Archives for April 2007

Maine’s Universal Healthcare Flops

Hmm, who would have thought (via the NYT):

April 30, 2007
Expensive Lesson for Maine as Health Plan Stalls

PORTLAND, Me., April 23 — When Maine became the first state in years to enact a law intended to provide universal health care, one of its goals was to cover the estimated 130,000 residents who had no insurance by 2009, starting with 31,000 of them by the end of 2005, the program’s first year.

So far, it has not come close to that goal. Only 18,800 people have signed up for the state’s coverage and many of them already had insurance.

“I think when we first started, in terms of making estimates, we really were kind of groping in the dark,” said Gov. John E. Baldacci, who this month proposed a host of adjustments.

The story of Maine’s health program — which tries to control hospital costs, improve the quality of health care and offer subsidized insurance to low-income people — harbors lessons for the country, as covering the uninsured takes center stage. States, including California, Massachusetts and Pennsylvania, have unveiled programs of their own, seeking to balance the needs and interests of individuals, employers, insurers and health care providers.

But as Maine tries to reform its reforms, it faces some particular challenges: It has large rural, poor and elderly populations with significant health needs. It has many mom-and-pop businesses and part-time or seasonal workers, and few employers large enough to voluntarily offer employees insurance. And most insurers here no longer find it profitable to sell individual coverage, leaving one carrier, Anthem Blue Cross Blue Shield, with a majority of the market, a landscape that some economists said could make it harder to provide broad choices and competitive prices.

I’m all for individual states trying this out, rather than a nationwide plan.

New car update

43.4 MPG.  A little disappointing given the 60/51 EPA estimate, but still a lot better than my old drive.  All done with the AC on, I might add, so that’s probably hurting the average.

And, it’s a fun little car so far.  We’ll see how it wears.

Why the VT shootings can happen again

The shooter was identified as being way more than two bubbles off level, was actually sent for a psych eval; the rest is history.

I have no illusions this couldn’t happen here in Texas.

In California, there are pretty liberal “5150” laws (the section of the Mental Health code that applies to emergency detention of psychiatric patients), and as one Officer eloquently explained “It’s an easy form to fill out”.  Apparently peace officers in California have some immunity for action based on a 5150 complaint, because I saw a lot of them.  My residency training program saw and ‘medically cleared’ at least 20 every night, then they went to an up to 72 hour hold, during which they’d be seen by a psychiatrist or two, and if felt to need more stabilization, a Judge was asked to act to hold them involuntarily for treatment.  I saw more than a couple of patients with 5150 tattoos (one on his knuckles), and they were pretty easy to clear.  Also, geographically defined, if you catch my drift.

That’s the way it worked optimally.  Occasionally we’d get a guy who said “this is what my girlfriend does every time she’s mad at me: she calls the cops, says I’ve taken an OD, and then tells them I’ll deny everything, so they bring me in here on a 5150”; his story would eventually check out, and he’d go home from the ED.  The vast majority were modestly to deeply disturbed patients who really needed the help.  I would have cared more, but I was a resident, and behavioral health evals could suck the life right out of you.  And the less said about the psych residents the better.


Here in Texas, there’s a great emphasis on personal liberty (“It’s not against the law to be crazy”), and that’s good the vast majority of the time.  There is indeed an emergency mental health code for the psychotic, deranged and suicidal, and it’s not easy to utilize.  There is no simple form, but a multipage affidavit that has to be signed by a judge prior to holding a patient for involuntary psychiatric evaluation, and that’s assuming you can get an officer to initiate the form in the first place (mere physicians cannot).  For a police officer to begin the paperwork, the patient must be in imminent danger of harm to self or others due to mental illness.

And, there’s the rub.  As the patient is in an ED, the cops tell us ‘they’re not in imminent danger, as they’re here in the ED’, and they refuse to initiate a hold.  It doesn’t matter to them that we have no psych facilities, that the patient refuses to agree to go voluntarily to a psych facility, they’re just not going to even try.  This puts the ED doc in a tough position (understatement), and there are some work arounds, but it can take hours and hours, and usually doesn’t result in the patient getting the help they need. 


Mental health laws are one of the things I’d like to see addressed in the country well before we try to change anything else.  I’m not going to hold my breath.

Wow, I made Annals of Emergency Medicine!

Unfortunately, in the News and Perspective, but there you are:

[GruntDoc], an attending emergency physician at Harris Methodist Fort Worth Hospital, had a problem. He’d just raised the ire of the nurses who work with him – and many who don’t—by posting a provocative entry to his popular GruntDoc blog ( titled “The Lifesaving Foley.”

In August of last year, he decided to write about “a peculiar phenomenon” he’d recently noticed with his nursing colleagues. “I’ll be in the middle of a code, look around and see a nurse studiously inserting a catheter into the patient,” he wrote. Then, he added, “We’ll be getting ready to intubate an agitated patient; I look and see the nurse is busy intubating Mr. Johnson.” And then [GruntDoc] took a jab he later regretted:

“I have no idea why. Really, I think they’re stressed out, and want to ‘Do Something.’ They see a task they’re comfortable doing, and so they do it. Indication or not, right time or not, utility or not. I’ve taken to calling it The Lifesaving Foley, for obvious reasons, though I don’t think it’s saved a life yet.”

Oops. Comments from, shall we say, moderately peeved nurses came fast and furious to the GruntDoc blog. A week later he posted a mea culpa entry to the blog titled “Some Nurse Love,” and listed a number of reasons why he appreciated nurses.

“I try not to write anything on the blog that I wouldn’t want to see on the front page of the newspaper,” [GruntDoc] said. “But in that case I don’t think the nurses were amused.”

Featuring Movin’ Meat, Trench Doc, Charity Doc, and Blogborygmi.  I don’t know about them, but I’m going to add this to the CV as a publication…

Dr. Schwab and the trans-vaginal cholecystectomy

Surgeonsblog: Holes shows once again why he’s a great additon to the medical blogosphere:

… According to those that advocate such things as pulling an appendix out a person’s mouth or anus, the aim is to reduce pain and scarring for patients. I call bullshit. I think the motivation is “Hey, look at me!”

I hope he isn’t assimilated by the borg, but that’s his decision.

MedBlogs Grand Rounds 3:31

Med Valley High

On Wednesday, last week, there was nothing. All was cold, lifeless, and devoid of wit and insight. Then, on Sunday night, there was a veritable Big Bang in my email inbox, a sudden explosion of posts from all corners of the blogosphere. It has been my pleasure as the host of Grand Rounds this week to visit blogs that I didn’t even know existed, so I’ll invite you now to sit back, relax and join me on a tour of the highlights of the medical blogging universe.

Every Tuesday!

I bought a new car this weekend

…a Toyota Prius.

This doesn’t mean I’ve decided to become some holier-than-thou eco-weenie.  It’s just a car that makes sense for me, and I really like gadgets, so win-win!

I left the house to go buy a Ford Expedition EL, roughly the size of a supertanker (and unfortunately without the supertanker of fuel needed to supply it), and I liked it enough: big, powerful, and total overkill for my purposes.  I had a little voice in the back of my head telling me this was a bad idea, and that voice somehow arranged for me to deal with the least interesting auto dealer I’ve met.  Following an hour of attempted financial abuse I finally left, without a deal.

Driving away, I asked myself what I needed, and came up with ‘fun commuter’.  I’d looked at the Prius online a decent amount ( the technology fascinates me), and knew it had all the electronic goodies I could possibly want.  So, off to the Toyota house.  (An aside: my daughter was with me, I asked her to call to make sure they had some for drives, and she asked the cellular operator for “The Fort Worth Toyota house”, which made me laugh, as it’s southwestern slang to call a dealership a ‘ brand house’.  The operator didn’t understand, so she had to ask for the Toyo dealer, and all was well).

The world is an odd place, so of course my salesman there wasn’t just a former Marine, he’d been on the same boat as me during my deployment (attached to our unit, but peripherally)!  After 5 minutes of conversations, it was off to the drive.  I liked it, and bought it.  Now I don’t know why they have any left on the lot, they’re pretty slick.

Oh, and I did some freeway to and from Dallas, and a commute to work, and I’ve gotten 44mpg so far.  It’s a far cry from the 60/51 advertised, but it’s still a whole lot better than anything else I’d looked at, and a lot better then the SUV I traded in (17mpg).


Now I need to decorate it like this guy, and for the same reason…

Dr. Leap and the ‘Ask Me’ button

Dr. Edwin Leap ( is probably the most gifted Emergency Physician writer (he’s so good he has a paid gig writing for EM News).  Here’s the latest available on the EM News site (which has gotten much better since I last bashed them):

Ask me. It’s a question being posed by a little badge now worn by nurses around the country. It seems harmless enough. At our little hospital, it means, Ask me if I’ve washed my hands. Seems like a reasonable and harmless question. Some places, it probably means, Ask me if I have done my time-out, or some other little administrative caution. It’s one more little reminder to do the right thing.

We get a lot of those these days. …

I was thinking. Maybe, as we do our time-outs and scrub our hands red, as we smile and get cups of ice and endure abuse with a smile, we could create our own Ask Me buttons. But let’s ask some questions with a twist. How about some buttons that ask the things clinicians want to ask everyone else? How about these:

Ask me: If my opinion has ever been silenced with the threat of firing.

Truly entertaining, a delight to read.

I think the Smithsonian is missing an exhibit

From a patient recently:


It's a truss

I’ve never seen one, but I’d read about them.

Rules for new Nurse Grads

No, not from me, from Head Nurse

Those of you who are about to graduate from nursing school will no doubt have noticed that it’s staying light later in the day, although other details might’ve escaped your notice. Since it’s spring, it’s time for the periodic Tips From Nurse Jo For New Grads…

Good recommendations, and humorously laid out for all to enjoy!

MedBlogs Grand Rounds 3:30

Fat Doctor: Grand Rounds Vol. 3, No. 30

And now, (drumroll please), my second attempt at Fat Doctor’s Grand Rounds. This is a Mayan calendar. The last year has been…special. A year ago, I was mired in a bad mood which turned into eight bilateral frontal lobe CVAs a week or so later. Thus, the first FDGR was devoid of the witty brilliance I had planned when taking on the task. I see now that I even screwed up the date on that post. Ha!

Since then, I’ve enjoyed the straightforward approach to GR, so I will stick to the basics. We had 39 submissions this time, many of them before the posted deadline! I always was picked last for kickball when in third grade (and years of therapy didn’t take away the pain), so I’m including all of them.

Another beaut.

Why do we remember the villains?

The VA Tech massacre is beyond my scope, and I have nothing to say that hasn’t been said elsewhere, better.

I would, however, like our society to resolve to forget the contemptible coward who killed these people. Nobody except their families remembers the names of those killed at UT, but everyone can place the name Charles Whitman.

And that’s a complete perversion of how life ought to be lived. Grotesque mass-murderers have no right to fame; quite the converse, they richly deserve ignominy, and anonymity. Let’s resolve to shun this subhuman and his memory, forever.



End of an Era Local: Merging hospitals a critical move

Merging hospitals a critical move
UMC will virtually close down this week as all of its acute care shifts to Community’s new facility.

By Barbara Anderson and Tracy Correa / The Fresno Bee
04/15/07 06:07:15

An era ends this week as University Medical Center — which for decades has served Fresno County’s poor and Central California’s trauma victims — shuts down as an acute-care hospital.

And another era begins in downtown Fresno, where an expanded Community Regional Medical Center opens state-of-the-art trauma and burn units, becoming one of the state’s biggest and busiest hubs for emergency services.

On Monday, ambulances will begin a three-day effort to move about 130 patients from UMC in southeast Fresno nearly two miles to the downtown Community Regional Medical Center. The former county hospital will lose its emergency room, hospital beds, intensive care — virtually shutting down the 1950s-era institution.

The move will consolidate all of those services at the downtown hospital — which, like UMC, is owned by the nonprofit Community Medical Centers.

The new emergency-trauma department covers 56,000 square feet — almost the size of a football field and one of the largest in the state. Community opened the emergency room in 2005, but trauma services now will be incorporated into the building.

Community officials said absorbing UMC’s patients will make the hospital one of the 25 busiest emergency and trauma centers in the country, seeing 120,000 to 130,000 patients a year.

I and Symtym trained at UMC (when Symtym was there it was Valley Medical Center, and was when I matched, then changed their name before I got there), but the closure of the facility makes me feel quite ancient.

I spent literally thousands of hours in that cave of an ED, learning through good instruction and not a little learning-by-doing, and its closure marks the end of an era.

Now they have more residents, and a lot more space, and they’re probably taller and smarter as well. Best of luck to the EM program, and so long, UMC.

BritMeds 2007 (15) is up

NHS Blog Doctor: The BritMeds 2007 (15)

This week’s selection is dedicated to the Secretary of State for Health who, as a result of yesterday’s story, will henceforth be referred to as Filthy Patricia.

Dr. Crippen isn’t feeling the love for the NHS leader.

JCAHO goes nuts, again

I was going to go crazy on this, but then found it had already been done:

Movin’ Meat: JCAHO Again!

JCAHO Again!

Sorry for the prolonged radio silence. Real life gets in the way of blogging sometimes. As my hero, Monty Burns said: “Family, religion, friends.. these are the three demons you must slay if you wish to succeed…” Well, I’m back with an annoyed rant, yet again on the Joint Commission. Apparently they have recovered from the temporary bout of sanity which caused their earlier hesitation and reinstated this odious rule:

Read the rest, and wonder at the world JCAHO thinks actually exists in an ED.