Absit Omen

So it was just last week, that I bitched, and I quote, "Where's all the pathology? I haven't seen a AAA in years. That's just not fair."

Yeah, you all know EXACTLY where this is going now, don't you?

The very next day. The very next day. I know it's just confirmation bias, but this is why people have superstitions. Naming calls.

This wasn't the most challenging diagnosis I'll make this week. The paramedics called it in as a "probable ruptured AAA." Which, in retrospect, certainly saved his life. Because we were ready on arrival. He looked unwell, a typical pasty, sweaty, ashen obese middle-aged-to-older guy. I barely spoke to him beyond the necessary few words and threw the ultrasound probe on his belly. Too fat -- couldn't see squat. His vitals were OK, so across the hall to CT he went. I was there when the images came across and I saw this appear on the screen:



A lovely ten-ish centimeter aneurysm with lots of clot within it and lots of free blood/hematoma in the abdomen.

And the rest went as you might expect, except that it went beautifully. We had 8 units of blood standing by, large bore access, and the vascular surgeon on his way to the ER. When the patient suddenly said "I'm starting to feel lightheaded," the nurse reassured him that it was just the pain medicine, but I knew better. Moments later, he was pulseless and I was intubating him. He got six units of blood via the rapid infuser and as soon as the OR could be made ready he was out of the department. Door to door, 38 minutes. Alive and with a pulse.

Funny aside: I got back from CT before the patient and I briefed his wife on the situation and plan. I warned her, "Now, a lot of things are about to happen really fast. A lot of people are going to swarm over him and it's going to get loud and chaotic and I want you to know in advance that this is more or less normal in these situations. This is serious but we're going to take good care of him." How little did I know! As a result, while her husband crashed, the wife sat there smiling, assuming that this was just what I warned her about. (Fortunately the chaplain came by to take care of her.)

Anyway, it was thoroughly exciting and satisfying. After the patient rolled, the staff were all exchanging high-fives, the orienting nurses were standing around all wide-eyed, and the charge nurse drawled, "I feel like I need a cigarette."

The awesome thing was that I barely needed to give an order. EVERYBODY did their job perfectly:
The medics made the call (and got 2 16-gauge IVs)
One tech ran to get the blood
Somebody (I don't know who) called the OR
Someone (of their own initiative) got the rapid infuser ready
The trauma coordinator RN came over to run the infuser (she knows it better than anybody)
The HUC got me past medical records just in time to give them to anesthesia

As much as I'd like to take credit, all I did was tell them to give lots of blood and put in the tube. It was totally a team effort, and it was a thing of beauty to behold. But it probably is a good thing we don't have to do this every day.

Now, since it worked so well before, what should I wish for next? I know! "Man, I haven't had a good precipitous delivery in forever! Those are so much fun!"

Y'all can thank me on my next shift.

Flying above the Earth

Courtesy of NASA:



According to the description, this begins over the Pacific Ocean and continues over North and South America before entering daylight near Antarctica. Visible cities, countries and landmarks include (in order) Vancouver Island, Victoria, Vancouver, Seattle, Portland, San Francisco, Los Angeles. Phoenix. Multiple cities in Texas, New Mexico and Mexico. Also visible is the earths ionosphere (thin yellow line).

If you squint pretty hard, I think you can see my house.

I am Han Solo

Patient, to me: I was admitted last week at The Big Hospital downtown and they did a whole bunch of tests and couldn't figure anything out.

Me: Can you tell me what tests they did?

Patient: Oh, they did them all -- every test you can imagine.

Me: I don't know about that. I've got a pretty good imagination.

Don't let your imagination run wild

Lest the students out there get disillusioned, it is probably a good idea to be upfront about the reality of being a doctor:


Maybe it's not always this bad, but in the ER there is a real ring of truth to this.

From the marvelous Saturday Morning Breakfast Cereal

Conversations from the back seat

Dramatis personae:

6 Year-old Son

3 Year-old Daughter

Setting: The back seat of my car.

3YOD: (looking out the window) I like that park. It's pretty. I wish I could play there.

6YOS: (world-weary and wiser) That's not a park. It's a cemetery.

3YOD: What's a cemeberry?

6YOS: A graveyard.

3YOD: Oh. 

3YOD: What's a graveyard?

6YOS: It's where they bury dead people.

3YOD: Why?

6YOS: Because they died.

3YOD: Why?

6YOS: When a person dies they put him in a grave in that yard.

3YOD: What's a grave? 

6YOS: It's a hole in the ground. They put the dead person in a box and put it in the hole.

[long pause]

3YOD: (delighted comprehension) Oh! And that's where they turn into zombies!

6YOS: Yes.

Why I get paid the big bucks

On the theme of knowing when and when not to follow the diktats of Emergency Medicine, one of the greatest challenges for a practicing ER doc is chest pain. Missed MI is still the biggest driver of malpractice costs, and last I hear, ER docs still send home something like 2% of patients who are having MI or unstable angina. Not good. So over the last decade we've gotten all these chest pain observation units and rapid rule-out protocols and early stress tests and all sorts of protocol-y goodness to fulfill every ER doctor's goal of never sending home an MI.

And it's good, and works. At least, for most cases. Consider if you will:

Mr Smith is 58 years old. He smokes, and was diagnosed with hypertension and high cholesterol several years ago. He is treated with medicines for these, but is not particularly compliant about taking them. He has a strong family history of accelerated cardiovascular disease, with a father who died of an MI in his 40s and a younger brother who has had a CABG. He presents with 24 hours of stuttering chest pain. It is episodic, lasting 2-10 minutes, dull, midsternal, without radiation or associated symptoms. It occurs sporadically both at rest and with exercise. On arrival, his ECG and troponin are normal, and he rates his pain as 5/10.

So this is a pretty straightforward case, isn't it? Slam dunk, admit to Card Tele, rule out & stress test. See? Protocol-driven medicine is fun and easy.

Oh, I forgot to mention something:

Mr Smith has previously had two MIs, has five stents in place, and says the pain he is having today is exactly the same as the last time he had an MI.

That gets your attention, doesn't it? I just ramped up my level of concern quite a bit. In this case, I am probably calling a cardiologist to see the patient in the ER and starting him on heparin and a nitro drip.

But I also forgot to mention a couple of other details:

Mr Smith had his last cardiac cath eight months ago, showing patent stents. His stents are three years old. He had a negative nuclear stress test three months ago. He also has a crippling anxiety disorder and has visited the ER for chest pain twelve times over the past year. He has been admitted seven times, ruling out each time.

Oh. Well, that does change things, doesn't it?

This is where protocol-driven medicine breaks down. Chest pain observation units are great for undifferentiated chest pain. but for someone with well-known, recently studied disease, they are less useful. Mr Smith is a real patient -- I changed nothing from the patient I saw yesterday. And I see a Mr Smith every single day I work.

The academic emergency physician will say, rightly, that I should treat the third Mr Smith exactly the same as the second one, because you cannot know when his noncardiac chest pain is noncardiac and when it is cardiac. A risk-averse doc will assert that he just admits any patient like this, because he does not want to run the risk of ever ever getting sued. But that is not practical or sustainable in the real world. I only have so many beds in the obs unit! There are only so many times you can admit someone for observation without objective evidence of active disease before you have to admit it's pointless. No matter where you personally set that threshold, there will be a patient who will visit you in the ER more than that.

I recall in residency a guy with known CAD who visited the ER for chest pain 550 times in a three-year span. We kept his ECG on the wall for easy comparison. After a while we stopped treating him with nitro and just gave him orange juice, which fixed his chest pain. But I digress.

If you work in an ER, someday you are going to send home a patient who presented with chest pain with a history of CAD. If you don't, then you are a crummy doctor with no clinical judgement. It's bad medicine and a poor stewardship of resources to admit every patient with chest pain. The difference between a good ER doc and a bad one, between an experienced physician and a robot, is acquiring the judgement to know where to draw the line, and how to do so safely.

I sent Mr Smith home, after talking to his cardiologist, observing him for six hours with serial ECGs and troponins, and arranging next day follow-up in the cardiology clinic. In this case, for this person, that seemed reasonable. For other patients, some of them do get admitted, depending on a million sometimes subjective variables -- how many ER visits, when they were last studied, how old the stents are, how the patients look, how bad their disease has been, how long the pain has been going on, etc etc etc. There's no good protocol for that.

Someday I am going to be wrong. In fact, I have been wrong, though with care there have been no bad outcomes. I can live with that -- you have to be able to live with that if you are going to survive long working in the ER.

This is the art of medicine. This ability to recognize patterns, to integrate a lof of variables and clinical data points and come out with an accurate, back-of-the-envelope estimate of risk, that is the hallmark of a true physician. It somes with time. We all start off as algorithm-driven neophytes and some never seem to progress beyond that point. But for the Mr Smith I see every day, who doesn't want to be admitted to the hospital again (he never does), but he also doesn't want to die, he really values having a "good doctor."

Violation of Dogma

I've recently been studying a lot for my upcoming recertification exam for  the Emergency Medicine boards. This actually may be why you have noticed me posing more than usual -- I have a clear and discrete task that I am supposed to be doing, which really encourages procrastination. But anyhoo, it has given me an opportunity to re-acquaint myself with all of the dogma we were taught in ER residency, and horrible amounts of mind-numbing trivia: deferoxamine is the antidote for iron overdoses, Brugada syndrome is a sodium channelopathy primarily affecting southeast Asian males, lymphogranuloma venerium is a rare STD caused by chlamydia.

Ugh. somebody please kill me. I hate this trivia SO MUCH that I'm half tempted just to show up and take the test cold. I'd probably pass. But it's a really high-stakes test and if I were to fail it would be expensive and embarrassing and would have unpleasant professional consequences. So I am going to make 100% certain that I will pass and that means reminding myself what the difference is between a Monteggia and Galeazzi fracture even though in the real world you just call ortho and tell them "Bone broke. Come fix."

It's not all bad, though, in that I have had the opportunity to refresh my memory about some uncommon stuff that you just DO NOT want to miss, because even though it's rare, if you miss it Something Bad will happen to a patient. Like, well, Brudaga syndrome, which is associated with unpleasant cases of sudden death. And since people not dying is kind of my raison d'etre, that's a fun and satisfying thing to review. In fact, it makes me kind of frustrated with my clinical practice. Where's all the pathology? I haven't seen a AAA in years. That's just not fair.

So I was particularly satisfied when I recently saw a kid with a classic You Do NOT Want To Miss This presentation. A 9-year old who presented 24 hours after a non-displaced midshaft tibia fracture from a bike accident. He had only mild pain at first, which is why the presentation was delayed. But over time the pain got worse and worse and finally the parents, perhaps a bit belatedly, decided to bring him into the little rural hospital where we sometimes work.

The fracture was spectacularly unimpressive. Sure, midshaft tibia is a bad place, but it was barely more than a hairline and it was completely non-displaced, in perfact anatomic position, and well-stabilized by the intact fibula. But the leg ... was a sight to behold. A skinny little fellow, his left leg was maybe three inches in diameter, but his right calf was about as big as my own. And tight as a drum. Bingo -- compartment syndrome.

That is when there is some swelling in an extremity which causes the pressure in the muscular compartments to be so high the muscle is deprived of blood and dies. And the patient is left with a non-functional limb. Don't miss this, and don't screw this up. Especially in an athletic nine-year-old. I wasn't sure this was compartment syndrome, mind you, but it was a really concerning presentation, with pain out of proportion to the fracture, progressively increasing pain, and severe pain with passive movement of the toes.

The management of compartment syndrome is clear: You stick a big Stryker needle in to measure the pressures, and if elevated, orthos fillets open the limb to restore blood flow. Ghastly, but it works. Only problem was that at this little hospital, there was only one ortho guy (since his partner got deployed to Afghanistan) and he does not like taking care of any pediatric stuff beyond the really simple cases. This is not simple. Also, I have never even seen let alone utilized a Stryker needle. So I called the local regional children's hospital and got their orthopedics resident on the phone.

The resident was a real piece of work who proceeded to abuse me because he thought my ortho guy was lazy and/or incompetent and was dumping work onto him, and he accepted the case in transfer only after reading me the riot act about how this was a surgical emergency and I needed to measure the pressures immediately and release the compartments immediately and I was endangering the child's leg by delaying care with an unnecessary transfer. I'm good at ignoring that sort of thing, thanked him for accepting the transfer, and got off the phone. In my heart, I felt that the kid would not need a fasciotomy, but I was not going to be the one to make that call. We had the kid downtown within the hour.

At the end of my shift I called the ER at the children's hospital and got the ER resident who was taking care of the kid. She was quite pleasant, and informed me that the kid had been splinted and would be admitted for observation. So, he didn't go to the OR, then, I thought. "What were his compartment pressures?" I asked. I was unsurprised to hear that ortho had not even checked the pressures. They just had examined the patient, somehow performed a visual/tactile/olfactory measurement of the pressures and decided it was fine. It must be wonderful to be a specialist and have that sort of godlike sensory powers.

I see this all the time, and it blows my mind. I was half-tempted to call the resident back and call him on the line of BS he had given me. I know that would have been pointless, but so tempting. The thing, though, is that this is what I mean when I talk about how real-world medicine differs from textbook medicine, like the case of the hangman's fracture the neurosurgeon wanted to send home.

I'm going to assume that the ortho guys at Children's were competent, and that they didn't just screw up. Possible, but they are specialists and pretty sharp. When I first spoke to the resident, he recited chapter and verse of the textbook at me, just as I would have to a medical student I was instructing (though I would have been nicer). But the real world is not black and white, and judgement is all about gauging the shades of gray and that involves instinct and experience.

See, I've never seen a true compartment syndrome, largely because I see the fractures on day one, before it has had time to develop. I palpated the kid's leg, and it was frighteningly tight, but there was some give there, just a bit. Maybe that was enough to tell an experienced ortho attending that it was not worth sticking the needle in. I don't know how it turned out, whether the kid went to the OR or not. The lesson, though, for budding ER residents out there is this: know the dogma, respect it, but don't be too insistent on it. There are cases where it needs to be followed and cases where it may not. The trick is to know the difference, or to get the patient to the right person to make the call.

F*ck the poor

What the hell. I give up.



If you can't beat 'em join em.

Curious

I just really wanted an excuse to post this video.

I had a few comments and private emails in the last post about the uninsured which I find really perplexing. They essentially say, "I'm charitable, I give to my church, I'm all in favor of voluntary charity. But when the government makes it compulsory and steals my money to give it away, that's not charity, that's fascism."

I'm paraphrasing, I admit. But not by much.

But it's one of those things that really make me scratch my head. These people have a fundamentally different understanding of the concept of charity than I do. Full disclosure: I was raised catholic and enjoyed endured 12 years of catholic education. While I have wound up not particularly religious (to say the least), it's fair to say that the core values of catholicism really have infected me, in a good way, at a very basic level. One of those values, one of the most important ones, is charity. Christ talked about it a lot. But what does "charity" mean? Or, maybe I should say, what does that mean to me, and how do I put it into action?

The definition of charity is:

1: benevolent goodwill toward or love of humanity
2  a : generosity and helpfulness especially toward the needy or suffering; also : aid given to those in need
    b : an institution engaged in relief of the poor
    c : public provision for the relief of the needy
3  a : a gift for public benevolent purposes
    b : an institution (as a hospital) founded by such a gift
4: lenient judgment of others

Love of humanity -- that's where I draw my moral compass from. Not some niggling distinction over whether a particular cause rises to my discretionary level of "this is important and I personally want to support it," or whether the plight of a particular person inspires me to contribute. Those are important aspects of charity, to be sure, and certainly maybe ones I could be better about. Nor do I view charity as a mere personal virtue, which allows me to take pride in my personal munificence. The concept of charity I absorbed was the first one: the universal goodwill and love for fellow mankind -- the rich, the poor, the drunk, the irresponsible, and the moral imperative to care for them. All of them.

That understanding of charity encompasses it all. Personal charity, giving of yourself to support those in need.  Institutional charity, where my (catholic, incidentally) hospital provides $30 million in indigent care annually. And yes, public charity, where society, as expressed in public policy, creates institutions and systems to take care of those in need.

That's why I favor universal insurance or whatever method of assuring that nobody would go without access to medical care. It's charity writ large. Policy goals are in some degree moral goals expressed and organized on a society-wide basis.

I don't want people to die unnecessarily.

I don't want people to suffer if it is preventable.

I don't want people's financial lives wiped out by illness.

This is why advocate for our country to create systems, be it individual mandates or medicaid or some other system, all too imperfect, to make sure that those who are needy can be cared for -- even if their need was created in part by their own irresponsibility. I pity them, and I hurt for them. We can do better for them -- indeed for all of us, since there but for the grace of god go we and those we care for.

So, anonymous commenters, I do not understand you. Your concept of charity is self-serving, narrow and harsh and not one I recognize. You give with one hand but turn a blind eye to those you deem undeserving. You place ideological purity in importance over real human suffering. You view charity as a personal virtue rather than as a force for good. Fair enough, I'm glad that you are so assured in your own moral rectitude. My vision is ... rather different.

And while I may understand your words, I don't think I'll ever really understand how you came to view charity that way.

I am aware of all internet traditions

Your headline of the day, which I swear to god I am not making up:

Gordon Ramsay's dwarf porn double Percy Foster dies in badger den

And, Badgers are Awesome:




Yes, yes, more badgers! Very cute:

And some real kick-ass badgers:




You are welcome. You may now continue your regularly scheduled daytime activities.

Freedom to die

I am always amazed at the viciousness that pops up in the comments when I post about the uninsured, and the human consequences of being uninsured. I've been running this blog for six years now, and it's been a reliable and persistent phenomenon. In my most recent post, about the guy who died of a dental infection, an anonymous commenter, no doubt a good christian, left this gem:

So I'm supposed to feel bad for this guy, pay more taxes to help fund a government program that will "help" this lazy person, all the while I have to provide free care to him in the ED, take money away from me that I earned through hard work, [...] What happened to this man is terrible, but I have no sympathy for him or his family. He refused to seek out ways to help himself. This is in no way my, or your responsibility.

To paraphrase, "Fuck him, the lazy mooching bastard got what he deserved. I got mine." I mean, wow. To describe this as callous indifference doesn't do it justice. Curiously, this sentiment is common and almost exclusively voiced from the political right. Christ talked quite a lot about universal charity and caring for one's fellow man, but for a non-trivial subset of conservatives, the gospel of "personal responsibility" trumps those other gospels, I guess.

You could see some of the same sentiment on display at the recent Republican presidential goat rodeo debate where Dr Ron Paul was asked whether society should allow those too poor or feckless to buy insurance to simply die. Dr Paul, to his credit, eventually said "no," though that is the general consequence of the policies he favors. What made news, however, was the cries of "Yes!" and loud cheers and applause that followed from the audience. 

Based on the commentariat here, I don't think that's an aberrant example of the ethos of the libertarian right. I do not think that's representative of all conservatives -- at least I fervently hope not -- but it is representative of some of the most active and vocal republicans, and particularly those who are driving the policy bus these days. Aaron Carroll at TIE thinks it's a product of hyperpartisanship: "Many people wanted their side to “win” so badly that they began to delight in victory and the political game to a point they forgot that we were discussing very important issues with a human cost." Maybe he is right, but the consequence of championing this sort of policy is the mental gymnastics people need to go through to convince themselves that their favored policy would not result in people dying or suffering unnecessarily.

The same commenter above added: 

Hypothetically, shadowfax, if you had no insurance and your wife was diagnosed with her breast cancer, would you just buy the vicodin and say, "nice knowing you honey?" I'm sure you would seek ways to help get her the treatment she needed. 

Sure, I would seek help. But like too many others, I'm reasonably certain that either I would not find it, or even if we did, major compromises would have to be made in the quality of her care.  That's a hard and fast rule of being indigent and sick. Things get delayed and some things you just don't get.  As an additional bonus, even if we did get some limited charity care, our family would suffer financial ruin as a result. The cost of chemo alone is well over $100,000, not to mention surgeries, radiation, hospitalizations, imaging and many ancillary tests. It's pure fantasy to think that someone would give us that for free. Conservatives talk about communities banding together to help a member in need -- church bake sales and the like. But the ability of individual voluntary donations to raise the amount of funds needed to care for a serious illness is equally fantasy.

A case in point -- a sad and highly ironic one -- was that Dr Ron Paul's former campaign manager, a man who managed to raise $19 million in political donations -- became ill and died of pneumonia in 2008 at the very young age of 49. He was uninsured -- he wanted to purchase insurance but was denied due to a pre-existing condition -- and the medical bills totalled $400,000. His friends started a financial fund to offset the costs. It raised $35,000. This was a well-connected person whose whole life revolved around raising money, and private charity failed to cover his medical bills by an order of magnitude. Why would anybody think that this is a reasonable and sustainable strategy for others, especially those who are in lower-income communities? What about those who are socially isolated and don't have a church or a large group of friends? 

Oh, there are charity clinics for folks like that, conservatives say. Which is equally a joke. This angry rant by a DKos diarist about her uninsured brother's experience with charity care for lung cancer tells a sadly typical story of what life is like for the indigent with a serious illness:

Steve worked 14 hours a day building beautiful guitars ... he barely eked out an existence with financial help from my husband and me. Money for health insurance?  Don’t be ridiculous. 

He was 63.  He had to start Social Security early so he could afford to eat.  He was too young for Medicare and too male for Medicaid.  This nation does not recognize the years he spent working for others and making this economy grow, it only focused on the years he worked for himself, creating instruments of rare beauty. 

When he had a pain in the butt, he had to wait until early in the morning of December 3rd to present himself at the ER of Highland Hospital, the Alameda County medical facility.  There are guards at Highland, and a football field full of plastic chairs for the indigent to use while they wait treatment.  He was sent home with a handful of Vicodin and a suggestion to follow up with a pulmonologist for the 3 cm spot the Xray showed on his lung.  The soonest appointment was Feb 25. 

He was in so much pain that he could not stand up for more than a few seconds at a time.  He got Vicodin.  And steroid suppositories.  His buddies came up with the $2000 a proctologist wanted to do an outpatient surgery.  But the hospital wanted $20,000 for use of the room for the brief procedure because he was uninsured.

Three months to see the specialist. When my wife was diagnosed, we got next-day appointments. I'm not asserting that her brother would have lived with better access to care -- sounds like he was palliative from the get-go -- but he probably would have suffered less, and statistically, some of the 50 million uninsured out there will die because of their limited access to care. And those who are lucky enough to get delayed, poor-quality charity care get it subsidized by the rest of us, as it is.

But the attempt to remedy the problem, initially proposed and embraced by conservatives, has disingenuously morphed into an un-American assault on liberty. The irony is pointed out by Danny Westneat of the Seattle Times:

So who should pay? Right now, we all do. 

What was so provocative about the question is that the health-reform plan routinely denounced as socialist — so-called Obamacare — seeks to get the freeloading guy to pay his own way. He'd have to get insurance or be fined. He'd pay for it himself, unless he were very poor. The idea is then there'd be no need for the rest of us to pick up his huge charity-care bills. 

It's true that coercing people to buy insurance is not "freedom." But what's so aggravating about the health-care debate is that neither is what we have today. It sure seems socialistic that all of us have to cover the uninsured guy's bills, as we do today. Yet an effort to stop doing that — to try to get him to pay for himself — is what gets derided as un-American.

Despite the existence of charity care and county hospitals, though, the human cost of uninsurance persists.  The best estimate I am aware of is that 45,000 people die every year because of their lack of insurance.

But, fuck them, because I've got mine. Am I right? They're lazy, irresponsible, poor, probably black, certainly unwashed and they have nice cell phones, so they are subhuman pieces of shit who deserve what's coming to them. And an individual mandate is an unconscionable impingement on my personal liberty.

This is, as best I can tell, the libertarian take on the ongoing crisis of the uninsured. We are all free, and some lucky duckies are free to die.

I apologize in advance to those conservatives and libertarians who are offended. I'm angry and I am ranting. I know you are not like those bad libertarians. Please go ahead and explain in the comments how the free market and the personal responsibility fairy will fix the system, or just point to the Republican health care proposal which will replace Obamacare when it is repealed. I've been waiting for quite a while to see that one, but they seem stuck on "repeal" with no clear plan to "replace."

Happy Talk Like a Pirate Day!

From the brilliant archives of Medium Large:

Instinct vs Expertise

A hard thing about being an ER doctor is that I know a little, sometimes very little, about a lot of things. When I am faced with a particular condition, I often need to call the specialist for that organ, who knows way way more about it than I ever will, and they all think I'm an idiot because I don't know as much about their organ as they do. There's a huge asymmetry of knowledge, and it can create some tension and conflict.

I'm OK with it, because I can ignore their condescension and I am secure with what I do know, and its limits. But sometimes I get perplexing instructions from the specialists. The emergency medicine dogma can be overbroad and a little hidebound and what the specialists will do in the real world often radically diverges from what the Emergency Medicine textbooks say to do. It's often an interesting learning opportunity for me, especially when it's a condition I don't encounter that much.  But I also have to work to maintain a flexible and open-minded attitude when I call a consultant and my side of the conversation consists of "Really? I didn't know you did that for this..." You need to know and trust your colleagues in other specialties, and know when to call BS on them and push to do something else, which is really hard to do when you are talking to someone who is so much more of an expert than you are.

So I saw this guy recently, a urban hipster who was perhaps a bit too old to be riding his longboard on the hilly streets of our fair town. He didn't seem to be too good at it, judging by the collection of crusted abrasions and aging ecchymoses he was sporting. He had been falling a lot recently -- we only get about a month of sun here, so I guess he was making the most of the summer weather practicing his new hobby.  He had a variety of complaints from his recent falls, but it was a wound infection that had driven him to come in. A bit of road rash on his thigh was looking a bit cellulitic and I thought might benefit from some keflex.

I had to go through the motions of doing a more or less thorough exam, and he was pretty tender on his neck, I noticed. He said it had been hurting for about a week, since he had fallen backwards and hit his head on a car fender. He demonstrated how his neck was fully extended at the moment of impact, and the resolving goose egg on his scalp correlated. I wasn't terribly impressed by any of his orthopedic injuries, but I did order a few plain films, just to CYA, and I included a C-spine series as well, which is rare for me since if I really think someone might have a C-spine injury CT scanning is the imaging modality of choice.

I actually got a little short of breath when I scanned through his images and this jumped out at me:

For those not accustomed to reading these, this is a fracture through the posterior part of the second cervical vertebra, also known as a hangman's fracture. You might infer from the name that this is an unstable, bad injury, and you would be right. And our hipster friend had been walking around (hell, skating around and falling) for a full week with this injury!  His neuro exam, I confirmed, was rock-solid normal. We popped a C-collar on him and I called the neurosurgeon at the local spine center to arrange transfer.

I had the opportunity to hold forth, as the nurses and techs gathered around the monitor to see the image, explaining that the "hangman's fracture" is a bit of a misnomer. Generally it is sustained from axial loading (as opposed to traction), which makes a ton of difference. The real-world mechanism is planting your forehead into a car windshield, that is, not hanging from a rope, and the spinal cord is typically uninjured in mechanisms of this sort. It's unstable and needs to be fixed, but there are many worse c-spine fractures you could have. My audience was very appreciative and I basked in their attention.

I was quite surprised, however, when I eventually spoke to the neurosurgeon. "It's a stable fracture," he told me, "he's had it for a week and his cord is fine. Put him in a hard collar and send him home. I'll see him in clinic next tuesday." It was one of those "What? Really?" moments I described above.

This surgeon, I should mention, was not some fly-by-night guy, nor was it the intern. He's a very respected professor at a university-affiliated trauma center. Not someone I am predisposed to argue with. I see hangman's fractures about, oh, once a decade, and he operates on them all the time. He clearly thought it was quite routine to send him home. And he did have a point -- it had been a week, after all. So with great discomfort, I acquiesced. For lay readers, it is important to understand that there are categories of stable spinal fractures that should go home, so it's not as crazy as it sounds. Not quite, anyway.

It seemed wrong, though, very wrong. I ran it by a couple of my partners and their eyes all got kind of big at the prospect, too. Without any clear plan, I decided to buy time and get the CT scan to better delineate the injury. After all, I reasoned, they will need it to plan the surgery when he goes to clinic next week.  ("Next week? Am I really going to send a C2 fracture home for a week without even seeing the neurosurgeon? This is nuts! I just can't.") I chatted with the radiologist who read the CT, who described the hangman's fracture and blah blah blah, lots of technical details that meant nothing to me. I had radiology send the images electronically to the trauma center and sent a message to the surgeon that there was a scan available, in the hopes that might change his mind.

The surgeon called me back about ten minutes later, with a hint of anxiety in his voice. "Please tell me you didn't send that guy home, did you? This is a really bad, unstable injury. I need to operate on him today." To his credit, he had the grace to be embarrassed about his earlier advice and acknowledged that I was right to have stuck to my guns on this case.

I still don't claim to fully understand the intricacies of this injury or what about it changed the surgeon's mind. I'm not a neurosurgeon. I am very glad, though, that in this case I listened to my gut and that I didn't send him home. My malpractice carrier is, too. Knowing when to call BS, when to say "No" is one of the hardest things about my job, because it's pure instinct.

A Song for Dr Rob

He knows why

This is what health care rationing looks like

The legislature in Washington State, like so many others, had a multi-billion dollar budget shortfall to fill this year due to the ongoing recession.  Like others, it looked at the Medicaid program as a place where money needed to be cut from the budget.  However, in what I believe to be a first in the nation (for now) approach, they directed the state Health Care Authority to find $72 million in savings specifically from Emergency Department utilization, and more specifically from those patients who over utilize the ED for non-emergent medical care.

The statutory language reads:

Emergency room visits in the Medicaid program will be limited to three non-emergent visits per year. The WSMA and the WSHA will be included in developing the criteria for defining non-emergent.  [...] The department shall collaborate closely with the Washington state hospital and medical associations in identification of the diagnostic codes and retroactive review procedures that will be used to determine whether an emergency room visit is a nonemergency condition to assure that conditions that require emergency treatment continue to be covered.

That doesn't sound too unreasonable, does it? Anybody who has ever been in the ER knows well that Medicaid patients come back again and again, and often for trivial or routine complaints. So the plan was to generate a list of agreed-upon non-emergent diagnoses and simply not pay for them after the third such visit.

It's sadly predictable what happened next. The HCA had been set a hard target of cost savings -- $72 million -- that they were mandated to achieve. They looked at the universe of true frequent flyers and their complaints and realized that they were not going to get to their goal by denying payment for the runny noses and toothaches that comprise the majority of non-emergent medicaid visits. So they expanded their definition of non-emergent diagnoses, and recalculated the savings. It wasn't enough, so they expanded the list of "non-emergent" diagnoses further yet, and again and again until they got the dollar figure they wanted.

The list, as it currently exists, consists of about 750 so-called "non-emergent" diagnoses established in the ER, for which the state will not pay, including such trivial, routine, and non-emergent conditions as:

Viral infection NOS
Viral enteritis
Strep throat
Scabies
Migraine headache

OK, I can get behind those as non-emergency ER conditions. I'd quite like to see those folks re-routed to clinics or PCPs. But wait, there's more! Other "Non-emergent conditions" for which the state will not pay include:

Chest Pain
Abdominal Pain
Asthma Exacerbation (acute)
Acute Cholecystitis
Hypoglycemic Coma
Pneumococcal Pneumonia
Pseudonomal Pneumonia
Calculus of Ureter (i.e. kidney stone)
Syncope and collapse
Salmonella Enteritis
Streptococcal Septicemia

I shit you not. There are many others -- these are just the most ridiculous "non-emergency" conditions that jumped out at me. It's also manifestly arbitrary and haphazard what made it onto the list and what did not. The HCA considers "Cholelithiasis with acute Cholecystitis" an emergency condition worth paying for, but "Acute Cholecystitis" is not. The state will pay for hand cellulitis, but not for the more dangerous foot cellulitis. All diagnosis codes which are "Sprains" or "Contusions" are denied, across the board.

For the record, the HCA did collaborate with the health community in that they met with physician and hospital groups, listened politely, and produced the diagnosis list unilaterally. Though the physician groups had many ideas for saving money such as case management, generic prescription utilization, and other ideas, they were rejected as outside of the statutory language of the budget. No mechanism was identified by which patients could be redirected to clinics, nor was there any allowance for the fact that trauma patients do not know in advance whether their injuries are fractures or sprains.

The idea, should this go into effect as planned, was that patients would redirect their care back to clinics and primary care providers. It's not going to happen, of course. Primary care, and especially urgent care, for medicaid patients essentially does not exist, not in any meaningful way. Sure, there are charity clinics and community health centers, but they are grossly oversubscribed and the access is minimal for acute or otherwise unscheduled care. The ERs remain open 24/7, and thanks to EMTALA, we cannot send patients away unseen. Sure, it's possible to do a medical screening exam at triage and deny non-emergent cases, but that's a liability nightmare, and would probably be a de facto violation of EMTALA if that was only done for medicaid players. (Though I am not a lawyer.)

There is no way, actually, to even know in real time if a medicaid patient presenting with a non-urgent complaint is one of the few who have met their three-visit limit. (97% of medicaid patients in this state visit the ER less than or equal to two times annually.) The ER doc and hospital will only find out after the fact when the claim is denied. Technically, we can bill the patient but that is a fig leaf because of course a medicaid patient won't be able to (or care to) pay cash for their ER visit.

There are so many things wrong with this that it's hard to know where to start.  Of course, it's primarily a cramdown for providers. The state just decided not to pay for a certain arbitrary list of things, and docs and hospitals have no idea which patients that will apply to and no choice but to provide the services anyway. Which is in a way, nothing new, since we've dealt with the unfunded mandate of EMTALA for three decades. What is new, and troublesome, is that the non-payment will be decided after the fact based on an arbitrary and wrong list of diagnosis codes. This is not entirely new -- it's what went on in the '90s and resulted in Congress passing the prudent layperson standard, which essentially ended such practices. However, it's new in that this is the first time a governmental payer has tried this particular stunt, and I have a feeling that a lot of DHSH directors in other states will be carefully watching this experiment so see if it takes. If it does, this may be our future once again.

So look closely, my friends. Rationing is here, not covert rationing, but open and unapologetic rationing. It may be blocked before it goes into effect; I hope it is. If not, look for it to be coming to a town near you real soon.

What happened to George Lucas?

An exercise in wishful thinking. If only it were true.

Dr Seuss explains healthcare economics

Oh The Jobs (Debt?) You'll Create! from Marketplace on Vimeo.

This certainly applies to the arms race going on in our neighborhood -- the proliferation of "Free-standing ERs," which provide high cost, luxury-themed care to wealthy communities which were previously well-served by existing facilities.

Nice places to get care, if you can access/afford them, but a short-sighted and improvident way to spend limited health care dollars.

Saturn Flyby

Wow. Just Wow.
5.6k Saturn Cassini Photographic Animation from stephen v2 on Vimeo.

The looming doctor shortage

Howard Dean wrote an op-ed defending the use of foreign international medical graduates:

Today, young physicians with degrees from international medical schools face skepticism from some in the American medical community. That strikes me as misinformed thinking, given the large number of international medical school graduates practicing in the United States, alongside American medical school graduates, and given that the American medical system depends on them to fill the growing doctor shortage. 

The federal Health Resources and Services Administration predicts there will be a shortage of approximately 55,000 physicians in the United States by 2020. We simply can't build the capacity to meet our growing needs for skilled physicians -- especially given budgetary constraints on schools receiving government subsidies. Even if the new medical schools now in the planning stages all come to pass, they won't turn out enough primary care physicians to meet urgent needs in urban and rural communities.

I actually don't have a lot to say about the IMG thing,  I have worked with and hired many IMG's and their skill and quality vary as much as US graduates. But this whole argument seems to miss the central point regarding the projected physician shortage. The supply of new medical graduates is not the choke point, under the current state of affairs. The choke point is the number of residency training slots.

The Balanced Budget Act of 1997 put a cap on the number of residency slots at 1996 levels. For those who don't know, pretty much all postgraduate medical education in the US is funded through medicare. That cap has remained in place ever since. Medical school enrollment has increased since that time, but the overall number of residencies has not (at least not by a meaningful measure).

There's a frustrating lack of information out there: a common misperception is that the AMA is somehow artificially restricting the number of doctors to keep reimbursement high. Nothing could be further from the truth. First of all, the AMA has essentially no say in the number of physicians trained -- that's largely the province of the AAMC, which has been warning of the physician shortage and calling for action for a long time. Furthermore, the AMA itself has been making the same call for years, too.

The problem is compounded by the fact that many residents, whose training is being paid for by the US taxpayer, are foreign-born and here on a type of student visas. When they are done training, they have to go home unless they can find an employer who is willing and able to sponsor them for a green card. I don't know how many US-trained foreign physicians actually do return to their country of origin -- not too many, I suspect -- but the wrongheadedness of the policy is maddening. If we are going to pay for their education, it should more or less automatically put them on a pathway to permanent residency.

Unfortunately, I don't see a solution in the works any time soon. In the current health care budget crisis, the likelihood that policymakers are going to increase funding for medical education is slim indeed. This means that physician extenders will continue to fill the gaps and provide more and more services. Some of this is just fine -- a PA or NP can be a great surgical assistant, fast track provider, or simple wellness care provider. But as medical students persist in their exodus from primary care, more and more complex disease management will fall on the shoulders of midlevel providers whose training is not intended to encompass it. Those patients who decompensate as a result, or who simply cannot access primary care services do to the shortage will be shunted to ... the ER, of course. The final dumping ground of American healthcare.

We are so screwed.

Top Ten Lies Told by Paramedics

Apropos of nothing:

1. Its not my fault, he kept moving.

2. This might stick a little.

3. I did say clear first.

4. I know where I'm going.

5. It's OK, I'll cut along the seams.

6. The ambulance is clean.

7. It's the flu, not a hangover.

8. The gloves are for your protection.

9. The patient refused the treatment.

10. I am in it for the money

Uninsurance shouldn't be a lethal condition

This is depressing:

A 24-year-old Cincinnati father died from a tooth infection this week because he couldn't afford his medication, offering a sobering reminder of the importance of oral health and the number of people without access to dental or health care. 

According to NBC affiliate WLWT, Kyle Willis' wisdom tooth started hurting two weeks ago. When dentists told him it needed to be pulled, he decided to forgo the procedure, because he was unemployed and had no health insurance. 

When his face started swelling and his head began to ache, Willis went to the emergency room, where he received prescriptions for antibiotics and pain medications. Willis couldn't afford both, so he chose the pain medications. 

The tooth infection spread, causing his brain to swell. He died Tuesday.

It can't be denied that his poor decision-making was the proximate cause of this guy's death (and many times I've gotten the maddening call from the pharmacy, "Doctor, the patient only wants the narcotics"). The underlying cause, however, was the fact that he was uninsured. Sure, he should have sprung the $4 to buy the penicillin at the big box pharmacy (though clindamycin can be costly, if he was penn-allergic). But he shouldn't have been in the position to need it in the first place. He should have been able to get the tooth pulled -- or better yet, filled before it needed pulling -- before it became abscessed.

Sadly, this problem won't go away when the ACA goes into effect in 2014 (assuming it does). I'm going to speculate here, but if this guy was so poor that the antibiotics were too expensive, he probably will (would've been) covered by medicaid under the ACA, which means that though his prescription probably would be paid for by medicaid, he still would not have had meaningful access to dental care, because most dentists won't see welfare patients.

But hey, at least we don't live in some sort of socialist dystopia where sometimes people have to wait for hip replacements!  Our Galtian paradise may be a bit rough, but it's got to be to keep the moochers from running over us.

Sigh.

It sucks that we are the only industrialized country not to have some sort of national insurance plan, it sucks that even the modest reform passed doesn't take effect for three years, if it ever does, and it sucks that people still die as a consequence of being uninsured.

Don't let the wingers tell you that there's no human cost to our crappy patchwork health care system. The children of Kyle Willis can tell you otherwise.