27 December 2007

We have a New Champion!

Oregon Woman Charged with Drunken Driving tests 0.55 percent.

Wowie. If I have seen higher, I cannot recall it, and they were certainly comatose, not operating a vehicle...

Catch-22

Scalpel had an interesting post today about treating a patient who was psychotic by any reasonable definition: hallucinating and with strong signs of potential violence, but at least partially cooperative with treatment. Scalpel and his nursing staff had to wrestle with the dilemma of whether they could administer anti-psychotic medications without his consent.

I always find this sort of thing interesting. In most cases, as long as you can document your clinical judgment that you believe that the patient was either unable to make an informed refusal of care, or presented an imminent danger to self or others, you're pretty safe doing whatever you need to in order to care for the patient. For ER docs, that often involves four-point leather restraints, sedation, occasionally medical procedures (i.e. gastric lavage, also known as pumping the stomach, or life-support such as endotracheal intubation), and often involuntarily detaining the person pending psychiatric hospitalization.

In our state, there is an interesting twist, though. To my knowledge, Washington is unique in that physicians do not have the authority to place patients on any sort of "72 hour hold." Not even psychiatrists. Instead, state law delegates this authority to trained officers of the court called "County Designated Mental Health Professionals," or CDMHPs.

It's an interesting system, and in my mind works well, though a bit kludge-y. I can basically do whatever I want to someone in my ER, provided that it is grounded in good medical reasoning. But if I think someone is or might be a threat, then I call in the CDMHP. They take over from there, and evaluate the patient and determine whether they meet the statutory definition of either an "imminent threat to self or others" or "gravely disabled." If so, they are detained, and the CDMHP finds a bed for them somewhere. If not, they are released, and both the CDMHP and I have immunity from liability should the patient go home and harm self or others.

But I get caught in the middle, in some cases, with a bit of a catch-22. I do not have the legal authority to detain them, so my clinical opinion is meaningless regarding whether the patient goes to the rubber room in the end. I must, however, do a medical evaluation and determine that there is no medical emergency or other non-psychiatric cause of the patient's behavior before I can call in the CDMHP. This usually involves some lab tests (a tox screen, for example) and maybe a CT scan of the brain, and the patient must be sober before the CDMHP can evaluate them. And they are busy. So there is always a lag time, sometimes significant, before the CDMHP evaluates the patient, and I need to control the patient during that time.

The best way to control an agitated, uncooperative, hallucinating patient is to administer an anti-psychotic med like Haldol, as Scalpel did. It's very effective, and much more pleasant than having them in leather four-points screaming and thrashing for hours on end. (Not to mention that physical restraints in such situations can be quite dangerous to the patient.)

Then, hours later, the CDMHP shows up and finds the patient polite and cooperative and not at all dangerous or disabled. The voices are gone and the patient no longer has the urge to kill. The CDMHPs ruefully shake their heads, agree that it sounded like he was pretty nutty when he first arrived, but, "Sorry, he just doesn't meet the criteria to be detained. Send him home."

So I have the choice of leaving the psych patients untreated for hours, possibly endangering patients and staff, or treating them early and precluding any more definitive treatment... argh. We do our best to work around it with short-acting sedatives and locked doors with heavy security presence. But when you have an irritating, obnoxious bipolar in the manic phase screaming sexual obscenities for hours on end, and your hands are tied, it's extremely frustrating.

It is, however, the happiest moment of my day when the CDMHP shows up, stands in the doorway for thirty seconds, then seeks me out and says, "Would you PLEASE get that guy some Haldol?"

25 December 2007

Merry Christmas from Seattle


We got surprised by an intense snowshower and had an unexpected white Christmas! Hope yours was as nice.

Cheers,

SF

23 December 2007

Truly Awesome



It took me a few seconds to figure it out, and then left me slackjawed.

God I love the internet.

21 December 2007

So, just don't fall

I saw this sign and thought it was amusing so I snapped a picture of it. Any guesses as to what happened about thirty seconds afterwards?

I think I actually cartwheeled. I didn't slide much, but it took me a while to find my left ski, which was about 50 feet downhill, standing straight up in the snow. And yes, there was an audience on the chairlift to bear witness of my humiliation.

Skiing karma.

Oh well. At least it was my only fall of the day. There's some consolation.

20 December 2007

Hatin' on the patients

Commenter JimII writes:
So, here's my question, do all doctors hate their patients? Or is it just ER doctors, or is it ER doctors who blog? It is funny because it is clear that Movin' Meat is an Oasis in the blogosphere desert of hate that is ER blogging, but it has nonetheless opened my eyes to the people being glorified every night on the TeeVee and lauded by popular culture. The hatred of the poor is particularly obnoxious. The constant snark about people with publicly funded insurance really bothers me.

I think JimII has a pretty valid point. I try real real hard not to slide down the slippery slope of contempt and hate towards my patients. But the truth cannot be denied that the ER is a particularly effective bottom filter of society. And that ER patients frequently are nutty, or self-destructive, and drug-addicted or alcoholic, or just malignant, manipulative abusers of the system. Medicaid patients, in particular, utilize the ER too frequently and for inappropriate purposes.

So I get it. ER patients are maddening (at least a significant subset of them), and one's blog is a great place to vent about them, as I did today over at MedPage. After all, isn't ranting what blogs are all about? I can, however, see how some people might interpret the ranting as excessive, and there have been times where, reading other medbloggers' posts, I have felt distinctly uncomfortable at the demonization of their patients. I'm not sure where the line is that separates a mordant sense of humor and a bleak cynicism from outright contempt. I often worry that I am crossing that line. There are some blogs that I just don't visit anymore because they were far enough over the line that I couldn't enjoy reading them. There are some blogs that seem to skate back and forth across the line on a daily basis.

I do remember one time in medical school, when I was very frustrated trying to care for an ornery patient at the VA, when a senior resident took me aside and told me that, "sometimes, it's OK to hate your patients." It was something of a seminal moment for me. Prior to that I had the wide-eyed naive idea that I would enjoy and like all of them, I think. Getting permission to dislike my patients was a big step in learning that clinical detachment that is essential to this job.

Having been given that permission, though, it can be a challenge to keep it in check.

19 December 2007

Can I get an AMEN?

Med Schools Fail at the Business of Medicine

Dr Wes said it! Can I get an AMEN?

I've blogged on this point before, and I will again. I couldn't agree more. What other vocational school leaves its graduates completely ignorant of the economic underpinnings of the industry they are training to enter?

Sing it, brother!

-----Updated-----

Arrgh. Even the usually sensible Graham doesn't get it. He seems to endorse the notion that:

The point of med school ... is to give you a foundation of knowledge to learn how to practice medicine, get exposed to all the medical specialties, and prepare you for internship. It’s residency that should be teaching doctors about how to be an attending.
Med school is about more than preparing you for internship. There's 30+ years of practice to follow, and you need to be prepared for that, also. It's not too hard to teach students some universal concepts about the business of medicine. A few lectures on contract law, some talks on professional negligence, maybe a bit on professional liability insurance, the difference between ICD-9 and CPT coding, a primer on various forms of reimbursement and how it is determined, the concept of Accounts Receivable, and some info on the RVRBS and how it relates to reimbursement. You hardly need an MBA. It could be done in a few weeks with half an hour three times a week, and could be crafted such that it would be applicable to students going into any specialty.

Don't kid yourself that residencies could or should do this. Residents are scattered all over the hospital working, and the lecture time in residency is a tiny fraction of that available in med school, and proportionately more precious. It would be better than nothing, and IMO, more advanced, specialty-specific talks on your future career should be a component of residency education. But as it is both residencies and med schools are abject failures in preparing future doctors for the realities of the medical economy. The result is that young doctors get exploited, and that doctors in general are crappy businessmen, and crappy advocates for health care reform. And that's an ongoing tragedy for the medical profession.

A successful haircut...

I got a haircut, and nobody noticed.

Yes, I am male.

17 December 2007

A Plea

To whom it may concern:


IF: you are a patient who has a complex ongoing medical problem, for example: cancer for which you are being treated; a major surgery for which you have had a series of awful complications; a recent transplanted organ; or some extremely rare genetic condition,

AND IF: your treatment is being coordinated by doctors at The Big Hospital Downtown

THEN: please, please, please for the love of God, do not come to my ER.

It's not that we don't want to see you. We would love to, but the fact is that we will not be able to care for you properly at our hospital, so don't come here. It's that simple. We are not bad doctors here, nor are we unused to to complex patients. Believe me, we have lots of cancer patients here, and our surgeons have lots of complications of their own, etc, etc, etc. But your doctors are not here. And your records are not here. I may not be able to get your records, and even if I do, it will take me hours and I will probably not get everything I wanted. Your care will be delayed and possibly harmed. And I may have trouble reaching your doctors because I don't know the secret access number to the paging services at The Big Hospital. And even if I am able to get your doctors on the phone, they don't know me, which means they won't trust me. They may assume that I am an idiot (a common prejudice towards community docs by academics), in which case they won't listen to a word I say. They may think that I am trying to "dump" a problem patient back on them, in which case they will resist any recommendation that I transfer you back to their hospital. Worse, they may actively try to "dump" a difficult case on us by refusing to accept you back. (It's funny how doctors' sense of "ownership" of a patient diminishes when the patient shows up at a distant hospital.) Or I may just get a resident who doesn't know you and doesn't give a crap; it's hard to get an academic attending on the phone at 2AM. And what's more, if the doctors at The Big Hospital Downtown refuse to aceept you in transfer, it's also possible that my specialists here will also refuse to take you on as a patient. They aren't supposed to, but it is predictable that they will tell me that you should just "go back Downtown." And then you, and I, are stuck in the middle with nowhere to go.
So don't come here. If you think you are getting worse, get in the car and drive yourself back to the Mecca where you were treated. By the way, that means don't call 911 for convenience of transport. They will ignore your protestations that you want to go Downtown and take you to the closest hospital, because they don't want to be out of service for an hour and half driving to the next county.
This is all assuming that you are not experiencing a true emergency. If you have sudden trouble breathing, or collapse, or have some other true, acute problem, then we are here for you.
Otherwise, don't come to my ER.
Thank you.

15 December 2007

Saturday Airplane Blogging

Bernard Zee has some awesome photos of the Blue Angels and more from SF's Fleet Week. Check out the high-speed sneak pass below -- the plane looks to be about 15 feet off the deck at 700 mph! Great flying, and great photography!


And check out the supersonic shockwaves causing optical distortion (better seen in the full-size image):
From Airliners.net, an image of a 757 on approach with a lovely example of compression condensation off the flaps as well as wingtip vortices.
And a nice beauty shot of a restored Beech Staggerwing, rebuilt from the frame up by the masters over at Pemberton & Sons in Spokane.

Now get off the internet and go enjoy your weekend.

14 December 2007

On Frequent Flyers

The Happy Hospitalist has an awesome and shockingly comprehensive list. Go read it.

Death of a thousand little cuts

I walked in to work for the morning shift a few weeks ago, staffing the "flex pod" of the ER -- an area of acute care, monitored beds which we open from 10AM-2AM. There was, predictably, a row of patients lined up waiting for me to see them, as the charge nurses love to stack the pod before the doc even arrives. There were, however, no nurses in sight. I signed on to the computer and skimmed through the complaints to see what my morning was going to look like: two chest pains, one shortness of breath, one generalized weakness, one abdominal pain/vomiting. Not too bad; par for the course.

The tech wandered over and dropped the above ECG on my desk, from the generalized weakness patient. Any medical students out there, or readers who remember my previous post, The Wrong Juice, might recognize the wide QRS complexes and peaked T-waves as being highly suspicious for Hyperkalemia, a dangerous elevation of the potassium level in the blood. Elevated potassium will also cause muscle weakness, and is well-known for causing sudden death. It's one of those medical emergencies that make ER docs smile, because it's real, it's dangerous, it's dramatic, and we can fix it. A quick review of this patient's chart showed no history of kidney disease or any reason for elevated potassium, but the ECG changes were decidedly new. So I leaped into action.

Or I would have, except that there were STILL no nurses anywhere to be found. Where the hell were they? I went and briefly said "hi" to the patient and did a cursory history, noted that he did not have so much as an IV line started, and then went looking for a nurse. Finally, one strolled in, carrying her cup of coffee and chatting with the unit clerk; apparently they had gone off to the coffee stand while waiting for me to arrive.

I pounced on her: "The guy in bed D has a really abnormal ECG and I think he might be hyperkalemic, so let's get a line in him and an iStat ASAP."

She looked at me with a blank expression, "Oh, OK. I'll get right on it." And she turned back to the clerk to finish their conversation. Stunned at her inactivity, I hesitated a moment before interrupting.

"No, I need you to do this NOW. This guy may well code on us if we don't get cracking!"

Visibly annoyed at my rudeness, she put down her coffee, rolled her eyes to the clerk, and shuffled off to the IV cart. Satisfied that she was on it, I wen on to see the waiting chest pain patient, with the instruction that she was to bring me the iStat as soon as it was back. Ten minutes later, I was finishing up with the chest painer who sounded like he might have unstable angina, and I came back to the nursing station to see the nurse sitting there drinking her coffee and continuing to gossip! "Where's the result on D?" I asked.

Nonchalantly, she replied "Oh, he was a hard stick and I couldn't get it, so I asked Betty to try."

I glanced in the room: there was nobody there. "So where the hell is Betty?"

"I don't know. She said she would be right over."

"Go get her right now and get an line in him!" With a sense of growing anxiety I went in to see the next chest painer, who had a history of several past heart attacks. I rushed through the H&P and came out to see the first nurse and Betty sitting there chatting amiably. "Well, do we have a line?"

"Oh, yes," Betty responded in a voice that made clear that she thought I was silly for being so worked up over such a little thing. She had been around for 30 years and thought all the doctors were like children, to be placated, but of no real importance. "But," she went on, "I got the line but it didn't draw, so I called for the lab to come draw the blood." She turned back to her conversation.

"Aaarrrgh! Get me a needle and I'll draw the damn blood myself!"

"Oh, don't be silly. Lab'll be here any minute." As I rooted through the drawer looking for a needle, I noticed the pulse ox on my next patient, who was short of breath, was 88%. Crap. Gotta prioritize. So I went to see that patient, hoping against hope that there might be SOMEBODY on shift today who would do their job. When I came out, the nurses had not moved, but they did confirm that the blood had been drawn.

"Where are the results?"

"I dunno. Maybe in the lab?"

Ultimately I had to personally walk down to the lab (not far, fortunately) to determine that yes, indeed, the patient's potassium was >9 (normal 3.5-4.5). On my way back I stopped by the charge nurse to discuss with her the fact that I had a very sick patient and the staff did not seem to share my sense of urgency. She promised to kick-start them, and fortunately, I had the patient treated and off to stat dialysis soon enough.

But the rest of the day was no different. Note that during this whole time the nurses weren't exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it's infuriating when you are stuck with the "B" team.

Death of a thousand little cuts

I walked in to work for the morning shift a few weeks ago, staffing the "flex pod" of the ER -- an area of acute care, monitored beds which we open from 10AM-2AM. There was, predictably, a row of patients lined up waiting for me to see them, as the charge nurses love to stack the pod before the doc even arrives. There were, however, no nurses in sight. I signed on to the computer and skimmed through the complaints to see what my morning was going to look like: two chest pains, one shortness of breath, one generalized weakness, one abdominal pain/vomiting. Not too bad; par for the course.

The tech wandered over and dropped the above ECG on my desk, from the generalized weakness patient. Any medical students out there, or readers who remember my previous post, The Wrong Juice, might recognize the wide QRS complexes and peaked T-waves as being highly suspicious for Hyperkalemia, a dangerous elevation of the potassium level in the blood. Elevated potassium will also cause muscle weakness, and is well-known for causing sudden death. It's one of those medical emergencies that make ER docs smile, because it's real, it's dangerous, it's dramatic, and we can fix it. A quick review of this patient's chart showed no history of kidney disease or any reason for elevated potassium, but the ECG changes were decidedly new. So I leaped into action.

Or I would have, except that there were STILL no nurses anywhere to be found. Where the hell were they? I went and briefly said "hi" to the patient and did a cursory history, noted that he did not have so much as an IV line started, and then went looking for a nurse. Finally, one strolled in, carrying her cup of coffee and chatting with the unit clerk; apparently they had gone off to the coffee stand while waiting for me to arrive.

I pounced on her: "The guy in bed D has a really abnormal ECG and I think he might be hyperkalemic, so let's get a line in him and an iStat ASAP."

She looked at me with a blank expression, "Oh, OK. I'll get right on it." And she turned back to the clerk to finish their conversation.

"No, I need you to do this NOW. This guy may well code on us if we don't get cracking!"

Visibly annoyed at my rudeness, she put down her coffee, rolled her eyes to the clerk, and shuffled off to the IV cart. Satisfied that she was on it, I wen on to see the waiting chest pain patient, with the instruction that she was to bring me the iStat as soon as it was back. Ten minutes later, I was finishing up with the chest painer who sounded like he might have unstable angina, and I came back to the nursing station to see the nurse sitting there drinking her coffee and continuing to gossip! "Where's the result on D?" I asked.

Nonchalantly, she replied "Oh, he was a hard stick and I couldn't get it, so I asked Betty to try."

I glanced in the room: there was nobody there. "So where the hell is Betty?"

"I don't know. She said she would be right over."

"Go get her right now and get an line in him!" With a sense of growing anxiety I went in to see the next chest painer, who had a history of several past heart attacks. I rushed through the H&P and came out to see the first nurse and Betty sitting there chatting amiably. "Well, do we have a line?"

"Oh, yes," Betty responded in a voice that made clear that she thought I was silly for being so worked up over such a little thing. She had been around for 30 years and thought all the doctors were like children, to be placated, but of no real importance. "But," she went on, "I got the line but it didn't draw, so I called for the lab to come draw the blood." She turned back to her conversation.

"Aaarrrgh! Get me a needle and I'll draw the damn blood myself!"

"Oh, don't be silly. Lab'll be here any minute." As I rooted through the drawer looking for a needle, I noticed the pulse ox on my next patient, who was short of breath, was 88%. Crap. Gotta prioritize. So I went to see that patient, hoping against hope that there might be SOMEBODY on shift today who would do their job. When I came out, the nurses had not moved, but they did confirm that the blood had been drawn.

"Where are the results?"

"I dunno. Maybe in the lab?"

Ultimately I had to personally walk down to the lab (not far, fortunately) to determine that yes, indeed, the patient's potassium was >9 (normal 3.5-4.5). On my way back I stopped by the charge nurse to discuss with her the fact that I had a very sick patient and the staff did not seem to share my sense of urgency. She promised to kick-start them, and fortunately, I had the patient treated and off to stat dialysis soon enough.

But the rest of the day was no different. Note that during this whole time the nurses weren't exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it's infuriating when you are stuck with the "B" team.


[Addendum: as Gruntdoc pointed out, criticizing nurses can be dangerous to your health, so note it's just the "B Team" that makes me crazy.  And there are docs on the "B Team," too.]

13 December 2007

Lover's Embrace

The Bad Astronomer is very, very good. Check out his top ten images of the year. Awesome.

Malpractice reform

Probably the most frustrating thing about the malpractice crisis is the "crap shoot" element that is introduced by carefully selected juries composed of uneducated laypersons making judgments on complex and controversial technical matters.

A lot of doctors on the web get very emotional about suits, especially ones in which they are named. And I think we all hate practicing in the environment of "what if it happens to me?" It's scary; every single day I wonder what will happen if the patient I am seeing right now will be the one to go home and die unexpectedly from some unforseeable disease or complication. The grieving family will take the stand and testify what a loving father/mother the patient was, a hired gun expert will testify that Dr Shadowfax was clearly negligent, and the jury will feel sorry for them and award the survivors a gajillion dollars.

So I practice defensively, admit more people than really need it, order a lot of tests just in case, and, most importantly, chart incredibly defensively, especially with anyone I am sending home.

It sucks, and it sucks all the more because I don't have any confidence that when I do get sued (it will happen, odds are) there is no reason for me to assume that the quality of the care I gave will have any bearing on the ultimate outcome.

What I want, both as a practicing physician and as the manager of a large medical group, is for a system that accurately relates "bad care" and financial liability. It's not personal, to me. Our group takes care of over 150,000 patients annually, and in a high-acuity environment like ours, staffed by fallible human beings, mistakes are going to happen. So compensating injured patients is and ought to be just a cost of doing business.

But the problem is that it's not predictable, or rather that it is predictable for the wrong reasons. A sympathetic plaintiff is a potent threat, and I can recall several cases which we settled despite excellent care, because the risk of a huge judgment was too high. On the other hand, I have seen a number of cases where the care was, let's say "debatable," but our attorneys play the game well and the lawsuit went away. Certainly we win more than we lose, so if some contend the system is rigged in our favor I wouldn't necessarily disagree, and we can tell a case that is a potential loser, so there is some predictability.

But it's still broken. We're compensating the wrong patients, and not compensating those that should be.

If I were to redesign the med mal system, I would include the following elements:

1. Patient compensation fund.
It would more or less replace professional liability insurance, and would require actuaries to determine to what degree it needed to be funded. Funding could come from a variety of sources, including "premium payments" by healthcare providers or by surcharges on healthcare services or even by taxes, if that was thought to be good policy. Patients who had been determined to have been injured through medical error or negligence could be compensated according to a standardized schedule.

2. Administrative health courts
Judges with training in healthcare law/liability would preside and juries would consist of a mix of doctors and consumer advocates with special training. Patients who thought they had been injured could apply to the courts, discovery & testimony would be gathered as they are today, and the jury would issue a finding of fact. Verdicts might be: no injury; injury due to error; injury due to negligence; injury due to gross negligence. The courts would have the authority and duty to refer cases of negligence to the license boards for review. A summary of the findings of every case would be made public (with details redacted for privacy) to allow the medical industry to learn from the cumulative experience of the courts. And -- critically -- cases which had been previously decided could be used as precedent to guide future care as well as future cases.

What do you think? I'm dreaming, of course.

The New GOP Savior

Not Fred Thompson. The other one.

10 December 2007

Awesome health wonkery

Working a slow night shift, and my brain is poorly functional due to sleep deprivation, and I don't trust myself to actually write a real, original post. So I'll throw out the links to the posts I found most interesting tonight:

Joe Paduda explains in the journal of the American Academy of Actuaries why he thinks health care reform may actually be inevitable this go-round. (warning: PDF)

I had drafted a post on why mandates of some sort are essential to making a national health plan work. Maggie Mahar does a much better job, so I deleted mine. Go read hers. Spoiler: it's all about the risk pooling.

MedinformaticsMD joins in the outcry about Sec Leavitt's "Don Corleone" offer that physicians can't refuse: get an EMR or miss out on those lavish medicare reimbursements!

DrRich at Covert Rationing writes about the government's regulatory speed trap set for physicians in the vague and ill-defined documentation guidelines.

06 December 2007

More on the NIE

Today, official White House Lying Sack of Cute, Dana Perino offered up this tortured explanation attempting to explain away the Liar-in-Chief's rapidly-growing nose...

Reporter: Dana, on Tuesday at his press conference, when the president was asked about when he learned about Iran's nuclear program being halted, was he being completely candid?

Perino: Yes, he was ... If you look at the rest of that sentence, what the president is -- the president was clearly told that there was new information that was coming in, but he wasn't told the details of it. And the president was also told that the intelligence community was going to need to go back and check out to find out if it's true. What I said is that [Director of National Intelligence Mike] McConnell told the president if the new information turns out to be true, what we thought we knew for sure is right: Iran does, in fact, have a covert nuclear weapons program, but it may be suspended. He said that there were many streams of information that were coming in. They could potentially be in conflict. They didn't have a lot of confidence in the information yet.

Reporter: But the president said, "He didn't tell me what the information was." But you're now saying he was told that Iran may have halted its nuclear weapons program and also that there may be a new assessment, right?

Perino: Right, but he doesn't -- he didn't get any of the details of what -- what the information was, in terms of what the actual raw intelligence was.

Reporter: But he didn't say "details." He just said, "He didn't tell me what the ... "

Perino: OK, look. I can see where you could say that the president could have been more precise in that language. But the president was being truthful ...
I suppose it depends on what the definition of "truth" is.

DailyKos fellow Bill in Portland Maine provides this hysterical take on Bush's Presser:

In the back of the new White House press briefing room is a small, nondescript booth in which a professional announcer records the proceedings in detail for the National Archives. C&J has obtained a transcript of his commentary from Tuesday's press conference with the president:

"President Bush is practically standing still now. He's dropped the news that he didn’t know until last week that Iran had suspended its nuclear weapons program; and, uh, he's being questioned by an NBC reporter. It's starting to get tense; it's---the tension had, uh slacked up a little bit. The president is spinning, uh, just enough to keep the truth from... He's burst into flames! His pants have burst into flames, and he's falling, he's crashing! Watch it! Watch it! Get out of the way! Get out of the way! It's fire---and he's crashing! He's crashing terrible! Oh, my! Get out of the way, please! His slacks are burning and bursting into flames; and the---and it's melting Helen Thomas's shoes. And all the folks agree that this is terrible; this is the worst of the worst catastrophes in the world. Its flames... Crashing, oh! Four- or five-hundred words into the press conference and it---it's a terrific crash, ladies and gentlemen. It's smoke, and it's flames now; Oh, the humanity! And all the reporters screaming around here. I told you; it---I can't even talk to people... Ah! It's---it---it's a---ah! I...I can't talk, ladies and gentlemen. Honest: his credibility is just laying there, mass of smoking wreckage. His poll numbers are plunging into the teens. Oh! And everybody can hardly breathe and talk and Lady, I...I...I'm sorry. Honest: I...I can hardly breathe. I...I'm going to step outside, where I cannot see it. Listen, folks; I...I'm gonna have to stop for a minute because... I've lost my voice. This is the worst thing I've ever witnessed..."

Fortunately Condi Rice stopped by and was able to snuff out the fire by staring at it.



(comic credit Dwane Powell)

Low Standards

One of the things in the ER is that we do the same thing over and over, and what is routine to us is very abnormal to patients. Certain things predictably draw comments from patients, and as a result, there are some conversations I seem to have over and over again. One predictable one goes like this:

The setting: seeing a normal, healthy female patient between the age of 20-40, for an acute complaint such as chest pain. As part of the physical exam, I need to look at the lower legs, shins and calves, to evaluate for edema or signs of a blood clot. I lift the sheet and if necessary pull up the hem of the pants legs to expose the skin.

Patient: Oh my God, I'm so embarassed. I didn't shave today!
Me: (reassuring tone) Don't worry about it, I'm just checking for fluid retention.
Patient: (increasingly mortified) I just never thought you would need to go there...
Me: It's OK, I'm not easily offended.
Patient: Oh, no, I'm so embarassed.
Me: (firmly) Listen, honey, this is the ER. 'Round here, if you've bathed at all in the last week you're ahead of the crowd. You really don't need to be embarassed.

It never fails to elicit a laugh, and to defuse the tension. But it's also true -- it seems that the hygenic standard for ER patients is ... somewhat lower than in my social circles. Sadly, I also have basically the same conversation doing pelvic exams.

Utterly Discredited

(Nurse K, skip to the next post, which is more medical and a bit snarky in a good way)

Been working; haven't had a chance to completely digest the import of the NIE release which indicates that Iran ceased working on its nukyular weapons program in 2003.

However, it seems to me that this marks the final and complete step in the discrediting of the Bush administration.

For sure, it fatally undercuts their well-publicized drive for increased international sanctions on Iran, let alone military action. Which is a policy setback for Bush, but not much more.

However, the damage this does to Bush's believability is more severe and probably more lasting. Granted, not that he retained any sort of reputation for integrity after the last six years of incessant lies, but this is a rare moment, to be savored, in which his bald mendacity is exposed on the international stage, beyond any sort of plausible deniability or spin.

Of course, he has fallen back on the standard conservative-caught-in-a-lie classic excuse "I have no clue what the fuck is going on," most recently covered by Al Gonzales, to the effect that he vaguely remembered someone wandered through his office in August, possibly his Director of National Intelligence, possibly someone on a tour, and maybe mentioned something new about the Most Dangerous Nation on the Planet. But he didn't get specific and Bush didn't ask. Meanwhile, senior staffers in the White House must have been aware of the conclusions of thie NIE for the better part of a year, but never bothered to tell their boss, Bush never followed up with the DNI, and Bush continued to warn of "World War III" with Iran, while down the memory hole the NIE went.

Well, until the DNI decided, on his own initiative, to declassify the NIE "since the new estimate was at odds with the 2005 assessment — and thus at odds with public statements by top officials about Iran — 'we felt it was important to release this information to ensure that an accurate presentation is available.'” Or, in other words, "since we saw that Bush was continuing to ignore countervailing intelligence reports just like he did in 2003 with Iraq and we wanted to call bullshit on him." Maybe the intel community didn't want to be the fall guy (again) when we invaded Iran and found no WMD nukes.

So once again we are forced to decide which is more credible: that senior leaders in the Republican administration, in this case including the President, are either shameless liars or criminally incompetent. Both are equally plausible, but given the history of cherry-picking intel to create a pretext for an ideologically-driven war of choice, I'd have to say that in this case it was deliberate effort to deceive.

It really is satisfying to see him get caught red-handed in one of his lies, and in such a way that it shreds the remnants of his credibility in front of the entire world. This duck just got a little lamer.

05 December 2007

Happy Ninja Day!


Today, Dec 5, is the fourth annual "Day of the Ninja." Celebrate by ordering a Ninja Burger -- delivered within 30 minutes or the delivery ninja commits ritual seppuku.

Now where did I put my black bodysuit and mask?

04 December 2007

A New Blogger

Blogging has now gone mainstream, as evidenced by bureaucrats like Secretary of Health and Human Services Mike Leavitt having blogs. (h/t to Roy at Health Care Renewal) I have to give him credit for stepping into the waters, addressing contentious issues, and allowing comments (though moderated). If only all of our government officials were so forthcoming....

Today's post involves the Sustainable Growth Rate, or SGR, which is the formula Congress established to determine how much physicians should get paid under Medicare. It's an unmitigated catastrophe. Sec Leavitt tries to explain the problem, and for such an arcane issue does a good job of succinctly doing so. Roy points out some of the problems with the SGR, but I also have some opinions. (shock!)

My $0.02:
The SGR was adopted as a mechanism to cap the growth in expenditure for physician services under Medicare. (ironic note: no other service line is subject to this sort of cost controls; facility expenses can and have increased exponentially. I have never heard a good explanation why physician compensation was singled out for this sort of limitation.) In essence, the Medicare budget for doctors cannot increase faster than the GDP per capita.

BUT, the number of new retirees eligible for Medicare increases every year. And they live longer. And they have more chronic illnesses. And we have more things we can do to/for them. So the total amount of services provided increases faster than the GDP. Since the total amount of dollars available is fixed, and the number of services increases, the value of a given service, year to year, must go down. Sec Leavitt implies that this is somehow our fault, that doctors just do "too many procedures," but really it's a fact of demographics and the advance in medical science. Last year physician reimbursement was scheduled to go down 5% under the SGR, but we got a reprieve (in exchange for accepting the imposition of "Pay for Performance"). This year, we are scheduled for a 10% pay cut. Sec Leavitt has proposed another last-minute reprieve; however, in the linked post, he proposes that this freeze in payment cuts be conditioned on the requirement that physicians adopt electronic medical records and prescribing.

Now, I'm a gadget guy, and I love our ER's electronic tracking system. This sometimes makes me a pariah among physicians, but I can live with that. But it's expensive. And for some, it can be slow and cumbersome, and cut productivity. And the medical records generated by these products are not exactly user-friendly. So while I am a big proponent of the EMR in general, there's a legitimate question of whether they are ready for prime time, and where the money to cover the costs will come from.

Yet the Secretary of HHS wants to make them a national standard as the price for averting an undeserved pay cut for doctors, caused by the short-sightedness of Congressional policy-makers. Nice. Here's the comment I left on his blog (in case the moderating staff kills it):

Sec Leavitt,

I applaud that you recognize that the SGR is indeed a fatally flawed mechanism for determining physician compensation. However, given that you admit fully and candidly that the formula for determining the value of physician services has failed, you then propose that, in order to obtain the deserved compensation for the services rendered, physicians must jump through expensive hoops in adopting EMRs? It makes no sense, and it smells of extortion, to piggyback onerous, unproven, and unpopular new regulations onto fixing the SGR.

To deal with this crisis fairly, the two items should be de-linked. Congress screwed up with the SGR, so Congress should fix it. If as a matter of public policy, the administration thinks that EMRs or P4P or whatever "initiative of the week" should be made law, then let's have a open and unrestricted debate on the issue on its own merits.

But don't insult us by making fair payment for our services conditioned upon physicians rolling over and accepting irrelevant restrictions and regulations. It's an abuse of power, and not the way good policy is developed.

I rather doubt it will do any good, but it does feel good to tell those in power what you think.