Well this is just awesome. I guess it's hard to get lost when as long as you keep heading North, you'll get there no matter what. Also the only place in the world where the runway is 36/36.
Posted by shadowfax at 10:33 PM
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Posted by shadowfax at 11:50 AM
By a vote of 60-40, the Senate agreed to end debate on a major package of health care amendments--and by doing so, signaled that the Democratic caucus is unified, and ready to pass a far-reaching reform bill straight down party lines.Finally, health care reform is in the home stretch.
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Assuming for a moment that your ER group’s ability to pay you fair compensation for your services is to some extent dependent on the group being able to get the best possible terms in the managed care contracts the group negotiates with commercial, Medicare and Medicaid managed care, and self-insured indemnity plans: here are some considerations that might be important to you.From CalACEP's Myles Riner. Very much worth the read.
Posted by shadowfax at 12:18 PM
Posted by shadowfax at 9:10 PM
It's the question an ER doctor hates, guaranteed to make each and every one of us cringe somewhere deep down inside:
"Hey, remember that guy from the other day?"
Oh God, you think to yourself, which guy is she talking about? That one with the funny dizziness? Dammit, I knew that was a stroke and the fucking neurologist said it was OK to send him home. I should never have listened to him! But you remain composed and smile and say "Which guy?"
Then you sit back and prepare yourself for the worst. And it is usually bad. C'mon, we work in the ER. Bad things happen here, and bad things happen to people after they are seen here. So it was with surprise that I saw the charge nurse smile and say, "You know, that guy you coded upstairs the other day? I just talked to Jenny in the ICU and they say he's doing great. He's going to be extubated this afternoon!"
"Seriously?" I was really and truly shocked. That guy was dead. Totally dead. Blue and with no brain activity. We coded him forever, and when the code finished with him still alive, we all knew deep down inside that at best we had saved organs for harvesting, that the probability of a decent neurologic outcome was nil.
Turns out that the ICU doc had gotten started on the hypothermia protocol right away and this may have done the trick. I ventured up to the CCU later that day and thumbed through the chart. No clear evidence as to the cause of the arrest, though smart money is still on PE. He wasn't extubated yet, but all signs were highly positive and he was indeed looking like one of those rare happy outcomes from a cardiac arrest. The ICU doc teased me, "What are you doing way up here? I thought you lived in the basement! You're going to get altitude sickness." I stole a line from Greg Henry, saying "I'm just here to make sure you're taking good care of my patient." I stopped in at the bedside but he was still pretty sedated and there was nobody there at the moment, so I took off back to the ER.
Five years ago, heck, two years ago, we weren't doing the therapeutic hypothermia drill and this would not have been such a happy thing. Amazing what developments creep up on you in the course of practice, and amazing how they translate into human outcomes. I was kind of bummed that I had missed the family, but such is life. Mostly I was bemused and gratified that our rather extraordinary efforts had borne unexpected fruit.
Continued yet again.
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Several outlets are reporting, and I can confirm, that Senate Democrats are considering a Medicare expansion as one item on a menu of concessions conservative Democrats would agree to in exchange for weakening or eliminating the public option in the health care bill.
Currently, Medicare exists as a single-payer system for seniors 65 and older. According to Hill sources, the idea would be to allow people under the age of 65 to buy in to Medicare. The option would be limited to people older than a certain age, though that age--and indeed the entire proposal--has yet to be agreed upon.
Posted by shadowfax at 1:46 PM
Color me unsurprised that Barack Obama didn't mention the public option in his remarks to the Senate last weekend. One of the dynamics that hasn't really penetrated in this debate is that the Obama administration is mainly interested in the cost controls. The president will throw the public option overboard if Susan Collins asks him nicely. Conversely, Peter Orszag will lay down in traffic to save the Medicare Commission. Generally, Democrats want to reform the health-care system because they want to cut the number of uninsured. The Obama administration's commitment to health-care reform stems from their belief that it's the first step towards cutting long-term deficits.In a lot of ways, Obama is proving to be a much more conservative President than one might have expected. Despite how the teabaggers might want to portray him as a raving liberal, he's decidedly not. Lord knows he's disappointing his liberal base, myself included, on many issues, with his cautious and often centrist approach. I'm inclined to give him the benefit of the doubt and trust him, since if nothing else he seems to be taking a very responsible line. On this point, he is probably right -- that long-term cost control needs to take precedence over the liberals' fantasy dream plan for health care reform.
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Vanity Fair finally had the bright idea to ask, "could you confidently explain what exactly the public option is to someone who didn’t know?" The answer:Which is pretty much why we should not be paying much attention to polls when figuring out how to actually do health care reform. Like anybody, I'm quick to trumpet a poll that favors my position, and to pooh-pooh a poll that is adverse. But in the case of health care in particular, there's not just the problem of an inattentive and uneducated public, but also the simple fact that there are even now like five or six versions of the Public Option and ObamaCare floating around out there. How can someone know what is actually the "Public Option" when the definition is yet to be determined by Congress? And what the hell is "ObamaCare" when the multiple irreconcilable versions are being drafted by a fractious and uncooperative Congress in the (frustrating) absence of strong leadership from the White House?
Posted by shadowfax at 11:48 PM
Health insurance giant Aetna is planning to force up to 650,000 clients to drop their coverage next year as it seeks to raise additional revenue to meet profit expectations.
In a third-quarter earnings conference call in late October, officials at Aetna announced that in an effort to improve on a less-than-anticipated profit margin in 2009, they would be raising prices on their consumers in 2010. The insurance giant predicted that the company would subsequently lose between 300,000 and 350,000 members next year from its national account as well as another 300,000 from smaller group accounts.
"The pricing we put in place for 2009 turned out to not really be what we needed to achieve the results and margins that we had historically been delivering," said chairman and CEO Ron Williams. [...] Aetna's decision to downsize the number of clients in favor of higher premiums is, as one industry analyst told American Medical News, a "pretty candid" admission. It also reflects the major concerns offered by health care reform proponents and supporters of a public option for insurance coverage, who insist that the private health insurance industry is too consumed with the bottom line.
Posted by shadowfax at 2:55 PM
Posted by shadowfax at 10:41 AM
Twenty-eight degrees and severe clear. The Cascade and Olympic mountains are startlingly beautiful in the clear morning sunlight. The USS Shoup is visible at anchor down the hill in the harbor. The ER is totally empty and I just bought donuts for the staff. (It's an apocryphal but long-standing tradition that the doctor has to buy donuts when the ER is totally empty.) Not a profitable shift for me but still a nice way to begin the day.
Posted by shadowfax at 8:51 AM
Crummy shift the other night: 23 patients in eight hours, and 21 of them were painful. For me, that is, not necessarily for the patients. Lots of worried well, influenza, some minor injuries and a few chronic pain players. Not a single sick one in the lot. One particularly irksome case was a chronic pain patient dumped on our ER from a neighboring ER, complete with discharge instructions reading "Go to (name of our hospital)." So by the end of my shift I was pretty well burnt out. But the last two patients put an interesting perspective on the night.
The first was a 99 year-old man. Yup, that's ninety-nine years old; born prior to World War One. He was having shortness of breath and it turned out he was in congestive heart failure from what turns out to have been his fourth myocardial infarction in as many months. For multiple reasons, common sense primarily among them, he was not a candidate for aggressive intervention like angioplasty. Fortunately he had a large and supportive family, who were quite reasonable in their expectations. After a difficult discussion, we admitted him on a morphine drip for comfort care, with a hospice consult.
The second was a 9-month old with a heart rate of nearly 300 beats per minute. It was pure chance that the family had noticed that his heart felt like it was racing. To tell the truth, I'm not sure I would have noticed that on my own kids. It was an irregular heart rhythm called SVT. In adults, SVT is typically a nuisance alone and rarely requires much treatment. In small children it is similarly benign with the exception that if it is prolonged (which is common, since a baby can't tell you his heart is racing) is can cause congestive heart failure. This child was lucky in that it was caught quickly and he suffered no ill effects. One quick dose of adenosine and he was all better.
So there you have it -- the bookends on my day. Two cardiac patients: one at the very end of life, one at the very beginning. I like a nice symmetry as much as the next guy, and this was a very satisfying "circle of life" conclusion to an otherwise unrewarding shift.
Posted by shadowfax at 6:22 AM
No, Val, the ER doc was not wrong. You are committing the logical fallacy of ex post facto reasoning. The CT scan was clearly indicated based on the presenting symptoms because the doctor did not yet know there was no dissection. Carl Sagan once wrote of the TV scientist who sadly lamented a "failed experiment" because it did not produce the expected results. That's the exact opposite of science! Any scientific investigation in which the outcome is known in advance is a waste of time. The test was successful because it provided useful information, and while the outcome was negative, the assay was by no means a waste.
George was right - he was getting old. The nurse was right - there was nothing emergent going on.
The ER doc was wrong - George didn’t have an aortic dissection. And I was wrong - there was nothing actively wrong with his heart.I feel badly that I contributed to a waste of healthcare resources.
Anonymity is a fantasy. It’s remarkably difficult to achieve. With small thoughts you can hide – in fact, no one cares who you are. If you offer anything worth hearing people will ultimately find out who you are.So terribly true. I was amazed, the first time I got picked up on Reddit, how quickly some clever commenters were able to figure out my identity. Since then, I've only kept up a very slight fiction of anonymity, all the more transparent when I got cited under my real name in some national publications. The only qualification I would add to this is that I keep my name and that of my hospitals off the blog, since I don't want patients to Google me after seeing me in the ER and immediately find the blog at the top of the search list. Not that it'd be hard to make the connection, but I don't want patients I have cared for to find the blog and have the fear that "he's going to write about me." And yes, I do fictionalize every patient story on this blog extensively. Bottom line: don't post anything on line that you'd be uncomfortable listing on your CV!
Posted by shadowfax at 3:01 PM