29 November 2007

We need more politicians like this

From The Guardian:

For 25 years Peter Garrett was the frontman of Midnight Oil, an Australian rock band known for its raucously loud music and protest songs about social and environmental issues. Then the bald 6ft 6in singer hung up his microphone, disbanded the group and exchanged his rock star clothes for the sombre suits of a politician. After a meteoric rise through the ranks of Australia's Labor party, he was yesterday named environment minister in the newly elected government.
I remember seeing them live at Chicago's Poplar Creek in 1990 (yeah, I'm old) and again in 1993 at the World Music Theater. Damn they put on a fine show. Peter Garrett was one of the most amazing performers I have ever seen. The amount of energy he expended performing would have put James Brown to shame. Midnight Oil still figures prominently in my workout playlists. Weird to think of him as a "Minister" of anything, but I guess that's Oz, innit?

28 November 2007

Ranting on the RUC

(Cross-posted with my other blog at MedPage Today)
Over at DB's Medical Rants, rcentor comments on the machination of the RUC, also known as the "RBRVS Update Committee" and the way in which it has skewed and poisoned the medical reimbursement system, as documented in a recent JAMA article.

I couldn't agree more, and wish this issue would get more attention.

I have some experience with the RUC via the ACEP Reimbursement Committee, and while I have been pleased to some degree by the facility with which the representatives of Emergency Medicine have worked within that milieu, on the basis of self-interest, I can't stand the way in which it is structured and works.

Key points from the cited JAMA Article:

Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. [snip]

This problem will only be resolved with full recognition of its origins. Because physician decision making profoundly influences health care expenditures,11 the forces that affect these decisions must be addressed. Practice type and physician specialty are critical factors; both are associated with higher rates of test ordering and hospitalization. Generalists with long, continuous clinical relationships with patients tend to generate lower health care costs for their patients. Current reimbursement incentives substantially favor procedures and technical interventions and offer financial advantages for expensive care, thereby encouraging specialty services. [snip]

The American Medical Association (AMA) sponsors the resource-based relative value scale update committee (RUC) [...] The RUC has 30 members (the chair only votes in case of a tie) with 23 of its members appointed by "national medical specialty societies." Meetings are closed to outside observation except by invitation of the chair. Only 3 of the seats rotate on a 2-year basis. Other members have no term limits. Seventeen of the permanent seats on the RUC are assigned to a variety of AMA-recognized specialty societies including those that account for a very small portion of all professional Medicare billing, such as neurosurgery, plastic surgery, pathology, and otolaryngology. Proceedings are proprietary and therefore are not publicly available for review. Traditionally, more than 90% of the RUC's recommendations are accepted and enacted by CMS. [...] The resource-based relative value scale system "defies gravity" with the upward movement of nearly all codes. In 2006, based on RUC recommendations, CMS increased RVUs for 227 services and decreased them for 26. [snip]

By creating and maintaining incentives for more and more specialty care and by failing to accurately and continuously assess the practice expense RVUs, the decisions of CMS have fueled health care inflation. Doing so has affected the competitiveness of US corporations in the global market by contributing to years of double-digit health care inflation that have consistently increased the costs of manufacturing and business in the United States over the last decades.

The continued and sustained incentives for medical graduates to choose higher-paying specialty careers and for those physicians in specialty careers to increase income through highly compensated professional activities have been associated with the dwindling of the generalist workforce. The lack of incentives for medical graduates to choose generalist careers in internal medicine, family medicine, and pediatrics has had a profound effect on the workforce mix and, ultimately, US health care expenditures.

Residents are choosing not to enter the generalist fields. For instance, among first-year internal medicine residents, less than 20% have interest in pursuing careers in general internal medicine. Past trends indicate that only slightly more than half of these residents continue this commitment to general internal medicine to the completion of residency. If this continues, as few as 10% of those training in internal medicine will to work as general internists.

There's more, and I encourage those of you with access to read the full article.

I have blogged in the past about the perversity of the reimbursement system and the way it inappropriately rewards procedural services over cognitive services. It makes me crazy that I get paid more for stitching up a minor facial laceration than I do for deciding whether your chest pain is an impending heart attack. (CPT 12052 (laceration) = 4.37 RVU; 99285 (E/M) = 4.01 RVU) Several other excellent health care bloggers have opined, some extensively, on the same topic.

I don't take much issue, as does rcentor, in the relative secrecy of the RUC. My experience is that horse-trading like this is something best done behind closed doors. We don't expect GM and the UAW to open their negotiations to the public, and in the same vein, I would not expect the inter-specialty wrangling to be aired publicly. What I do take issue with is the composition of the committee, which I see as the key driver of weighting towards specialty services and procedures.

As noted above, the RUC is to a very large degree dominated by specialists. There is, I am reliably told, an informal alliance between the procedure-based specialists, which would include surgeons (General, Thoracic, Ortho, Spine, Neuro, Urology, Plastics, Optho, ENT, OB/GYN) and "medical specialists" who derive much of their revenue from procedures (cardiology, radiology, anesthesiology, dermatology). Together these specialties control about 60% of the seats allocated to medical specialty societies. The primary care specialties, in contrast, control only 13% or three votes (Internal Med, Family Med, and Pediatrics). (Four, if you count Emergency Medicine, which is naturally aligned with primary care.)

Notable in the compostion of the RUC is the inclusion of most of the surgical sub-specialties, and almost complete exclusion of the medical ones. Oncology, Neurology, and Pulmonary are there, and not a single other medical specialty is represented. Neither is there any proportionality to the representation. The 6,000-member American Society of Plastic Surgeons has the same amount of influence as the 124,000-member American College of Physicians.

In a self-serving game of "you scratch my back," the proceduralists support the inflated work values of one another's new procedures, and as the values float further and further higher over time, and as the number of procedures grows, the value of office-based or cognitive services diminishes in relation. And as there is only one pie to split up, the slice of the pie that goes to primary care shrinks and shrinks. Now we are at the crisis point. Primary care as currently practiced is no longer economically sustainable, and medical school graduates see this and make a rational choice to pursue more remunerative careers.

Sadly, I don't see this changing unless there is a major revision to how the RVU system is determined, and I fear that the established players are well-enough entrenched that they will be able to derail any meaningful reform. This is an arcane enough issue that it's hard to explain to the policy-makers, and those whose income would be threatened by changes will predictably object and confuse the issue enough to obstruct the changes. But at least this topic is beginning to gain attention and traction at a national level, and maybe, just maybe, this might be a small first step on the road to reform.

Loyalty oaths

I can't decide whether this is more hilarious or creepy:

Virginia GOP Will Make Voters Sign Oath
Voters planning to vote in Virginia's Republican presidential primary will be required to sign an oath swearing their Republican loyalty, the AP reports.

'The oath leaves such voters with a touch choice to make: "lie," "stay home from the Feb. 12 elections and keep your options open," or "commit to an unknown Republican candidate nine months before the election."'

Sure fits the GOP model, though, loyalty to party before all else....

Small Victories Part Two

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

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

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

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

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

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

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

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

22 November 2007

Holiday Blogging

Light blogging this weekend, I expect. I leave you to debate this conundrum in the coments:

Which would you rather do, muck out gutters that have not been cleaned in seven years, or drain a large perirectal abscess, and why?

Having done both in the last twenty-four hours, I know which I would choose...

20 November 2007

Small Victories

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

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

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

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

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

19 November 2007

My apology to Nurse K

A genuine medical post.

Read it here.

Advise and Consent

Conservative provocateur Catron commented regarding the previous post on recess appointments:

Presumably, you felt just as much outrage over Bill Clinton's many recess appointments. Or are they only "unconsitutional" when a Republican makes them?
Fair question, and deserving a fair response:

There is a difference between the context, degree, and manner in which the two presidents used this authority. Clinton issued 140 recess appointments; Bush is on track for somewhere around 220. Clinton issued almost all recess appointments in the six years in which Congress was controlled by the opposing party; Bush has used this authority to a great degree when his own party controlled the Senate. Clinton, to all evidence, generally pursued consensus appointees; Bush is notorious for appointing polarizing candidates and has never sought input or consensus from the opposition party.

During the last six years of the Clinton Presidency, the republicans in control of congress obstructed consideration of Clinton's appointees, including in many cases refusing to even schedule hearings on them and/or refusing to bring them up for committee votes. During the Bush years, the Senate has been incredibly compliant in confirming Bush's nominees, even (amazingly) when it was controlled by democrats. Good data is hard to come by, but in a brief Google search, it appears that the Senate has confirmed ~95% of Bush's judicial appointees, whereas under Clinton the number was closer to 70%. (I'd appreciate a correction if anyone has better numbers.) Many of the cases in which Bush used the recess appointments were for applicants who had already been rejected by the Senate or in some cases, who he did not even submit to the Senate, knowing that they would never get confirmed.

It is difficult to define an objective distinction between valid use of this authority and abuse of this authority. Having said that, the conclusion I draw from the above is this:

Clinton used RAs to resolve the political stalemate created by a hostile congress which refused, in bad faith, to act on his appointees;
Bush has used RAs to evade the constitutional requirement for Senate approval, or to over-ride the Senate's rejection of his candidates.

Clearly both Bush and Clinton used the power other than it was intended by the Founders and I would support restrictions on its use in the future.

16 November 2007

More Like This, Please

After six years' worth of Bush abusing the constitutional power of recess appointments, finally congressional leaders are doing something to rein him in:

Dems to Bush: No recess appointments for you

Reid is simply not going to let the Senate go into recess, preventing the Little Emperor for doing an end-around and bypassing it. Small, but nice.

And more on the Death of Irony -- Salon's Glenn Greenwald points out this gem:

It's genuinely hard to believe that the writers of George Bush's speech last night to the Federalist Society weren't knowingly satirizing him. They actually had him say this:
When the Founders drafted the Constitution, they had a clear understanding of tyranny. They also had a clear idea about how to prevent it from ever taking root in America. Their solution was to separate the government's powers into three co-equal branches: the executive, the legislature, and the judiciary. Each of these branches plays a vital role in our free society. Each serves as a check on the others. And to preserve our liberty, each must meet its responsibilities -- and resist the temptation to encroach on the powers the Constitution accords to others.
Then they went even further and this came out:
The President's oath of office commits him to do his best to "preserve, protect, and defend the Constitution of the United States." I take these words seriously. I believe these words mean what they say.
To top it all off -- by which point they must have been cackling uncontrollably -- they had him say this:
Others take a different view. . . . They forgot that our Constitution lives because we respect it enough to adhere to its words. (Applause.) Ours is the oldest written Constitution in the world. It is the foundation of America's experiment in self-government. And it will continue to live only so long as we continue to recognize its wisdom and division of authority.
Much more after the link.

15 November 2007

Things that don't make sense

CNN sez:

Military Air Space to be holiday 'express lane'

WASHINGTON (AP) -- Ahead of the holiday travel crunch, President Bush ordered steps Thursday to reduce air traffic congestion and long delays that have left passengers stranded.

President Bush, accompanied by acting FAA Administrator Robert Sturgell, outlined a plan to reduce air traffic congestion on Thursday.

The most significant change is that the Pentagon will open unused military airspace from Florida to Maine to create "a Thanksgiving express lane" for commercial airliners.
I don't know which is more depressing, that Bush thinks this is a plan that will actually ease congestion, or that the stenographers in our media are so ill-informed about aviation issues that they parrot this "express lane" catch phrase without actually analyzing whether it would actually, you know, work.

Thing is, unless this military airspace Bush is opening up happens to contain several dozen new commercial airports with terminals and runways and scheduled service, it's not going to do thing one to improve holiday travel. You see, the skies are what we pilots call "really big" and we just don't need much more maneuvering space to fit all the airplanes in them. In fact, every registered airplane in the US could be in the sky at one time and they would fit perfectly fine! As long as none of them ever had to take off or land, that is. Airports are somewhat smaller than the sky, and have limited capacity. The runways can handle only so many takeoffs and landings at once, there are not enough terminals for the scheduled commercial flights even absent delays, and the approach corridors to major airports can handle only so many planes at once.

To be fair (not my strong point) the rest of the article did list some more technical and useful measures the FAA is taking, and yes, in the event of inclement weather, a little more flexibility in re-routing might make delays less common. I particularly liked the idea of raising takeoff and landing fees at peak hours -- that makes sense and might encourage airlines to shift flights out of the peak times. None of these measures, however, fully addresses the fundamental problem -- too many airplanes trying to get onto too few runways at too few commercial airports at the same time.

I wish I'd said that

A couple of excellent posts out there in the EM blogosphere today.

Ten out of Ten writes about the factors that make a good shift, and I couldn't agree more. The right pen is essential to me -- I do so much writing that I am obsessive about having my special gel-ink pen which makes charting a pleasure. And having the "A" team of nurses will make or break your shifts as well. Go read it.

Over at Backstage Pass you can read about things that cause inefficiency in the ED. Since we are in the middle of building a new ED and trying to optimize the workflows of all the staff, this post really resonates with me.

14 November 2007

Memes

I don't generally do them, but I ran into a fun one over at EMS Haiku, and I've had a crappy day so I thought I would hijack it and indulge myself.

My Five Favorite aircraft:

Beech StaggerwingElegant and refined, aesthetically perfect. There's one that flies out of my home airport every few weeks and I love hearing the growl of its radial engine as it flies over my house... just beautiful.

Supermarine SpitfireEngland's premiere fighter-interceptor of WWII, with its distinctive elliptical wing, forever locked in mortal combat with its foe, the ME-109, in the Battle of Britain.

Lockheed Constellation
Lovingly remembered as the "Connie," with the triple-tail design and gracefully arching fuselage lines. Last of the great piston- and propeller-driven airliners in the Golden Age of Aviation...

Adam A500
As modern as the Connie is archaic, but sharing the same graceful design elements of flowing lines and a distinctive tail. The A500 was designed by Burt Rutan (legendary designer of the Voyager, Global Flyer, and Spaceship One). It features twin engines with centerline thrust, advanced avionics, seats six in luxury, cruises at 225 knots at 25,000 feet, and will set you back a cool $1.25 million. This plane is why I still play the Lotto.

Pitts Special
Short, squat and incredibly maneuverable, the Pitts has come to represent aerobatics in the public mind. Since its introduction in the 1960s it has been eclipsed in competition by more agile spindly, ugly little things, but the Pitts remains a staple at airshows world-wide and is capable of any aerobatic maneuver that you can think of.

Tough to edit the list down to only five. I could list a dozen WWII planes alone as "favorites." (How could I leave the Corsair, or the Lightning off my list??!?) Decisions, decisions. I won't tag anyone with this, since I detest memes for the sake of memes. But if you like planes, feel free to run with it.

12 November 2007

The Death of Innovation?

Kevin links approvingly to a piece by the Happy Hospitalist which, by means of an unusual extended analogy involving pens, decries universal health as stifling to innovation. I think the Happy fellow may have a valid point in his follow-on post about the perverse facility reimbursement schemes used by medicare and the ways in which the rigging of the healthcare market drives competition in unsound ways; but I also think he draws an specious conclusion, though a common one among opponents, in asserting that universal healthcare will somehow stifle inflation.

Coincidentally, The Shrill One pointed me to a stellar piece over at The New Republic by Jonathan Cohn which makes precisely the opposite point:

Much of the innovation in healthcare is driven not by the private market, but by public financing, whether by the $28 Billion spent on the NIH each year, by researchers in other countries which do have universal health care, and by US taxpayers who fund Medicare and its coverage of innovative services (often at a premium cost). And the private market? While Cohn does not dispute the important role it plays, he also points out its intrinsic perversity:

[...] a lot of the alleged innovation we get from private industry just isn't all that innovative. Rather than concentrating on developing true blockbusters, for the last decade or so the pharmaceutical industry has poured the lion's share of its efforts into a parade of "me-too" drugs--close replicas of existing treatments that offer little in the way of new therapeutic advantages but generate enormous profits because they are patented and because companies have become exceedingly good at promoting their sales directly to consumers.

The most well-known example of this is Nexium, which AstraZeneca introduced several years ago as the successor to Prilosec, its wildly successful drug for treating acid reflux. AstraZeneca promoted Nexium heavily through advertising--you may remember the ads for the new "purple pill"--and, as a result, millions of patients went to their doctors asking for it. Trouble was, the evidence suggested that Nexium's results were not much better than Prilosec's--if, indeed, they were better at all. And, since Prilosec was going off patent, competition from generic-brand copies was about to make it a much cheaper alternative. (The fact that Prilosec's price was about to plummet, needless to say, is precisely why AstraZeneca was so eager to roll out a new, patented drug for which it could charge a great deal more money.)

The Nexium story highlights yet another problem with the private sector's approach to innovation. Because the financial incentives reward new treatments--the kind that can win patents--drug- and device-makers generally show little interest in treatments that involve existing products.
And one more recent media report highlights a reason to be leery of private, for-profit funding of healthcare: Health Net, a major insurer in California, avoided paying $35 million in benefits by canceling the policies of 1600 patients who became ill with cancer or other expensive illnesses. The policies were typically canceled based on a minor inaccuracy or omission on application paperwork, and "Cancellation Specialists" were paid bonuses of up to $20,000 for hitting targets for number of policies canceled.

I just don't understand the opponents of a national health system. I just don't understand.

11 November 2007

Wikiwasting

From the brilliant xkcd.
I suffer from a related malady. See more over here.

10 November 2007

The Sh*t hits the fan

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

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

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

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

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

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

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

08 November 2007

Minor victories

Sad, but this really made my day: I just saw five patients, in a row, who all needed to be in the ER. Not for anxiety, or for alcohol and drug abuse, not for poorly controlled chronic illnesses, but for real, honest-to-goodness emergencies.

In no particular order there was:
An acute hemiplegic stroke
Acute Appendicitis
A fall with a head injury and moderate grade concussion
An acute arterial thromboembolism to the hand
(Most excitingly) a acute hemoperitoneum due to a ruptured artery in the abdomen (oddly enough, the splenic artery)

Wow. It's almost like I was working in a real Emergency Room or something.

The Office is Closed

Which is to say that NBC's The Office is the first major show to close production due to the writers' strike. Apparently the reason is that the cast and crew refused to cross the writers' picket lines. Star Steve Carell called in "sick" with the greatest work excuse ever:

Additionally, I've been told that Steve Carell informed NBC he is unable to report to work because he is suffering from “enlarged balls.” Not just enlarged, I'd say, but brass ones. The source on this one adds, "We wish him a happy, slow recovery."

06 November 2007

A new threat

In which I am confronted with a new danger from an unhappy patient.

Read it here.

The ER remains a profoundly strange place to work.

Mission Accomplished

Can't say we didn't see it coming, but it's official: Bush is now more unpopular than Nixon at his lowest -- the most awesome unpopular president evah!

Meanwhile, Bush reached an unwelcome record. By 64%-31%, Americans disapprove of the job he is doing. For the first time in the history of the Gallup Poll, 50% say they "strongly disapprove" of the president. Richard Nixon had reached the previous high, 48%, just before an impeachment inquiry was launched in 1974.
But he's not done yet! There is one more record left to break: lowest approval rating. He has only another four points to go (in Gallup) before he will be the undisputed champion. I have faith in him.

The Death of Irony

Regarding Musharraf's suspension of the Pakistani Constitution:

MS. PERINO: These extra-constitutional measures ... are deeply disturbing and not something we can support...


Q: Is it ever reasonable to restrict constitutional freedoms in the name of fighting terrorism?


MS. PERINO: In our opinion, no.


I don't know how they stand the sheer cognitive dissonance.

Blogger no likee video today. Watch the exchange here:

02 November 2007

The worst words in Emergency Medicine

via radio, from EMS:

"Car vs child in driveway."

Backed over and dragged. Very very lucky -- only rib fractures and minor pulmonaqry contusions.

Why I got a car with a back-up camera.

Showmanship

In which I play the hero. Read it here.

Also, now you can bookmark the RSS feed here.