Archives for September 2009

Holman Jenkins: Why Obama Bombed on Health Care –

Holman Jenkins: Why Obama Bombed on Health Care –
Someday this country will have a health-care debate that’s not abject in its idiocy.

It will involve a term used by Congressional Budge Office chief Doug Elmendorf, who has become a notoriety for harping on the word “incentives.” The same word was used the other day by Warren Buffett, about what’s missing from the health-care plan on Capitol Hill.

We actually prefer the formulation of Duke University’s Clark Havighurst, who speaks of restoring the “price tags” to health care.

Now that’s a concept that the public could actually make sense of

Amen.  The lack of pricetags, and ‘skin in the game’ is directly responsible for a lot of the healthcare spending explosion.  Market, please.

It’s All Excessive Medical Care In Hindsight « The Central Line

It’s All Excessive Medical Care In Hindsight « The Central Line

Wow.  Very nice rant from Graham.  Another ED basher gets is head handed to him.

I sent a guy with a normal EKG to the cath lab (Updated)

9/30: Update: due to popular demand, I have added the EKG to the end of the post, with some follow-up.

I sent a guy with a normal EKG to the cath lab.  Let me tell you my side of the story.

Dude was minding his own business when he started having crushing, substernal chest pain.  I see dude by EMS about 45 minutes into his chest pain.  He’s had the usual: aspirin, 3 SL NTG’s an IV, a touch of MS (I can abbreviate here, as it’s not a medical record) and is continuing to have pain.

He describes it like you’d expect (elephants have a bad rep in the ED), and looks ill.  Frankly, he looks like a guy having an MI.  Sweaty, pale, uncomfortable, restless but not that ‘I’ve torn my aorta’ look.  The having an MI look.

Every EM doc knows the look.  I didn’t ask about risk factors.

On to the proof: the EKG.  EMS EKG: normal.  ?What?  Yeah, maybe there’s some anterior J-point elevation, but not much else.  Our EKG: Normal.

Normal EKG’s, patient who clinically looks like he’s having the Big One.

I’d like to tell you I agonized over the decision, but I didn’t.  Cath lab called, Interventional Cardiologist says he’ll meet the patient in the cath lab.  (Insert excellent nursing and tech care here; time to cath lab 28 minutes, no labs back yet).

Excellent tech comes to me after transporting patient to cath lab.  “The cardiologist wanted to know why you sent him a patient with a normal EKG”.  ?Are they going to do the cath? I asked.  “Yes, but he wasn’t happy”.  Supportive team thinks I did the right thing, but, sending a guy with a normal EKG to the cath lab?  I don’t blame them for some averted gazes.

Cardiologist comes looking for me an hour later.  Doesn’t look happy.

C: Why did you send that patient to the cath lab?
Moi: He was having an MI.
C: He had a totally normal EKG.
Me: Yes.
C: What made you think he was having an MI?
Me: He looked sick.

(An aside: I could have whipped out some BS about some minor historical feature, blathered on about his elevated J points, etc, but I’m stupid and just said what I meant).

C: After I started the cath, another cardiologist looked at the EKG, and agreed it was normal.
Me: (Sinking feeling) And?
C: 100% LAD occlusion, high proximal.  I stented it and now he’s good.
Me: So, good?
C: It’s the first patient with a normal EKG I’ve cathed, and he had a 100% LAD occlusion.

Some small talk later, the cardiologist leaves.  I have no doubt the cardiologist cannot decide if I’m an idiot or a savant.

I’m neither.  I’m an ER Doc.  Who got lucky.



First troponin was normal; second, several hours later, was nearly 30 (with our high normal being 0.05).

Symtym lives one of every EM Docs’ nightmares: patient in your own ED

It’s a Friday, early afternoon, so the bike trail will be lightly used. Traveling through old Fair Oaks to take the wooden pedestrian bridge across the American River. Crossing the bridge there is a 180° turn on the south down–slope of the bridge that takes you back to the bike trail along the river—another 90° at the end of the bridge approach and you are heading west. Gravel! Gravel?

From following his Twitter feeds he’s recovering, though rib fractures will make you aware that we do breathe.  A lot.

Good reading, and he dodged a big bullet here.

Then there’re things you can do that you shouldn’t…

AMNews: Sept. 21, 2009. Should you keep patients from commenting online? … American Medical News
What do physicians have in common with restaurants, dry cleaners and plumbers? All are being critiqued online by the public.

Is there anything you can do about it? Yes. Have your patients sign a contract promising not to talk about you online.

First, this sort of thing just feeds the idea that docs are out of touch at best.  (The people who would sign this are the kind who wouldn’t even think about it anyway, or are willing to lie to get the medical care they came for).  Really, this is as stupid as a Loyalty Oath.

Second, if I’m a patient and my doc handed me one of these, I’d laugh and walk out. I hope you will, too.

I have a hobby.

Writing about shooting is probably not going to broaden my audience (as this isn’t a shooting blog, I’m not an expert by any means so there’s no reason to consider what I write) and runs the risk of driving away a few readers.

OTOH, it’s my blog, and this is what interests me.  Also, there’s no HIPAA for shooting, so I can talk about it.

I’ve recently become interested in long-range shooting, have taken a long class, gotten myself a very nice setup, and done a little practice.  I do it for a lot of reasons: I like the precision and self-control required, there’s plenty of technology (more than I thought), feedback is immediate on the target, and I finally found a sport I can do lying down.

(I’m not a hunter.  Mostly because it doesn’t interest me, and I’m not hungry.  Should I miss a few meals, I’ll have no trouble becoming a hunter, and this training would come in handy.)

Speaking of training, I am fortunate to live fairly close to a high-end training center that specializes in just that.  I took one of their courses, bought a very much better rifle after the class, and did some training afterward, though not enough (dang job).  One of the best ways to see if you’re learning something is to compete, so off to a long range shootout yesterday.

The competition was quite well organized, well (and safely) run.  The competition was to shoot sporting clays, which were 120mm (4.7”), 90mm (3.5”) and 60mm (2.4”) orange targets.  From 400 yards.  Clays are fun to shoot as they usually break very nicely, visible through the rifle scope, so hit/miss is easily discernible.  Big=10 pts, medium=20, little=30, so relay max =150 points, with 5 relays in the competition.  Oh, and you get 8 minutes to fire a maximum of 10 shots per relay.

There was a sighting-in period, then the competition.  I had to move my firing position after sight-in, as my rifle has a muzzle brake (it reduces my felt recoil substantially: my rifle goes boom but doesn’t kick) but it blows air backwards.  This was showering the shooter next to me with dirt.  So moved, built a little barrier with a soft rifle case, and he’s good.

First frame I had the first-competition jitters: all these guys are better than me, and I haven’t actually practiced at this distance; there were a bunch of shooters who brought massive shooting benches from home, with clamps to hold their amazingly detailed rifles and their 40 power scopes in place, I’m shooting prone.

Before my first shot, my goal: be in the middle.  At the end of my 10 rounds, new goal: don’t be last.  Terrible shooting, just awful, and it’s all me.

Second frame: better, but left the two little ones; cleaned the third frame, and left one little one on 4&5.  I might make the middle!  As with most things, being comfortable makes all the difference.

There were 6 perfect scores, all bench shooters, and they had a one-shot shootoff; 48 shooters, I scored 550, for 16th place.  Upper third!  That’s encouraging, but the gunner in me now has to do better.  I enjoyed it, and exceeded my expectations quite a bit (especially with quite the inauspicious start).

Next: handloading!  Time to get the variation out of the ammo…

Many thanks to the Tarleton State High Power Rifle Team for pulling and resetting targets.  They did a quick and terrific job, helping the competition go as smoothly as I can imagine.

Report a bad doctor to the authorities, go to jail? : Respectful Insolence

Report a bad doctor to the authorities, go to jail? : Respectful Insolence

I just found out via one of the mailing lists I’m on of a very disturbing case in Kermit, Texas. Two nurses who were dismayed and disturbed by a physician peddling all manner of herbal supplements reported him to the authorities. Now, they are facing jail:

That’s appalling.  Read the excellent post (Orac’s a truly gifted, and prolific blogger), that points out the Texas Medical Board has made it clear the nurses did nothing wrong.

Astonishingly bad.  I’d echo one of the commenters in Orac’s post that these two nurses may soon be the richest people in Winkler County.

This blog has not been abandoned.

Please don’t tow it.  (What follows is just stream of consciousness crud to see if I remember how to type. It’s not interesting.  Go read Kevin, or Rob, or Kim).

Yes, I’m in quite the slump.  I’ve had several terrifically interesting, challenging cases recently, but they’re “So interesting” I cannot blog about them.  I cannot figure out a way to anonymize them to my satisfaction.

(I know my blogs’ in a slump, as today I only had one comment-spam attempt.  When even the spammers give up, you know it’s bad).

The irony is that I’m going to BlogWorld (where bloggers will congregate) and I’m in the worst blog-slump I’ve had.  And blogging about blogging is fully as interesting as this post.  You see my predicament.

As an aside, by youngest child, just left for college, texted me last night she was disappointed that I hadn’t done a blog post about her birthday, which was earlier this month.  It was a conscious decision, as just because I have a blog I try not to use my family for filler (unless they agree in advance).  So, nice to know she wouldn’t have minded much.

I’m having an interesting adjustment to the Empty Nest.  It’s only been a few weeks, but with just the two of us we’ve discovered how quiet the house really is (and that the cat squeaks when she walks.   Seriously).  So, I’m in an adjustment period, and this too shall pass.

A Mis-named diagnosis

“Welder’s burn” (ultraviolet-induced keratitis, i.e., sunburning the cornea) is mis named.

It should be named “welders’ helpers’ burn”.  I haven’t ever seen an actual welder with one, but have seen many new welders’ helpers with it.

Something for the numerologists

From @scanman on twitter:

Twice today the date & time will read 09.09.09 09:09.09 Won’t happen again this century.

Nice to know.  Set your alarms, and annoy people when it happens.

Well, phoo

I just took down a post in which I had a terrific metaphor for my main point.  I thought.

Unfortunately, my metaphor was wrong.  So, it made my point, well, less pointed.  So,  I’ll approach the idea from a different tack.

Thanks to reader Eric for the early heads-up.

Weirdest prescription?

From an old HS buddy (also a Navy Man) now in healthcare:

Texas law makes almost any item with a doctors prescription exempt from
sales tax.

(most details at : RULE §3.284 Drugs, Medicines, Medical Equipment, and
Devices (Tax Code §151.313) Item 11 is the sort of catch all.

What is most odd item you have been asked for a prescription for purely for
tax-free purposes?

Sellers of the Select Comfort beds, and hot tub/spa dealers are very aware
of this law. Presciption needed for bed, letter and presciption needed for
hot tub/spa.

Oddest request received at clinic where I work: one for in ground pool,
heated and deep enough for water aerobics.

While I don’t notice it on that list, food for helper animals is exempt
from sales tax.

Intersting also, repair parts for devices are exempt, but not
*improvements*. If you replace like for like wheel on a walker, it is tax
free. Replace with improved wheel-taxable.

I’ve never been asked to write a prescription for anything like that in the ED, but I’d be willing to bet my off0ce-based colleagues have.  Care to share?


First, a big thanks: over 10K comments here.  For a site with nothing to say, that’s a lot, and I appreciate it.

Second, I reactivated SpamKarma, so if you try to post a comment and it gets choked, let me know.

Texas okays partner treatment for STD’s without an exam

TMB Allows Expedited Partner Therapy

I hadn’t heard this, and think it’s a generally good idea.

Physicians now may treat the sex partners of patients diagnosed with chlamydia or gonorrhea without first examining the partner, thanks to an amendment adopted by the Texas Medical Board (TMB).

The amendment allowing expedited partner therapy took effect June 24.

TMB amended its rules to allow a physician to provide for a person with whom he or she does not have a "proper professional relationship … the prescription of drugs for a partner of a patient who may have a sexually transmitted disease."

The Texas Register notice of the amendment says TMB "determined that the amendment to the rule addresses a serious public health issue and is intended to allow physicians to treat persons with sexually transmitted diseases as early as possible or prevent such persons from contracting sexually transmitted diseases from their partners. The board finds that the amendment will allow for the immediate treatment of sexually transmitted diseases contracted by partners of patients and therefore remove a current peril to the public health, safety or welfare."

The Texas Department of State Health Services has developed a fact sheet [PDF] on expedited partner therapy.

This specifically excludes treatment of men who have sex with men due to their need to be tested for HIV, etc.

From a Public Health standpoint this makes sense.  I wonder about how to write a prescription for a partner, and documentation requirements surrounding that.  Double the Rx for the patient in front of me and tell them to share their pills like other things?  Get the partners’ name, and write a second Rx (which then has me potentially writing a prescription to a patient who’s allergic to the medication…).


Advice from the peanut gallery?