30 December 2008

This song is not a rebel song

Back when they were great.

28 December 2008

In Vino Veritas

Enjoying the Alexandria Nicole 2006 Quarry Butte Bordeaux-style blend.   Hoping you all are having a nice evening.

Status Report

Went skiing with Gili and Bunnie the Younger, who had never been on skis before. She did very well, with a brief lesson and even venturing onto the Daisy lift. However, there was the obligate Epic Crash, when her speed got out of control and she plowed into a snowbank and had to be dug out. Much fun was had. Hope you all are having a nice break.

25 December 2008

Christmas Excitement

The grandparents, paternal aunts, and uncle Gili got in yesterday. There are 22 inches of snow on our back deck. It's STILL COMING DOWN, heavily. There are huge tree limbs down all over. No vehicles can get in or out, not even the jacked-up 4x4. We are on generator power, but the internet is working. I got "Clone Wars Lightsaber duel" for the Wii. We are well stocked with Celebration Ale and Christmas cookies. I ask you: could this possibly be the BEST CHRISTMAS EVER?

I think you all know the answer to that. Hope yours is as great!

24 December 2008

In the Drunk Tank

A classic. Happy holidays to you all.

Going Analog

Family in town to share in the joys of the SNOWPOCALYPSE so I'll be occupied for the next few days. Light posting, if any, to be expected.

Merry SNOWPOCALYPSE, everybody!

23 December 2008


Riffing on SandnSurf's bad joke:

How do you hide a dollar from a radiologist?

Pin it to the patient.

How do you hide a dollar from a surgeon?

Put it in a textbook.

How do you hide a dollar from an internist?

Put it under a surgical dressing.

How do you hide a dollar from a plastic surgeon?

Ah, that's a trick question: there is no way to hide a dollar from a plastic surgeon!

OK, so who can tell me how you would hide a dollar from an ER doc?

22 December 2008


I swear, the Boston Globe's Big Picture feature is an absolute treasure. Be sure to check out #11 and #25. Too cool.

I'm Impressed

I'm working the early shift here in the ER today, and because of the historically bad weather here, I left really early for work.  The commute was scary, but the streets were empty of traffic, and I arrived at 5:30 AM for my six o'clock shift.   As I exited the parking garage, I noticed a man in work clothes shoveling off the walkway to the hospital.  I was fiddling with my cell phone (actually texting the wife to let her know I made it OK) so I didn't pay him any mind.  I was surprised when he greeted me by name, and more surprised when I looked at him more closely and realized it was the CEO of the hospital.

Shoveling snow.

At 5:30 AM.

In the garage.

The CEO.

I was stunned.  I made a little joke about how he's been reduced to pushing a shovel, and he replied with good cheer, "Well, somebody's got to do it, and half the staff wasn't able to make it in, what with the roads and all.  The last thing I want is for an employee or patient to slip on their way in -- that's be all we need!"   We chatted for a minute and parted ways.  As I was finishing my text, I noticed him stop to greet a couple of nurses on their way in, and thank them for coming in to work today.

Now that's leadership.   He could have rolled in at eight and gotten a status report from the managers.   He could have noticed the snow and called security (or whomever) to go shovel it.   But here he was, in the dark and freezing cold, doing the job that needed to be done, and not coincidentally setting the example and the tone for the rest of the staff during a difficult time.   I've worked with some less-than-stellar leadership in my time, and it's a painful thing.   Having good leaders is absolutely critical.

Well done, Dave.

O now, who will behold
The royal captain of this ruin'd band
Walking from watch to watch, from tent to tent,
For forth he goes and visits all his host.
Bids them good morrow with a modest smile
And calls them brothers, friends and countrymen.
With cheerful semblance and sweet majesty;
That every wretch, pining and pale before,
Beholding him, plucks comfort from his looks:
A largess universal like the sun
His liberal eye doth give to every one,
Thawing cold fear, that mean and gentle all,
Behold, as may unworthiness define,
A little touch of Harry in the night.

 -- Henry V, Act IV, Prologue

21 December 2008


Oh my this is fun (crazy, but fun). Seriously, we've had more snow than I can recall in my adult life. Eight inches in the last 24 hours, on top of what we've gotten the last few days. The kids are having a blast sledding, and I went sledding to work, sliding all over the freeway in a six thousand pound sled. (Sleds, as you may recall, have primitive steering and no brakes. That was consistent with my commute.)

Is it too much to ask that in the worst winter storm of the last decade, that people only come to the ER if they are actually sick? It was a busy shift, 24 patients in 8 hours, and maybe three of those people needed the ER. WTF? You came out in these conditions for the abdominal pain you've had for three months? A wound check? Seriously?

And still more on the way. Woo hoo!

Public Service Announcement

If you have lost power and you are running a generator, the Garage is not the ideal place to site your generator. Carbon monoxide and all that.

But you all knew that already, right?

19 December 2008

Social networking gone civic

This is cool: the Seattle DOT and Washington State DOT have twitter feeds giving out info regarding the storm and current conditions.

Also, our school district texts my wife when schools are closed.

Technology is cool.

Late Night



The Big Picture's Year in Review. Amazing, sad, and beautiful. You need to check it out. It's a three part series: Part One, Part Two, Part Three.

How (not) to run a code

Happy has a nice post from a week ago about his experiences running in-house codes; it rung very true with me, as I too have run many many codes. The thing that made me laugh was his description about how his younger colleagues run to the codes. Like Happy, on principle, I never run to codes. The stroll there is a useful time to put myself in the right frame of mind to effectively run things, and I know by the location the code is at that there will be trained providers doing ACLS when I arrive (plus, as Happy alludes to, more than half the time the code is a false alarm). In fact, I affect a studied nonchalance about the whole thing -- it's no big deal, I'm such a badass, nothing can ruffle my feathers. It amuses me to do so, and I've been told (to my surprise) that my calmness in the chaos inspires confidence in my leadership. Call it an unintended benefit.

There was one code, though, which in retrospect could have been run a bit better.

This was a few years ago. I was standing in the nursing station chatting with one of my partners about something or another. It was one of those odd moments when we were the only ones in the station. The nurses were all off at their tasks, as were the techs -- very unusual, in that there are usually a dozen nurses and half a dozen techs on shift at any given time. And the unit clerk had stepped out for a moment. So there was just the two of us in the area when a woman rushed out from room seven and announced, "I think my dad's coding!" We reflexively looked at the monitor, which showed asystole, and we bolted into the room.

The patient was indeed unresponsive and not breathing. There was no pulse. We jumped right into action. My partner started chest compressions as I fumbled for the Ambu bag and hooked it up to oxygen. We were a little discombobulated as we got to business -- we are never the first responders and are not used to the role. I can't remember the last time I did CPR. I can ventilate a patient in my sleep, but usually the RT fetches and hooks up the equipment and just hands it to me. So it was with a sense of accomplishment and pride that, after a short time, we met one another's eyes and knew we had the important bases covered. I was bagging, and he was doing great CPR. Not too bad for a couple of docs, right?

There's a moment in the classic Monty Python "The Miracle of Birth" sketch when the doctors look at one another and say "something's missing -- what could it be?" and then simultaneously realize: "Patient!" We had one of those moments as we both thought "what's next... need to intubate -- where's my tube? And someone should be giving meds, and hey, who's going to do that if I'm bagging and you're doing CPR? Hey! Where are all the nurses?"

"We should get some help," my partner weakly offered. There was a security guard standing slack-jawed in the doorway. "Call a code!" we told him, but he was overwhlemed and just stood there. No help. We were stuck. I couldn't stop bagging and he couldn't stop CPR. What were we to do? I remembered the "code blue" button on the wall, and stabbed at it. A minute later, the overhead announcement went out: "Code Blue, ER, room seven." The reinforcements came pouring in moments later, and boy were they surprised to find the two of us there trying to resuscitate a patient all on our own!

They got to work right quick and we soon had him intubated and with a pulse. Honestly, I don't know how long our little "delay" was -- probably a minute or two. It felt like forever. Afterward, we all had a good laugh at our expense. Happy put it well: Without a team there. Without a crash cart. I am but a bystander. And we got a vivid reminder why in CPR class they teach you that the first thing you do in an arrest is call for help.

Genuinely disturbing

Medium Large rocks.


Ezra Klein suggests that Nurse Practitioners could just "take over" primary care and girlvet over at Emergency Room Nurse makes the same argument, extending it to the ER as well.

There's some validity to this argument -- limited validity, I must emphasize. There's certainly a role for mid-level providers (MLPs) in both primary care and in the ER. We utilize PAs (which are comparable to NPs) to great effect in our fast track, where they work within a defined scope of practice and with a subset of patients who are unlikely to have a complex or dangerous condition. Properly trained, they are cost-effective and valuable members of our group. What they are not is this: physicians. No disrespect, but they are mid-level providers; this implies that there exists a level of sophistication and quality of care somewhere between that provided by a doctor and a nurse. That's consistent with my experience. Their academic background is not as strong as that which physicians go through, and the selection process is less rigorous. The duration and intensity of their training is less, and due to their practice environments, the breadth and depth of their experience is lesser.

Again, no disrespect -- I employ a number of fantastic PAs that I would allow to care for my children. But they are not doctors. Girlvet pointed out that 90% of EM could be carried out by NPs. Perhaps. I'd put the fraction a bit lower, but whatever. If you are one of the 10% who needed something more, and all you get is an NP, you're screwed. (Note: that 10% would still be 10,000 patients annually in my ER.) And it's not easy to figure out in advance who the one in ten is who will need the doc.

While some primary care can be performed by a MLP, There was one comment at Ezra's piece that "primary care providers rarely treat anyone that has anything (really) wrong with them. by that i mean anything that wouldn't go away on its own given enough time." Oy. I suppose that things like diabetes and hypertension will go away on their own (just like "All bleeding stops... eventually."), but the management of chronic diseases is fantastically complex and not something that a simpleton with an algorithm can successfully pull off. I think people really do have no clue what it is that PCP's do. It's maybe not as immediately gratifying as Emergency Medicine, but it ain't easy. Some of it -- wellness care and some acute care -- certainly can be performed by MLPs, so long as they have access to a doc for the unexpected and complex issues that invariably do arise.

As for the general assumption that adequate NPs and PAs exist and could be convinced to provide primary care, I agree with Kevin that this is unlikely. There aren't 40,000 unemployed NPs hanging out waiting for primary care jobs, and even if there were, there are better opportunities to be found elsewhere for them. I know what we pay, and I know what some local surgeons pay their MLPs. Suffice it to say that these guys make more than most pediatricians or family practitioners. Shameful, but that's the market. Why on earth would they volunteer to take a (substantial) pay cut to do the job of primary care?

Finally, Ezra argues, that "I'm not aware of any consensus showing worse outcomes when patients see nurse practitioners." Sure. That'd be one hell of a study to do, particularly difficult in light of the fact that most patients change PCPs every year or two and that the relevant "outcomes" differences are undefined and probably undefinable (see the debate over how to define quality). Seriously, you're implying that we should assume that docs and MLPs are equivalent, absent evidence to the contrary? That's a stretch which absolutely defies common sense as well as my experience. If that were the case, indeed, it would not make sense to increase the pay of PCP's, but to cut it, as the job is too easy for a doctor.

No, Ezra is on the right track in the first part of his piece, in which he argues that the compensation system should be rejiggered to incentivize graduating doctors to enter primary care, and possibly to mitigate the cost of medical eduation for those entering primary care. I am sure that PAs and NPs will continue to play a role, possibly a growing role, in the provision of primary care. It is, however, highly unrealistic to expect that physicians can or should be displaced as the chief providers of primary care in the future.

18 December 2008

I hate to admit it

Not to join the ranks of the colleague-bashers, but one thing that has bugged me since we got a internal medicine hospitalist program is that "direct admits" seem to have become a thing of the past. It used to be that if an internist had a patient in their office who clearly needed admission, they called admitting, gave orders, and the patient went directly to the floor. Nowadays, they have to call the hospitalists, and they usually ask that the patient go to the ER for assessment prior to admission. They argue that the workups are easier to do in the ER, and that some of the patients can go home after some intensive ER therapy, and we bristle at the added cost, the added burden to the busy ER, and the feeling of getting dumped on.

It's a little annoying, but what the hell, it's not like we can prevent it so I suck it up with good grace.

So today I got a call from a clinic doc who I have known and respected for a long time. He was very apologetic: he had a lady with obvious pyelo who was clearly sick enough to be admitted and he had to send her to the ER. The hospitalists had been called, and did not want to take her without an ER evaluation. He made it clear from his tone that he thought they were being weak and that this was another waste of time and effort. As I always do, I thanked him with good cheer and said we'd be happy to see her.

Well, when she showed up, there turned out to be more to the tale. She was septic as hell, with a blood pressure in the seventies. Her lactate was four and a half, and she turned out to have not pyelo but a right sided diverticular abscess. (I was proud of figuring that out, since it really did seem like pyelo.) She went not to the floor, but to interventional radiology and then to the ICU. A little while later I happened to speak with the hospitalist, who inquired if the patient had ever showed up. I related the tale, and he laughed and said, "Yeah, it sounded funny. That's why I had them go to the ER first." I hate to admit it, but he had a point.

Damn it.

Note: Yes, I realize that there are probably a lot of direct admits that I never know about because they do bypass the ER. I'm not going to let some tawdry facts get in the way of a good rant.

17 December 2008


It's a weird thing that pretty frequently I see a patient for abdominal pain, and he or she will tell me that they even "tried vomiting" but it didn't help.


I don't know why, but it seems to be a widespread belief that vomiting will make you feel better.   I hate vomiting.  It leaves me covered in sweat, shaking, and weak as a kitten.  I avoid it at all costs.   And people do this deliberately.  Amazing.

16 December 2008


Just for the record, I have to agree with Dr Rob that the anti-primary care screed over at Emergency Medicine News is, well, it's just embarrassing. I've put out my fair share of poorly-thought-out or inflammatory posts, so I can sympathize. But Dr. Glauser is not just wrong, he's cringe-inducing in his ranting. As they say on the interwebs: Epic Fail.

Rob makes a couple of nice observations:

  • There are some really angry doctors out there. Any time people are fighting over their share of money, you see their worst.
  • There are many physicians out there who don’t respect primary care. They seem to think that we do our job because we couldn’t get into “better” specialties.
  • Emergency Medicine News should edit more carefully.

Hear, hear.

15 December 2008

14 December 2008

The View from my Window

Kind of rare around here. Not much, but it'll do for some killer snowmen and a snowball fight!

13 December 2008

Worth 1000

GruntDoc has a great pic over at his place.

Helmets are mandatory where I live now, but every once in a while I go back to Chicago, and I see someone ride a motorcycle down the street sans helmet. It's always startling to me, and shocking that nobody else takes note of it. It's as if you were at a nice cocktail party and a naked man walked in, poured himself a drink, and left, without any of the other partygoers batting an eyelash. Of course, why would they? It's a perfectly common sight, to them. But I can't get over the "Hey, that dude's not wearing a helmet!" reaction. My friends all think I'm a rube, now.

I learned the value of a helmet firsthand a couple of years ago. I was skiing in icy conditions, in the late afternoon on a cloudy day. The light was really flat and I did not see the six-foot drop-off until I was well into mid-air. In fact, I never did see the drop-off, but I inferred its existence from the absence of snow under my skis. I was going pretty fast and hit hard on my back, with my head whiplashing back onto the hardpacked ice. Due to the helmet, I was merely stunned; I am convinced that I was in subdural territory had my skull been without protection. I've always been conscientious about wearing the brain-bucket; since that day I am downright fanatical. And since one of our ERs is right down the hill from the pass, every skier and boarded who comes in without one gets that lecture.

On that note, they picked up fifteen inches of snow last night and should be opening up soon. I can't wait!


Making me think of Ramona over at Suture for a Living:

Apple T-shirt Quilt Available on EBay

Bidding there currently at $200. I suspect it will go for a lot more.

If you're wanting a quilt with a bit more social value, though, you can't do any better than bidding on this quilt:
It features the beloved Zippy the Lobster, and the proceeds go to the Childhood Brain Tumor Foundation. Instructions to bid can be found here. It may not have the Apple logo on it, but it is imbued with several extra insulating layers of good karma which are guaranteed to make you feel all warm and fuzzy when you wrap it around your shoulders. The auction ends Dec 15, so you'd better hurry!

12 December 2008

I think I've read that book

John Moltz (of CARS fame) is doing it wrong.

Let him know.

Deep Thought

Wondering why it is that my placing a stethoscope on a patient's chest is universally interpreted as a signal for the patient (or a family member) to begin talking.

No story, just a picture



First-born Son recently learned "My Country, 'tis of Thee," in kindergarten, and it is his favorite song.  He sings it all the time, as a high-pitched, atonal dirge, with most of the words wrong, over and over.


Kill me now.

10 December 2008

Please have your parents sign and return

In case you weren't paying attention, ACEP released its national report card on the State of Emergency Care in the US today.  The result looks like a lot of my high school report cards -- a lot of C's, a couple of D+'s, and a B here or there.   (Insert joke about the state of the educational system here -- we're a C- nation.)

My state did surprisingly well in Quality/Patient Safety as well as Public Health and Injury Prevention.  However, we rated an F in access to care, which it completely unsurprising.  We rank absolutely last in the number of inpatient beds, and in the number of psychiatric beds, and also in the number of ICU beds.   We also suffer from a shortage of primary care physicians, which exacerbates the fact that our state has half the number of ERs as the national average.   Explains things like this, I guess.

Our state also did poorly (D-) in the liability climate, which was interesting.   We don't have caps, but our average award is less than average by a small amount.   (It would be nice if premiums reflected this, which they most assuredly do not.)

I'll have some more on the national conclusions and recommendations later, when I'm not at work.

How would you handle this?

I recently saw a patient who was sent to the ER for treatment of an acute DVT.   I was surprised that he was not already on warfarin because he had a history of multiple previous DVTs and even two pulmonary emboli, with no clear explanation as to why he had recurrent clots.   He explained that his primary care doctor was opposed to warfarin and had put him on a "natural blood thinner," which was also good for his cholesterol.  I looked this med up (I can't remember the name) and found some references which stated that this substance was essentially worthless for either of these indications.   He was being treated by a local naturopath, he added, who had told him that the warfarin was damaging his kidneys and his liver.   He seemed a bit skeptical of this, since he had been maintained on warfarin for many years without any side effects.   I explained to him that he was going to need to go back on the coumadin (and low molecular weight heparin) for at least the next six months, and probably, given his history, for the rest of his life.   He seemed quite content with this plan.

His wife expressed some concern about the quality of care her husband was getting from his doctor.  He was rather medically complex, with blood pressure, heart and vascular disease, diabetes, and other chronic medical conditions, and I was frankly surprised that a naturopath would care for such a complex patient.   They both wondered whether he would be better off going to an internal medicine doctor, and his wife openly asked if I trusted naturopaths.  She hoped that I could set him up with an internist to manage the initiation of coumadin; the patient himself seemed amenable to this, and looked to me for a recommendation.

Tough one.  I hate to steer someone away from their doctor; it feels unprofessional or discourteous.   But it was the patient and his wife who had opened the door...

So what do you think I should have done in this situation?   I have the standard MD bias that naturopaths are credulous purveyors of woo, which in this case was supported by the fact that his hypercoagulable state was being treated with a placebo.   In addition, this gentleman was quite genuinely complex from a medical management point of view, and I felt he would probably menefit from an internist's expertise.  On the other hand, I am completely ignorant about the training and scope of practice of NDs, and a review of the records showed that a reasonably competent work-up had been done for hypercoaguability (Factor V, Homocysteine, anticardiolipin, though not a complete work-up), and that he had been seen by appropriate medical specialists when needed.   Calls to the ND's answering service were not returned.

So how would you handle this?  Would you send him back to the ND?   Would you set him up with an appointment at the local internal medicine clinic?   Is there a compromise position here?

Cast your vote in the comments, and show your work.


I've done this -- sort of.

Source: Saturday Morning Breakfast Cereal -- check it out.

08 December 2008

How to pay for universal health care

By Barry Ritholz:

1. Set up a large, well capitalized hedge fund. About $5B should do it.

2. The prospectus of the fund should note its purpose is to “Seek out profit opportunities via arbitraging inefficiencies in the markets and health care system of the United States.” Include standard “Socially Conscious” fund language in clauses such as Do well by doing good.

3. Launch the fund — and promptly max out your leverage. Today’s environment makes it difficult to go 50 to 1, but getting 10 or 20 to 1 should not be much problem.

4. Use the money to write Credit Default Swaps with a notational value of $3 trillion dollars. The premia on these CDS should be about 10-15% or so.

5. Rollover the cash premiums — about $350 billion dollars worth — into a national fund. Use it to buy health care insurance for all US citizens.

6. Declare that due to current credit conditions, your unfortunately must announce to your counter-parties that you will be defaulting on these CDS. Note that significant amounts of this paper are held by JP Morgan and Citi. Another trillion is held by China and Japan, with Sovereign Wealth Funds owning the rest.

7. Send out a press release announcing “systemic risk.” Tell the Treasury Secretary and the Federal Reserve Chief that your imminent collapse will wreak global havoc. Apply for bailout.

Congratulations! You have National Health Care!

Repeat for any major government program: Alternative energy, School Vouchers, Mars Mission, Global warming, Missile Defense Shield, etc.

Note: This is how all government spending programs will be funded in the future.
Makes as much sense as any other plan I have read so far.

Uninsurance claims a life

This is as sad as anything else I have seen in a long time. A woman in her mid-thirties came in to my ER with a near-completion of a suicide attempt. Her husband reported to me that she had been diagnosed with bipolar disorder for a number of years, and had been doing extremely well on medications -- well enough to get married, start a career, and have a family.

Unfortunately, their family had hit some hard times and both she and her husband were temporarily out of work. He found a new job, but during the transition their health insurance lapsed. Her psychiatric medications, all brand-name, were terribly expensive, and money was tight around the house. So they made the decision that she would go off her meds, just for the couple of months until his new insurance kicked in. The risk seemed pretty small, since she had been doing so well for a very long time.

The first few weeks off the meds were not too bad, though she was moody and irritable. They had a fight a couple of weeks later, and then another. But other than that, there didn't seem to be any indication that she was slipping off the cliff. Then, after a fairly minor disagreement with her husband, she went and did something impulsive, with no warning.

And that's when she came in to see me.

After a short course in the hospital, she succumbed to her self-inflicted injury.

The sad thing, other than the terrible human tragedy, was how unnecessary this was. Why on earth did they think she could go off her meds? That was a bad decision on their part, but the consequence was an undeserved death sentence. Didn't they know they could apply for a free supply of meds from the manufacturers? Didn't they think of going to their church, or some other charity source for assistance? Couldn't they have gone back to her mental health provider to see if a cheaper prescription was available for the short-term?

But they were not sophisticated, medically, and didn't think of these options. They were self-reliant, figured this was their problem and they would figure out a way to get through it. They made the wrong choice, and now she is dead, and their children have no mother.

This is what makes me nuts about this whole universal health insurance debate. You have the folks on the right who deny reality and claim that those who are uninsured "choose" to be uninsured and that we shouldn't force people to pay for coverage they don't need or want. The conservative ideologues who theorize that the problem is that Americans have too much health insurance and what we really need is to let patients make rational decisions about where to allocate their health care dollars. The traditionalists who like their employer-funded health care plans who are afraid of severing the link between employment and health insurance.

This case, in a nutshell: a real, actual person whose life was lost due to our insane patchwork health care system. This case is an example of why we need fundamental reform of our health care system. One life is just an anecdote, I know, but writ large, how many times does this happen annually among the 60+million who are uninsured at some time in any given year? What is the gross morbidity and mortality that our insurance system exacts from our society?

Employer-based health care is great, so long as you are stably employed. If you lose your job, your health is at risk. Or you face the devil's choice of paying the mortgage or paying for your meds (or COBRA coverage). While I understand the general resistance of Americans to part with the known and understood health care which their employer pays for, a system which ties employees to a job for the insurance, which burdens employers relative to their foreign competitors, and which has no realistic provision for the newly unemployed to retain health care is both callous and stupid, from a policy perspective.

Despite the rhetoric regarding "patient directed health care," the truth is that patients do not always make rational decisions. Patients will, not in all cases but with a knowable statistical likelihood, forgo needed care, spend money on the wrong priorities, and generally lack the knowledge base to decide how best to spend their health care dollars. (Even if there was price transparency, which there is not.) This is not to say that patients are incapable of making these decisions, but that the consequences of shifting this burden onto patients does have a direct human cost.

It is fairly clear that, with the incoming Obama administration, the consensus is building towards a fundamental restructuring of the health care funding system. The designation of HHS Secretary Daschle, in addition to the Baucus white paper and the Kennedy committee are clear signals that the Democrats are serious about moving forward. The labor movement has found their strange bedfellow in the small business association, and even the medical lobbies are cautiously in favor. There's a lot that can go wrong, and a lot of heavy lifting to be done to transform the rhetoric into reality. I can only hope that they are successful, and that they do it right.

There are a lot of people whose lives may depend on it, even if they do not know it. It's too late for one patient and her family. Their children are eight, five, and two years old.

06 December 2008

Two for one

I came on at 7AM and the ER was going through its daily decompression routine. The night-time doc was just brain-dead exhausted and going through the motions in getting rid of his last few patients. There were a few stragglers from the overnight shift who had not yet been seen, and I jumped on them, full of caffeine and energy. A toothache. A laceration. Room 3-1 contained a very nice but weary mother whose six-year old son had a sore throat. It was obvious strep, and a quick prescription later, they were on their way. I felt kind of bad for them, since they had been waiting for three hours, but that's what happens when the night shift is backed up.

Then the new patients started showing up, and I just kept on moving through the tide. A headache. Vomiting. I went back into room 3-1 to see a teenage girl with an ankle injury and stopped short as I saw the same weary mother sitting there by the bedside. "You again?" I blurted out. I had a brief moment of panic -- had I forgotten to discharge them and had she been sitting here the whole time? No, there was a new patient -- the ankle injury (the boy with strep was there at the bedside, as well). The mother explained that no sooner had she gotten home than she had gotten a call from school that her daughter had fallen on the steps, so here she was, back again, in the very same room. She ventured a weak smile.

Her daughter had a nasty fracture-dislocation, which I reduced and splinted. Again, I sent them on their way with well wishes and an admonition not to come back again! What a terrible day for the poor woman. Well, at least they'll have a story to tell.

05 December 2008

What's on your iPod?

I've got a slightly longer commute than I used to, and I've been getting slowly addicted to podcasts. I can't stand any radio with commercials or call-ins, and NPR has way too many shows about gardening or forgotten 1930s jazz icons to sustain my interest. Lately I've been listening to and enjoying, in no particular order:

Car Talk
Rachel Maddow (MSNBC)
Countdown with Keith Olbermann
The Mac Observer's Mac Geek Gab
The Mac Cast
The Onion Radio
Grammar Girl
The Skeptic's Guide 5x5

So what're you listening to these days?

What the hell

I'm about two-thirds of the way through a night shift and it's driving me up the wall. I've seen sixteen patients at this point, and of them, three have been "legit" patients (a fractured humerus, a kidney stone, and an MI). The other thirteen have been completely bogus. Worse, of the sixteen, nine by my estimation were addicted to or dependent on narcotics (including the kidney stone: argh). This is just painful. No pun intended.

04 December 2008

iPod vending machine

At the car rental terminal, Dallas-Fort Worth airport. Yeah, it does
sell iPods.


A kick in the gut

No conversation in the ER that begins with "Hey, remember that guy from the other night?" is going to turn out well. It's an absolute law.

The case that the charge nurse was reminding me of was a young man whom I had admitted with a head injury. It was typical high-schooler foolishness: he was screwing around with his friends and managed to fall out of a moving car. The car was going pretty slowly when he exited the vehicle, maybe ten miles per hour, but he managed to hit hit head on the pavement on his way out. Concrete and asphalt are very unforgiving surfaces when they come into contact with a skull, and this case was no exception. He had a nondisplaced occipital skull fracture, and a tiny subdural hematoma.

Those injuries looked nonsurgical, but the bigger problem initially seemed to be the frontal lobe contrecoup contusion -- literally a bruise in the tissue of the brain. The frontal lobe of the brain is responsible for many of the higher functions, and the injury to this area causes a lot of functional impairment. In this case, the patient was showing signs of frontal release. He was agitated, confused, rambling incoherently, and (most disturbingly to his family) inappropriately hypersexual. He was, they reported, exceedingly well-mannered, ordinarily, and never even swore. But he was quite disinhibited by his injury.

His family was one of the nicest I have encountered in a long time. They really struck me by how great they were, even under substantial stress. They were warm and kind people, even taking time to thank all the nurses who cared for their son. I reassured them that his injuries, while serious, did not appear to be life-threatening. We had a long conversation about traumatic brain injuries and the potential complications and rehabilitation, and I felt that it really helped them get their heads around what had happened. They went up to the ICU, under the care of our neurosurgeon.

So it was with utter shock, five days later, that I heard the charge nurse finish her sentence: "You remember that guy the other night with the head injury? He just died upstairs!"

Apparently, his brain had swelled, and young people have tight heads -- not a lot of room in there for swelling. When the brain grows bigger, it displaces the cerebrospinal fluid from the skull, then can even cut off the blood flow as the pressures increase. A nuclear medicine scan had confirmed brain death.

It was terrible, but to me it was also incomprehensible. He had had a GCS of 14 when I took care of him, and just didn't have the hallmarks of someone at high risk for mortality. Should I have sent him to the regional trauma center? There was nothing really on initial presentation that implied he needed it. Other than getting a bolt -- an intracranial pressure monitor -- he never had developed lesion that could be addressed with surgery. Neurosurgery can be frustratingly futile, sometimes.

And I felt (and feel) terrible for his poor family. I bonded with them more than usual, and their suffering must be terrible. I went upstairs to the ICU after my shift, but they weren't around, and the transplant team was getting ready for harvest. The ICU nurses had a very grim satisfaction that it would be a "full harvest" -- all the organs were in great shape.

I don't really have a take-home point for this post. If I did, it might be: shitty things happen to nice people who don't deserve it. Or perhaps: this job will surprise you again and again, and you need to dispel that false sense of certitude when prognosticating. But whatever. Mostly, this was just a crappy case and I wanted to vent. Thanks for reading.

03 December 2008


Yeah, they've got it about right:

I liked the 1984 take-off -- nice use of irony.

Also, Hulu is pretty darn cool.

01 December 2008

Should ERs screen for HIV?

This blogger at the Utne Reader implies so.

Great. That's all we need. We're already screening for Domestic Violence, Depression, Fall risk, various and sundry immunizations, alcohol abuse and Jeebus-knows-what-else. Why not add one more critical social issue to the laundry list? The ER can be the one-stop shop for all epidemiologic screening! We'll do your cholesterol, your PSAs, your PAP smears, and colonoscopies on Tuesdays!

Don't come in for anything frivolous, though, like chest pain or a motor vehicle accident, because the primary and secondary surveys will have to wait until the triage nurse asks you if you have "ever felt unsafe or threatened in any of your personal relationships." Seriously, they have to ask everybody these questions. I always feel bad listening to the nurses as they have to go through the litany of screening questions which are completely unrelated to the serious issue which brought the patient to the ER.

So why not add HIV to the list?

The biggest reason, IMHO, is that it's not germane to our practice, and not relevant to the patient's presenting complaint (in 99% of cases). Furthermore, it would bog us down and worsen the delays in the waiting rooms as we complete the screenings. If a patient comes in for an ankle sprain or some such, they need to get blood drawn for an HIV test? That's gonna take 10-30 extra minutes (depending on phlebotomy's availability), not counting the detailed consents which most institutions perform before HIV testing. Then what's the turnaround time for the test to run? 30-60 minutes at best, I suspect (factoring in the sample transport time and lab processing time). This would be a minimal issue for patients with six-hour abdominal pain work-ups, but the large number of patients with simple or quick complaints would be slowed down. And the docs, already overburdened with a thousand other tasks and interruptions, would have the responsibility to counsel each and every patient on the meaning of their test (negative or positive), and that counseling is sure to provoke a conversation that eats into the time I have available for the rest of my patients.

This is not even considering the liability. If a test is misreported by the lab, or simply missed by the physician, or if the patient leaves prior to the result being communicated to them, this creates a terrible burden on the providers. And if a test is positive, and the patient does not get adequate counseling or follow-up, whose responsibility is that?

No, routine HIV screening should not be performed in the ER. It's not our job, we're too busy, and we don't want the extra liability. And I kinda wish that society and the government would stop pretending that the ER is the only (and universal) point of contact that Americans have with the health care system.

Inexorable Trend

Buckeye Surgeon has an interesting post about an academic surgical/trauma program which, it seems, is trying to poach the good cases redefine trauma surgery as "Acute Care Surgery." In short, the Orlando program is making a (rather lame) argument that they should do not just all trauma, but all the acute surgical cases in the region, as "specialists" in acute care surgery.

I can't add much to Buckeye's commentary -- it's dead-on. This is a play for dollars and training cases, and completely unjustified from an economic, efficiency, and quality of care perspective. But there's another, tangentially related point here. Buckeye asks whether trauma surgery, as a specialty, is viable. In my humble opinion it is not, at least not on a large scale. As a niche it will persist as long as guns and motor vehicles do. What will happen, I predict, is that "Trauma surgery" ultimately will, in fact, transform itself into (or be replaced by) a new specialty of "Acute Care Surgery," which might be more simply described as "Surgical Hospitalists."

This specialty, rather than sucking cases from community centers to academic, will function somewhat the other way. The surgical hospitalists will metastasize to smaller institutions, instead of centralizing to the academic centers. The market makes a compelling case for surgical hospitalists in community facilities (on an efficiency basis), which will promote community hospitals retaining more surgical cases and transferring fewer cases to the Mecca.

Think of it this way: every ER call, every acute case, every in-hospital consult represents a time burden for the on-call surgeon. At academic hospitals, this burden is typically borne by the in-house residents, 24/7, so there is no real cost (other than to the limited sleep of the intern). If you are a community surgeon, trying to see patients in clinic, or operate on your scheduled cases, or get some sleep before a full day of clinic, this burden is rather more onerous. Cases get canceled, clinics get backed up, and you are tired and overwhelmed. Call is not easy for community-based surgeons, and the cost to their paying, elective cases, is significant. There is a compelling need for these doctors to want to end the "on-call" system.

Surgical hospitalists are the answer to their prayers. They handle the bogus (and unprofitable) trauma cases. They handle the ER and the consults. They free you up to focus on your own patients. And it's not a bad lifestyle either, for the hospitalsts. They work shifts, have a predictable schedule, get to operate a lot and generally get to do the "fun" surgical stuff. This is often most appealing to newer graduates, who are closer to their training and perhaps more comfortable with hospital-based medicince, complex cases, and

The economics of the case are the most challenging. A hospital would need a certain volume of acute cases to support a surgical hospitalist program. I've not done any research on the matter, but my back-of-the-envelope guess would be a 200-bed hospital with a 40,000-visit ER would be the smallest facility that could keep their surgeons busy. And who pays? As with internist hospitalists, they may not generate enough pro-fee revenue to cover a competive salary. Perhaps the facility itself might subsidize them, to keep the call schedule filled and to keep the community surgeons happy. Perhaps the community surgeons would see enough value in the efficiency to hire their own hospitalists. Or maybe each surgeon would take their turn in the barrel. There are a variety of models that could work for this program.

I should point out, in fairness, that our facility has had such a program in operation for a few years now -- maybe as many as four. I am not quite sure. It's been a huge success for all of us -- the ER, the internists, the clinic surgeons, and the surgical hospitalists (I mean, the acute care surgeons). If I need a surgical consult, they can be there right away, even at three AM. They come to see patients more, rather than just asking for a CT scan and a call-back. They are willing to admit more cases which could have been challenging dispositions, and they have service agreements with the internal medicine hospitalists for the overlapping cases (SBOs, gallstone pancreatitis, etc), so "dumping" on internal medicine never happens any more.

Better yet, it's vastly improved the relationship of our two departments. The in-house surgeons are in the ER enough that it's just part of their routine and they don't resent the calls, because they bring an attitude of "this is what I'm here for." The community surgeons still occasionally get calls from us, but more often during working hours and less often at 3AM, and thus they view us as less of a burden and more as valued colleagues.

I don't know for certain whether this model will catch on in the larger sense. Maybe surgical care is too fragmented into small competing practices. Maybe you need a really busy facility to support them. I think it's the future, though, and I know it's been an amazingly positive experiment for us.