30 September 2009

Haylee made me this


Haylee spent a while in the ER with me today.
She was not happy with me that I made them stick her with needles.
She is nine, and likes to draw, and occupied her time in the ER with this sort of thing.
Haylee was very happy not to have to get her appendix removed.
So she gave me her best drawing.
I like it a lot; it's an endangered species but she couldn't remember its name.

Sometimes my job sucks.  Sometimes I really like it.  Today was one of those days.

29 September 2009

Patient Safety

Organizational quality, which includes patient safety, patient empowerment and standardization of care has been an interest of mine for quite some time now.  It's more challenging in the ER where we see so many different diseases that it's difficult to find ways to do the same thing every time in specific cases.  But in care settings such as the ICU, or the OR, protocols and checklists are becoming the norm and with good reason.   They have been shown to save a lot of lives -- and not incidentally save a lot of money. 

Dr Val of Get Better Health (click through to see the recently relaunched site) had a nice interview series published with Paul Levy, CEO of Boston's House of God Beth Israel Deaconess Medical Center about what they are doing to encourage patient safety.   It's only six minutes long, but well worth the time:

This series was underwritten by Johnson & Johnson, the firm so nice they named it twice.

28 September 2009


Had some fun at Qwest Field yesterday. Got to play with my new 300mm lens, with mixed results:
Matt Forte on the run
Turns out that it's hard to shoot good pics *and* watch the game simultaneously. Also, passing plays are a lot harder to capture, especially from the stands.  Running plays develop slower and you can get some key moments:
Forte "Down by Contact" on the one yard line.

I love this static shot on the goal line.  As you can see, we had good seats, and it was beautiful fall football weather.3rdandgoal

Of course, this was the best pic of the day:

Final score!

Yeah, it wasn't the cleanest win, but Cutler is starting to look like a decent acquisition, and I'm liking the rookie wideout Johnny Knox, who amazes me.  He is the exact same size as me: 6'0", 180 lbs. And he's playing in the NFL taking hits from these behemoth linebackers.  Wowie.  'Course, we are a little different in that he does a 4.26 second 40-yard dash.  I'm a bit slower.

27 September 2009

Flogging Molly

Inexplicably mashed up with Doctor Who:

Ain't life grand?

25 September 2009

H1N1 Rap

Can't quite decide whether this is kinda cool or really cringe-worthy.

Family Portrait

Family Portrait
Click to embiggen
Son number two has finially figured out representational drawing.  I'm the big guy in the middle; Big brother is on the right, and baby sister on the far left.  Mommy is, for some reason, absent from this drawing.  According to son number two, "She's grocery shopping." 

24 September 2009

Annoying Bias

I like Ezra Klein.  He's serious, and studious and laudably progressive.  But his approach to physicians is becoming lamentably more adversarial.  From his commentary on the NYTimes article on Medical Malpractice:
But the best way to reduce malpractice costs would be to reduce malpractice. The problem isn't in courtrooms so much as on the operating table. But because it's doctors who are angry about malpractice suits, most of the fixes are from their perspective. What we need is malpractice reform from the patient's perspective. That wouldn't be the system we have now, or mere caps on damages: It would be serious work and investment in better practices.  (Emphasis added.)
This is not the first time that Ezra has voiced this perspective, and it's just wrong.  It's also offensive, but that's beside the point.  I can see where Ezra gets this -- he's a policy wonk and heavily into the quality buzzword lingo.  It demonstrates a problem with the organizational quality initiatives which focus on patient safety and medical errors: they generates a fixed belief (especially among non-clinicians) that all medical errors are malpractice/negligent and that they are preventable through best practice measures and innovation in the delivery of health care.  But the Pollyanna-ish belief that "if doctors were just better, we wouldn't have these lawsuits" betrays a lack of real-world experience actually delivering health care. It betrays a fundamental confusion on the distinction between Quality Improvement and Negligence.  It's distressing that even some of the better health care policy people bring this sort of ill-informed understanding to the debate.

I admit that I was a skeptic at first when the "pin-headed bureaucrats" started pushing these quality standards down on us.  Part of the problem was that the recommendations seemed too trivial (hand-washing? really?), and part was that some were actually wrong on the science (antibiotics within 4 hours for pneumonia).  But I've come around over the years.  I've come to realize that there are things that we do over and over that can be done better, that can be standardized, and that can have a huge impact on cost and on human lives.   If you haven't read Atul Gawande's seminal piece on checklists, you should.   I'm now an enthusiastic supporter of finding the ways we can improve quality, and developing real best practices that work.

This, however, has little to do with malpractice.  There is an ill-concieved proposal floating out there that doctors who follow to-be-established "best practices" should be protected from liability, that there should be a "rebuttable presumption" that there was no negligence if the defense can show quality guidelines were met.  Spiffy.

Consider the Emergency Room: the greatest liability cost for ER docs in gross dollars is Chest Pain, most typically relating to missed MI or missed PE or missed TAD.  And rightly so.  It's a common complaint, and it can have huge costs, both economic and human.  This ought to be a perfect substrate for best practice standards, right? 

But it doesn't work well in real life.  There are too many variables for a safe harbor to pragmatically be applied and be defensible. 

Let's consider a fairly famous case.  A 54-year old man presents to the ER with chest pain and syncope.  His ECG shows evidence of an acute MI.  The doctor follows the "best practices" approach and administers beta-blockers, blood thinners, activates the cath lab and the patient goes off for urgent revascularization.  Woo-hoo! All Quality Standards Met!  Unfortunately, the patient's name is John Ritter and he is found to have an Aortic Dissection mimicking an Acute MI and he dies.  

Under the utopian "Quality Shield" the defendant doctor is going to claim that the standards were followed, but the plaintiff's attorney is going to rebut that presumption with ease.  There are enough inconvenient details (some relevant, some not) that the "Best Practice" defense will be torn to shreds, and this will be the pattern in each and every case that is brought.  Plaintiffs' lawyers will become skilled in the argument that the Best Practices were followed but not in a timely manner, or that they were followed incompletely, or that they were incorrectly applied.  It sounds great on paper, but it is going to be an utterly toothless protection in application.

And that's just for the disease which lend themselves to standards and best practices.  Consider the most common lawsuit against an ER doc: wound care problems, most commonly a wound infection or retained foreign body.  These cases are usually not lethal, so the dollar value is low, but the frequency is high.  The variability of lacerations is so high that I can't even get my head around "best practice" protocols beyond no-brainers such as irrigating and exploration of the wound.   And once again, the "best practices" will offer little real life protection, because the plaintiffs will simply allege that they were not, in fact, followed.

Of course, in the aggregate, malpractice liability for ER docs is clumped into "other stuff" -- the bizarre and uncommon things that we see (and occasionally miss).  The funny and inexplicable neurologic symptoms.  The subtle fracture not easily visible on x-ray.  The atypical appendicitis.   It's hard to see how reasonable safe harbors could be developed to have any impact on these pathologies, and the significant liability associated with them.

So Ezra, keep on arguing for healthcare delivery system improvement; I'm with you on that.  But I'd rethink your stance on medical malpractice reform, because it's seriously misguided.

23 September 2009

Malpractice and Defensive Medicine

A thoughtful and (dare I say it) balanced look at medical malpractice in today's NYT:

Malpractice System Breeds More Waste in Medicine - NYTimes.com
The debate over medical malpractice can often seem theological. On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive. On the other side are those liberals who see malpractice reform as another Republican conspiracy to shift attention from the real problem. [...]

The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.

The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.
The cost of malpractice is a tough metric to measure, both economically and epistemologically.   I was interviewed for an article on this topic in the WSJ a couple of weeks ago.  I wound up not getting quoted (so much for fame, thou cruel mistress), and I think part of the reason was that I wasn't able to give an example of a case where fear of malpractice was clearly the sole driver of a particular expense.

"Oh, come on, doc!" I can hear the myriad of commenters howling, "what about that 37 year old with no risk factors and really atypical chest pain that you admitted the other day?  If that wasn't 'defensive medicine,' then what is?"

Yes, you are right: it was defensive in the extreme.  But what was the motivation?  Was it fear of getting sued?  Yes, and more.  Doctors are a risk-averse bunch, ER doctors especially.  But there are so many risks inherent in the practice of medicine that it's really hard to sort out which risk drove which intervention, and to what degree.

To take the above example a little further, mostly I was afraid of being wrong.  My assessment of him was that the likelihood he was having any sort of a life-threatening emergency was exceedingly low.  Put a number on it?  Probably less than one percent, possibly much lower.  The easy thing to do would have been to roll the dice and send him home.  I've done it every day I have been in practice, and the odds in this case that I was correct in my gut instinct overwhelmingly supported that path of action.  To admit him to the cardiac ward is hard: I'd have to convince a reluctant patient that he had to stay; I'd get the "really? Come on!" reaction from the internist on call; more paperwork to do, more phone calls to make; and I'd have to live with the sinking feeling in my gut that I was part of the problem of waste and overutilization in American healthcare.  It's hard.

So why did I admit him?  Because I was afraid of being wrong.  Being wrong, especially as an ER doc, has all sorts of negative events assorted with him.  In rough order of frequency, any one or more of the following things might possibly happen when you make a "wrong" choice:
  1. Your partner the next day says, "Hey, remember that guy you sent home yesterday? Yeah, funny thing, he came back with an MI and went to the cath lab.  He's fine."  This sucks, is embarrassing, causes self-doubt and second-guessing, is scary, and affects your future practice.  And note that the patient was "fine" in this outcome!
  2. You run into a cardiologist in the doctor's lounge in a week. He says "Why did you send Mr Jones home? He was obviously having unstable angina, and didn't he tell you his brother had died from an MI? He's OK, but his ejection fraction is 40% and I'm having him fitted for an ICD.  You guys in the ER need to be more careful with these cases."  Maddening. This is the same cardiologist who refused to accept an admit from you last month on a patient with a better story.
  3. You get a phone call from your Medical Director noting that an "Unusual Occurrence" report has been filed regarding your care of Mr Jones and would like a written explanation of your decision-making process for review at the next QA meeting of the department.  Embarrassing and humiliating, but not too scary.  The Medical Director is sympathetic and on your side, but you have to go through the process.
  4. You get a letter from the hospital medical staff office asking you to come to the Med Exec committee regarding a complaint reported by the cardiologist. Very scary, because this goes in your "permanent record," and if you get too many reprimands here, you're unemployable.
  5. You're in the ER three days after you saw the case, and the charge nurse takes you aside: "Remember that weird chest pain dude? He came back in arrest/is in the ICU on a ventilator/needs a transplant/was found dead at home/etc."  You sit down and take a deep breath and commence feeling terrible.  Then you get scared.  Then you start rationalizing.  But mostly you feel guilty because it was your responsibility to take care of that guy and he died because of you.
  6. You get a phone call from Risk Management.  The family has made contact with the hospital and would like to undergo a disclosure, and your participation is considered essential to defusing the situation.
  7. You get a certified letter with an attorney's return address.
So when the WSJ reporter asked me why I made the defensive decision -- wasn't it just the fear of getting sued?  Nope.  It's a fear, and a significant one.  But it's possibly the least likely of all the bad things that happen when you are wrong.  If you've been sued, especially if you thought it was frivolous, or you lost, or if you know someone who's lost big, that fear is magnified beyond its real probability.  But it's just one disincentive among many, and even if you eliminated the possiblity of getting sued (or reduced it greatly, as they have in Texas), there are still so many "punishments" for an "error" that I suspect that the cost of Defensive Medicine will change little.

Kevin Drum has a good summary:

The Real Cost of Medmal | Mother Jones
Trying to isolate and quantify the blame for each particular unnecessary test just isn't possible.

Still, $60 billion is a reasonable enough guess, and trying to reduce that cost is, as Leonhardt says, a no-brainer. Unfortunately, the real problem with our medical malpractice system isn't that it costs too much. The real problem is that it's a lottery. Some people get money they don't deserve because it's cheaper to settle with them even if their claims are frivolous. But far more people who are victims of genuine malpractice never sue and never get a dime. A genuinely fair reform, one that cut frivolous malpractice suits but also did a better job of compensating everyone who was genuinely injured, would almost certainly end up costing us more, not less.
Exactly so. (Emphasis added. I think Kevin used a more expansive definition of "malpractice" than I might.)  The current medical malpractice system is in dire need of reform: it's slow, inefficient and unfair.  The inflated med-mal insurance premiums I pay harm me and my practice as truly as the failure to compensate them harms patients who were injured.  But those who think that it will significantly "bend the curve" and make inroads to controlling health care costs are mistaken.

Fun coda: the example patient cited was real, from the other day.  He truly had no cardiac risk factors and very atypical pain.  I seriously considered sending him home.  He ruled in for an evolving MI.  Score one for defensive medicine.

How to Annoy an Anesthesiologist

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

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

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

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

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

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

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

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

22 September 2009

Cool Saturn Pictures

Casinni at Saturnian Equinox
Whereas the earth is tilted at 23 1/2 degrees, Saturn's obliquity as astronomer call it is very close, almost 27 degrees. So, Saturn has seasons as it travels around the sun. Since its year is about 30 earth years, Saturn has much longer seasons. Twice during the long Saturnian year the planet goes through an equinox, where the sun shines directly on the planet's equator and one of those equinoxes is happening now.

Nifty stuff.

Paying for Quality

Ezra has a cool theme day with a whole bunch of health care delivery experts talking about cool or useful avenues for reforming health care delivery.  I'd recommend it to anyone serious about understanding the complexity and challenges of reform.  But one thing in his intro really caught my eye:

Delivery System Day!
Fairly few political journalists know anything at all about the medical delivery system.  Despite my best efforts, I'd include myself in that number. I focus too much on insurance. And I don't have as tight a grasp on medical delivery questions as I'd like. I get the basic sketch -- pay for quality rather than volume, manage care coherently rather than episodically, develop evidence and integrate it with IT platforms that help providers put the knowledge into practice...
I just don't know how this is ever going to work in real life.  Quality is such a nifty goal that sounds good and certainly has some elements that can be defined and measured and in certain chronic diseases can certainly do a lot to improve care and save money.  Ditto for the "medical home" or "continuum of care" or whatever buzzword we're using for that this week.

Here's the problem: there is such a narrow subset of medical problems that can be managed with this sort of approach that its effect on health care systems and health care expenditures can only be marginal.  For example, the patients I saw last night had:
  • Acute Appendicitis
  • Increased pain s/p hysterectomy
  • Closed head injury wanting narcotics
  • Suicidal ideation
  • Chest pain and anxiety
  • Facial wound bleeding due to coumadin
  • First trimester vaginal bleeding (three of these)
  • Nonspecific pelvic pain
  • Child with fever
  • Tonsilitis
  • Suspected child abuse
  • Migraine headache
  • Incarcerated inguinal hernia
  • Acute kidney stone
  • Fainting
  • Patellar dislocation
These are the ones I remember -- I saw over thirty patients.  It was a high-volume, low-acuity night.  So how on earth are we going to define "quality" for these disparate complaints?  I'm sure there are some easy things we can identify: the febrile child should have had blood cultures, maybe, and the syncope needed an EKG.  But the buzzwords fail when you look at the panoply of issues and complaints that people come to the ER with.  I have no clue what the "medical home" will do for the anxious person with chest pain. Again, this is not to say that chronic disease management isn't a great thing, and blood sugar control and blood pressure control and all that are great goals.  We can save some money with that.  We can reduce human suffering.  organizational quality is something I really believe in.  But it's not enough to completely modify the mode of health care delivery, or reimbursement.  That extra 2% of my medicare reimbursement I receive for participating in PQRI is not going to revolutionize the way the ER works, and, forgive the negativism, but any effort to expand it to a global program is bound to fail.

Scary Stuff

ER Doc, cyclist and blogger SymTym writes about waking up to find himself in his own ER:

Several hours later I’m aware of being in the main trauma resuscitation rooms at one of the hospitals I work at. Wife is at the gurney’s side and one of my partners is at the door saying something—not heard or not remembered at this time. Left chest is incredibly sore...

Sounds like he's getting better -- glad to hear it.  An ER doc up this was was hit by a car riding his bike a few years ago and suffered a spinal cord injury.  He's made a remarkable recovery and has a blog (who doesn't?) about it over here. It's a scary world out there.

Merely posing the question was an act of pure optimism

The triage note on the chart sounded none too concerning, but was a little short on detail: 27 month male with fever to 104 degrees.  I went into the room to see the dad, maybe thirty-ish and clean-cut, well-dressed, with his happy two-year-old on his lap.  Dad greeted me politely and the child ignored me while continuing to methodically eat Cheetohs from a bag.

Uh-oh, I thought, this is not going to go well.

You may be wondering why I knew from the moment I set foot in the door that this was going to be a challenging interaction, but to me it was a clear as the day is long.

Well, I see Alex has quite a fever tonight -- 104 degrees.  How long has he been sick?
I'm not sure, doctor.  I was at work all day today.  I don't think he had a fever yesterday, though.
Has he had any other symptoms?
[blank stare]
You know, cough, runny nose, vomiting, that sort of thing?
Oh, I wouldn't know about that.  His mom was with him all day.
I see (looking around hopefully) and where is his mom?
She's at home with the baby.
Of course.  Has the baby been sick at all?
Ummm.  Not sure.
What made you decide to bring him to the ER?
Well, apparently he was having trouble breathing, and she called the on-call doctor who told her to bring him in.  That was just when I was getting home from work, so I took him.
Can you tell me anything about the trouble breathing?  Was he wheezing? Did he have a barky cough? Was he turning blue?
Sorry, I didn't see it.
So who is his primary care doctor?
He sees a pediatrician.
I might have guessed that. Do you know the pediatrician's name?
No, but he's at one of the downtown clinics.
But you don't know which one, do you?
Does Alex have any medical problems?
[blank stare]
You know, asthma, diabetes, any surgeries and the like?
I don't think so.
Does he take any medicines or is he allergic to any medicines?
Ummm. Not sure.
This is *your* son, right? You have met him before?  It's not just a street urchin you brought in on a lark?
Yeah, he's really my son.
Oh God, you're an idiot and I can't talk to you any more.  Can you call your wife so I can talk to her?
[cell phone call placed and real history obtained from mom]

As he put his son on the gurney for the exam, I noticed his jacket had a Microsoft Vista Development Team logo on the breast pocket.  It figures, I thought to myself. 

But that's being unfair to the Vista people, because one thing I have learned is that most if not all fathers who bring their kids to the ER are completely clueless about their kids' medical histories.  It's a universal thing.  Which is how I knew I was in trouble when I walked into the room -- mom wasn't there.  Dads like to be gallant, when mom has been home all day with sick kids, it's like, "Oh no, honey, you must be exhausted -- you rest, I'll take the kid to the ER." But they are, en masse, completely unequipped for the actual task at hand.  The kid doesn't just need a chauffeur to the ER, they need someone who can give me detailed observations and history.  They need a mom.

And just for reference, when my kids are sick, I let their mom take them to the doctor.  For the same reason.

Sadly, some of the above dialog took place only in my head.  It was actually a much longer conversation, and the dad literally knew nothing, nothing at all about his child.  For a while I was fancying I had wandered into the Cheese Shop sketch, posted here for your enjoyment:

20 September 2009

A good primer

The Unstable Business of Emergency Medicine - Interview Questions for New Grads of Residency
While in the midst of the job-hunting process, I uncovered a file I created for myself when I finished residency. It had a list of Interview Questions to ask a potential employer. Many of the questions were very good, however, now having had a chance to look at the questions through the eyes of experience, I discovered that much more information should be given so the new graduate can truly understand what they can expect from their first job.
From Dr Brenner. Good stuff to think about if you are looking for a job, especially your first job out of residency.

Interestingly, I was recently interviewing a candidate who seemed to have a pretty strong opinion that he wanted to work for a small "democratic" group as opposed to a large corporate group (i.e. the multi-hospital contract management groups). 

So, I asked him, what do you mean when you say "democratic"?  He really didn't know, though he ad-libbed a decent interview reply.  But it was clear that he'd never really thought about it, or defined to himself what a democratic group is.  Rather, he'd been indoctrinated by his faculty that big groups=bad and small groups=democratic.

This is not an uncommon attitude among ER docs, especially new ones, and it's not without validity -- some mega-groups were/are notorious for abusing/ripping off their docs.   But truth be told, I've seen more abuse from small groups which purport to be "democratic" but in fact are quite dictatorial.  And in fairness, there are a few mega-groups which actually are quite democratic.

So what is a democratic group?

There are two key qualities that make a group democratic, in my opinion.  One is that it should be democratic in governance: There should be equal ability for all physicians to have a voice in the management and direction of the practice.  All physicians should be partners (perhaps after a reasonable "tryout" period), and all should have access to leadership roles (at least as often as they turn over).  The decision-making process should be inclusive and transparent.

The other necessary quality for "democracy" is that the group should be egalitarian in its operations.  Compensation and bonuses should be fair; perhaps driven by a predetermined formula, agreed on and understood by all.  New physicians should be paid fairly and not exploited.  Buy-ins for new partners, if required, should reflect the value of the group's assets and not simply an opportunity to enrich the existing partners.   Scheduling should be fair, with all partners working comparable ratios of weekend, evening and night shifts.  Vacations and holidays should also be fairly allocated. Seniority should not be excessively rewarded.

In my experience, the large groups occasionally fit this description more than independent practices.  Their size requires standardization of practices, especially financial.  On the other hand, the small scale of a small group allows the concentration of power in the hands of a small few, who are able to skim profits off of new docs without even appearing to do so. 

The point here is that size should not be used as a proxy for whether a group is one that you want to work for.  Ask the questions Dr Brenner outlines and do not be shy about it.  I respect candidates who clearly have prepared themselves and understand what to look for in a practice.  More to the point, if a potential employer doesn't want you to be asking questions, or won't answer questions satisfactorily, that's probably a really good sign that you don't want to work there.

19 September 2009

Feeling Wonkish

Kids are sleeping and I've the house to myself, but I am feeling too lazy to practice karate so (what else?) I decided to flip through the 543 proposed amendments to the Senate Finance Health Reform Bill.

So there'll be lots of attention to Amendment 261-- "Schumer/ Cantwell C2: Establish Public option as passed by HELP Committee," as well as the classic Amendment 250 -- "Wyden C3: Exchange plans as good as Members of Congress."  But I thought I'd be a tad more provincial and see what's in the cards (possibly) that might affect Emergency Medicine.

Most notable, I suppose, are the Stabenow amendments 71-73. which seem to replicate the "Access to Emergency Services Act" language.  Stabenow D-6:
This amendment first establishes the United States Bipartisan Commission on Access to Emergency Medical Services to: (1) identify and examine factors in the health care delivery, financing, and legal systems that affect the effective delivery of screening and stabilization services furnished in hospitals that have emergency departments pursuant to the Emergency Medical Treatment and Labor Act; and (2) make specific recommendations to Congress within eighteen months of enactment with respect to federal programs, policies, and financing needed to assure the availability of such screening and stabilization services and the coordination of state, local, and federal programs for responding to disasters and emergencies.
Ok, a commission, that's nice.  And it touches on boarding in the ER as well:
Second, this amendment directs CMS to convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards for hospitals and guidelines, measures, and incentives for implementation, monitoring, and enforcement of such standards.
And also Stabenow D-7:
This amendment would provide a 5% Medicare reimbursement bonus for services provided by an emergency room physician or by an on-call specialist for services performed in an emergency room
This is significant because it's the first time (to my knowledge) there has been a funding source identified for this provision.  It should help to keep the on-call rosters full, to a limited degree.  Also also Stabenow D-8:
This amendment would eliminate the payment reduction for emergency room physicians and for services provided by on-call specialists in an emergency room that the Chairman‘s Mark identifies as an offset for the primary care/general surgery bonus.
Hmm. A carve-out for EM from the primary care bonus.  Sure, it's good for me, but I am not sure it's good policy.  Probably won't pass anyway.  Cantwell has what seems like a significant addition (D-2):
Hospitals committed to starting new osteopathic or allopathic residency training programs in one of eight medical specialties or a combination of specialties (family medicine, internal medicine, emergency medicine, obstetrics/gynecology, general surgery, preventive medicine, pediatrics, or behavioral and mental health) could secure start-up funding to offset the initial costs of starting such programs.
Not EM specific, but at least a little effort to address the physician workforce issue.  Menendez has a good point in the insurance regulation portion (C-6):
Each health care plan and health care insurance issuer offering coverage in the exchange shall provide enrolled individuals coverage for emergency services without regard to prior authorization or the emergency care provider‘s contractual relationship with the health plan. Further, enrollees may not be charged co-payments or cost-sharing for emergency services furnished out-of-network that are higher than in-network rates.
This is important.  It's hellish dealing with authorizations in the ED.  Kyl (C-24) has an interesting carve-out for ER docs (and specialists in the ER) with regard to malpractice:
This amendment would regulate lawsuits for health care liability claims related to the provision of services provided in the emergency room.
  • Set a statute of limitations of three years after the date of manifestation of injury or one year after the claimant discovers the injury, with certain exceptions.
  • Require a court to impose sanctions for the filing of frivolous lawsuits.
  • Limit noneconomic damages in a civil medical liability lawsuit to $250,000 from any provider or health care institution, not to exceed $500,000 from all providers and health care institutions. It would also make each party liable only for the amount of damages directly proportional to such party's percentage of responsibility.
  • Allow the court to restrict the payment of attorney contingency fees and limit the fees to a decreasing percentage based on the increasing value of the amount awarded.
  • Prescribe qualifications for expert witnesses.
  • Require the court to reduce damages received by the amount of collateral source benefits to which a claimant is entitled.
  • [and more]
I like it, but again, I see no reason why these common-sense provisions should be restricted to the ER only.

Bear in mind that all of these are just proposed amendments, not part of the actual bill itself.  Many (I daresay most) will not be incorporated into the actual bill.  Though the democrats are better than the republicans were in accepting minority amendments, it's relatively unlikely that many of them will be accepted.  It's also worth noting, I suppose, a couple of key points in the Chairman's Mark itself:
Page 17: Definition of Four Benefit Categories.
Four benefit categories would be available: bronze, silver, gold and platinum. No policies could be issued in the individual or small group market (other than grandfathered plans) that did not meet the actuarial standards described below. All health insurance plans in the individual and small group market would be required, at a minimum, to offer coverage in the silver and gold categories.
All plans must provide preventive and primary care, emergency services, hospitalization, physician services (and lots more)

So emergency services must be included in all health insurance plans.  Kinda common sense, but good to see it clearly defined.
Page 93: National Pilot Program on Payment Bundling.
The Secretary would be required to develop, test and evaluate alternative payment methodologies through a national, voluntary pilot program that is designed to provide incentives for providers to coordinate patient care across the continuum and to be jointly accountable for the entire episode of care starting in 2013.[...]
The pilot program may cover the following services: acute care inpatient hospitalizations; physician services delivered inside and outside of the acute care hospital setting; outpatient hospital services, including emergency department visits...
Not liking this so much.  Bundling seems like such a great idea, but when the ER docs' fee is bundled in with the hospitals' fees, well then you get a sticky situation.  How much does each party get? Who decides?  How can physicians retain any financial independence from their partner hospitals in this sort of model?  There's an old saying that "democracy is three wolves and a sheep voting on what to have for lunch." It's not entirely apt, but in this case the ER docs would be the sheep.

The other thing that I gained from reading this is a real appreciation of how tricky lawmaking really is.  This bill, after modification to some greater or lesser degree in committee, will need to be merged with the HELP committee bill and then (one hopes) with the House bill.   That's a real challenge!  Sure, there will be the big partisan battles, but all the little line items are the hard parts, I think. When you come to a provision like, say the Stabenow amendments, which have no clear partisan bias and a marginal effect on cost -- and bear in mind that there may be hundreds and hundreds of these in each bill -- how do you decide which are worthy of keeping, and which get tossed?  Presumably you can't keep them all, and many are probably in direct conflict.  Unless the advocate for a particular bill is at the conference table, it's gotta become a little arbitrary.

Talk like a pirate day

17 September 2009


A new blog, probably temporary, by one of our vascular surgeons who is volunteering at Landstuhl Army hospital in Germany:

Jay's German Journal

Didn't know he was doing this, and am mighty impressed.  I'll be following with interest

16 September 2009

There's an App for that

From the Unofficial Apple Weblog
One choice often made by me personally is Guinness. But what if I want a Guinness after a long day but can't figure out where to go and get one? Fortunately, there's an app for that: the Guinness Pub Finder.

To commemorate the 250th anniversary of Guinness on September 24th they have created a new iPhone and iPod Touch app that will, according to the company, allow "consumers of legal drinking age across the US (to) join the celebration and more easily raise a toast with friends in the future." Which, of course, sounds great unless you happen to live in Alaska, Arizona, Arkansas, Georgia, Hawaii, Indiana, Kentucky, Montana, Ohio, Pennsylvania, Texas or West Virginia where the app is forbidden by law from working. Yeah, I don't get it either.

Even if you can use this app for its intended purpose, it actually isn't just about helping you find a drink, although it does do that pretty well. Here's a breakdown of its main features:

o. Locate a Pint - uses GPS to locate the consumer and the pubs serving Guinness nearest to their current location. It then provides name, address and telephone number of the pub chosen, access to directions, and an email setup to invite friends to join.

o. Know Your Pint - provides a tutorial on the 6 Steps to Creating the Perfect Pint, and also includes a ruler that can be used to measure your pint's head.

o. Fun Extras - includes animated screensavers, a countdown clock to the "Arthur's Day" celebrations and a live feed of the latest news regarding the Guinness 250th Anniversary celebration

Are Progressives finding their backbone?

Nah, it can't be:

Rockefeller to Baucus, Conrad: Co-ops Are a Sham, Public Option Is a Must | TPMDC
As part of that study, [Rockefeller] asked the Government Accountability Office to bring together all of the research it had done over the years into the effectiveness of co-ops in the insurance market. Today, he sent a fairly scathing letter to Finance chairman Max Baucus (D-MT) and chief co-op advocate Kent Conrad (D-ND) regarding the results.

Rockefeller, who says he regards the public option as a "must," writes, "there has been no significant research into consumer co-ops as a model for the broad expansion of health insurance. What we do know, however, is that this model was tried in the early part of the 20th century and largely failed."
This comes on the heels of Rockefeller's assertion that he cannot vote for the Finance bill in its current form.  Interestingly, lame duck senator Roland Burris (D-Blago) said today that he will vote against any bill that does not contain a public option.   Viewed in the context of the House Progressive Caucus' insistence on a public option in any health reform bill, it really makes one wonder whether progressives are finally discovering their spines and trying to flex a little political muscle for the first time in a generation.  It's heartening, and should make for some good political theater this fall.

Of course we all know how it's going to end: they're democrats, and ultimately, they will roll over as they always do.  Just like the Cubbies, and every bit as reliable.  Prove me wrong, guys!

Well, that's helpful

Current Law
No provision.

Chairman’s Mark
The Chairman‘s Mark would express the Sense of the Senate that health care reform presents an opportunity to address issues related to medical malpractice and medical liability insurance. The Mark would further express the Sense of the Senate that states should be encouraged to develop and test alternatives to the current civil litigation system as a way of improving patient safety, reducing medical errors, encouraging the efficient resolution of disputes, increasing the availability of prompt and fair resolution of disputes, and improving access to liability insurance, while preserving an individual‘s right to seek redress in court. The Mark would express the Sense of the Senate that Congress should consider establishing a state demonstration program to evaluate alternatives to the current civil litigation system.
As I suspected, window dressing.

Source: BaucusCare Chairman's Mark (PDF)


Well, I'm not sure that I really need to add anything to Nate Silver's clever summary:
Baucus Compromise Bill Draws Enthusiastic Support of Senator Max Baucus (D-MT)
I swear that headline would not be out of place in The Onion.

So, to summarize: Baucus has bent over backwards and enraged the electoral base of Democratic party by moving his bill further to the right in order to attract Republican votes for a "bipartisan" bill.  The result: zero Republicans in support.  The interesting consequence is that Democrats also are now turning against BaucusCare, with Jay Rockefeller (incidentally, the Chair of Finance's Healthcare subcommittee) in open opposition to the bill as proposed, and Wyden and Kerry expressing "concerns."   It's even possible that the bill might not make it out of committee -- though it's more likely that Finance liberals would pass it out of committee and try to merge this with the more progressive HEELP bill on the floor.

As for the bill itself: it pretty much sucks.  It keeps the most important check-boxes filled: individual mandates, the Insurance Exchange, standard insurance regulatory reforms.   So it's still well within the conceptual framework that the HEELP bill and House bill have established, which is good news. 

The bad news?  Well, no public option, of course.  Worse is how stingy the subsidies are.  The very poor would be reasonably cared for, but the combination of an individual mandate plus weak support for lower-middle-class families is a recipe for electoral suicide: an unpopular law that doesn't work.  The problem here is that if you force people to buy really expensive insurance (up to 13% of income) but do nothing to make it affordable, either people won't do it (and risk the penalties) or they'll buy shitty insurance that doesn't really cover anything, thus defeating the purpose of the act.  It will be hated, and it won't work.

[UPDATE: as pointed out many other places, this bill does not have an employer mandate, but a "free rider" provision that  may well have some very pernicious consequences on employment.  I don't pretend to know much about that sort of thing, though.]

15 September 2009

Number 37!

Everybody else is linking to it, so here it is:

We're #37 by Paul Hipp.

A cute little indie rock video "celebrating" the US as having the 37th best health care system in the world, behind the UAE and Costa Rica, among other warm, spider-infested countries.  It's catchy and has gotten enough attention to be vetted by PolitiFact's TruthMeter -- earning a rating of "Mostly True" amid a wonkish discussion of overall performance vs overall attainment.

The ultimate point here, I think, is not where we rank, in that lists are meaningless and even outcome measures are grossly overrated.  The point, made so eloquently is the song is:
We're Number 37
And we got something to say
We pay more for less
40% in fact
Lets bite some fingers off
Shout at the handicapped

Yes, we pay a lot more and get less for what we do pay.  Though I don't know about the coda there, but I suppose you get the idea.


Ezra Klein - A Number Is Worth a Thousand Words
The average cost of a family health insurance policy in 2009 was $13,375.

Over the past ten years, premiums have increased by 131 percent, while wages have grown 38 percent and inflation has grown 28 percent.

If health-care costs grow as fast as they have over the past five years, the average premium for a family policy in 2019 will be $24,180. If they grow as fast as they have over the past 10 years, premiums in 2019 will average $30,803.
Yeah, that's exactly our experience.  A bitter irony of my position is that I administer our group's benefits and, as a physician group, every single year we have more and more trouble finding health insurance, and every year it gets 5%, 10%, 15% more expensive.  We're lucky; although our doctors bear the full cost of the premiums, the income levels are such that it is tolerable.  Our PAs are more impacted by the escalating costs; by necessity we cover the full cost for our few non-clinical employees.  I can't imagine how difficult it must be for a regular small business with lower salaries to absorb these costs.

I saw a comment somewhere that while the wages of middle-class workers were more or less stagnant during the last decade, if you count the increased cost of health insurance (which is part of total compensation, though not typically counted as "income") then the average worker did enjoy significant increases in compensation over the 2000's.  Um, Yay?

Malpractice Reform?

From The Atlantic:
The Menu of Malpractice Reforms - Philip K. Howard
The President committed in his speech to Congress to promote pilot projects to solve the problem of defensive medicine. "I've talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs," he stated. "So I'm proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine."
A range of malpractice reform proposals will probably be considered over the next few weeks, and it's probably useful to catalog them, and identify the advantages of each.  All of these reforms have significant merit, but special health courts are by far the most important in reducing defensive medicine.  Each of the reforms can be combined with others, and it would be preferable to combine the best features of each.  Here's a summary:
This is a very nice read. Click through for the full read.  If you are unfamiliar with the proposals floating around out there, this is a good primer. I am a proponent of special healthcare courts, analogous to the tax courts.  I don't really expect anything to be in serious consideration given the political climate, but it would be nice, and there have been some encouraging noises, so it is a possibility, albeit remote.

Defining the scope of the problem: the uninsured

Last week, in his Big Speech, it was noticed that President Obama hedged a little bit in his language regarding the numbers of the uninsured. Despite the fact that the newly-released Census data reflects conventional wisdom, that the number of uninsured totals around 46 million people, the President cited "over 30 million" as the number of the uninsured.  OMB director Peter Orzag has a typically wonkish post explaining their numbers -- about 39 million uninsured citizens & legal residents.  Some of those -- a few million, it seems -- are eligible for various public health care insurance programs but for a variety of reasons are not enrolled.  So they settled on the vague but defensible "over 30 million."

Anthony Wright expands on this a bit over at TNR's The Treatment, pointing out that, depending on how you count, the numbers could be much higher indeed.  For example, the "millions" of people who are not enrolled in Medicaid and CHIP often are not because the states that administer the programs have in many cases raised administrative obstacles to enrollment, delayed enrollment and even closed enrollment, in order to reduce the strain on their budgets.  And if you count the number of non-elderly Americans who at some point in the past two years were uninsured, the number is over 86 million -- one out of three people.   While at any given point in time, the numbers may be much lower, overall, the population of people at risk of being without healthcare coverage is quite large.

Yet, voices from the right continue to dispute even the more conservative census figures.

Yes, Those Uninsured Numbers Are Legit | The New Republic
It seems the attack on the 46.5 million doesn’t just seek to undermine the facts; it seeks to both minimize the problem, and place the blame for being without coverage on the uninsured themselves. [...] But this pervasive argument by health reform opponents, made by Sen. Orrin Hatch on Meet the Press, or Rep. Dan Lungren at a town hall meeting here in Northern California, suggests their true stance… that most of the opponents simply don’t see a big problem in the first place.  President Obama should not avoid this rhetorical fight. If opponents
want to deny the established Census figures describing the health
crisis, to minimize that the problem isn’t that bad, or to blame the
victims of our broken health care system, that’s a debate I am
confident health reform supporters will win.
I think this is right.  The uninsured may not be the best sales pitch, because most people don't see themselves as a member of that group, but reminding people that reform offers security & stability in healthcare coverage is a compelling promise.  Moreover, as opponents of reform try to resurrect the "America has the best health care" argument, it's handy to remind them that the health care system in the US really is terribly broken and in need of reform.  As the specter of rationing is raised to scare voters, the fact that we are already rationing by income should not be forgotten.

14 September 2009

I'm Back

Had an incredible time at Lake Crescent. Saw the International Space Station pass over (twice! Wowie is it bright!). Saw the most amazing surf I have ever seen in my entire life at Rialto Beach.

And we played in the tide pools off the evocatively named Tongue Point, off the Strait of Juan de Fuca.We hiked, we canoed, we grilled burgers on the lake shore and we drank lots of Deschutes' finest. Now I am back, refreshed, relaxed and rejuvenated. The kids are back in school, and I will be back at work tomorrow. Expect more new content soon.

10 September 2009

Off the grid

Lake Crescent
Uploaded with plasq's Skitch!

Going to Lake Crescent for a few days.  Hopefully we'll have more sun than last year.  It's beautiful either way, and I feel sorry for those of you who don't live in a temperate rainforest.  I'll be back Monday, and if y'all could have the whole healthcare thing solved by then, I'd be grateful, OK?

Feel free to use the comments to tell me why your part of the world is a nicer place to live...

09 September 2009

Is Doctors' Income the cause of health care inflation?

Ezra Klein - The Provider Problem
Medicare keeps costs down somewhat better than private insurers, though not as well as private insurers did in the '90s, and they do it by paying providers less money. Providers hate them for it, and that's why doctors and hospitals and drug companies and device manufacturers have been so aggressive in opposing a public plan able to use Medicare rates. It's also why Medicare's growth rate is totally unsustainable -- Congress keeps delaying the cuts in doctor's payments that the Medicare law requires.
Ezra has an interesting post in which he posits that the problem in health care economics is that the rate of inflation of health care persistently exceeds the general rate of inflation.  Fine; I do not think anybody is in disagreement on that point any more.  He goes a bit further, wrongly, I think, in implying that the solution is just to pay doctors less.  

The background here is that in the late '90s, Congress decided to impose a cap on how much medicare expenses for physician services could increase in any given year, using a complicated formula called the Sustainable Growth Rate, which was indexed to GDP growth.  I should note that for some reason, Congress decided not to cap the increase in expense on hospital services, but to let the growth of Medicare Part A accelerate unrestrained.  (The hospital industry must've had better lobbyists.)

The SGR ran into trouble immediately, and required pay cuts for physicians, and Congress repeatedly caved and canceled the pay cuts.  So, Medicare Part B grows year over year, at a rate ahead of that of inflation, and the logic seems simple: we need to pay physicians less!

But that ignores the fact that much of physician's revenue does not go to that physician's income.  Most doctors (ER docs being an exception) have offices to maintain, nurses and assistants to pay, healthcare premiums for this employees, in addition to the malpractice insurance and billing expenses.   Medicine is not a low-overhead game any more!  My gut feeling was that physician income has been stagnant-to-declining over the last decade.

So I went to the Bureau of Labor Statistics and I manually pulled the data on physician income over the 1999-2008 timeframe, and the inflation rate for the same time span and saw that I was more or less right:
physician income vs inflation
Note that for the first six years, physician income was less than inflation, and 2006-7 was only a little bit above the overall inflation rate.  Also note that for two years physician income was actually negative.   2008 was the only year in which physician income increased faster than inflation.

A note as to methodology: the BLS tracks doctor's income by specialty, not as a single profession.  I pulled the data for General Internal Medicine, Family Practice, and Surgery, and averaged them.  Including surgery, unsurprisingly, greatly improved the income figures.  Internists' and Family docs' income lagged inflation every year but 2008.  This was not weighted, either -- there are many more Internists and FPs than surgeons, while I weighted them equally.  (Also, the BLS changed data collection methods in 2002, creating a spurious increase of 33% that year, so I threw out that year and interpolated for the above graph.)  This is not a rigorous analysis, but it gets the point across that individual physician income has not been the driver of overall healthcare inflation.  If anything, I think these methods tend to understate the degree to which physician income has stagnated during this period.

So why have global physician expenditures gone up so fast during the last ten years when physicians are, by and large, not seeing the increase in their bottom lines?  Several reasons, I think:
  • As overhead costs increase, doctors squeeze more work into the day just to keep up with rising expenses.
  • As the baby boomers age, and as lifespans continue to increase, patients are older & sicker, and physicians appropriately provide more intense care to this needier population.
  • As new technologies, procedures and therapies are developed, physicians employ them more, generally at increased cost.
  • For Medicare in particular, the graying of America simply means there are more people enrolled in Medicare.
So while doctors are providing more services, the increases are in low margin services or the increases are consumed by increased practice expenses.   I am sure there are more factors as well.

So, Ezra's suggestion that simply paying doctors less (i.e. implementing the SGR-mandated cuts) would have some effect on reducing the global expense for physician services, it would do little to change the trendline towards increasing costs.  Put another way, it would lower the setpoint of the curve without changing its slope.  It would also, incidentally, have a dramatic effect on physician compensation, since the other costs of a medical practice are fairly inelastic, and the lost revenue would come directly out of doctor's salaries.

I don't have a solution to the costs problem, and I am not sure anybody else does either.  Cutting hospitals' reimbursement would have terrible effects; hospitals are under tremendous economic stresses as it is, and I know most hospitals have razor-thin profit/surplus margins.  Medical devices are expensive, but they are so critical to the improvements in health care that I do not think anybody has the stomach to cut them.  Pharma probably should be cut, but their lobby has defended them very well.  There's no good answer.

But it is overly simplistic to think that doctors' compensation is at the root of the runaway costs problem.

08 September 2009


I haven't looked at the numbers lately, but Altered Mental Status, or AMS, must be in the top ten, if not the top five most common ER presentations.  AMS, as a triage complaint, is like a bizarre little birthday present for an ER doc.  You just don't know what you're going to get when you walk into the room -- and there's a tremendous range of possibilities.  It could be someone with a stroke, or a septic septuagenarian.  Odds are, it's just a drunk, or someone stoned on street drugs, or overdosed on prescription meds.  Less exciting and much more work (and infinitely more likely to be a huge pain in the butt).  They may have nothing at all, or something really trivial like a fainting spell.  Sometimes you get the really interesting stuff presenting with AMS: a first time DKA or a carbon monoxide poisoning, for example, which is a fun detective game requiring good clinical skills.  I've seen it all, a million times over, so I'm quite comfortable with the protocol, but you never really know what it is till you get in there.

This was a little old fellow who had been found down by his family this morning.  He had been in great health and living alone more or less independently despite being almost ninety.  His daughter had spoken with him the night before and he had seemed fine, though they had been concerned about a progressively worsening unsteady gait.  He was found in his bathroom (they went to check on him when he did not answer the phone in the morning) and his bed had not been slept in, so it was safe to presume he'd been on the floor all night.  He had a goodly sized contusion on his cheek and forehead, already purpling up nicely, implying that he had gone to ground pretty hard.   He was awake but cold (about 34 degrees body temp), having been on the floor all night, but his vitals were otherwise normal.  His mental status was not terrible, but he was definitely groggy and slurring his speech a bit, and his neuro exam (limited due to his mental status) was nonfocal.

So, by simple probability alone, I constructed the following preliminary differential, looking for a common cause for both the fall and the AMS:
  • UTI causing weakness and instability
  • Some other infection causing weakness and instability
  • Bathroom-associated syncope (common in the elderly)
  • A simple mechanical fall (too weak/shook up/head injured to get up)
  • Stroke (less likely given the exam, but always possible)
  • Floor-dweller's disease (hypothermia, rhabdomyolysis, dehydration, renal failure, etc; unlikely given the short down time)
  • Medication effect (gotta get the list)
  • Dementia with family denial (also common)
  • "The Other Stuff"
And we went ahead and triggered the standard work-up.  Truth be told, I was busy chatting and the exceptional nursing staff had already ordered the complete work-up before I even got in to see the patient (yes, I am a redundant feature of our ED).  Shortly thereafter, he was lined & labbed, cleansed and foleyed and off to CT scan while I got to know the family a bit.  Unlike the standard neglectful/overanxious families, they were really nice, reasonable, well-grounded folks -- an absolute pleasure to talk to.  That should have been a red flag for me.

The "Code Blue" call from CT scan was my next wake-up call.  Truth be told, it wasn't a code per se, but the excitable CT tech called one anyway when the patient began to seize as he came off the table.  (Fair enough.)  A bit of ativan ended the seizure and the team whisked him back to the ED while I skimmed through the images.  This caught my attention right quick:


If you don't look at CT scans often, let me help you out a bit:


Vasogenic Edema is swelling in the brain induced by increased pressure or inflammatory conditions.  It can be seen from the late effects of a stroke, from severe hypertension, or from a brain tumor.  I knew this wasn't stroke-related because of the acute onset and the relatively normal neuro exam.  Hypertensive encephalopathy is more global, not localized (and his blood pressure was OK). And, though CT isn't great at showing mass lesions, that whitish thing sure looked like a tumor.  When I got back to the ER, a quick biopsy of the records showed that he had been treated a couple of years ago for Stage Ib adenocarcinoma of the lung, now thought to be in remission.  This cancer does commonly metastasize to the brain.  Damn.

So the story (or at least my portion of it) ends there.  I got to tell this nice family that "Pop's" cancer was back and that it was probably going to kill him.  We did the usual acute interventions and he went upstairs.  And I moved on to the next patient, who happened to be a drunk and here for altered mental status.

And that's AMS for you in a nutshell.  You never know what you're going to get.

And, just for the record, cancer sucks.

07 September 2009

Bedside Ultrasound in the ED

An interesting take on ultrasound in community medicine from the EM Blog:

Community Hospital: Ultrasound Free Zones
Why is it that every EM resident training in the USA learns Bedside Ultrasonography (BSU) during residency, and then upon graduation goes out into the cold ultrasound-less world of the community hospital ED? Is rapid ultrasound so available in these hospitals that their skills in BSU are really not necessary? Hint; NO, THAT IS NOT IT! Well if that isn’t the explanation, then what is?
Another blogger (Jan Shoenberger) on this site noted the disconnect between academic environments and the “real world” noting that many new grads are unprepared for the realities of practice. One example of this is that they know how to do BSU but will likely never have a chance to use that skill.
The posited reasons why ultrasound hasn't penetrated community hospitals are part right: ED Directors who don't keep up, radiology turf battles, etc.  But I have to say that the reality of bedside ultrasound has never quite lived up to the hype and its purported potential.

For reference: We have had ultrasound capability in our ED for about seven years, I think.  We work in a busy (100,000 visit), high-acuity urban/suburban center without too much trauma.  About two-thirds of our physicians were trained in ultrasound use in residency, including two or three docs who did ultrasound fellowships. The verdict?  About half of our docs never use the machine, and of those of us who do use it, we have infrequent need for it.

For example, in the community, vascular access has not been a terrifically challenging issue.  I rarely have to do central lines, and when I do, a blind approach works fine.   Blunt trauma goes straight to CT scan.  Potential AAA cases are infrequent and almost always are stable enough for CT (and as often as not the vascular surgeon wants the CT before operating anyway). Biliary studies are challenging and unless the results are pretty clear most docs are not comfortable performing these studies without confirmatory follow-up.  I would not be able to rule out torsion with the machine we have (Sonosite Micromax), and so I tend not to do pelvic ultrasounds in non-pregnant patients.  The other "indications" such as retinal detachment (really?) are rare enough and require enough operator skill that it's just not practical or necessary in the typical ED.

Where we do use the ultrasound a lot is for OB exams, especially in the anxious/spotting first-trimester moms.  It takes ten seconds to find the heartbeat, print out a picture, and the patient goes home happy and quickly.  That's awesome -- it's a common presentation and the ability to quickly turn those cases around saves a ton of time and money.  I also use them for paracentesis on liver patients -- which can also be done blind, but since we have the machine, why not?

The bottom line is that these machines are expensive, and the utilization needs to be high enough to justify the cost (especially if you are not billing for the studies).  The "real world" experience is pretty marginal there.

Now don't take away that I am opposed to bedside ultrasound -- I love it.  I recently diagnosed a ruptured cornual pregnancy with it, and having that capability really expedited the patient to the OR.  I don't use it every shift, but pretty frequently.  I was highly instrumental in convincing our hospital to purchase it. But the business plan -- the cost/benefit -- is a challenging argument to make to administration.  "Well, Mr CEO, I'd like you to spend $50,000 to buy a machine that won't bring in any additional revenue, will be used infrequently, and is guaranteed to piss off the radiologists."   We sold it based on quality of care and patient safety, especially for the infrequent cases where it really can be lifesaving, and we are lucky enough to have collaborative radiologists who work well with us on this issue.  So we won that round.  But I can't bring myself to be too critical of the ED director who chooses other matters to expend political capital over, especially in a smaller ED.

Addendum: yes, I know that bedside ultrasound can theoretically generate revenue.  But it's not easy: you need an ED doc who is enthusiastic and committed enough (or compensated) to champion it in radiology, oversee the image archiving and QA, and ensure that the docs performing it are doing it right.  You need a friendly radiology department (or a powerful ally on the medical staff).  And you need compliant payors who actually reimburse for ultrasound, which they do not in many areas.  A lot of stars have to align to make bedside ultrasound a financially valuable service, and that is very challenging in a non-academic setting.

06 September 2009

God Bless America

I drive by this house every day on my way to work:

Click to embiggen
The photo (snapped from my car window) doesn't do it justice.  Yes, the house is painted red, white and blue like the flag.  There are at least a dozen flags out front.  You can't tell, but the door is blue with white stars and has "God Bless America" hand-painted on it. There are placards with patriotic slogans stenciled on them strewn across the lawn and porch.  The owner frequently adds more flags or bunting, as the mood strikes him, and in nice weather there is often a huge American flag draped across the roof.  It's quite a sight and everybody at the hospital knows "that flag house."

I recently had the pleasure of meeting the owner.

It was a truly memorable encounter.  He was in the ER with his wife, an amiable lady with a truly startling number of facial piercings.  (And it takes a lot to startle me.)  He was perhaps in his late forties, of indeterminate ethnicity, but I might guess Samoan.  The most striking thing about his appearance was the American flag tattooed on his face like this:


Actually, most of his body was covered in tattoos of one variety or another, but beyond the American flag on his face, you tended not to notice them so much.  His hair was long and frizzled and would have been quite an afro had it not been gathered into a topknot on top of his head like one of those troll dolls.  He had (I swear I am not making this up) a bone through his nose -- a long slender gracefully curved bone about seven inches long, transversely piercing his nasal septum.  Among other less remarkable piercings, of course.  He began and ended every sentence with "God Bless America," as in:
God Bless America, doctor, I'm really concerned about my wife because she's been getting these dizzy spells a lot more this week, God Bless America.
And he was one of the nicest people I have ever had the pleasure of meeting in ten-plus years of working the ER.  Pleasant, respectful to a fault, genuinely grateful for any attention or kindness he or his wife received.   This aspect of his personality was thrown into such stark relief by his appearance, which screamed "mentally ill scary freak" but nothing could have been further from the truth (the scary bit anyway; I can't vouch for his sanity).  We spent a fair bit of time working through their issues and came to a happy disposition, and I was quite honestly sorry to see them leave.

People are so wonderful -- wonderfully strange in some cases -- and I am so happy that I am in a job where I get to interact with them every day.

God Bless America.

04 September 2009

Just Sayin'

If your medication list includes Namenda, you probably shouldn't be operating a table saw.


The stripes are radiopaque threads in a pack of 4x4 gauze blotting the blood from the hand.

(radial neurovascular bundle of index finger intact; marginal soft-tissue coverage, flexor tendon shredded. In case you're interested.

03 September 2009

Cool Ad

Via Crazy Andy

The Human Cost of Woo

I saw one of the most disturbing things of my career recently -- and that is really saying something. 

This was a young woman, barely out of her teens, who presented with a tumor in her distal femur, by the knee.  This was not a new diagnosis -- it had first been noted in January or so, and diagnosed as a Primary B-Cell Lymphoma.   By now, the tumor was absolutely huge, and she came to the ER in agonizing pain.   Her physical exam was just amazing.  The poor thing's knee (or more precisely, the area just above the knee) was entirely consumed by this massive, hard, immobile mass about the size of a soccer ball.  She could not move the knee; it was frozen in a mid-flexed position.  She hadn't been able to walk for months.  The lower leg was swollen and red due to blood clots, and the worst of the pain she was having seemed due to compression of the nerves passing behind the knee.  It was like something you see out of the third world, or historic medical textbooks.  I have never seen its like before.

So we got her pain managed, of course, and I sat down to talk to her and her family.

What I learned was even more amazing.  The patient had been seen by the finest oncologists in the region upon diagnosis.  They had all recommended the standard treatment of a combined regimen of chemotherapy and radiation.  She had, however, steadfastly refused this treatment.  She preferred, she said, the "Gerson Protocol."  This is, she continued, "a way for the body to heal itself with a combination of detoxification and boosting the immune system."

In a less grave situation I might have laughed and asked "So how's that working for ya?"  As it was, the tears from her only partially-controlled pain took any humor out of the situation.  She was very frustrated that the Gerson therapy wasn't working yet, but she did not perceive this as a failure of the treatment.  Her theory was that the severity of her uncontrolled pain was keeping her immune system suppressed and preventing it from working.  If, she hoped, she could just get her pain under control, she would finally start to get better.

I spent a lot of time with this young lady.  Listening as well as explaining.  She was dead set against chemo, which to her mind was equated with the "toxins" which had caused her cancer in the first place.  She wrote off the oncologists as pushing chemo "because that's all they know how to do, and it never works."  She had, in fact, burnt all the bridges with the various oncologists who had treated her, and was now left with only a pain specialist and a primary care doctor trying to do what little they could for her. She was equally frustrated by doctors in general, who "won't do anything to help me."

I could see why she felt that way; when a patient refuses the only possible effective treatment, there is not really much we can do to help her.

I did what I could.  I talked to both her doctors, and I called a new oncologist.  The oncologist, a wonderful man, promised to make time to see her in his clinic, even fully forewarned of the "baggage" she would be bringing with her.  She was happy to receive the referral, though I warned her that the new oncologist would be recommending more-or-less standard treatments.  Ultimately, she went home and I was left to reflect on the futility of the situation and the absolute wickedness of the charlatans and hucksters out there who promote this sort of thinking.   From the late Dr Gerson, to his modern-day counterparts Andrew Wakefield and Jenny McCarthy.

Most woo is harmless -- but that's because most woo is directed at chronic, ill-defined, or otherwise incurable conditions.  Think chronic fatigue or fibromyalgia.  Wave a magnet at somebody, get them to do a lot of enemas and go on a special diet, and you get to write a book and go on Oprah and collect a lot of money.  If the subjects of the "magical thinking medicine" think they are better from the intervention, then so much the better.

But the really pernicious thing about allowing fantasy medical theories and treatments into the mainstream is that when they gain enough credence among the masses, they will tend to be used in place of real medical treatments that work.  Like vaccines.  Even the anti-vaxxers have a limited and indirect harm -- of the many thousands of children who go unvaccinated, only a very few get measles and even fewer die.  It's a real harm, but one which is easy to miss if you're not affected personally.  But when woo supplants real medicine against lethal diseases that actually have effective treatments, the harm is so much more severe and so apparent that it cannot be left unrecognized.  Because of the practitioners of "alternative" medical treatments who irresponsibly and dishonestly teach people to distrust medicine and embrace unscientific treatments, this young woman is enduring incalculable pain, and may well lose her life.

It's sad, and it's an outrage.