04 February 2015

In Defense of the Hyperangulated Blade

Let me begin, as is my wont, with a story. Let's say, for the sake of discussion, that I was moonlighting at Janus General Hospital. I had a patient signed out to me by my partner: a young patient with COPD, influenza, and pneumonia. He was on BiPAP and supposedly stable waiting for an ICU bed. Murphy's law being what it is, immediately after my partner left, the patient deteriorated and clearly was going to require intubation. He had all the predictors of being a tough tube, so I made sure to have my back-up plans articulated and ready to go.

My go-to technique for quite a few years is video laryngoscopy (VL) with the hyperangulated blade of the GlideScope. My back-up is direct laryngoscopy (DL) and my ace-in-the-hole is the gum bougie. I'm not a huge fan of fancy tricks like awake intubation (too much work, and I'm lazy) and in any event, this guy was too sick for that. Since this was a daunting airway I made sure to have all the stuff ready to go, including our quick cric tray.

I couldn't get the tube with the GlideScope. While I had a nice view of the larynx, there were frothy secretions welling up through the cords so quickly that between the time I suctioned and tried to place the tube, I lost my view. Faced with crashing sats, I tried to bag him back up, but couldn't ventilate. I got his sats from 50% all the way up to … 75%, and he clearly wasn't going higher. So I had my partner prepping the neck while I went back to the old stand-by, DL, and I was able to snake the bougie in through the foam and successfully passed the tube (much to the disappointment of my partner, who was kind of excited at the prospect of doing a live cric). Here endeth the story.

Now I share this to highlight a couple of points regarding airways. I could make the point regarding the importance of having your back-up plans ready and practiced and not being afraid to progress to a surgical airway, but that point has been made at great length and far more articulately by others. It is a good illustration of the principle, though.

I'm more interested in comparing the relative benefits of VL vs DL and particularly the geometry of the blades.

I admit to being disappointed in seeing the cognoscenti of airway masters coalescing around the position that VL is at best, a necessary evil, and that if it must be tolerated, it should be performed with a standard geometry blade. The C-MAC device, which has a Macintosh-style blade with an attached screen, seems to be the device of choice. (For the record, I have not been paid by either device maker but am more than willing to accept bribes, if any are on the offering.) They make a good argument that the C-MAC is better because it helps develop/preserve the DL skill-set, is its own built-in back-up with no need to change devices, and for attendings allows good supervision of trainees. I agree with all these points.

From my perspective, though, I still favor the GlideScope, which differs from the C-MAC in that it has a hyperangulated blade. (There may well be other brands out there with similar shapes, but I’m not as familiar with them.) And despite the failed airway above (my first ever failed airway in hundreds of cases with this tool), the GlideScope remains my first-line intubating approach in most if not all cases.

A couple of important caveats: I had been intubating with DL for many many years before I ever touched a Glidescope. DL is the ultimate and necessary skill that must be completely mastered before moving on to the hyperangulated blade. For trainees: stick with DL till you've done a few hundred. This is a varsity level device. For occasional intubators it might be a good idea to stick with DL to keep the skills sharp.

I, however, am in none of those categories. I have intubated hundreds if not thousands of people over the years, am highly comfortable with my DL skills, and I continue to intubate pretty frequently. And here’s why I will continue to use my GlideScope until they pry it from my cold, dead hands:

It is a better tool that is easier to use & harder to mess up.

There. I said it. I am, as I said, very lazy, and I will always choose the easy and reliable tool over the dodgy tool which requires a lot of effort to use correctly.

This is why I believe it to be so: when I perform DL, I need to establish a direct line of sight with the larynx. Unfortunately, mother nature thoughtlessly designed the human anatomy so that there are lots of fleshy bits between my eye and your vocal cords. There are lips, teeth, the tongue, the glottis, the salivary glands, and all the redundant fat, muscles and soft tissues of the sublingual space. If I want to establish that direct line of sight, I have to get your head & neck in perfect positions, put the tip of my blade in precisely the right spot, seated in the vallecula, and then lift, sometimes with quite a lot of force, and then I have to hold the blade in place and sort of squint to see way the hell down there for the cords. Blade a little too shallow or too deep? U NO SEE CORDS! Blade slightly off midline with tongue oozing around it? NO CORDS FOR YOU. And the motor skill to lift just the right way is tricky. Rotate the blade and not only do you not see cords, you break teeth. You have to lift up and forward just a bit, and if it’s not quite right, you have to apply cricoid pressure bimanual manipulation to see your target.

This does not look comfortable

I can do it. I’m pretty good at it, still. But there’s a lot of room for error, and sometimes it’s really freaking hard. Even as an experienced intubator, there are times that I am sweating bullets or feeling like I dodged a bullet when I succeed on a tough tube. Because you are fighting the anatomy, and the anatomy is set against you.

But the GlideScope, well, it’s designed so that with no manipulation of the native anatomy, it will drop directly into the necessary position and provide a beautiful view of the larynx. Every damn time. No lifting. No squinting. No fiddling. And if the fleshy bits (excuse the technical anatomic jargon) are still in the way, I don’t care. I can still see my target. It's even forgiving of less than optimal patient positioning. With the GlideScope all the airways are easy, because your tool is designed to work with, not against, the anatomy. That’s the beauty of the hyperangulated blade, and that’s why it has been so widely adopted. You don't need to manipulate the anatomy to see your target, and reducing that step reduces the possibility of error and a failed airway, or at least relieves the cognitive workload of the procedure. It’s rare that I ever have to take a second look, and it seems like every tube slides in effortlessly. And reducing the cognitive workload, reducing provider stress, is not a small benefit when you are dealing with a critically ill patient. If I don’t have to sweat the tube, I can better dedicate myself to management of the patient’s overall condition.

It just fits!

Yes, VL has its limitations. I didn’t say it was perfect. Secretions, blood and gastric contents can confound any intubation, particularly video. Electronics are fallible. Back-ups are necessary and you need to be able to use them. And the use of VL and the hyperangulated blade is a different skill set. Since you can’t see the larynx directly, you need a decent spacial understanding of where you are blindly shoving the blade/tube and the degree of force (or lack thereof) that is safe to use. That only comes with experience and attention to the differences between DL and the hyperangulated blade. It's kind of like tying your shoes in the dark - not exactly tricky, but you do need to be able to visualize what your hands are doing without seeing them directly. But after performing many many intubations with both types of device, I feel that intubations with the GlideScope are easier and less fraught with error.

The airplanes at my flying club are equipped with really cool GPS-linked 3-axis autopilots. But when I was learning to fly, we focused exclusively on basic stick-and-rudder skills, and never touched the autopilot. As I got more advanced, however, we began to use the autopilot more and more. Finally, by the time I was IFR certified, I could take off, turn on the autopilot, fly the entire trip and a linked approach on it, and turn it off just as I began the landing flare.

I see this as highly analogous to the DL-vs-GlideScope debate. You still need your basic airmanship skills. Without those, you die. But the autopilot is a tool which, correctly used, is more reliable than you are at keeping your wings level and frees up your mind and attention for other critical tasks and therefore should be used as much as possible. For those who are more comfortable with DL or VL with a standard geometry blade, I am not saying that there is any evidence-based benefit to GlideScope or that there is clear superiority - keep doing what you're doing if it works for you. This is a personal preference based on my own skill set and how I have found these tools to work. But, contra the growing consensus that VL-with-a-standard geometry-blade is the way to go, I would suggest that outside of the training environment, there are distinct advantages to the GlideScope and would not relegate it to an afterthought among the modalities of airway management.

07 July 2014

On Call

Every ER has its call roster, that sacred list of oracles, laying out who we can call when our patients need some service that we cannot provide. If I need a cardiologist, or a neurosurgeon or even a dermatologist for some acute emergency condition, all I need to do is ring up the operator and tell them, “This is the ER doc, I need [insert name of specialty here].” And like magic, ten minutes later, I’m talking to the local expert in whatever the patient has.

Fun fact: in the last month, I have consulted both physiatry and rheumatology from the ER.

So I was a little surprised recently when I had a patient with a nine-millimeter proximal infected ureteral stone and I called the operator to get me urology, only to be told, “There’s nobody on call for urology.” Huh? I pulled the call roster from the wall and scanned it:

Urology - No Coverage
Opthalmology - No Coverage
ENT - No Coverage
Plastics - No Coverage

Wow. That’s a lot of specialties that we don’t have access to. For the record, we are not some little 40-bed rural hospital. We are a 100,000 visit facility that styles itself a “regional medical center” and accepts transfers from a large catchment area. And evidently there are multiple services we no longer offer, at least not in the evening and at other inconvenient times.

Why is this? Because these local specialists have decided, as individual groups, that ER work is taxing, difficult, low-paying and high-risk. (Tell me about it.) And one by one, they have decided to quit. They just said, “Nope, not covering the ER any more.” And our hospital is not the only one facing this problem. It is, in fact, probably the biggest challenge facing emergency medicine nationwide.

Now I get it. I die a little inside when I have to call in a board-certified urologist at 0300 to put in a foley on some poor 87-year-old in urinary retention, after all my nurses and I fail to get it in. I really hate inconveniencing them, especially when it’s something that I maybe should have been able to handle myself. But that’s the life of an ER doc and I am pretty inured to it by this time. (Maybe I’m all the way dead inside?)

Which is why I was kinda incensed by the recent post over at Kevin’s site: Should Doctors be paid overtime for taking call?

The cardiologist writing that post painted a beautiful picture of how much call sucks, and I get it. I know the absence of call played into my decision to pursue Emergency Medicine as a career. But the question posed, in the context of the current situation, feels almost like blackmail: “Pay me or I’m gone, too.”

The history here is that being on call has pretty much always been a service that is part of the practice of medicine. No matter your specialty, if your patient got sick at night, you would be called in to deal with it. As the number of patients without established doctors grew, most hospitals had “no-doc” coverage rotating for unassigned patients. When you are on call, you don’t get paid for phone calls, but you do get paid if you have to come in and see or admit a patient (presuming they have insurance). In the old days call may have been a practice-growing revenue stream, but for a long time now it’s been a poorly-reimbursed time suck for most specialists.

A growing trend we are seeing nationally is for specialists to demand — and receive — reimbursement from the hospital just to be on call. Our hospital being a skinflint catholic shop responsible steward of resources told the specialists to pound sand, which led to their absenting themselves from the medical staff and call roster. But many hospitals, especially those in highly competitive markets, have started to pony up and pay docs to take call.

The math of this is really challenging. Once you are paying one group to be on call, it’s hard to justify not paying all of them. The most demanding, in my understanding, have been ENT, Hand, Neurosurgery, Optho, Plastics and Urology. The going rate seems to be about $1,000 per night, though YMMV. Ironically, these are among the least-consulted and highest-paying surgical subspecialties, which further creates an unseemly impression of physician greed. But if you meet their extortionate demands, that winds up costing the hospital $6,000 a day, 365 days a year, or about $2.2 million annually, assuming all the other specialists don’t pile on with their own demands. That’s for nothing, mind you: for being “available” without doing any work. No calls? You still bank nearly as much as I did for a busy shift of seeing patients.

And there is a tendency to see the hospital as the font of endless dollars, but hospitals are in rough shape. Their typical profit margin is in the 2-4% range, frequently dropping to zero or negative when the economy dips a bit, and under relentless pressure from medicare and insurers to accept lower reimbursements. While it’s tempting to look at the gross revenue and assume that of that $50-100 million, "surely the hospital can afford to pay to keep me on call,” in reality that is not the case.

The grim reality is this: we pay more than any other society for health care (and get less for it). There is no new money coming into the system; quite the opposite. When specialists demand extra money for a service that they have previously provided not for free but based on only professional reimbursement, that’s going to pull resources from somewhere else. Maybe it’ll be fewer ER nurses. Maybe it’ll be fewer staffed inpatient beds. It’s going to come out of the budget somewhere.

Which is why I am kind of glad our facility held firm in the face of the extortion of the surgical specialists. These guys all make ~$300K a year. I feel that if I (also well paid) have to see folks at 3am as part of my gig, they should too, and not command some premium for the service.

Am I bitter? Yes, a little. But much of that comes from the fact that I see the consequences of the specialists who opt out of call. I feel like they are still really well paid and are shirking their duty to the community and to the patients. That patient with the kidney stone? I had to transfer him out of our gleaming $500 million hospital to the county facility where a resident could take care of him. His care suffered because of the greed and entitlement of the local specialists; this wasn’t the first or last time I will encounter this problem. I don’t like seeing patients used as pawns, and I get a little enraged when local doctors jeopardize patient care over economic concerns. As I see more and more physician practices being bought by hospitals, in part to secure their call networks, I see these guys digging their own graves.

So, no, I don't favor paying specialists for being on call. Suck it up, guys, and do the right thing for your patients. Structure your practices to make call suck a little less, maybe. I empathize. When I'm sitting in a mostly empty ER at 4AM, I'm not getting paid either. But overall, we both make enough to have pretty good lives and still not opt out of caring for those who are unlucky enough to get sick at inconvenient times.

16 June 2014

Pain and Suffering in the ER

I took a recent family trip Down Under and had the good fortune to be in Australia's Gold Coast at the same time as the SMACCGold Conference. (Well, it wasn't entirely a coincidence.) I was happy to get to make it there one day and it was a great experience. I got to meet uber-tweeter and stalker Minh LeCong, organizer and LITFL dude Chris Nickson, St Emlyn's own Simon Carly, the Irish EM blogger Andy Neill, Kangaroo Island doc Tim, and many, many more. I had an extended conversation with Karel Habig of Sydney HEMS under the misapprehension that he was Cliff Reid. (Did I mention the open bar?) Sorry about that!

I haven't the time to do a full write up now, except to note that this was the only conference I've ever seen where there was an open bar in the exhibitors' center ... at 9AM. Because 'Straya.

I love the SMACC guys and I love the SMACC ethos. One of the cool things about it is that they put their talks online, freely available, as part of the FOAMed (Free Open Access Medical Education) concept. So if you missed it, you can enjoy the full conference after the fact. Most of the talks are short, usually less than 30 minutes, and they have a rather different focus than that which you will find in more traditional academic EM.

The talk that I most enjoyed, was this one, by St. Emlyn's co-blogger Iain Beardsell. It's a bit of a head fake, and not the topic one would have expected to emerge as the show-stopper, but it sure was for me. You can watch it here:

Iain Beardsell - Pain and Suffering in the ED from Social Media and Critical Care on Vimeo.

You can see most of the talks on Vimeo where they are posted in full video format, or download them as iTunes audio podcasts to listen to them on your way to the ER. The opening ceremony ... a surreal experience ... is truly not to be missed.

Best of all – SMACC is coming to the US next year, of all places, to my hometown, Chicago. The dates are June 23-26, so be sure to be there!

07 June 2014

Someone is WRONG on the internet! (Hospital admission edition)

The grandiosely-named "MD Whistleblower," recently wrote a post, reblogged at KevinMD, entitled "Why the ER admits too many patients."

I will begin with the time-honored ad hominem attack, since I am aware of all internet traditions. "Whistleblower MD"? Really? That's so cute. You see, as a whistleblower, he is a genuine hero, someone who is willing to expose himself and his career to enormous personal risk in his unrelenting search for truth. Unlike the rest of us, who are just random jerks on the internet with a bunch of opinions. He's a truth-seeker, so his opinions should be given special weight and are clearly objective, unbiased, pure Truth. Or maybe he's just another opinionated jerk like the rest of us, and in this case, a spectacularly ill-informed one.

Having said that, I would like to explain why he is wrong, in all the myriad ways, in his contention that emergency physicians (EPs) admit too many patients because of improper motivations. Note that I am not going to argue that EPs don't admit too many patients - that's a legitimate discussion to have and there may be some merit to the case, though the pendulum is clearly swinging against the trend of excess admissions.

The Whistleblower, a gastroenterologist named Dr Michael Kirsch, alleges that EPs admit patients who do not have a need for inpatient care for the following reasons:

  • EPs are incentivized monetarily for admitting patients.
  • Hospitals pressure EPs to inappropriately admit patients.
  • EPs admit to minimize malpractice risk.

The third point, I will agree, has some merit, so we will leave that alone. The first two, however, are profoundly ignorant to the realities of the actual practice and economics of acute hospital medicine (from all perspectives - those of the EP, the hospitalists who do the admitting, and the hospitals themselves).

First of all, remember that a substantial majority of EPs are not employed by the hospital, and receive their sole reimbursement from the patient's insurer, for the professional service bill. This means that whether I admit the patient or send them home, presuming that I did some sort of work-up and considered complex data and potentially risky diagnoses, I've got a level 5 chart on my hands. Nothing more is to be gained for the physician if the patient is admitted. Not. One. Penny.

In fact, admitting the patient will likely decrease my net productivity and thereby, compensation, and certainly generates more work and makes my job a ton harder. Bear in mind that Whistleblower MD stipulated that we are talking about patients who do not meet inpatient criteria.

So if I want to get this borderline patient admitted, I have to get a skeptical hospitalist to agree to accept the admission. They know full well when I'm slinging them a line of BS, and if I try to elide the truth to get the patient admitted, my credibility with them the next time I try to admit a borderline patient is shot. So I need to be honest that it's a BS admission - whether it's a social admit, or an observation admit, or someone who just doesn't look right. Hospitalists are under extreme pressure from hospitals not to admit patients like this (more on that in a moment) and they also tend to be overworked and disinclined to admit another patient if the patient doesn't need it. So most hospitalists are going to try to block this admit, or make me do some extra work to try to get the patient home, or if nothing else subject me to a withering cross-examination that takes away from time I could be using to see another patient and making more money.

Then, let's say I get the patient admitted. Great. I win, right?  Well, if I work in some sort of utopian ER where admitted patients go directly to the floor and become someone else's problem, yes. In the real world, unfortunately, admitted patients tend to board in the ER for many hours, sometimes many many hours, often on hallway gurneys. So this admitted patient, who could have gone home, is now going to squat in one of my beds for hours, congesting the ER, consuming nursing resources and preventing me from seeing patients languishing in the waiting room. To be clear: excessive admissions, as an EP, cost me money.

Now what about the hospitals? Are they going to be pressuring EPs to admit more, or even, as Whistleblower hints, improperly financially incentivizing admissions?

Again, to even suggest such a thing reveals a disconnect from reality that only a specialist who hasn't practiced acute care medicine in a decade could possess.

See, Medicare decided some years ago that inpatient care was costing too damn much. So they decided that they were going to get really aggressive about reviewing admitted cases, and then, retrospectively, denying payment for patients who were incorrectly admitted as inpatients when only observation care was indicated. Observation care reimburses the hospital only about one-sixth the amount that inpatient care does. They've gone through some contortions to try to clarify what they mean, including redefining the criteria for inpatient care and issuing the infamous two-midnight rule. So rather than pressuring EPs to admit more, the hospital administrators and utilization review folks have become intensely focused on reducing preventable admissions, and correctly categorizing observation admits as such. Hospitalists are generally the most sensitive to the hospital's concerns on this front and tend to act as a first line of defense in trying to keep the marginal admits out of the hospital.

Then you consider RAC audits. These bounty-hunting contractors are empowered to examine hospital records and retroactively recoup improper payments years after the fact. This year, RAC audits are expected to result in hospitals having to return over $3 billion to the government. Oh, and hospitals face penalties for re-admitting patients to the hospital within 30 days. Oh yeah, and medicare general medical admits generally have a flat to negative contribution to the hospital's profit margin.

So, um, no, hospitals are hardly pressuring EPs to admit to keep the wards full.

Finally, the real evidence that Dr Kirsch couldn't find his ass with both hands and an ass-finding device is the ignorance of the real revolution in ED care over the recent years: the proliferation of new treatments and decision-making tools which have allowed EPs to treat formerly admitted patients as outpatients. Consider just a few that occur to me off the top of my head:

And many more. While the valiant Whistleblower derides EPs for admitting tummyaches, the truth is that EPs are treating more and more people with formerly inpatient diagnoses as outpatients and saving the healthcare system countless dollars. We are not perfect: there are patients whose clinical need is genuinely indeterminate from the ER, and there are some indecisive or anxious docs who admit more than is strictly necessary. If Dr Kirsch wants to inform himself on the facts and make policy suggestions to improve care, his voice would be welcome. On the other hand, if he just wants to make ignorant insinuations towards the improper financially-driven motivation of an entire specialty, perhaps he would be better advised to stick to performing $6000 screening colonoscopies.

(hat tip to Whitecoat for flagging this egregious post. If you haven't it, you may wish to check out his own snark-filled rebuttal.)

12 April 2013

Gone Electric

Haven't written much in a while, but thought I'd throw in an off-topic post, just for the heck of it. A couple of months ago, I made a major change in my life: I traded in my old car, a 2004 BMW 530i and I went and got a Tesla Model S

Yep, I'm a proud member of what's been described as the "world's more expensive beta test."

I've had it now for almost exactly two months, and I thought I'd share my observations.

First of all: cost. Yes, it's an expensive car. No denying that. However, it's not quite as crazy expensive as the sticker price makes it seem. My default plan was to replace my old BMW with a new one, probably the 550. The Tesla actually specs out about the same in the cost department. There's 10% sales tax on the BMW, but my state has no tax on electric cars, and there's a $7500 federal tax credit, which helps narrow the gap quite a bit. Then, depending on the assumptions you make, the cost of fuel should actually make the Tesla cheaper over time than the BMW. I figure that over 100,000 miles (I put 130K on my old one), I'll spend about $22,000 on gas for the BMW. Electricity costs for the Tesla over the same time period should be about 10% of that figure, which could in theory make the Tesla substantially cheaper. A lot depends on the big unknown of the battery life. The one I got is warrantied to 100k miles, but the replacement cost and whether I should lay away costs towards a replacement at 100k miles is unclear. On the other hand, Tesla maintenance should be near zero. It has so few moving parts - pretty much brakes, tires and running gear; contrast that with replacing the clutch on my BMW which was over $3000. Just looking at cost of propulsion, so far I'm averaging about $0.028 per mile, compared to about $0.25 with the BMW. 

It's a pretty car. It's got a rear-focused profile which reminds me of the Jaguar XK8. I happened to get mine in something approximating a Jaguar green, which looks lovely in the sunlight but alas looks black in gray light (so in the cloudy Pac NW, it mostly looks black). The front styling looks a little like an Aston Martin, but the LED "eyebrow" lights around the headlights are distinctive and unique. 

I also like the layout. There's no engine, so the front hood hides a medium-sized trunk. I can carry my emergency supplies plus a suitcase or gym bag or groceries or lawn chairs, but it wouldn't handle a golf bag. The back is a hatch design and since I have 4 kids I got the jump seats:

The girls are sitting directly on top of the drive train, which is shockingly small. There are no gears to speak of, and no transmission. The engine revs from 0-30,000 RPM or something ludicrous like that, and is directly mated to the rear wheels. 

The interior is outfitted to match the price, easily comparable to the BMWs and Mercedes of my experience. Certainly consistent with a luxury car's expectation. I think I detect a little roughness in the fit & finish -- a little buzz from the inexact fit of the air vents, maybe. Nothing major. More puzzling is the spartan approach to storage and utility. The cupholders (there are only 2) are small and oddly placed behind the driver, and there is only one very small shelf useful for holding, say, a cell phone or some sunglasses or other doo-dads. Other than the glove compartment, there are no other storage compartments anywhere in the car. There is a lovely flat space in between the front seats (no drive train to create a floor hump) and I can toss my ipad or my wife's purse there. But it's not the same. 

The center console is a bright, sharp LCD:

The center number is your speed, and the left blue bar is an analog display of your speed. The right yellow bar is your instant power usage. Yellow means you are discharging the battery, and green means you are regenerating it. You can configure the side panels to show what you want; I have media on the left and energy stats on the right. In the right corner is a Lego figure my son made a few years back, which is the totem of my car. When you're in navigation mode, on the left is a perspective-style view of where you're to go, which is pretty intuitive and easy to follow without taking your eyes too far from the road. The center green bar is battery status and ideal range in miles. The display, as a whole, is exquisite. I'm super impressed with the design and the care that went into it and how easy it is to use. 

The big display in the center console has gotten a lot of press. It's a multifunction display which is very familiar to those of us with aviation backgrounds! It's also bright and sharp, but placed such that when you use it, your eyes are well off of the road. One very cool thing is that the rear view camera can be used while driving and supplants the rear view mirror to a large degree. The view out the rear hatch is not that great, so the fish-eye lens actually give better rear and blind spot awareness. The camera is super sharp and bright (it was raining when the above pic was taken, so it's a bit blurry). I leave it on most of the time. Below is the nav, which is powered by Google maps. You can swap out various functions or make them full screen. The media lets you choose between radio, internet radio, satellite (if you pay for it) or your local media, such as an iPhone or flash drive. The energy function lets you monitor your power usage and efficiency and is super addictive. I usually wind up trying to beat my "high score" for a given route. But that requires you to drive slow, so I turned it off. There is a browser window, which you CAN use while driving, if you're reckless enough. Fortunately (?) it's super slow, both the 3G internet and the browser itself, such that it is essentially useless, so there's little temptation there. Supposedly there's a 4G and wifi option in the works, which would make it more useful, but so far there's little risk of driving and surfing. Data is free for now, but we will probably have to pay up in the future. The phone app syncs your contacts, if you have a smartphone, and makes it super easy to call or navigate to anyone in your phone book. And unlike ANY other car I have ever used, the voice control functionality is actually pretty useful. As for the stereo:

It goes to eleven. 

The driving experience is pretty damn awesome. It's been said over and over again, but the acceleration of this thing is just sick. It's hard to describe what "instant" throttle response really feels like till you've experienced it. I've driven some really fast cars in my time and this car is quicker to respond to drive input than any I've experienced. The Porsche 911 does have more acceleration, but only by a bit, and even then it has the ups and downs of its power curve, while the Tesla has maximum torque from the moment you stab at the right pedal till you let off. While it's impressive off the line, it's almost more impressive when you're doing 40 and can still fling your head back against the rest as you punch it to 60.  I've had it as high as 110, and it still felt like it had plenty to give, though it's electronically limited to 125 mph.

Also unusual is the braking: you rarely touch the brake pedal. The moment you let up off the throttle, very strong regenerative braking begins, recharging the battery. You are actually thrown forward slightly if you let off the throttle at speed, and the brake lights come on. (They are controlled not by the brake pedal but by an accelerometer.) For someone used to a manual, it's you need to relearn how to drive, slightly. This car does not coast. 

The handling is good. This is in fact a very heavy car (4700 lbs curb weight) and it does feel that way when cornering and stopping. It takes corners very well and is more than competent at high speed. I am a bit spoiled from the stiff handling of my BMW, which I miss. The suspension and ride of the Tesla are distinctly softer, if perhaps more comfortable. 

One other odd experience is that you never turn the car on -- or off. You walk up with the key (which is shaped like a little matchbook Tesla) in your pocket. The door handles extend as you approach, you sit down, put it in drive, and go. No ignition, no parking brake, no "on" button, you just go. And when you get to your destination, you just put it in park, get up and walk away. It knows you have left, and applies the brake, locks the doors, and powers down. I'm always feeling like I have forgotten a step. 

Charging has been a non-issue so far. I had a standard 220-volt outlet (like a dryer outlet) put in my garage and I just plug the car in every night before I go to bed, as I do my cell phone. There are charging stations all over Puget Sound, but since I've 200-300 miles to play with I've never needed to charge outside of my garage. I get about 30 miles of charge per hour, so I can pretty much completely recharge overnight, even if fully drained. You can also set the car to charge during off-peak periods, when electricity is cheaper.

The rated range is 240 miles, and the ideal range is 300 miles. My experience is that I can count on the 240 miles pretty reliably. In order to get the ideal range, I'd need to drive a lot slower and also live somewhere flat, since hills really eat up the charge. But as I live at the top of a 7% grade, I accept that I will never get the ideal range. I can do road trips, but it takes a bit of planning to make sure that you can get there and that there are charging stations en route in case you need it. There are a number of good apps that tell you where to find charging stations, what sort they are, and whether they are free or charge (about 50/50, it seems). 

On the subject of apps, there is a Tesla app for the iPhone. Its main use, as far as I can tell, is to allow me to preheat the car at 2AM when I'm getting ready to leave the ER. It's nice to come out to a cozy preheated vehicle. It can also be useful for finding your car in a parking lot, or checking the state of charge. But it doesn't do much else. 

Overall, I love it. I love the fact that I never have to fill it with gas. That was a chore that I always hated and tended to make me late for work -- even later than is my norm. Now I've gone 2500 miles without setting foot at a gas station, which is pure heaven. Yeah, it's green, especially in the NW where almost all our energy is hydro. But that's not why I wanted this car. Frankly, I would still love it if it ran on ground-up puppy dogs. I'm not in this for moral superiority. I've done too many terrible, terrible things to claim that mantle. I love it because it's a hoot to drive, and because it's the coolest damn gadget I've ever seen: the ├╝ber-gadget, if you will. And I am all about the gadgets. 

15 January 2013

Mayor Bloomberg and Narcotics

I may be just a bit late in commenting on this, but last week (which was like ten years ago in Internet time) there was a bit of hue and cry regarding Mayor Bloomberg's report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the Emergency Department.

Initially, I was concerned. I completely agree with the comment from the linked article: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians... “It prevents me from being a professional and using my judgment.” The verbiage used regarding the new rules was worrisome: restricted sharply... city policy ... will not be dispensed ... regulatory authority to impose, and the like.

I'm like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to "the government coming between you and your doctor" as it was so memorably put in the past. And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.

While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:


Well, that's a horse of a different color, isn't it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines, and in individual cases, the doctor can freely exercise his or her judgement. I'm good with that. So what about the meat of the policy?

Key points that jumped out at me:

  • A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
  • Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl or methadone through the ER, and not refilling these meds
  • All narcotics to be electronically prescribed (to limit forged prescriptions)
  • Changing the defaults on EMRs to have lower amounts of tablets dispensed.

Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won't be into see ortho for a week, well then a week's worth of pain meds is reasonable, for example. In our state, we put forth some very similar guidelines in our "Seven best Practices" for reducing ER overuse and abuse.

The "guidelines" are particularly useful for a practicing doc in that it gives you permission to say "no." Currently, if I see a patient whom I suspect is "working me" for narcotics, but I don't have clear evidence to support that suspicion, I am in a bit of a bind. In such cases, there's no objective evidence of disease — back pain, neuropathy, etc — but that doesn't mean there isn't real pain. If I say no, I run the risk of patient complaints and a letter from the CEO. If I say yes, I then get bogged down in negotiations over how much and what drug. The guidelines offer a compromise: a limited supply of less potent meds. If the patient ups the ante or tries to demand more, I can point to the guidelines and explain that we have a policy, that it's not personal or judgmental, but is simply our "best practice." Even better is that there are clear guidelines against refills and treating of chronic non-cancer pain in the ER.  All this is meant to give doctors faced with a demand for narcotics the institutional backing to say no, and tacitly recognizes the fact that doctors have been complicit in creating the problem through excessive opiate use.

I note that endorsing the proposal in NYC was the New York chapter of ACEP, which is also heartening. The problem of ER abuse and prescription narcotic addiction/diversion is a real issue, and it is growing. We, as ER physicians, need to take ownership of the problem, as much as we can, and take leadership in developing measures to mitigate the problem. If we don't, then it is predictable that someone else, likely state governments, will come in and impose solutions on us -- and those "solutions" are likely to be heavy-handed, draconian, and probably ineffective.

So. from what I can tell, New York's approach seems very well-reasoned and hopefully pretty effective. I am also encouraged by an addendum that several private hospitals in the NYC area have announced that they are also going to follow these guidelines (which properly only apply to city-owned hospitals). I'm also particularly pleased that the process we went through in our state has begun to be used as a model for other states to follow!