28 June 2010

ACEP going off the rails

I don't know what is going on with ACEP lately, but it's disheartening. Their abdication of responsibility and engagement during the health care reform debate was depressing. Then there was a rigged poll designed to elicit a predetermined result.  Now I see a bizarre op-ed piece in USA Today authored by ACEP President Angela Gardener:
Opposing view on drug addiction: Don't make us 'pain police'
The patient-physician relationship is sacrosanct, demanding candor and trust. In the emergency department, trust is built in nanoseconds because patients and doctors do not have prior relationships. Knowing that any pain prescription will be entered into a large, public database might prevent patients from being truthful, or in the worst case, from seeking needed care. ... As an emergency physician, I can assure you that the drug abusers who use the emergency room simply to get a prescription drug fix represent a micropopulation of the 120 million patients who seek emergency care every year in the USA. ... Put bluntly, if legislators have money to spend, they should spend it where it will do the most good for our patients, and that is not on drug databases.
I really don't know what to say, other than to wonder whether Dr Gardner and I practice in the same United States in which abuse of prescription drugs is growing exponentially and in which "drug-seeking" patients are a part of each and every shift worked in the ER, where deaths due to overdoses of prescription medications are on the rise, and where diversion of narcotics is a serious and growing problem.

Dr Gardner is correct when she writes that drug-seekers are a "micropopulation" of ER patients.  But that is a meaningless measure of the problem.  Acute myocardial infarctions are also a "micropopulation," as are hip fractures, asthmatics, and most every other complaint you choose to split out from the nation's ER census. (Indeed, in many ERs, low back pain is the #1 discharge diagnosis.) To minimize the problem, to dismiss it as a "micropopulation" is to willfully turn a blind eye to the disease and its human cost.

And make no mistake: addiction to prescription medication ruins lives, and kills people.  I vividly remember the tragic case of Debra. A combat veteran, she had been thrown out of the Navy after acquiring a chronic painful condition which had been poorly managed, leading to dependence on opiates and sedatives. Dependence turned into addiction and I saw her numerous times over a two year period.  In some cases she was looking for refills, in some she complained of pain exacerbations, and in some she was unresponsive after overdoses.  It was a real challenge figuring out who was supplying her with meds (she had dozens of doctors) and in the end she was reduced to taking veterinary sedatives ordered from Mexico. I spent a lot of time trying to get her into treatment, without success.  One day I saw her name on the list of patients to be seen. I sighed and went into the room and was shocked: it was the same patient, but a very different person. She had a tracheostomy tube and was on a ventilator; there was a tube in her stomach for nutrition, and one in her bladder for elimination. Her mother, with a sad look, sat by her bedside. (No family members had ever accompanied her to the ER before.) She explained that a couple of months prior, Debra had overdosed again, but this time she had stopped breathing and had suffered an anoxic brain injury, leaving her in a permanent vegetative state.

I am sure that Dr Gardner knows this, but it bears emphasis: drug addiction kills. 

We ER docs are on the front lines of this as so many other social challenges. We need all the tools that are available to combat these problems. I agree that it would be onerous to be required to check a database every time I wrote for a controlled substance. That should be changed. But if it is possible to compile the data, give it to us and let us use it as needed when we have concerns.

Because trust needs to be established between the doctor and patient, and in some cases the maxim, "trust, but verify" is appropriate.  If I have concerns that a patient is not being honest with me, if I have concerns that their story doesn't sound quite right, information is an important tool to open up the discussion and maybe prevent further tragedies, or at least reduce the role of the ER physician as an unwitting enabler of ongoing drug abuse.

It's depressing to see the leaders of our specialty opposing such common-sense measures to improve patient  safety and enhance our ability to deliver appropriate care.

26 June 2010

No story, just some pictures

No trouble with this diagnosis: perforated peptic ulcer. Most awesome physical exam ever. I wondered if he was faking it, since he had a history of chronic abdominal pain, but the fever and tachycardia convinced me it was real.

Enjoy these impressive images.  Even the scout image was awesome:


This a lateral view of the abdomen, and check out those air-fluid levels!  In case you are not familiar with these films, what you are seeing is the fluid in the abdomen (which should not be there) layering out with the exceptional amount of free air inside the abdomen which most definitely should not be there.  It may be easier to see if you turn the image on the side:

pneumoper annot

And on the CT itself, you can see the incredible amount of air in the abdomen. Man, that is impressive.  I wonder whether it was under tension and hissed audibly as it came out.


The mortality for this sort of thing is incredibly high. Last time I checked, he was doing well in the ICU.  Some people have nine lives...

25 June 2010

Rand Paul, self-certified physician

I had meant to write about this, but Bob Wachter got there before I did, and, let's be honest, does a much better job than I could have.  For those not following the drama, Rand Paul, MD, son of nutjob libertarian Congressman Ron Paul is running for (and likely to win) the US Senate seat in Kentucky.  He's gone the full Palin in not speaking to the media after he stumbled by suggesting that he would have opposed the Civil Rights Act.  But one tidbit I had noticed but has received little media attention is this:

Enter into this arcane but important debate one Dr. Rand Paul, libertarian, Tea Party heartthrob, son of presidential candidate Ron Paul, and (gulp) perhaps the future U.S. Senator from Kentucky. Paul, an ophthalmologist, has long claimed that he is board certified.

But it turns out that the American Board of Ophthalmology (ABO), the official ABMS board for the field, hasn’t heard from Dr. Paul since 2005, which was when his initial certification lapsed. As the Louisville Courier-Journal reported this week, Dr. Paul is now certified by an organization called the National Board of Ophthalmology (NBO).

Which is convenient, since when the NBO incorporated in 1999, the documents list one Rand Paul as both its founding president and director. The NBO went out of business in 2000, but Paul resurrected it in 2005, just in time to revive his lapsed board certification. In contrast to the ABO, which has a staff of 11 in its Philadelphia office, the NBO’s address is a UPS box in Bowling Green. Rented by, well, you know.

Yeah.  Convenient.  Whatever you think of Paul's politics, this is a pretty concerning matter from a point of view of professional integrity. Dr Paul claims some some bogus "protest" over some policy of the ABO, but it doesn't change the fact that Paul just invented a board certification out of whole cloth and essentially lied about his certification status to his patients and hospital affiliates. I'm on record as opposing back-door "alternate" Board Certifications like the AAPS, but they at least pass the sniff test -- there is an external standard, an exam, and the AAPS was not created by one individual for the sole purpose of certifying said individual.  I actually wonder whether it might rise to the level of criminal fraud: I know nothing about the law in KY, but I believe some states have statutes which criminalize misrepresenting one's professional credentials.  My experience with our state's medical quality assurance board also makes me wonder whether the KY medical board would approve of this sort of chicanery.

Ultimately, it will be up to the voters of Kentucky to decide if Dr Paul is the sort of person they want representing them in the Senate.  It's dishearening that the media may not have adequately informed them of this issue, but I can hope that come November the choose wisely and reject him.

Friday Flashback - Advice for Interns Part Four

Yesterday, I tried to give some tips on efficiency in the ER using generalities and philosophic concepts. Sometimes it helps to be a little more concrete, both in terms of the chronology and the mechanics of the patient interaction. This is how I try to function, and how I advise our new hires:

BEFORE you see a new patient
  • Make mental rounds on your current service
  • Dispo any patient who is ready before picking up a new patient
  • Skim the chart rack and pre-order obviously needed studies on waiting patients; medicate patients in pain
  • Order rooms set-up in advance for laceration repair or pelvic exam
  • 30 seconds with the old records is worth 10 minutes with the patient
WHILE you see the patient
  • Keep your history “On Track”
  • Document in real time at the bedside
  • Determine the patient’s “agenda” and address it expressly (especially if narcotics are a point of contention)
  • Determine a treatment plan and disposition and TELL THEM before you leave the room
IMMEDIATELY AFTER you see the patient
  • Know your decision tree
  • Determine the rate-limiting step and make it priority #1 in the work-up
  • Order the bed for obvious admissions
  • Tell the nurse what you are going to do
  • Start therapy early – a medicated patient is a cooperative patient
  • Order all tests in parallel and not serial manner
  • Utilize Point of Care Testing when available
  • Utilize evidence-based standards for ordering tests
  • Minimize screening tests
  • Defer necessary but non-urgent work to another setting
  • Staged therapy – write orders for progressive medications based on defined criteria. Involve the nurses in the plan and encourage them to take initiative in managing the therapy.
  • Set triggers – in the orders set a trigger where someone will notify you when a decision point has been reached
  • Delegate: RNs may titrate meds; techs can irrigate, dress, and splint; Physician Assistants can suture.
  • Anticipate obstacles for discharge – road test the patient early, call NH or family to ensure the patient can go back, etc.
  • Minimize unnecessary consults or those without an action plan attached
  • Avoid the “I want to run this by you” conversation – know what you want the person to do before you pick up the phone, and begin the conversation with “The reason I am calling you is that I need you to do X…”
  • Don’t play ping-pong – know who you want to do the admit, and if they balk, ask them to call the other service to negotiate the admission.
  • Make sure the patient’s agenda has been addressed
  • Address the 3 Golden Needs: They feel better; They are reassured; They know the next step.
  • Discharge them yourself if possible (Nurses will love you!)
  • Redirect Office consults to direct admits when possible
  • Lower threshold to admit patients with expected prolonged work-ups or ED therapy
  • Admit earlier; write admit orders immediately to ensure the patient goes up immediately
  • Make a strong sales pitch to hospitalist, intensivist, and specialist colleagues: get the admitted patients to the floor ASAP
  • Look at the schedule and talk to the next-leaving doc to determine whether they need to stay late, or call in an extra body early
My $0.02. Again, this is not all original material (the bit about the 3 Golden Needs I vaguely recall from an ACEP lecture) so I cannot take full credit.

Originally Published 22 June 2007

24 June 2010

What GruntDoc said

I meant to write about this, but GD said it for me:

Emergency Medicine Excellence Award™

HealthGrades Identifies Hospitals Among the Top 5% for Emergency Medicine

HealthGrades is proud to announce that the first annual analysis of hospital emergency medicine programs found that the best-performing hospitals consistently outperformed all other hospitals for all eleven cohorts studied.

via Emergency Medicine Excellence Award™.

Neat, especially as Giant Community Hospital, where I humbly serve in the ED, is on the list.  As we got the award, I will not question, or even investigate, the methodology…

Nice to be noticed.


The only distinctions I would offer are that:
a) I serve but not humbly.  "Humble" just isn't in my repertoire.
b) Our Giant Community Hospital was the only one on our state to be recognized. Which is a huge thing considered there are some well-known downtown institutions which are rolling in cash who apparently don't perform as well as their low-rent suburban neighbors, though they still seem to have awfully high opinions of themselves.  Yeah, it may be meaningless, the methodology may be bogus, but I'm sure going to relish it.

The Impact of the SGR

A commenter in a previous post asked how much money I personally have lost due to the SGR fiasco.  I was initially kind of taken aback by the question.  At first I thought he was trying to discredit my policy positions by implying that since I have a vested personal interest in the matter I am not to be trusted.  Well, it's true -- I do have a direct financial stake. Full disclosure on that point, I guess.  For what it's worth.  I'm sure the reader was just wondering, though.

To be technical, as yet, I have lost nothing, because we pay ourselves based on revenue already booked, and the impact of any cuts won't be felt until three months or so down the road.  And also, nobody expects the cuts to stick.

But it's an interesting question, and I thought it was worth exploring what would happen to us if the cuts were to be enacted.  Here's what I found out.

We average about 1,900 medicare patients per month, in our practice which sees about 125,000 patients annually.  So Medicare is about 19% of our payer mix.  The typical Medicare patient codes somewhere between a level four and five, with the average bill being 4.3ish RVUs, with the net result being that we bill about 8,600 RVUs to medicare every month. Medicare pays about $36 per RVU under the 2009 standard, so our monthly expected revenue is about $310,000. Under the new, lower, conversion factor, the revenue will be about 20% lower, so call it a $65,000 loss every month.  Our practice would lose about $800,000 for the year if the cuts went through and stayed.

One of the consequences of being an owner/partner in a practice is that there are fixed overhead costs, and that the only variable cost is physician income.  So if the revenue floats up -- or down -- that directly impacts take-home pay.  We have about 40 doctors, so the average doc seeing 2.5% of the patients will take 2.5% of the lost income.  Meaning that for me, so far, my share of the loss would be (drumroll please) $1600 per month, or $20,000 annually.

Would that suck?  You bet.  Do ER docs deserve a lot of sympathy?  Maybe not -- we are paid reasonably well overall, and being hospital based we have no option to suck it up and try to recoup it from commercial payers by demanding higher compensation for privately insured patients (yes, Ezra, it does work that way).  But the plight of ER docs is not why the SGR catastrophe is catastrophic.  We can't refuse patients based on their insurance. But office-based physicians can, and do.  It's not that primary care docs are opting out of Medicare in meaningful numbers -- they aren't.  But what they are doing is simply refusing to see new medicare patients, turning them away at the door. (To be more precise, what practices generally do is limit their number of medicare patients to a certain fraction of the overall census, and refuse to enroll new Medicare patients until a spot "opens up.")

And the relative impact is much worse for office-based physicians; our overhead is low.  For an ER group the amount of revenue which goes to practice management can run 10-30% (depending on how lean the practice is run and what they count as overhead).  For clinic-based docs who have to pay rent, buy supplies, pay wages and benefits for staff, etc etc etc, the impact is much more substantial.

To put it more formally: consider an ER practice which runs 25% overhead, leaving 75% of revenue for physician compensation.  There is a 10% drop in revenue; this results in a 13.3% drop in take-home pay for the doctors.  Bummer, but tolerable. Now consider an office-based practice which has 70% overhead. The same 10% drop in revenue results in a 33.3% cut in physician income.  How do you think the typical doctor will react to that?

I should be clear: I have no clue what the typical expense ratio is for an office based physician. 70% is what I heard once as the upper end, so I used that to illustrate the point. The point is that if the SGR cuts go through, the impact will fall disproportionately on the already-strained primary care network.  This will predictably worsen the crisis Medicare patients experience with limited access to care, as PCPs further close their practices to money-losing Medicare patients.

23 June 2010

Focused vs Thorough

I get emails, and one which caught my interest was this recent one from loyal reader Nurse J (lightly edited):

"Do you assess everybody that comes into your ER for everything, or do you just assess the complaint?

I am a newish critical care nurse at A Great Big Hospital, and my wife is a sixth year ICU nurse at a Smaller Hospital. They reviewed a case of an older female who presented with and complained of "flu-like" symptoms. She got treated for said complaint, then also casually mentioned some chest pain......and you know the rest. Stat EKG, ST elevation, elevated cardiac enzymes, and on the way to A Great Big Hospital we go. Only now her door-to-cath lab time was shot.

So, do you only assess to the complaint in the ER? Is that the ER standard? As an ICU nurse, I look at every square inch of my patient at least once or twice a shift, and of course, different patients also require different focused assessments. I loved my rotations in the er, but many times, if the patient seemed stable, I would see nurses not even assess each patient. If you (ER peeps) do have a policy or guideline about only assessing to the chief complaint, then that makes sense. Unless someone is Bleeding, Pulsatingly Bleeding, or has a case of Extra Holes, you don't really need to rush in, the doc will be in in just a minute."
The first thing I would like to draw attention to is the wonderful invention of "Extra Holes" syndrome -- I will be stealing that lovely phrase in the future, I promise you.

As to the general question, the answer is "it depends." We very much tailor the level of the assessment to the patient's complaint and comorbidity. Being an ICU nurse is a very different thing from being an ER provider. (For general discussion, the docs and nurses take similar approaches to assessments in the ER.) When you are working in the ICU you are taking care of a population that is pre-screened to include the sickest and most complex patients that come though the doors, so being compulsive and thorough is essential. It's not surprising that providers habituated to that environment might adopt the position that a comprehensive assessment is the only adequate way to practice: anything else can lead to suboptimal outcomes like the one cited above.

The challenge facing generalists like ER docs and nurses is that we see the unscreened population. We are the first filter. This is where the art of medicine starts to come into play.
It's pretty apparent, of course, that a diabetic presenting with abdominal pain is going to need a detailed and fairly thorough evaluation: there's high risk of a wide variety of Badness and casting a wide net is essential so as not to miss things. On the other hand, it's also obvious that a healthy patient with an ankle sprain needs very little beyond a focused exam of the extremity and a set of vital signs. In fact, when I work fast track, it's common for me to see, treat, and discharge patients before the nurse can even get in the room!

The tweener cases are the ones where we really earn our keep. Consider a common ER presentation: low back pain. 99% of low back pain that we see is trivial -- orthopedic injuries, chronic pain, occasional sciatica. This needs little to no nursing assessment, by and large. I would not criticize a nurse who did not do a comprehensive assessment on such a patient (especially if they were in fast track where I'm in the room first!). But just this month I have had one caudal equina case and one kidney stone presenting as sciatica, and one of my partners had an aortic aneurysm presenting as low back pain. And you need to filter those cases out from the masses of benign presentations: you can't CT scan everybody.

One strategy we use is that of layered evaluations. The first point of contact for a patient is triage, and the triage RN does the first assessment to get a sense of sick-or-not-sick, and risk factors for Badness. Then there is the primary nurse who does a more detailed assessment, then the doctor. At any time there is a possibility the person doing the assessment will redirect the care flow. The chest pain sent back to the cardiac area of the ER might be seen by me and I may cancel all the labs because it's clearly just a broken rib, or conversely, the Fast Track nurse might kick a patient out of Fast Track to a more acute zone if she realizes that this is worse than it was billed initially.

Judgement is essential in this sort of thing. If a patient comes in with, say, a migraine headache, that is really what they need treatment for. If you fail to fix the headache, then you have failed from the patient's perspective. If the patient should mention in your obligatory review of systems that they have had chest pain, you need to understand when you need to chase it and when it's a dead end that you not need to explore. If you drop the headache work-up and chase the bogus chest pain, you'll have a pissed-off patient who doesn't want to be admitted for something that wasn't his primary complaint, even if you do address the headache. On the other hand, sometimes the real problem is kind of buried in the review of systems. I had someone come in for "asthma" who just wanted a refill on his inhaler (he thought). I noticed that he was tachy, not wheezing, and kind of pale. So I did a more complete review of systems on him than I would ordinarily do on a "med refill" patient, and why yes, doctor, my stools have been kind of dark and his hematocrit was 22 due to a bleeding polyp.

In fairness, it was the triage nurse who pointed out that he looked pretty pale!

I try to stay complaint focused -- it's essential in an environment where demand exceeds resources every single day of the week. Otherwise you get bogged down and overwhelmed. It's just as easy to drown in data as it is to miss things by being too cursory. But you need to keep an open mind and be prepared to cast a very wide net -- especially on old ladies with "Flu-like" illnesses!

22 June 2010


Which way is that cat turning?  Close your eyes and imagine it turning the other way, and it reverses direction.

(h/t Richard Wiseman)

Drip Drip Drip

If you asked me, back in the oh-so-distant past when I was just getting started, what I'd like my Emergency Medicine blog to look like, I'd have described something that sounds like what Life in the Fast Lane looks like today.  Which is to say, it's a blog which is heavy on the education and academic stimulation but also full of off-beat humor, irreverence and attitude in addition to great story-telling (an absolute prerequisite for an EM blog).

I admit I don't get more than half their jokes, but that's to be expected: they're AUSTRALIAN, for pete's sake. But the incomprehensible humor just adds to their charm, just like their accents, weird musical instruments and their propensity for knives:

Anyway, today's post caught my interest and I thought I would riff on it a bit.


Some people hate them; I don't mind them, fortunately.  I once had one of my partners offer to deal with the 300-pound patient with chronic pelvic pain if I would take the nosebleed in room 18.  (You can imagine how quickly I grabbed that deal!)  Go on over to Life in the Fast Lane and do some regular book-learning about nosebleeds before you read on. It's worth the read, and I'll wait.  Go on!

(humming the Jeopardy theme song)

Ah great!  You're back! 

Now let me share some hard-won tips and tricks for managing nosebleeds in the real world.

1.  Physical exam lends little to the work-up. It's worth looking in the nose (barely) but it's all a god-awful bloody mess and you'll rarely see anything of value in an actively bleeding nose, so don't torture poor old ladies trying to decipher the source of the bleeding from the exam. Posterior bleeding does not mean a posterior source, by the way. In my world a "posterior" bleed is defined as a "bleed with a non-visualized source which doesn't stop with standard ER measures."

2. Afrin.  Use it and use lots of it. Afrin and compression will resolve 90% of ER nosebleeds (based on a study which I just imagined based on the last ten years of clinical practice).  If nothing else, Afrin will make your physical exam easier, if you insist on doing one.  No nosebleed should ever be un-Afrinized.

3. Vital signs.  The most awesomely humiliating event of my residency was when I called the ENT resident to the ER for a nosebleed which we simply could not stanch. He showed up and as he wandered into the room, he called out over his shoulder, "I assume you did something about that blood pressure."   "That what?" I thought to myself as I picked up the chart.  The blood pressure was 230/120. Aye aye aye. The nurse snuck in and gave a dose of labetolol as the resident examined the patient.  Somehow the bleeding was easier to control thereafter. It may not be a proven cause of nosebleeds, but it's hella hard to control the bleeding with that sort of pressure driving it.

4. Silver Nitrate.  Banish it to the dark ages. Compress or Pack. There is no in between.

5. Coumadin/Warfarin: The cause of most all the difficult bleeds. Forget Vitamin K; it won't help you in time, and FFP is really just for the crashing patient.  What do you do to stop the difficult coumadin-induced bleed?  The ER doctor is the master of "duct tape and baling wire" solutions and this is foremost among the situations in which ingenuity is called for.  What I do is pack the nose with DRY packing -- it doesn't matter much what you use. Merocel is common, the rapid-rhino balloon works OK, too.  Then once the packing is in, I immediately place the patient supine and slowly drip thrombin solution in to the packing.  The thrombin activates the clotting cascade, of course, and the packing keeps it close to the area that is bleeding, so the likelihood of developing functional clot in the anticoagulated patient is pretty good.  You can actually soak the rapid-rhino in the thrombin solution before you insert it. I hear thrombin is expensive so I use this only for the cases where I'm up a creek without the proverbial paddle.  But it has yet to fail me.

6.  Analgesia. Nasal packing hurts.  Seriously uncomfortable. I work like hell to avoid it. When I have to do it I want the nasopharynx seriously numb. High-pressure sprays like cetacaine blow right past the nasal area and provide incomplete relief.  I put a good 10cc of viscous lidocaine up there (the urojet applicator works particularly well for this purpose) and I leave it there for ten minutes.  Go and see the next patient while this absorbs. Better yet, it acts as its own lubricant while you insert the packing!  It still hurts, since there's a lot of bony pressure on the nasal turbinates, so I always still warn the patient it will be uncomfortable. But this gives better relief than any other method I have found.

7. "A" stands for airway. Bleeding that goes back down the pharynx will usually pass through to the stomach and cause harmless vomiting.  Once in a while, however, the posterior clot will extend, and it can get into the larynx. Assess the patient's voice, and LOOK into the posterior pharynx for a telltale "string" of clot heading south.  If present, get your MacGills and pull it out. It can be scary how much clot can accumulate in the trachea before the patient's airway closes off!

8. Check platelets if anything seems funny. I've twice diagnosed ALL presenting with nosebleeds.  Not all nosebleeds need blood work, but keep the thought in your head.

9. Check the tetanus. Nasal foreign body is a (rare) cause of tetanus. If you pack a nose, it's as good an opportunity as any other to update the tetanus immunization.  And don't forget the antibiotics. Toxic shock is a zebra complication, more commonly sinusitis due to imparied drainage can result from packing.

10. The most frustrating thing about nosebleeds is their propensity to recur.  If you get a bleed stopped without packing it, the chance is 50/50 they'll make it past the parking lot before it restarts. AMBULATE the patient around the department before discharge, and spend some precious bed-time observing the non-bleeding patient before discharge.  Bounce-backs are incredibly frustrating (especially at the end of your shift). So take a little extra time to be sure the bleeding is well and truly stopped before letting them go.  Also be sure to warn them against nose-picking or blowing for 24 hours. It's amazing -- patients have a nose full of clot and they want to extract that clot with their fingernails!  Leave it there until it's hardened and then and only then can you pick and blow your nose.  Otherwise, you'll be right back in a couple of hours.

Thanks for the great post, guys, and GO SOCCEROOS!

C'mon, it's not like the US has a chance, either.

21 June 2010

Aw Crap

The World's Most Dysfunctional Legislative Body, the US Senate, finally managed to pass a "doc fix" last week -- a 2.2% update to the MPFS retroactive to June first, paid for by some offsets on hospital reimbursement. Their solution involved splitting it off from the more bitterly disputed jobs bill, which is much more expensive and difficult to pay for.  Great news, right?
Pelosi: 'No reason' to pass standalone doc fix
House Speaker Nancy Pelosi (D-Calif.) over the weekend put a damper on legislation preventing Medicare doctors from receiving a steep pay cut this month, arguing that the fix passed by the Senate Friday is "a great disappointment."
Not only is the five-month pay window "inadequate," Pelosi said, but separating the so-called "doc fix" provision from the tax extenders bill threatens the larger proposal.  
Aw crap.

I can see where Pelosi is coming from -- as a matter of tactics, she really wants the jobs bill to pass, and keeping high-priority items like the doc fix attached maintains pressure on Congress to move the whole package through. Split off the "must pass" elements and the other provisions wither on the vine.

So I get it, but, well, crap.

17 June 2010

What's the difference between "Eureka" and "Duh"?

There are some days where you see your patients and the diagnosis is clear and obvious more or less immediately, or where at least your workups are direct and give you clear results.  Those are satisfying days.  Then you have days when the diagnoses kind of drop into your lap, which is also nice.  Then you have days like yesterday.

Every damn patient I saw had something real wrong with them, most something serious. In not a single case did I take the direct route to the diagnosis, but sort of spiraled in on it instead, with lots of tangents and dead ends along the path.

Like the guy who came in post op day 5 from a laminectomy, diffusely weak, tachycardic and hypoxic.  He had a PE, of course.  It took me hours (plural) to realize it.  Duh.  Post-op, tachycardia, hypoxemia.  Why was PE not first on my differential?  Because I'm not being fair to myself -- there was a lot of data I had to filter and a whole bunch of other diagnostic options occupied my attention, initially.

For example, as I mentioned, he had back surgery and was feeling weak, with increased back pain. My initial concern was a spinal cord lesion, like an epidural hematoma or spinal infection. So I wasted a lot of time talking to the neurosurgeon, getting the MRI, talking to radiology, etc.  Also, his blood pressure wasn't great, and with the tachycardia I was worried about a post-op infection/sepsis, so we were also doing the septic work-up as well.  And pain control was a significant challenge/distraction.  And the initial oxygen saturation that I saw was 92%, which doesn't sound too awful and in fact I kind of skimmed over, not considering that he was on supplemental oxygen at that time. So really, his room air sat (not recorded on the chart) was probably in the high 80's on arrival.  It wasn't until his oxygen requirement increased and his sat with oxygen dropped into the 80's that the nurse brought her concern to my attention.  I literally smacked my forehead with the palm of my hand when I finally managed to put 2 and 2 together and get four.  Once you realize it, you wonder how stupid you must have been not to see it before.

All of my patients were like that yesterday. This one was memorable because it had the eureka moment.  But there were way more patients with "what the hell" moments and hours of frustration.

"The most exciting phrase to hear in science, the one that heralds new discoveries, is not Eureka! (I found it!) but rather, 'hmm... that's funny...'"
- Isaac Asimov

16 June 2010

A Scary Story

The man I was seeing was very young and completely healthy. 38 year old software engineer at a Major Operating System Manufacturer.  Nice guy. He had come in with complaint of a swollen leg and it didn't take a genius to see that there was a blood clot in it. We got the ultrasound and confirmed that he had actually a fairly large clot.

After that diagnosis was made, I had to determine the course of treatment.  For a simple clot in the leg, you get a shot of blood thinners and you go home on blood thinners.  However, if the clot has gone to the lungs, the consequences can be lethal, so you stay in the hospital for more intensive blood thinners and close monitoring. I asked him is he had any shortness of breath or chest pain, and he said no.  I asked if he had had any at all over the last few days and he clearly denied. He said he had just climbed three flights of stairs before coming in and had no problems.  I asked if he had any dizziness or fainting and again he said no.  When I pushed him, he though that maybe about three or four days ago he had a short time when he was dizzy and nauseated but it was mild and self-limited. I looked at his vitals: normal heart rate, respiratory rate, blood pressure, oxygen level.  All very reassuring, and he looked like the proverbial rose.  The likelihood of him having a blood clot in the lungs, I decided, was very low.  It would probably be OK to send him out.

But still, he had that dizzy spell.  And it is kind of a big clot.  OK fine, I'll get the CT scan of his chest to rule it out.  It's a waste of money, stupid CYA medicine, but I'll just do it.

About an hour later I got a call from the radiologist. As I have said, the radiologists don't call you to tell you that a test was normal. They call for Bad Things only, things they want you to know right away and things that they want to document on their report "Dr Shadowfax personally informed at 1835hrs."  And this was a Bad Thing. Not only did this guy have blood clots (plural) in his lungs, there was as much clot burden as you can have without a saddle embolus.  It was described as "Large bilateral PEs from the distal pulmonary veins into the segmental veins of all five lobes of both lungs."  Holy Crap!  And I was thinking of sending him home!  I rechecked him, and he still looked and felt great. He was a little annoyed that I insisted on admitting him.  The resilience of youth, I guess.

I suspect that he may not do well. He's fine now, but with this much clot he's likely to develop right heart failure, pulmonary hypertension and long-term problems as a result of this. He didn't qualify for t-PA or thrombectomy, not with normal vital signs.  I wondered to the hospitalist whether he might benefit from some interventional radiology procedure where they break up the clots with ultrasound or catheter-directed t-PA.  I hope he does.  Here are the scary pictures:


Red arrows show clot in the pulmonary arteries.  And as always, when I make a scary diagnosis by good fortune:

15 June 2010

Drawing Pad

As a hugely famous blog author I get tons of solicitations for links, reviews and the like.  Most of them I ignore, sometimes because they are off topic, sometimes because I just don't have the time/energy to closely consider the proposal, sometimes because I am actively opposed to the proposal (I get a lot of press releases from conservative think tanks and also from chiropractors and other practitioners of woo).  Once in a while I get a freebie -- a bit of software or a book for review.

Most of the time I don't get around to actually reviewing it, either because I didn't read/use the product, or because I did and didn't like it. I suppose you could argue that in those cases there's more value in the review than otherwise, but it feels like sort of a jerk maneuver to publicly trash their product.  (Exceptions could be made if the product were really bad, I suppose.)

So all this is a lead-up to a review of an app sent to me by the developer of the Drawing Pad app.  It was another freebie, and this one I thought was worth writing about.

Drawing pad is one of a number of sketch apps for iPad/iPhone, but it distinguishes itself by attention to design and function.  The interface is simple, with a drawer on the right (which you can hide) with a variety of drawing tools: brushes, pencils, marker, eraser, stamps, and stickers. You can choose a paper background, a photo from your iPhoto library, or a blank background.  It's visually very appealing and absolutely intuitive.

I'm not much of an artist (to put it mildly), but I can see the fun in playing with this app:
Where it really shines is when the kids get hold of the iPad. They can play with this for hours.  (They especially love the sticker options!)  And it doesn't take long for them to figure out the tools and options, even the little ones who can't yet read.

Another thoughtful detail is the export page. You can email an image, save it to an album, save it to iPhoto, or directly export it to Twitter or Facebook.

If there were any criticisms, I would say it is that the pencil and crayon tools give you basically the same effect in a different line size.  The brush tool and the marker tool are indistinguishable as well.  I'd like the "paint" to look a little more wet or liquidy.  It'd be nice if there were a smudge/smear option or a text option.  Also, if there was a way to resize the stickers, that would also be nice (maybe there is but I missed it).

It's a great bit of fun and I can also see using this to annotate images for posting on the blog (if I ever figure out a decent blog editor for iPad).  The cost is $1.99 which strikes me as a fair price point for a well-designed casual-use app.

Department of Useless Research

My mailbox every morning has a missive from ACEP in it with the recent news pertaining to EM.  Mostly it's decent stuff, though there's a bit of dross in there too.  One thing I have noticed is the apparent proliferation of research which just seems to tabulate certain injury patterns.  Like this morning's headline:

Nearly A Million Americans Taken To EDs With Weight-Training Injuries Over 18-Year Period. 
The New York Times (6/15, D7, Bakalar) reports in Vital Statistics that "a new study finds that from 1990 to 2007, nearly a million Americans wound up in emergency rooms with weight-training injuries and that annual injuries increased more than 48 percent in that period." Approximately "82 percent of the 970,000 people injured were men, according to the study, which appeared in the April issue of the American Journal of Sports Medicine." Individuals "were most often injured by dropping weights on themselves, crushing a body part between weights, or hitting themselves with the equipment."
Seriously?  Somebody thought this was a pressing enough public health problem that they had to perform a study on it?  And it got published?  Wow.  (I'm not surprised that it made the lay press, being kind of off-beat.)  There was another, more spectacularly useless one a few months ago where they reported that the number of ER visits due to people tripping on their pets was on the rise.

I'm not sure why people keep doing these pointless studies. I suspect that it has to do with the availability of large databases of ER visits in easily searchable form. Database mining is a lazy man's way to get published without putting a lot of thought into the subject.  It's a pity, because there are lots of really important research questions which do pertain to the ER which go unanswered because they are hard. 

14 June 2010

Some Sad News

Thai was a regular commenter who gave me a lot of grief.  He had a much more conservative view, especially on the economics of medicine and the outlook for the future, with or without health care reform.  He was dogged in arguing his point, but he was always respectful and on-topic. When I saw his name pop up in the comments I always had to brace myself for the vigorous back and forth that was sure to follow.

We went to the same residency program, a few years apart. We never met but we corresponded a fair bit off-line.

I just found out that he died last week after sustaining a heart attack.  He left behind a wife and four boys.  I'll miss his contributions, and my thoughts are with his family just now.

In lieu of flowers, his family suggests donations to the Thai McGreivy, M.D. Memorial Fund, which was established by the family in Thai’s honor to fund educational scholarships for excellence and intellectual curiosity in science, mathematics and economics.  To contribute by check: Make checks payable to the “Thai McGreivy, M.D. Memorial Fund/CFNCR” And mail them to: The Community Foundation for the National Capital Region Attn: Kenny Emson, 1201 15th Street NW, Suite 420, Washington, DC 20005

iPad use in the ER

GruntDoc and a few others asked me about the medical apps available for the iPad.  As I said in my previous post, I am not at this time using my iPad in the ER.  However, that clearly is not the case for many other ER docs, and I would encourage any who are using it to email me their experience and I can post it for others to learn from.  Having said that, there are certainly a number of excellent medical apps for the iPhone and iPad and if the circumstances are right for you, it could be a great addition to your daily work.

Bear in mind this is written from the point of view of a practicing physician.  There are a gajillion educational applications which are excellent for medical students or EM residents. But my needs are not in the educational line anymore (at least so I hope!), rather the tools I use every day in clinical practice.
Here's where I envision the bang for the buck being with an iPad in the ER:

EPIC is one of the most popular electronic medical records in the large clinic/hospital environment.  It's not my favorite: we are on Picis and have had a great experience with it.  But Picis is not supported on the iPad (it's a browser-based system and only fully supported on IE6 & 7, I think).  If you work in an EPIC shop, however, you are in luck.  There is an EPIC client for the iPad, called Haiku.  If your IT department licenses Haiku, that could be a spectacular situation.  I'd be very interested to hear from anybody who has experience with this set-up.  There's a meaningful likelihood that we may convert to EPIC, so it's not entirely an academic question for me.

As an e-book reader the iPad is unparalleled.  Some of the most useful and prestigious EM texts are available online in PDF format.  You will need a reader like GoodReader, but the files are only 60-90MB and you can have Rosen's, Roberts & Hedges, and Auerbach in your hand all the time. 

I have been a user of UpToDate for several years. I find it to be expensive but a great value. It almost always has an answer to my question when I am at the point of care, and you get CME as well.  It's probably my most or second-most used reference on a day-to-day basis.  There's no app per se, but I saved a bookmark icon to the home page and it "feels" like an app, though it is technically browser-based.  The mobile web site is pretty well optimized for mobile Safari, so it is pretty functional.  And did I mention that you get CME for everything you look up?

Epocrates: I remember carrying around the Tarascon Pharmacopeia for years and years. It was my annual ritual: when the new year's edition was released I would get it and carefully transfer all the useful notes from the back cover of my old one to the new: phone numbers, passwords, etc. Those days are long past.  Now Epocrates has replaced it as my primary drug reference.  It is not perfect: it's a bit slow, not yet iPad optimized, and has an annoying habit of popping up messages or demanding updates when I am trying to get a piece of quick information.  But it is 100% reliable in getting me the information I want when I want it, and it is free.  In fairness, Tarascon does have a few apps, but they are kind of spendy and it is hard to compete with "free," so I have never seriously checked them out.    

Medscape: A free reference which is pretty useful.  Not quite as robust as UpToDate, but as I said, free is hard to compete with.  UpToDate gets me my answers more rapidly and with less hassle (Medscape interface is a little click-happy).  If you don't feel like shelling out the cash, this could be a good alternative, and is effectively a companion app to Epocrates.  It has free CME, which is nice, but a little test is required; UpToDate allows passive accumulation of CME based on subjects you research.

Medical Calculator: This is one of a few generic apps which provide useful formulae. Nothing you can't get in 5 seconds with Google, but nice to have right there in the palm of your hand.  

The Wheel RE: A cute, old-fashioned OB wheel-of-misfortune pregnancy slide rule. Oddly, the slide rule interface is still better than any digital calculator I have come across, at least for me, since I routinely have to calculate forward or backwards depending on what date(s) the patient or I may know or not know.  

eRoentgen: This app helps you determine what diagnostic imaging studies are most useful in picking up certain conditions.  It's not too useful in that you have to search by suspected diagnosis, and you have to use their exact phrasing (i.e. Abscess, Epidural will yield a result but epidural abscess will not).   

Stat ICD-9: A free coding app.  Fortunately I don't self-code my charts, so this is primarily for curiosity use.    

I would be remiss if I did not once more plug 1Password, which is an absolutely essential app for anyone in a hospital with multiple IT platforms, each requiring its own unique signature.  This will save a lot of neurons and prevent a lot of gray hairs (from the aggravation over repeatedly forgetting your passwords). 

 There is also the fine blog iMedical Apps which has a excellent set of reviews and other useful tidbits on uses of the iPad and iPhone in clinical practice.  Also not to be missed is the review by ER physician and CMIO of Beth Israel John Halamka describing the use of the iPad on clinical teaching rounds.

A Cautionary Tale

The patient's presenting ECG:
pre epi
The same patient's ECG after administration of IV epinephrine:
post epi
Note the difference?

For the uninitiated, the second tracing reveals new elevation of the ST-segments in the anterior and lateral leads suggesting an acute myocardial infarction. Epinephrine can do that, via a variety of mechanisms including sudden increase in cardiac workload with abruptly increased rate and afterload, and also coronary artery vasospasm, especially it there is pre-existent coronary artery disease present.

In this case the use of epi was, um, pretty justified: the patient brady'd down and became asystolic as we were attempting to intubate him for respiratory failure due to his severe metabolic acidosis from hemorrhagic shock from a GI bleed with a hematocrit of 18. So let's just say he had a lot going against him. (Also, he was 300 lbs and I was mighty happy to have the GlideScope which made a potentially very difficult intubation a non-event.)

The take-home message, however, is to be judicious with the use of epi, especially in older patients.

You have been warned.


Well, as of today, we are getting reimbursed 21.3% less than the previous baseline level for medicare patients. This SGR mess has progressed right beyond tragedy into farce. I feel bad for all the small practitioners out there who are highly dependent on their week-to-week cash flow to pay the rent, office staff, etc. This could be a real hurt for them.  It won't damage our practice, since we are big enough to buffer the stutter in the revenue.

One thing I had not reckoned with is the havoc this wreaks on the billing offices. I was speaking with out rep at the very large ER billing firm we use for our claims processing and collections. They bill 5 million ER visits annually.  He was on the verge of tearing his hair out. They have repeatedly had to jury rig their computers to hold claims  for a certain payer, not something that is a normal part of business, then send all the claims out at once, then hold them again, then apply a new fee schedule and send all the bills out at a lower rate, then hold them again and rebill at the old, higher rate, then reconcile the accounts for the partial payments received.  For me it's an annoyance and a strategic threat. For them, it's an operational nightmare.

11 June 2010

Friday Flashback - Advice for Interns Part Three

I am one of the more efficient docs in our group. Not the most efficient, but I do pretty well. Because of my leadership position within the group, I spend a lot of time thinking about operational processes and efficiency, and because of my reputation for being a “fast doc” I field a lot of queries from partners on how to do better. So I thought I would share some of my thoughts with you. The ability to move the meat effectively is really a win-win-win – you do better (both reputation and financially), the ED flows better, and the patients are happier and get more timely care.

Be motivated
It sounds stupid, but if you are not coming to your shift with energy and a strong motivation to clear out the rack, you are not going to. It’s not always easy to get yourself in this frame of mind every day, but the way I think of it is that we are paid more than 95% of all Americans to do this job, and it’s not supposed to be easy. You need to take a moment before you walk in the door to put on your game face and get yourself just a bit psyched up. Leave your home life at home. Most importantly, pay attention to your productivity – know what most docs at your facility do, know what you usually do. Set yourself a goal, and a stretch goal. Track your progress – within the shift, and over the longer time frame as well. If only via the Hawethorne Effect, this alone should increase your operational efficiency.

Be organized
“Never begin a shift with an empty stomach or a procedure with a full bladder.” So sayeth a wise elder partner. Try to bring a consistent approach to things. This is idiosyncratic, but find what works for you and do it every shift. Show up a few minutes early and spend some time assessing the state of the department before leaping into the fray. Make sure you have your favorite pen, or PDA, or whatever gadgets/accessories you find useful. I carry an index card with the name and sticker of every patient I have seen. This allows me to keep track of the patients’ progress, to-do items, location, etc. I do mental rounds with my list every twenty minutes or so. Whatever works for you. Pay attention to your work environment. Make sure your charting station meets your personal needs.

Focus with unwavering intensity upon achieving the disposition.
I joke, but it's not really a joke, that I am an unusual type of doctor, because I am not looking for a diagnosis; I'm looking for a disposition. Direct your workup towards the life threats and emergencies. The moment you know the patient cannot go home, start the process of bed assignment and transfer of care to the inpatient team, as these are usually the rate limiting steps. Avoid “the long goodbye.” Many times I have seen someone waste hours chasing their tail with multiple consults and tests when it was perfectly clear the patient needed to be admitted for a work-up. It’s a radical new concept in American medicine that the work-up does not end at the elevator. Note: this may take a little salesmanship. The admitting docs like things neatly packaged. See this post for advice on how to make the pitch to your consultants.

Initiate Treatment Early
A medicated patient is a happy patient. The sooner you get pain meds, anxiety meds, diuretics, etc, into the patient, the sooner they will feel ready to go home – and the higher your patient satisfaction scores will be! Every patient who comes in has some sort of agenda. You should be able to figure that out in the initial point of contact, and address it explicitly. Especially so if they are drug-seeking and you intend to decline to provide narcotics. Say so up front, get the fight out of the way, and you won’t find yourself hamstrung when it comes time for discharge. Stage your orders and let the nurses know what the plan is (i.e. Toradol and vistaril, if no relief of pain in 30 minutes, then dilaudid 2 mg IV q30 min till relief). That way the therapy can proceed on autopilot while you are doing something else, and you will have fewer interruptions.

Be selective in your testing strategy
When able, utilize point of care testing – istats and the like. Don’t order a full lab panel if the only data you care about will be in the istat. Don’t order ANY test unless a) it will be resulted while the patient is in the ED, and b) is required for the correct disposition. Defer urgent tests to the outpatient setting – that chronic pelvic pain patient doesn’t really need the ultrasound at 2AM. Enlist the PCPs, when available, as your allies in setting an outpatient work-up in motion. Be evidence-based in your ordering rationale. The toddler with a cough and fever doesn’t need that CXR if their oxygenation is 99% and the lungs are clear.

Your productivity is measured in patients per hour. This is impacted by your average length of stay and also by the number of patients you carry at a time. I think of it as water flowing through a pipe – the rate of flow and the diameter of the pipe determine the total volume capacity. Pay attention to the size of your pipeline and learn to carry one or two extra patients at a time. It can dramatically improve your personal throughput. When possible, try to intercalate all your complex patients with a couple of simple ones. It makes the shift more interesting and allows you to fill some idle time while waiting for the mega-work-ups to finish. And if allowed, cherry-pick like crazy the last hour of your shift. It can clear out the bottom of the chart rack and really put your productivity over the top wile helping you get out more or less on time.

Of course you should apply the usual caveats and disclaimers – not all of these prescriptions are applicable to all cases, all facilities, all practitioners. Look at your practice and see where the opportunities for improvement are. Use your judgment and pick the items from this list that make the most sense for you and your practice. Also, I should give credit where it is due: much of this as been cribbed from talks given at various seminars on ED operations. I don’t recall the lecturers’ names, and this is my own synthesis, but I cannot take credit in toto for the contents. More later.

Originally Published 20 June 2007

10 June 2010

Pushing Boundaries

I had a speaking engagement this morning.  It was at another hospital, for their ER docs, speaking on a topic I know reasonably well, namely, medical malpractice insurance and the technical details involved in the back-end operation of a plan.  I did not really know these docs, but I had reason to expect a friendly reception.  Unfortunately, a heavy administrative and shift load prevented me from preparing for the talk like I would have preferred to.  So it was no PowerPoint, no pretty handouts, just a brief outline which I had sketched at 1:30AM after my shift, and five hours of sleep before the talk.

It went great. I may stop using PowerPoint altogether.  Wasn't it a US Army general who commented that "PowerPoint is making us stupid?"  I spoke for about 45 minutes without notes, answered a lot of questions, and was well received.

Afterwards. I reflected with a friend that there was a time that speaking extemporaneously in front of a group of peers/strangers would have been a source of great anxiety.  Now ... it's just Thursday. It felt good, like I was in my element, and it did help that I have done a lot of work on the subject.  Still, public speaking is always one of the scariest things I have to do, and I was nonplussed that it was coming so naturally.  My friend responded that he was not surprised in the least.  "You haven't realized it but your job has been changing over the last few years.  You're not just a doctor and not just an administrator anymore.  You talk for a living now. So it's no wonder that you're getting comfortable with it."

Then he added, with a wicked edge in his voice, "Just wait until you're speaking to 1,500 people."

Yeah, that will bring the anxieties right back, won't it?

The Beautiful Game

A guest post by Dr. Matlatzinca

I am acutely afflicted by World Cup Fever (WCF). Though lacking official recognition in the current ICD-9 or proposed set of ICD-10 diagnostic manuals, I can offer my expert opinion as to the validity of this entity. Some might compare it to Superbowl Mania, March Madness, or even humorously to Fall Classic Ennui Wasting Syndrome. The sad truth about WCF, however, is that it is a much more serious diagnosis requiring understanding from the medical community and support from society in general. Once the importance of this condition is recognized, I'm sure that congressional hearings will lead to substantive legislation to protect the population from this serious episodic epidemic.

Consider the associated comorbidities, not to mention the acute rise in violence that can be precipitated by, say, a semifinal or final win. In Italy experience has shown a dramatic rise in the number of suicides, acute MIs, strokes, and major depressive episodes. It is expected that Spain and Germany, two of the EU's leading economic regions and countries where WCF is endemic, will see a 15-20% drop in GDP due to the limbic-system associated paralysis which is a common feature of WCF. Even England (not the entire UK) is taking preparatory action to prevent impulsive deployment of strategic nuclear weapons against the US in the event that Nuclear Sub commanders become afflicted with the impulsive irrational behavior also common to WCF.

In the United States WCF has been a low prevalence condition, though its incidence is most definitely on the rise. The success of the MLS (with expansion, even!) is one of the "leading edge" warning signs that epidemiologists tout as a harbinger of the extension of the WCF pandemic to the USA. I for one will be trying to cover up my symptoms as much as possible. The sad lack of recognition of this condition in the US leads those of us afflicted with WCF to seek ways to justify and compensate for what is seen as irrational and aberrant, even irksome or annoying behaviors. I would encourage others suffering from WCF to raise visibility for our condition and enact change through increased awareness. Hopefully this will avoid embarrassing situations.

Consider, for example, my experience during the 1998 World Cup (held in France). I was an intern working on the Heme/Onc ward. The typical patient on this ward is much sicker than average, and it is not uncommon for codes or other alarming events to occur throughout the day. On this day, however, all the patients appeared to be relatively stable. We had a couple of transplant patients that were somewhat tentative, but nothing a good antifungal + triple antibiotic therapy couldn't take care of. My attending at the time was the primary transplant attending, and shared my partial Mexican heritage. Rounds had been uneventful, if somewhat repetitious as the other various team members had to contend with our WCF-induced fragmented attention span and impaired short term memory. Finally we finished the work, however, and during the lunch hour we had a brief period of time during which we could catch up on the game of the day by sneaking into one of the patient rooms and turning on the TV. It happened to be a Round of 16 game between Mexico and Germany. The first half had been scoreless, but a mere 2" into the second half, Mexico scored a goal. My attending and I watched the action live, and as Luis Hernández "El Matador" put the ball in the back of the net we both SCREAMED AND WHOOPED. The entire complement of nurses, respiratory therapists, pharmacists, and other interns/residents stormed the room hot on the heels of the Heme/Onc fellow, in an extremely high-level of alertness and looking around for the patient in need of resuscitation. Once my attending and I became coherent once again (maybe 10-15 minutes) we were able to explain that there was not, in fact, a patient suffering acute overwhelming blood loss, septicemia, or brain herniation. Most of the first responders returned to their work with shakes of their head, puzzled looks and obvious lack of empathy. Except for the Charge Nurse. She remained behind to chew us out for our flamboyant display in the middle of a busy ward full of sick patients. We agreed to keep it down if only she would not shut off the game.

Well, we managed to keep it down for a whole 30 minutes, until Klinsmann scored the tying goal. The Charge Nurse came back to chew us out again and turn off the TV, though we argued successfully with the help of other witnesses that the noise she heard was actually coming from the throats of 80 million Mexicans who all screamed in horror at watching our squad's demise.

Mexico play in the opener against South Africa (the host nation) tomorrow. If your Charge Nurse comes to ask what all the commotion is about, feel free to blame it on Dr. Matlatzinca as long as you take the time to explain the epidemic of World Cup Fever that is about to engulf her unit for the next month.

09 June 2010


The Oils:

I'm busy today. Chat amongst yourselves.


Admiral Allen looks like every Coastie I have ever known:

Do they select for that quality when they choose their Admirals?
No disrespect, BTW. They're the least recognized service, and that's a shame.  Because they do good work.

07 June 2010

Avoiding my homework, Or, Chris Rangel makes me sad

I have some enthralling legislative language to read before a meeting tomorrow with a local legiscritter. (Yeah, I'm no longer an amateur wonk; I also get paid for this stuff.) I don't want to read it. I've opened the email that contains the bills, I've considered clicking on the PDFs to open them, I've gotten up and gotten a beer, I've opened the PDF's but hidden them, I've chatted with my wife, I've just about emptied my feedreader and I still don't want to get to work.

So I'm going to write a post about Iron Man instead.

First of all, as a long-time comic book geek, I loved both the Iron Man movies. They exactly captured the spirit of the comic, with understandable adaptations for live action. (I always liked the cover story of Tony Stark being paraplegic. I was bummed when they "cured" the character.) Anyhoo, if you have an iPad, don't, I repeat don't download the Marvel App. Seriously, I've been in recovery from my comic addiction almost as long as Tony Stark has been in recovery from his alcoholism, and the Marvel App is like a shot of pure heroin for an ex-junkie (if I may mix my metaphors). I downloaded it to show my wife a little about Thor (apparently the next Marvel movie adaptation), and immediately spent like $30. It's a beautiful app, though, and the "frame by frame" animations are simply stunning. I'm firmly back on the wagon now. I haven't deleted the app yet, but I swear I will tomorrow.

So where was I? Oh yes: Chris Rangel, MD.

He's been med-blogging like forever, even longer than me and I am rapidly becoming a grizzled veteran of the blogosphere. He's a good writer and always a lively read. I'd have him on my blogroll if I had updated it at any point since the days of Flea and Barbados Butterfly. (I think I'm going to leave my blogroll as it is forever, preserved as it were in amber, like a window back into the heady days of 2007.) Dr Rangel recently wrote about Iron Man, with some choice words regarding the plausibility of the "palladium poisoning" that was afflicting Tony Stark and the other issues with the biochemistry of the film.

Now first of all, let nobody cast the first stone here regarding the fisking of a fictional story's technobabble. As a proud owner of the Star Trek Technical Manual back in the day, I and my friends went through the science of Trek in meticulous detail; we may have actually been forced to learn some real physics in the process. My favorite invention remains the "Inertial Dampening Field." So there's a long and storied history of nerdy science-types getting a little too interested in, and bent out of shape over, the implausible technical details of the story and the scientific liberties that are necessary to make science fiction work.

But c'mon, man. If you want to get all bent out of shape about the science of Iron Man and the first thing that you can think of to criticize is the biochemistry, you're missing the forest for the trees, my friend. I mean, it's completely bogus on so so many levels. For example, consider the forces applied to the suit of armor that Stark wears. When Iron Man first escapes from the bad guys in the first movie, he doesn't really have control over his jet boots and he slams into the sand at a speed of about 84m/s, with a resultant deceleration force of 3267 m/s2. So at under that sort of force, the armor can maintain the integrity of the body and maybe even the skeleton (which is closely coupled to the suit) but the internal organs will move around and that sort of force will wreak havoc on your soft and plump innards. The heart is heavy and pendulous -- it sort of hangs off of the aortic root, which is firmly tethered in place. Sudden stops can cause the heart to swing forward and shear right off the aorta, which is not real good for your health. That sort of acceleration is probably not so good for solid internal organs like the liver or spleen, either. They're not real elastic and deceleration forces against the abdominal wall can bruise or even shatter them. Later, when Iron Man goes toe-to-toe against the other robot-dude and he gets punched in the head by a heavy steel fist? The armor, once again, will protect the skull and maybe even the face, if the fit is snug enough. But the brain is mobile within the cranial cavity. It is slightly less dense than the CSF, so when the skull is abruptly decelerated the CSF displaces the brain away from the site of injury and the brain bangs into the interior wall of the skull away from the impact causing a countrecoup injury (fun fact: it was a high school kid who demonstrated this mechanism). This impact can cause bleeding around the brain or bruising and axonal shear within the brain parenchyma.

So all I am saying is that if you really want to poke holes in the science of Iron Man, the biochemistry is pretty rarefied territory to be mucking around in, when the basic kinematics of the whole concept are entirely impossible. Hmm. Maybe if Stark integrated an inertial dampener into the suit that just might work! It's trek technology, but I'm almost certain that an "arc reactor" would generate more than enough energy for an IDF, and if he had a solid-state accelerometer the response time would be quick enough....

OK, I think we can make this work. But, please, nobody tell Dr Rangel that there's really no such element as kryptonite, OK? It'd really ruin Dark Knight for him.

Note: hat tip to science blogs' Dot Physics for some really superior science fiction geekery.

Follow-up on the declaration of war on doctors

Just wanted to add something to my post from the other day about physicians and collusion in bargaining.
1.  Nothing in my post was intended as a defense of the status quo.  The landscape in negotiating with insurers is so tilted away from physicians it's not even funny.  This is even more problematic in states where balance billing has been banned.  In those states the insurers have no incentive to negotiate at all with physician groups, since they can simply dictate rates.  In states with more open contracting rules, there is still no truly open and fair market for physician services. There are a few causes that contribute to this condition:
- Asymmetry of size.  Insurers are huge organizations with enormous market power. The typical physician group is either a solo practitioner or a small group. The insurer can afford to drop a provider or group with little more than inconvenience to their enrollees, but when a doctor or group drops an insurer they run the risk of a large slice of their business evaporating. Larger medical groups can operate on a more even footing with insurers, which is one reason among many that the trend towards large group practices has been accelerating.
- Resources. Insurers have a department that exists solely to maintain their provider networks. They have people who do nothing but negotiate contracts on a daily basis every day of the year. Doctors or their business managers do so maybe once a year or less often. That sort of experience and skill also helps depress the prices physicians can command for their services.
- Asymmetry of knowledge.  The insurer has contracts with hundreds if not thousands of doctor groups. They know what they pay every doc in the state, and they know the high-end and the low-end and their profit point. Doctors know only what their contracts are.  Not only that, we are prohibited from knowing what other groups are contracted at, because of collusion rules. This also puts doctors at an incredible disadvantage in negotiating reasonable reimbursement rates.

2. There is a way around this handicap. As one commenter points out, there is a large multi-specialty surgical group called Proliance which does very well (I hear) with their contracts because they are tenacious and skilled negotiators.  However, they can do this because although each doc in Proliance is a member of a true group practice.  Which means that they all share a common tax ID number and share revenues.  How they internally divvy up the money is their business.  But since they took the risky and difficult step of truly and legally integrating their practices into a single corporation, they are legally a single entity and thus their acting as a group is legal -- you can't collude with yourself, or there's no such thing as a conspiracy of one. 
This is also why the members of the IPA ot smacked down by the FTC in the other case cited by the Mise Blog. They got cute and tried to affiliate without incorporating, and that doesn't pass muster. If you want to have the market clout of size, you need to be willing to take the significant step (and risk) of joining your practices more or less permanently.

3.  Government fee schedules are a joke when it comes to competitive marketplaces. They are truly contracts of adhesion -- no negotiating permitted. I'm all for physicians dropping them to make the point that the rates are unrealistically low, and it's a pity that it can be necessary because it really does hurt patients. But you still can't boycott them as a group.

4.  Unions -- doctors are not allowed to join/form them.  I think it's because we are considered management, but I am not sure. Anyone else know the background on this one?

Thanks for all the thoughtful feedback on this interesting issue. 

06 June 2010

How to get an equipment upgrade

Our ER is probably typical in that much of the equipment can be pretty dated. Half of the computer workstations are still running IE6, and the printers/faxes/copiers are all similarly vintage. The hospital tries to save money by only upgrading when something breaks. The printer by the docs' station is a particular problem for us since it's a high-use device -- it's responsible for all prescriptions and discharges. When it jams (which is frequently) or starts spewing toner all over our prescriptions, it bogs down the ER because we can't discharge anybody till it is fixed. It's a very frustrating and recurring problem.

The other day, I came on shift and began, as I always do, by picking up the first chart and removing a patient label. I keep a running list for each shift: it keeps me organized and lets me track my productivity. I looked around for a blank piece of printer paper for my list, and there was none, so I pulled the tray out of the doctor's printer to get one.

Either I pulled harder than I intended or somebody had greased the skids, because the whole fricking tray came right out, kept going, and flew out into space and down onto the floor, smashing into a million pieces. It made a huge noise and the ER stopped dead while everybody in the nursing station turned, startled, in my direction and stared at me. An uncomfortable pause followed.

"Lisa," I said to the charge nurse in my most authoritative tone, "I've decided we need a new printer."

"Very well, Dr S," she responded, very formally. "Will there be any other equipment you would like to upgrade today?"

"I'll let you know. Just listen for the crashing noise."

At that point we all laughed and began cleaning up the mess. Lisa had the last laugh on me. She got IT to come and replace the printer tray. Just the tray.

05 June 2010

P-51 Flying Day

Paul Allen was complicit in the crime against humanity that was MS-DOS, and he has been atoning for it ever since. His most recent expiation is the Flying Heritage Collection, which restores and preserves historic warbirds.  It just happens to be based in my hometown.  Most impressively, it actually flies all of them that are airworthy!  As much as I love the Museum of Flight, it's a boneyard, albeit an impressive one. Ditto the Smithsonian. This is to the typical air museum as a zoo is to a natural history museum: it's alive.

There were about 1500 people there (my off-the-cuff estimate) and it was the first nice day we have had all year (notice the strange bluish color of the sky!) and it was quite an event. It's not often you get to see one of these beauties fly, let alone three.  I love the growl of the

You can see a more complete photo gallery here.

Fun facts: the red-tailed plane, 'Val-halla" is owned and operated by Apollo 8 astronaut Bill Anders, whom I have met. Today his son Greg was flying.  The unsual name of the yellow-checkered-nose one, "Upupa Epops" was because the pilot was an amateur ornithologist.  There's a moving video of the pilot being reunited with his airplane after its restoration.  The original nickname of the striped P-51B, now named "Eva," was the much more poetic "Impatient Virgin."  Fittingly, the event was joined by a juvenile bald eagle.

I brought the two boys with me, and they were thrilled.  Son Number One was unusually quiet and mesmerized by the aircraft. Son Number Two was perched on my shoulders for a better view and breathlessly narrated the entire show in a high-pitched squeak, to the amusement of the crowd in our vicinity.

They're flying the Messerschmidt Bf-109E in two weeks.  Wonder if I'm off that day...

iPad Killer Apps

I wrote the other day about my general impressions after using the iPad for a month.  But the device, shiny and lovely though it be, isn't much use without applications to flesh it out.  Over the last few weeks, I have developed a pretty robust set of apps I use in my day-to-day life.  Note that I am not at this time taking the iPad to work.  There are a few reasons for that.  First and foremost I worry that a mobile device like this will grow legs and walk away.  The second reason is that our EMR does not have any ability to integrate with the iPad, and because I am at a workstation much of the day so I have access to the internet, references, and all sorts of medical tools on the computer, and the iPad doesn't add a ton to that, at least not with my current workflow.  And not least, our IT system is locked down pretty tight, so my ability to bring in a new device onto the hospital network is nonexistent.  Interestingly, I was told that Harborview has purchased 2,000 iPads.  I will be very interested in seeing what they do with them.

So for now, I am using the iPad as a personal device, and these are the apps I have found most valuable.  All links open in iTunes, BTW. 

Productivity Tools:
Apple's word processor.  At launch time it was the only word processor available for the iPad, though I am sure that has changed.  It's spendy -- $9.99 -- but worth it.  The elegance and attention to detail are all you expect in an Apple product.  I can make full-quality multimedia documents right there on the iPad.  I am sure there are cheaper ways to do word processing on the iPad, but this is very nice and full-featured.  The interface is rather different than Word, so it will take some relearning.  Some of the conventions are weird and frustrating, others are so awesome you will wonder why they never did it this way in Word.  I have not tried Keynote or Numbers yet.

The iPad really doesn't have any sort of file management system, so you need something to get files onto the device.  Dropbox is that tool.  It's free, and basically a cloud host.  You get a 2GB storage limit for the free account and can upgrade for a small premium.  I'm still using the free account but it works so smoothly that I will almost certainly wind up upgrading eventually.  The way it works is that you set up the desktop client and it creates a Dropbox file on your computer.  Anything you put in there is synced to the cloud. You can have the client on multiple systems (say a home and work computer) and can access it on the internet as well.  And of course anything you put there is accessible on the iPad, also.  So you can throw your PDFs and word documents there for reading or editing later.  You can also share folders.  An ER doc reader offered me some interesting educational files (thanks!) and I just sent him a link to my dropbox and he threw them in there.  My office manager wanted some PDFs and I sent her a link to the folder in my dropbox. It's great.  My days of carrying around USB dongles or emailing large attachments are over.

This is a project management program which has morphed into my external brain.  It's so powerful that I don't really know where to start. Create a note or web clipping or scan a document or an audio note or whatever you like -- there are all sorts of options to add content to Evernote.  It also is a cloud computing service, and all your stuff is up there on the cloud.  You can tag, sort and organize however you like.  Images get automatic OCR done on them so they are also searchable.  I have hundreds of recipes on mine, all the scanned menus from local take-out places, scans and meeting notes from work projects, a karate knowledge base and class records, a running list of blog drafts, and more.  It synchronizes across multiple platforms (desktops, iPhone, iPad, and web) so you always have access.  It's awesome.  I got the premium service and will use it forever.  I hear Bento is also nice but I'm committed to Evernote myself.

A great app for viewing PDFs, which is a necessity since I think the iPad cannot do this natively.  It's $0.99, which is a rarity for such an essential app on the iPad. It does a lot more, allowing you to view doc files, read ebooks, view pictures, and the like. 

1Password Pro
This is a must-have app for anyone working in the hospital environment.  How many logins do you have?  Do you have to change them all every 90 days?  I have about a dozen and most of them have all sorts of password restrictions. 1Password allows you to securely store them all for $6.99.  (There's also a free version, which is not bad.) Better yet, if you spring for the desktop client, which is a little more expensive, it keeps them all synchronized across your desktop, iPad and iPhone. The desktop client integrates into your browser and can save passwords for web sites, and of course you can put your banking information there, too.  There's a personal-information section too, where I keep my kids' social security numbers and other sensitive data.  The encryption is ultra-strong, so you don't need to worry about security.  Just don't forget your master password, or you're screwed!

New York Times
Visually just like reading the actual newspaper.  Very nice.  Does not give the full content of the actual paper, as apparently the NYT has a deal with the Kindle to provide exclusive content there.  So it's a selection of the top articles, but let's be honest, they're the only ones you read anyway!

This is a beautiful, lovely app premised on the unlikely theory that newsworthy events occur outside of the United State.  I love to open up the app and look at it, but the stories are all so ... foreign.  Unsettling.  I am not sure that the underlying premise is going to work.  Still, sometimes they have stories about the US (like the oil spill) and funny stories about weird places like "Greece," which I assume is a fictional land cause nowhere real could be that messed up.
Another great, elegant news app.  These folks all put a lot of thought into how news stories should be presented on the iPad.  Their solutions all differ slightly, and it's a matter of taste which you prefer.  But they are all excellent.

The Weather Channel Max

You see, it's "max" because regular Weather Channel is not extreme enough. It is comprehensive and pretty to look at.  I only wish you could set the preferences to start on the local weather page, because although the splash screen is pretty, it slows me down in an annoying fashion.

Blogs and social media

Feeddler Pro
This is an RSS client for your Google reader account.  It's $4.99 and honestly, I am not sure I would buy it again.  The app works fine and does exactly what's promised.  Some people gripe about the bait-and-switch on the free version, which becomes crippled after one month.  I can see being annoyed by that. I'm more of the mind that the app just doesn't seem to offer much advantage beyond the Google Reader interface in Safari.  I've more or less stopped using it.

Another underwhelming app.  It works with a variety of blogging platforms and allows simple text blog entries, and you can add photos.  Whee.  No text formatting, no hyperlinks (!!) and terrible customer support.  For $2.99, it is not worth it.  If there were a basic HTML editor, I would be entirely more positive about this app.  I can email in a plain-text post to any of my blogs without paying anything.  Sadly, there does not appear to be a good blog editor for the iPad (at least not one that works with Blogger).

This makes me angry.  Seriously, there's no excuse for the official Facebook app not to be iPad-optimized yet.  I guess they're too busy trying to destroy their company with ill-considered privacy abuses.  At least it's free. If anyone knows a Facebook client for iPad that doesn't suck, let me know.

There are a lot of Twitter clients out there.  I like this one best.  It's free, easy on the eyes, and works well.  Unfortunately it does not have the facebook integration that the desktop client does; I don't know why.


Another visually stunning app.  This has tons and tons of recipes and the ability to suggest ones as well.  You can put the iPad in a ziploc, prop it up in the kitchen, and use it as a guide while you cook.  Also, you can have it email you a shopping list with the ingredients needed for a particular dish.  Free and highly recommended.


Kicks ass.  Free, though you need an account. Watch streaming video instantly, manage your queue, etc.  Online selection is not as robust as I would like.


A great pilot's app.  Plan your flight, get briefings, file your plan, get charts and maps, all on the iPad.  While the app is free, the service is $75 a year.  That might sound like a lot, but it's 30 minutes in a Cessna, and compared to the amount a Garmin or Jeppsen subscription will cost, it's a real bargain.  I haven't been flying as much as I would like lately, but when I am next in the cockpit, this will be on my kneeboard.  (They also make iPad-specific kneeboards.)

I've been playing X-Plane on my mac for well over a decade.  It's always been the best flight sim out there, and it's as good on the iPad.  There is actually a whole family of X-Plane games: the regular game, X-Plane Trainer, Racing, Airliner, Carrier, Space Shuttle, Apollo and Extreme.  The trainer game is free, and the Shuttle game is $1.99, the others are $9.99 each.  The only complaint I have is that the apps are expensive enough that I would expect bigger maps, and would not think that you should have to pay multiple times for what amounts to different versions of the same game.  The more traditional model would be to pay once for the game and a smaller fee for add-on maps/planes/scenarios.  My favorite in terms of fun and replay value is the racing game, which lets you race a bunch of classic warbirds through windy canyons. I am not sure if these are iPad optimized, but you can't tell if they are not.

Flight Control HD
Bid farewell to many productive hours when you get this addictive little game.  You try to direct multiple planes to the runways to land without crashing into one another.  But there are different types of planes with different speeds, that can each only use particular runways, and they come from all directions.  Fun and frustrating!


Another classic mac game ported to the iPad. I actually don't play it much, but my seven-year-old loves it. $2.99 and always fun. Not iPad optimized but scales well.

I think this is the best chess app for the iPhone/iPad.  $7.99 but a lovely interface with lots of options. You can get hints, look at a library of openings, set up the board to play puzzles (my seven-year old loves this -- I make him do all sort of fun endgames), and the engine is tough enough that I have difficulty on the hard levels, but flexible enough that beginners can beat the easy levels.  There may be tougher chess engines out there, but unless you are highly-rated you probably won't max out this one. And the customer support is great.  Highly recommended.

Silly, simple, fun and utterly utterly mesmerizing.   Very cute.  My five- and two-year-olds love this game, and I have spent more time playing it than I am prepared to admit.  $0.99.

Monkey Flight
A side-scrolling arcade-style game powered by (no joke) monkey farts.  What's not to like?  I have no idea where my wife found this one, but the kids love it and I do too.

If you can't tell, my kids have appropriated the iPad for their own use quite a bit, and I am not ashamed to use it as an electronic babysitter from time to time.  The interface makes it simple for the youngest kid to use (though have some screen wipes standing by for sticky-finger residue) and there are actually about a dozen kid-appropriate games on my iPad that I'm not bothering to comment on.  It's really great for casual gaming, and I certainly play more games on it than I do on my computer now. 

Are there awesome programs that you use on your iPad that I didn't list?  Let me know in the comments -- I'm always on the prowl for cool new apps.