Archive for March, 2007

via Captain’s Quarters, who’s been watching Bob Newhart DVD’s in the hospital while his wife recuperates from an apparently successful kidney transplant (best wishes to all).

The episode they’re watching has the professionals in their Medical Arts building setting up a co-op, with “disastrous results”:

….When a rational basis for regulating the demand for services is removed, the demand increases exponentially. Without that regulating force of money, the demand far outstrips the supply, creating shortages. It shows that money offers an objective control on demand so that the market can have flexibility in increasing supply and benefitting suppliers in a manner that barter simply cannot. Without it, there is no objective way in which to prioritize and ration access to services.

There’s a lesson in there for advocates of single-payor systems and nationalized health care, in which decisions on rationing get transferred to the government rather than the consumer or supplier. It’s not a direct analogy, but the episode certainly suggests an example for that as well.

Another spot-on observation.

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On money, medicine and anger at edwinleap.com
It’s very disappointing to have been blogging for several years and have so many ‘new’ bloggers (Dr. Leap, Panda, you) be so much better writers. Thank goodness I’m better looking (maybe).

Dr. Leap, well, leaps to the answer:

My friend, Dr. Carol Rivers, hit it on the head. People are happy to pay for what they want, just not what they need. It’s frustrating to have to pay a medical bill. But it’s less frustrating to buy a new truck, get a new lap-top, go to a concert, buy a pay-per-view sporting event. People in our society spend money like crazy on what they want. It’s just that health care is not what they want. They want health, like everyone, but a huge number of people consider paying a doctor or hospital bill unfair.

Unfair is something we need to address in medicine, in healthcare, and in policy discussions.

Many of my readers don’t want to know what I think of unfair as it applies to healthcare, and I’m cogitating how to explain myself.

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Single Payer Shell Game : PANDA BEAR, MD

Now look, I don’t have a degree in economics and I don’t belong to a think tank where I am paid to shill my particular brand of public policy. On the other hand, I have a little common sense and have kept my eyes open.

If you were to get in a scrap with a mean old junkyard dog and he managed to sink his teeth into your scrotum, from that point forward the dog is totally in charge. You may have the complete use of the rest of your body and even though, from a real estate point of view, the dog has laid claim to a fairly small portion of your property, where that dog goes you will go and you heart, mind, and soul will follow willingly.

Thus begins an explanation of objections to ‘Single Payor’ that I’d be glad to take credit for. Except he wrote it before I did. Oh, and better than I could, as well.

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Medviews

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If you watch TV medicine, what you see are a lot of terrifically successful codes, with patients getting back a normal pulse and blood pressure in a matter of mere moments, and that’s where the commercial break begins; it’d be a bit much if they stood and walked out of the hospital before the commercial, that’s why. When they die on TV, it seems the only one who makes the decision is the doctor, which always strikes me as strange, even given televised unreality.

Real life, as you might expect, is different. Not only are there no commercial breaks, the codes usually end with the patients in the state they arrived: dead. Oh, we do all the right things, give medicines in the appropriate doses (which I’m pretty sure would give a rock a pulse, at least momentarily), shocks, ventilation, etc. And yet the survival rate is abysmal if you arrive at the ED with CPR in progress.

The reason has to do with the cascade of damage required to cause the heart to quit in the first place. Stop breathing long enough for the heart to stop (Anna Nicole Smith) and even the Olympic CPR team cannot recover from the profound acidosis and ischemia that was necessary to stop the heart and attract attention. It’s even worse if it was a heart attack that caused the heart to stop: the damage to the heart muscle needed to stop it is substantial, but once it’s deranged there’s not a whole lot CPR is going to add. (This is not to say CPR is futile, it’s clearly not, so do it). What I’m saying is that if the medics cannot get a patient back in the field there’s not a heck of a lot more that can be done in the ED.

Not that we won’t try. We’ll literally wear ourselves out doing CPR, getting IV access and an airway, and generally being as obsessive about trying to save a life as you’d hope we’d be. Everyone tries hard, and as a group revel in the occasional success, but it’s so occasional we can even get someone’s heart restarted so they can die in the ICU it’s notable. And depressing.

When I was but an EMT lad in an ED I witnessed something I’ve incorporated into my own practice, and I think every doc should do it. When it’s ‘that time’, time to stop the resuscitation, in every instance I say something along the lines of “Okay, we’ve been coding this person for xx minutes, and there’s been (brief summary): does anyone here want to do anything else? If so, tell me now”. This does two things which are important for everyone in the room who isn’t dead: it makes them part of the decision making process, and it empowers them to very easily object should they wish, for whatever reason, to continue. “I’d like to give some (whatever)” is then totally fine, and they’re not having to object in a vague way that they’re not done yet with what can be a terrifically personal struggle to save someone none of us has met, or knows as anyone other than a patient. We give the whatever, and after a while, given the persistence of death, I’ll give my speech as many times as it takes (so far, twice has been all, but I’d be perfectly willing to go on for a long time), because it’s important for everyone involved to acknowledge that they did what they could, and to be comfortable with stopping.

Codes end, very occasionally with a happy outcome, more often than not with a patient under a sheet, but the people who were there need to feel like they had a chance to do all they could.

Death is forever, and so is guilt; I want to make certain the dead don’t take the living with them.

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And, they were all about my shirt.

Today I wore a nice pink-striped shirt to the second job.  The regular gig uniform is scrubs and a lab coat.  It’s a nice coat, monogrammed and everything (and the FAAEM gets a lot of ?what does that mean? queries), but we’re all dressed the same, day in and day out.

The second job is a lot more individual, dress code wise.  A number of the physicians wear jeans and a collared shirt, +/- a lab coat, and I wear nice slacks and usually one of these really neat camp shirts.  The ‘hidden pockets’ are a nice place to stash prescription pads, my Tarascon’s pharmacopoeia, and the like (and make for double-takes from people who see me produce items from nowhere).  Today, none were available.

So, my choices in the closet were Hawaiian loud, Hawaiian less loud, or my nice pink shirt.  Easy choice.

And, it was terrifically weird getting a lot of compliments about wearing pink.  To me, it’s just another color, but apparently I’m wrong on that front.

For the record, I have no trouble wearing pink, but I don’t do it to prove a thing, I have nothing to prove.

Except that I’m not completely sartorially challenged.

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I enjoyed six days off, and did a lot of around-the-house things.  Now I’m back to work, and the backwards-clock scheduling leaves me little time for my normally voluminous and well-reasoned discourse.

So, here’s some links that I need to get done:

Change of Shift, at Geena’s.  The Geena who should have been the first four-time host of Grand Rounds.

Brit Meds at Dr. Crippens’.  How does he have time to do all this?

Radiology Grand Rounds at Middlesex Xray, also a UK blogger.

Enjoy their efforts!

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Originally posted 3-21: Updated (see below)

…and didn’t even know it.

I was reconciling the online charges today and found a couple of big charges to an Internet florist, which was notable because I didn’t buy any flowers from that florist.  Oh, I did a couple of years ago, but that’s it.

First, I called my bank, and they recommended calling the company first.

Second, I called the company, and found very nice and supportive folks on the phone.  Their customer relations person told me that the caller got my card, name and address correct (terrific).  They also told me the three cities the flowers went to, none of which I know anyone in.  So, my money has been refunded, and they have a flag on my card of some sort to prevent its use.

Then, after thinking about 30 seconds, I called the bank back, and after laying it out they immediately stopped my card number, and I’ll get another some time this month, probably.  They were nice, too.

And now, I’ve filed a fraud report with a credit reporting service, so they’re watching for new account requests. 

Oh, I got two calls from the flower company with “I have the flower recipient on the other line, and they want to know who sent the flowers”, with two very disappointed operators when I told them the story, nicely.  One of them called back and gave me some information on who they thought sent them the flowers, with a name so rare there’s only one that pops up in the US.  Weird.  We’ll see.

I hate thieves.  I hope I can help find this one.

Update: So, the person who called back was appalled she’d gotten fraudulent (if nice) flowers, contacted me, and forwarded me several emails for an Internet suitor.  Again the same extremely unique name, and markedly poor English grammar and punctuation.  Oh, and he’s bragging about sending flowers on my card, not knowing she’s aware, and guess what:

hi xxxxxxxxxx,
how as your day been? cool i guess! the flowers are just a sign of our love i want you to keep and cheerish it well. just the way you would do to me…………….xxxxxxxxx you need to do me a little favour.my mum in nigeria is very sick and would be operated upon.i need you to do some money order for me i would give you the full details soon but you will get parcel containing the order in 2days time.
xxxxxxxxxxx

(the x’s are not hugs; they’re where I’ve taken out their names, in case you’re drinking).  (And stop drinking so early).

Hmm.  This seemed like a pretty good facsimile of a money laundering operation at best, or full-on bank fraud at worst.  Some Googling brought about the Wikipedia answer, a Romance scam:

A romance scam essentially occurs when strangers pretend romantic intentions, gain the affection of victims, and then use that good will to gain access to their victims’ money/bank account or by getting them to commit financial fraud on their behalf. Most of these scams seem to originate from, and are prevalent in West Africa (especially Nigeria) although they are becoming increasingly common in Russia and Eastern Europe. Another emerging region is Thailand and The Philippines or any other country where ‘mail order brides‘ are available.

Here’s where I screw up it gets funny.  I sent an email back to the flower girl outlining my suspicions, with a link to the Wiki article, etc.  Well, it was supposed to be sent to the flower girl.  I sent it to the scammer, by mistake, along with the flower girl. 

I’m a doofus.

But I’m not trying to scam anyone.

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F.D.A. Rule Limits Role of Advisers Tied to Industry - New York Times

By GARDINER HARRIS
Published: March 22, 2007
WASHINGTON, March 21 — Expert advisers to the government who receive money from a drug or device maker would be barred for the first time from voting on whether to approve that company’s products under new rules announced Wednesday for the F.D.A.’s powerful advisory committees.

Indeed, such doctors who receive more than $50,000 from a company or a competitor whose product is being discussed would no longer be allowed to serve on the committees, though those who receive less than that amount in the prior year can join a committee and participate in its discussions.

A “significant number” of the agency’s present advisers would be affected by the new policy, said the F.D.A. acting deputy commissioner, Randall W. Lutter, though he would not say how many. The rules are among the first major changes made by Dr. Andrew C. von Eschenbach since he was confirmed as commissioner of food and drugs late last year.

Advisory boards recommend drugs for approval and, in rare cases, removal, and their votes can have enormous influence on drug company fortunes.

Emphasis mine.

And, are you kidding me?  They aren’t already precluded from ruling on their competitor’s products if they have significant holdings in a company in front of the committee?

I’ve always given the FDA the benefit of the doubt.  Now they just get doubt. 

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Two back to back blog posts in my RSS reader, and they are both on the same wavelength: there’s a time when doing everything is right, and a time when it’s wrong.

Charity Doc with Why?

Panda Bear, MD with Obels for Charon.

Recommended.

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This week, at Blog, MD:

Introduction

It is a privilege to host the current issue of the medical blog Grand Rounds. As an afficionado of medical history, it is remarkable to see this latest incarnation of process that has “evolved from centuries-old practices that trained physicians by means of apprenticeships.” (Mueller et al., Mayo Clin Proc 2003 ). Medical grand rounds have morphed from ward-based teaching or using an illustrative case presented in an auditorium (as illustrated above) to a lecture format.

Elegantly done.

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Whoever decided popcorn ceilings were good in garages never tried to get cobwebs out of them.

And yes, Dad, I’m finally cleaning my garage.  Yoohoo, vacation!

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Overlawyered: "I’ll sue ya"

Amusingly enough, docs are left out.

Update: Thanks to a commenter I learn it’s a Weird Al song. No wonder I liked it.

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NHS Blog Doctor: The BritMeds 2007 (11)

Have a read, toward the bottom, at the joys of socialized medicine as it relates to young docs matching for residency positions. They’ll be lucky to have any doctors training at all in 5 years with that going on.

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Via the Fort Worth Star Telegram:

FDA says pills can cause ’sleep-driving’

by LAURAN NEERGAARD

AP Medical Writer

All prescription sleeping pills may sometimes cause sleep-driving, federal health officials warned Wednesday, almost a year after the bizarre side effect first made headlines when Rep. Patrick Kennedy crashed his car after taking Ambien.

It’s a more complicated version of sleepwalking, but behind the wheel: getting up in the middle of the night and going for a drive - with no memory of doing so.

The Food and Drug Administration wouldn’t say exactly how many cases of sleep-driving it had linked to insomnia drugs, but neurology chief Dr. Russell Katz said the agency uncovered more than a dozen reports - and is worried that more are going uncounted.

Given the millions of prescriptions for insomnia drugs, Katz called the problem rare, and said he was unaware of any deaths…

I had a sleep-driving case, within the last six months or so (some details are changed).  The actual patient care was ho-hum, but the story is interesting.

An adult male patient came to the attention of firemen when he fell asleep on the horn in front of their fire station.  At about 3AM.  The firefighters found a patient who would arouse but then go directly back to sleep.  He’d answer his name, but that was about it.  No smell of alcohol, no drug paraphernalia present.

Notable was his car: the left front wheel had no tire, but no other major or even minor damage to the car.  There was a groove in the pavement made by the wheel and the PD, thinking maybe they could find his origin, followed the groove.  They returned after a bit stating it went for miles, and had no idea how long he’d been driving on the one rim.  They surmised he’d hit something while driving, blew out the left front, then drove on the shredded tire until it fell off, then a while longer, fortuitously stopping at a fire station.

EMS reported normal vitals on arrival to the hospital and we had to go through the story several times, as usually an altered patient from a vehicle with virtually any damage gets a big trauma workup, but there was no evidence of damage (except the missing tire).

The physical exam clinched the ‘tox’ thing for me, though at the time we had no idea what.  Normal vitals, pulse-ox, blood sugar.  Normal exam except when asked questions you’d get the right answer, then a volunteered answer you didn’t expect: “I’m Jim Jones,…my service number is xxxxxx…..and my Sergeant is…” followed by sleep.  As he was well beyond military service age, this kind of answer seemed odd.  As time progressed, the arousable periods got slowly longer, and we got a phone number.

A number which clinched the diagnosis, as it produced a spouse with a new pill bottle for the patient.  She hadn’t been aware he was missing, and was more than a little startled at the events.  Yes, the (sleeping pill*) was fairly new, no he’d never had a sleepwalking history she knew of, etc.  Several hours he awakened with no ill effects and went home.  Not an exciting case, but after a few years in EM you enjoy the cases where patients don’t die and it’s a little interesting.

So, my recommendation is to have somebody hide your keys when you take the sleeping pills, but that’s just me*.

*Not actual medical or legal advice, no actual product is mentioned or implied.  Your mileage may vary, void where prohibited, and thank a lawyer if you read crap like little tiny asterisked text.

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