24 December 2009

Instrument approach plates for Santa

Instrument Approach Lets Santa Land in Bad Weather | Autopia | Wired.com

Well this is just awesome.  I guess it's hard to get lost when as long as you keep heading North, you'll get there no matter what.  Also the only place in the world where the runway is 36/36.

Merry Christmas!

Christmas Eve Genius

Medium Large has been on a sick and twisted Christmas tear.  Don't miss it.

The boys of the NYPD choir were singing Galway Bay

Shane McGowan is a sad man, ferociously ugly and a terrible alcoholic. He is in the running for the worst teeth in Western Civilization.  But he wrote some of the saddest and most beautiful songs I have ever heard.

Health Care Reform: the Optics of Success

I've had a couple of days off work now, and it being close to Festivus, I've spent a fair amount of time driving back and forth from the mall, parties, various errands, etc.  I tend to listen to news radio (at least until the commercials start driving me crazy and I have to turn on my iPod), and I've also caught some of the nightly teevee news. The lead story, of course, has been the deal and imminent passage of the Senate health care bill.

Now, I've been like, all-health-care-reform, all the time for about eleven months now, and so deep in the weeds that, for me, the big news was that Wyden got a modified version of his "Free Choice" amendment into the bill.  Woo Hoo, amIright?  But being so deep into things, I rarely gave much thought into the "How's this going to play in Peoria?" argument.  Further, since the Senate deal involved a gutting of the most progressive provisions, which has sparked the traditional round of fratricide in Left Blogistan, it certainly has not felt exactly like something to celebrate so much as something to swallow.

So I was a little surprised by the tone of the Emm-Ess-Emm's coverage.  It was laudatory, even triumphant.  It intoned gravely about the "historic" passage of reform.  There were clips of Obama praising the bill.  There were the obligatory counter-clips of GOP back-benchers grousing about the bill being Bad For America, but overall, the subtext was this:

Obama/Democrats Win Big.

Seriously?  No mention of the horrible price Lieberdouche exacted for his support?  No mention of the humiliation of the Senate leadership by the Conservadems?  No "Obama forced to accept crappy-ass compromise" storyline?  Nope.  Wow.  Sure, there was the obligatory mention of the "controversial" public option and its death, but in the context of "Obama Wins" this was relegated to no more than a brief aside.   Bear in mind that I'm talking network news, NPR and local news outlets mostly, not the WaPo or other "insider" publications.

It is, of course, not yet a sure thing that the whole bill will ultimately pass.  Byrd is only barely still legally alive, and the thing could fall apart in conference if the House refuses to sufficiently abase itself before the awesomeness and glory of the Senate.  If it does, however, this really is a win.  It's a win as it is judged by the most important arbiters: the voters who are outside of the beltway and not intimately interested in the details of policy.  Yes, I know that reform polls poorly right now; that's to be expected given the controversy and continuous attacks on the proposals.  Once there is a final bill enacted into law, the coverage shifts from "beleaguered reform" to "reform triumphs" and the proponents get to take a victory lap in the media touting the great things the reform does contain.  (And that's even before the goodies start to get handed out.)  I suspect that public opinion will swing back in favor of the reforms, and the majority of people who are not directly impacted will file it away under "Well, that's settled, then, isn't it?" and go back to watching So You Think You Can Dance.

This is not to dismiss the anger of the teabaggers -- I do not doubt that it is real.  I also do not doubt that the Democrats will lose seats in 2010.  It's a natural year of retrenchment.  However, it would have been pure suicide for the Democrats to have embarked on reform and failed to deliver.  That would have set the stage for 1994 redux.  If reform does pass, economic fundamentals being what they are, the Dems will lose seats in both chambers, though I doubt they'll lose control of either, but they'll lose far fewer than they would have if reform had failed

If health care reform, the linchpin of Obama's and the congressional Democrats' election campaigns, were to fail, it would send the following message: Democrats are incompetent and cannot be trusted to govern.  (Which may not be too far from the truth, politically.  Insert Will Rogers joke here.)  Voters can accept partisanship, but they are not tolerant of incompetence. (See 2006 and Katrina.)

Obama understands this.  He understands that the Public Option or any of the other liberal shibboleths could and must be discarded if that if the price to get the vehicle across the finish line.  Which is why he never threw his weight behind it or drew any lines in the sand.  He is prepared to sign anything Congress gives him, and it's a happy coincidence that the "final" reform bill is looking to be flawed but highly worthwhile.  It may not be the eleven-dimensional chess his supporters credited him with, but it is the hallmark of a relatively savvy political operator.  If and when he gets to have the big signing ceremony, he will reap the rewards of his pragmatism.

23 December 2009

Moviemaking 101

Well, it's only a few years late, but despite its lack of timeliness, this is the best review of Star Wars, the Phantom Menace that I have ever seen.

Specifically, it lays out in great detail and illustration why it sucked so badly:

Supposedly it's a ten-part review, but I'm reasonably sure that I have neither the stamina nor the time for such an endeavor.

21 December 2009

The path to 60

Senate Overcomes Key Health Care Hurdle | TPMDC
By a vote of 60-40, the Senate agreed to end debate on a major package of health care amendments--and by doing so, signaled that the Democratic caucus is unified, and ready to pass a far-reaching reform bill straight down party lines.
Finally, health care reform is in the home stretch.

I've not written much about this lately because, frankly, I haven't had too many original insights. Also, it's been such a rapidly-moving target that it's difficult to take a position on a new proposal before it's dead and the senate has moves on to something else entirely. I still haven't much more to say than has been said many times elsewhere, but just for the record:

This is a great bill, and a historic accomplishment for the Democrats.

Am I disappointed? Yes. It's a flawed bill, and could have been much better. The process could have been better handled. Why Baucus was allowed to string out the Gang of Six negotiations so long is a mystery.  Why the White House didn't take a more active role will be long debated.  The politics were and are atrocious.  It's frustrating to see a republican caucus more dedicated to obstruction than to the national welfare.  It's frustrating to see douchebags like Lieberman and Nelson hold the whole thing hostage at the last minute.  On the other hand, it was pointed out that the whole thing was, in a way, made possible by the conservative Club for Growth.  When they targeted Arlen Specter for a primary, he became a Dem, without whom they would not have had 60 votes.  Isn't life funny?

I do wish that we had obtained a meaningful government-run insurance option, but I console that loss with the fact that we did get:
  • $880 Billion in subsidies for the vulnerable poor to obtain health insurance
  • About 95% of all Americans covered; not universal, but close
  • Great regulations on insurance companies' abuses: community rating, guaranteed issue, no recissions
  • Competitive marketplaces where insurers must compete against one another: the Exchanges
  • Fiscal responsibility: a deficit-reducing bill
  • A strengthened Medicare Commission
  • Payment reforms
If you'd made me this offer in 2006 I would have jumped at it.  It's a great start.  It's more than Clinton could do, and it's success where Carter, Kennedy, and Truman failed.  I can live with it, and support it enthusiastically.  And I'll also support improving it and modifying it as soon as President Obama's ink is dry on the final legislation. 

But I don't want to count my chickens just yet.  There's a conference committee to get through, and neither the House nor the Senate Dems can spare any more defections if the final bill is to pass.  Health care reform is still terribly tenuous, but it is at this point looking likely to pass.

And that's a great thing.

18 December 2009


I got to work last night at eleven pm, to find two doctors and one PA sitting there playing with their fingers and staring at the ceiling.  There were maybe five patients in the entire department.  So I sent the other guys home.  They were all scheduled to leave in the next couple of hours anyways.

Predictably, in the hour after they all left, nine patients registered, and I wound up seeing a grand total of 24 patients in the last six hours of my shift, including a head bleed, an emergent dialysis with potassium of nine, and a DKA.  Never sat down to eat much less anything else.

Gaah.  Of course it's my own fault for daring to send them home, and for bringing work in to do on the shift.  Everybody knows that ER volume is directly proportionate to the amount of reading material you bring in!

The only silver lining is that the last patients were reasonably simple and I walked out of there thirty minutes after the end of my shift.  I was so stupid from lack of sleep I could barely figure out how to get the keys into the ignition of my car.

Now if you'll excuse me, my pillow awaits.

17 December 2009

Aviation coolness

As was widely reported, the Boeing 787 finally took flight the other day, only two years behind schedule.  I was lucky enough to watch live on Boeing's web broadcast as the Dreamliner took off from 34L at KPAE.  I used to live in the traffic pattern for that runway, and I still kinda miss all the planes flying over my house.

One thing really caught my eye watching the plane in silhouette, flying off into the misty sky:


Seriously, check this out:

Boeing 787 Dreamliner First Flight

and this

787 wing flex

Wowie.  The wingtips appear to be elevated above the top of the fuselage.  As amazing as they are, these screen grabs understate the degree of flex that was apparent in the initial video.

According to this, the wingtips can flex up as much as 26 feet!  (though that's at 150% of max load.)

The visual effect was elegant, graceful and beautiful, to be honest.  It looked very much like a bird soaring.  But I wonder how comfortable passengers will be looking out the windows and seeing the unmistakable upwards curve in the wing?  (Note: conventional airliners' wings also flex, but the effect is not as noticeable.)  I guess that's what happens when you build a plane out of plastic.  Also, the linked blog speculates that if they do a wing-break test, the wings might be so strong/flexible that the wingtips could actually meet over the top of the fuselage.  How cool would that be?

You're on what?

I've not been blogging much lately because of work craziness and traveling.  One of my recent travels, however, was not for work but for pleasure.  I've been studying karate (a traditional Okinawan version called Shorin-Ryu) for over fifteen years.  There's a national federation to which I belong and there are seminars three or four times a year taught by some of our more senior instructors.  This was one such seminar, and it focused on joint lock and grappling techniques, some of which our style shares in common with other martial arts such as Akido and Judo. 

At one point I was working with a fifth-degree black belt instructor, "Bill."  Super nice guy, and absolutely amazing in his speed and techniques.  He was also very kind in teaching me a number of useful tricks and nuances of the techniques we were working on.  There was a sequence which culminated in a choke-hold, and he was unhappy with the manner in which I was choking him.  We stood facing one another, and he demonstrated on me, reaching in with thumb and forefinger held claw-like and squeezing behind my trachea towards the base of my tongue. 

It really hurt. 

As he demonstrated, several other students gathered around to watch.  While Bill held on to my throat, I reached out and mirrored the choke hold on his.  "Is this right?" I asked.

"Not quite," says he, "You need to reach up more, like this."  He squeezed a bit harder and I nearly went to my knees.  I adjusted my grip and squeezed some more. 

"Like this?"

"Yeah, that's about right,"
he gasped in a somewhat strangled voice, increasing the pressure on my throat once more.

So I responded by squeezing a bit more, and he did the same.  I could feel his internal carotid pulsations quite distinctly underneath my fingertips. We stood there, pained smiles on our faces, and looked at one another for a bit.  An unspoken question hung in the air: "How long are we going to let this go on?" It was only a matter of time (seconds, in all likelihood) before one of us lost consciousness.  It seemed like it lasted forever, but after a few moments, by mutual agreement we pushed one another off to general laughter.

In karate seminars, it's always funny to watch people hurting each other.  I don't know why.

That evening, back at the hotel, a large number of us went down to the hot tub to soak our bruises.  The warm water soothed the pain, as did the beer we imbibed.  I noticed Bill was not getting in the tub, but sitting by the side.  I asked if he was not going to join us, and he demurred: "I can't use hot tubs," flashing a medic alert bracelet, "I have a heart condition and I am on coumadin."

It took a moment for this to sink in.  Coumadin is a powerful blood thinner, and something of a mixed blessing.  If you are prone to life-threatening clots, it can be life-saving.  But it has so many complications, usually in the bleeding line: bleeding ulcers, severe bruising, and significant sensitivity to even minor trauma.  My mind flashed back to earlier when my fingers had been wrapped around his windpipe.

"Holy crap!" I blurted out, "You're on coumadin and you let me squeeze your trachea?  Are you out of your mind?  What's your INR?"

"2.8," he responded, confirming that his blood was indeed adequately thinned.  He laughed.  "It's no big deal. I don't even bruise."  It was true.  He showed me his forearms, free of the bruises that were already flowering on my own.  "My doctor says it's OK for me to do karate.  He brags about me all the time."

"I'm going to brag about you, too," I responded.  "But I still think getting into the hot tub probably wouldn't have been the most dangerous thing you've done today."  He laughed and handed me another beer.

I checked his throat the next day -- not a mark to be seen.  I tried not to be too mindful of his anticoagulation when we sparred, but it made no difference in any event -- he kicked my ass so thoroughly that I never had a chance to injure him!

It still makes me shake my head.  Is there a worse possible hobby for someone on coumadin than martial arts?  The mind reels.

Payor Contracting 101

Ten Key Elements to Successful Contracting with Managed Care Plans « The Central Line
Assuming for a moment that your ER group’s ability to pay you fair compensation for your services is to some extent dependent on the group being able to get the best possible terms in the managed care contracts the group negotiates with commercial, Medicare and Medicaid managed care, and self-insured indemnity plans: here are some considerations that might be important to you.
From CalACEP's Myles Riner.  Very much worth the read.

10 December 2009

The Denouement

Security is an issue in the ER, and we try to be careful about it.  Patients and their families have been known to stalk physicians, nurses, and other staff.  Most nurses don't have their full names on their badges for that reason, and we don't give out the doctors' schedules or anything like that.  I didn't think anything of it when I came in for a shift and the unit clerk told me that some patient's family member had been calling for me.  They didn't say what it was for, and the clerk didn't get their name, and I shrugged it off.  The next day, they had called again.  Once more, there was no name or message, but it made me distinctly uneasy that there was someone out there who really wanted to find me.  Who was this?  Some drug seeker, angry that I had not been free enough with the oxycodone?  Some process server with a notice of a malpractice allegation?  One of my many female admirers?  The mind reels.

The next day, once again, there was a message waiting for me.  This time it was the charge nurse who had taken the call, and she had gotten some more information: it was Mrs Jones, who wanted to meet me and thank me for "saving her husband's life."

Comprehension dawned.

I had almost forgotten about the megacode of last week.  I looked Mr. Jones up in the computer and saw that he was doing very well.  So when I got a moment I went back up to the ICU to check in on him.

He was asleep, but his daughter was at the bedside.  She was a beautiful young woman, in her late teens or maybe twenty years old.  I introduced myself and we chatted; she wept and thanked me profusely for our efforts.  She told me how great her dad was, and how much it meant to have him still around.  Eventually the noise woke him up and he asked me who I was.  I introduced myself as one of the doctors who had worked on him when he had his cardiac arrest. Too late, I saw her frantically waving her hands behind him, clearly mouthing the words, "We haven't told him!"

"I had a cardiac arrest?"

Awkward.  "Um, yeah.  A little one.  Nothing much really."

"So what did you all have to do to me?"

"Well, we just ... ah ... pushed on your chest a bit and gave you some medicines."

"Oh." He mused a bit.  "So that's why my ribs hurt."

He let it drop, and we had a nice conversation.  He thought it was 2006, but otherwise was pretty oriented.  A fellow Bears fan, we talked football.  He asked how Jay Cutler was working out.   Awkward.  "He's had some good games, but a few rough ones. I think he could use some more support from the offensive line."  I didn't have the heart to tell him about Favre.

On my way out, he stopped me.  "So doc, was I dead?  Was it pretty bad?  How close was I?"

How do you answer that?  It's hard to be honest when you don't want to agitate someone who is still pretty ill.  I went for the euphemism: "Well, your heart wasn't beating effectively, so you were unconscious.  From your perspective, it was more like a prolonged fainting spell.  But you're still here, so clearly you weren't dead."  One of my old professors had liked to say that the difference between fainting and dying is that you wake up.  That seemed to satisfy him, and we parted.

I had given my card to his daughter, and Mrs Jones and I traded emails and voice messages for several days till we finally hooked up.  She and her youngest son came by the ER and she enveloped me in a crushing hug.  I'm not usually the hugging type, but in cases like this I can make an exception.   She told me in very affecting terms how grateful they were to all of us.  Her nine-year-old told me, in the non sequitur manner of the young, that he had just gotten his black belt in Tae Kwon Do.  She told me about her husband's work, the church he runs, how he was the glue holding their family together.  I told her that I was just one part of a large team that had done the work.  She left, still wiping tears, promising to bring cookies to the ER for us to enjoy.

There are so many codes I've run.  So many times I've told families that their loved one is dead and gone forever.  So many times I've left the room to the sound of strangled sobs and tears.  Bad outcomes are the rule, perhaps not surprising in a situation when the patients come in already dead or actively in the process of dying.  So many times I've called the ICU doc for the admission after resuscitation, knowing that the pathology -- the head bleed, the anoxia, the sepsis, etc -- is overwhelming and undoubtedly lethal.  Like many health care providers, I too become habituated to death, jaded by the inevitability of mortality, enervated by the futility of the rigmarole.

These few cases, the happy endings: they are so rare, and when they do happen so often they are so utterly unexpected, like a bolt from the blue, that when someone defies the odds and defies all logic in surviving and not only surviving but doing so unscathed it doubles and triples the delight we take in their good fortune.  It reminds us not to be cynical, that though you do CPR on a hundred people, not all of them will die, so you should focus your effort and energy on the one whose chest you are compressing right now, because this might be the one who makes it all worthwhile.  That's the payoff -- a dozen cases and more of suffering and tragedy for the one whose wife hugs you and promises you cookies.  That makes it all worthwhile.

And the cookies don't hurt, either.

08 December 2009

I don't like surprises

It's the question an ER doctor hates, guaranteed to make each and every one of us cringe somewhere deep down inside:

"Hey, remember that guy from the other day?"

Oh God, you think to yourself, which guy is she talking about? That one with the funny dizziness? Dammit, I knew that was a stroke and the fucking neurologist said it was OK to send him home. I should never have listened to him! But you remain composed and smile and say "Which guy?"

Then you sit back and prepare yourself for the worst. And it is usually bad. C'mon, we work in the ER. Bad things happen here, and bad things happen to people after they are seen here. So it was with surprise that I saw the charge nurse smile and say, "You know, that guy you coded upstairs the other day? I just talked to Jenny in the ICU and they say he's doing great. He's going to be extubated this afternoon!"

"Seriously?" I was really and truly shocked. That guy was dead. Totally dead. Blue and with no brain activity. We coded him forever, and when the code finished with him still alive, we all knew deep down inside that at best we had saved organs for harvesting, that the probability of a decent neurologic outcome was nil.

Turns out that the ICU doc had gotten started on the hypothermia protocol right away and this may have done the trick. I ventured up to the CCU later that day and thumbed through the chart. No clear evidence as to the cause of the arrest, though smart money is still on PE. He wasn't extubated yet, but all signs were highly positive and he was indeed looking like one of those rare happy outcomes from a cardiac arrest. The ICU doc teased me, "What are you doing way up here? I thought you lived in the basement! You're going to get altitude sickness." I stole a line from Greg Henry, saying "I'm just here to make sure you're taking good care of my patient." I stopped in at the bedside but he was still pretty sedated and there was nobody there at the moment, so I took off back to the ER.

Five years ago, heck, two years ago, we weren't doing the therapeutic hypothermia drill and this would not have been such a happy thing. Amazing what developments creep up on you in the course of practice, and amazing how they translate into human outcomes. I was kind of bummed that I had missed the family, but such is life. Mostly I was bemused and gratified that our rather extraordinary efforts had borne unexpected fruit.

Continued yet again.

Hey Dummy

They're not allowed to actually write "Hey Dummy, look here" on the x-ray report, but this is what the radiologists do when they want to make sure the idiots in the ER won't miss the key finding on a film (in this case, a bit of glass from an automobile window):


The wonders of digital radiography allow this to appear on my computer screen.  In the old days they did it with a grease pencil and a post-it note.

Cauliflower Lung

A rare and lethal condition, demonstrated here on post-mortem dissection.

International Vegetarian Union

Bloody hysterical. And very well done.

via Laughing Squid

07 December 2009

I could live with that

Senators Consider A Menu Of Options, Including Medicare Expansion, As Public Option Alternative | TPMDC
Several outlets are reporting, and I can confirm, that Senate Democrats are considering a Medicare expansion as one item on a menu of concessions conservative Democrats would agree to in exchange for weakening or eliminating the public option in the health care bill.

Currently, Medicare exists as a single-payer system for seniors 65 and older. According to Hill sources, the idea would be to allow people under the age of 65 to buy in to Medicare. The option would be limited to people older than a certain age, though that age--and indeed the entire proposal--has yet to be agreed upon.

Not as good as a strong public option, but a strong public option ain't in the cards, and a neutered one is barely worth the fight.  This is better than nothing, and since "nothing" is looking more and more likely what the progressives might get, I'd take it.  From a simple political perspective, liberals have been getting rolled again and again by the centrists and conservaDems, so this meaningful expansion of Medicare represents a genuine "win" for liberals, and those have been in short supply lately. 

I have to see the details and think through the policy implications (adverse selection, anyone?) before a final judgment.  Still, this looks god ont he face of it.  One more thing: Open the exhanges!

Obama and fiscal conservatism

Ezra Klein - The Obama administration doesn't care about the public option and Congress doesn't care about cost control
Color me unsurprised that Barack Obama didn't mention the public option in his remarks to the Senate last weekend. One of the dynamics that hasn't really penetrated in this debate is that the Obama administration is mainly interested in the cost controls. The president will throw the public option overboard if Susan Collins asks him nicely. Conversely, Peter Orszag will lay down in traffic to save the Medicare Commission. Generally, Democrats want to reform the health-care system because they want to cut the number of uninsured. The Obama administration's commitment to health-care reform stems from their belief that it's the first step towards cutting long-term deficits.
In a lot of ways, Obama is proving to be a much more conservative President than one might have expected.  Despite how the teabaggers might want to portray him as a raving liberal, he's decidedly not.  Lord knows he's disappointing his liberal base, myself included, on many issues, with his cautious and often centrist approach.  I'm inclined to give him the benefit of the doubt and trust him, since if nothing else he seems to be taking a very responsible line.  On this point, he is probably right -- that long-term cost control needs to take precedence over the liberals' fantasy dream plan for health care reform.


At our hospital, the overhead paging system is fairly infrequently used.  At 8:30 PM they announce that visiting hours are over and will all guests please get the hell out go home, and, being a religious institution, they pray at us twice daily.  A little musical scale is played when a baby is born (an arpeggio going up the scale if a girl, down scale if a boy; I've long wondered if there's a subtle message to be had there).  After working there a decade, I've learned to ignore these routine announcements completely.  Then there are the "codes" that are called overhead.  These are preceded by a chimed single note (a middle D, I think) and followed by the specific code.  There's the "Code Blue" which is, of course a cardiac arrest, and there are the trauma codes: these are for me.  Code Red is a fire and Code Gray is for the security team: I ignore them.  Patients must think I have a strange tic because if I hear the chime while we're talking, I stop in mid-sentence and cock my head to listen whether it's a code I have to respond to. If it's not one for me I pick up where I left off, but if I have to run from the room, patients usually understand.

So it was the other day.  I was giving a guy with strep throat his discharge instructions when the Code Blue was called.  I bolted upstairs and arrived at the room as several nurses were heaving a large man back into bed.  There's that "doorway moment" when you hit a code, in which you make an instantaneous, almost subliminal assessment of how bad the situation is.  "Very bad," was my thought as I moved to the head of the bed.  The patient was dusky blue and covered in sweat.  He was a middle-aged man, mildly obese, with a full head of dark brown hair.  He had no respiratory efforts and was completely flaccid.  Within moments I had him intubated, they were back doing CPR, and a monitor was being hooked up. 

There was no pulse and the monitor showed a flat line, meaning no cardiac electrical activity at all.  It was a weird code: an otherwise healthy guy admitted for a simple pneumonia.  Not the sort of patient you expect to drop dead on you with no warning.  He had just gotten up to go to the bathroom, his nurse explained.  The down time before I tubed him was probably five, maybe ten minutes, we guessed.

Generally speaking, when someone dies suddenly, you've got a few minutes to get them back.  Every passing minute makes the likelihood of a successful resuscitation diminish drastically.  And the minutes dragged on and on in this code with no response whatsoever.  There was a progressively increasing sense of fatalism among the dozen or so health care providers gathered around the bed, working to save this man's life.  This guy was dead.  He was not coming back.  Uneasy glances were exchanged.  The urgency and crispness drained out of the room.  The initial energetic, high-quality CPR was replaced by slower, weaker chest compressions.  People shook their heads and checked their watches.  The unspoken question, "How long are we going to flog this?" hovered in the air.

That's my decision, and sometimes it's a hard one.  The really and truly dead are pretty easy to call, but this guy was "still warm," as they say, and I wasn't quite ready to give up.  Besides, he was showing me a few things on the monitor which at least kept things interesting.  We played with it like a mega-code, going through the different arms of the algorithm: asystole, V-Fib, V-tach, bradycardia, PEA and more.  I gave some helpful feedback to the folks doing CPR, even venturing a few bars of "Stayin' alive," to rueful chuckles.  Some gallows humor was exchanged.  But there was a very deep, very firm conviction among the entire team that by this time we were going through the motions, and the outcome was now set in stone.  The chaplain was trying to get the patient's wife on her cell phone, and I called the primary care doc.  The patient's complexion never altered a whit from that deep violaceous hue, and there were no signs of life beyond the squiggles on the monitor, never associated with a pulse.

On a lark, we decided to try t-PA, a clotbuster drug, in case there was a blood clot in the lungs causing the arrest.  I was chagrined to learn, after ordering it, that it was going to take 5 to 10 minutes to prepare.  "We have to keep doing this for another ten minutes?" I thought to myself, but having ordered it I felt like it would have been obscene to reverse myself because it was inconvenient.  So we rode it out and kept going while the drug was prepared and run up from pharmacy, keeping ourselves entertained during the interim by fiddling with pointless vasopressor drips.

Good thing we did: as the t-PA arrived at the bedside, before it was hooked up, suddenly the chaotic cardiac tracing became more organized and normal-looking.  The respiratory therapist murmured in amazement, "Hey, there's a pulse!" 

"It won't last," I thought to myself, "It never does." But to my surprise it did.  This development, if anything, further depressed the mood in the room.  We had been coding him for fifty minutes.  That's an eternity, and without oxygen for that long his brain was so much scrambled eggs.  Someone made a coarse remark about a tracheostomy and a nursing home, which reflected the sinking feeling that it would have been better at this point for him to have died.

When the ICU doc started getting prepped for an arterial line, I knew my part in this drama was over.  The ER nurse and I made our exit, stripping off our gloves.  "It's Miller Time," she quipped, and we both convulsed with silent laughter as we stood at the elevator.  Back downstairs, the guy with strep was really annoyed at having had to wait for a solid hour for his discharge.


Insurance companies and the for-profit business model

I got a surprising number of comments on my post from Friday about Aetna.  To recap: Aetna's profit margin this year was less than in previous years. It was, however, still profitable and in fact beat analysts' expectations. Aetna made the decision to raise premiums to improve their profit margin; this, according to Aetna, will result in 650,000 individual group and individual members losing their insurance from Aetna.

First of all, I need to point out to all of you commenting on this post that you're not helping me out here.  I'm trying, I really am trying to get away from the policy stuff and get away from the political stuff and get back to the clinical and humanistic side of medical blogging.  And I put up a throwaway repost of something from the Huffington Post and you go and spark an interesting discussion in the comments.  And I'm drawn in like the moth to the flame.  You're killing me.

On the substance of the matter: In a fit of pique I called Aetna "fuckers," which creates a reasonable impression that I think Aetna was somehow behaving reproachably.  Well, sort of, sort of not.  My feeling is that Aetna is behaving perfectly appropriately within the system as it exists, but the for-profit insurance model itself should be abolished.  In the current world, Aetna has a fiduciary responsibility to its shareholders to maximize their profits.  It's not just a good idea; it's the law.  Moreover, Aetna is traded on the NYSE, and like any other publicly traded company, if investors are concerned that profits are in jeopardy, the stock will plummet and stockholders will suffer.  So the executive team at Aetna has a real and genuine mission to maximize profit, and to make a public show of how hard they are trying to maximize profits.  It's their reason for being.  They took a rational look at the market, made the profit/volume calculation, and decided they were better off selling fewer donuts at a higher profit per donut.*

Which is a fine thing to do if you're selling donuts, but Aetna is insuring lives.  It's a little galling to see the profit/life calculation being made so brazenly.  But in fairness, it should be pointed out that some or most of the 650,000 people who can no longer afford or no longer choose to pay Aetna's higher prices will not become uninsured or go on welfare.  Some may wind up uninsured (especially in the horrific small business/individual market), but the larger number, especially in the large group market, will simply elect a different option, be it UnitedHealth or one of the Blues or whomever. 

So why is this a problem, if it's mostly one insurer shuffling off customers onto its lower-margin competitors?  Simply: Aetna is doing this in part as a form of cherry-picking, what insurance types call "adverse selection."  They want to retain the lowest-cost, healthiest customers, and get rid of those who have medical conditions that cost money.  One of the most efficient ways to do this is to raise overall costs.  The individuals (and the smaller groups) who have expensive conditions are already paying more due to their higher loss ratios, so they are the most sensitive to cost -- and the first customers to leave in search of cheaper insurance.  Devilish, isn't it?  While this is a win for Aetna (and yes, *every* insurance company does this), it distorts the market when companies are successful at it.  The result is segregated pools of sicker people with higher costs.  This drives up the overall cost of insurance for those who need it the most and defeats one of the key purposes of insurance in the first place: risk-sharing.

The trickle-down consequence is that the number of the uninsured inevitably increases as all the companies engage in this practice of profit-maximization.  Some of the 650,000 soon-to-be-former Aetna members will wind up uninsured.  But as most move down the food chain of insurance companies, the costs increase there, and profit margins shrink, and these companies also increase the price of premiums.  As a result, some enrollees at these plans will be priced out of insurance. It's not a one-to-one thing, but it's a certainty that this sort of activity contributes to the growth of the number of Americans without health insurance.

Another problem with this strategy is that it does represent a significant inefficiency in the health care market.  Put bluntly, insurance company profits are expensive.  The annual profits for the top five publicly-traded health insurance companies total somewhere in the $25 billion range.  Yes, that's a small fraction of overall spending on health care, but it's also a full quarter of the $100 billion that the "huge" health reform bill will cost annually.  As someone invested in public health, it's frustrating to see that sort of money parasitically siphoned off of a system that is already crumbling under its expense.  (Note that I say parasitically not as a moral condemnation but in the strict sense of not adding value for the costs incurred.)

Would life be better if all insurance companies were not for profit?  Good question.  It's true that some of the most vicious, dirty players in the insurance game are not-for-profit insurers.  Where markets are competitive, they behave like the for-profits.  (This fact is in my opinion the strongest argument for the public option.)  But as was pointed out, the not-for-profits do bear a sense of responsibilty for their communities and you seldom see a non-profit exit a market unless they have been driven bankrupt.  Further, the surpluses generated by not-for-profits are generally much smaller than the profits generated by their public brethren, and they are reinvested in the business or returned to subscribers.

It wouldn't be a panacea to take the profit motive out of health insurance, not by a long shot.  But it would be a good start.

And just for reference, I would generally agree that the provision of health care by physicians should also be not for profit.  Which is not to say that the doctors should not be compensated -- but that the corporations should not be publicly owned and that the revenue generated by doctors should go to the doctors, not to shareholders. But that's another topic altogether.

*Side note: I grew up in Chicago, and at the Museum of Science & Industry there was a primitive computer economics game where you were the owner of a donut shop and had to figure out the optimal price for your donuts. It was fun but tough for a nine-year-old Shadowfax. Anybody else ever play that game?  Says something about me that that I thought an economics computer game was "fun."

06 December 2009

Polling and the Public Option

HL Mencken famously said that "No one ever went broke underestimating the intelligence of the American people."  Which is a great reason to be leery of polls when looking at anything other than projecting likely election results.  Ezra notes an illuminating recent poll:

Ezra Klein - Two-thirds of Americans don't understand the public option
Vanity Fair finally had the bright idea to ask, "could you confidently explain what exactly the public option is to someone who didn’t know?" The answer:

Which is pretty much why we should not be paying much attention to polls when figuring out how to actually do health care reform.  Like anybody, I'm quick to trumpet a poll that favors my position, and to pooh-pooh a poll that is adverse.  But in the case of health care in particular, there's not just the problem of an inattentive and uneducated public, but also the simple fact that there are even now like five or six versions of the Public Option and ObamaCare floating around out there.  How can someone know what is actually the "Public Option" when the definition is yet to be determined by Congress? And what the hell is "ObamaCare" when the multiple irreconcilable versions are being drafted by a fractious and uncooperative Congress in the (frustrating) absence of strong leadership from the White House?

Anyway, Reuters says 60% of Americans want a public option so clearly I'm right and all of you who disagree with me should shut up and bugger off.

Sunday Night Shanty

God Damn them all.

Also, some people have way too much time on their hands.

04 December 2009

Why insurance companies should be not for profit

Aetna Forcing 600,000-Plus To Lose Coverage In Effort To Raise Profits
Health insurance giant Aetna is planning to force up to 650,000 clients to drop their coverage next year as it seeks to raise additional revenue to meet profit expectations.

In a third-quarter earnings conference call in late October, officials at Aetna announced that in an effort to improve on a less-than-anticipated profit margin in 2009, they would be raising prices on their consumers in 2010. The insurance giant predicted that the company would subsequently lose between 300,000 and 350,000 members next year from its national account as well as another 300,000 from smaller group accounts.

"The pricing we put in place for 2009 turned out to not really be what we needed to achieve the results and margins that we had historically been delivering," said chairman and CEO Ron Williams. [...] Aetna's decision to downsize the number of clients in favor of higher premiums is, as one industry analyst told American Medical News, a "pretty candid" admission. It also reflects the major concerns offered by health care reform proponents and supporters of a public option for insurance coverage, who insist that the private health insurance industry is too consumed with the bottom line.

Note that it wasn't that Aetna wasn't already profitable under the lower fee structure. It just wasn't profitable enough to keep investors happy.

Ah, it's a pity Harry Reid is such a shitty Senate Majority Leader, because if he wasn't, we'd get a meaningful public health insurance plan and put these fuckers out of business.  Or at least make them duke it out with a lean competitor. 

The Onion Health Report

LOS ANGELES—A report published Monday in The New England Journal of Medicine warns that the nation's obesity epidemic has reached a new level of crisis, with many overweight Americans' increased girth rendering them physically unable to end their own, fat lives.

"We've known for some time that obesity can cause heart disease, diabetes, strokes, and other potentially life-threatening illnesses," said report author Dr. Marjorie Reese, director of UCLA's Obesity Pathology Clinic. "But the fact that obesity impedes suicide is truly troubling. It appears that the more reason people have to die, the less capable they are of doing so. They are literally trapped in their grotesque, blubbery bodies."


It goes on quite a while, in spectacular detail. Click the link for the full story. Hysterical, and as they usually do, the geniuses at The Onion hit pretty close to home.

My day thus far

Twenty-eight degrees and severe clear. The Cascade and Olympic mountains are startlingly beautiful in the clear morning sunlight. The USS Shoup is visible at anchor down the hill in the harbor. The ER is totally empty and I just bought donuts for the staff. (It's an apocryphal but long-standing tradition that the doctor has to buy donuts when the ER is totally empty.) Not a profitable shift for me but still a nice way to begin the day.


Crummy shift the other night: 23 patients in eight hours, and 21 of them were painful. For me, that is, not necessarily for the patients. Lots of worried well, influenza, some minor injuries and a few chronic pain players. Not a single sick one in the lot. One particularly irksome case was a chronic pain patient dumped on our ER from a neighboring ER, complete with discharge instructions reading "Go to (name of our hospital)." So by the end of my shift I was pretty well burnt out. But the last two patients put an interesting perspective on the night.

The first was a 99 year-old man. Yup, that's ninety-nine years old; born prior to World War One. He was having shortness of breath and it turned out he was in congestive heart failure from what turns out to have been his fourth myocardial infarction in as many months. For multiple reasons, common sense primarily among them, he was not a candidate for aggressive intervention like angioplasty. Fortunately he had a large and supportive family, who were quite reasonable in their expectations. After a difficult discussion, we admitted him on a morphine drip for comfort care, with a hospice consult.

The second was a 9-month old with a heart rate of nearly 300 beats per minute. It was pure chance that the family had noticed that his heart felt like it was racing. To tell the truth, I'm not sure I would have noticed that on my own kids. It was an irregular heart rhythm called SVT. In adults, SVT is typically a nuisance alone and rarely requires much treatment. In small children it is similarly benign with the exception that if it is prolonged (which is common, since a baby can't tell you his heart is racing) is can cause congestive heart failure. This child was lucky in that it was caught quickly and he suffered no ill effects. One quick dose of adenosine and he was all better.

So there you have it -- the bookends on my day. Two cardiac patients: one at the very end of life, one at the very beginning. I like a nice symmetry as much as the next guy, and this was a very satisfying "circle of life" conclusion to an otherwise unrewarding shift.

03 December 2009

Not dead yet

I've a lot to say, but haven't had the time or energy lately to blog -- work, family, real life, they so get in the way of my idle amusements.  I've a few things on tap, but for the moment I'll content myself with simply linking the more interesting things I've read recently.  In no particular order:

Life in the Fast Lane, an Australian Emergency Medicine blog, has been on fire recently with some of the greatest medical posts I've seen in years.  Notable recent posts include the worst imaginable complication of chest tube placement -- must be seen to be believed -- and an excellent educational post with the most improbable title, "Code Blue in the Mortuary."

Dr Val writes about her father-in-law's ER visit and work-up for chest pain.  The ending is a happy one, but Val totally misses the point in her post-event musings:

George was right - he was getting old. The nurse was right - there was nothing emergent going on.

The ER doc was wrong - George didn’t have an aortic dissection. And I was wrong - there was nothing actively wrong with his heart.

I feel badly that I contributed to a waste of healthcare resources.
No, Val, the ER doc was not wrong.  You are committing the logical fallacy of ex post facto reasoning.  The CT scan was clearly indicated based on the presenting symptoms because the doctor did not yet know there was no dissection.  Carl Sagan once wrote of the TV scientist who sadly lamented a "failed experiment" because it did not produce the expected results.  That's the exact opposite of science!  Any scientific investigation in which the outcome is known in advance is a waste of time.  The test was successful because it provided useful information, and while the outcome was negative, the assay was by no means a waste.

Dr Rob writes that he's also struggling with real life, and we're all hoping that he gets distracted right back into blogging soon.  Until then, I have dibs on the Llamas!

Dr Bryan Vartabedian writes at Better Health about doctors blogging anonymously:
Anonymity is a fantasy. It’s remarkably difficult to achieve. With small thoughts you can hide – in fact, no one cares who you are. If you offer anything worth hearing people will ultimately find out who you are.
So terribly true.  I was amazed, the first time I got picked up on Reddit, how quickly some clever commenters were able to figure out my identity.  Since then, I've only kept up a very slight fiction of anonymity, all the more transparent when I got cited under my real name in some national publications.  The only qualification I would add to this is that I keep my name and that of my hospitals off the blog, since I don't want patients to Google me after seeing me in the ER and immediately find the blog at the top of the search list.  Not that it'd be hard to make the connection, but I don't want patients I have cared for to find the blog and have the fear that "he's going to write about me." And yes, I do fictionalize every patient story on this blog extensively.  Bottom line: don't post anything on line that you'd be uncomfortable listing on your CV!

Speaking of patient stories, there is a promising new ER blogger in town: StorytellERDoc.  I like what I've read so far very much, and will be watching eagerly to see if he can keep up the challenging pace he's set for himself.

One another note, I liked Roger Ebert's cranky and petulant rant in the Sun Times about politicians inserting non-science-based beliefs into their public policy positions.  I'd complain about the tone of the piece, but Ebert's clearly on the side of the angels on this matter, so I'll let it be.  Hmm. That "angels" metaphor doesn't really work in this context, does it?

OK, gotta pick up #2 son from school now.  More real medicine stuff coming soon, I promise.

29 November 2009

Fricking Awesome

Spectacular footage from NASA -- ground, air, and SRB/ET video -- from the launch of Atlantis on STS-129.  Long, but totally engrossing.  Check it out here, oddly enough, on Facebook.

25 November 2009

Words Absolutely Fail Me

Is it just me or is this the GREATEST COVER EVER?!?

24 November 2009

The best political blog post I have read this week

TAPPED Archive | The American Prospect
Which Party Is Best Prepared to Save Us From the Robot Apocalypse?

Arthur C. Clarke famously said, “Any sufficiently advanced technology is indistinguishable from magic.” But if science fiction has taught us anything, it’s that any sufficiently advanced technology will inevitably rise up to enslave us. So if you want to get ready for the day when your Roomba declares that maybe it’s time for you to start crawling around on the floor sucking up dust, it might be a good idea to evaluate the Republican and Democratic approaches to this problem.
Best line: "Just as the GOP doesn’t really think there’s a health-care crisis, they don’t seem to be concerned about a robot uprising."

Yes, it's silly.  Still, go read it.

What if the Earth had rings?


POTUS assigns some homework

According to TPM, President Obama and his henchman, Rahm Emanuel found this blog post by the Atlantic's Ron Brownstein a "good summary of cost containment" according to Harry Reid's health care reform bill.  Therefore, it became assigned reading for White House senior staffers.

And it actually is decent summary.  I haven't read the full bill myself (heck, I can barely find the time to read for the LLSA exam!) but the article explicates a few provisions which I had not heard about and sound pretty promising in their ability to "bend the cost curve."

While the whole piece is worth a read, I'll provide a summary of the summary, or at least the bits that I found interesting.  My observations and comments in italics:
"[MIT Healthcare economist] Gruber may be especially effusive. But the Senate blueprint ... also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush."
Um, I guess this is good. McClellan is a wonk, not just a politico.  But I was not overly impressed with the direction he led CMS.  But some bipartisan support is nice, if ultimately only symbolically.
"[T]he Reid bill maintains virtually all of Baucus ideas' for shifting the medical payment system away from today's fee-for-service model toward an approach that more closely links compensation for providers to results for patients."
It's a baby step away from fee for service, just a baby step.  Will the results be dramatic, modest, or marginal?  That's the trillion-dollar question.
"The CBO projected that the bill would reduce the federal deficit by $130 billion over its first decade."
Not news but always worth repeating.
"[T]axing high-end insurance plans ... Economists argue that such a tax will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount."
I'm astonished that this will be so effective (to the tune of $35 Billion per year) given that the tax is on plans costing more than $23K annually.  Who has a plan costing that much?  It does effectively put a hard cap on premium costs as they continue to inflate, or at least causes consumers to bear more of the cost for such plans.
"[C]hange the way providers are paid for delivering care to Medicare recipients; the hope was that once Medicare instituted these reforms, private insurers would also adopt many of them."
I think you can count on that.
"[T]o reward Medicare providers who deliver care more efficiently and penalize those that don't. ... hospitals under current law must report on their performance in treating patients for common conditions like heart problems and pneumonia; under the bill, their Medicare payments, for the first time, would be affected by their ranking on those reports. Hospitals would also be penalized if they readmit too many patients after surgery or allow too many to acquire infections while in the hospital itself. Another provision would begin the process of applying such "value-based purchasing" toward other providers like hospice providers and inpatient rehabilitation facilities."
We all knew this was coming when McClellan started P4P.  It's good (I think) to see it finally implemented, but it's hardly a novelty in the health reform world.
"The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. ... the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum."
Wow.  I was unaware of this.  Would it be unfair to call this the "Gawande provision?"  That New Yorker article was highly influential.  As someone who works in a "high quality low cost" system, I like the idea of being paid for being more efficient -- we have been penalized for many years.  I like that it is budget neutral.  I worry that since it does not decouple payment from volume, that the low-efficiency area practices may respond by simply further increasing volume to make up for lost revenue.  When it's a revenue neutral game, there will always be someone at the bottom -- will this polarize practice patterns or reduce the disparities?  I don't know.
"[E]ncourages groups of providers to establish doctor-led "accountable care organizations" to more comprehensively manage patients' care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of "bundled" payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors."
Pilot programs don't excite me too much.  Bundling worries me, that physicians will become highly subordinate to the hospitals, not in terms of practice style as much as the economics.  How do you work out revenue-sharing, especially when the physicians have little leverage?  Beyond that, these are intriguing but small cost-saving possibilities.
"[The] independent "Medicare Advisory Board" ... to offer cost-saving proposals when Medicare spending rises too fast; Congress could not reject its proposals without substituting equivalent savings. Since the board would be prohibited from offering changes that raise taxes or "ration care," and since the legislation initially exempts hospitals from its recommendations, it could choose to promote the sort of payment reforms the bill establishes. (More prosaically it might also clear away some of the expensive coverage mandates that Congress imposes on Medicare under pressure from different elements of the medical industry)"
This is pretty potent, and possibly a force for good.  It's a very big threat especially to the medical device industry, which for too long has been able to escape any rigorous cost-benefit analysis for new devices.  Which is not to say that the innovation is bad, but the costs have escalated dramatically and this may bring some rationality back to the system. 
"[A] second institution the legislation creates: a Center for Medicare and Medicaid Innovation in the Health and Human Services Department. Though this center has received much less attention than the Medicare Commission, it could have a comparable effect. It would receive $1 billion annually to test payment reforms; in a little known provision, the bill authorizes the HHS Secretary to implement nationwide, without any congressional action, any reform that department actuaries certify will reduce long-term spending."
Wow.  That really flew under my radar.  It sounds like it has pretty broad powers, and a broad scope.  This could be extremely effective at controlling costs, and de-politicizes the process of reforming payments, which is good.  I worry about the reforms that it might ultimately recommend.   Definitely a double-edged sword, from the perspective of a health care cost generator practicing physician.
"Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.)"
Yes, this is a pity.  However, I blame this entirely on the Republicans.  We know that the Democrats have been four-square against tort reform for time out of mind.  There is no way they were going to put it in their bill on their own.   If Chuck Grassley had offered five solid GOP votes for the overall package in return for real malpractice reform, I am sure that Obama would have jumped at it.  Who wouldn't?  There would have been no last-minute drama over whether the bill was going to pass, the compromises would have been made in committee, and both the Democrats and GOP would have been able to claim to their constituencies that they had accomplished long-standing objectives.  Instead, the GOP chose immutable opposition as their strategy and as a result the bill reflects not one of their priorities.  Reap the whirlwind, boys.

Overall, it's promising -- as a start. I don't think this will be the end, not by a long shot.  A large number of critics claim that the health reform bills do "nothing" to control costs.  This is not nothing -- not by a long shot.  Whether it will work at all, or whether it will do enough are open questions.  I also find it interesting that the providers who have been most concerned about the escalation of health care costs (I'm looking at you, Kevin) have not weighed in on this element of reform.  As a provider, I have really mixed feelings about the potential for cost containment to (further) erode physician autonomy and to (further) reduce physician income.  However, no sane person can look at the rate of medical inflation and not see the burning need for cost containment.  I just worry that too much of it will fall on our shoulders, since reining in costs any other way is tricky and politically unpopular.

There, Mr President, I've done my homework.  Do I get extra credit?

H1N1 Impact

My daily email from ACEP tells me that the H1N1 influenza epidemic has finally peaked and is tailing off.  That is consistent with what we are seeing in our ER at the present time.  We got hit a little bit in April and more in May, but then seriously slaughtered in October, as you can see from the chart below, provided for all you data junkies:

From the beginning, 2009 was shaping up to be a banner year.  2008 had represented our high-water mark with 290 patients per day on average.  We were well ahead of that pace even before the emergence of the swine flu, with Feb-April all at record volumes.  You see the first true peak was in May when influenza (and the public fear of influenza) first became widespread. Things tapered off over the summer (if by "tapered off" you mean "remained at historically high levels).  Then we got the next peak in October: it was the first time we have ever seen 10,000 patients in a month.  We averaged 325 patients/day, 12% above our old baseline, and had peak days of about 390 patients, a full 33% above the old baseline.  The acuity remained reasonably low; at any given time, on average, we have had 12-15 inpatients with influenza.  Some of them, however, have been quite sick, and there have been a few young, healthy people who have been critically ill with influenza, which is very sobering.  Year-to-date, we are on pace for 112,000 patients, a 7% increase from 2008.

Operationally, I couldn't be prouder of our team.  They handled the historic influx of patients with aplomb.  Despite the fact that we felt that we were at maximum capacity before this all began, they took on the challenge and kept things running smoothly.  Our LWBS rate remained below 1%, and the door-to-bed time actually decreased from 9 minutes to 7 minutes.  It has been an amazing performance in trying circumstances.  Our processes that we have put in place held up beautifully, but it was without doubt the people behind the processes that made it possible for us to get through this epidemic successfully.

I'll be interested to see if there is a "third wave" of H1N1 in the late winter, when seasonal influenza usually peaks.  Perhaps it will just be predominantly the seasonal flu strains, or perhaps they will blend into one another.  I'm still anticipating a worse-than-usual flu season, but if the vaccine supplies ever do catch up, it may mitigate the outbreak somewhat.

On a slightly related note, there are now being reported outbreaks of Tamiflu-resistant H1N1:

CIDRAP >> Clusters of resistant H1N1 cases reported in UK, US
Nov 20, 2009 – Health officials in Wales today announced the identification of a cluster of patients in a Cardiff hospital who are infected with oseltamivir-resistant pandemic H1N1 influenza.

Also today, Duke University Medical Center in Durham, N.C., reported that oseltamivir-resistant H1N1 viruses were found in four very sick patients hospitalized there over the past 6 weeks. A Duke press release said all four patients had been in the same hospital unit, but it did not specify how many were there at the same time.

In Wales, the National Public Health Service (NPHS) said five patients in a unit at the University Hospital of Wales that treats people who have severe underlying health conditions have been diagnosed as having oseltamivir-resistant pandemic flu, and three of them appear to have been infected in the hospital.

Up to now, just one probable instance of person-to-person transmission of oseltamivir-resistant H1N1 flu has been reported. In September the US Centers for Disease Control and Prevention (CDC) reported oseltamivir-resistant pandemic H1N1 flu in two girls who stayed in the same cabin at a summer camp in western North Carolina.

Note to Dr Feelgood: this is why we don't hand out Tamiflu to every poor sucker with a fever and bodyaches.

23 November 2009

I love me some graphs

Especially interactive graphs.

GE made a graph of the average annual cost of patients with eleven common chronic diseases.  Go check it out, marvel at the coolness as you grab the sliders and spin the wheel o' misfortune. 

Take home point: hypertension is the single biggest driver of medical cost in all patients age 33 and up.  Go figure.

20 November 2009

Friday Night

Off to the ER.  Enjoy yourselves some classic Tull:

19 November 2009

Awful and horrible and disgusting

Whatever you do, do NOT go read this post at Life in the Fast Lane.  Especially if you are prone to nightmares.  It's a post ostensibly singing the praises of bacon, a good and noble purpose which we all can respect.  But in reality it contains images so profoundly repellent that you may well claw your own eyes out in sympathetic horror.

The only thing I found surprising is that the nasty little creatures described do not hail from Australia.  I thought Oz had the market cornered on stinging, dangerous vermin.  I guess since these bugs aren't actually bearing lethal poison they're not up to Australia's standards: too tame.

So instead of scarring yourself for life by reading that terrible post, go over to Archie McPhee's and buy yourself some authentic Uncle Oinker's Gummy Bacon instead.  You know you want some.

Senate HCR Reax

As you are probably aware, Harry Reid released the Senate's version of the merged health care bill yesterday.  I don't think I can add much to what has been said elsewhere, so I'll spare you the painful rehashing of the details.  You're welcome.

As usual, Igor Volsky at the Wonk Room has the essential details.

There's a lot of comments that could be made about this bill.  It's nice to see that it's fiscally responsible.  It's not only deficit-neutral, but it actually pays down the deficit by $127 billion.  Not too shabby.  Of course it does that by deferring the best benefits of the bill to 2014.  That's not too great, especially because there is going to be an election between here and then.  If the health reform has been on the books for five years and has not done much to improve access to health care (which it will not have until the exchanges open in 2014) there's a very strong chance that the voters will punish the Democrats for broken promises.  I understand that this compromise was necessary to make the bill affordable and get it passed, but it may have been a very bad decision strategically for the Democrats.

The thing that I think is striking was that in the face of an explicit filibuster threat from Lieberman, and open waffling from the ConservaDems, Reid kept the opt-out Public Option in the bill.  I was quite expecting it to be thrown on the sacrificial altar, and it's so watered down and minimized that I was more or less resigned to it.  Moreover, Reid had a private chat with Nelson, Lincoln, and Landrieu in which he discussed, among other things, moving the bill to the floor using the non-filibusterable reconciliation process.  It wasn't couched as a threat, but the message was clear: block this and we will bypass you and make you irrelevant.  Does he have a secret plan to get health care through reconciliation intact?  I haven't got a lot of faith in Reid, and I won't be surprised if he buckles, but I like his positioning at this point.

How patients face Bad News

Dr Rob wrote yesterday about breaking Bad News to patients.  It's a great post and well worth a read.  I suspect that for Dr Rob, as for most primary care physicians, Bad News is a fairly uncommon part of their daily life.  For ER docs, it's perhaps not an every-day expectation, but in even a moderate-acuity ER it generally is a near-daily part of the job.

I had a shift recently where I was The Raven.  I went from room to room, it seemed, dispensing Bad News.  Not the most fun shift I have had.  "You know that numbness in your hand?  Brain tumor.  Sorry."  "Hey, that vaginal bleeding? Turns out your baby died a couple of weeks ago.  Bummer." "That chest pain you had yesterday went away because you completed your infarction.  You're probably going to need a new heart now.  Just sayin'." "Wow.  Your liver's big. Did you know you had mets?"

The thing that struck me during that shift, as it has so many times before, is how differently people experience and process Bad News.  It's almost like a case-control study, since I have a fairly standard method of dropping the hammer on the poor folks who receive The Badness.  How they respond seems more dependent on the patient-specific factors than on my delivery.  For example:

Option 1: Hysterics.  Common in the young, common with less serious bad news, and also common in certain distinct social/cultural groups.  More common in the families of the afflicted than in the patients themselves.  Can present with simple weeping, but can easily escalate to high drama.  Faux seizures and violence against walls are common elements.  The most distressing thing I have recently seen was a young man harshly mistreating his girlfriend/fiance who was having a miscarriage.  We were all kinda sorry he didn't cross any bright lines so we could have called the cops on him.  Challenging to manage in the short term, but tends to blow over quickly.

Option 2: Paralysis.  Perhaps the most common response.  As Dr. Rob says, "Saying words like “cancer” is like dropping a bomb; people won’t hear much else in the visit after you say that."  So true.  The unexpected "Hey, that's a tumor" on CT scan commonly results in this sort of emotional vapor lock.  It's much worse when there's no action item and when the patient doesn't feel that sick.  Typical physical findings include the fixed thousand-yard stare and monosyllabic responses to direct questions.  For me it's a non-management item, since I'm usually passing the baton to the inpatient team, but I feel bad for these folks.  I feel obligated to try to draw them out of the catalepsy, but in truth, these folks just usually need some time to process.

Option 3: Incomprehension.   A real challenge when it's genuine:
"So it'll just ... grow back again, will it?"  I've heard the equivalent of that many times.  "So they'll just cut out that liver mass then, will they?"  No, it's metastatic.  They can't cut it out.  "Right then, so after they cut it out, I'll be fine."  No, I just told you they can't cut it out.  To be fair, I suspect many cases of supposed incomprehension are just paralysis with a facade of incomprehension.  Denial, if you will.

Option 4: Fatalism.  Reminds me of an Onion story: "Faced with the prospect of a life-threatening disease, the 34-year-old husband and father of three drew a deep breath and made a firm resolution to himself: I am not going to fight this. I am a dead man. On Feb. 20, less than a month after he was first diagnosed, Kunkel died following a brief, cowardly battle with stomach cancer."  This actually seems more common with cardiac or stroke patients.  I tell someone that they are having a heart attack, and they just sort of check out and let events overwhelm them.  I recall one guy heading off the the cath lab, all of 45 years old, telling his wife, "I've had a good run."

Option 5: Stoicism.  Directly proportionate to the degree of familial hysteria, it also presents on its own.  I personally am quite comfortable with the stoics, because I think I identify with them.  A more long-term thinker might worry about their coping skills when the shit ultimately hits the fan and the stoicism runs out.  But in the short term it's a useful mechanism to defer the anxiety and grief than accompanies Bad News, and it's probably the easiest for me to manage.

Option 6: Creepy stoicism.  There are things so awful that the stoic response is glaringly maladaptive.  I remember a dad, informed of his young son's death, who calmly responded that the Good Lord giveth and taketh and are there papers for me to sign?  Wowie.  Sick sick sick.

Option 7: The mature response.  I don't know how to better describe this, but some people have the gift of a capacity to absorb the bad news, allow an appropriate shared emotional reaction, and turn back to me with an "OK, that sucks, what do we do now?" demeanor.  I'm not sure I'll handle it that well when it's my turn. I hate this because it's an article of faith in the ER that the nicest people always have the worst outcomes, and these are the folks that I tend to really like, personally.

I'm sure I've missed a few variations, and the possible combinations of the types are near-infinite.  As a student of human nature I am fascinated by the differences and commonalities in the responses.  I feel sympathetic grief for these folks, the few among the hordes of worried well congesting the ED who bear real life-changing illness.  Generally I don't get to do much to help them.  I'm the perennial bad guy -- I drop the bomb and then shuffle them off to someone else to get better -- which is a pity because I'd really like to have a positive contribution to their care.  I console myself that the bearing of the Bad News is an important job in itself, that well-done it can position patients to accept and move forward, whereas poorly-managed it can be highly traumatic.  So by being tactful, careful, and supportive in my presentation, the diagnosis can be the first step in the therapy. 

But it's still never fun.

18 November 2009

it's a cartoon so it must be cute

LOL, as the kids tragically unhip thirty-somethings say.

via ERP

Back Doors

This post at The Central Line caught my eye:

Texas Recognizes ABPS Certification

The Texas Medical Board ruled on Oct. 20 that physicians certified by the American Board of Physician Specialties (ABPS) could advertise themselves as board certified to the public.

The ABPS is the certifying body of the American Association of Physician Specialties (AAPS). The ABPS sponsors 17 boards of certification, including the Board of Certification in Emergency Medicine (BCEM).

For a number of years, ABPS, in conjunction with AAPS, has been seeking recognition from various state medical boards, requesting that they allow physicians certified through an ABPS board to advertise themselves as board certified. The organizations were successful in Florida in 2002 but were recently rebuffed by the State of New York due to the lack of residency training as a qualification for ABPS board certification.

ACEP does not recognize BCEM as a certifying body in emergency medicine.

This is bad. I've mostly stayed out of the internecine squabbles in the house of medicine, for a variety of reasons. Mostly because 99% of the issues are incredibly petty and provincial; for that reason I have a hard time getting/staying interested in these issues. This is a little different.

For background, the certifying body for Emergency Physicians for the last 30 years has been the American Board of Emergency Medicine (ABEM), which itself is under the umbrella of the American Board of Medical Specialties (ABMS), which has been the standard board certification organization of all allopathic physicians for the last 75 years. There is a companion organization for osteopathic physicians. The ABPS is relatively new in the last three years, though it is an offshoot of an organization which has been around for about 25 years, and it also purports to provide Board Certification in various specialties.

As it relates to Emergency Medicine, the ABPS is problematic. Specifically, it allows physicians to seek certification in Emergency Medicine without completing a training program in Emergency Medicine. It accepts training in a Primary Care specialty or, oddly, Anesthesiology, as equivalent to an Emergency Medicine residency. As best as I can tell, Emergency Medicine is the only such specialty certification for which the ABPS does not require completion of an ACGME-certified specialty training program. Residency training is required for ABPS certification in Radiology, Ophthalmology, Family Practice, Anesthesiology, and Orthopedic Surgery, at least. Why is Emergency Medicine held to a different, lower, standard under ABPS?

Unlike the other specialties, there are thousands of doctors practicing Emergency Medicine who are not residency-trained. This is in part an anachronism due to the relative youth of Emergency Medicine as a specialty; there are many ER docs who have been working in the ER since well before the ABMS recognized Emergency Medicine as a distinct specialty. It is also true that there are more ER positions than there are residency-trained graduates of EM residencies, and this is likely to remain the case for the foreseeable future. Even as new training programs open, the rate of graduation of new residents barely makes up for the retirement of practicing ER docs, let alone makes up the gap in the number of untrained ER docs.

Even today, many young primary care docs tire of the drudgery of office practice and give it up for the easier lifestyle and higher compensation of the local Emergency Department. Many small ERs, especially those in rural areas, have trouble attracting good physicians and as a result are willing to credential almost any physician willing to staff their department. This is not an ideal circumstance, of course, but when your ED cannot find doctors any other way, it does become something of a buyer's market.

So it is necessary to recognize the existence of the thousands of moonlighters and other variously-competent doctors working in the nation's ERs; it's a reality that is not going to go away any time soon. It's actually a good thing that there is a certifying body that can guarantee some minimum level of competency for these practicing physicians. As long as we have the necessary but undesirable situation of untrained physicians working in the ED, I am not opposed to the existence of the AAPS program.

What I am opposed to is the dishonesty of these physicians and their organizations in presenting themselves to the public as "Board Certified." This is misleading in the extreme. Board Certification has always been held to mean a high standard of training and accomplishment. It is a standard across 24 specialties. For an alternate organization to set itself up and promote a lower standard is disturbing. More disturbing is the manner in which the ABPS/AAPS slipped this in through the Texas Medical Board apparently in the dead of night with no public discussion. If there is to be equivalency between ABPS/AAPS and the ABEM, it should be agreed upon after a full and open debate. For myself, I do not think that this equivalency is merited. The ABPS is like ACLS and ATLS -- a nice merit badge to show that you're not likely to hurt anybody while working in the ER, but not the same as a specialty training certificate. But if Texas (or any other state) medical board decides otherwise, then that decision should be the product of a public debate and consensus among the physician leaders in that state.

If the implication of the linked article is accurate, this decision was the result of a shameful bit of political sleight of hand. I hope that ACEP is successful in reversing this ruling.

Ultimately, this is a manpower situation that Emergency Medicine needs to come to grips with. While new residencies continue to open in drips and drabs, and existing residency programs expand a bit, the rate of increase is far too slow. Unfortunately, the funding from Medicare which underwrites the cost of graduate medical education is very hard to come by in this difficult budgetary environment. In an ideal world, the residencies would grow to the point that all Emergency Physician positions would be filled by, you know, trained Emergency Physicians. I don't know whether that will happen in my professional lifetime. The consequence is that many of the nation's Emergency Departments will continue to be staffed by untrained doctors of uncertain quality. That is a pity for the patients who come through the doors, who are after all a captive audience, unable to make a choice of their treating provider. They deserve better.