31 March 2009

Late night

I liked John Cale's version better, but a song like this is hard to do badly.

Award Fatigue

Thomson Reuters Announces 100 Top Hospitals Award Winners | Thomson Healthcare
The Thomson Reuters 100 Top Hospitals®: National Benchmarks study is based on the 100 Top Hospitals National Balanced Scorecard that evaluates performance in nine areas: mortality, medical complications, patient safety, average length of stay, expenses, profitability, cash-to-debt ratio, patient satisfaction, and adherence to clinical standards of care.
Our facility is on the list for, I think, the fifth year running -- this year we were the only hospital in our state so recognized.   It's natural after a while to stop paying attention to this sort of thing, but it really is a big deal.    It's not the end-all and be-all of hospital quality, but it shows that our leadership, our processes, and our caregivers are doing great work.   (I will take personal credit, of course.)  

Seriously, I am very proud of our institution.   From the OR to the ICU to the ER, we've accomplished some incredible things, and in an environment where financial resources are scarce.   To the (very) limited degree that I had anything to do with it, I'm pleased.  Mostly, I'm lucky to be affiliated with such a highly functional group of people.

Nice Gig

Got a nice email from pediatrician Rahul Parikh, med-blogger/columnist at Salon.   I wasn't even aware that Salon had a blog section.   Rahul also had a nice perspective piece at the LA Times yesterday.

I've not had time to peruse his work in depth, but he takes on the woo of Jenny McCarthy and the Mercury Militia, gives props to Obama's health care reform efforts, and covers the JAMA Mafioso response to their covered-up conflicts of interest.   So I like his perspectives and sense a kindred spirit.

More, I'm impressed by anybody that's able to write "real" columns, as compared to blog posts.   I've neither the time nor attention span to develop a thesis, research it, and pad it out to a thousand words, and then polish it to the point that it's fit for a major publication.  I throw out whatever occurs to me on a given day, anything that catches my interest, and if it's a bit half-assed or rough around the edges, I can live with that.  There's always tomorrow, or this afternoon, or whenever the next post goes up.   Not that I don't try to be thoughtful or have a point, but it takes a lot more craftsmanship to meet the standards of the LA Times.

So well done, Rahul.  I'll be keeping an eye on you, and don't be a stranger.

That's Just Bizarre

A 88 year old male with a history of steroid-dependent COPD and steroid-induced diabetes sustained a small cut on the palm of his left hand.   This was a 1cm puncture wound inflicted with a kitchen knife while washing dishes.   It was a minor cut, the bleeding controlled easily (despite the fact that he was on warfarin) and he did not seek medical attention immediately.  Three days later, he presented to his primary care doctor because his wrist and arm were swelling up; he was sent to the ER for assessment.

On exam, the patient had subcutaneous emphysema on the dorsum of the hand and circumferentially all the way from the wrist to the shoulder.   There was no erythema, tenderness, or fluctuance.   The wound was clean and dry without evidence of infection.  There was no pain with range of motion at any joint, and the compartments were soft (indeed, squishy).   The patient was afebrile and well-appearing, and the white count was normal.  An MRI of the extremity was obtained:

Uploaded with plasq's Skitch!

Uploaded with plasq's Skitch!

Uploaded with plasq's Skitch!

I apologize for the poor resolution -- for some reason I could not download the nice high-res images.   The black spots under the skin, between muscle groups, and (weirdly) around the bones is air.  According to the radiologist, there was no evidence of fasciitis, or any other inflammatory/infectious process.

A general surgeon, a hand surgeon, and an internist spent a while puzzling over this with me.   The big concern was that gas in the soft tissues is the hallmark of certain very bad infections -- think gangrene and the so-called flesh-eating bacteria, which are terribly life-threatening.   The patient didn't look infected, but being diabetic and on steroids and nearly 90, they sometimes don't show you the evidence of infection.   The MRI was more definitive that it was probably not infected, but if not, then how the hell did all that air get up there?

Ultimately, we played safe, admitted him for IV antibiotics and observation.   My theory was that the cut on the palm was acting as a sort of ball-valve mechanism where each time he opened and closed his hand, he pumped a little more air into the palm, which then tracked up the arm as more and more air got insufflated.  

People are weird.

The Uninsured

Long-time readers of this blog know that the crisis of the uninsured is probably the issue I care more about than any in medicine.  I care so much because I hate seeing these poor folks come into the ER with the consequences of their inability to find a doctor, and because I don't like not getting paid for what I do, and because the system that allows working people to fall into the gap between insurance and medicaid is so staggeringly unfair.

Doc Rob has a thoughtful and moving piece over at his place, from the office doc's perspective:

The Uninsured | Musings of a Distractible Mind
This is when one of my billing staff comes to me with the “what do you want to do?” question regarding them. Most of these are people I know. I don’t think of them as customers, I think of their kids and parents. I think about the medical struggles they have faced or the tragedies they have endured. I like my patients. Playing “hardball” is not that easy when you have an emotional attachment to your “customer.”
I don't have that problem, fortunately.   Unlike Rob, I am a commodity, and I am OK with that, and my interactions with patients are mostly one-shot affairs.  

But it puts a much more human face on "the uninsured," instead of viewing them as a nebulous mass of the great unwashed.

30 March 2009

University of Chicago in more trouble

WhiteCoat has a reasonable rundown on the events surrounding last month's death in the waiting room at University of Chicago Medical Center -- as well as a satisfying but spurious idea of how UCMC should respond.   The news is that now CMS is looking into this as an EMTALA violation, which, based on the facts as presented, it almost certainly is.   The headline is that Medicare could pull its certification of the hospital, which is technically accurate, but terribly unlikely.

UCMC is in trouble.   There's no mistaking that fact.   They're being crucified in the media over their ER, and with good cause -- their ER is a nightmare, even for an inner-city academic center.   It seems to be a self-inflicted problem caused primarily by bad senior management -- not of the ER, but of the facility.

I've spoken and corresponded with some people with direct knowledge of the situation there.  The problem is that the hospital does not want to provide basic medical care as its sore mission.  They want to focus on their "Programs of distinction," and to the degree that general medical care is an impediment to that mission, they are willing to throw it under the bus.

The administration of UCMC portrays this as a financial necessity, which is half true.   Their motivations are clearly in part economic -- oncologic and surgical subspecialty services lines are far more profitable than general inpatient medicine, apart from the more favorable payer mix such referrals tend to bring.   However, to claim this is a necessity is an absolute sham -- UCMC has had operating income of >$80 million annually for the past two years running, with a better than 8% margin.  This is a staggering feat in the world of hospital finance.  Even in these difficult times, they managed to retain a 1.8% margin in the fourth quarter of 2008.

How to they do this?   Put simply, they ration care provided to the local community.   Although the medical center has over 590 beds, only 50 beds are available to medical patients admitted through the ER, and only 9 ICU beds are available to ER patients.   This in a facility with over 80,000 ER visits annually!   When a patient presents to UCMC's ER needing admission, if there are no "ED beds" available in-house, or if there are but the ER resident cannot convince the medicine resident that the patient "needs the university," then the patient cannot be admitted to the hospital, and must be transferred.   The ER residents spend more time making phone calls with neighboring facilities trying to arrange tranfers than they do providing direct patient care.

I can see some people saying, "Fine, I can see the logic in that, where's the problem?"  There might not be one if there was a receiving hospital right across the street that would take all transfers, no questions asked.   But that's not the case, and patients needing admission languish in the ER for many hours (and days) while the ER staff seeks an inpatient facility that will take them.   This reduces the number of beds in the department that are avilable for assessment and care of new patients.   The UCMC ED is already undersized, at 30 beds for 80,000 patients (generally, one bed is good for 1,500 annual visits, and at 2,000 visits per bed, an ER is considered over capacity), and if there are seven beds taken out of service, then the capability to move new patients through the department is hamstrung, as the department capacity is reduced by 25%.

The result?   Seven-hour waits to be seen, a LWOBS rate of 10-20%, and people dying in the waiting room.

And it gets worse.   UCMC recently closed its fast track and laid off its mid-level providers who had staffed it, many of them fifteen-year veterans of the facility.    If, as has been claimed, the crisis at UCMC was caused by a deluge of patients with minor conditions, then it makes no sense to close fast tract, but to expand it to streamline the flow of minor patients without consuming ED resources.   Unless, that is, your strategic goal is to eliminate the ED as a service line, in which case the next logical step would be to downsize the ER by a third, and reduce the inpatient beds available to ED patients by half.   Which is exacly what they planned.   After 190 of their doctors (mostly housestaff, it seems) signed a letter of protest, the university may have partially backed off of this plan.

But the message is clear: the University is actively trying to get out of their obligation to provide emergency services and is trying to position itself as a purely referral-based provider of specialty care.   They would probably close the ER entirely if the Illinois Department of Health would allow them -- which might almost be better than the tragicomic sham of an ER they are currently supporting (or, more accurately, failing to support).   In this, I don't blame the doctors and nurses staffing the ER at UCMC.   I've been at institutions where the administration did not support the ER, and there's no way to turn that around until there's a change of management.  I'm sure the clinical staff are doing the very best they can in the shameful situation their hospital has placed them.

There are a lot of factors nationally which place the emergency care safety net in jepaordy; this is not a case of the national picture on the small scale.   This is a case of a crisis caused by willful and deliberate mismanagement.

So with the firestorm of negative PR, condemnation by medical specialty societies, and now a death in the waiting room, is it finally time for UCMC to pay the piper?   It's encouraging that the trifecta of CMS, IL DOH, and TJC are displaying interest.   Whether real reforms come out of this will depend on exactly how aggressive the regulators' approach is.   I've been a victim subject of these agencies' tender mercies in the past, and they commonly take a very adversarial position in these matters.   Given the egregious nature of the policies UCMC has put forth, I have some cautious optimism that the regulators will hold their feet to the fire and demand real changes.  


The complaint raised by conservative senators against the public plan option in a health care reform plan is that it would be an "unfair playing field" which would disadvantage private insurers.

My response has generally been dismissive to this line of argument.  The senators making it have generally been shills for the insurance industry and inclined to oppose reform in any case, so it's not overly cynical to view their objections as not entirely in good faith.  Even so, my thought has been, what of it?   Let the market decide.   If, as the conservatives fear, the public plan winds up being cheaper and better and the public freely votes with their feet and their dollars to choose it, then GREAT!   But if, as some doomsayers predict, the private insurers will select out the healthiest patients and the public plan winds up saddled with the sickest patients and highest costs, then isn't that good for the insurance industry?

Joe Paduda makes an interesting argument that the public plan would actually not be anti-competitive:
Sure, price is a factor - but it is not the most significant factor - not by a long shot. By keeping patients out of the hospital, a private plan would eliminate utilization and prevent price from ever becoming a factor. So, even if a service area was dominated by a public plan, a private plan that did a really good job of keeping members healthy and out of the hospital would deliver lower costs.
And also:
The reality today is that almost every market is already dominated by a very few health plans, so much so that in most markets, there really is very little market competition amongst health plans. [...]  If anything, a robust public plan would add competition to many markets, competition that would, if anything, increase consumer and provider choice.

How exactly is that bad?

Interesting perspective.   I doubt it will convince the AHIP advocates, but hopefully there's someone on the Hill explaining this sort of thing to Olympia Snowe and Arlen Specter.

End it, don't mend it

Doctors Call For Rebasing Medicare's Sustainable Growth Rate (SGR) - Health Blog - WSJ
Every year or so, we hear that some big Medicare pay cuts for doctors are on the way. Almost every time, Congress swoops in at the last minute to block the cuts. Leaders of the AMA and other big doctor groups have been in Congress lately asking for a change to the underlying system that keeps creating these near misses.

At issue is the “Sustainable Growth Rate,” a formula Congress created in 1997 to try to keep payments from spiraling out of control.

[...] Testifying at a recent Congressional hearing, leaders from the AMA, the American College of Physicians and the American College of Surgeons praised the budget. The AMA official called for setting a new, higher baseline for SGR.
I've also written about the SGR in the past.   Put simply, it was an index placed on physician compensation under medicare, enacted (IIRC) as part of the Deficit Reduction Act of 1997, designed to prevent medicare's physician costs from exceeding a certain fraction of the GDP.

Makes sense, when you think about it in the abstract, doesn't it?   But it never worked.  The number of beneficiaries grew, and they lived longer with more chronic illnesses, new technologies and services were developed, and GDP growth slowed, so the formula was triggered, and in 2002, physician compensation was cut by 2%.   Then in every subsequent year, the formula called for larger and larger cuts.   Three years ago, the cuts mandated were 10%; this year, the cuts mandated under the SGR total 21%!   But every year the Congress steps in at the last minute (and sometimes later) to stop the cuts.   Changing the physician compensation formula is such a daunting and politically exposive task, that they never take it on: just kick the can down the road to next year.

I've always thought that doctors were unfairly singled out with the SGR to begin with.  Why is it that there was a cap placed on the growth in expenditures for physicians, but not hospital expenses, nor medical devices, nor pharmaceuticals?   The real answer is because the AMA is a laughably impotent lobby. There's no rational basis for capping the growth of one expense -- the smallest -- and not the others, other than political strong-arming and opportunism.

Which is why I'm annoyed to see our leaders on Capitol Hill calling for setting a new, higher baseline for the SGR.   It was a bad idea, unfairly applied, and did not work.   To the degree that physician compensation is addressed in healthcare reform, the position of the physicians' lobby ought to be that the SGR should be ditched and not replaced.  Cost containment should not be applied to just one sector of the health care industry, and certainly not in such a blunt, indiscriminate manner.

28 March 2009

Deep Thought

To the 22 year old young lady (gravida 9, para 4) I saw recently for issues related to her current, unplanned, pregnancy:

You, and your family, would probably be well served if you looked into the idea of birth control.

Just a suggestion.

Making me Laugh

Kung Fu Monkey:
There are two novels that can change a bookish fourteen-year old's life: The Lord of the Rings and Atlas Shrugged. One is a childish fantasy that often engenders a lifelong obsession with its unbelievable heroes, leading to an emotionally stunted, socially crippled adulthood, unable to deal with the real world. The other, of course, involves orcs.

Cost per unit delivered

CNN has an interesting anecdote about medial tourism:  a woman traveling to India for (I assume) a heart valve replacement, for about 5% the estimated price of the same procedure performed in the US -- travel included!
"They [U.S. hospitals] told me it would be about $175,000, and there was just no way could I come up with that," Giustina said. So, with a little digging online, she found several high quality
hospitals vying for her business, at a fraction of the U.S. cost. Within a month, she was on a plane from her home in Las Vegas, Nevada, to New Delhi, India. Surgeons at Max Hospital fixed her heart for "under $10,000 total."
Granted, the quoted price is the inflated price given to the uninsured -- the typical actual cost (or at least the reimbursement) for an open-heart procedure is, I think, closer to $40,000.   I am also assuming that this is an open heart, though the lede confusingly refers to the procedure as fixing "atrial fibrillation."  I can't think of any A-fib treatment costing $175K, but leaky valves can lead to A-fib as a consequence, so that's my guess.

On a related note, Ezra has a disturbing anecdote of an involuntary medical tourist:
Last weekend, my best friend, an aid worker in Sierra Leone, was in a motorcycle crash. Injuries were serious but not life threatening. The worst of it were three breaks in his leg: Two clean, one less so. After a couple days in a Sierra Leone emergency room, his evacuation insurance kicked in and he was flown to a small town in Germany (no one quite knows why) to receive treatment. My friend does not speak German. He does not know anyone in Germany. He wants to come home and receive his care in the states. He wants a doctor he can communicate with and nurses who can understand his requests and friends who can speak to him and calls that aren't subject to international fees. But his insurance is refusing the request. Medical treatment, they're arguing, is simply too expensive in America.

As a matter of economics, they're not wrong. In their seminal paper, "It's the Prices, Stupid," Uwe Reinhardt and Gerard Anderson marshal an impressive array of evidence to prove that the cost problem afflicting American health care is a per unit problem: It's not that we use more care, or use more technologically advanced care, but that we pay much more money for any given unit of care.
And that's really the driving factor behind all this medical tourism, isn't it?   We can chant over and over that "America has the best health care in the world," and that may be true to a degree, but the fact is that many other countries have modern, top-notch health care capabilities at much lower costs.  Of course, as the CNN article also points out, "The salary of a U.S. surgeon is five times that of a surgeon in India."   American physicians are also much better paid than in most developed countries:
Although the United States now has relatively fewer physicians per 1,000 population than the OECD median, its total national spending on physicians as a percentage of GDP is double the OECD median (2.9 percent in 1999, compared with an OECD median of 1.3 percent). [...] Physicians’ incomes are much higher in the United States than they are in other OECD countries. In 1996, the most recent year for which data are available for multiple countries, the average U.S. physician income was $199,000.27 The comparable OECD median physician income was $70,324.
The data is a little old, but I don't doubt the comparison is still valid.   This is something that most physicians would rather not talk about when we rant about the need for cost containment -- myself included! Physician compensation is not unique, however, in that all of the cost indices for the various service lines of US health care markedly outstrip their OECD counterparts.   So cost containment/reduction initiatives will need to be focused broadly, not just on the doctors, if US costs are ever to be brought in line with (or at least not get further out of proportion to) foreign countries.

Epidural Publicity

An alert reader pointed out this article on CNN:

But after hearing about Richardson's death, the McCrackens wondered if Morgan was really as OK as she seemed. After all, Richardson had been talking and lucid immediately after her fatal injury.

When they went upstairs to kiss Morgan good night, she complained of a headache. "Because of Natasha, we called the pediatrician immediately. And by the time I got off the phone with him, Morgan was sobbing, her head hurt so much."
She turned out to have an epidural, the same as Natasha Richardson, but did very well.

This is a weird case on several levels.  She wouldn't even have qualified for a CT scan in the ER based on generally accepted criteria.    The "lucid interval" is usually hours, not days.   And young people -- kids especially -- have tight heads and generally worse outcomes than middle-aged or older adults.   But it does highlight the value of education and public awareness.

Mother Nature's rebuttal

Louisiana Gov. Bobby Jindal gives the GOP response to President Obama's address Tuesday.
Know-nothing conservative wunderkind Bobby Jindal, tapped to respond to President Obama's NSOTU, used his national TV platform last month to sneer at "wasteful spending," including "$140
million for something called 'volcano monitoring.'" (scare quotes in original)

In a bit of karmic wonderfulness, Alaska's Mount Redoubt erupted last week, allowing the USGS to educate Governor Jindal: this is volcano monitoring.

AVO Image
Bonus geek points for the USGS: Redoubt eruption updates and ashfall forecasts have their own Twitter feed.   "Another explosive eruption of Redoubt volcano occurred at approximately 01:20 AKDT (0920 UTC). NWS reports a cloud top of 50,000 ft above..."

Volcanoes are cool.   Volcanoes that debunk right-wing canards are cooler.

27 March 2009

You want socialism? We'll give you socialism!

Socialist senator Bernie Sanders (yes, he really does call himself a socialist) has introduced a single-payer health reform bill in the US Senate.   Kossack DrSteveB discusses co-sponsors and cost containment within the plan.

On the merits: fair enough, I can concede that single-payer does have the best potential for real savings, efficiency, and slowing down the growth in health care costs.   The downside is the inevitable government abuse of its monopsony power and subsequent downward pressure on physician reimbursement.

On the politics:  I don't want to be dismissive, but this doesn't have a chance in hell of becoming law.   Even the moderate consensus-based compromise plan will be a herculean task.   But it does have its use -- a bit of pressure from the left to encourage Senate leaders to keep the public plan as a viable part of the final health reform package.  This is particulary nic in light of recent comments by Senator Baucus, as (sort of) reported by Time's Karen Tumulty:
The insurance companies hate [the public plan], saying it is would be unfair for them to be forced to compete with the government. Many health care experts, however, argue that this provision is crucial, as a means of holding down health care costs. [...] Conservatives oppose it as well, because they see it as a first step toward a Canadian-style single-payer system.

What Baucus had to say will not give much comfort to those who support the idea of a public plan as it is presently being proposed. He strongly suggested that its main value, at this point, is as a bargaining chip to get the health insurance companies to agree to other things that reformers want to see:

"Essentially, it's to keep it on the table to encourage the private health insurance industry to move in the direction it knows it should move toward—namely, health insurance reform, which means eliminating pre-existing conditions, guaranteed issue, modified community ratings.  It's all those actions that insurance companies must take in order to provide affordable coverage. And the public option helps encourage the private companies to move in that direction, because they're worried. We might have to modify the public option to get enough votes. I hear some concerns among Republicans about the public option. The main purpose is to keep the health insurance feet to the fire."

I think it is essential that there be a public plan to force the insurance companies to compete on cost, customer service, and efficiency.   And that there be private plans to force the public plan to compete on the provider side with fair payment rates.   Talk like this of the public plan option as a bargaining chip does cause me some concern.   So, while it may be politically DOA, it's not altogether a bad thing for a purely public plan (single payer) to be emerging on Baucus' left flank.  

Wow this is cool

“208 OSEOsidades” by Saúl Hernández
Lots more mini-skeleton sculptures at the site.

Via Street Anatomy (where else?)

26 March 2009

Velocity tracking

One of the metrics we monitor at our practice is the speed with which monies are collected.  Mostly this reflects on the performance of the billing company.   Generally it's a good thing to know how many "Days in AR," or days of charges still in the accounts receivable.   Low numbers are better, reflecting less "inventory on the shelves" and a shorter time from service provided to payment received.   This number can, however, be "gamed" if the billing agency were to move delinquent accounts off the books rapidly.   Ideally, they will rapidly write off the obviously uncollectable accounts (i.e. homeless patients with no billing address, charity cases, and the like), while keeping the accounts that have potential on the books and working them to collect what they can. 

One other fun thing to do is compare the payers against one another to see who's paying in a timely manner and who is not.  (Widen the browser window or click here to see the full image.)Payer Velocity
Your mileage may vary.  Our state is an aberration in that traditional Medicaid is a very fast payer; compare that to Illinois, where they are eight months behind.   Of course, we joke, it doesn't take very long to pay nothing!  

You can see that, as is typical for most large billing agencies, Medicare is generally the fastest, with 70% of accounts paid in 15-60 days, and less than 20% aging beyond 90 days.   All the commercial agencies underperform, with fewer accounts current, and many more accounts >90 days old -- these usually result from denials, requests for more documentation, subrogation claims, and pure orneriness.  Auto claims and Worker's Comp, unsurprisingly pay the slowest, involving as they usually do lots of third-party liability and often requiring investigation.

Bear in mind that the vast majority of the revenue will in fact come from the first 60 days; claims that go over 90 days are rarely in fact paid.  The private insurers count on this -- a claim delayed is a claim denied.  Also, we are non-aprticipating with many of the commercial payers, which also tends to slow things down, since the common practice is to send the check to the patient, who then (we hope) will forward it to us.

The utopian dream would be a payer that had the speed & efficiency of Medicare with the payment rates of the privates.  

Dream on...

This is just insane

But well worth the read:

Life in the Fast Lane -- The Mark of the Beast

The man’s eyes were a cold blue deeply set above a bedraggled beard. Scarred knuckles at the ends of tattooed arms hung from a bare torso that bore the stigmata of a lifetime of violence - teeth marks, cigarette burns and various healed gashes and punctures. In another time he might have been seen leaping from a longboat onto frozen foreign sands or gnawing on a shield in a berserker frenzy.


Vijay links to an interesting point on the growth of teleradiology:
The dayhawk phenomenon has grown out of hospital satisfaction with the rapid service hospitals receive on outsourced off-hour interpretations by nighthawk teleradiology groups. Hospital administrators and referring physicians have begun to wonder why their local radiology groups cannot deliver the same level of service for daytime radiology reads that they are receiving from nighthawk groups.
I agree with Vijay that smaller radiology groups will probably lose out, but not because of defensive medicine, as he posits.  I think it is just the economy of scale -- that larger groups with centralized reading facilities are better able to staff nights, weekends, and specialty reads.  As radiology interpretive services becomes more and more a commodity, that trend will accelerate.   We're lucky, in that our tele-radiologists are the same local docs we have always had, just grown up a bit and providing services to a dozen local hospitals.  They came close, though, a few years ago, to losing their contract at our large hospital because of terrible customer service.   It was that threat that forced them to re-engineer their processes and become an absolute paragon of superior service.   Now, they are so good that I often have a dictated report on the chart before the patient is physically back from the scanner.

I wonder, though, how hospitals that outsource to regional or international vendors manage the services that require an on-site radiologist -- fluoro, ultrasound, and other radiologic procedures.   Some could be performed by IR, but a lot of smaller hospitals don't have full-fledged IR services.   It's a big risk, I think, for a hospital to completely demolish its local radiology capacity.

I hate spam

Got hit with a major comment spam assault today.   Over a two-hour period, I got over a hundred "comments" full of links for chinese-language pages.   Weird.  And they weren't, as far I could tell for WoW gold, viagra, or even porn (which at least is a sort of universal language).   I think I cleaned them all out, but if you see any still there, let me know.   It was a major PIA.   If this happens again, I may have to look at better spamkiller apps.   Anyone know of ones that work for blogger?

Cootie Vaccinations

If you don't read the Bad Astronomer, you should.   And it looks like, courtesy of the BA, I have a new webcomic to add to my aggregator.Web comic Overcompensation

Click the image to see the full toon.

25 March 2009


Passed the test.  Video of the kata can be seen here, if you like.   Bonus points if you can spot when I nearly hit Tim in his head with the Bo (staff). 

Now I don't have to test again for (at least) three years...

What I'm drinking tonight

Brutal Bitter Ale - Rogue Ales Brewery - BeerAdvocate
Poured with a thick and persistent head. Opaque caramel colour with moderate carbonation. The initial esters were a potpourri of floral and fruity notes. I kept sniffing it to see how many things were hidden away in the aroma. Very rich.
Flavour is astonishingly rich and fruity. Grapefruit abounds but also a hint of toffee maybe or caramel that prevents too much puckering. This is a massively flavoured bitter. The label says it's Hedonistic and it is. It's almost too much flavour which makes the drinkability score lower but everything is balanced perfectly. Awesome.

We're out of Dilaudid

Apparently there's a national shortage.  Our frequent flyers are unhappy.   "But doctor, morphine just doesn't work for me..."

We might as well hang out a sign and close down the ER till stocks are replenished.

23 March 2009


I've long been on record as being a fan of the police.   Not these guys, though I liked them too.   But the Garda, the gendarmes, the thin blue line.   And not just because they let me off of tickets on a semi-regular basis.   I work with them on a more or less daily basis, and that experience has led me to really appreciate and respect the job that they do.  

The other night, the local boys brought in a patient for a psychiatric evaluation.   He had been suicidal, and had attempted to shoot himself.   Something had gone awry; perhaps the gun has misfired, and perhaps he just missed.  It wasn't clear.   But he barricaded himself in his house when the police responded, and he had fairly clearly been attempting suicide by cop.   He remained armed, and was deliberately provocative and uncooperative.   In many cases, this will result in a police shooting.   But the fact that the police knew in advance that he was suicidal, and that he repeatedly asked them to shoot him, led our local police force to take a carefully restrained approach to the situation.

Just for reference, for those readers not acquainted with law enforcement practices, typical police procedures when confronting an armed individual does allow deadly force, with a fairly low threshold for action.   If a suicidal person is holding a gun in his hand, he is as capable of pointing it at the police as himself, and the police will shoot to protect themselves and their fellow officers if they must.  "Make sure you go home at the end of the day," is not just a cliche in law enforcement.   So, to be clear, the situation that our cops were in would have justified deadly force with no question whatsoever.

But they did not shoot him.  They remained under cover as much as they could, and did their best to negotiate with him.   After much effort, this was unsuccessful, and he was disarmed and taken into custody with a combination of a K-9 team and a much-maligned less-lethal weapon.

Truth be told, the dogs did a fair bit of damage, and I had some suturing to do to fix up his face and arms.   The patient (drunk, of course) was extremely upset that they has sicced the dogs on him, and was completely oblivious to how close he had come to perishing in a hail of bullets.

The thing that struck me, seeing the patient after the fact, was what an incredible job the police had done in saving this person's life.   He would have shot himself, without intervention, and could easily have killed a police officer.   This could easily have been the leading story on the evening news.   Had they shot him, no inquest board in the world would have faulted them.   But they held their fire, remained safe, and managed to defuse the situation with a combination of perseverance and creative thinking.

That's professionalism, and you've got to respect it when you see it.

Colbert Nation Strikes Again

Space Station Colbert? : ScienceInsider
NASA's online contest to name a new room at the international space station went awry. Comedian Stephen Colbert won.

The name "Colbert" beat out NASA's four suggested options in the space agency's effort to have the public help name the addition. The new room will be launched later this year.
Awesome. The other thing that makes me laugh is that among the other leading write-in options was "ubuntu." Geeks rule.

My prediction is that they will go with "Serenity," itself a nod to geek culture, but the name Colbert will be featured somewhere on the module and Colbert will make a big deal about it, generating some great PR for NASA.   At least that would be the smart thing to do.

Follow-up on Natasha Richardson

Regarding actress Natasha Richarson, who died after an apparently trivial fall, the medical examiner issued his report showing that the incident lesion was an epidural hematoma after all. Not a huge surprise, in that the "lucid interval" was so classic.

It reminds me of a case I blogged last year, about a young skier who arrested on the hill. In that case, I heard the post-mortem showed that the minor fall which had preceded the arrest had caused a fractured clavicle. The bizarre element there was that the clavicular fracture fragment had lacerated the subclavian artery (a complication which I had never even dreamed of) and the patient had exsanguinated into her thorax. And every year a few skiers die of asphyxia after falling into tree wells. Just last Tuesday I helped dig out a snowboarder who had gotten himself stuck in one -- fortunately head-up.

There are so many stupid ways to die out there -- not stupid in the sense that the victim did somethign stupid, but stupid in the sense that some little trivial thing suddenly winds up much bigger and worse than you would ordinarily expect. Sad.

Back on the original point, the Director of Trauma Services for McGill University Health Center, Montreal's trauma center, recently said that the lack of helicopter transportation may have been critical in her injury progressing beyond survivability. I think that may be an overstatement in this case. Certainly the 2-1/2 hour ground transport to Montreal didn't help matters, but the 2 hours' delay in getting to the first hospital put them so far behind the eight-ball that it would have been very difficult to save her in any case.

Having said that, it does kind of boggle my mind that they don't have some sort of medevac capability in a province the size of Quebec. I trained in Maryland, and for that fairly small state there were no fewer than eleven Dauphin helicopters operated by the State Police for EMS transport. And Quebec doesn't even have one? Amazing. Before the "single-payer sucks" advocates jump on this, I would like to point out that in Maryland and many other localities, EMS is paid for primarily out of tax coffers, not by the insurers. This is not about single-payer.

Others commented that it was kind of funny that she wasn't taken to a trauma center straight away, and suggested that too, is a failure of Canadian health care. I would like to point out that would be common at many US ski resorts. I work at times at a level 4 trauma center that is the closest receiving facility to a major ski area, and we get all of the trauma from the resort. Most of it is simple orthopedics, and we are well equipped to handle that. Anything more dramatic gets stabilized, bundled up, and shipped to the local level 2 or 1 center, as appropriate. Except we have helicopters for when it is necessary.

22 March 2009

NYT graphs the recession

The Geography of a Recession - Interactive Graphic - NYTimes.com

Click through to the NYT for the fully interactive map.
My county has seen its unemployment double over the last year. Also, bear in mind that the second-lightest color goes all the way up to 10%, which is itself fairly high. [corrected stupid error, thanks to a commenter.] It's pretty amazing how many counties are all the way in the 15%+ unemployment range already.

Medical Malpractice reform under Obama?

Don't count on it.

Open Left:: Obama's Donor Base--A Reminder By Industry
Rank Industry Total
  1. Retired $44,524,860.00
  2. Lawyers/Law Firms $42,861,936.00
  3. Education $22,342,123.00
  4. Misc Business $15,457,514.00
  5. Securities & Investment $14,442,282.00
  6. Health Professionals $11,532,962.00
Source: Open Secrets.

Though perhaps I'm being too nihilistic here. McCain's list looked pretty similar -- though the numbers are much lower due to his decision to funnel most of his campaign contributions through the RNC. Perhaps the real take-home message is that lawyers and their lobbies are better organized and better funded that the physician lobbies, and that lawyers are more politically engaged. That was certainly our experience a few years ago in our state, when we tried to get med mal reform passed via initiative. The local ATLA affiliate ran rings around us in fundraising, and though our polling looked good for tort reform, after the lawyers' lobby saturated the airwaves with misleading ads, the initiative failed by a narrow margin.

I should point out that every time I mention ACEP or the AMA on this blog, I get a comment or an email from a doc who complains that they "don't represent me" and so they will never belong to it. To which I say, fine, that is your prerogative, but the consequence is neutered advocacy groups with very little clout in the nation's and states' capitols.

Bottom line: if physicians want to be better represented in policy and politics, we need to be better funded, better organized, and better engaged.

(F)lannigan's Ball

Dropkick Murphy's

Brilliant. Uninterrupted audio version here.


19 March 2009

Ambitious or Crazy?

It's not like comprehensive health care reform and universal coverage was going to be a simple thing.   The costs are just staggering -- the consensus estimate has been $100 billion per year, with some estimates running to $150 Bn annually.   The unlikely bedfellows are growing more and more uneasy, as unions, businesses, and insurers begin to eye one another warily.  The interest groups, including the physicians' lobbies, are greedily (and apprehensively) eyeing the pile of money and wondering how it can be divided up.   Add to that the surprising and earnest acknowledgment from the administration that health care costs must be contained for this to work.

So it's not as if Obama was setting himself up for a small challenge in undertaking reform.

But did he really have to go and open this can of worms?
The Obama administration and key congressional Democrats are taking a hard look at the nation's medical malpractice system as part of a broader health care overhaul.
Wow.  As if there weren't enough possible roadblocks to health reform, ya gotta throw this in, too?

To my surprise, there are signals from influential democrats that malpractice reform may actually be on the table in a meaningful way:
  • President Obama told business leaders last week that ideas to save money like "medical liability issues - I think all those things have to be on the table."
  • "It's an essential piece for there to be enduring reform - reform that will stick and will get a significant bipartisan vote in the United States Senate," said Sen. Ron Wyden (D., Ore.)
  • Senate Finance Committee Chairman Max Baucus (D., Mont.) cites costs including fast-rising medical malpractice insurance premiums and so-called defensive medicine, [and] has proposed giving states grants to develop alternate litigation, such as "health courts" whose judges have health care expertise.
  • Rep. Rob Andrews (D., N.J.), who chairs an Education and Labor health subcommittee: "It's hard for me to imagine a result that gets to the president's desk that doesn't deal with the medical malpractice issue in some way,"
The AMA takes a predictable position on the matter:   “If the bill doesn’t have medical liability reform in it, then we don’t see how it is going to be successful in controlling costs,” said Dr. James Rohack, president-elect of the AMA. “Why spend the political capital and energy in passing a bill if it is not successful?”  And in response, the ATLA (Orwellianly renamed the American Association for Justice) is circulating a 29-page pamphlet opposing its inclusion.

My suspicion is that this won't make it into the final package -- it's too explosive, and has too much potential to derail the whole thing.   However, its inclusion might be a useful tool to co-opt the AMA and suspicious physicians' lobbies into support (or at least to mitigate their resistance).  It may also be a bargaining chip to bring along some republican support.

Quite frankly, the biggest argument against inclusion of med mal reform in the "cost savings" part of the plan is that it is not entirely relevant.  Estimates vary wildly as to the systemic costs of liability and defensive medicine, but I suspect that even the dream package of med-mal reform would not realize the huge savings necessary to include it as an integral element of cost control.  Accept for the sake of argument the higher estimate, that the costs are $200 Bn annually, which includes defensive medicine.   Is it reasonable to expect that the culture of aggressive testing, CYA practice, and the stigma of missing a diagnosis will just evaporate?   I doubt it.  As long as there exists the idea of these "bad doctors" who hurt patients, doctors will still fear being labeled and punished, and practices will change little.   There may be some marginal saving to be had there, but it won't be $200 Bn, and probably not a tenth of that.   Furthermore, if there were no-fault injury compensation funds established, that would indeed go a long way towards limiting the infrequent and egregious jackpot jury awards.   But that might be balanced by the larger number of smaller payouts for cases which occur today but never see the light of day in the high cost-to-entry litigation system we now have.  If malpractice insurance premiums are actuarily sound (a big if), then premium prices should be minimally affected by that sort of cost-shifting.

Perhaps I'm being too nihilistic.   It's inarguable that the liability system is broken and needs to be fixed.   Comprehensive reform presents an opportunity to sever the Gordian knot.   Maybe Obama is crazy taking it on, but maybe, just maybe, he's crazy like a fox.

Let's hope.

My 0.04 seconds of populist outrage

Via the Washington Monthly:
AIG MEASURE CLEARS HOUSE: The House passed its measure today to recoup the controversial AIG bonuses. While there was some question going into the vote as to whether the two-thirds needed for passage would be there, the bill was approved rather easily
[...] The bill would place a 90 percent tax on bonuses paid out by firms receiving at least $5 billion in bailout money. The tax would apply to individuals and families with overall income exceeding $250,000..

We now return you to your regularly scheduled programming.

18 March 2009

Obama and Health Care (Inside baseball)

Jonathan Cohn at TNR has a nice piece today about how Obama himself was instrumental in keeping cautious advisors from killing health care reform before it even got off the ground. It's titled, appropriately enough, Stayin' Alive
It was amid these conditions that the debate over the budget got underway. A series of formal and informal discussions unfolded in the White House and outside it, and Obama was not present for all of them. Particularly in Obama's absence, the voices of the skeptics often predominated. "It was scaring the hell out of the rest of us," says one of the advisers who favored more aggressive action.

And health care, in the end, might have gotten pushed aside--except that one very senior official in the administration kept insisting that it stay on the agenda. That official was Obama himself. Repeatedly, the president made clear that he was not abandoning health care reform.
Nothing earth-shaking here, but it's an interesting window into the operations of the White House, and the management style of this President.

Talk and Die

Kevin has a bit of speculation about actress Natasha Richardson, who reportedly, suffered a head injury during a ski lesson in Canada.   She is universally described as seriously ill, with some reporting that she is brain dead.  Hopefully that will turn out to be an exaggeration.

It has been noted numerous times that while she was not wearing a helmet, she was on a beginner's hill having a private lesson when she fell, with the implication that she was not engaging an a particularly risky activity.  True enough -- the serious injuries only rarely occur in these settings. 

But the really key thing to recognize in these injuries, is that although snow is soft, ice is hard, as hard as concrete, and even a low-risk mechanism of injury such as a fall from a standing position is more than sufficient to crack the skull.   A fall on skis, or ice skates (especially ice skates) needs to be recognized as a high-energy mechanism of injury.    This is why I'm such an aggressive advocate of wearing a helmet while skiing or snowboarding -- one of the hospitals where I work is the closest to a regional ski resort and we see lots of head injuries there.   Fortunately, helmets are fashionable wear for the teens these days -- they like it because it makes them look "extreme."

As for the mechanics of the "talk and die" syndrome, the blogger at Kennedy's Tumor has a differential:

1. Epidural Hematoma
2. Subdural Hematoma
3. Subarachnoid hemorrhage

To which I would add:
4. Cerebral contusion
5. Diffuse axonal injury

I recently wrote about a young man with nonsurgical head injuries who surprised us by dying.   He differed from Ms. Richardson in that he was clearly concussed, while media reports describe her as asymptomatic for the first hour or so.   But who really knows?

I'd favor an epidural hematoma, myself, as the most likely cause of the problem, but it would be anything.   I'd differ from Dr. T in that I think a non-traumatic SAH is possible but pretty unlikely -- we know she fell and it seems needlessly complicated to presume a pre-existent lesion.  Ultimately, though, it's a huge tragedy for all involved, and very sad even if she does pull through.  The take home message is for everybody who straps on skis to get yourself a goddamn brain bucket and wear it religiously.  I do -- and it's saved me from a few concussions (or worse).   Better yet, it keeps your head warm and keeps your ipod ear buds in place.  It's a win-win!

Ms Richardson is now confirmed to have died.  My condolences to her family.

16 March 2009

Shout out for a quilter

Suture for a Living: Double Irish Chain Baby Quilt

I was stunned when the generous Dr Bates offered to make a quilt for my baby daughter, and all the more stunned when it arrived -- not stunned that it arrived, but at how lovely it was.  See for yourself:

I don't know the first thing about making a quilt, but I can recognize something beautiful and well-made when I see it.   The only conflict we have is that, although it's clearly meant to go in her crib, and be used and loved, we are tempted to frame it and hang it on the wall as a work of art!

And she got the whole Irish thing in there too.  It means nothing to me, but I told my mom, a crafter in her own right, that it was Irish Chain and she nodded knowingly and said that it was a nice pattern.

Thanks so much, and if that whole plastic surgery thing doesn't work out, I've an idea of a second career for you...

The Death of Print Media

The Seattle P-I is set to publish its last edition Tuesday

Bummer.   It was the better of the two papers in Seattle.   Though, truthfully, I'm more or less ready to stop reading the dead-tree editions anyway.  I've always enjoyed sitting down with the paper and coffee, but except for the comics, I've been getting all my news on the web for the past few years.   Then both local papers recently shrank quite a bit and rolled several sections together.   I suppose it made sense from a cost perspective, but seemed destructive from a business perspective -- your business model is outmoded and the customer base is shrinking, and you think that giving us less product is the way to become profitable again?   Sheesh.

For that matter, the only reason I can think of to keep getting the print editions is as a sort of civic-duty subsidy to keep local investigative journalism alive.   Which isn't much of a reason, I must admit.

I don't think this will be the last major publication to shut its doors.   Kind of sad -- the end of an era.  

I'm Back and I'm Bald

I'm home, and much fun was had by all. More importantly, I've raised over $8,000 for pediatric cancer research -- so far. Donations are still open through, well, they're actually welcome any time! Nathan's Network raised $19,000, and Baldrick's en masse is up to $8 million -- so far.

The video below is my shaving: I'm on the left.  In the center is team member Carlos, and on the far right, poorly seen in the video, is team member Maria, who I particularly respect as brave and beautiful for shaving!  

St Baldrick's 2009 from Shadowfax MD on Vimeo.

Enjoy the video, but be advised that if you watch it, you are morally obligated to donate! Otherwise, you're just a common thief!

I joke -- enjoy the clip, but if you can, it is not too late to make a gift:


Click here to Donate

15 March 2009

The consequences of the Economy hitting healthcare

Some folks wonder why the economy impacts health care, which seems on first glance to have an inelastic demand curve -- that if you're sick, your perceived need for health care should not vary based on the economy.   But that in fact is not the case -- patients/consumers are highly sensitive to economic factors in their health care consumption, and much of that is elective.   The NY times has a nice article on that phenomenon today:

Bad Economy Leads Patients To Put Off Surgery, or Rush It - NYTimes.com

The slowdown is likely to have significant financial repercussions. Elective operations are typically covered by private insurance plans that tend to reimburse hospitals and doctors at higher rates than government insurance programs like Medicare and Medicaid. As those payments dwindle, so do hospital profit margins and the resources to provide charity care to a growing number of uninsured.

“Elective admissions could represent only 9 or 10 percent of a hospital’s admissions and yet represent 25 percent of its bottom line,” said Michael A. Sachs, chief executive of Sg2, a health care consulting firm. “They’re the patients that subsidize the underfunding associated with Medicaid and Medicare patients and uncompensated care.”

This is consistent with what we're seeing at our facilities.  The ER's not terribly effected -- yet.  Volumes are up a tick, and the uninsured rate is up ten percent: overall the effect is minimal.   But our parent institutions are suffering badly from the above factors, and layoffs and severe budget cutbacks are the rule of the day.  Management is coping with it well, but these are indeed tough times, likely to get worse as the recession deepens.

13 March 2009


Better pics and possibly video to follow when able.

12 March 2009

The Home Stretch

Well, with just over 24 hours to go before the shaving, I've raised over $7,000. I set an ambitious goal in this challenging economy, and have made it over 70% of the way there. I'm pretty happy with the results so far, bearing in mind that a significant fraction of donations come in after the event (and all the way till the end of the year). I may yet hit the goal.

For all of you who have given: I thank you, and look to see pics of my gleaming scalp soon. For those of you who have considered doing so, thank you for your consideration and indulgence.

This is a tremendously important cause, and even small donations are helpful. So please consider making a donation -- and there are collateral benefits. I was talking with our family priest and he told me that as a matter of doctrine, all donors to St Baldrick's go directly to Heaven, completely bypassing purgatory.* So you got that going for you, which is nice.

Click here to Donate

*Not Really.

11 March 2009

Charlie Brown, re-imagined

If you're like me, you've probably spent a fair amount of time wondering, "What if Frank Miller had done Peanuts?"   Now you need wonder no more:


Every single day I get down on my knees and thank my Noodly Creator for the glory that is the internet.

(h/t Crazy Andy)