27 February 2010

Working in the shadow of the beast

Our new hospital is finally taking shape. Won't be open for another year, but it's looking good.

Got a tour of the new ER under construction the other day. GodDAMN it's going to be huge. I'm getting excited in anticipation.

What's wrong with the Senate?

Jim Bunning seems to be a wonderful example:

The Senate, which was supposed to pass an omnibus bill including an extension of uninsurance benefits, an extension of COBRA benefits, and (not incidentally) yet another temporary patch on the 21% cuts in Medicare physician reimbursement, failed to do so on Friday before it adjourned early for the weekend. At least that's the top-line headline, and most people never read further than that when it comes to wonky policy/process articles like this.

The real reason that the bill is stalled (and that the cuts which are deadlined at 2/28 will go into effect) is, as they say, the Gentlman from Kentucky, Senator Jim Bunning.

Bunning, it seems, had mounted a quixotic mini-filibuster of the extension. He wants some (I'm not sure which) of the various extensions to be funded out out of the stimulus monies, which would mean that projects for which that money had been budgeted will have to be canceled. According to reports, he rejected to having this put up for a vote, knowing that he didn't have the votes to support it, and chose instead to just obstruct out of pique. It's important to note that Bunning does not have, it seems, the support of republican leadership in this, and he knows full well that Reid will just push this through to a vote which will pass the extension as it was written. So it's a futile, meaningless gesture, assuming that the entire GOP caucus doesn't rally behind him, which seems unlikely. The Democrats forced Bunning to stage a mini-filibuster, which angered him to the point that he cursed at fellow senators on the floor and whined that this was making him miss a basketball game.

"Let them eat cake"?

In the end, this is not going to prevent the extension of the Medicare patch -- or uninsurance benefits and COBRA benefits, something of great importance to those suffering in this recession. The rules allow Reid to file for a vote after a certain time frame, and the only reason this is news at all is because it was a last-minute vote and apparently Bunning blindsided Reid with his procedural hijinks.

But it's a great example of the many ways that the Senate is deeply dysfunctional and subject to being held hostage by a determined minority -- even when it is a minority of one. Will this add fuel to the drive for reform of the filibuster? Possibly. But it's a great example of why reform wouldn't necessarily be a bad thing.

The Desctructive power of a Tsunami

By now you've all probably heard about the terrible 8.8 magnitude earthquake that struck Chile in the pre-dawn hours this morning. While our hopes and hearts are with the survivors, Phil Plait of Bad Astronomy posed the most amazing image of the modeled impact of the resultant tsunami:

Yikes. How violent must the earthquake have been to spread that amount of energy over half the globe? Phil writes:
I’ll note that the magnitude scale doesn’t translate perfectly to energy released, but roughly speaking an 8.8 quake releases the energy equivalent of 20 billion tons of TNT, or 400 time the largest nuclear weapon ever detonated (Tsar Bomba, a 50 megaton test done by the USSR in 1961). If the measurement hold up, this will be the fifth or sixth strongest earthquake recorded since 1900. The strongest ever recorded, in 1977, was magnitude 9.5, also in Chile.
Note: apparently the image was generated by NOAA, and also, interestingly, apparently the Richter scale is no longer in use. I did not know that.

26 February 2010

I get letters

Lots of them -- press releases, requests for links, guest posts, spam, and the like.  It seems like 99% of them are mass-mailed without regard for the content or themes encountered on my blog.  (No, I don't want to host a dialogue on womens' gynecologic health -- nothing against it, but it's not really my gig, ya know?)  But every once in a while I get one that catches my attention, though not always in a good way, or at least not always in the way the author might have hoped.  For example, I got this from The "Trent & Company Marketing Communications" which I assume to be some PR agency:

Recently, congress introduced the “Dietary Supplement Safety Act of 2-10,” which, if passed, will drive up the cost of dietary supplements and restrict access to them. The bill will place added costs through tax dollars on relatively low-priced, scientifically proven, dietary nutritional supplements ... In a time when Americans are seeking more alternative, preventative healthcare solutions instead of relying on expensive drugs, this bill not only threatens businesses that manufacture supplement products but the American consumer who is now seeking ways to improve  health before they spending money on doctors visits and prescriptions. Organizations such as the Life Extension Foundation manufacture highly effective nutritional supplements under strict pharmaceutical grade, FDA standards and are marketed under some of the most stringent restrictions placed on any products sold anywhere in the world.

At first I was confused as to whether this was supposed to be something the author wanted me to support or oppose.  My gut instinct is that anything which "restricts access" (code for "regulates") supplements is a good thing and to be supported, but the tone of the letter implied opposition.

So, with a sigh, I plowed ahead and read the whole damn thing.

Yeah, this turned out to be a missive from a pro-supplement lobbyist trying to gin up opposition to a bill which would indeed improve the shoddy-to-nonexistent regulation of the "Dietary Supplement" industry.  The bill was, to his credit, introduced by one John McCain.  And it would be a very good thing if it were to pass. 

I was going to expand with a detailed exposition on the minimal regulation of the supplements industry, 90% of which are placebo and some of which are potentially dangerous, and how this bill would change that, but it turns out another highly prolific, well-known semi-pseudonymous blogger got there first.  I don't think I can improve on what he wrote, so I'll just give you the link and let you read it yourself.  Key graf:
The bill has a number of good features. One part that I like is that the DSSA mandates that all adverse events be reported to the FDA, including non-serious ones ... it also includes expanded power for the FDA to issue cease distribution and notification order requiring that the manufacturer cease sales and marketing of the supplement in question. It also provides a mechanism for a hearing within ten days for the manufacturer to defend itself against the charges. After the hearing, the FDA may then issue a formal recall if it finds adequate evidence that the supplement is unsafe. While it is true that the DSHEA does currently allow the FDA to ban supplements, it does not, as I understand it, give the FDA the power to issue a rapid order to cease distribution or to mandate a recall this quickly, nor does it require supplement manufacturers to register with the FDA. All in all, it is a welcome modification of a very bad law. Although it does not go far enough, it is a bill that supporters of science-based medicine should support.
That was pretty much my reaction, too.  Let your congressperson know.

Medical Relief Missions in Haiti

One of our docs is heading down to Haiti next week.  We, as a group, all agreed to cover his shifts in order to support his deployment.  I'm kind of jealous -- it sounds like a fascinating and rewarding experience, and a chance to do some real good.  Another of my residency mates just left the USS Comfort where she had been providing volunteer services.

Paul Levy over at Running a Hospital has a good narrative of one of their ER doc's experience in Haiti.  Worth a view.

It's one of the paradoxes of Emergency Medicine that our best professional experiences are born out of other people's worst experiences.  Haiti certainly qualifies.  Bravo Zulu, guys.

Friday Flashback

Tale of Two Patients
It all happened in Room 14, bed 2. The two of them came in a few hours apart and were like carbon copies of one another. Both middle-aged men in their late forties, somewhat overweight, blue-collar machinists. Both fully insured but had not seen a doctor in ages because "I just hate doctors." Both with large, dedicated, anxious families at their bedsides, certain that if Dad went in to see the doctor -- in the ER no less -- it had to be serious!

Both felt foolish for being there and apologized for "wasting my time."

I could have just photocopied the first medical record and used it for both of them. 

Chest Pain
- feels like gas bubbles in the chest, non-radiating
- comes and goes for a week, worse today
- not worse with exertion nor relieved by rest
- not associated with nausea or shortness of breath

Past History
Told he had high blood pressure but was never treated.
Thinks the last time it was checked, his cholesterol was "a little high"
Father had early-onset heart problems

Both were symptom-free in the ER and had normal ECGs and a normal troponin.

I had identical, almost verbatim, conversations with both of them. "The good news is that the tests here look good and I can say that you are not having a heart attack." A quick look of relief flickered across both faces at this point as both wives exhaled deeply and said "Oh thank God." A pregnant pause follows. "The bad news is that the pain you describe is in some ways like heart pain, and you have risk factors for heart disease. I can't tell for sure whether there might be an impending heart attack, and we need to interpret these symptoms as a warning sign that further testing is needed. I want to admit you to the hospital for observation."

At this point, relieved and embarrassed, both wanted to just go home. Both tried to bargain -- promised to take meds and follow up with a doctor. Both wives demonstrated irritation and told their husbands not to be stupid. Both husbands irritably told their wives that "I knew it was nothing."

"Here's the thing, Mr _____," I respond, "I think the chance that this is your heart is low -- probably 5% or less. You like those odds, don't you?" Two nods with a subtle see, I told you so glance to to the wife. "But that's one in twenty," I continue, "and I am going to see twenty patients today. Do you want to be the one? Are you feelin' lucky, punk?" (The last bit delivered in my best Dirty Harry voice.) Both slumped back in defeat and their wives thanked me with immense satisfaction.

You never know. Both described symptoms much more suggestive of acid reflux than heart disease. I probably admit ten or twenty patients for observation for chest pain for each one that rules in. It's hard to do, because people hate to be admitted, the hospitalists don't want to do the admit, and it's a lot of work to admit someone. But you do it, because you don't want to fall into the "fallacy of knowing" and thinking you can predict in advance who will and who will not turn out to have "real disease." It is not very rewarding, and you feel like an idiot calling up the admitting doc twice in a row with a "low risk rule out that sounds more like GI disease than angina."

Patient number one was discharged from the hospital after eighteen hours of observation and a negative stress test. Patient number two had a triple bypass today, after ruling in and have three-vessel coronary artery disease showing up on angiogram.

Originally posted 30 January 2007

25 February 2010

A surprising argument on EMTALA

This is not what I expected to see in my inbox today: 

Minnesota Governor and Presidential aspirant Tim Pawlenty:  Let's repeal EMTALA.

No, seriously.

Via The Hill:
Pawlenty: Let ER's turn away patients to cut costs

Emergency rooms should be able to turn patients away to cut costs, Minnesota Gov. Tim Pawlenty (R-Minn.) said last night

Appearing on Fox News's "On the Record with Greta Van Sustren" last night, Pawlenty said the federal law that mandates ER treatment should be repealed.

"Well, for one thing you could do is change the federal law so that not every ER is required to treat everybody who comes in the door, even if they have a minor condition," Pawlenty said. "They should be -- if you have a minor condition, instead of being at the really expensive ER, you should be at the primary care clinic."

Supporters of the federal law would content that many people go to ERs precisely because they do not have the insurance to pay for a primary care physician.

Van Susteren was also skeptical about Pawlenty's proposal, pointing out that it's difficult to tell what's a minor condition without treating it.

VAN SUSTEREN: OK. OK. But you come in with chest pains, and like, you get horrible chest pains. Now, it could be indigestion, which is minor, or it could be heart, which isn't minor. So then...

PAWLENTY: You have to do a little triage. That's for sure.

VAN SUSTEREN: Right. I mean, so the problem is, it's got -- I mean, there really is sort of -- it's not that easy.
When you are in a conversation with Greta Van Susteren and she seems like the sane and reasonable one, you know you are in trouble.

I suppose what this really reveals is that Pawlenty is an idiot when it comes to health care policy, but then I hear his antics in Minnesota with MinnesotaCare would support the notion that he's either an idiot or callously indifferent on the issue, anyway.

Nothing new to see here.  Move on, people.

24 February 2010

More on Anthem

I don't think I can say it any better than mcjoan:

Anthem Blue Cross is making the case all by itself for healthcare reform:
Anthem Blue Cross broke law more than 700 times, official says
California Insurance Commissioner Steve Poizner says the insurer failed to pay medical claims on time and misrepresented policies from 2006 to 2009. The firm faces up to $7 million in fines.
I'm shocked.  An insurance company failing to pay claims in a timely manner?  That's unpossible!

Actually, that's pretty much SOP for most insurers: deny and delay at will, and dare providers/consumers/regulators to punish them.  Fines (when there are any) just go back to the insureds as increased premiums, and any time the providers/consumers are fatigued out of demanding the insurers actually pay, that's pure profit for the insurance company.

Pass. The. Damn. Bill.

St Baldrick's Approaches

Cancer sucks.

Cancer sucks more (if that's possible) when it's a kid suffering from cancer. 

Kids shouldn't die.  It seems like such a simple sentiment, almost a truism.  But they do, and each one who dies leaves a gaping hole in their families, and their friends and their communities.  And it's just wrong.

There's a feeling of futility when you see a child you know terminally ill, and an intense desire to do something about it.  When Nathan Gentry died two and a half years ago, I knew that I wanted to do something to try to prevent more children from dying.  Fortunately, there is a organization dedicated to supporting research into cures and treatments for childrens' cancers: The St. Baldricks Foundation.

St Baldrick's plays off the tradition of friends, schoolmates, and family members shaving their heads in solidarity with the kids who lose their hair due to chemotherapy, and extends it to the larger community.  Baldrick's raises millions of dollars every year for kids' cancer research, and after carefully screening applications for the most promising projects, grants over 85% of that money directly to the investigators working on treatments.

I'll be shaving my head in Seattle on March 15, at the Fadó pub.  I'd like to ask for your support and your gift to help in the fight against pediatric cancers.

Please click on the link, and make whatever donation you can, large or small.  The larger the gift, the greater impact it will have, but even the most modest gifts help! Know that you're donating to a good cause, and enjoy the warm and fuzzy feeling that good Karma brings to the generous.

Thank you.

Click here to donate.

Ignore your teeth and they'll go away

DentalCariesOne of the least-favorite complaints for an ER doc is the patient with dental pain. It's one of those low-level annoyances. The typical dental pain visit takes about three minutes and no mental effort -- it's usually not a challenging interaction. It is just about risk-free and reimburses nothing. But it's frustrating because usually there's nothing an ER doc can do for the toothache but write a script for antibiotics and narcotics. Some practitioners like the dental blocks, though I usually don't bother because they're such a temporary band-aid. And many of the patients complaining of dental pain are repeat visitors for the same problem, so there's a tendency to write them off as drug-seekers, which some but not all of them truly are.

The problem is that the dental pathology we see is real, and awful. I'm not talking about the scumbags with their meth-mouth, though that's bad enough. I see a lot of regular folks, middle to lower-class, and look into their mouths and see maybe a dozen intact teeth, with the other 20 teeth either in a state of advanced decay or, more commonly, just broken off at the gum line. No wonder it hurts! There's often signs of a brewing periodontal abscess, but even without an infection it still makes me wince to see. And I check the records and see that this patient has been in the ER ten times for dental pain. So I ask, "Have you thought about seeing a dentist?"

The response never varies: "I've called all around and nobody will take me because I've got no dental insurance/they don't take the DSHS insurance."

And I believe them. Bear in mind I'm not just talking about the completely indigent, but also the working poor who may have health insurance but do not have dental coverage and cannot afford the all-cash cost of dental care.

There are free clinics, and the traveling dental van, but they are totally overwhelmed by the demand, and in many cases they cannot perform the very difficult extractions and other procedures required by the severe dental disease they are faced with. And they tend to give priority to children and women, which leaves the poor males without any access to care. The best I can do is give them a referral to the University dental school, which is 30 miles away and not really accessible by public transportation.

That, my friends, is the definition of futility.

Harold Pollack over at TNR's The Treatment has a highly link-worthy piece about this problem, and how it represents a huge gap in the health care reform debate.
[M]illions of Americans do not receive needed dental care. Crummy teeth have long provided a painful and stigmatizing symptom of extreme poverty. Medicaid often provides meager coverage and pays dentists very little. (Dental care is a continual problem for many low-income Medicare recipients.) The Washington-area death of 12-year-old Deamonte Driver from an untreated tooth abscess brought public attention to the most dire potential consequences of untreated dental concerns. ... Basic dental care is not particularly costly. Unfortunately, it is generally restricted to its own silo, separate from the rest of American medical care. Some dental leaders such as Burton Edelstein and Allen Finkelstein have argued for a stronger focus on prevention, and a greater integration of medical and dental concerns. They face difficult challenges in dental care financing, existing public policies, and the mores of the dental profession itself.
Part of this is linked to the collapse of Medicaid programs nationwide. But the "separate silo" point is particularly incisive. Why is dental care not generally considered part of health care? Why are dental policies typically a separate insurance policy from health care insurance policies? When states mandate health care insurance plans to cover basic health services and preventative care services, why is dental care not considered part of this? If mental health parity is to be included in health care reform, it is a missed opportunity for health care reformers not to have included dental health parity in the reforms as well.

By the way, I'm not criticizing the dental profession here. Most of the local community dentists do offer some charity care and some discounted care. The reality is that as private businesses, they can't afford to give away all their time for free, and the demand far, far exceeds the capacity of the dental community's ability/willingness to provide charity care. Counting on charity to fill the gap is clearly not a realistic solution to the problem.

This has been -- and remains -- a major blind spot for the health care policy wonks, and looks to remain so even if the health care bill moves forward. More's the pity.

22 February 2010

The Death of a Meme

I remember the first Hitler YouTube video I saw -- He was mad because the Cowboys lost.  I laughed like crazy, and it seemed particularly appropriate that Hitler would have been a Cowboys fan.  That was quite a while ago.  Then it was quiet for a while and then all of a sudden, it seems that Hitler was mad about just about everything.  It got old quickly.

Now, I present you this truly awesome work of art.

Sublime.  And now, I submit, the meme must die and no more Hitler YouTube vids may be created ... ever.

Why no Public Option?

It's been pointed out that the majority-vote reconciliation procedure would be a perfectly appropriate to re-introduce a public option (or even a medicare expansion) to the health care reform bill.  Reconciliation is supposed to be used for items which impact the budget and the deficit - essentially spending items and tax items.  Insurance exchanges do not, which, I suspect, is why the insurance exchanges remain state-run in the Obama proposal, rather than the preferable national insurance exchanges -- an attempt to modify that proposal in reconciliation would likely have been ruled out of order by the Senate parliamentarian and stripped from the bill. 

But the public option is another story.  It's pretty directly germane to spending and would likely be bullet-proof there.  There are certainly 50+ Senators on record in favor of a public option, and indeed 20 are already agitating for its inclusion in reconciliation.  It might also help bring some House liberals back on board.  And, has been pointed out, reform will be better electorally if the bill passed is a popular bill -- the public option is and always has been popular among the general public (not that most people really know what it means, but that's another story).  It's more popular than the Senate bill is.  So why isn't it in the Obama proposal to go through the reconciliation process and sweeten the deal?  In fact not only is it not in the plans, by all evidence, there's a surprising lack of enthusiasm from Democratic leadership, with the White House remaining silent and leaving it up to Reid, whereas Reid says that presidential support is necessary to reinstate the public option.

A few reasons I can think of:
  • Obama himself has never been a committed supporter of the public option.
  • The most recent "consensus" version of the public option was pretty weak and may be perceived as just not worth fighting for.
  • Democratic leadership has already resigned themselves to the loss on the option and are focused simply on getting a general bill passed.
  • Congressional Democrats are terrified of November and too timid to tack something "controversial" back on.
  • The Democratic coalition is, in reality, too fragile to survive the reinstatement of the public option.
I suspect that all are true to some degree, and I worry most about the last one.  The House whip count is something that insiders are very concerned about.  The Stupaks and the Blue Dogs are by no means certain in their support -- indeed, many did oppose the original House bill, and while their votes weren't ultimately needed, if they are needed, it's not clear that they'd be willing to take a risk by coming back on the compromise bill.  This seems wrongheaded to me -- the new bill is more conservative than the original House bill they opposed, and the electoral consequence of the bill's failure is probably more dire than the consequence of a conservative/swing district's representative voting in favor of a successful reform bill.  But it is what it is.

Ah, Democrats.  Is there nothing you can't screw up?

Back from the dead


No, not a horde of shambling zombies murmuring "Braaaiinnnsss..." although that does make for a lovely mental image.  It's the President's health care reform effort which has been most improbably resuscitated (again).

In case you missed it, there is a health care summit occurring at the White House this thursday, and everybody's invited (except me, as usual).  President Obama set the stage today with the release of his health care bill.  Except it's not really a bill.  It's a set of minor (or not so minor) adjustments to the bill which the Senate has already passed.  It's designed to make the bill, which is substantially more conservative than the now-dead House bill, tolerable if not acceptable to House liberals, and to remove some political distractions.

You can read the 11-page summary here [PDF], or just click through to Igor Volsky's excellent summary.  Or if you're too lazy even for that, here's the executive-executive summary:
  • Affordability - more generous subsidies to lower and mid-income families
  • Excise tax on high-cost insurance - still present but weakened and deferred till 2018
  • Payroll tax on high-income earners, no income tax surcharge (as in House bill), also taxes certain investment income
  • Individual mandate - weakened a bit but still present
  • Employer mandate - none, but with free rider provision for large employers strengthened
  • Insurance exchanges - state based, begin in 2014
  • Insurance regulations - no recission, pre-existing condition exclusions, no lifetime limits, preventative services must be covered.
  • Medicare donut hole - completely closed
  • Public option - absent
  • Anti-trust exemption for insurers - not repealed
  • Nebraska Medicaid deal - removed
  • Total cost -- increased by $75 billion (not sure what the revenue changes are or whether it is still deficit-reducing, since the CBO has not yet scored it).
  • Medicare Advantage - not ended, but will slowly phase in payment reductions to insurers administering it to bring back to medicare baseline
There's actually a lot more -- community health center investments, increased measures to restrict medicare waste and abuse, encouring generic drug availability and more.  I am not entirely sure whether these are new or are elements tossed in from the House bill.

Politically, this is going to be highly entertaining.  The GOP's response so far is incoherent at best; they called on Obama to post his proposal online at least 3 days before the conference so it could be reviewed, and then criticized him for doing so, complaining that it precluded any negotiation.  The White House counters that this is merely their "opening bid" in discussions, but the GOP seems fairly set in refusing to discuss any reform efforts that do not include a complete scrapping of the whole measure.  The White House is also trying to emphasize that this is a highly moderate bill, even setting up a special web site to trumpet the Republican ideas and amendments already included in the reform bill.

Most tellingly, if the GOP remains steadfast in its refusal to engage in any meaningful compromise, the White House is signaling that they are prepared to move through reconciliation and pass the bill without any republican support.  Clearly they have made the political calculation that it would be better to pass the bill and run in November on a record of accomplishment, even with a bill that is less than they would have liked and tarnished in the public eye than it would be to run having failed in their signature effort.  (Note, though, that much of the public opposition to the health bill is from the left, on the basis that it does not go far enough.)  If the GOP does not play ball (as it certainly appears they will not), then they are quite likely to get completely steamrolled, if the democrats avoid shooting themselves in their own feet (again).

It's also important to note that the process here does not require a whole new bill -- the Senate bill is already passed through the 60-vote filibuster, and the House can simply pass it as it is.  The reconciliation process is a majority-rules vote with only 50 votes needed.  So long as the House can hold its skittish caucus together, the legislative door is wide open for the Democrats to walk right through.

Jonathan Chait over at TNR makes a wonderful point about the freakout that we are going to witness from the GOP if the Democrats are ultimately successful in getting across the finish line:
Ever since Scott Brown beat Martha Coakley, conservatives, with very few exceptions, have been convinced that health care reform is dead. ... All the Democrats needed to do was have the House pass the Senate bill. If they insisted on changes, most of those could easily be made through reconciliation, which only requires a majority vote in the Senate. Most conservatives paid no attention to this basic reality, though they did indulge in some gloating mockery of those of us who pointed it out. ... You can imagine how this feels to conservatives. They've already run off the field, sprayed themselves with champagne and taunted the losing team's fans. And now the other team is saying the game is still on and they have a good chance to win. There may be nothing wrong at all with the process, but it's certainly going to feel like some kind of crime to the right-wing. The Democrats may not win, but I'm pretty sure they're going to try. The conservative freakout is going to be something to behold.
Given the freak-out we've already seen over this bill (I can't remember whether Obama is supposed to be Hitler or Mao any more) I can only imagine.

19 February 2010

Guest Post: Erasing Memories

Dr. Matlatzinca here with a surprise appearance.

Sometimes it feels like every time I learn the name of a new antibiotic I forget the name of someone I know. I've had numerous friends tell me that was the case with them as well, and a microbiologist professor I know frequently says that for every students' name he learns, he forgets the name of a species of bacteria. It seems that there may be a neurobiological mechanism underlying this bit of folk wisdom.

The research article is done on Drosophila, focusing on a protein called Rac. Yes, it is "only" fly research, but the interesting thing is that it appears that higher expression of the protein leads to flies forgetting about a particular association (in this case, a nasty smell accompanied by a foot shock).

I love seeing the advances being made in neurobiology. Maybe one day I will remember that Dr. Shadowfax gave me access to his blog so that I could share these kinds of interesting tidbits.

News story at Physorg and full paper available online (access required).

Friday Flashback

Oh, the pain of it all! Oh, the pain!With Apologies to Dr Zachary Smith. . .

The first seven patients I saw today were in the ED for:

  • Dental Pain (ongoing for three years)
  • Back Pain (third visit in one month, 18 in 2006)
  • Migraine Headache (six visits in a month, and second ED visit in 18 hours)
  • Back Pain (this one was legit)
  • Chronic Recurrent Abdominal Pain (ran out of Oxycontin and doctor "out of town")
  • "Cyclic Vomiting Syndrome" (in which only narcotics stop the vomiting)
  • Oxycontin withdrawal
Sometimes I wonder why I bother. I occasionally wish my job demanded something more than a valid DEA license, and decision-making skills beyond "yes narcs" and "no narcs." It just drains the carpe right out of your diem to start the day off in a series of ugly little dogfights over drugs with people whom, to put it charitably, you have concerns about the validity of their reported pain.

Now please don't jump to conclusions here. Pain sucks, and in the common event that I know to a reasonable certainty that someone is suffering, I am quite free with the narcotics. That's a big part of my raison d'etre. The problem is that increasingly, it seems that the chronic pain complaints far outnumber the acute pain complaints, and treating chronic (or recurrent) pain in the ED is fraught with difficulty to say the least. You don't know the patient, they come to the ED over and over for the same thing, they are demanding (both in terms of time expended and emotional energy), some are dishonest, there always seems to be some barrier to treatment which requires ED therapy ("Doctor out of town," "Lost prescription," "Only a shot works," "Threw up my pills," etc), and there is never objective evidence of physical disease.

These folks are colloquially referred to as "drug seekers." I wasn't trained in how to deal with them, and haven't seen any good educational/research on the topic. That which I have seen seems to have been infected by the Pain Thought Police, whose first law is that "Only the patient can tell you if the pain is real," and whose second law is "All pain is real." (You can see the problem there, at least from my point of view.) So of necessity, my approach to these folks is sort of ad hoc.

Off the top of my head, I would describe most of the "problem patients" as falling into a few distinct groups:
  • Malingerers: Want drugs for diversion or recreational use
  • Organic pain superimposed on narcotic addiction
  • Organic pain superimposed on psychiatric condition
  • Minor injuries in individuals with poor pain tolerance
  • Primary psychogenic ailments
These probably comprise 80% of the repeat visitors we see for narcotics. I commit heresy -- The Pain Thought Police would have us believe that organic pain and narcotic addiction can never co-exist. Any ED doc will tell you the truth. The real problem for me is that there are a couple of other categories:
  • True organic pain of long duration
  • Acute pain in a narcotic-habituated individual
And my job is to sort out the wheat from the chaff, so to speak. I try to find a way to say "no" to the first group of "seekers" in a manner that is therapeutic, honest, defensible, and not too much of a pain in my ass, while acurately sorting out the occasional individual who looks like a "seeker" but in fact is "legit."

It sucks. You wind up feeling judgemental and mean, you have to make people cry, and when you are wrong, you feel absolutely horrible -- and you always have that nagging doubt in your head, "Was I too harsh?" This is honestly the most emotionally challenging thing I have dealt with as an ER doctor -- not as hard as having a child die on you, but more of an every-day sort of low-level emotional parasite. Some ER docs say "Why bother?" Give 'em what they want -- it's easier and everybody's happy." No complaints to administration that way, either. We euphemistically call these docs the "candy men," but in truth I feel like a more honest appellation would be "pushers."

When I came home, my wife cheerfully greeted me and asked brightly, "So how many lives did you save today?"

Oh, the pain of it all. . .

[PS -- Don't miss the Follow-up to this post.]

Originally posted 28 October 2006

17 February 2010

Flying through Ireland

What a beautiful country.   Never seen it from the air before.  I also wonder where they got that footage -- in the US, flying that low can get you in a heap of trouble with the FAA, not to mention getting yourself killed.  Still, cool.

Saving Medicare


Newt Gingrich (Dear God, why does anybody pay attention to him any more?) published an op-ed in (where else?) the Wall Street Journal the other day in which he gave Obama what I am sure is some very well-intentioned advice on the health care thing.  Among his nuggets of wisdom:
Don't cut Medicare. The reform bills passed by the House and Senate cut Medicare by approximately $500 billion. This is wrong. There is no question that Medicare is on an unsustainable course; the government has promised far more than it can deliver. But this problem will not be solved by cutting Medicare in order to create new unfunded liabilities for young people.
Sounds great, except for the internal contradictory concepts of "usnsustainable" and "don't cut," but hey for rational analysis.  Maybe we can get a better sense of where this concerned citizen is coming from by examining what he proposed when he was in elected office:
As Speaker of the House, Gingrich sought to cut 14% from projected Medicare spending over seven years and force millions of elderly recipients into managed health care programs or HMOs. “We don’t want to get rid of it in round one because we don’t think it’s politically smart,” he said. “But we believe that it’s going to wither on the vine because we think [seniors] are going to leave it voluntarily.”
Oh.  Erm... awkward?

This is really the key to understanding that with the current health care reform efforts, we are not dealing with honest players.  Republicans decry "cuts" in medicare, which are not really cuts but more of an end to giveaways of public money to private insurance carriers.  Republicans decry fraud and abuse in the system (which are real problems) as evidence that the government cannot administer health care effectively, but then misrepresent efforts to reduce waste as "cuts" in services to senior citizens.  And lest some apologize for Gingrich's "former" views, make no mistake, they are very much in the mainstream of what the GOP would like to do if they ever came back to power.  Consider GOP rising star Paul Ryan's "Shadow Budget" which would essentially privatize medicare and greatly reduce its spending -- far more than ObamaCare would.  And yet they have the audacity to position themselves as defenders of medicare.  Defenders!  The program most loathed by conservatives (with the possible exception of Social Security), is the one they claim to be ardent protectors of.

I call bullshit.

16 February 2010

Reversing the metaphor

Well before Atul Gawande's "Checklist" article, the example of aviation's quality/safety procedures had been commonly held out as a model for how health care should operate.  Root Cause Analysis of adverse outcomes, no-fault reporting and the like were promulgated through health care, with highly positive effects.  The safety record of surgical anesthesia is directly attributable to their adoption of aviation's procedures. 

This is, however, the first time I have seen a proposal that aviation should work more like health care:

Oh my god, listing to the "service rep" talk in this video gives me the chills -- they have so perfectly captured the bland institutional inflexibility that I have experienced from every corporate drone from Verizon to our health care carrier.  It's perfect.

(h/t Kevin MD)

Going Bald Once More

Yup, St Patrick's day is soon approaching, and that means that St Baldrick's day is also approaching.  My ER's a bit understaffed this year and the event I had hoped to attend in Chicago fell through, so I'll be shaving here in Seattle, at Fado's pub on March 15.  Come down and join us, raise a pint, and chip in to help beat children's cancers.

This is my third year doing this, and I do it in memory of my friend Nathan Gentry, who lost his battle with Neuroblastoma at age seven, and in memory of Henry Scheck, who passed away from Medulloblastoma.

Children's cancer research is underfunded compared to adult cancers, in part because they afflict fewer people, and in part because the huges successes in treatments for some leukemias and lymphomas have made the need seem less dire.  But when it's your kid who is diagnosed with a malignancy, and you're talking to the oncologist about research protocols (something like 90% of pediatric cancer patients are enrolled in clinical trials), you realize how vital -- and how tenuous -- the funding for these experimental treatments is.

So I ask you to take a moment, click through to my donation page, and donate what you can to support my efforts with St Baldrick's Foundation this year.  It's a great cause, and whatever you can afford is highly appreciated.

Thanks for your consideration.

Click here to donate.

15 February 2010

Guinness, evolved

Good stuff.

Not dead yet?

ObamaCare is weakly protesting "I think I'll go for a walk," while the pundits insist "You're not fooling anyone." 

But are the pundits wrong on this?  I've long since given up the caricature of Obama as the Jedi Master playing eleven-dimensional chess games against hapless opponents.  His post-Coakley strategy, however, of playing it cool and allowing the dust to settle may well pay dividends in the end.  The televised bipartisan summit idea may breathe much-needed life into the initiative, and based on how he schooled congressional republicans at their retreat, I'm not surprised that they are reluctant to participate.  This is a nasty little Catch-22 for the GOP, though, because if they choose to boycott, I can't think of a photo-op which would better illustrate GOP obstructionist tactics than the camera slowly panning across a row of empty chairs with the nametags of republican leaders sitting in front of them.

But will it be more than a photo-op?  History suggests not.  While Obama once again holds out key Republican priorities like Medical Malpractice Reform as an incentive to compromise, the GOP has rejected such overtures before, and despite the death of the public option and despite the inclusion of several republican ideas in the bill, they remain steadfastly committed to obstruction.  In fact, Boehner's preliminary response to the President was to insist that their participation was contingent on the Democrats' willingness to scrap the proposal and start from square one.  Bipartisanship only works when there are two parties willing to compromise, and despite multiple painful policy concessions from the left, there has not been a single discrete commitment from the other side of the aisle describing the basics of a compromise they would find acceptable. 

I suspect that the summit will consist of much posturing and a great show of reaching out to the intransigent GOP, and then both sides frantically playing the spin game to drive the narrative that it's the other guys who are being inflexible.

Reminds me of my last negotiations with the Blues.

It's also worth noting that although polling (for whatever you believe it to be worth) indicates that the reform bill has lost much public support, there is also a strong feeling from the public -- by a two to one margin -- that this crisis is severe enough that lawmakers should not walk away from the efforts to achieve comprehensive health care reform:

Compromise is hard (it's been excruciating for this liberal), but it has to be bipartisan.  It will be interesting to see whether the GOP is willing to bring anything to the table to seal the deal. And if they don't, they deserve to have the Democrats ram their bill through on a straight party-line vote over their objections.

This is too important to fail.  We need to pass the damn bill.

14 February 2010

Invade a Hospital

Via Andrew Sullivan

Note: the cited numbers may well be bogus. But the overall point remains that access to health care should be a national priority on a par with national defense.

13 February 2010

Late Night Saturday

A hysterical foreign public awareness clip for condom use.

So, so very not safe for work.  But, and I say this in all honesty, I have never seen a cuter animated cartoon penis.

12 February 2010

Insurers behaving badly Part Two

Why This Matters: A Colorado Story
Via the Boulder Daily Camera: Jennifer Latham is a Colorado preschool teacher with four children, who suffered multiple, debilitating injuries when she was hit by a car in 2005. She spent two months in the hospital recovering, running up $185,000 in medical expenses. She was lucky to have health insurance.

Or so Latham thought. Shortly after coming home, the insurer, Time Insurance Co., told her that it was refusing to pay the bill and that it would be canceling her coverage outright. The reason? When applying for her insurance coverage, the insurer said, she'd failed to disclose two past medical incidents--an emergency room visit for shortness of breath and an episode of uterine prolapse. Not only did that leave her on the hook for $185,000; it also left her without insurance, since no private carrier would touch her after the injuries and cancellation.

Latham had the good sense to sue--and a Colorado jury had the good sense to side with her. Last week, it ordered Time Insurance Co., which also operates as Assurant Health, to pay her $37 million. Latham's lawyer had asked only for $7 to $8 million in damages. Apparently, the jury found the whole incident revolting.

I had heard about this. Assurant, I think, is the plan administrator for our health plan, which has a nasty habit of imposing financial penalties on our employees for non-emergency use of the ER.

Remember, by the way, that all of our employees are Board-certified Emergency Physicians. Apparently the judgment of the claims-editing computer software at Assurant, which uses the diagnosis code to decide which claims to pay and which to reject, is more reliable than the judgment of ER doctors about their families' health needs.

And remember, that if the health care bill dies, the above practice, of retroactive recissions, will remain legal.

Pass the damn bill.

Vancouver 2010

This is beautiful.   If you haven't visited Vancouver, you should.  It's a beautiful city, especially in the summer.  I'm also a sucker for time-lapse photography. I love the way the fog ebbs and flows and surges, just like water.  Very cool.

I'm kind of bummed that we are so close to the Winter Olympics and will not be able to go.  It's a simple matter of cost, kids, and the fact that I'd rather be skiing myself than watching someone else ski, even if that someone else *is* Bode Miller.  So we'll be in California skiing this week -- posting may be light. 

But next year, with the frenzy and the construction of the Olympics over, we will most definitely be looking at real estate in Whistler.  At least so I dream.  if nothing else, I'll get to do the men's downhill run, and that will be cool.  I'll pretend I'm Bode Miller.

Friday Flashback

Each word a hammer

Every ER has a "Quiet Room." Small, drab, windowless little rooms, with a couch and a couple of chairs, a phone and some tissues, all alike. Nothing good ever happens there.

I've walked into the quiet room hundreds of times. Eyes look up to meet me, full of apprehension and dread. Nobody is ever happy to see me. They are afraid of me, I think. They want very much to talk to me, but they are deathly afraid of what I will say.

"My name is Dr. Y. Are you David's wife?"

"Are you her father?"

"Is John your brother?"

"Are you Anne's husband?"

It's a weird conversation. I begin with pleasantries and very concrete small talk. They play along. Always. The stupid little social niceties frame the conversation and allow it to develop in a bizarre but comprehensible manner.

"Did you know your dad had heart problems?"

"You know the accident was pretty serious, right?"

"Was she awake when you saw her last?"

Start with a question. Either rhetorical or very concrete. Sometimes it prompts a long story, but usually the answers are pretty short and direct. But the question sets the stage. Sometimes a subtle shift in tense can presage what's coming. Deep breath.

"I wish I had good news for you."

"I think you know that he was pretty sick."

"Her breathing was pretty bad when she got here."

"You know the paramedics were doing CPR."

Then let it fly.

"I'm sorry to tell you that he died."

Each word a hammer.

"I'm sorry to tell you that she died."

With each hammer blow their faces crumple like so much tin.

"We were not able to restart his heart, and he died."

Each word a hammer.

"The paramedics did everything they could, but she died."

Weeping and wailing. Rage. Questions. Disbelief. Shouting. Quiet acceptance. Silent tears. It's never quite the same, after. I can talk a bit more, but it doesn't matter. They don't hear or remember anything I say from that point on. Perhaps a polite lie that the deceased did not suffer. Who knows? True or not, it seems to be good to hear. Offer more information. Ask some more questions, maybe. Then an awkward departure. That's tough. What do you say to end that particular conversation? "I've got paperwork to do"? "I've got to go take care of the living"? You show up, introduce yourself, devastate a total stranger with eight words, and leave. They tell me I'm pretty good at it. An artist with the hammer. I guess that's good, though a dubious distinction. Lord knows I've had enough practice.

So I promise to come back, I put my hammer back in my pocket, leave them amidst the wreckage of their lives, and move on.

Originally posted 14 May 2006

11 February 2010

The Return of the Bride of the SGR

Speaking of the collapse of the health care system...

The SGR patch is back on the docket!

You may remember that there is a 21% cut in physician reimbursement by medicare this year mandated by the SGR formula. (As an aside, I highly recommend this passionate post by Dr Rob about why he continues to accept Medicare patients despite the fact that it is bad business to do so.) You may also remember that Congress punted to the end of February (oddly enough) when they were unable to come to a solution prior to the end of 2009.

Word on the Street (Wall Street, that is) is that another annual SGR patch will be attached to the Senate jobs bill.

Interesting. Last I heard, the GOP was set to filibuster the jobs bill as part of their return-to-power-by-bringing-America-to-its-knees strategy of relentless obstruction. (Was that excessively cynical? Perhaps. But it's also true.) Will the inclusion of the SGR patch make it harder for republicans to filibuster the jobs bill? I confess that I'm not all that informed about its prospects, so I hesitate to predict.

Sometimes I almost wish that Congress would allow the SGR cuts to go through. It'd hurt my business immensely, but the firestorm that would ensue as private physicians dropped out of Medicare en masse might actually be a good thing in the long run, as an impetus for Congress to fix the physician reimbursement problem once and for all.

I'm getting sick of this Groundhog-day style repetitive drama.

Insurers behaving badly

I get lots of press releases and the like in my email. Much of it is off-topic for an EM blog, much of it is spam and link-trolling, and most of it gets deleted out of hand. But I was surprised to see an email from a PR flack with the email address of cms.hhs.gov. Really? I'm getting PR spam from Medicare and HHS now? My goodness, they are really scraping the bottom of the proverbial barrel, aren't they.

As it turned out, this was one of the few releases that was actually of some interest to me, regarding Wellpoint/Anthem's staggering 39% premium hike in California, and Secretary Sebelius' Sternly Worded Letter [tm] in response. And I see that Waxman has decided to haul the Wellpoint execs before the House healthcare committee for some public humiliation

Now, I'm not going to comment on the dems making a little political hay out of an insurer behaving badly, except to say "it's a bit late for that, innit?"

But the over-arching point here is important and should not be missed: the problems facing the crumbling US health care system will not be going away if or when Obamacare finally is taken off the respirator.

Jon Cohn has an informed and fair take on the situation for Wellpoint. To summarize, he suspects that this is due to the adverse selection death spiral of individual policies in a climate of declining enrollment (due to the recession) and rising costs. That actually makes sense to me, and he explains how insurers actually manage individual policies, which I previously didn't know. It's worth a read.

While the prices may have gone up by two-fifths in certain (less desirable) segments of the market, according to Cohn, costs overall for Wellpoint only (only!) went up 9% in 2009. You see the general trend of major insurers like Wellpoint and Aetna racking up huge increases on some policies, forcing others out of their systems altogether. You see overall health care costs continue to increase. You see the number of uninsured Americans increase to 52 million. The looming catastrophe in the system is not going to abate without intervention.

Many on the right, and many spooked moderates, will cheer if the health care reform bill does die. I hold out hope that it will be resurrected, but maybe it's a fool's hope. It's a pity that the opponents of the reform efforts have in many cases become so caught up in the imperfections of the bill or their ideological hang-ups about the mechanics of the bill or the insanely-divorced-from-reality rhetoric about the bill that they have managed to lose sight of this simple fact:

If there is no reform this year, we're not just back where we started, but actually continuing to lose ground as American health care collapses in on itself. We will get further and further behind the eight-ball the longer we let it go without intervention.

If health care dies, there political reality is that there will be no further attempts at comprehensive health care reform for another generation. And matters will get worse and worse as a result. Let's hope that the congressional democrats can see this clearly enough that they can break away from their mutual self-immolation pact and pass the damn bill.

10 February 2010

Bad at math

I've been on a run of good luck lately, and I thought to myself that I should capitalize on it and buy a lottery ticket.  Lotto's a pretty rare indulgence for me, maybe one or two tickets a year at most.   I've always joked about it as the tax on people who are bad at math.  (There's a bitter truth in there, by the way.)  But occasionally I do buy a ticket -- the one-dollar daydream about exactly which airplane I would buy if money was no object.  (An EADS Socata TBM 850, if you're curious.)

So when my wife was checking out the results of the local school levy vote, I noticed a banner ad for our state's lottery, and clicked through for no particular reason.  What I saw took me aback: the breakdown of the actual odds of winning.


I already knew the lotto was a sucker's game, but I had no clue that it was that bad.  40:1 of winning?  Yikes.  Just for reference, slot machines in Vegas will pay out 98 cents on the dollar over the long run, and the roulette table pays out 95 cents on the dollar.  The lotto pays out 2.5 cents on the dollar if I'm doing my mental statistics right.

So, I admit, I'll still buy my one-dollar daydream the next time I'm at the grocery store, and I'll feel all the more foolish about it now that I know exactly how terrible the odds are.  But then I think about the poor lower-income/lower education souls who are pooling their money and buying $20 worth of tickets a week.  That's real retirement money they're spending on their daydreams, and it's our own government that's bilking them out of it.  At least when I go to Vegas I have a fun time and free booze. 

Update: Eric the Pragmatic Caregiver says it's better than 1:40 payout.  I don't really know what the definition of paramutual wagering is and am too lazy to Google it.  But he says the payout for lotto is more typically 50-60 cents on the dollar.  I'll assume he knows what he's talking about because I sure don't.

08 February 2010

You can't win 'em all

Seems like I've been on a real run of chest pain patients lately.  Which is fine -- it's part of the gig.  I did have a very interesting pair the other night.  They were seen in sequence, right next to one another, in room 7 and room 8.  They were both totally healthy woman in their mid-fifties.  And they were both over-the-edge, crazy, crawling-out-of-the-gurney anxious.

Anxiety is an awful red herring in the work-up of chest pain.  People who are having an anxiety attack often if not always manifest some chest pain (pressure, tightness, whatever) as a prominent symptom of their anxiety.  On the other hand, someone having a heart attack who is experiencing chest pain will also be anxious -- and for good reason!  I probably see ten patients with simple anxiety for every one patient I see with "real" chest pain, so just by probabilities and pattern recognition an ER doc might easily dismiss the anxiety cases, just blow them off.  Which would be a real mistake, since when you blow off these cases you absolutely will miss things.

So you have to pick and choose what you will work up and how far you will chase the zebras.  Most of this you are going to do by Bayesian analysis: looking at the patient's age and general state of health, incorporating some basic data like ECG, blood tests, and how well the patient's history fits with classic patterns of disease.  So the 25-year old who is hyperventilating and hysterical because her boyfriend was hitting on another girl probably will get minimal work-up, whereas the septuagenarian with a history of diabetes who has an elephant standing on his chest is a slam-dunk admit.   Those are the easy cases -- the extremes of probability.  We joke that it's the cases in the middle that are why we get paid the big bucks.

These two cases were real doozies as far as figuring out what to do with them.  The first patient was, as I mentioned, about 55 and completely healthy.  She had this sharp pain that had been migrating all over her chest for several days.  It was not exertional, nor was it associated with shortness of breath, fever, cough, etc.  She sometimes felt it between her shoulder blades, and sometimes it was worse with a deep breath or movement.  it was a very fleeting pain, and clearly seemed related to some situational stresses she was having at work.  ECG, labs and chest x-ray were completely normal, as was her exam.  The pain in the back did catch my attention: that can be a historical element associated with Aortic Dissections, a vascular catastrophe in which the aorta basically tears itself apart.  So I did a CT scan on her to evaluate the aorta, which was normal.  After a standard cardiac observation was completed, she went home with some xanax.

The second patient was even stranger in her presentation.  Her complaint was listed on the triage note as "chest pain" but she started telling me about this tooth that had been bothering her, and she had bitten down on something and it had gotten much worse.  The tooth pain was radiating over the top of her head and also down her neck into her shoulder and back.  She was so anxious that she could barely get out a coherent sentence and she would hyperventilate herself into vomiting.  She complained that after vomiting she felt a burning pain in her mid-chest, which was why she was billed as "chest pain."  It sounded pretty clearly esophageal.  As I took in this history, I wondered whether I should even work this up at all as chest pain, but the ECG and troponin had already been done (from triage) so I decided to roll with it.  She also had a normal exam, and felt much better after some ativan.

She slept through most of the night shift after that.  I would rouse her from time to time, and other than a deep conviction that she had something terribly wrong, she actually seemed to feel much better.  Never complained of any more pain.  I considered scanning her, but mindful of the one "wasted" un-indicated CT I had just done on room 7, I was feeling a little gun-shy.  I hate to shotgun tests, and this one seemed even less useful than the previous.  Eventually, I figured that "you just cannot scan everybody," and I put her in for the cardiac observation and discharge protocol, like the other woman.

By now, you probably can see where this is going. The next morning, when the patient's observation period was done and she was set for discharge, she still didn't feel right.  Fortunately, an alert nurse spoke up and asked the new doctor on shift to re-evaluate the patient.  He did, and really didn't see anything much different, but out of a general sense of "I should probably do something," he ordered a CT scan.

And it showed:

Yes, she had a Type A aortic dissection.  Quite lethal when not treated.  My partner reported that when he got the call from the radiologist, he got all sweaty and weak in the knees, it was so unexpected.  Fortunately, the diagnosis was made and she went to the operating room for repair.

I've reviewed this case with our medical director, and his words were, "If I had taken care of this patient, she would be dead, because I doubt I would have even kept her for observation."  I don't feel that it was a "miss" so much as a "Damn!  Who'd've thunk it!"  But still, the irony is maddening that I had two weird, anxious ladies and I picked the wrong one to scan.  Crap.

There are a number of good learning points to take from this "near miss," however.

1.  Listen to the nurses.  In my opinion, the hero of this story is Kathy, whose gut told her something was wrong and she brought it back to the doc.  Woe unto the physician who blows off a nurse in this context.  Whether or not you miss this case, if you disregard their advice, it's all the less likely that he or she will be willing to stick their neck out and ask for a re-evaluation in the future.  Nurses are so much closer to the patients that their input will save your ass if you're smart enough to listen.

2.  Beware sign-outs.  Most ER docs are reluctant to get involved with a patient dispositioned by a previous doc.  I get it -- who wants to re-open Pandora's box? But like it or not, they are your responsibility, and sometimes a fresh pair of eyes/ears are all that is needed to unlock the puzzle. 

3.  Keep an open mind.  In this case, I admit that I was a little annoyed at this patient for her strange behavior, and just for the injustice of the universe at subjecting me to this sort of thing, and that bias would have made it difficult to really re-evaluate her with an open mind.  I hope I could have, but I'll never know in this case.  My partner was able to do so, and that made the difference between getting the diagnosis and missing it.

4.  Dissections are strange beasts.  I've seen several now, and none of them had the classic presentation.  I've learned to respect the isolated neck/back pain, and, on reflection, the incredible anxiety tone of almost every dissection I have seen is a remarkably consistent feature.  Having a high index of suspicion is essential.

5.  D-dimers are useful to screen for dissections.  I did not originally order a d-dimer on this patient, but it was positive in retrospect.  It appears that the majority of cases of dissections do have a positive d-dimer, which makes sense when you think about the physiology of the study.  While the correlation does not seem to be strong enough to use d-dimer solely as a test to exclude dissection, it does appear to be useful as part of a rational strategy to determine which patients you might choose for further investigation.

07 February 2010

Our National Holiday

The best Super Bowl commercial you will see this year:

I will be rooting for the Saints in return for the national service they have done by ending Brett Favre's season.

However, I am predicting a 10+ point for the Colts.  Prove me wrong, guys!

05 February 2010

Friday Flashback

Listen to your Gut (literally)
"Doctor, we need you in Room 15, right now!"

The call came from an experienced ER nurse and I knew better than to hesitate. It was near the end of my shift, but I put down the matter I was handling and hurried over to see the new patient. As I walked in the room, I could see that it was Something Bad [tm]. The patient was supine and rather grey-looking. The red numbers on the automatic blood pressure monitor read 54/30.

That's low. Really low. Low enough that you shouldn't be conscious, but as long as she laid flat, she said she felt OK.

It was an odd presentation. She really had no complaints -- just felt faint when she sat up. She had felt perfectly fine till a couple of hours ago -- no chest pain or fevers or trouble breathing or anything. Except maybe, she conceded, some mild abdominal pain, and maybe had diarrhea once. The list of Bad Things [tm] in the abdomen started subliminally cycling through my head as I pushed on her belly -- ruptured Aorta, dead gut, perforated bowel, etc -- but her belly was soft and essentially non-tender, which would *not* be the case with a perforation. A quick look at her Aorta with the ultrasound was normal. I felt like there was something I was missing, but I was side-tracked by the *huge* peaked T-Waves on the ECG the nurse handed me.

Peaked T-Waves are a sign of a very high blood potassium level, an imminently life-threatening condition. So at this point I stopped thinking and leaped into full-on ER doc mode. Two IVs. Lots of IV fluids. Insulin and calcium to lower the potassium. Antibiotics . . . just on general principles. Full lab panels -- she's in renal failure, which explains the potassium, though not the low blood pressure. Dopamine for the blood pressure. Get a ICU bed for her and call the ICU doc. 

"Whatcha got?" she asked as she strolls in.
"I'm not sure, but it's bad. A 77 year old female with unexplained shock, I presume septic, acidotic with pH 7.05, new onset acute renal failure. She looks better on pressors but I still don't understand the primary cause. She had some abdominal pain but it's pretty mild. Otherwise, she has no symptoms at all."
"Righty-ho," says she, "Send her up when the bed is ready and we'll sort her out. If you can, call nephrology and get her set up for urgent dialysis, will you?"
"No troubles."

So I start back to work on my other patients, pleased that I have stabilized and dispositioned an incredibly sick person in such a short time. It took maybe an hour, probably less. I look at my list of patients for the day - 21 in 8 hours. Damn, I'm really hitting my stride. Given that almost half of them were admits, and three to the unit, I feel pretty good about the efficiency there. I may even get to go home within an hour of the end of my shift.

But I'm bothered. I still don't really have a diagnosis on this last lady. Ordinarily, that wouldn't bother me. I like to say: "The goal of the ER doctor is to keep the patient alive long enough for them to become someone else's problem." And that is just what I have done. Mission accomplished, and I can go home, right? But there's something I'm missing here. I can't put my finger on it, and it's bugging me. 

Then the nurse comes to me and tells me that the patient just passed some stool, and it was bloody. Eureka! I literally smacked my forehead with my hand. She has dead gut, which is to say that a segment of her small bowel has lost its blood supply (most likely a blood clot) and has died. That would completely explain the sepsis, acidosis, and renal failure. A quick call to the surgeon -- patient to CT scan, and off to the OR for exploratory laparotomy. Her odds are poor -- dead bowel is a Very Bad Thing Indeed. But had I let a couple of hours go by till the busy ICU doc got to see her and figure it out, the odds of survival would have been fast approaching zero. 

I now realize the thing that was bothering me was that I *knew* all along that it was dead gut -- it was the second thing I thought of -- but I had gotten so distracted by the other stuff that I had just lost track of it. All it took was one random piece of data from the nurse to trigger that connection and it came up from my subconscious to the front of the brain. I'm glad it did. And I walked out of the ER exactly one hour after the end of the shift.

Originally posted 26 August 2006

04 February 2010

The Mountain's Out

After weeks of steady rain/drizzle and rare if any glimpses of blue sky, it's always a shocking thing to drop the kids off at school on a clear morning and see Mt Rainier towering over the southern horizon.  It gives me a visceral jolt, like, "Hey where the heck did that massive thing come from?  Has it always been there and did I never notice it?  Or did it just sprout up like a spring flower?"

By the summer, which is quite clear in this state, I've gotten used to its presence again.  But the incessant grey of winter makes me forget that it exists.

Listen to the patient

Sometimes in this job you just get lucky.  You have an elusive and/or dangerous diagnosis just dropped in your lap.  Something devastating that you would never have been able to tease out otherwise just gets handed to you by the patient.  There's a catch, though: you have to be smart enough to know when to listen to the patient, when not to blow off their crazy talk as just crazy.

So it was recently when I saw a guy with back pain.  From the chart, it didn't sound like anything complex: a middle-aged to older guy, maybe 60 or so, with a history of chronic back pain and multiple surgeries for the same.  He was on Oxycontin 80 mg three times daily (a very high dose, and a red flag for an ER doc naturally suspicious of drug-seeking behavior).  I went to see him, and it was clear in seconds that this dude was JPN: Just Plain Nuts.

He was a real character, in a good way.  He was one of those old Vietnam vets with the leather vests and long graying hair.  His wizened face bespoke many years of cigarette smoke, and his crazy eyes hinted at a long history of illegal substances.  Of course, he had no veins left from years of IV drug use, but he told me he was "too old for that shit any more," and I believed him.  He was a dedicated biker, and had not let the loss of his right leg in a motorcycle accident dampen his enthusiasm for the hobby.  He had a method, he told me, of using his prosthetic to operate the rear brake, while relying primarily on the front brake, since the poor sensitivity in the right led to overbraking and rear-wheel skids. 

It was such a mishap which had led him to lay down his Harley a couple of months before, and the road rash on his hip had developed a MRSA abscess before eventually responding to antibiotics.

This is all stuff I got from him after the fact, though.  Initially, he was in so much pain that he could barely give me any history at all.  Writhing on the gurney as much as possible without jostling his back, he was all-but-nonverbal.  He gasped, in a gravelly but intense voice, "Doc, I just know, I just know that I've got an infection in my back.  I can feel it!  It's there!"  With great effort, he sat up and stared at me with an insane expression that I remember from Hulk Hogan's glory days, lids fully retracted and teeth bared in a rictus of pain, "I can feel the infection in my eyes!  Behind my eyes!  It's fire and pressure and it's pure poison!  I just know it!"  And with that he collapsed back onto the gurney, mute, into his own private and rather unpleasant little world.

I couldn't examine him for anything.  His whole back hurt -- heck, he hurt everywhere.  Forget a neuro exam.  After about five minutes I gave up the whole effort as futile.

I mused on the "infection" thing, though.  What the hell.  Osteo?  Diskitis?  Epidural?  How would he know if he had an infection there?  No fever.  Abscess -- risk factor -- so not exactly implausible.  Did I have any evidence for it?  Not a shred.  Anything to suggest that this was just chronic pain?  Nothing but his two dozen ER visits for chronic back pain.  For some reason, I decided, "Fuck it.  I'm just going to get an MRI on his back."

This is highly unusual for me.  In our group of 40+ docs, I am the lowest utilizer of diagnostic imaging services.  Generally, I have to have a high level of concern to get an MRI from the ER (though they are far more common than they used to be).  Yeah, I also ordered the other stuff -- you know, the stuff Vijay wants before he'll authorize the MRI -- a white count, CRP, Sed rate, etc.  But it was 8AM and the radiologist must have been undercaffeinated, because he just said OK without asking any questions.

He was over at radiology as the labs started to come back: sed rate>100, CRP>200, WBC 24,000.  Wow. That all looks bad.  Glad I decided to scan him.  The MRI?  You guessed it:
Well fuck me sideways and call me a donkey, but there's the epidural abscess, just like he said it would be.  How the hell did he know?  I mean, really, how did he know?!?  Because he told me the diagnosis from the moment I saw him. 

My Irish mom used to always say that God looks after children, fools and drunks.  I don't know that this was divine intercession per se, but I consider the unlikely sequence of events: an unreliable patient asserts he has an unlikely disease, I, without supporting evidence, order the difficult-to-obtain test, the radiologist fails to erect a roadblock to the test, and against all probability, the patient has exactly what he said he did. With early surgical intervention he avoids permanent paralysis. If I hadn't listened to him...

There for the grace of God go I.

03 February 2010

Not dead yet

Been pretty quiet here lately.  I've been working clinically quite a lot, and have some cool things going on in my professional life that I just can't blog about -- more's the pity.  It's funny, with several years of blogging under my belt, when something interesting happens, my automatic instinct is to post about it.  I've just gotten used to living my life in a very public fashion.  But it's not a great way to run a business -- there are lots of things that simply have to be kept confidential.  So I compartmentalize it, but I still can't stop writing the hypothetical blog post in my mind and thinking how cool it would be.

Yeah, I'm a terrible tease.  Sorry.

I've got a few posts ready to come out over the next few days if I have time to put them in decent shape, but till then I'll content myself with linking to an interesting commentary via GruntDoc:

GruntDoc  We’re Failing Our Residents: Training ED Docs for the Real World
Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day.

Right on.  I used to joke, after doing a residency at Hopkins where there were no fewer than three separate ENT services on call every day, that it was a huge culture shock coming to a community hospital, even a relatively busy one.  When I was frustrated I would loudly exclaim "Whaddya mean there's no oculoplastics in-house on-call?" in a joking tone, or I would muse "So how long have you people had electricity anyways?"

But I think this article slightly misses the point.  After three years of critical care training and trauma care, after working with specialists shoulder-to-shoulder every day, that stuff is actually not too hard.  You do a few peritonsillar abscesses with the ENT resident, you do a million trauma resuscitations with the surgeons, and you can replicate their thinking and decision-making with reasonable quality.  When I got out of training I was pretty comfortable calling up a surgical consultant and telling them what needed to be done (or at least giving them enough information to formulate a plan). 

It was the little stuff, the low-acuity stuff that was the real head-scratcher.  I still remember the first time I saw hand-foot-mouth disease.  Kinda embarrassing, now, the work-up and effort I put into what is today a doorway diagnosis.  The mandibular dislocation.  The lacerations in odd places.  Foley catheter trouble-shooting.  The rashes.  The weepy umbilicus stump.  A lot of primary care-type issues.  All of this was stuff that I just had to figure out on my own, jury-rig it with duct tape and baling wire and hope to hell that I had gotten it right.  And now that I'm one of the more senior docs, I see my new graduate colleagues struggling with the same things.  Fortunately, I can be a resource to them and show them the tips and tricks that I discovered, just as my senior partners were for me.

I don't think I'd say we're failing our residents, though.  This stuff is not too hard to figure out, and the breadth of the problems that you will see in an ER is so huge that it's just not possible to see everything in a three-year residency, much of which is spent on off-service rotations.  It's certainly more important that our grads be able to do the critical care and procedures to a very high standard of quality from day one after graduation, and this in fact has been my experience.  The folks we have hired universally have been comfortable managing the really sick patients, and I think that's the important thing given the limitations of training and the need to prioritize topics.

The source article does make another criticism of ER residency training that I have been harping on for years:
 We're Failing Our Residents...
Residency programs train physicians in some of the most inefficient EDs in the land. Relative value units of emergency medicine work per hour in the teaching hospital setting is typically half that seen in private practice. And residents train in a culture where customer service is an unaffordable luxury amid the chaos of the typical academic ED. ... These safety net patients have nowhere else to go and so will tolerate greater waits and delays without leaving. On the other hand, community hospital patients are more likely to be adequately insured, and have higher service quality expectations. [...]

We continue to graduate physicians with no proper training in health care management and few of the leadership skills necessary for working in a health system that is increasingly organized around team care and team management. ... [T]he academic emergency medicine anti-business bias should be replaced with the realization that no emergency medicine practice can survive or prosper without sound business leadership and management skills. These abilities are not typically necessary in the world of academic emergency medicine, but they are imperative in the rest of the practice world.
This is a predictable consequence of the RRC core curriculum requirements and the incredible emphasis placed on the inservice exam scores.  The residency directors teach to the test.  Billing, management, healthcare economics, and ED operations are not on the test, so they're not in the curriculum that residents are exposed to.  It's a rational choice, if youa re a residency director. If you have an open lecture slot, you can have someone come talk about difficult toxicology cases or billing stuff, you for the tox, no question.  (Plus, many academic docs have never worked outside academics and so they have no experience in billing/management/ED operations, so they can't informally teach residents in the ER.)  The consequence is that ER docs graduate naive and vulnerable to exploitation by their employers, unprepared to succeed in their new job, and left to figure it out along the way or not.

To their credit, some residencies have recognized this deficiency and have made small steps to remedy it, but it's generally inadequate.  Still, credit where it's due.

It's also telling that this criticism of ER residency training, coauthored by several respected and accomplished leaders in the field, was published not in ACEP's Annals of Emergency Medicine, nor in Academic Emergency Medicine, but in the trade publication, Emergency Medicine News.  I have to wonder whether this was a deliberate choice on the part of the authors, or if the "respectable" journals shied away from such a topic.