10 April 2012

Malpractice and sporting events

This came across my twitter stream; I forget the source:

From Outside Online, an article about how physicians are increasingly hesitant to provide volunteer medical coverage at athletic events:

Last year, 13 Americans died during running races, and another eight while competing in triathlons. While those numbers might seem troubling, the deaths are attributable mostly to the booming popularity of endurance sports—13 million Americans enter running races each year, and 2.3 million compete in triathlons. But the rising participation and the proportional death toll—especially in cases like Hass’s—highlight the need for quality medical care at these events. And usually that care comes from volunteer doctors. 
At least it used to. More and more doctors are refusing to donate their services, and it’s for one frustrating reason: they can’t get medical-malpractice insurance. Most doctors’ insurers typically won’t issue one-day policy riders for sporting events, and race organizers haven’t stepped up to offer alternative coverage. After the 2008 Ironman World Championships, volunteer medical director Franklin Marcus famously resigned because race organizers had refused to offer coverage
I've run into this myself, and it can be a really tricky issue. The problem is that this is a place where Good Samaritan laws and "duty" overlap in a way that's murky at best and damaging at worst.

For those not familiar with this aspect of malpractice law, here's a ten-second primer. In order to be liable for malpractice, three things need to be present:
1. A duty to treat
2. A breach of that duty (commonly thought of as "standard of care")
3. A harm resulting from that breach

So when a patient rolls into the ER, as the ER doc who has agreed to be present for emergency cases (or as a surgeon who has agreed to be on call, etc) the duty is implicit. Also, of course, when there is a pre-existing doctor-patient relationship that duty is satisfied. But what of the "man on the street" situations? If I am walking down a street and see someone keel over, I'm under no obligation to render assistance (in most jurisdictions). I have no duty to treat. In theory, that means that I could render aid without any risk of being sued, and in order to encourage physicians to render aid in such situations all 50 states have passed so-called "Good Samaritan laws." They vary from place to place, but they generally immunize a doctor from malpractice barring recklessness or willful and wanton negligence should they render emergency assistance.

The problem is that this usually only applies when you have no duty to treat. So if I am at a (not at all hypothetically) karate tournament with my dojo and I see a contestant injured, I can provide first aid without fear of malpractice. But if I am asked in advance to be the "tournament doctor" then it becomes a murkier issue, because then I am acting as an agent of the event and its organizers and as such might meet the definition of "duty to treat." This raises a whole secondary set of concerns — are the facilities and supplies adequate to treat injured contestants, can I pull an athlete who wants to continue, etc. Some locations extend Good Samaritan protections to doctors who act as volunteers without expectation of compensation. Others do not. Most organized athletic events have some sort of liability insurance, but that would probably not cover a physician's professional liability, and smaller events (say, a recreational kids' soccer league or a local karate federation) don't have the resources to get their own med-mal policies.

So this puts the doc in an uncomfortable situation. We want to support the local organizations, whatever they may be, but you have some tough choices to make. You can go "naked," without insurance, which is not unreasonable in most cases since the actual risk of injury, let alone getting sued is very low in most activities. But for some sports, the risks are higher, and many doctors are too afraid of getting sued to run that sort of risk. So then you are left begging your insurer for a rider allowing you to do this or begging your skeptical partners to make this an underwritten part of the group's policy. The cost for this sort of coverage is trivial, and in fact some insurers will give it for free, but some insurers and some groups won't allow it at all. It varies a lot by specialty. Ortho docs, in my experience, tend to be much more invested in local athletics (if nothing else, it's good business!) so they are more comfortable viewing this as a necessary and reasonable business expense. Pediatricians, too, since there are so many kids' sports leagues and the serious injury rate is so low. Your mileage may vary.

It was nice to see in the linked article that malpractice coverage is becoming more available (and at a very affordable price of $60 per doc). Hopefully that will become the standard for event liability insurance in the future.

06 April 2012

Doctor density map

This is cool, via wonkblog:

The availability of basic health care varies radically from place to place across the nation.
To the left of the vertical slider bar, counties outlined in orange had no doctor's office in 2009, according to the Census Bureau. Clark County, Mississippi, for example, had a population of over 17,000 but no doctor's office, while Manhattan had a doctor's office for every 500 residents.
The map to the right shows the relative availability of primary health care providers by county. Enhanced access to health care is key to improving the health of Americans.
doctor map
Uploaded with Skitch!

In health care, as in everything else, it's location, location, location.

05 April 2012

He says he's not dead



"You're not fooling anyone"

Ah, the life cycle of a blog: from posting every few days, to multiple posts a day, to posting every couple of weeks. Is "Movin' Meat" on its way to permanent hiatus? I don't know any more than you do. Recently my free time has seemed to be consumed by work, the kids, karate, and when I have time to play on the computer, I seem to spend more time on Twitter. In any event, I'm not hanging it up, and I do intend to keep posting, at least as often as I have something to say and some time to thoughtfully present it.

To make up for the recent radio silence, I offer you this true anecdote from last weekend which qualified me for my twelfth Dumb Guy Award:


I used to have a perfect 40-year track record of never accidentally setting the house on fire. Unfortunately, I can no longer say that is the case. My Lou Gehrig-like streak has been broken.

So, we have dogs. (Relevant.) If we leave food on the counter for more than a minute or two, it becomes dog food. Also, the damn cat. So both Liza and I have a longstanding, almost automatic habit that as soon as we are done eating, all food is immediately covered or otherwise put away. Sometimes when we have pizza or some otherwise largish dish, Liza would put it in the oven to keep the critters away from it. I have objected to this practice on the grounds that I think it's unsanitary to leave unrefrigerated food out and also because from time to time I turn on the oven and it starts smoking and I pull out the charred ruins of yesterday's dinner. In fact I have ... discussed this with Liza a few times. (I was going to say that I have yelled at her for it, but one does not yell at Liza if one wishes to keep one's ears.) At any rate, it was a pet peeve of mine, and we have discussed it. And since those discussions, it has been a fairly uncommon thing to have leftovers in the oven any more.

The other night, we had pizza, as we usually do on Friday nights — movie night at the Shadowfax homestead. (Relevant.) Last night, Liza and Son #2 went to the Sounders game, which is soccer. Son #1 had his friend Ethan over for a playdate/sleepover, and I was of course minding the two girls as well. I was absorbed in a complex task on the computer, and Liza had thoughtfully gotten a frozen bakable platter of Mac'n'Cheese rather than abandon the children to my tender ministration, by which I mean neglect. After Liza left, I turned on the oven to preheat and went back to the computer room, immediately forgetting about the oven. A few minutes later, Son #1 shouts that something smells like smoke. I ran to the kitchen to be confronted by thick black smoke pouring out of the vent on top of the oven. I hit the fan, deactivated the oven, and opened the door to see large sheets of flame shooting out.

From the pizza boxes. Which I personally had put in the oven and forgotten.

A lot of things started happening at once. All seventeen smoke detectors in the house started going off at ear-splitting volume. The kitchen started filling with smoke VERY quickly. The little girls started freaking out at the noise and the smoke. I realized that this was not the sort of fire you can beat out with your hands or a cup of water; it was in fact growing as I watched it. I remembered where the fire extinguisher was (in the cabinet next to the oven), retrieved it, and pulled the safety pin. I aimed it at the flames and squeezed the trigger.

Now, I will pause here to note that I have never before discharged a fire extinguisher. I had only a vague idea of what happens when you do. You point it at the fire, FWOOOSH, magic smoke happens and the fire is out. Simple, right? I did not know (and was not really thinking about it deeply at the moment) that the magic smoke is in fact a very very fine white powder, ejected under high pressure into a very confined space. To say that the mess it left was catastrophic would be an understatement. "Unholy" would be a better description of the results. A huge cloud of white dust billowed back from the oven and covered my face and every single surface in the kitchen.

I peered into the oven through the haze, and saw that the boxes were no longer burning. I retrieved them, still smoking faintly, and set them on the counter by the window. I noted then that there were still (or again) decent sized flames shooting out of the oven. I am guessing that some of the pizza or box had adhered to the roof of the oven, but I don't know. FWOOSH again, another huge backblast of white particles and the fire in the oven was out. Unfortunately, the pizza boxes on the counter had managed to re-ignite themselves and were shooting flames about four feet up. Another brief blast of mystery white powder all over the counter and sink and wall and cabinets, and the pizza boxes were once again downgraded to smoldering, with a few flickers of flame. I realized the fat in the cheese of the pizza (there was quite a bit left) was going to be really hard to put out, and the extinguisher was nearly spent so I picked up the boxes and ran out back. The air from running caused the flames to flare up in my face quite dramatically. Perhaps the white powder covering my face protected me from serious burns; we shall never know. I pitched the blazing boxes onto the back lawn and went back inside to contemplate the smoky, snowy ruin of our kitchen.

The good news was that we now had a fire-free house, which is a something of a luxury when you really consider the alternative. The bad news was that the smoke was thick in the air, burning my eyes, the girls were sobbing uncontrollably, the fire alarms were shrieking, and the oven was a horrible mess I didn't even want to think about. Son #1 was a champ at this point, rounding up the girls and consoling them and keeping them out of my way. I ran through the house opening each and every window. It was 44 degrees, so soon the girls were crying *and* shivering. The smoke upstairs was so thick it was actually sobering. Way up in the playroom it was so dense I was coughing and my eyes were tearing. I couldn't turn off the fire alarms, but they shut themselves off after a few minutes. Slowly the smoke began to clear.

I surveyed the damage. Nothing serious, really. Just a huge mess, and nobody hurt. So a victory when it comes to kitchen fires. Son #1 and Ethan came down and started writing their names in the dust that covered everything. I sent them away when they started to pour out water to create paste. Teagan lectured me in her "important" voice about the big big fire that we had in the oven.

Outside, on the lawn, the pizza boxes burned prettily.

I sent Liza a text, and got the following, concerned, supportive response:

sms

I poured myself a big glass of wine, for courage, and set to the cleanup. THREE HOURS with the shop vac, all the while enduring insightful commentary and overt taunting from my nine year-old son. He truly has the genes of a champion taunter, and I think he felt entitled since he continued to watch the girls for me. Ethan was reserved and polite; a nice kid. But he looked at me with an air of quiet disdain, which is a painful sense to get from a kid. After a while I noticed that the dogs were trying (OF COURSE BECAUSE THEY ARE DOGS) to eat the still-smoking remains of the pizza on the lawn, so I had to go out and deal with that. I surrendered and gave them all the blackened pizza that wasn't actually hot to the touch, which they ate greedily, because they are dogs. I slipped on the wet wood getting back on the deck and nearly broke my leg, catching myself just in time. Shaking a weary fist at the sky, I went, defeated, back into the house.

When Liza got home, she was actually quite understanding and did not beat me up at all, beyond noting that the place smelled (and smells) like a campfire. She was very complimentary at the cleanliness of the kitchen, which bore almost no sign of the disaster. With a childlike sense of wonder, she surveyed the rest of the house and noted how far the white dust had spread (all the way to the kids' bedrooms, the wet bar, the front room, pretty much the entire house. Son #2 was disappointed to have missed the excitement. I got quietly drunk and went to bed; the boys stayed up till 3AM giggling.

So I now hereby claim the title of DUMB GUY as is my right and my due until such time as Matt or some other guy commits an act of idiocy.

I will say in defense of my Dumb-ness that while anybody can make the careless mistake of turning on the oven without checking it, the fact that I had many times berated my loving wife for her habit of putting the boxes in there, and then proceeded to do the same damn thing myself qualifies me for the willful stupidity element of the award, with bonus points for irony. And the consequence of the mess and the humiliation in front of my son and his friend certainly meets that criteria.

Submitted for your consideration.