and you can vote for your favorite candidates. International Medical Corps is in the top five. They work on hunger and malnutrition in developing countries - a highly worthy endeavor. Vote them up, and they may be eligible for up to $1.5 million in funds. (You do not need to be a cardmember to vote. Sign in as a guest.)

22 September 2008

It's about respect

There's a nice post over at ER Stories about treating other members of the medical staff, and in particular about how it can impact your relationship, as an ER doc, with your colleagues in other specialties.

The transformative power of these interactions, I think, is that it forces the doctor-patient to view the ER doc in a different way. I joke that ER docs are at the bottom of the prestige ladder in the house of medicine: everybody I talk to thinks I am an idiot because I know less about "their organ" than they do. They don't see the huge majority of patients we successfully manage on our own; only the cases when we need help. And then we seem weak. When I call, say, a cardiologist (invariably at 2AM) with a patient with a funny rhythm, it's often because I don't know the best way to handle it and I need help. The cardiologist, irritated at being woken with what is (to him) a trivial issue, may view this uncharitably. Similarly, when I call the orthopedist about a dislocated hip that I just can't get back in, he too may view this as yet another sign of incompetence on the part of the ER.

I recall, though, once when a cardiologist brought in his wife -- she had fallen on the ice and had a nasty trimalleolar fracture-dislocation of the ankle. I interpreted the x-ray at the bedside, sedated her and reduced the fracture, and splinted it. She went home with ortho follow-up. (I offered her admission, which she declined.) As they left, the cardiologist gratefully offered me the most awesome back-handed compliment I have ever received:

"You guys did great. I was really surprised -- I figured you'd just call ortho to take care of it. I didn't know you guys could, you know, actually do stuff."
Um, thanks. I think.

Seeing us manage issues that they do not know how, demonstrating that we do have competencies that they were not aware of, can be very powerful. As the author at ER Stories referenced: once you have done so, your future interactions with those individuals can be much improved by a new-found mutual respect. In fact, the more contemptuous the specialist is, the more dramatic the turn-around tends to be.

Add to this, of course, that the specialist probably may feel grateful towards you, and that there is the obligatory intimacy required when a colleague becomes a patient. There's nothing to teach you humility like having to let someone do a rectal exam on you when you were bad-mouthing them the day before!

I would be remiss if I did not point out that the vast majority of our colleagues in other specialties do, in fact, treat us with respect and courtesy. Even they, though, sometimes have their eyes opened a bit when they get to see us do our thing.

(Another great way to earn the respect of your colleagues is to be involved in the medical staff affairs of your hospital. Sitting in meetings with you and hearing you voice intelligent opinions on the affairs of the hospital also will help your docs gain respect, visibility and credibility in the medical staff. But that's another post.)

Briefing Book

MSNBC has a nice comparison of the two candidates' health care plans. Nothing new here if you've been following the discussion, but it's fair and well-presented -- quite an accomplishment given the subject matter.

On an amusing if meaningless note, here's something to add to the list of things McCain has said that he probably wishes he had not:

"Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation." (Emphasis added)
Ouch, indeed. Even the WSJ op-ed board, a highly conservative bunch, can't help but recoil at the inartful phrasing and abysmal timing.

And on the subject of "They like me! They really like me!" Yours truly was featured along with Joe Paduda and Dr Val (high company indeed!) over at the Medblogger Roundup for a grassroots medical organization called Healthcare United. I had not previously heard about this group, and haven't delved too carefully into this organization's details, but I like their principles of universal coverage, patient choice and cost control. I'll be keeping an eye on this group in the future.

Cell Phones

As usual, xkcd makes me say "hell yes."

And to wish I had thought of it first.

19 September 2008

I almost forgot

Today is International Talk Like a Pirate Day!


And from the delightfully perverse mind of Ces Marciuliano, I present you this:
If you're not reading Medium Large, you really should be.


Focke-Wulf 190D12

The only flying example of this aircraft in the entire world. Though the plane is fully airworthy, due to the irreplaceable airframe, they do not fly it.

Hawker Hurricane

The unlovely companion to the Spitfire, but the plane probably more responsible for winning the Battle of Britain.

Supermarine Spitfire Mk Vc



The cowling is off and they are pre-flighting the aircraft. It's scheduled to fly at noon tomorrow.

18 September 2008

McCain's Health Plan

McCain never talks much about his health care plan. Probably because it's not an issue the republicans fare well on, while it is a core Democratic issue. Maybe also because his plan doesn't really offer much to take on the critical issues in American health care today. He's got a plan, because it's sort of obligatory to have one, but it's just not an important issue to him or a core part of his campaign to be elected. (Which is unfortunate for him, because health care still ranks highly on the list of voters' concerns.) But there's been a lot of talk recently about the McCain health plan, after the journal Health Affairs published a review of the estimated impact of the plan. My take home points from the wider discussion are these:

  • This is an incredibly risky scheme. For the past 60 years, healthcare in this country has been financed through employers. While this is a poor system at best, McCain's plan to tax healthcare benefits as income will radically change that. McCain's plan is to replace this system with: nothing at all, tossing 20 million consumers into the private insurance market to sink or swim on their own.
  • This scheme places consumers' health at risk. The cross-state marketing of insurance means that insurers will domicile in states with the least protections and safeguards for consumers.
  • This represents a hidden tax increase on consumers. Yes, there is a tax credit of $5,000 per family, but with a family premium costing upwards of $11,000 annually, it is not hard to see that most families will wind up paying more out of pocket, and paying more in taxes. (Some analysts differ on this point.) And for those employers who continue to offer health care as a benefit, it represents a massive payroll tax increase, making job creation more difficult.
  • Roughly 20 million consumers would be forced into the private insurance market, which typically features higher premiums, higher deductibles and lower benefits.
  • Patients with pre-existing conditions would be commercially uninsurable and no viable market exists to cover them, neither now or in the McCain plan.
  • More people are estimated to become uninsured under this plan, which also does nothing to remedy the 45 million who are currently uninsured.
According to Health Affairs:
“The McCain plan would shift coverage toward the nongroup market, lead to reductions in the comprehensiveness of coverage in that market through deregulation, and encourage employer-based coverage to become less generous as well. These changes would have the effect of shifting costs from insurance premiums toward out-of-pocket payments, and people with chronic or acute illnesses would likely incur much higher out-of-pocket health care costs than they do now. [...] The McCain plan will force millions of Americans into the weakest segment of the private insurance system — the nongroup market — where cost-sharing is high, covered services are limited and people will lose access to benefits they have now. [...] These changes would diminish the security of coverage for most Americans, especially those who are not--or someday will not be--in perfect health."
While this sounds somewhat dystopian, understand that for conservatives, it is the intent of the plan! It's a feature, not a bug! The right wing believes that Americans simply use too much healthcare, and the solution is to make insurance more expensive and less generous, and to increase the cost for patients.

Health Affairs also has a skeptical critique of the Obama plan. I was a little disturbed by the fact that two of the three authors of this review have significant conflicts of interest, whereas the McCain authors are, as best I can tell, standard-issue academicians. So there was some ideological bias in the review, IMHO, but it was not a hack job. The key point, I think, is valid: Obama's plan does not control spending. Perhaps I am cynical, but since this plan was posited pre-election, I am not surprised that Obama chose to elide over the difficult decisions and cuts that might become necessary to control costs -- the electoral success record of politicians who promise tax hikes and benefit cuts is not so good. Ezra said it well: "The quiet assumption of the plan, however, is that the steady march of health inflation ensures that, eventually, cost control will be introduced into the equation."

What is given short shrift in this analysis, are some of the key advantages of the Obama plan:
  • It creates a market for small business (like mine!) to purchase affordable coverage for their employees.
  • It allows individuals who wish to keep their existing coverage to do so.
  • While not universal, it would bring 15-30 million of the uninsured into some degree of coverage.
  • It reforms the insurance industry so that those with health problems are not discriminated against.
Neither plan is perfect -- I've not seen one that is. And, no, Kevin, neither does squat to address the primary care crisis. That is, however, a micro-regulatory proposition of the sort that doomed HillaryCare, and I'd just as soon see that get worked out between the AMA, ABMS, and CMS, because the devil is in the details on that one. But they do certainly accurately reflect the ideological values of the parties: the republicans are free-marketeers at all costs, deregulators extraordinare, and willing to throw consumers to the wolves to do so. The Democrats, while dodging the question of spending, craft a plan to increase the fairness and inclusiveness of health care funding for all Americans.

It's a pity that we never got a chance to do this in 2000, before the republicans bankrupted the federal government.

17 September 2008

How to Annoy an Anesthesiologist

I had a minor surgical procedure today (I'm just fine, thank you). As usual, when I am incognito, I can't help tweaking the medical professionals just a bit. And since this was the outpatient surgical center, nobody knew I was a doctor. So I had a pleasant time chatting with the nurses and receptionists, they brought me back and got me prepped and hooked up. We chatted a bit about the news of the day. And then the anesthesiologist came in to do his pre-op bit, and going through his routine rapid-fire questions.

"We're going to be giving you an antibiotic in your IV. It's called Ancef. You're not allergic to anything, are you?"
"No." (He starts the IV running. After a moment, I "remember") "Though once I had anaphylaxis to Kefzol." (He nearly knocks me over lunging to shut the IV off.)
"Did you take any medications this morning?"
"No. Well, only my coumadin."
"Why are you on coumadin?"
"I don't know. They never told me."

Rolling down the hall to the OR my stomach growled audibly. I groaned a little and rubbed my stomach. "Man, I shouldn't have had so many waffles."

As they positioned me on the table and I started feeling a little light-headed from the Fentanyl I told him, "I was told once I might have myasthenia gravis. I hope that's not a problem for you."

As I drifted off to sleep I told him I was going to be really pissed if I woke up with a colostomy. (I was not going in for an abdominal procedure.)

Fortunately, he had me figured out pretty quick. Which was good because I didn't actually want to get my case canceled. I really should be more careful, though, because payback can be a bitch. When I woke up I half-expected to see a faux colostomy bag taped to my belly.

To paraphrase Patrick O'Brien, nobody has ever taken so much pleasure from so very very little wit as I do.

(originally posted March 2007. I got nothing today.)

You Can't Handle the Truth!

Count the Lies

Obama finally starts hitting back on the McCain campaign's serial untruths:

Or how about this whopper? From the AP:

Move over, Al Gore. You may lay claim to the Internet, but John McCain helped create the BlackBerry.
At least that's the contention of a top McCain policy adviser, Douglas Holtz-Eakin. Waving his BlackBerry personal digital assistant and citing McCain's work as a senator, he told reporters Tuesday, "You're looking at the miracle that John McCain helped create."
McCain has acknowledged that he doesn't know how to use a computer and can't send e-mail, one of the BlackBerry's prime functions.
Of course, this isn't really a "lie" per se, more like a deranged claim by an increasingly desperate campaign. But the pathologic willingness of the McCain campaign to disregard reality is still staggering.

How about another from the serial liar, or mentiroso, as the case were:

If you, like I, are Espanol-impaired, a translation can be read here. And yes, it's awesome: breathtaking in its dishonesty. The immigration bill was supported greatly by the Democrats, including Obama, who voted for a couple of amendments which did not pass and were not responsible for the ultimate defeat of the bill at the hands of McCain's right-wing base. Mr "Principles" McCain himself has now said that he would no longer support his own immigration bill, in favor of "border control." But they run an ad painting Obama as anti-immigration.

Even Fox News can't ignore their lying any more.

War is Peace
Freedom is Slavery
Ignorance is Strength
We have always been at war with Eastasia

16 September 2008

Four and a half hours

I was unhappy to wake yesterday to see this headline in my inbox:

Researchers say tPA can safely be used four-and-a-half hours after stroke.

There has long been a disconnect between the promise and marketing of tPA and its real-world value and usage. It's almost every day I see a billboard or hear a public service announcement on the radio urging people to get to the ER immediately after onset of a stroke. Of course, I fully support this kind of messaging, but the sad thing is that of the many many patients with strokes I see in the ER, the overwhelming majority are not candidates for tPA. The most common exclusion is the time interval, but many are excluded due to other factors -- age, blood pressure, trauma, vague or changing symptoms, or the absence of stroke symptoms severe enough for the benefit to exceed the risk.

And that's the rub: there is risk with tPA, a significant risk, and depending how you slice the data, the benefit in many cases is minimal.

For this reason, I think I am like most ER doctors in that in many cases of someone presenting with a stroke, I "look for the exclusionary criteria." Only in really clear-cut cases -- a severe, disabling benefit in an otherwise functional person presenting in less than 120 minutes --
am I enthusiastic about recommending the clot-buster. Otherwise, I offer the patient and their family the option, along with the data, and allow them to make an informed decision, but I am reluctant to endorse the use of tPA. Taking a smallish stroke and having it undergo hemorrhagic conversion is an awful thing. Since the mortality is almost the same, and the outlook for functional recovery is comparable (though not quite equal) with and without tPA, my feeling is that it is best reserved for cases where the benefit is clear and compelling. Regardless of the situation, it winds up being a nuanced, complex decision in each and every case, with very high stakes for the patient.

And let's not forget that there are hordes of personal injury attorneys out there ready to sue you if you give tPA and it goes bad, and to sue you if you do not give tPA. High stakes and no win for the ER doc!

Families want to do something when their loved one is having a stroke. If they have heard about tPA, they often come in with the expectation that it will be used, or at least a bias towards "doing something." Teling them that either there is nothing that can be done, or that there is an option but you can't wholly endorse it can evoke an angry or negative response from the family. In this litigous environment, the emotional factor only adds risk, regardless of the ultimate decision.

So it's a little frustrating to see that the cohort of patient with whom I am going to have this converstation may be getting a lot bigger. While I haven't gotten deeply into the data, on quick review, it seemed like delayed tPA didn't seem to offer much in the way of improved outcomes, and there was no rush to revise the current standards, which is good. I'll be watching to see if there is more movement towards relaxing the criteria.

15 September 2008

Man Bites Dog

Suburban Doc linked to Slate's interesting article on ER crowding and over-use.

Kudos to the authors for having the ability to see through the conventional wisdom that it's the uninsured and the non-urgent care that drive the overcrowding crisis:

The oft-repeated claim is that if we can just find a way to get the abusers out of the E.R. waiting rooms, we'd eliminate many of the high costs associated with health care in the United States. The problem is that this story of the healthy, cavalier, uninsured E.R. abuser is largely a myth. . . . the uninsured don't even use the E.R. any more often than those with insurance do. And now, a new study shows that the increased use of the E.R. over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor's office.
This fact (emphasis mine) is the most striking thing I have learned in the time I have been following the crisis in Emergency Medicine. Though one minor quibble: the situation is both better and worse than presented above. According to the CDC, the number of ED visits in 1996 was 90 million, not 67 million, so the increase is a mere 32% instead of the 67% reported above. What they did not report is that the number of hospitals with EDs has declined from about 6,000 in 1990 to 3800 in 2006. So, while the number of visits increased, the number of ED beds to accommodate those visits declined precipitously.

As a working ED doctor, I and my colleagues do tend to focus on the perceived over-use of the ED by uninsured and medicaid patients, and the CDC data does back that perception up. The uninsured are twice as likely to visit the ER, and medicaid patients are four times as likely to visit the ER as commercially insured patients (82 vs 48 vs 21 visits per year per 100 patients). But according to the recent data cited by the Slate authors, this was not the driver of the rate of increase of ED visits -- it's the insured patient who do have doctors.

So why is this demographic increasing their usage of the ER? On the physician side:
  • Inadequate pay for, and numbers of, PCPs forces them to schedule their clinics fully, leaving little time for acutely ill patients in the office.
  • PCPs have no financial incentive to reduce ED utilization
  • Malpractice concerns are a positive incentive to direct ill patients to the ER
On the patient side:
  • Consumers' unwillingness to accept scheduling delays in obtaining tests or consultations.
  • Patients' perceptions that they did have an emergency.
  • Perception of quality care at the ED.
  • Convenience and 24/7 availability of the ED.
For our part, EDs have been a willing victim in this crisis. Most EDs make no effort to screen or redirect patients who do not, in fact, have an emergency. (This can be done under EMTALA, though care is needed.) Many hospitals market their EDs as fast, efficient, and high-tech, hoping to attract more paying, insured customers. We create fast tracks to move minor patients through more rapidly, freeing up resources for the truly ill. But all this does is increase the capacity of the ED, and health care follows the "Field of dreams" paradigm: build it, and they will come. Increased capacity drives increased utilization.

Some of these trends are irreversible, I think. The ED is an efficient, albeit expensive, place for rapid and focused evaluations. This fact alone ensures that the ED will remain the resource of first resort for patients who need or want an urgent work-up. As hospitals wake up to the fact that their financial health is increasingly reliant on the performance of the ED (more than half of hospital admissions now originate there), it is predictable that more resources will be dedicated towards expending and updating EDs. In fact, in my neck of the woods, I can think of half a dozen hospitals, my own included, which recently have or soon will be undertaking major renovations to the ERs. This will, however, not solve the overcrowding problem, since these expansions are generally behind the curve and at best barely adequate to meet the future growth. The need for excess capacity to meet surges -- pandemic flu, natural disaster, etc -- is rarely if ever built into the new development.

Even if the nation's ERs all suddenly expanded to a size that they could meet current demand, that would only remove one bottle-neck. The inadequate number of hospital beds and obligate boarding of admitted patients in the ER will continue, putting strain on the capability of ED staff to care for new patients. And the continuing collapse of primary care in the US will shunt more patients in as well.

Good for my business, I guess. More volume, more docs: growth is good, right?

Well, good for me; maybe not for the nation's health. Sorry about that, guys.

13 September 2008

McCain vs the truth

Andrew Sullivan said it best recently:

"John McCain isn't running against Barack Obama. He's running against reality."

John McCain is willing to say anything to get elected.


There was a time when John McCain was an honest and pragmatic politician. He was the victim of one of the nastiest smear campaigns in recent history in 2000, and it probably cost him the presidency. He conducted himself well in that campaign and never stooped to the gutter politics of Bush and Rove. But now, he has sold his soul to the sons and daughters of Lee Atwater, and is willing to lie and lie again if it will win him the White House. Consider, if you will, this ad. I won't link to it directly, you can find it yourself if you like. The tag line:

"Obama's one accomplishment? Legislation to teach 'comprehensive sex education' to kindergartners. Learning about sex before learning to read? Barack Obama. Wrong on education. Wrong for your family."
The truth? The legislation was intended to teach children how to avoid sex predators and molestation. John McCain, friend of pedophiles!

According to the Obama camp, "Last week, John McCain told Time magazine he couldn't define what honor was. Now we know why." He stands next to Palin while she repeats her lie about the Bridge to Nowhere. He lies about Obama's tax plan, falsely stating that it will raise taxes on all Americans (nonpartisan agencies agree Obama's tax plan would cut taxes on 80% of taxpayers). He lies about Obama's health care plan. And he sheds crocodile tears about sexism, when he himself used the lipstick line on Hillary, and thought it was hysterical when a supporter called her a bitch. He lied when he asserted that Palin never requested earmarks when she asked for $200M in earmarks this year alone. He claims to put country first, and named a patently unqualified person to be his successor.

Over the past eight years, John McCain has abandoned every principle he once held that made him stand apart from the ideologues in his party: tax policy, immigration, torture, and more. He has sold his soul to the "Agents of Intolerance," as he once called them, and embraced the christianists who want to dismante the wall between church and state.

The McCain campaign cannot run on the disastrous legacy of the republican party over the last decade, nor can they run on their ideas for solving America's problems, because they have none. Their only option was to run on the stirring biography of their candidate, a man of integrity and honor.

John McCain has forsaken that honor, and in doing so, has shown himself to be morally unfit for high office.

12 September 2008


We got new monitors in the ER. They are nifty, gee-whiz gadgets that have more functionality and better monitoring capacity. They are multi-colored, five-lead, omni-capable devices that can monitor heart rate, rhythm, respiratory rate, oxygen saturation, temperature, exhaled carbon dioxide, mixed venous oxygen and the stock price of Google, all in real time. And they go "Bing!"

The nurses got trained exhaustively by the company representatives, with special required meetings and classes to learn all the knobology and features and functions. They had to pass a little test at the end, and it was all very well done and now we have spiffy new monitors, Hooray!

Of coure, the docs did not get trained. We never do on any of the new toys. Most of us didn't even know that new montors were coming; we just noticed one day that the tone of the "Bing!" was different than before. At the department meeting, after the monitors had been in place a few weeks, there was a very brief introduction for the docs which basically consisted of how to turn the machines off and how to silence the alarm. (Bing!)

This seems typical of how physicians are introduced to new technology in the hospital. While the nurses, techs, and other (hospital employee) personnel are carefully and seriously trained how to use the new gadgets, the doctors are just somehow assumed to have this awesome brainpower that we can pick it up and go to town with it. And frankly, that's how we ususally do it. New intubating scopes? Fiberoptics cameras? Minimally invasive tube thoracostomies? Just figure it out at the bedside. Hopefully, a nurse will be there to show you how to turn it on, and which end to hold.

It's like in residency, the teaching mantra was "See one, Do one, Teach one." Only we omit the "see one" and proceed straight to "Do one."

Do I exaggerate? Yes. A bit. Do I have a solution? Not really. Our docs, I think, are not unlike other physicians in that there are many many demands on our attention and limited time and limited capacity to receive incoming information. We have one marathon 6 hour meeting a month, where usually 40-60% of our docs can attend: should we spend the on the new CMS core measures, or the new CHF pathway we have developed, or the process changes for lab results, (etc etc etc), or the new monitors? That's in addition to the risk management and QA we do, the finance management, HR and scheduling, and maybe a little time for CME if you can swing it.

Try to tack all that on top of a full-time job with rotating shifts. Something's gotta give, and training seems to be the one we can get away with most easily.

The funny thing is that we do seem to get away with it. My group has seen over a million patients in the time I've been here, and we haven't had an adverse event due to misuse of a medical device by a physician. I think that's due to the low numbers bias. The aviation industry (and the cult of six sigma) view the error rate in terms of errors per million, and of that million patients we have seen, only a small fraction have been subject to use of a medical device, whether it's a suture kit, or laryngoscope or a defibrillator. So the "n" for the patients at risk is low enough that statistically we shouldn't expect to see an error yet, and when we do the error rate will be several logs worse than six sigma.

As a counterbalance to that depressing post, I offer you this guilty pleasure:

Houston, we have a problem

Oh my. A serious mishap at the LHC.

See it here.

10 September 2008


Did they find the Higgs Boson? I don't know, but you're reading this, so at the least it didn't destroy the earth!

Yay science!

08 September 2008

I learned something today

From Saturday Morning Breakfast Cereal. Funny, funny, very sick awful comic.

Seriously, I recently had a guy with a complex ear laceration. He had rolled his ATV and tore the hell out of his pinna (the upper ear) and almost pulled it off of his scalp. It was as challenging a laceration as I am willing to tackle myself without Plastic Surgery backup. I finished a very nice job of putting it back together, but it just wouldn't stop bleeding. Ears are, like the scalp, very vascular, but you can't use epinephrine on them to blanch the blood vessels and stop the bleeding. So direct pressure is the only option, but that can be tricky with the complicated three-dimensional structure that is the ear. And this wound was really just ooozing and oozing and would not stop. So I created a bolster to go behind the ear, and an absorbent pad to go over the ear, and I wrapped an ACE bandage around the head several times, really tight, to create a pressure dressing. And it worked beautifully -- finally, the bleeding seemed to be stopped.

As I stepped away from the patient, I noticed his scalp (he was bald). It was a deep purple hue. I realized that my clever pressure dressing had effectively created a tourniquet for the scalp. What the hell was I going to do? I couldn't just leave it like that, could I? If I loosened the dressing, the bleeding would stop again. Maybe I should just leave it on. What were the ill effects of a scalp tourniquet left on overnight? I'm pretty sure there's no good research on that topic. So how long was it going to take for a good solid clot to form so the bleeding would not restart? Maybe an hour or two.

"How's your scalp feeling?" I ventured to ask him.
"It's OK, maybe a little tingly."
"Um, you may find it a little uncomfortable when you get home. If you do, it's OK to loosen that wrap I put on, after a couple of hours."
"OK, thanks doc."

There just is no instruction manual for this job.

Monday Morning Funny

07 September 2008

Are you stupid?

Because they think you are.

The most surreal and almost amusing part of the RNC was watching McSame try and try again to claim the mantle of change. They hope that the voters will forget who has been running Washington for the better part of the last decade. They hope that if they say the word "change" often enough the voters will overlook that they are promising to continue every major policy of the disastrous Bush administration. (The most amusing part was seeing Bush's sad little communique from exile, while the republicans all hummed and tried to pretend he didn't exist.)

While the focus on McCain's bio was stirring, and his paean to bipartisanship encouraging, it's important to remember how his actions and votes have defined him in the past, and what a McCain administration might look like. As Barabara Boxer ably put it:

Last night at the Republican National Convention, John McCain used the word "fight" more than 40 times in his speech. In the 16 years that we have served together in the Senate, I have seen John McCain fight.

I have seen him fight against raising the federal minimum wage 14 times.

I have seen him fight against making sure that women earn equal pay for equal work.

I have seen him fight against a woman's right to choose so consistently that he received a zero percent vote rating from pro-choice organizations.

I have seen him fight against helping families gain access to birth control.

I have seen him fight against Social Security, even going so far as to call its current funding system "an absolute disgrace."

And I saw him fight against the new GI Bill of Rights until it became politically untenable for him to do so.

John McCain voted with President Bush 95 percent of the time in 2007 and 100 percent of the time in 2008—that's no maverick.

We do have two real fighters for change in this election—their names are Barack Obama and Joe Biden.

The Path to 270

So to my disappointment but no particular surprise, McCain is enjoying his own convention bounce and it appears that this race is reverting to its pre-convention status, which is to say a virtual tie. Now a lot can happen in the next two months, and a swing either way will render any analysis obsolete. But if there are no major changes, how are things looking likely to shake out?

My take: Obama has the inside track to victory, though not the way you might expect. Here's how.

First of all, Florida and Ohio are, as always, "tipping point states" for Obama. If he wins those, he probably does not need much more help beyond the core democratic states. But they are (at best) toss-ups right now. Does that mean the outcome is obliged to boil down to those two states? Well, the Obama team sees a bigger map, and so do I. How can Obama realistically win without OH and FL?

I have the 2004 map at the top for reference, and we'll use that as a baseline. The first requirement for Obama is to hold all the Kerry states. Is he doing this? So far, I would argue yes. Michigan is the big prize that McCain will make a play for, but Obama has held a consistent lead here and I don't see it flipping, especially in this economy. PA also is an enticing target for McCain which is likely to be a huge waste of his limited resources. New Hampshire voters are notoriously unpredictable and have liked McCain in the past; this state could prove an Achilles' heel for Obama in a close race.

The next goal for Obama is to hold the states he's looking likely to flip based on the current status. These are Iowa and New Mexico. 538.com currently gives Obama a 90% likelihood of taking IA, and 87% in NM, so these are not "safe" per se, but they look very good for our man. This takes Obama up to 264 EVs

So the final task for Obama if to find his winning margin. The most likely place for that, interestingly, seems to be either Colorado or Virginia. Both have been historically red states which are trending blue. Both have recently revitalized state democratic parties. Colorado has a democratic governor, looks highly likely to have two democratic senators next year, and has democratic majorities in the US house delegation and in both state houses. Even absent a bounce from the DNC having been held in Denver, this seems to be highly fertile ground for Obama. Virginia might be a tougher nut, but is certainly also within reach. It has a democratic governor and will also have two democratic senators in 2009, so democrats can clearly win statewide races here. But the wins so far have been very narrow, and as part of the old Confederacy, it's not clear how much Obama's race will impact votes: there is a large African-American vote, but Obama has been very weak in the rural, white-dominated areas. It's highly winnable, but I think that if Obama takes VA, then he's probably already won OH and the point is moot, whereas I can easily see Obama winning CO while losing OH.

There are certainly other opportunities for Obama, some of them quite surprising -- MT, ND, NC, IN, and NV. Again, like VA, I view these as states which Obama will probably only win if the election is swinging widely for Obama, and as such these probably are not going to be tipping point states. However, expect Obama to spread the field and campaign heavily in these states, forcing McCain to play defense. If the race is close, it is possible that one of these states could provide Obama with an unexpected path to 270, though that would be truly bizarre.

It's just that kind of year.

Oh, and if you're not already reading it, you really should add 538.com to your list of daily reads. The most sophisticated and useful statistical analysis of polling data I have come across anywhere.

04 September 2008

The Surge

8 AM in the ER. The lobby suddenly fills up with middle-aged male patients, all with seemingly trivial complaints. "Feet pain x years," "Rash," "Headache," "Ankle sprain (last week)," and the like. All of the patients have the same address on the demographics.

The local homeless shelter.

They make everybody leave at 8, and when it's raining, they all troop over to the ER where it's warm and dry. The smart ones complain of chest pain, knowing that will probably buy them four or five hours of bed rest, and maybe a meal.

I roust them out as briskly as I can.

It's all part of the routine.

03 September 2008

Post-LP Headaches

When you come to the ER with certain complaints, most commonly an acute or very severe headache, it's normal for the ER doctor to do a spinal tap. This allows us to rule out serious causes of the headache, typically meningitis, subarachnoid hemorrhage, and occasionally pseudotumor cerebri, but obtaining and analyzing a sample of spinal fluid. However, one known risk of performing a spinal tap, or lumbar puncture (LP), is that the needle hole will not properly seal, and a spinal leak will develop. Unfortunately, this results in a headache which is often worse than the original headache!

In this business, it seems that things come in clusters, or at least those are the things you notice. I have noticed a large number of patients coming in with post-LP headaches. This is not only uncomfortable and a hassle for the patient, but it's a hassle for us, too, since we have to get anesthesiology to come down for a "blood patch" to stop the leak, and that throws a crimp into everybody's schedule.

Our ER docs have always done LP's with a 22-gauge "Quincke" needle -- it's a beveled, hollow-bore needle, and the standard needle in our LP kit. I've read that use of a "Whitacre" needle, which is needle-pointed and side-bored can be less traumatic and have a lower incidence of the post-LP headache.

I've tried to use a Whitacre a few times, though, and found it to be a terrible pain in the butt, or at least there seems to be a steep learning curve. The needles are thinner and more bendy, and the blunt tip makes it a lot harder to penetrate the thick, fibrous ligaments of the spinal column. Of the half-dozen tries I've made with the Whitacre, I've maybe been successful twice, had to bail and switch to a Quincke twice, and totally failed twice. (My success rate with LPs in general is well over 90%, so this is quite unusual for me.)

Anyone out there have much experience with this needle? Are they as great as they are made out to be in terms of the low complication rate? Are there any tricks or tips to make it work better? I've heard about using an 18-gauge "introducer" needle, but that seems a bit dodgy to me. I'm going to give it a few more goes to see if I can make it work, but right now I'm not feeling too great about this idea.

02 September 2008

Oh yeah, I forgot

So I am seeing this elderly man for syncope. He came in via EMS, having keeled over and fainted at the dinner table with his wife; fortunately, he woke up fairly briskly. As it had happened, I was hanging out in the nurses' station when the EMS phone rang, so I answered it, and took the report from the medics. It sounded fairly routine, and a few minutes later when they came rolling in to their assigned room I was there to greet them. (We were not real busy, for once.)

The medic was one I did not know. We have tremendously good medics and I have come to trust and rely on them over the years, so although this was a new face to me, I took him at face value when he told me that there was nothing out of the ordinary to report: just another old fella who fainted, normal vitals, looked fine, no clear cause. For his part, the patient was sitting up in the gurney, smiling and taking in the sights.

The medics finished offloading and took off. I interviewed and examined the patient, and ordered a whole slew of tests. The story was a little concerning, since when someone (especially an older person) faints without a clear cause (fever, dehydration, using the toilet, getting up too quickly), you worry about cardiogenic syncope -- that the heart had abruptly stopped effectively pumping blood, most often due to an aberrant rhythm, either too fast or too slow. This can be tricky to sleuth out, though, because it's just like when you have an intermittent electrical problem with your car -- when you take it to the dealer, they can't reproduce the problem, and thus can't figure out what needs to be fixed. Similarly, when someone gets to me with suspected cardiac syncope, they are usually back in a normal heart rhythm and thus I can't tell what happened. So they generally get admitted for tests and observation, but it's frustrating because frequently we are unable to sort out the ultimate cause of the event.

So it was here. His ECG was normal for me, and his tests were all fine, so I planned on admitting him to the hospital team. I pulled the chart off the rack and began going through all the papers to make sure I had everything I was going to need. As I did, a sheaf of papers, including the ambulance report and about a dozen ECGs from the ambulance fell out. The local EMS uses these cardiac monitors which spew out tracing after tracing, on their own, whenever the machine sees fit. I flipped through them, and the first few were fine, but the fourth one stopped me short. it looked exactly like this:It was the most obvious ventricular tachycardia I had ever seen, and appeared to have lasted about thirty seconds. Damn, well that explains that! One mystery solved and I've got a diagnosis. But why the hell had the medic not seen fit to mention it to me? I mean, sheesh, for most medics that would have been one of their most exciting runs of the day, and they'd be bugging me to push lidocaine and putting on the defibrillator patches and all that good stuff. Yet this medic had been exceptionally blase about the whole thing. Had he even noticed it? I referred to the report. Yup, right there he wrote down "V-tach" as the rhythm. Unbelievable.

A bit later, the same crew came in with another patient. I discreetly took the medic aside and asked why in heaven's name he had not bothered to mention the V-tach. He gave me the same look my three-year-old gives me when I ask him why he's not wearing underwear and weakly replied, "Oh yeah, I forgot about that."

What can you possibly say to that? I'm not a vindictive guy, but after some, shall we say "emphatic counseling," I made sure to send a note to the medical director that this individual might bear a little extra supervision or education.

And let that be a cautionary tale to all the ER docs out there: always review the paramedics' and nurses' notes. You'll never know what's in there unless you look.

Why bother participating in P4P?

Kevin, MD wrote about Medicare's "dismal" pay for performance in a recent post. While I don't disagree with Kevin's point that the minuscule payments are barely worth is as things stand, I think that Kevin may be missing or eliding the real point of P4P and where it is going.

First, understand that the program, technically known as PQRI, Physician Quality Reporting Initiative, is not actually pay for performance. It's pay for reporting, as Medicare road-tests its data collection capabilities. In order to qualify for the payment, you only have to report your data on a certain fraction of patients on a limited number of performance metrics. For example, in EM, there are (IIRC) eleven metrics we could choose to report on, and you only need report on five of your choice. If you report data for 80% of eligible patients in each of those five categories, you get paid. It is important to understand that you don't need to be doing a good job in those categories, you just need to capture the data.

Second, the payment is tiny. For a large practice with a typical payer mix and $10 million in gross revenue, the PQRI initiative might be worth $15,000. Not to scoff at five figures, but that's a rounding error in an eight-figure budget. So why bother?

Well, there's no good reason to, right now, and this program is not really targeted at small practices or billing companies. The intention here is to bring the big institutional players on board. If you consider a big biller in EM, or any other field for that matter, with say 4 million patient encounters, maybe a third of which are medicare, and an average charge of $100 per visit -- and now you're looking at $2 million in "incentive" to develop the capacity to seamlessly capture the P4P data. That's enough cash that most large organizations (already paranoid about compliance) will find it "worth it" to buy into P4P. That done, CMS can test the system, refine and expend the metrics, and -- here's the crucial part -- increase the amount of money at stake.

And don't misunderstand -- while now there is an incentive, a bonus payment, for those who choose to participate, soon there will be bonuses for those who participate and perform to par on the metrics, and penalties for those who do not perform well, and larger penalties for those who do not bother to report.

So why should the typical small practice participate now? No reason, other than the prepare yourself for the onslaught of more and more metrics with more and more value attached to them which are coming down the track like a runaway locomotive. I don't know -- the amounts may never be significant to small independent practitioners. They can opt out of Medicare, or they can take the hit and never notice the lost revenue. But for large practices, or for institutional clients, if Medicare follows through on its threat and puts real dollars at stake, then you had damn well better be ready to report compliantly and completely or eat it big time.