This is Halloween

In the soundtrack the prologue is voiced by Patrick Stewart. Much better; I have no idea why they changed it to the other guy in the movie itself.

 

Now if you'll excuse me, I'm going to go raid my kids' candy stash...

Friday Flashback - Showmanship

I have been practicing a style of Okinawan Karate for a number of years now.  It's a simple, practical fighting style -- nothing showy or acrobatic, which is good for me since flexibility is not one of my strong points.  One of the key features of this style is a heavy emphasis on joint locks and grappling techniques, called tuite.  Frankly, this is my favorite part of training.  When someone has grabbed you and thinks he is controlling the situation, you can easily and simply use his own grip against him to turn the tables and put him on the floor.  I am continually amazed at the inventiveness of the old masters: how they understood body mechanics and topology and applied that to develop techniques in which one can place leverage on a joint in an unusual and powerful manner with only a simple and subtle movement.

You may think I'm a little off-topic, that I have become confused and think I am on the KaratePage Today site.  Not at all, my friends.  You see, I have had occasion from time to time to put my karate skills into more ... direct application ... in the ER.  Mostly it has been intoxicated or psychotic patients who needed a little focused pain to restrain them until an intramuscular injection of Haldol could take effect.  Once, a belligerent drunk attacked a nurse and I took him to the floor until security could get there and put on four-point restraints (followed by the local police applying handcuffs).  But, frankly, most of these have been psychosocial, not medical, applications of karate.  But not always.

 

I was working not terribly long ago at a site where we have double-coverage, and my partner asked me to help out with a dislocated shoulder.  We generally tag-team these procedures.  One of us plays anesthesiologist while the other does the procedure.  That way one doc can focus on the procedure without worrying about the patient's depth of sedation, ventilatory status, airway status, etc., and the other doc can focus on performing sedation safely.   

When you are doing the sedation, though, it's really not too engrossing, and like any good short-attention-span ER doc, I tend to watch the "main show" with interest.  This particular patient happened to be a rather obese woman, who unfortunately was so plump that we couldn't even palpate any bony anatomical landmarks.  After an uneventful induction of deep sedation with Diprivan, I watched "John" go through the standard maneuvers to reduce the offending joint.  He applied traction, external and internal rotation, extension and elevation with traction, and even some futile attempts at humeral/scapular manipulation.  He pulled and pulled until his face was red and his scrubs were stained with sweat.  He never got that satisfying "clunk" that indicates a positive reduction, but we both wondered if it might be in anyway.  The post-manipulation range of motion seemed normal, and sometimes if the shoulder is loose enough, you really don't feel the joint reduce.

The "post-reduction" film dashed our hopes.  Still out, despite all John's close-to-heroic efforts.

With a hint of malice in his voice, he said, "This time I'll push the drugs, and you can pull on the arm."

Fair enough.  I like a good reduction.   I stood by the bedside, while the various choreographed motions went on to re-induce sedation, and pondered the procedure.  John is more muscular and likely stronger than I am.  I had just watched him do every usual technique that I would have tried.  How was I going to reduce this one where he had not?  My mind wandered and entered one of those lateral drifts.  I thought about some tuite I had recently worked upon in karate class.  There was one nasty technique, involving a wrist-elbow-shoulder lock.  Not too useful in a fight, I had thought at the time, but it put a lot of very uncomfortable pressure on the shoulder if you could get it.

In the interim, a small crowd had gathered at the bedside.  (The ED was near empty, and a difficult reduction is always a popular diversion.)   A nurse nudged me, interrupting my reverie, "She's ready.  Let's see what you've got."   Still thinking about that joint lock, I picked up her right hand with my right hand, threaded my left beneath her forearm, up through the crook in her elbow, then over and behind her humerus.   I pressed down on her hand, levering against my left arm, while lifting and pulling a bit on her humerus with my left.  Immediately, without any hesitation, the shoulder popped in with a satisfyingly audible clunk.

Mildly surprised, I said, "There, that seems to have done it."   The crowd dispersed, murmuring appreciatively.  John was staring at me.  "What the hell did you just do?"   I explained that it was just a trick with leverage and showed him how to do it.  I elected not to tell him where I had come up with it and that I had never tried it before.  It would have ruined the moment.  

Now he thinks I'm some sort of genius.

I can live with that.

Originally Posted 2 November 2007

I'm a sucker for time lapse

And these are Freaking Amazing!

 

Landscapes: Volume One from dustin farrell on Vimeo.

It's totally worth it to watch in HD

Rapping about condoms

Clap your hands but don't get clap on your glans!

I love it.

Some sunlight on the corruption of the RUC

Interesting article (front page!) in the WSJ today about the RUC:

Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement. [...]

The RUC, as it is known, has stoked a debate over whether doctors have too much control over the flow of taxpayer dollars in the $500 billion Medicare program. Its critics fault the committee for contributing to a system that spends too much money on sophisticated procedures, while shorting the type of nuts-and-bolts primary care that could keep patients healthier from the start—and save money.

I'm glad to see the RUC getting some much-needed scrutiny, and skeptical scrutiny at that. But they miss the point with the "fox watching the henhouse" angle, or at least they paint with too broad a brush. "Doctors" are not a monolithic group, and it is those subdivisions that make the RUC such a dangerous agency.  The author manages to touch on the critical dysfunction here:

"This system pitted specialty against specialty, surgeons against primary care," says Frank Opelka, a surgeon and former RUC alternate member who is vice chancellor at Louisiana State University Health Sciences Center in New Orleans.

Primary-care groups have pushed for more representation on the committee, and their leaders have argued its results are weighted against their interests. 

Dr. Levy says the committee is an expert panel, not meant to be representative, adding: "The outcomes are independent of who's sitting at the table from one specialty or another."

I believe is where one would feign a coughing spell and blurt "bullshit!" into your hand. While the theory is that the members are there as RUC members, the reality is that every specialty lucky enough to have a seat on the RUC leverages that seat as an opportunity to advocate for the economic interests of their specialty.  The general surgeons are famous for sending a team of lobbyists, lawyers and (really) healthcare economists to make sure the RUC does not make any changes that would undermine the income of surgeons. (And yes, ER docs also have representation, though they bring a less impressive posse, and they do advocate for EM-related services to be up-valued.) This is referenced in the (oddly unlinked) accompanying article, where primary care physicians recounted an epic battle from a few years ago:

At one point, the debate reached such an impasse that J. Leonard Lichtenfeld, who represented the American College of Physicians, and at least one other RUC member, Tom Felger, who represented family physicians, actually came close to ending their involvement in the talks, and asked for a break in the meeting, according to both men. They felt a surgical faction was blocking their push, they say.

"I was willing to leave the negotiations," Dr. Lichtenfeld says. "I felt that we were being stonewalled for economic reasons."

On the other side, surgical groups had argued there wasn't strong evidence that visits with patients had gotten more difficult. "There were some bitter feelings," says John O. Gage, who represents the American College of Surgeons on the panel.

This touches on an arcane point of procedure the RUC utilizes: a code is assumed to be correctly valued unless it can be shown the amount of work involved in that service has changed. So you are not allowed to claim that the codes are fundamentally imbalanced or misvalued or that the effects of the current valuation are undesirable as a matter of policy. You have to contort yourself to make the case that somehow what you do has gotten harder, that it is different from what it was five years ago. At least that's what you have to do to increase a code's value. They rarely go down in value, despite the (nicely documented in the article) fact that surgical procedures reliably require less work as time goes on and technology/practice make them easier to perform. So the effect is that surgical procedures are even more overvalued than they were to begin with. It's also telling that the RUC relies on self-reporting surveys of doctors to determine the work that goes into a particular code. I frequently get these surveys that tell me that how I answer this survey may impact how much I get paid for this service in the future, so how much work is this service: a little, a lot, or a super-lot? The validity of these surveys which are reported by people who have an interest in their results and *know* that their responses will translate into dollars gained or lost is pretty much nil.

But this is a less biasing factor than the non-representative make-up of the RUC itself. Check out the WSJ's awesome interactive graphic about the RUC. When you view it on their site, you can mouse over the RUC members and see their specialty affiliation:

You will note that the relative specialty vs primary care representation on the committee is striking. Not only are primary care (and other so-called "cognitive" specialties) far outnumbered by their surgical/procedural colleagues, consider that these few primary care docs represent a cohort of physicians far larger than the specialists in actual practice.  One neurosurgeon has as much representation as 150 internists in this body.

Now I would agree that this does not need to be a strictly democratic process as a matter of principle. While we Americans are kind of ingrained with the idea that equal representation is the ideal, there's no reason that it has to be the case with this sort of body.  However, as a matter of policy, in terms of creating economic outcomes and incentives that would tilt the balance towards higher quality, lower cost health care, a more representative or weighted composition of the RUC would be preferable. 

I should also add that while I rail against the corruption of the RUC, it's not meant as an indictment of the people on the RUC, but the process and the system. I know the EM representatives of the RUC (past and current) and they are absolutely awesome people of high integrity. But it is also fair to say that they understand the game they are playing, on a very pragmatic level, and they work within the framework they are given to produce the best results for Emergency Medicine. Good people, bad system.

If I were king (I can't count all the times I have said or thought that) I would remove the fig leaf of objectivity and allow RUC members to openly advocate for their interests (which they are already doing sub rosa), coupled with a rebalancing of the RUC to provide more proportionate representation. Then I would hire a couple dozen Jonathan Grubers to crunch the numbers and make recommendations to the committee, based both on physician work as well as on the macroeconomic impact of the RVU valuations.  Of course, if I were king I'd also probably disband CPT entirely and also the New York Yankees, so maybe it's just as well nobody has seen fit to entrust me with that much power. 

Yet.

The Democratic Electoral Strategy

As usual, the Onion nails it. What could possibly go wrong?

 

Democrats: 'If We're Gonna Lose, Let's Go Down Running Away From Every Legislative Accomplishment We've Made'

 

WASHINGTON—Conceding almost certain Republican gains in next month's crucial midterm elections, Democratic lawmakers vowed Tuesday not to give up without making one final push to ensure their party runs away from every major legislative victory of the past two years.

 

Party leaders told reporters that regardless of the ultimate outcome, they would do everything in their power from now until the polls closed to distance themselves from their hard-won passage of a historic health care overhaul, the toughest financial regulations since the 1930s, and a stimulus package most economists now credit with preventing a second Great Depression.

 

"There's a great deal on the line, and we know it isn't going to be easy for us," said Senate Majority Leader Harry Reid (D-NV), speaking from the steps of the Capitol. "But if we suffer defeat, we will do so knowing we cowered away from absolutely anything we produced that was even remotely progressive or valuable in any way."

 

"And we will keep cowering right up until Election Day," Reid continued. "From Maine to Hawaii, in big cities and small towns, we will collapse into a fetal position and refuse to take credit for our successes anywhere voters could conceivably be swayed by learning what we have achieved on their behalf."

 

[...] According to party leaders, the Democrats are putting their sweeping new health care law at the top of the list of accomplishments to back away from, mainly by allowing its most popular provisions—federal subsidies to make health care more affordable; allowing children to stay on their parents' insurance until age 26; and rules that prevent sick people from being denied coverage—to be summarily dismissed as "Obamacare."

 

"Thanks to our efforts, a lot of people don't even realize they may already be benefiting from these reforms," Rep. Melissa Bean (D-IL) said. "They certainly don't realize they might be one of the 30 million currently uninsured people who will be provided coverage by the time the law is fully enacted."

 

"You can be certain we'll keep that information a deep, dark secret until we're thrown out of power," Bean added.

 

Japan's supreme contribution to human culture

I really don't know what to say about this, except that it's the GREATEST THING EVER MADE BY HUMAN BEINGS!

 

Srsly. Wow.

 

Make sure you check out what happens to the cat.

Death of a Gummi Bear

Awesomeness enhanced by the soundtrack (apparently a cover of DKM's "Shipping up to Boston")

Great Ideas that won't work (part 27)

Peter Orzag is a super smart guy.  He's a wonk's wonk. Serious, articulate and innovative, he possesses some serious nerd-fu powers, and I'm a huge fan of this former OMB director. (We all have a favorite, don't we?)  

But he doesn't know jack about medical malpractice, it seems.

Ezra pointed out a clever idea the Orzag wrote about in his NY Times column regarding medical malpractice reform:

As President Obama noted in his speech to the American Medical Association in June 2009, too many doctors order unnecessary tests and treatments only because they believe it will protect them from a lawsuit. Instead, he said, “We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines.” [...] What’s needed is a much more aggressive national effort to protect doctors who follow evidence-based guidelines. That’s the only way that malpractice reform could broadly promote the adoption of best practices.

Well, it sounds great, especially from a policy nerd's point of view: you kill two birds with one stone. Encourage adoption of evidence-based medicine, and also provide doctors with much-needed protection from baseless accusations of malpractice.  What's not to love?

Nothing, except the fact that it wouldn't work.

Seriously, I have reviewed lots of med mal cases, and, sadly, "failure to follow evidence-based standards" isn't a common allegation of professional negligence.  It's "failure to diagnose" and technical errors that tend to be the big money-losers in the legal arena. Evidence-based standards don't help.

Consider the biggest money-loser in Emergency Medicine: missed MI.  I'm not sure there are formal evidence-based standards for the diagnosis of myocardial infarction, but if there were they would probably be pretty straightforward, along the lines of get an ECG and order serum troponin, maybe with some subrecommendations about serial troponins if the first tests were negative; most of the existing guidelines focus on the most efficacious proven treatments of MI once it has been identified.  But if I may slightly fictionalize a case I recently reviewed, there was a guy who presented in the ER with a toothache. He thought he lost a filling and was triaged to fast track. He never complained of chest pain, though he did have nausea and vomiting (attributed to the tooth pain) and a triage nurse had recorded a complaint of left arm numbness.  He was discharged with penicillin and pain medicine and a referral to a dentist. He came back with a V-Fib arrest  about 8 hours later and subsequently died.

In retrospect, it's pretty apparent what happened here. The treating doctor simply never considered "chest pain" and cardiac issues as an avenue he should work up. An ECG was never ordered, because why would you?  I think this case was not malpractice (that was my opinion) in that this was a very atypical presentation of the disease and most reasonably prudent physicians would not have been able to correctly diagnose this particular MI, based on the information that was available at the time the patient presented. Evidence-based standards really only apply when the diagnosis is already made, or when the presentation is typical enough that standardized work-ups are appropriate.  Orzag's clever idea would not provide much of a line of defense for the physician who simply misses the diagnosis (whether it was his fault or not).

Similarly, if you do follow evidence-based standards, that won't shield you from allegations that you did so incorrectly. Another case I recall was a baby whose mother dropped it on its head and suffered an epidural hematoma. The ER doc did follow what would likely be the evidence-based guidelines and ordered a head CT. The bleed was diagnosed and treated appropriately. The child had a poor neurological outcome, and the plaintiffs later claimed that some trivial delays in the ordering of the CT scan were the cause of the bad outcome.  While in this case, the delay did not cause the bad outcome, it's hard to imagine that the "I followed the guidelines" defense would quash the lawsuit, and in some cases a delay really could cause harm and perhaps should be considered as grounds for negligence.

Then, finally, there are the claims that rely on faulty technical performance. Consider a patient in whom the ER doc follows the guidelines in securing an endotracheal airway, but cannot do so and as a result the patient suffers an anoxic brain injury. Evidence-based treatment is not at all relevant to the question of the physician's competence in adequately intubating the patient.

So what I am saying is that Orzag's proposal, attractive as it is, would not be particularly effective in changing the overall culture of defensive medicine or the jackpot mentality that pervades the medicolegal culture. It would provide physician defendants with an attractive line of defense in some occasional cases, which is welcome.  But as a panacea, or even as a driver of improvement in either of the desired policy arenas, it would be completely ineffective.

Friday Flashback - The Sh*t Hits the Fan

I posted the other day about a satisfying evening in which I was fortunate enough to see a number of acute cases in a row. Frankly, none of them took a ton of diagnostic acumen -- bread and butter stuff for emergency medicine, really. It was, though, a nice day.

One thing that struck me about a particular case was how quickly it went bad -- very very bad.

It was a woman in her child-bearing years who suddenly collapsed (i.e. syncope) while watching a football game. She came in looking ill but with stable vital signs, complaining of severe abdominal pain which had come on at the moment she fainted. Her hematocrit on arrival was 27 -- indicating either chronic anemia or acute blood loss.

So I'm no dummy -- the first thing I thought of was a ruptured ectopic pregnancy. But her pregnancy test came back negative. I am an experienced ultrasonographer -- don't ask me to find the common bile duct, but I can see blood very reliably if it is there. So I dropped the ultrasound probe on her abdomen, and the results were perplexing. There was definitively no blood in Morrison's pouch, or in the spleno-renal recess, or in the pelvis. There was an odd hypoechoic stripe across the body of the liver. It looked like a blood vessel, but was too linear. In retrospect it was probably blood in the falciform fissure, or some anomalous similar structure. But again, there was clearly no free blood in the peritoneum at that time. But based on that odd finding, I called in the ultrasound tech for a formal study.

A very short time later (it was chaotic -- fifteen minutes?), she crashed. She became unresponsive and profoundly hypotensive, with a heart rate around 150 (from the 80's). Annoyingly, in her throes as she passed out, she managed to pull out both her IVs. A repeat hematocrit came back at 21 -- she was clearly losing blood rapidly; the ultrasound tech arrived while we were re-establishing IV access and beginning aggressive volume and blood resuscitation. He dropped the probe on the abdomen and I uttered a four-letter word, because the DRY abdomen I had seen shortly before was now FULL of fluid.

Fortunately, it was not difficult to persuade the on-call surgeon to come in and take this young lady directly to the operating room. The surgeon did a superb job to stanch the bleeding (from her ruptured Splenic Artery Aneurysm) and perform an emergency splenectomy. The patient survived (thanks in no small part to the Cell Saver) and did very well.

What was striking was how very quickly she went from "ill-but-stable" with an empty belly to "moribund-with-belly-full-of-blood." Amazing.

Originally Posted 10 November 2007

Times Change

GruntDoc posted about the classic ER doctor's nightmare: “You know that patient you saw yesterday?” was how the conversation started.

I've been there.  I know the bolt of adrenaline, the cautious, "Yeah, why do you ask?" that you always respond with.   But one thing that our Brave New Technological World has brought to us is this: the email of doom.

Your institution may vary, but for us, the adrenaline-producing email comes with the subject line of "SECURE Email for Dr. Shadowfax" and it links to the hospital's (damned) HIPAA compliant encrypted webmail interface. Nobody ever uses it because it's a hideous pain in the ass, except the official hospital quality officer who is responsible for reviewing all "Unusual Occurrences," which is the euphemism for unexpected deaths, bad outcomes, 24 hour returns, patient complaints, nursing complaints, etc.  Nothing good.  So when you see the awful subject line, you just know that whatever is waiting in there for you is an unpleasant little Christmas present, the sort you don't really want to unwrap but you have to.  Just as an extra bit of pain they make sure the login process is as slow and cumbersome as possible. Two entries of your password (which has to be changed every ninety days, natch, and you can't re-use passwords). 

The awful, truly awful thing about these emails is that they are only generated by BAD things. There's no possibility that this will be a patient compliment, or a "well done." So as soon as you see the header you are bracing yourself for whatever bit of awfulness lies within. It's not necessarily anything your fault. People get worse. Subtle presentations become more clear over time. Nurses mess things up and patients complain about the dirty guy in the waiting room (these also go to the secure email, for your comment). But as soon as you see the "SECURE Email" header, you are sure that it was that dizzy guy from yesterday, and you're cursing yourself for sending him home until you finish the login process and find out that it was really some dude unhappy that you only gave him ten vicodin.

I think that sometimes our medical director sends out trivial emails on the secure email system just to screw with our heads.

Of course it goes both ways.  As the "boss" for our group I have found that people dread seeing my name on the caller ID, and the meanest thing I can do is leave someone a voice mail saying that I need to meet with them. It's like when you were a kid and you got called to the principal's office, that sense of "What did I do?" (or in my case, "What did I do that you found out about and can you pin it on me?"). So I try to be really clear when I'm calling about a minor thing so people don't freak out, but the power of intimidation is amazing, even when I don't want to be intimidating, which is pretty much all of the time. Worse, sometimes I do have to call someone in for a "real meeting," and that's just hateful all around. 

I also remember the old medical director, a close friend, used to call from the office just to chat, and when I saw the caller ID I also had the panicked sense of "Crap, what did I do?" until I answered and found out he just wanted to talk about the Chicago Bears.

Which in my mind ranks right up there with sending out trivial emails on the SECURE system as the hallmark of an absolute bastard.

Squee

Just Another Drunk

The guy in room 8 was a drunk, "just another drunk." It sounded like he was pretty hardcore -- homeless, been living on the street for a while, refused at the mission.  The story sounded benign: he had been sleeping in a bush somewhere, and some Good Samaritan had called the ambulance, but he denied trauma or any other problem.  Just had so much to drink that he wasn't able to get back to his regular spot under the bridge. Alcohol level somewhere north of 300.

I was a little curious, though, because a quick review of the records showed that he hadn't been in our ER before.  Most of the resident homeless alcoholics in our community stop in the ER every so often, if only for a laceration or a sammich once in a while.  And I also noted that his age was 75 years old.  That's a remarkable feat of longevity for someone living on the street.  So when I saw him, I was a little more inquisitive than usual, just to be sure I had constructed the narrative correctly.

I had.  He was not exactly new to our community; he had been staying in the local jail for six months.  Prior to that he had been living on the street in a town a bit further south.  But once released, he hadn't bothered to go back "home" since one bridge is much like another.  So he stayed in our fair city instead. He was surprisingly cheerful in spite of it all.

He looked wiry and weather-beaten, someone who knows how to survive on the street, but also frail and vulnerable due to his age.  While he was clearly expecting to be discharged back out, I was a little apprehensive about letting him go on his own.  I probed -- "Do you have any family?  Anyone local that you could stay with for a while?"

He considered for a moment.  His face darkened, just briefly, and he responded, "No. No family."

That made me sad.  We discharged him once he was ready -- there weren't any other good options. He had no acute medical needs to justify an admission.  We used to have some detox beds but once the recession hit, social services were slashed to the bone, so that's not available any more. There are some local charities, but quite frankly they are not equipped to handle someone like him, and I'm not actually sure that he was interested in any "treatment" at this point.

But I reflected, as I completed his chart, after he left, on that moment of hesitation before he said he had no family, no friends, nobody on this earth that he could look to for help.  He had considered the question.  Clearly he was going through a mental checklist of his own, remembering all the people that he once had relations with before he decided all of those doors were closed to him. Seventy-five years alive and all alone.  What a tragic legacy.  What were the stories to be told there?  Estranged spouses and girlfriends?  Children, now grown, who longer wanted anything to do with him?  Or had he somehow, improbably, outlived them all? Was he the survivor in his small social circle?  That's a kind of isolation, a kind of loneliness that I'm not sure I can really understand. What frailties, what demons drove him to such lengths? His story would have been long, fascinating and sorrowful to hear, I am sure. But he wasn't inclined to share it.

Seventy-five years and not a single person who gives a shit about you. What a legacy of failure for a lifetime's efforts. No wonder he wanted to lose himself in drink. But really, he wasn't so different from many of the others who pass through our doors for a few hours. He just had lived longer. Most of the 40- and 50-year old homeless alcoholics are the same, they just meet their ends sooner due to the elements or the drink or violence or accident. They don't make it to a diamond anniversary.

I have a couple of uncles who succumbed to alcoholism, lost their careers and families and everything, winding up on the street. I've watched my cousins go through the cycles of anger and regret and forgiveness. They wanted to badly to save their dads, and they couldn't save them from themselves no matter how they tried. And so it was with the guy in room 8.  He got his sammich, some vitamins and juice, and he was off to fend for himself, and there was nothing we could do for him except be here for him when he needs it.

Of all the sad things we see in the ER -- and there are plenty -- this seem to me to be one of the saddest and least appreciated, and by far among the most common.

Body of an American

Difficult

Friday Flashback - Small Victories Part Two

I work from time to time at a rural hospital up in the mountains. It's a pleasant change of pace from the high-intensity trauma center where I do the majority of my shifts. The acuity, volume, and patient population vary dramatically, as you might expect. The Big Hospital sees over 100,000 ED patients annually, whereas the rural shop sees less than 20,000.

One interesting consequence is that the nurses in the little hospital seem to know all the patients, either socially or from previous ED visits or both. Depending on the circumstances, it can be very helpful or very awkward (or both). One recent night, a woman came staggering into triage clutching at her lower back. The charge nurse groaned upon seeing her, and took me aside: "We know her from before. She's a big-time drug seeker, and has been caught on more than one occasion altering and forging prescriptions from this ER." She pulled out a binder where we keep "care plans" for patients with chronic pain and narcotic issues. The patient's history was laid out there in its sordid detail, and supported the Medical Director's recommendation that this individual not be prescribed narcotics. "Just kick her out of here, will you," the nurse suggested.

As helpful as this kind of advance knowledge is, I kind of hate it. I still have to go in and see the patient, and it's very hard not to be prejudiced about the encounter and give the patient a fair evaluation. Especially when the vast majority of time the prejudice would have been accurate. So I try to push the "drug-seeker" conclusion out of my mind until after spending some time with the patient. But it's not easy.

This encounter, however, did not seem likely to diverge from my preconceived expectations. She informed me that this was her standard back pain for which she was on a staggering dose of narcotics (OxyContin, 80 mg TID plus oral Dilaudid!) but the pain had just become intolerable. It was with a sense of despair that I went through the formulaic questions necessary to differentiate chronic back pain from an acute emergency, and her answers were bland and unrevealing. I noticed, though, that she was sort of writhing on the bed, and when I asked her directly, she said that, yes, in fact, the pain was coming in waves. Hmmmm. Might there be something more than myofascial back pain?

So I got a simple test: a urinalysis. It showed a microscopic amount of blood in her urine. The nurses rolled their eyes at me when I ordered a CT scan of her abdomen, but to my mild surprise and infinite satisfaction, the scan showed a large obstructing kidney stone!

It just goes to reinforce the old adage that even drug-seekers get sick, too. But then I found myself with a conundrum: how on earth was I going to control her pain. When you are on high doses of pain medicines, they lose their potency, and I estimated that I could use all the morphine in the hospital without making a dent in her pain. Worse, she had deteriorated somewhat in the time it took to get the scan, and when I saw her again, she was pale and covered in a sheen of sweat.

Predictably, she was "allergic" to Toradol, as many drug-seekers claim to be (it doesn't provide the euphoria that narcotics do) but when I questioned her carefully she said it just "upset her stomach" and "doesn't work for me." So I explained that I thought narcotics would not help her pain, but I thought Toradol might, and she agreed to give it a try.

Forty minutes later I checked on her again and she was resting comfortably. With gratitude, she said, "I can't believe how well that stuff worked! I never would have thought it." A little while later, she went home, feeling "100% better," and I faxed some prescriptions over to the pharmacy for her. By god, it is satisfying when things works like they are supposed to, and in this case, it perfectly split the Gordian knot of pain management in the opiate-addicted patient.

Originally Posted 28 November 2007

Sunshine Highway

In a DKM sorta mood lately:

Cheers.

Life's little and not so little victories

I groaned when I read the chart.  It didn't look promising, and in fact it looked downright painful.  A flog -- might take a ton of work and involve a difficult disposition.  And worse, I had picked it up with only a little more than an hour to go in my shift.  These are the "witching hours," when there's not really enough time left to perform a work-up and dispo a patient, but when there's a long enough time left before your relief arrives that you can't in good conscience let the patient wait.  I toyed with the idea of saying "hi" to the patient and getting labs ordered and seeing if I could sign it out to the next guy.  Not too unreasonable if it was going to require some time-consuming test, which it looked like it might.  I braced myself for the worst, squared my shoulders and walked into the room.

To my surprise, I found myself calling the admitting doctor fifteen minutes later, diagnosis in hand.

There were red flags all over the chart to begin with:

• 75-year old woman, speaks only Ukranian: Great. I'm going to have no capacity to communicate with this lady. Not to stereotype, but in my experience there's a strong cultural reticence among elderly eastern european women.  Translators help only a little bit.
• One month of fever, temp at triage 38.5: She's old and febrile, so it's going to be something real. This is not a worried well person I can blow off, reassure, and send away.
• Headache: Oh shit, am I going to have to do a spinal tap on this little old lady? Jebus, let it not be so.
• Seen in ER three times this week, and in clinic twice: What possible reason is there to think that I am going to figure this out when five previous doctors have not?

Yeah, there are times when ritual suicide seems a more attractive option than sticking your head into the morass, but this is the life I have chosen.  I threw myself into it. The scene in the room was verging on the comical.  This stout, wizened old woman could have been the embodiment of Mother Russia herself, so classic was her broad, deeply lined face.  She lay back on the gurney, her head wrapped in a white babushka and a floral scarf around her shoulders. She was wearing a pair of oversized wrap-around sunglasses similar to the cheesy old Blu-blockers. For some reason her family had carefully wrapped a couble of ER blankets around her head and her lower body, so she looked as if she were partially mummified.  She was attended by two very concerned, ridiculously attractive younger Russian women.

As I had anticipated, the old lady said not a word for herself. Her daughter and granddaughter did all the talking, and when I tried to address questions directly to the patient, the old lady gave monosyllabic replies, which her family amplified on translation to full paragraphs.  The story was both reassuring and alarming.  She had already had CT scans, spinal tap and blood work on more than one occasion, with no diagnosis. So at least I was unlikely to have to repeat the tap, I reflected.  But she also had now lost the vision in her left eye, and the right eye was very blurry.  The daughters were also concerned about the new swelling of her eyelids and face.

Indeed, I noticed that there was a significant amount of periorbital edema, bilaterally, and also some faint erythema.  I wondered whether the vision loss was from the eyelids being swollen shut, maybe a facial cellulitis, or possibly even a retrobulbar cellulitis could cause fever and vision loss.  I mused on these possibilities as I went to examine her.

She flinched violently away from me as I touched her face to remove the sunglasses.  So it was very tender.  I wanted to examine a bit more thoroughly, so I moved to push her babushka back. This provoked quite a reaction!  She slapped my hands away and unleashed a rapid diatribe in Ukranian.  I didn't understand a word of it, but the meaning was quite clear: she did not want me to touch her babushka!

I was firm, however, and she submitted to my requests (with some coaxing from her daughters), and when I peeled off the head-blankets and afore-mentioned babushka, I was struck by these two large, bright red swollen lines running up the sides of her temples.  Right ... along ... the course ... of the ... (wait for it) ... temporal artery!  It was the most amazing thing I have ever seen, and quite tender, as well. I immediately went back to the computer and checked her previous labs -- sure enough, her sed rate was 75.  Somehow, one of the previous five docs had ordered the right test and managed not to put two and two together.  Maybe the patient didn't let him touch her babushka!

Not to be critical, of course. This was not an easy history or exam, and it was probably way more obvious by the time I saw it. (Her sed rate was over 140 by that time, so there really had been progression of disease.)  And Temporal Arteritis is ridiculously rare -- I've been doing this for well over a decade and I have never actually seen it before. I can't vouch for the fact I would have figured it out on the first visit. But it wound up being enormously satisfying: I got this "red flag case" admitted and started on IV steroids, with an optho consult, all in a little over half an hour.  And I got to feel, perhaps undeservedly, terrifically clever for being the guy that figured it out, or at least being the guy who removed the babushka.  Sadly, this may not make much of a difference for this lady -- the visual loss is often permanent.  It's also the exception that proves the rule: I wrote recently about the general uselessness of the physical exam. This is one of those cases where exam was everything, and why you still have to do it.

Also, I just love saying "babushka."  That word has got such a lovely round feel to it: baBOOOshka.  Babuska. Babushka.  I'm really a simple man with simple pleasures.


(Also, I know that Ukranians and Russians are not the same thing, just like Irish and Scots aren't, and they hate being conflated together. Permit me my rhetorical flourishes.)

The God of Cake

This may well be the greatest thing I have ever read:




via Hyperbole and a half

I would never have guessed

I try to be polite and respectful to all the members of our care team, from nurses to techs to paramedics and on down the chain of every care provider who works in the ER.  I thank them for doing their jobs, whether it's security, housekeeping, social work, you name it. I try to make each and every one of them feel like I recognize and value what they do for the team and for our patients.

But it's hard. There are 300 nurses alone in our ED.  How am I, name-impaired individual that I am, supposed to remember all their names, with nurses coming and going all the time?  Which tech has a sick kid?  Which housekeeper was it whose husband I took care of when he hurt his eye?  I try, but I confess that I am just not good at it, and more, when I am in the department I'm usually pretty focused on the task at hand -- moving the meat, as they say.  Which doesn't leave me much time for socializing.

So it was a pleasant evening which gave me some leisure to chat with the rest of the staff, as we had nothing much going on.  One of the folks hanging out in the department was one of the security guards.  I remembered him, among all the guards, because he was a bit older, he always wore all the gear -- bulletproof vest and harness and everything -- and he was impeccably professional in the way he interacted with everybody.  I liked him, when we had occasion to interact.

I was unpleasantly surprised when he referred to his impending departure from our hospital's employment.  I asked what he was planning to do, and he explained that he had landed some mid-level executive security position at the local major international airport.  He seemed enthusiastic about the move so I congratulated him, but noted that it was a little bit of a jump, both geographically and industry-wise.  He commented that it fit real well with his background, in a way that made it clear that he expected me to understand the reference.  I bit: "Do you have experience in aviation?" I asked.

"Well sure, didn't you know that?" he responded.

I insisted that I had not, but being interested in airplanes I was curious.

"I was a captain with [major airline] for twenty-five years," he replied, "but they make you stop flying when you turn sixty."

My first thought (suppressed) was "You're over sixty?" which was followed immediately by "Holy crap! You're an airline pilot? That's so cool!"  We spent the rest of the quiet shift engrossed in the planes he had flown and interesting experiences he had in his career.  Curious note: he had gotten into security because as a pilot he had enrolled in the pilots' Federal Air Marshal program after 9/11, but he had never imagined that would be his "second career."

I reflected on how unfair it is that pilots are forced into retirement when they are still very much in the prime of their productive careers, and how odd it was that he had come from a job that, prestige-wise, was every bit the equal of an ER doc if not greater, to a "lowly" security officer in a hospital.  He seemed happy enough, or at least content.  Ultimately, the most important thing I took away from that conversation was a reinforcement of the fact that you cannot make assumptions about people based on their current role.  You just never know what skills or experience or history people have that may not be apparent on casual interaction.

The Deserving Poor

One the the benefits of visiting Vegas for the ACEP conference is that I met an alum at the dinner for my residency program, who also happens to be a health policy wonk, ER doc, and progressive blogger.  Who knew?  Anyway, she is currently blogging over at Doctors for America (formerly Doctors for Obama, I recall), and she put up this very nice post:

The "Deserving Poor" and the "Undeserving Poor"

A cruel disparity exists in the US.  Most states in the nation currently recognize two separate groups of the poor—the “deserving poor” and the “undeserving poor.” The deserving poor include pregnant women, children and their parents or caregivers, and the disabled.  The undeserving poor largely consist of childless adults.  The deserving poor are provided with health coverage through the Medicaid program.  The undeserving poor—no matter how destitute they are—do not qualify for Medicaid benefits.  As of 2006, there were about 9 million adults without dependent children living under the poverty line who were uninsured.

I highly recommend you click through to read the rest, and add Progress Notes to your reader -- there aren't enough openly progressive medical blogs out there.

On a policy point, I would like to point out that this is one of the real advantages of the PPACA -- it expands medicaid to 133% of the federal poverty line and eliminates this notion of the "undeserving poor," and does so in a very efficient manner.  Medicaid is by far the most cost effective method of expanding insurance coverage.  More importantly, the PPACA takes this cost almost entirely on the federal budget.  This is important because state budgets are strained to the breaking point by medicaid, and the costs of medicaid are highly counter-cyclical. By that we mean that as the economy craters and state revenues plummet, more and more people find themselves jobless and become medicaid eligible and the cost to states for medicaid soars at exactly the time they can least afford it. So by paying for the medicaid expansion federally, health insurance is expanded relatively painlessly to state governments.  I might add that another benefit of the feds paying for the medicaid expansion is that they will now be responsible for the bulk of medicaid costs in most states, which sets the perfect precondition for a full federalization of medicaid.  This would be great on so many levels: standardized enrollment and eligibility criteria, roll the administration under CMS instead of making 50 state governments reinvent the wheel, and free the states' inelastic budgets from the crippling and ever continuing explosion of the costs.

Now I can already hear the objections -- "Medicaid is shitty insurance!" "I lose money on every case!" "Coverage doesn't mean access to care!"  All true.  Of course, this is mitigated at least somewhat in that the PPACA brings medicaid reimbursement for primary care services to parity with Medicare services.  Medicare may not be the greatest payer, but it's an improvement for sure, and this will also improve access to primary care.  (It's also another argument for federalizing Medicaid -- it would probably create parity for all service lines.)  But it's also a darn sight better than nothing, which is exactly the alternative offered by those advocating for the repeal of health care reform.

Bastards on Parade

No, not wall street banksters. Classic DKM:

Better audio, but no video can be heard here.

What I'm reading this morning

Pediatrician and economist Aaron Carroll over at the Incidental Economist cites some interesting data which dispute the popular myth that Canadian patients and doctors are fleeing their health care system for the US' health care.  In fact, there has recently been a net migration of physicians from the US into Canada, a fact which surprises me but given the relative population sizes perhaps shouldn't.

via Health Reform Watch:  HHS Grants $727 Million To Community Health Centers.  This money is funded out of $11 Billion allocated in the much-derided PPACA (health care reform law) for construction and expansion of CHCs, and is on top of $2 Billion allocated for that purpose in the ARRA (Stimulus act).  We have a new three-story CHC going up down the block from our hospital, replacing a much, much smaller older clinic.  Given how overburdened they are with underserved patients, this may have a great effect increasing access to care in our community.

The Hill's healthcare blog says a preliminary decision on the lawsuit filed by states Attorneys General against the PPACA is expected by Thursday.  Most observers expect the judge to allow the suit to move forward, though it may be narrowed in scope a bit. Talking Points Memo has a round up of all the active lawsuits against the Health Care Reform Law.

via, xkcd: Pumpkin Carving.

Rand Paul, ophthalmologist and nutjob candidate for Senate in KY, can't quite decide how he feels about Medicare.  He's called for a fix to the SGR and at the same time suggested substantial increases in out-of-pocket costs for Medicare beneficiaries.  Last night in a debate, he seemed to suggest means testing Medicare, and his opponent pounced.  It probably won't make a difference.  

via Balloon Juice, apparently the Economy is Just Fine, Never Mind All the Fuss:

Pay on Wall Street is on pace to break a record high for a second consecutive year, according to a study conducted by The Wall Street Journal.

Oh, well. Problem solved.  You're welcome.

This is depressing: apparently GM's been lying about the Volt, their new electric car.  Promoted as all-electric drive and capable of 230 mpg, it appears that it's actually good for about 37 mpg and about 30 miles of electric-only operation, and the gas engine does power the wheels. So it's basically a bigger, less efficient plug-in version of the Prius.  OK, I guess, but way way short of the hype. 

This is not to be missed.  Colbert tears apart Republican Rich Iott, who wore a Waffen SS uniform as part of a Nazi-re-enactment hobby.

The Colbert Report	Mon - Thurs 11:30pm / 10:30c
Rich Iott Wears a Nazi Uniform
www.colbertnation.com
Colbert Report Full Episodes 2010 Election March to Keep Fear Alive

Best line: Iott said his Nazi reenactment was simply "a father-son bonding thing." Colbert said: "That's right. Fathers bond with their sons in all kinds of ways. Building a boat, fixing the car, solving the Jewish problem."

ACOs -- the Gathering Storm?

Those of you who have read this blog for any length of time know that I have been a pretty strong advocate for health care reform.  This has been primarily motivated by my passion for universal coverage, but also with my frustration with the cost of the current health care system, the generally crummy outcomes and the overall level of fragmentation in the whole affair.  Even today, I had to repeat blood tests on a cancer patient who came to the ER. He had had blood tests at the cancer center ACROSS THE STREET before presenting, but, so sorry, our computers don't talk to theirs and it's after 5pm now, so forget about getting those results. 

So it's with a mixture of enthusiasm and dread that I consider the coming onslaught of ACOs.

What are ACOs?  They're the buzzword of the day, that's for sure.  Everybody knows they are the Next Big Thing.  They're coming.  We'll all be in an ACO by next Tuesday for sure.  It'll be nirvana.  Right? 

Sorry, I'm still not clear what they are, and why are they coming again?

Definitions vary a bit, but in general ACOs are an effort to reduce the cost and increase the quality of care by:

1. Eliminating the traditional fee-for-service payment model
   
2. Integrating the delivery of health care
3. Shifting financial risk onto health care providers

The idea being that if health care providers (meaning hospitals, clinics and physicians) are all, as one, responsible for decreasing the cost of health care delivery, they are more likely to band together in a way that will improve care and thereby decrease excess costs. Something similar was tried in the '90s - capitation - in which the risk was simply offloaded to doctors.  This failed because there was no effort to include other health care stakeholders, and because physicians rebelled against this model.  Similarly, the hospitals have long been incentivized to reduce the cost of care through the Inpatient Prospective Payment System, but that does not involve physicians and still is linked only to a single inpatient admission.  The envisioned reforms differ because they will provide only a single payment, bundled among all involved providers, and the payment will extend beyond a single site of service, but be for an entire "episode of care."

A necessary prerequisite for such bundled payments is that there needs to be an entity designated to receive and distribute these payments.  That's an ACO -- Accountable Care Organization.  The PPACA authorizes Medicare to begin pilot programs in ACOs and bundling starting in 2012, with a clear eye towards making this a national model.  My view had been that this would necessitate that physicians all become hospital employees, but this is not necessarily the case.  it does require closer relationships and partnerships between physicians and hospitals, however. An article in Health Affairs by Elliot Fisher (considered the originator of the ACO concept) outlined possible models:

1. Integrated Delivery Systems
Integrated delivery systems involve a common ownership of hospitals, physician practices, and—in some cases—an insurance plan. Some examples are Kaiser Permanente, Group Health Cooperative of Puget Sound, and Geisinger Health System. These systems typically have aligned financial incentives, electronic health records, team-based care, and resources to support cost-effective care.
2. Multispecialty Group Practices
Multispecialty group practices usually own or have a strong affiliation with a hospital. Examples of this type of arrangement include Mayo Clinic and Cleveland Clinic. They usually do not own a health plan but, rather, have contracts with multiple health plans in their areas. Most have a long history of physician leadership and highly developed mechanisms for providing coordinated clinical care.
3. Physician-Hospital Organizations
These organizations are a subset of the hospital’s medical staff. One example is Advocate Health in Chicago. Most were formed in the 1990s in response to managed care pressures to negotiate with health plans. Some function like multispecialty group practices, focusing on reorganizing the delivery of care to achieve more cost-effective coordination. Although they may be less well suited than integrated delivery systems or multispecialty practices to qualify as ACOs, many could structure themselves to meet the criteria for that type of organization.
4. Independent Practice Associations
Independent practice associations consist of individual physician practices that came together largely for purposes of contracting with health plans. Over time, however, many of these have evolved into more-organized networks of practices that are actively engaged in practice redesign, quality improvement initiatives, and implementation of electronic health records. One example is Hill Physicians Group, in Northern California. Such organizations could qualify as ACOs, and that might encourage other independent practice associations to evolve similarly, given sufficiently strong financial incentives and technical assistance.
5. Virtual Physician Organizations
Finally, a number of small, independent physician practices, many located in rural areas, can organize to become “virtual” physician organizations, such as Community Care of North Carolina. This process can be led by individual physicians in rural areas or by a local medical foundation, state Medicaid agency, or similar organization that can provide the leadership, infrastructure, and resources to help small practices develop disease registries; implement electronic health records; share information; and provide better-coordinated, cost-effective care. These virtual networks could qualify as ACOs and serve as models for other groups of small practices.

In our locality, we have both #1 and #2, and they do contribute greatly to high-quality, low cost health care in our community. I've seen the way the stakeholders and physician leaders work together, and it has led to some great results.   It's not clear to me whether this is scaleable -- whether it can be translated into other communities where there is no tradition of collaboration between docs and hospitals, where caregivers at different sites view one another as rivals and enemies rather than partners in care.  I don't say this, by the way, as an indictment of other communities.  Our locale is unusual in that there is one big hospital and one big multispecialty group and one big HMO.  They partner by necessity, and there is little to no local competition.  In other places, where there may be multiple hospitals competing with one another for business, multiple physician groups trying to play one off over another, surgicenters and free-standing ERs skimming off the cream, the economic environment may make it very difficult indeed to bring these players to the table together in an ACO.

The other concern I have is what this may do to emergency medicine as a specialty.  About half of ER docs are already hospital employees or effectively hospital employees (faculty foundations and the like), and the remainder work for independent physician practices.  As Myles Riner put it, " EPs are going to have to find ways to share risk in ACOs as independent practitioners or as hospital employees without sacrificing significant income or undermining practice quality and autonomy."  This represents a significant challenge.  ER docs tend not to belong to the big multi-specialty groups that will bring significant clout to the table in the management of an ACO.  We also are highly subject to leverage from our hospitals in contract negotiations.  We are in a vulnerable position and risk getting squeezed between the big players in the formation of ACOs and the distribution of revenues.

What's the old saying? "Democracy is three wolves and a sheep voting on what to have for lunch."  The ER is small enough that we're little more than a snack for the big guys, but we will be hard pressed to keep them from eating our lunch out of sheer opportunism.  We are going to have to make a strong case for the value of our services in the episodes of care that pass through the ER.  It's also going to be difficult to resist the pressure to simply become hospital employees.  Hospitals may suddenly rediscover an interest in directly employing (and controlling) their ER docs when the financial risk is so greatly magnified as it will be under bundling payments for episodes of care.  While there's nothing wrong, per se, with being an employee, it tends to depress income.  Physicians who are entrepreneurial, who are working for themselves tend to be more effective at running a lean practice and at effectively billing for their services. When this becomes outsourced to the hospital, practice bloat sets in and under-coding for ER physician services becomes the rule.  For physicians who want to maximize their value and the return on the care they provide for their patients, it is best to be independent.

The best advice I can give to ER docs (and frankly, any hospital-based physicians) who are considering how this is going to impact their practices is this:

• Don't Panic. The history of US health policy is littered with the smoking carcasses of fads like these that never quite caught on. ACOs may become the national model in the future. But we're still eighteen months away from pilot programs.  There's a lot of time before we know what will happen, and this may very well come to nothing.
  
• Develop a close partnership with your host institution. (Always good advice.) Demonstrate that you are aware of these macro-trends, and that you are prepared to work with them to maximize quality and efficiency.
• Demonstrate that your practice adds value to the patient's care.  Embrace protocol-driven care as a mechanism to improve consistency and quality and seek for ways to align the incentives of your physicians and the institution.
• Encourage collaboration with community providers. If ACOs do become the default model in the future, practices which have already built relationships with their community partners will be better positioned to withstand the changes and perhaps even prosper.

Here are a couple of excellent (more detailed) primers on ACOs, from the blogs Health Reform Watch and The Health Care Blog:

A Guide to Accountable Care Organizations, and Their Role in the Senate’s Health Reform Bill

Pitfalls of PPACA – Accountable Care Organizations

Health Care Reform Law upheld (for now) in Federal Court

Not the final word -- far, far from it, one would expect -- but the first verdict on the merits of the constitutionality of the PPACA:

On Thursday, U.S. District Judge George Caram Steeh issued a ruling in Thomas More Law Center v. Barack Obama. It's one of a dozen lawsuits the opponents of health care reform have filed in federal courts, in an effort to roll back the Affordable Care Act. But it is the first case in which a judge has issued a verdict. And the verdict is pretty much a wholesale win for reform.

The plaintiffs in this case are the Law Center, a conservative public interest law firm based in Ann Arbor, Michigan, along with some Michigan residents. The focus of their lawsuit is the individual mandate--the requirement, which becomes effective in 2014, that all Americans obtain a "creditable" health insurance policy. ("Creditable" is wonkspeak for a policy that includes basic benefits, as defined by the government.) According to the plaintiffs, the federal government has no right to impose that requirement, since it would compel people to spend money on health insurance instead of some other good.

In response, the Obama Administration has argued the authority to impose the mandate lies in two separate constitutional provisions--one that gives the federal government power to regulate interstate commerce and one that gives the federal government power to tax for the sake of promoting the general welfare. Steeh basically agreed with both propositions.

So, good.  This is what basically all legal scholars have been saying all along: the law as crafted is completely within the traditional interpretation of the powers of the Federal government.  What (or who) will ultimately decide this, I suspect, is Anthony Kennedy. This will go to the Supreme Court.  At some point, a Federal judge who is a member of the Federalist society will strike down the law, and the Supreme Court will be called on to resolve the lower-court conflict. Or, if the law is upheld on appeal across the board, plaintiffs will appeal to the SCOTUS, and it's hard to imagine them turning down such a major case. In fact, the Roberts bloc will be only too happy for an opportunity to radically restrict the reach of the Commerce Clause (a long-time irritation for small-government conservatives), and at the same time deliver a crushing partisan blow to liberals. The four center-left judges will support the traditional interpretation of the Commerce Clause. What will Kennedy do? He's generally been relatively small-c conservative, but has been willing to sign on to some fairly radical rewritings of constitutional law (Citizens United, most prominently).

I honestly have no idea what is going to happen at the SCOTUS level, and an awful lot of power is concentrated in the hands of one relatively inscrutable guy.

Buckle up, folks.

Why do we spend too much on Health Care?

Aaron Carroll over at The Incidental Economist has been running an excellent series on health care spending in the US, and how much more we spend than the rest of the world, on a per capita basis, as a percentage of GDP, and by category.  It's an excellent series and I wholly recommend it.

Summary graph:



Hint: the US is the lavender-ish line on top.  As he says, is there anything about this graph that isn't concerning?

Also, here's a fun interactive tool which shows the same basic thing.  Not that we didn't know that we spend tons more than everybody else on health care.  That fact has been beaten into our heads over and over recently. What we want to know is why do we spend so much more than everybody else, with an eye to what we can do to bring the escalation of costs under control.

So his conclusion?  As the kids say on The Facebook, "It's complicated."

It's not obesity.
It's not Pharma's fault.
It's not the trial lawyers.
It's not overpaid doctors.
It's not the insurance companies.

It's all of these and more.  It's that every element of our system costs more. All of these factors feed into the extra 7% of GDP that we spend on health care. Doctors do make more in the US -- but physician salaries are only a small slice of the excess spending:



The depressing conclusion I reach when I look at these numbers is that any sort of a fix for this in our professional lifetimes has become vanishingly small.  The Affordable Care Act may make some small inroads into cost containment. Emphasis on "may" and "small." It certainly does not do enough.  And after the rancid demagoguery from conservatives during the health care debate, and the price democrats are set to pay at the polls next month, what is the likelihood any politician will tackle this issue again during the next decade?  And this was a modest, moderate set of reforms patterned along the lines of those previously advocated by conservatives.  We need sweeping change, and we got baby steps and half-measures.  Worse, the republicans actually want to repeal the small improvements that PPACA makes. We need to fix, improve, and expand on the health care reforms, but the party (likely) in power wants to go in exactly the opposite direction.

Sigh.  We're so screwed.

I fart in your general direction

Via Sully, this is a brilliant bit of history:



I smile just imagining what that censor must have been thinking to himself as he saw the film for the first time. I also like the way the producers blandly throw about the most classic phrases as if they were trading chits.

Friday Flashback - Small Victories

The triage note was not encouraging. "Migraine. History of same x 10 years. Workups included (-) CT, MRI scans. Has had daily migraine x four weeks. Pain not relieved with Imitrex today." A quick glance at the previous visit list revealed a number of ER evaluations for headaches, though not too many. He usually got dilaudid for his headaches.

"Migraines" suck the life force out of me. They are rarely in fact, migraines, but simply tension headaches versus undifferentiated headaches. The frequent headache patients usually require large doses of narcotics to "fix" and have strong affective components to them (I've cured a few migraines with ativan, an anti-anxiety medication which has no pain-relieving properties). There are many frequent headache patients who are simply seeking drugs. I try to avoid narcotic meds when possible, because of abuse potential, because they often provide only short-term relief, and because they can induce rebound headaches.

This guy seemed nice enough. He didn't present the dramatic emotional display that many faux-headaches show, and he was a somewhat unusual headache patient in that he was a) male and b) gainfully employed. I offered him the same initial treatment I do any other benign headache: toradol, a non-narcotic pain reliever, and some vistaril, an anti-nausea medicine. I braced myself for the inevitable objection: "That doesn't work for me" or "Oh, I just remembered, I'm allergic to toradol." But it didn't come. He had never heard of it, and apparently trusted me enough to give it a go. So I ordered the meds and went off to see the next patient in the queue.

Forty-five minutes later I dropped by his room to see how he was feeling. He was sitting up, with the lights on, rubbing the back of his neck with a look of amazement on his face. "Doc, I don't know what it was that you just gave me, but it was magic! I feel better than I have in weeks!" His wife wondered why no ER doc had ever given it to him before.

He went home happy and feeling well, and I went to see the next patient with a smile on my face. It's so nice when things work like they are supposed to...

Originally Posted 20 November 2007

More ER animations

A better setting than the ER patient faking a seizure, which was inexplicably set in what appeared to be convenience store. This at least looks medical. But I am a little concerned about the red blood infusion just hanging in the background, not connected to anything. I'm pretty sure the Joint Commission would not approve of that.

If you do this in an email, I hate you

Brilliance from theoatmeal.com:



There are several more examples there, each more infuriating than the last. My favorite line: If you don't know what BCC is, then you probably shouldn't be using email.  Worth the click.

I can't help thinking this is cute

There's no reason.  It's nothing we haven't seen a dozen times before, including the classic, "ER patient faking a seizure" one and the iPhone vs HTC Evo series.  But here I am, embedding it anyway. Why can't I stop myself?

The Deadliest Cough Syrup

Pediatric overdoses can be something of a mixed bag. Most -- indeed almost all -- are utterly harmless. Either the stuff consumed was in a quantity which is sub-toxic (which is why pediatric bottles of tylenol are so small -- to limit the possible total dose if little Johnny likes it so much he drinks it all) or the stuff ostensibly taken was not actually taken.  Of course, many OTC medicines and a surprising number of prescription medications are also relatively innocuous even at very high doses.  On there other hand, some OTC meds are surprisingly toxic, particularly some cough and cold formulations, and there are a few really dangerous meds for kids -- the so-called "one pill kill" meds.

So when I saw the two-year-old in room six was here for an overdose, I was not particularly worried.  You need to be alert for the bad things, but in general these are benign presentations. I saw from the triage note that he had drunk a whole bottle of cough syrup.  As I went to see the kid and his parents, I ran through a mental list of what possible toxic effects he could have from that. Dextromethorphan can make you pretty weird. Antihistamines also can cause some problems, in a high enough doses.  A little kid with a whole bottle of that could actually be pretty sick. It would all depend on the formulation he drank and what ingredients were in it.

I was relieved to see a happy, completely normal-looking and -behaving kid with normal vital signs.  Mom was beside herself with fear and guilt, as usual, but otherwise seemed a normal, reasonable parent.  Fortunately she had had the presence of mind to bring in the bottle of the offending agent.  I eagerly accepted it from her shaking hands and scanned the label to review the ingredients. I was relieved to see this box:

In case you can't read the label, it's clearly marked as "Homeopathic Cough Syrup."  (I can't recall if it was this brand or another similar one.) I chuckled a bit and the mom asked if there was anything wrong. I explained that the theory of homeopathic medicine is that the lower the dose, the more potent the effect, and so the most dangerous overdose would be if he had not taken any! The mom looked confused at that, so I gave up on my terribly clever joke and explained that this stuff was entirely inert sugar water, harmless as an overdose and useless as a medicine. I did want to double-check to ensure that there weren't any bizarre ingredients (just because it says homeopathic doesn't mean it doesn't actually contain active compounds), and I wasn't familiar with most of the listed ingredients:

Causticum 6X HPUS
Drosera Rotundifolia 6X HPUS
Ipecacuanha 6X HPUS

The last one almost sounded like real medicine, but a quick call to poison control confirmed that it was essentially inert.  (Funny note: the box lists the water as an "inactive ingredient," but I thought water's magical power of memory was what made homeopathy work?)

So I was able to reassure her that her child would be fine, and educate her so she didn't waste any more money on snake oil. (She wasn't a devotee of homeopathic medicine; she'd just grabbed the bottle off the shelf at the pharmacy.)  It was a happy ending, and gives me a change to repost this classic James Randi takedown of homeopathy (as well as other charlatans and hoaxters):

Telemedicine via iPhone

I was seeing a youngster on a recent Sunday morning, an aspiring linebacker, playing the local Pop Warner football league who had injured his right fourth finger in a tackle gone awry.  It was kind of an ugly fracture -- angulated, rotated, and involving the growth plate. (Salter-Harris II, for those keeping score at home.)  Looking at it, and knowing that it was the young fellow's dominant hand, I was a little apprehensive about reducing it myself. It's not too complex to reduce a finger, but you really want it done right, and you hate to subject the kid to multiple attempts.  Since we have a hand surgeon on call, I decided to give her a buzz and get her take on the injury and whether she wanted to do it herself.

When she called back, I could hear that she was breathing hard. I explained the situation and asked if she was in a place where she could review the films. Almost all of our orthopods have the ability to look at x-rays from home, but she explained that she was at the gym in the middle of a work-out, so there was no luck there.  I tried to describe the images, but either I wasn't being clear or she just wasn't able to visualize what I was describing. Finally, an inspiration born of frustration hit me and I asked her what sort of phone she used.  "iPhone," she replied, and I quickly got her number and told her to stand by.  Hanging up, I blew up the images as big as I could on the monitor and took photos of the screen with my iPhone and sent it to her via MMS:

Uploaded with Skitch!

No, they're not really diagnostic-quality, but they are more than good enough for the surgeon to assess.  She assured me that there was no reason I should not reduce it myself, and talked me through how she would approach the reduction.  I did, and it went fine:

Uploaded with Skitch!

And yes, I sent her the post reduction images too, with an editorial comment about how awesome I am...

While I was in Vegas I was relating this story to a friend of mine who is a corporate compliance officer (cause compliance guys are never-ending party types), and she was just horrified. "You sent patient information out over an unencrypted network?!?"  In her eyes, this is only a slightly less grievous sin than pederasty. But I showed her the images, still on my phone, and pointed out that (unintentionally) I had framed the images so there was no identifying information visible.  No PHI, no HIPAA violation! That made it OK, she agreed.

This may be something of the way of the future, as smartphones with high-resolution screens become more ubiquitous among physicians.  It's a clumsy hack, to be sure, in that there is inevitable image degradation in taking a photo of a video monitor. Next time I may take a moment to save as JPG, crop and email the x-ray at higher resolution, but it was so quick to snap the pic and hit "send."  It's all the more frustrating because this sort of thing is just begging for a technological solution that already exists -- OsiriX. But of course, this is dependent on people downloading specialized software and going to great effort to configure it.   With most hospital networks locked down as tight as a rat's anal sphincter, I'm reasonably sure that they won't allow sending images outside their controlled domain.  So for the foreseeable future, it'll be quasi-legal work-arounds, so long as our IT departments are ruled by Mordac, Preventer of Information Services.