31 July 2007

Link-fest

Too tired to seriously blog today, so here are some fun links:

Japanese One-Click Award! Truly a Zen masterpiece. Well, it's inexplicable anyways. Via the NYTimes' brilliant David Pogue.

The Bad Astronomer is anything but bad. Today he has a pretty picture - and I love pretty pictures - and a beautiful, almost elegiac explanation of its origin.

Crazy Andy Sullivan loves to psychoanalyze Hillary Clinton. He's hated her for years. But since his apostasy from the Cult of W he doesn't know who to love. I think he's falling for Obama. Today he compares Hillary's approach with Barack's, and I think he's right on. (I always worry when I find myself agreeing with Crazy Andy.)

By the way, for those who care, my current Dem President preferences are:
Obama (strong)
Edwards (lukewarm)
Richardson (cautious)
Hillary (better than a republican)
Biden (kill me now)
Dodd (who?)
Kucinich (crazy elf)
Gravel (hysterical!)

30 July 2007

Back-up cameras

We recently ordered a new vehicle, a mini-van/SUV crossover, and though it was an expensive option, we ordered the rear-view/back-up camera.

This is why.

29 July 2007

At Rest

Nathan Gentry passed away this morning with his parents at his bedside. He was seven years old, a beautiful child, and very brave. He suffered greatly in his struggle with neuroblastoma, and I hope he is at peace. He is sorely missed, and I grieve for him, and for his parents and little sisters.

It's so very wrong.

Sunday Morning Snark

Jesus' General riffs on Bush's new national health policy.

28 July 2007

Sono-Seekers

Nurse K over at Crass-Pollination writes about the "Sono-Seekers." It's a totally true and frustrating abuse of the ER. Basically, these are pregnant women who come in to the ER just for the purpose of getting an ultrasound (absent any medical indication for an ultrasound).

There's an important distinction here: when there's legitimate concern for a miscarriage, I don't at all mind seeing pregnant women. A miscarriage is traumatic and scary, and the unknown prospect of losing a pregnancy is a hard thing to live with. So these folks come to the ER, because they are genuinely anxious and there is often no other venue for them to get an answer promptly. That's fine; it's what we're here for. (No, technically not an emergency, but a reasonable use of the ER, IMHO.)

But Nurse K is right on the money that there is a subset of patient who just want a picture of their baby and have either no symptoms or minimal/exaggerated symptoms to justify an ultrasound. I also have noted a tendency for these individuals to be younger (or emotionally less mature) and government-funded. Many times I have had them complain that they don't want a pelvic exam or blood tests -- they just want the ultrasound. Commonly, they have known for a while that they are pregnant, but haven't yet bothered to see an OB.

The way I handle it is designed, however, to answer the critical medical question in the most efficient manner possible, and coincidentally, happens to frustrate the sono-seekers. If the patient has previously had a documented IUP, and has an unimpressive history or findings on exam, I just check fetal heart tones. Normal FHTs do not exclude the possibility of miscarriage, but they do make it an order of magnitude less likely. I find that reasonable women (i.e. not the malingerers) generally are greatly reassured by this -- both my reassurances that their chances of keeping the baby are good, and by the simple therapeutic value of hearing their child's heartbeat. And conversely, if FHTs are absent or abnormal, then there is at least some medical indication for an ultrasound. But it annoys the malingerers to no end when I tell them that there is no medical indication for an ultrasound and discharge them with a referral to OB.

If, however, the patient has not previously had an ultrasound (and I do have to check the records, since some of the sono-seekers lie and say they have not), then I am more or less stuck with some sort of imaging to rule out an ectopic. Some might say that the presence of FHTs essentially excludes an ectopic, but I am not that brave. I do a bedside ultrasound on these folks, and I document a positive IUP and fetal heart movement for the medical record. But our bedside machine does not print out the little pictures which the sono-seekers so cherish, and I don't make a big production of "show and tell" with the exam (i.e. reviewing the fetal anatomy, speculation on gender, etc). It's a quick "Ah, here it is. Looks OK" and show's over. It's often a three-hour investment of time for the 30-second exam, and again, leaves the malingerers unsatisfied.

It sounds judgmental and even vindictive, doesn't it, this strategy to block these folks from accomplishing their goal? But it is not without reason. People who abuse the ER for some sort of secondary gain, be it narcotics, ultrasounds, or what-have-you, are tying up limited resources and diverting these resources from people who really need them. When you have ambulances being diverted from overcrowded EDs every thirty seconds, when you have waiting rooms full and patients in the hallway, it's not surprising that we get jealous of the resources we do have. Part of the way to do that is by not rewarding the bad behavior. It's easy enough for me to go ahead and order the ultrasound, or to go ahead and write the prescription for vicodin. But positive reinforcement only encourages more of the same.

I'm glad to hear that I'm not the only one fighting the good fight.

27 July 2007

What's in a greeting?

In our community, when we need to contact the police, we have to call 911. This is at the request of the local law enforcement agencies, I think because it makes it easier for them to route the call to the right department (local police, sheriff, state patrol, etc). But it's usually just routine stuff that we need ("Hi, this is The ER, Officer Jones dropped us off a suicidal patient but he didn't leave a report..."), and I always feel bad about bothering them. It's because of how they answer the phone:

"911, please state your emergency."

I love it. It's so direct and imperative. And it is utterly clear: if you do not have an emergency, you should not be calling 911. So even though we are supposed to call 911, I still feel guilty about doing so.

I should adopt this as my mode of greeting patients. Instead of my usual, "Hi, I'm Dr Shadowfax, what brings you in today?" I could introduce myself as "Hi, I'm Dr Shadowfax, what is the nature of your emergency?" It makes the point that we are not the 24-hour medical convenience clinic, but the Emergency Department.

There's no point to it, really. People would just think I'm nuts and be offended and my Press-Ganey scores would go down. Oh well, it is nice to imagine, though...

24 July 2007

Every Breath Hurts

I'm a dangerous man. Mostly, I am dangerous to myself. I was at Karate yesterday and working with a partner on some grappling drills. As instructed, my partner (a pediatrician, of all things) took me to the ground, hard. I was quite ready to go down, and as I slammed to the mat, face first, I put a hand down, to break the fall. Unfortunately, I was going to ground so fast that I was not able to get my hand out of the way before my torso crashed down on top of it. The right side of my chest landed with my full weight on top of my closed fist.

I am pretty sure that I have one or maybe two fractured ribs ($239 each, right?) and every time I breathe, cough, or sneeze, I get a new education in the meaning of pain.

Also, somewhat later, I managed to smack myself in the head with my nitan bo. Sheesh. I really shouldn't be allowed outside the house unsupervised....

Best Chief Complaint ever?

I love nurses. Specifically, I live our triage nurses. At our facility, they only let the best nurses, with the most experience and the best bullshit meter (and best ability to spot the one "sick" patient amidst the worried well) to work at triage. It's a little bit of a controversial policy, since the better nurses don't all like to work triage, and some of them feel punished having to work out there more often. But it works well, operationally.

We have a computerized patient tracking system which incorporates all the nursing notes, including triage. The patient's chief complaint is chosen from a preformatted list, and if the complaint just doesn't fit any of the options, our triage nurses default to "PAIN - MULTIPLE" and explain in the narrative portion of the triage note. Sometimes they have a little fun with the story-telling, in an understated, "you need to read between the lines" sort of way. Because it's the medical record, you can't write anything that will get you in trouble. But they still want to say "Holy Shit!" at some of the things that come through triage.

Picking up a patient described as "PAIN - MULTIPLE" is something like unwrapping a present from a schizophrenic gift-giver. It could be something as simple as a MVA on a backboard or it could as easily be an anxious patient with multiple somatic complaints. So it is always with a sense of curiosity and utter dread that I open up the triage note to see whether I have unwrapped a nice little gift or a proverbial lump of coal.

So today, I saw my obligatory "PAIN - MULTIPLE" patient, and with a mixture of horror and delight read the following narrative (which I swear is reproduced verbatim, in its entirety):

22 y/o male, reports that 2 years ago, during foreplay, allowed GF (girlfriend) to squirt douche up his penis. Ever since then, complains of: excessive sweating.

The Reassurance Work-up

I had an attending in my training program who took a dim view of human nature; I recall that once told me that "if it weren't for alcohol and human stupidity we'd all be out of jobs." While I agreed at the time, I can now attest that he had it only half-right. To be sure, I still see many alcohol-fueled misadventures bringing folks into the ER. But I have come to the conclusion that if it weren't for anxiety and its attendant disorders, we would be out of jobs.

I blogged the other day about a rambling lady with, as they say in medicine, "multiple somatiform complaints" which is Med-Speak for "absolutely friggin' nothin'." Scalpel commented:

Patients like these are frustrating, simply because we know after about a minute that nothing is seriously wrong with them, but we also are often inclined to do a megaworkup to CYA for all of their potentially serious complaints.

Which is completely accurate. It's a terrible thing with these anxious types, because you absolutely cannot blow them off, since even anxious people get ill (and being sick makes them even more anxious). I recall a couple of years ago one of my partners blew off a guy with anxiety and chest pain (he had a history of neither). It turned out he had a thoracic aortic dissection which we did diagnose, but only after a substantial delay, and the patient died. So I hate doing the Review of Systems on the anxiety-driven cases, since they almost always have some complaint related to their chest which might be some sort of atypical angina. We joke that in these cases the RoS is "positive," meaning that for every system we ask about, the patient has a positive finding ( Cardio - Chest Pain and palpitations, Respiratory - Shortness of breath, Neuro - Headache and dizzy, GI - abd cramps and constipation, Skin - itchy and tingly, Eyes - blurry visions and spots, etc etc etc), and you just pray for the complaint of "palpitations" rather than "chest pain" since you can get away with a mini-workup for palpitations, but not for chest pain.

My trick is, however, to ask a lot more questions about their chest pain, because the more I ask, the more details they invent -- that it's not really pain per se, but like ants marching across the skin of the chest, or the pain in their chest shoots around the back and down the legs, for example. If they wind up getting so far off the beaten path that I can make a compelling case that the symptoms are non-physiologic and completely atypical for any cardiovascular complaint, then I can with some degree of comfort document that and defer a work-up. It's a dangerous game to play though, since some of these folks are professional consumers of healthcare services and know the "classic" symptoms of angina pectoris and will recite them as if from a textbook (despite their negative nuc stress and cath within the last two months). And it's hard to document that sort of history and then let them go home.

Fortunately, for the a significant majority of anxiety-driven complaints, I am able to tease out enough history that, on clinical grounds alone, I can conclude that there is no acute life-threat. But that still leaves the question -- what do I do with/for the patient? Experience has taught me that these folks are unwilling to leave the ER without a whole battery of comprehensive tests, so convinced are they that there is something seriously wrong. I have devised a simple, cheap and quick "reassurance work-up" for these folks which consists of:
an ECG, an i-Stat, a D-dimer, and a troponin. Sometimes I add a chest x-ray if it seems helpful. (We are lucky in that most of these tests can be done in the ED's stat lab with a turn-around-time of about 15 minutes.) Then I sit down with the patient and invest a few minutes telling him or her about all the tests we did and all the Bad Things we ruled out. I list each electrolyte separately, the normal blood sugar (we ruled out diabetes), normal blood counts (rules out anemia), ruled out heart attack, blood clots, aneurysm, etc etc. It's interesting how well patients respond to that. The long list of things "you don't have" seems to really be effective in reassuring patients. Then a quick laugh -- I ask the question for them: "Great, doc, you told me what I don't have, so what do I have? Well, I can't tell you what is causing your symptoms, but there are only x number of Bad Things that can cause symptoms like yours, and you don't have any of those Bad Things, so I know it is safe for you to go home, we will keep an eye on it, and I expect that it will go away on its own."

Again, it's surprising how happy this approach makes people. I get genuine thank-yous and (generally) they leave smiling and reassured. And my patient satisfaction scores stay high and the bed is quickly opened up for the next poor soul languishing in the waiting room.

23 July 2007

Thoughts on Nathan


You may recall that I have several times previously blogged about a young child with Neuroblastoma, Nathan.

I'm sad to say that Nathan is losing his battle with this terrible disease and it seems his time is drawing near. His parents, Luke and Susan, are two of my closest friends and they have shared their story with heartbreaking honesty and an astonishing intimacy. Their fortitude through this journey has been incredible, and my heart aches in anguish for them as well as for Nathan.

I wish I was there for you guys, and with you.

Love.

20 July 2007

Things I did not expect to do today

1. Clean human urine off the kitchen counter

Explanation: Second-Born Son was allowed to go sans diaper for potty training purposes. He somehow (with the help of First-Born Son) climbed up onto the counter and well, you can guess the rest.

It's not that we didn't expect a potential mess with this strategy; I just didn't expect it there.

Bush to America: Do Not Question Your King

Washington Post:
Bush administration officials unveiled a bold new assertion of executive authority yesterday in the dispute over the firing of nine U.S. attorneys, saying that the Justice Department will never be allowed to pursue contempt charges initiated by Congress against White House officials once the president has invoked executive privilege.

Breathtaking in its audacity. I've said for quite some time that the most serious damage Bush is doing to our country is the structural damage to the system of checks and balances. So if the President can claim executive privilege for any reason and there is no Congressional or Judicial oversight, what does this do to the ability of the other branches of government to restrain the imperial president?

Before the conservatives respond with a reflexive defense of Bush, bear in mind that in 2009, there may well be a President Hillary, and you just might want to exercise oversight on her administration.

I really can see only one recourse left to Congress at this time:

Article 3: Contempt of Congress.

In his conduct of the office of President of the United States, Richard M. Nixon [...] had failed without lawful cause or excuse, to produce papers and things as directed by duly authorized subpoenas [...] and willfully disobeyed such subpoenas. The subpoenaed papers and things were deemed necessary by the Committee in order to resolve by direct evidence fundamental, factual questions relating to Presidential direction, knowledge or approval of actions demonstrated by other evidence to be substantial grounds for impeachment of the President. In refusing to produce these papers and things, Richard M. Nixon, substituting his judgement as to what materials were necessary for the inquiry, interposed the powers of the Presidency against the lawful subpoenas of the House of Representatives, thereby assuming to himself functions and judgments necessary to the exercise of the sole power of impeachment vested by Constitution in the House of Representatives.

In all this, Richard M. Nixon has acted in a manner contrary to his trust as President and subversive of constitutional government, to the great prejudice of the cause of law and justice, and to the manifest injury of the people of the United States.

Wherefore, Richard M. Nixon, by such conduct, warrants impeachment and trial and removal from office.

What should Health Care reform look like?

Faithful reader and devil's advocate Felix writes:

Dear Dr. Shadowfax,

I am confused. You just explained, lucidly and cogently, that idiots like yours truly subsidise the Medicare and Medicaid patients, not to mention the uninsured, so that you can earn enough money in a shift to have a plumber unclog your commode at home.

And then you go on to say, why, Medicaid is so wonderful, let's have more of this?

This is a great point regarding Medicaid and I'd like to riff on it a bit. There's an old adage in Washington DC that "programs for the poor are poor programs," which is to say that they are underfunded with all the negative consequences attendant. Many attribute the success of Social Security and Medicare to the fact that they are endowed across all social classes and that seniors can be relied upon to raise holy hell if any politician tries to touch them, whereas it's well known that poor people don't vote, and there is rarely any electoral consequence for politicians who cut their programs.

But why on earth would you presume that I want Medicaid for all? This seems to be a common misunderstanding among the flat earth crowd who are reflexively opposed to universal health care -- they assume that whatever reformers propose will look like Canada or Britain's NHS or Medicaid or some frankenstein-esque amalgamation of all their worst bits. Either they haven't bothered to read any of the serious proposals or they are deliberately setting up strawmen to bolster their vacuous arguments.

Let me be clear on this point: I favor health care reform which will abolish Medicaid. Medicaid sucks on so very many levels it's hard to explain. The pathetic reimbursements are only its worst feature to me (a doctor) -- the medicaid recipients can tell you in great detail how much it sucks from their side, and state lawmakers and administrators will fill your ears with horror stories from their point of view.

Most damningly, Medicaid fails to fulfill its goal -- to give access to health care to the 'deserving poor' (an arbitrarily defined subset of the actual poor). Sure, beneficiaries have "insurance" but they do not have access. Try finding a PCP who will accept new Medicaid patients. Meaningful access requires coverage which provides meaningful and sustainable reimbursement.

But when you read the health plan advocated by serious individuals, you see that many of them are quite different. Most involve public-private organizations offering community-rated plans funded by premiums collected from insureds, generally with subsidies for low-income persons. Several, including my current favorite, Senator Wyden's Healthy Americans Act, would outright abolish Medicaid. They preserve multiple payors competing against one another, which would prevent a single-payor monopsony depressing provider reimbursements. Plans can even offer different levels of benefits from catastrophic to comprehensive coverage.

You may, should you choose to take the effort to look, note that not a single presidential candidate is advocating a single-payor system. Yet even rational voices like Kevin are obsessed with attacking single payor. Argue against it all you like, guys, but you're wasting your breath. That horse is dead, that dog won't hunt, whatever metaphor you like.

So, Felix, no, I don't want more Medicaid. I want a universal system that covers everybody at the same level (r/t provider reimbursements), so that the shell game of cross-subsidization stops and everybody has access to at least some basic level of real health care coverage.

Thanks for reading.

19 July 2007

This is gonna take a while...

The Triage Chief Complaint: Weak and dizzy

"Hi, I'm Dr Shadowfax. What brings you to the ER today?"
"Well it started two years ago, when my doctor gave me some skin cream and it caused me to start having heart palpitations. He said it wasn't from the skin cream but I stopped the cream and the palpitations continued so what did he know anyway? So I had the palpitations for two years every morning at 7 or 8 o'clock but then they stopped, and I hasn't having the palpitations any more but I would still get sort of sick-ee like I was having them only there was no thumping in my chest like my heart had stopped and then in October I had this headache..."

I put down my pen and affix a smile and a look of keen interest on my face. I wonder if the Cubs won today? Have I let her talk for long enough that I can interrupt her and redirect this? Should I just let it go as "palpitations" and do the "reassurance" work-up? Oh Lord she still hasn't stopped. It's like some Monty Python recital. How many patients are waiting to be seen just now? Gaaahhh.

18 July 2007

The Shell Game

Let's say that you are going merrily about your business, mowing your lawn or what-not, and you suddenly experience severe, crushing chest pain. Alarmed, you come in to the ER, quite appropriately. The handsome and compassionate ER doctor performs a detailed history and examines you. He reads an ECG, does an x-ray and some blood tests, and consults with a specialist. Ultimately you are admitted to the hospital and since we're playing hypotheticals, let's just say you make a full recovery.

It's most likely that your ER visit will be coded as:
768.5 Unspecified Chest Pain (ICD-9 Diagnosis Code)
99285 Emergency Department Evaluation/Management, Level 5 (CPT Code)

The current 'value' of the 99285 code is 4.74 RVUs (Relative Value Units).

The doctor who took care of you likely uses a fee schedule in which charges are set by multiplying the RVUs of a service by some monetary conversion factor. The conversion factors range between $90-$150/RVU. Let's use $100, for convenience. So your bill will be:
4.74 RVU x $100/RVU = $474

Now there are many things about the billing system which defy any reasonable concept of fairness. But this is a fee which actually strikes me as fair and reasonable. It's a high-stakes game, and if the handsome ER doctor sends you home in error, you may well die. Of every 20 patients presenting to the ER with chest pain, maybe one is the real deal. Picking out the one is not easy and is very risky. So I will defend a $500 fee as just compensation for a difficult and important service.

But that's not what the handsome ER doctor will get paid. The doctor's fees are honored more in the breach than the observance. The doctor will get paid depending on the payor class of the patient:

Bill Gates (cash customer): $474
Commercial insurance: variable from $220-400
Medicare: $161
Medicaid: $90
Typical "cash customer" (aka uninsured) $25

Now a typical ER will see about 15-20% of its patients as uninsured, another 20% Medicaid, and maybe 20-25% Medicare patients. So that's 60% of the patients who are in the lowest reimbursement categories (more if you count Tricare, the military insurance program, Worker's comp, etc). The weighted reimbursement for these patients -- two-thirds of all comers -- is probably about $90. Figure the doctor will pay 10% to a billing company, 10% to the malpractice carrier, and 5% in administrative overhead, leaving take-home pay of about $70 for evaluation of chest pain in the ER.

I pay more than that to have a plumber unclog my toilet.

But, clever and astute reader that you are, you notice that I exclude the other 30% of patients, who are insured. How much insurance companies will reimburse is strongly influenced by state regulations and how good the practice manager is at negotiating contracts. When I go in to negotiate with the insurers in our state, I am very up front with them: we need a high level of reimbursement from their patients to offset the poorly- and un-reimbursed care provided to the government- and un-funded patients in the ED. They don't like hearing that, but they do know the reality. Cost-shifting is the reality of the day, as health care financing in this country slowly implodes. While the insurance companies aren't exactly going to give away the farm, they can be induced to agree to higher rates to offset the uncompensated care.

Why should you care?

Because if you, like me, are employed and pay premiums for health care, you have probably noticed those premiums spiking. Our group's premiums have increased by 10-15% per year for the last seven years, and our experience has been typical of or better than the national average. How long can you keep paying 15% increases? How long is your employer willing to? How long till your employer drops the company-funded health plan and you get to join the 20% of my patients without insurance?

Yet some people think that a universal health plan would be a bad thing. Some people think it would be too expensive. Some people think that the 'market' will come up with a solution. Of course, these are by and large the same folks who thought invading Iraq would be a great idea.

17 July 2007

The Weirdest Damn Thing I've ever seen

I will preface this with the obligatory disclaimer: I shit you not.

The complaint was "Visual hallucinations," and the patient was not exactly the sort of individual you would expect to be hallucinating. He was a middle-aged, affluent corporate executive, a sharp and high-functioning individual with no history of either substance abuse or mental illness. He was, therefore, rather perturbed by the little red and green elves he kept seeing all over the place. He knew they weren't real, but they just wouldn't go away. (We attributed the fact that they were red & green to the fact that this case occurred shortly after Christmas.)


My partner, "Bill," was a superb physician, but I would never let him take care of me in a million years. Not because his skills aren't good: they're excellent. He's one of the best doctors I have ever had the honor of working with. But Bill is what is known in the business as a "black cloud," or, less politely, a "shit magnet." Somehow he always manages to get the most awful, obscure, or just plain bizarre cases, and when he works, the crazies always come out in force. In fact, it was Bill who signed out this gem to me. So when he came to me with this case, perplexed and looking for advice, I was not particularly surprised. It seemed par for the course for him. The work-up in these cases is pretty straightforward and almost always unsatisfying: rule out medical causes and consult psychiatry. So Bill orders a slew of labs and a CT scan of the brain.

This is where it gets weird. Um, weirder. For some reason, Bill ordered a Troponin, which is a blood test marker of heart damage. I wouldn't have ordered it -- there's no logical connection between the heart and odd psychiatric symptoms. I would have probably confined my lab tests to electrolytes, blood sugar, a drug screen, that sort of thing. But Bill, conditioned by the strange stuff he sees, casts his net a bit wider. And the troponin came back strongly positive.

Which was completely unexpected. We had not even done an ECG. But when he saw the troponin, Bill immediately ordered one, and saw something like this:

Which was even more unexpected. The following amusing conversation with a cardiologist ensued:

"So I have a guy here having a heart attack with a positive ECG and troponin."

"Great. I'll be right in. Is he still having chest pain?"

"Well, that's the funny thing. He's never had any pain."

"Interesting. What was his presenting symptom?"

"Visual hallucinations. Elves. Christmas elves, we think."

"Bullshit. You are kidding me, right?"

But we faxed him the ECG, which was really quite convincing, and the cardiologist came in reluctantly, and somewhat dubiously took the patient to the cath lab. Sure enough, the patient had a high-grade obstruction of his LAD, and upon opening it, that patient's ECG returned to normal. The next morning on rounds, the patient thanked the cardiologist for saving his life, and ventured that he didn't want to seem ungrateful, but the elves were still bothering him, and could he please do something about that? Psychiatry saw the patient and concluded that he wasn't crazy. So the neurologist was called in and noticed an odd motor tic every time the patient looked at the elves, who were always sitting to his left. The neurologist speculated that the hallucinations might be a form of a partial complex seizure, so he started the patient on an IV drip of dilantin, an anti-seizure medicine.

And the Elves went away.

So there you have it: Acute Anterior Myocardial Infarction presenting with Partial Complex Seizures manifested as hallucinations of Christmas Elves.

And that, ladies and gentlemen, is the weirdest damn thing I have ever seen.



(Apologies to Steven Colbert)

16 July 2007

Moore vs Gupta -- in the Octagon!

I hadn't intended to go here. I haven't seen Sicko, and don't intend to. (My summer film viewing will be limited to Ratatouille, The Simpsons, and Harry Potter. I have kids.) I do want to comment on the Moore vs Gupta kerfuffle. For those who didn't see it, Moore was on CNN and Dr Sanjay Gupta did a "fact-checking" of his film, Sicko. They have since been bickering about the various facts Moore asserted in his film and Gupta's adversarial framing of the fact-check. CNN has issued a tempered retraction, and Moore has taken his usual combative approach.

So I'm not much interested in the actual numbers in this case. Moore said the US spends almost $7000 per capita on health, Gupta says it's just over $6000. Depends on your source and the year. Sheesh. Either way, it's still something like twice the OEDC average.

What I am forced to wonder is why CNN and Gupta felt the need to run a hatchet job on Moore, implying that his numbers were cherry-picked and somehow by implication his conclusions are untrue? All the more perplexing since their current line is "Hey, really, we all agree about this stuff anyway and Moore's trying to create conflict where there isn't any?"

Moreover, how come Wolfie & the gang will let right-wing apparatchicks spout complete and utter bullshit without ever once even challenging them, let alone "fact-checking" them in this manner? Why are they trying to hold Moore to some higher standard than they hold conservatives? To be fair, I am happy to see the media sort-of start to do its job with regard to calling bullshit when they see it -- I just wish they were so diligent about their duty to truth and facts with right-wingers.

As usual, Ezra comes pretty lose to the heart of the matter, I think. Money quote:

Here's a guess, though: Michael Moore elicits a very specific type of status anxiety in mainstream journalists. Moore's product -- passionate, provocative political commentary -- is a close cousin of the media's product -- bloodless, boring political commentary. ... What he does is, broadly speaking, in the same realm as what they do. But there are differences between the product he puts out, and what the media offers. A major one is that Moore's releases strike massive emotional chords with the American people, setting off weeks of heated discussion every time he unveils a film. ... So there's an acute desire on the part of the press to separate what Moore does from what they do, both in order to explain away his successes and to underscore their own assumed strengths (objectivity, rationality, etc). His failings may be manifold, but that hardly renders him unique. His treatment, however, is unique. The world is full of political provocateurs and public hotheads, but only Moore triggers the media's all-too-absent obsession with factual accuracy. Ann Coulter doesn't, and Al Franken doesn't, and Rush Limbaugh doesn't, and Mitt Romney doesn't. Only Moore. Because he scares them.
Or to put it less charitably: Moore's clear reporting of the terrible shambles that is our health care system and advocacy for serious reform makes one wonder what the hell Dr Sanjay Gupta has been up to the last seven years and why he and CNN have not made an central issue of the developing crisis. So Dr Sanjay has to take down Moore and make him look like a liar in order to preserve the veneer of his own credibility.

Journamalism at its finest. Heckuva job, Sanjay.

First Pass


She was, my patient conceded, "a bit overweight." In medical terminology, she was morbidly obese. She weighed about 280 pounds, and her BMI was somewhere over 50, seeing as she stood only five foot two. In more vivid verbiage, she might have been described as resembling nothing so much as a bowling ball, a round body with spindly legs and arms jutting out at improbable angles.

Her complaint was "headache" and her temperature was 102.8 degrees Fahrenheit. She was on multiple immunosuppressants, including steroids, for a mixed connective-tissue disorder. There was no apparent explanation for her fever -- no urinary tract infection, no cough or runny nose. As I gently flexed her neck forward, she winced.

And I winced.

Because there was just no option -- she needed a spinal tap to assess for meningitis. And with a body type like hers, the likelihood was that it would be a flog. I could see where this was going to end up -- a half hour of torturing this nice lady trying to get the tap myself; a call to interventional radiology and the obligate half-hour delay in the call-back; enduring the open scorn (best case) or scathing abuse (worst case) of the radiologist who was called in the middle of the night to do the procedure under x-ray guidance. There was seven hours left to go in my shift, I reflected, and I would be lucky if I could get the disposition accomplished before then.

So, first off, I got set up to give it the obligate college try. Lie her on her right side and set up the table as usual, as if this is anything other than going through the motions. I set up the test tubes, neatly in a row, as if there is a chance they will soon be filled with glistening CSF. I go through my usual pre-procedure patter, trying to put her at ease and trying to get myself to believe that this is just like any other tap I will do this week.

Sitting on my little stool, face to face with the small of her back, I could not find a single anatomic landmark to guide me. The spinous processes were buried under a thick layer of fat and not at all palpable. The iliac crest at the top of the hip-bone was similarly obscured. For that matter, I couldn't even positively identify the midline! The nurse and the patient's husband watched me, their expressions full of a simple confidence that I would quickly put this to rest. How little they know, I thought. I was careful to give her a healthy dose of numbing medicine and premedicated her for the procedure with dilaudid, figuring I was about to be causing her some pain. I made my best estimate of the locations and angles I would try, placed the needle against her clean skin and closed my eyes before sliding the needle in by feel alone. I waited for the sudden, hard resistance that would indicate I had just rammed the needle into bone. But it didn't come. Bemused, I pulled the stylet back and peered into the hub of the needle. Crystal clear fluid briskly welled up and began to drip out.

My jaw was hanging open behind my surgical mask, but my eyes and voice hid my astonishment as I said "We're in," in my most professional tone and began to collect the fluid. The nurse cooed, "There, that wasn't so bad, was it?" And the patient replied, "I didn't feel a thing. Is it always that easy?"

Easy? Yeah, that's the word for it: easy. Well, as far as they know...

-----------------------------------------------

The icing on the cake came an hour later:
WBC: 0
RBC: 0

The Shrill One speaks

I can't add anything to this, so I present it nearly in the entirety. Krugman:

Being without health insurance is no big deal. Just ask President Bush. “I mean, people have access to health care in America,” he said last week. “After all, you just go to an emergency room.”

This is what you might call callousness with consequences. The White House has announced that Mr. Bush will veto a bipartisan plan that would extend health insurance, and with it such essentials as regular checkups and preventive medical care, to an estimated 4.1 million currently uninsured children. After all, it’s not as if those kids really need insurance — they can just go to emergency rooms, right?

O.K., it’s not news that Mr. Bush has no empathy for people less fortunate than himself. But his willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada. The claim that the uninsured can get all the care they need in emergency rooms is just the beginning. Beyond that is the myth that Americans who are lucky enough to have insurance never face long waits for medical care.

Actually, the persistence of that myth puzzles me. I can understand how people like Mr. Bush or Fred Thompson, who declared recently that “the poorest Americans are getting far better service” than Canadians or the British, can wave away the desperation of uninsured Americans, who are often poor and voiceless. But how can they get away with pretending that insured Americans always get prompt care, when most of us can testify otherwise?

A recent article in Business Week put it bluntly: “In reality, both data and anecdotes show that the American people are already waiting as long or longer than patients living with universal health-care systems.”A cross-national survey conducted by the Commonwealth Fund found that America ranks near the bottom among advanced countries in terms of how hard it is to get medical attention on short notice (although Canada was slightly worse), and that America is the worst place in the advanced world if you need care after hours or on a weekend.

We look better when it comes to seeing a specialist or receiving elective surgery. But Germany outperforms us even on those measures — and I suspect that France, which wasn’t included in the study, matches Germany’s performance. ...

On the other hand, it’s true that Americans get hip replacements faster than Canadians. But there’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.

The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.

13 July 2007

Universal Health ¹ Socialized Medicine

A Plea for clarity and precision in verbiage:

Universal Healthcare: a system in which every person has access to and funding for medical services. Can be publicly funded, privately funded, or most commonly, a hybrid.

Socialized Medicine: a system in which medical services are furnished directly by the government. Typically involves government ownership of clinics and hospitals and public employment of providers. May exist on its own or in a parallel structure with private medicine (e.g., the VA).

Please note that the terms are not interchangeable, and that even the more radical proposals being floated do not approach the level of Socialized Medicine. In fact, most rely heavily on involvement of the private sector. Even the bete noir, Single Payer, Medicare-for-All, is not true socialized medicine. It is a government monopsony with all the attendant drawbacks, but is only public funding of a private healthcare delivery system.

On that note, there is a pretty good breakdown of the presidential candidates' health care plans over at the Huffington Post.

Thank you for your attention,
Your friendly neighborhood semantician.

11 July 2007

I stand corrected

I have said before that "Just go to the ER"is not a national health care policy. Apparently, I was wrong. Yesterday, Our Dear Leader said otherwise:

"The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America," he said. "After all, you just go to an emergency room."
Oh sweet Jesus, the man is an idiot and a buffoon. It's bad enough to have the uninformed troglodytes think that "just go to the ER" is a substitute for actual access to health care, but this man ostensibly directs policy. I would say I have higher expectations from the man who inhabits the oval office, but sadly, it would be hard for me to have lower expectations for him.

It is perhaps a bit of unintended honesty, though. I guess it explains 7 years of inaction on the uninsured crisis, doesn't it? If he really believes that all the nation's health needs can be met in our humble departments, what reason is there to fix the system?

1.21.09

09 July 2007

Perverse incentives


Byzantine \By*zan"tine\ (b[i^]*z[a^]n"t[i^]n),
a. Of or pertaining to Byzantium.
b.
A highly intricate system characterized by bureaucratic overelaboration bordering on lunacy
c. Relating to medical billing processes

I recently reviewed a chart for a patient who had been in a car accident. It was an old man who had sustained multiple injuries and was seriously ill, admitted to the ICU with multiple consultants. I was struck by one feature of the chart -- the bill was absolutely huge. Far beyond what is typical for even a serious trauma.

There were the standard items:
Critical Care, 30-74 minutes, $596
Chest Tube, $574

So a pretty sizable bill just there -- $1100. But that was in fact the smaller part of the bill. The balance:
Fracture care: Shaft of clavicle, $489
Fracture care: Nasal bone, $79
Fracture care: Rib, $239 x 3 ribs fractured
Fracture care: Metacarpal bone, $490
Fracture care: Pelvis, $1157
Fracture care: Medial mallelous of ankle, $705
So, for fracture care, the total sum was a princely: $3600

Now I should point out that these are gross charges (gross, indeed!), and actual collection on these charges may vary from 90% (in a commercially insured case) to about 30% (Medicare) to 0% (no insurance). But even so, look at the disparity! The fracture care is more than triple the cost of the actual life-saving treatment this patient required.

Just to be clear, the patient had sustained a head injury (fortunately, a minor one), requiring CT scan of the head and neurosurgical consult. There was the chest injury requiring the ER doc to cut a hole in the chest wall to let out trapped air and release the pressure which was preventing the heart from filling with blood. Internal injuries in the abdomen required consultation with a general surgeon. And the patient was elderly and frail, with other medical conditions and was in shock. The ER doc spent over an hour on this case alone, and did a tremendous job pulling someone's grandfather through the "Golden Hour." It's a Medicare patient, so he'll probably get $300 for his efforts.

BUT, he put on a few splints, x-rayed the right body parts, and did a very careful dictation noting all the injuries. And for that, he'll get three to four times the remuneration he did for the hard, scary, critically important life-saving efforts.

So, for the health policy types:
The system is fundamentally and irredeemably broken. Fix it now.

For ER interns:
In order to compliantly bill for definitive care of a fracture in the ED you must be sure to document:

  • The name of the broken bone, the anatomic location of the fracture, and whether it was open or closed
  • What interventions you performed (i.e. reduction, splint, strap, analgesia, ice, etc)
  • Post-intervention assessment (i.e. neurovascular status, pain level)
  • Follow-up plan
In order for the ER doc to legitimately bill for this service, you must actually provide the same care which would have been provided by a specialist. If follow-up with a specialist is required (say, for cast placement), the reimbursement will probably be split, with the majority going to the initial physician.

Sheesh, no wonder the average salary of an orthopedic surgeon is twice that of an ER doc, which is itself half again that of a family practitioner.

08 July 2007

Hills

I HATE HILLS
I HATE HILLS
(gasp)
I HATE HILLS
(gasp)
MOTHAFUCKA
(gasp)
MOTHAFUCKA
(gasp)
(gasp)
(gasp)

07 July 2007

Number Three

Thanks to those who commented. No, we don't know the gender. You'll hear more after the New year, I suspect!

06 July 2007

Yowza

From Swampland:

* 45% favor "the US House of Representatives beginning impeachment proceedings against President George W. Bush;" 46% oppose.
* 54% favor "US House of Representatives beginning impeachment proceedings against Vice President Dick Cheney;" 40% oppose.

For context:
Aug-Sept 1998 (Before Impeachment)
* Average support for impeachment and removal (10 polls): 26%
* Average support for hearings (6 polls): 36%
Damn. I new he was unpopular (26% approval at most recent) and I knew he was polarizing, but holy smokes, this is remarkable.

Praise from Caesar

The Unit Supervisor just came to me in the ED and took me aside. She is a somewhat crusty lady, thoroughly professional but no-nonsense, the sort who takes shit from nobody and is not above, when required, telling an ER doctor exactly what he can go do to themself.

"I don't get a chance to say things like this very often so pay attention. I had three of my very best nurses ask me this morning, if they could be assigned to this area because they heard you would be staffing it." She paused. "So I guess you must be doing something right."

Praise from Caesar . . . is praise indeed.

05 July 2007

This Modern World


Tom Tomorrow, as usual, says it far better than I ever could...

Least Emergent Chief Complaint of the day

Insomnia.

I shit you not.

Ten patients into the shift and not a single one of them "needed" to be in the ER. Foot pain x 3 months. Chronic neck pain (no significant changes -- just got scared). Homeless & got nowhere to go. Ingrown fingernail. Etc.

Sigh. It's going to be a long day.

03 July 2007

Here we go again...


ER Physician scheduled for 12% Medicare pay cut in FY 2008.

Justice, Republican style

Wasington Post
THE SUPREME Court this week declined to review the case of Weldon Angelos, leaving in place his obscene sentence of 55 years in prison for small-time marijuana and gun charges. [...] But it confronts President Bush with a question he will have to address: Is there any sentence so unfair that he would exert himself to correct it?

So far, Mr. Bush hasn't found one. He has commuted only two sentences, both of inmates who were about to be released anyway. Mr. Angelos, by contrast, is a young man and a first-time offender who is now likely to spend the rest of his life in prison. His crime? He sold $350 in marijuana to a government informant three times -- and carried, but did not display, a gun on two of those occasions. Police found other guns and pot at his house. The U.S. district judge who sentenced him in Utah, Paul G. Cassell, declared the mandatory sentence in this case "unjust, cruel, and even irrational." He noted that it is "far in excess of the sentence imposed for such serious crimes as aircraft hijacking, second degree murder, espionage, kidnapping, aggravated assault, and rape." And in an extraordinary act, he explicitly called on Mr. Bush to use his clemency powers to offer what he as a judge could not: justice. Judge Cassell recommended that Mr. Bush commute the sentence to 18 years, which he described as "the average sentence recommended by the jury that heard this case."

Mr. Bush put Judge Cassell on the bench. As a law professor before that, he was a staunch advocate of tough justice; his chief claim to fame, in fact, was having pressed the Supreme Court to overturn its landmark Miranda decision requiring police to read criminal suspects their constitutional rights. His exceptional discomfort with this case -- and his passionate plea for presidential mercy -- ought to carry weight even with a president so disinclined to use the powers the Constitution gives him to remedy injustices.
Unless you're rich, white, and Republican.

Things which will blow your Wa


Wa is very important to me. From my limited understanding, "wa" is a concept in Japanese culture referring to an internal sense of harmony and well-being. I shelter, protect and cultivate my wa religiously. It is what gets me through difficult shifts without going mad.

So yesterday, I arrived home from a birthday party with the kids, still in my swimsuit and wet from the pool. Tired and utterly relaxed, I had a beer out from the fridge and on the counter with the bottle opener in my hand.

The Phone Rings.


"Hi, Doctor. It's Jennifer in the ER. Are you coming in to work this evening? We were expecting you at 6:30."
"I don't think I am working today."
"We have you as the 6:30 doc on the schedule. Did you make a trade?"
"Um, no. Let me check my schedule and get back to you."

My Outlook calendar has me quite clearly as OFF today, but the master ER schedule does show me as working. Crap! How did that happen?

I ultimately got to work only an hour late (only!) and that was only by virtue of a very quick change of clothes and some serious extralegal driving. Fortunately, my partner whose shift had been scheduled to end at 6:30 was gracious in accepting my humble apologies.

But my wa was completely and utterly blown.

Predictably, the shift wound up being like crap. Nothing worked. I never got my flow, the rhythm, the groove. Nobody had an obvious diagnosis. Hospitalists were all rightly skeptical at half-baked admissions. Pissed-off patients wound up walking out dissatisfied. I kept losing track of patients (Room four? I thought they were discharged an hour ago!) and orders somehow kept appearing on the charts for the wrong patients (thank god for alert nurses who repeatedly saved my ass). And all attributable to the fact that I arrived late, flustered, and not in the right frame of mind for the shift. Man, I'm no good at all without my wa.

Sigh. And I am working again at 6:30 tonight.

01 July 2007

Advice for EM Interns - Part Five

Compensation.It's a dirty topic in medicine. Nobody ever wants to admit how much they make, or how that number is derived, or even that money ever has any role in patient care. But that is an elaborate fiction. Money talks, and nothing motivates people like money.


In EM, there tend to be two camps with regard to pay: hourly and productivity-based. Hourly pay is exactly what it sounds like -- you clock in and clock out and get paid a flat hourly rate. Rates vary widely (especially based on geography) but my understanding is that nationally, the average ER doc will get about $125-150/hr.



Productivity pay systems can be much more complex, but generally can be summarized as: instead of an hourly pay rate, you get paid per patient. In most cases, the compensation is determined by the number of patients you see and by the dollars billed per patient. Dollars billed per patient generally relates to how well you documented the patient encounter and your decision-making process and whether your charting quality was sufficient to allow your coders to capture all the legimate charges.



Some might find this to be off-topic: what does compensation methodology have to do with efficient operation of the ER? I include this here because I strongly believe that in order to optimize the processes in your ED, it is important to have medical staff who are motivated to be as effective as possible. I have worked in settings in which pay was hourly and those which were 100% incentivized. The difference is remarkable. In environments in which a person's individual compensation is not at risk, the motivation to give 100% effort is attenuated. Some docs will do their best because they are altruistic, or for Press-Ganey scores, or just because they are energetic – they are usually the top 25% of docs in any group, either way. But the average doc does about 10% less work, and the bottom quartile really dog it when there is no disincentive against phoning it in. The cumulative effect of this productivity decrement is significant and can really impact the smooth operation of the ER, not to mention the bottom line of the group.

I am sure the comments will fill with stories of lazy ER docs who went to the cafeteria while charts piled up in the racks, places where one doc would be busting his hump while the other spent hours dictating, where two lazy docs played a game of chicken to see who could go the longest without picking up the 300-pound vaginal bleeder. I've seen it time and again. The nurses ask, "Can they not schedule Dr Tortoise with Dr Slug? The department comes to a halt when they are working together." Cases like that are far far more common when the docs are paid hourly.



But when each patient has a direct measurable financial value to the practitioner, each additional patient is viewed not as a burden and extra work, but as an opportunity. What a tremendous transformation in perception! This directly translates into docs who are eager to see patients, and even docs competing to get the next chart from the rack, which in turn translates into shorter waiting times and faster patient flow through the department.



I will also editorialize that I believe productivity-based compensation is fairer. If an individual highly-productive doc is responsible for a certain amount of income for the group, it is perverse to take some of that revenue and redistribute it to the less-productive practitioners. This is what effectively happens under hourly compensation systems. Docs are aware of this fact and it certainly breeds resentment and damages the group morale.



Having said that, there are challenges to a pure productivity payment system. There is an incentive for docs to chart surf, to skip the time-consuming patients in favor of the quick and lucrative patients. The only solution to this is a strong ethic and trust among the partners that cherry-picking is not permitted, or alternatively, a pod system in which patients are assigned to doctors (instead of the other way around). Similarly, there can be an incentive to skip the uninsured or Medicaid patient in favor of the fully funded patient. Our group handles this by paying docs a flat rate per RVU generated, which effectively blinds the practitioner to the patients' payer class: a Medicaid patient is potentially worth exactly as much as a Blue Cross patient.



Some groups try to compromise by utilizing a hybrid system – part base salary and part productivity. The drawback to the hybrid system is that the hourly base salary weakens the incentive effect of the productivity component. If you imagine the productivity distribution of ER docs, there is a normal bell-shaped curve just like in any other population. About 50% of the docs cluster around the mean, and about 25% excel and 25% underperform. So in an "average" hybrid system, something like $80/hr is guaranteed, and $40/hr is based on production. That half of the docs whose production is about average will have pay within a few dollar an hour of the mean. For those who are high or low performers, there is a variation in pay, but the typical range is relatively small compared to the base salary ($5-15/hr). More significantly, the reward for working harder is small, and the punishment for inefficiency is small.



Conversely, the magnitude of the incentive in a fully productivity-based system is much higher; the range between the highly effective and less effective docs can be $50/hr or more. That sort of variation in pay provides a very powerful motivation to all the docs to be as efficient in moving the meat.



There are some counter-arguments I have heard to this approach, which have not been borne out in my experience. For example, concerns that docs who are too motivated by the money will lose focus on quality of care and rush patients through without taking the time to ensure that the diagnosis and treatment are right. However, the fear of being wrong, and the fear of liability provide a powerful counter-balance, which seems to keep docs honest. Some said that if docs get paid based on dollars billed, they'll just order a lot of unnecessary tests to make the bills bigger. But in real life, a CT scan takes a long time and prevents the doc from seeing other patients in that bed, so unnecessary tests actually tend to hurt docs financially. Others were concerned that doctors would hurry through the personal interaction with patients and the satisfaction scores would go down. But truly, patient (dis)satisfaction is more strongly linked to delays in care, and by reducing the door-to-doctor time, scores are more likely to go up, even if the docs spend less face time with the patient.



Physician compensation is complex, and there's no one right way to do it. Some groups, or some EDs, may have unique circumstances which would render incentivized compensation undesirable. But if your ED is underperforming and the docs are the rate-limiting step, smart utilization of financial incentives can bring your performance up to where it needs to be. If you are a graduating resident looking for a practice in which the docs are paid fairly and have a direct financial stake in the operation of the ED, make sure you get the details of the physicians' reimbursement system.

Pac NW


How to know you're from the Pacific Northwest



1. You know the state flower (Mildew).
2. You feel guilty throwing aluminum cans or paper in the trash.

3. Use the statement "sun break" and know what it means.
4. You know more than 10 ways to order coffee.
5. You know more people who own boats than air conditioners.
6. You feel overdressed wearing a suit to a nice restaurant.’
7. You stand on a deserted corner in the rain waiting for the "Walk" Signal.

8. You consider that if it has no snow or has not recently erupted, it is not a real mountain.
9. You can taste the difference between Starbucks, Seattle's Best, and Veneto's.
10. You know the difference between Chinook, Coho, and Sockeye Salmon.

11. You know how to pronounce Sequim, Puyallup, Issaquah, Oregon, Yakima, and Willamette.
12. You consider swimming an indoor sport.

13. You can tell the difference between Japanese, Chinese, and Thai food.
14. In winter, you go to work in the dark and come home in the dark - While only working eight-hour days.
15. You never go camping without waterproof matches and a poncho.
16. You are not fazed by "Today's forecast: showers followed by rain," And & then; "Tomorrow's forecast: rain followed by showers."
17. You have no concept of humidity without precipitation.
18. You know that Boring is a town in Oregon and not just a State of Mind.
19. You can point to at least two volcanoes, even if you cannot see through the cloud cover.
20. You notice, "The mountain is out" when it is a pretty day and you can actually SEE it.
21. You put on your shorts when the temperature gets above 50, but still wear your hiking boots and parka.
22. You switch to your sandals when it gets about 60, but keep the socks on.
23. You have actually used your mountain bike on a mountain.
24. You think people who use umbrellas are either wimps or tourists.
25. You buy new sunglasses every year, because you cannot find the old ones after such a long time.
26. You measure distance in hours.
27. You often switch from "heat" to "a/c" in the same day.
28 You design your kid's Halloween costume to fit under a raincoat.
29. You know all the important seasons: Almost Winter, Winter, Still Raining (Spring), Road Construction (Summer), Deer & Elk Season (Fall).


(Source unknown)

Aiiieee!

Make the bad man stop, mommy! Make him stop!

Some sick individuals abuse an iPhone to see if they can break it.

The iPhone wins!