Lobsters of Medicine

I’ve never cooked lobsters but was reminded of the trick to the recipe today: if you try to put lobsters into boiling water you’ll have a big fight and it won’t go well, but put them in cool water and slowly turn up the heat, by the time they realize there’s a problem they’re cooked.

I thought about this while turning sideways between gurneys in the hall to get through to the next patient of many.

The temperature in my ED continues to climb, but I’ve been here so long it just seems like it’s getting a little warm.

ED’s everywhere have rising census, increasing demands, physical plants that aren’t keeping up with the crush.

Coal mines have canaries.  Medicine has lobsters.

It’s getting warm, but there’s plenty of time.


Texas College of Emergency Physicians

Texas College of Emergency Physicians has a new website, it’s good looking and easy to navigate.

They sent me a temporary login and temp password, so I went to fill in the information.  I didn’t finish.  Way too many ‘required’ fields in their registration section.  It’s really none of their business what hospital I’m practicing at, but I’d have to fill all of that in, with phone numbers and zip codes, to be an online member.

Not today.

The AMA’s statement to the President about Health Care Reform

Here’s a .pdf file of the statement, signed by the President of the AMA and several professional organizations and specialty boards.

It is well written and well intentioned.  It’s also just filled with the gobbledygook that comes from big groups that don’t get the problem.  It’s ideal from a big-group perspective, in that all but one or two of the goals is already underway, and the hardest one isn’t under their control (interoperable EMR’s).

As the letter is 3 1/2 pages long I could spend a lot of time analyzing every aspect (several of which I agree with), but I’m going to focus on the thing that jumped out at me.

…We are committed to creating a cultural transformation that better supports delivery of the highest quality care for individual patients and communities and which, among other strategies, will allow for a more appropriate allocation of finite resources.  These two elements are extremely important, and we hold ourselves accountable to achieve them.

Buzz-words: “cultural transformation” and “appropriate allocation of finite resources” are the two that make me cringe, but feel free to find your own.  What does ‘cultural transformation’ even mean?  There’s no vision for changing any culture in the document (it’s a nice list of goals to increase efficiency, but that’s not a ‘cultural transformation’).  It talks about being patient centered then talks about all the things medicine needs to do, and nothing about the patient.  It’s patently dumb to continue to see the self-contradictory statements ‘highest quality care for the individual’ and ‘appropriate allocation of finite resources’  jammed together unironically.  As a physician my duty is to my patient, not some theoretical need of another patient or patients with the same or different concerns.  The idea individual docs will act paternalistically about the husbanding of resources while engaging in a true beneficent relationship with their patient makes no sense (thanks, mandatory ethics class).

You know what would be a cultural transformation? Cost transparency in medicine, linked to patients spending their own money on their care*. It’s irrelevant what an MRI costs if you’re not paying for it directly.  Think there wouldn’t be some competition in the marketplace then?  Of course, to do that you’d have to get the government and insurance companies out of the way, let doctor groups negotiate just like every other industry, etc.  There’s a culture change.

Free=more.  There is no Nirvana where people get everything they want for free that doesn’t cause shortages and skyrocketing costs.  There has to be some moderator on the continuous and enormous increase in healthcare spending, a point everyone agrees on.  In the current model prices are invisible, payment is unfathomably byzantine and not borne directly by the patient (unless you’re uncovered, then you’re really in a tough spot), so there’s little reason not to get another MRI, CT ‘just to be sure’, etc.  Prices spiral.

So, give us a market, get Uncle out of the way (mostly), and let people decide on their care based on a true cost/benefit ratio.  There’s a real cultural transformation.

* Yes, I am aware most people with health insurance pay through payroll deductions, and it can be a very very big number; yes, you are paying for your care but in a very inefficient way, paying monthly and probably not using care monthly.  Additionally, what you’re paying usually isn’t the entire cost your employer pays.

DB’s Med Rants slurs EP’s

A doctor I used to think had it together shows himself to be yet another ED basher, and a rather arrogant one to boot.

In a blog post today Dr. Centor unloads egregious tripe on me and my colleagues:

The second major concern is over use of technology in the emergency department.  Ask any practicing physician about testing in the ED.  Patients have too many imaging studies.  I think we all understand why those studies are done, but a significant percentage are clearly unnecessary.

Now clearly, ER physicians have a high exposure to malpractice claims.  When in doubt, they image.  The emergency department is often overwhelmed with patients, so technology trumps the history and physical examination.  We need a multispecialty panel to develop reasonable standards for technology use in the ED.

In case you missed it I’ll rephrase: there are too many imaging tests in the ED because EP’s are too lazy or stupid to do a history and a physical exam, so we just CT everybody.  Additionally, EM isn’t an actual specialty, so other specialties need to meet and tell them what to do.

The contempt he (and apparently his friends) hold the ED in is inexplicable though sadly common.  I’d like to have him explain the patronizing ‘I think we all know why these studies are done’ that’s not doublespeak for ‘they aren’t as smart as we internists are’.

First the monetary rebuttal to this load: as of 2006, ED care was 3.5% of the total healthcare budget.  Squeeze out all the negative imaging studies and it’d be less, but getting a margin out of 3.5% to make a dent in total healthcare expenditures would be difficult to say the least.

EP’s image patients after a history, a physical examination, and in order to rule out life threats while still focusing on the most likely diagnosis.  The statement “when in doubt, they image” is both dismissively arrogant and ill informed.  Are there a large number of scans done in EDs?  Yes.  I’ve called Dr. Centor on this bias hobby horse of his before, but he doesn’t want to hear it.


As for needing ‘multispecialty panels to develop reasonable standards for imaging in the ED’, he’s ignoring two very important things.  First, EM is an actual specialty with its own standards and unique fund of knowledge, since 1979.  From ACEP:

In 1979 emergency medicine was recognized as the 23rd medical specialty, a major milestone for ACEP and its members. The American Board of Emergency Medicine, the independent certifying body for the specialty, was also established and the first certification exam was given in 1980.

Second, EP’s do the studies they do because they have a higher diagnostic yield in the shortest amount of time.  A urologist would prefer an IVP for that hematuria and flank pain, but the CT will pick up the renal artery dissection a lot better than the IVP ever will.  EM is past needing specialists telling us their worms’-eye-view imaging recommendations, thanks just the same. 


Dr. Centor’s proposals about the ED are unwarranted from an economic perspective and unfounded from the medical.  Let’s hope nobody offers him that Health Czar post, and that if there is such a person they focus on actual problems and not peeves. 

Hot Air » Blog Archive » What you get with a nanny state: A large, powerful nanny

Hot Air » Blog Archive » What you get with a nanny state: A large, powerful nanny

Do you still think that diet and exercise choices are no one else’s business? Not when other people pay your medical bills. If I have to pay for my neighbor’s doctor bills, I’m going to demand that he stops smoking, stops eating pizza five nights a week, and starts getting some exercise. If necessary, I’ll find a way to make him stop.

America: Land of the Free Medicine and the Home of the Brave Nanny.  And before you think ‘nobody would do that’ go to a homeowners’ association meeting,  wonder at the level of concern about grass length and fence height, then consider how these same people will like your Krispy Kremes.

Michael Yon – Online Magazine – Bullies

Michael Yon – Online Magazine: Border Bullies

Empowered bureaucratic bullies. We can, and certainly should, do better.


More on the California Good Samaritan debacle

Thanks to fellow medblogger Symtym I’ve read the decision in the execrable event blogged about yesterday.

Here’s the actual text of California’s Good Samaritan Law:

California Health And Safety Code Section 1799.102

No person who in good faith, and not for compensation,
renders emergency care at the scene of an emergency shall be liable
for any civil damages resulting from any act or omission.  The scene
of an emergency shall not include emergency departments and other
places where medical care is usually offered.

I have to tell you, that seems pretty straightforward to me. You help (not for profit), you’re covered.

Now, for the problem: the decision is here (.pdf file), and it exemplifies why normal people don’t trust lawyers.

Here’s the crux of their reasoning (page 2 of the ruling):

We hold that the Legislature intended for section 1799.102 to immunize from liability for civil damages any person who renders emergency medical care. Torti does not contend that she rendered emergency medical care and she may not, therefore, claim the immunity in section 1799.102. Accordingly, we affirm the judgment of the Court of Appeal.

Why do they believe that to be the correct reasoning?

One can infer from the location of section 1799.102 in the Emergency Medical Services division, as well as from the title of the act of which it is a part, that the Legislature intended for section 1799.102 to immunize the provision of emergency medical care at the scene of a medical emergency.

This is remarkably obtuse; where does health and safety legislation go, except into H&S legislation.  Thank goodness it wasn’t in a farm bill, else it’d only apply on farms.

To say I disagree with this interpretation (as a non-lawyer) is a bit of an understatement.  Read the whole decision to see the tortured logic involved.

I find myself in agreement with the dissent by Baxter J (at the bottom of the decision).  He’s supposedly a liberal activist judge, but no matter, he’s right on here.

Health and Safety Code section 1799.1021 states that “[n]o person who in good faith, and not for compensation, renders emergency care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission.” (Italics added.) Nothing in this clear statement limits or qualifies the kind of emergency aid — medical or nonmedical — that an uncompensated lay volunteer may provide without fear of legal reprisal from the person he or she tried to help.

He goes on to point out the absurdity of the majority decision:

Thus, in the majority’s view, a passerby who, at the risk of his or her own life, saves someone about to perish in a burning building can be sued for incidental injury caused in the rescue, but would be immune for harming the victim during the administration of cardiopulmonary resuscitation out on the sidewalk. A hiker can be sued if, far from other help, he or she causes a broken bone while lifting a fallen comrade up the face of a cliff to safety, but would be immune if, after waiting for another member of the party to effect the rescue, he or she set the broken bone incorrectly. One who dives into swirling waters to retrieve a drowning swimmer can be sued for incidental injury he or she causes while bringing the victim to shore, but is immune for harm he or she produces while thereafter trying to revive the victim.

The legislature wrote what it meant, in plain language.  The California Supreme Court says the plain language isn’t correct, that their intent was clearly different than that written.

Nothing good will come of this.  I can only hope the California Legislature doesn’t go broke before they can clarify their very plain language so even lawyers can understand it.

(The defendant is going to go to trial over whether her actions were negligent, which is pretty much unavoidable.  I’m told that she’ll probably win, as juries are made of more reasonable people than lawyers.  That doesn’t change the problem this decision will make for all society.)

California gets even more screwed up: predictably, Good Samaritans (Decent People) hardest hit

I cannot believe this is happening in a civilized society (even California):

California Supreme Court allows good Samaritans to be sued for nonmedical careLos Angeles Times

The ruling stems from a case in which a woman pulled a crash victim from a car ‘like a rag doll,’ allegedly aggravating a vertebrae injury.

By Carol J. Williams
December 19, 2008

Being a good Samaritan in California just got a little riskier.
The California Supreme Court ruled Thursday that a young woman who pulled a co-worker from a crashed vehicle isn’t immune from civil liability because the care she rendered wasn’t medical.

The divided high court appeared to signal that rescue efforts are the responsibility of trained professionals. It was also thought to be the first ruling by the court that someone who intervened in an accident in good faith could be sued.

This will have a chilling effect on all Good Samaritans, and not just in California.

In case you didn’t get the message, here’s a Professor of Constitutional and Bioethics Law at USC:

Noting that he would be reluctant himself to step in to aid a crash victim with potential spinal injuries, Shapiro said the court’s message was that emergency care "should be left to medical professionals."

(Also, fires should only be fought by Firemen, so be sure and let your neighbor’s house burn down; don’t keep the mugger from beating the old lady, law enforcement is for the Police only, etc).

Did this Professor of Law not think about the lives saved by CPR every year, and how this will be interpreted by them?  Bystander CPR, and the heroic actions of many a Good Samaritan, are endangered by decisions like this.  That trust in your fellow man, and a belief that government is run by reasonable people, is perishable.  This kind of ruling will kill it, for good.  Horrible.

Prepare to burn to death in your car as people drive by, unwilling to be victimized by a legal class without scruples and a society without morals

I sincerely hope there’s an appeal, to benefit at least good sense if not human decency.

via Life in Manch Vegas

Update: HotAir got the same message:

Hot Air -- get your fillThe court has sent a signal to the people of California: don’t get involved.  If someone’s drowning, don’t jump in the lake and save them.  If someone’s trapped in a car that’s about to explode, sit there and watch the show.  Just make a phone call, and who cares that it might be several minutes before an EMS team can make it to the scene?  If you sit on your hands, no one can sue you for all you’re worth.

Predictably, their post is better than mine, making the same points and others, so make sure you read it all.

Primary Care Funding Increase: a rant and a reply

Dr. Glauser at EMNews vents his spleen a bit about a general feeling that Primary Care needs more funding:

bannerSay what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.

This did not pass unnoticed by an excellent primary care blogger, Dr. Rob at Musings of a Distractible Mind:

This guy is not arguing, he is ranting.  Why?  My suspicion is that he sees the fact that increased reimbursement for primary care physicians means potentially decreased reimbursement for emergency physicians.  That does not mean you shouldn’t trust his arguments – he could use the same against me.

Read them both, and join the argument.  I’m for paying primary care better, because they need some more flexibility (though I have my concerns, too).

BBC NEWS | Asia-Pacific | Chinese girl gets ‘kiss of deaf’

BBC NEWS | Asia-Pacific | Chinese girl gets ‘kiss of deaf’
“While kissing is normally very safe, doctors advise people to proceed with caution,” wrote the China Daily.

Another reason normal people think docs are stupid.  Look at that quote.  Dumb.

PalmPistol is now an FDA recognized medical device

via Medgadget I was made aware of the PalmPistol, a single-shot 9mm weapon apparently intended for contact-wound distance self defense.  One of their marketing focuses is for the disabled, with amputations, arthritis, etc.

Images from the PalmPistol website.

The trigger is on the top and is thumb-activated, and I’ve got to assume the buttons in the front have to be depressed as a safety, which seems like it’d be hard to use unless you’ve got a decent grip, a thumb and at least two fingers.  How that’d make it easier to use for people with hand problems I don’t know.  I think a derringer type pistol would do the same thing, but Medicare won’t pay for a Derringer (and I sincerely hope they don’t start paying for this).

I also don’t know of any other firearm that’s been approved as a medical device (but I don’t follow that, either).  It is ATF recognized as a firearm, so it’s got the same restrictions on ownership, transportation and prohibited facilities as any other firearm.

There is a market for this sort of thing.  I would bet the disabled and frail are targeted by our permanent criminal class, and they should be able to use any legal means of self-defense available.  If the look of a conventional firearm drives them away, maybe this will help.

I won’t be writing any prescriptions for one, however.  When used the prescriber is going to get a brush with an attorney (especially if used in a suicide); doctor, did you screen the patient formally for homicidal or suicidal tendencies?  Did you make sure they knew how to use it properly?  Fill in your second-guessing here.

So, interesting marketing.  Best of luck with it.

Wealthy Corporate Beggars and Congressional Hypocrites

Political post, feel free to skip.

The CEO’s of the Big 3 automakers went hat in hand before Congress to plead for unearned taxpayer dollars to continue their operations.  Apparently their plan was ‘give us 25Bn and we’ll see that it’s spent properly’.  As a business proposition that seems lacking, and thy were sent away empty handed.  Good.

But there was a bit of hypocritical theater by some goofy congressman, a ‘show of hands of those that came here on a biz jet’ or somesuch.  Of course, these CEO’s all make a heck of a lot of money and haven’t flown commercial since they were Senior VP’s.  This is common in the world of the Big Money CEO’s, and was a spectacularly tone-deaf thing to do when pleading for other peoples’ money as a handout.

Yet, the hypocrisy award goes to a congress which yearly racks up Trillion dollar deficits hectoring business owners for flying corporate jets.  I’d have given a lot of money to have one of the Big 3 CEOs ask “Congressmen, I’d like to see a show of hands of those who rode the bus to work, given the terrific job you’ve done of generating massive budget deficits”.

I can dream.

Great moments in bad customer service: DirecTV Style

Life’s been good to me, and today I wanted to upgrade two of my regular DirecTV boxes to HD boxes.  So, a call to customer service to get a couple.

(I had tried to do this online, but stopped when it wanted to charge me for an HD installation, which I already had: that should have told me the legendary DirecTV customer service was slipping).

The phone call started fine, through the phone tree that has very good voice recognition, and within a few minutes I was talking to a nice rep who knew her stuff.  She was unfailingly polite and professional throughout; this isn’t about an individuals’ poor service, it’s about a company that’s setting policies designed to drive away customers.

me: I’d like to upgrade two of my DirecTV receivers to HD, please
dtv: I’d be glad to help you with that.  Oh, I see you ordered an HD receiver last December, so I can only give you one.
me: Why’s that?
dtv: You can only order 2 in a year.
me: Why would that be?  I’ve never heard of a company that didn’t want business…odd.
dtv: It’s just the policy.  (appropriately business-polite expression of sorrow).
dtv: I can have an installer come out (second week of November) to do an installation.
me: Installation?  We’re swapping boxes.  I’m going to unplug one and plug in the replacement.  I really don’t need an installation.
dtv: It’s a no-charge installation.
me: It’s not about the charge, it about waiting two weeks for someone to swap a set-top box.
dtv: Your account isn’t able to have a drop-ship.  (Apologies again).
me: Well, let’s cancel this order while I decide whether to keep this service.
dtv: (in that ‘let me see if I can fix this’ voice’) Hang on just a second.
me: Ok
three minutes on hold here…
me: What are we waiting on?
dtv: I’m canceling your order.
me: You need me to stay on the phone to cancel my order?
dtv: Yes.  If you hang up your account information goes off my screen.
me: You’re kidding?
dtv: No sir.

I’d like to reiterate this isn’t the phone-persons’ doing (unless she really really misunderstands several policies, which I doubt), it’s about a company that has made some really bad choices about equipment, and set up some terrible customer service interaction software for their personnel.

I’ve got an email out the the good people at Weaknees for the same boxes (whom I should have turned to first anyway), so we’ll see.

Update: Weaknees sold me two, and assures me by email (after hours) that they’ll be activated without a problem. I suspect that’s the case. (They hadn’t heard of a limit on receiver numbers, either).

The Happy Hospitalist: What Kind Of Patient Are You?

The Happy Hospitalist: What Kind Of Patient Are You?
So I ask the question, what type of patient are you? Are you contributing to the demise of the third party model so ingrained in our current culture. A third party model whose cost structure has risen exponentially due to rapidly rising costs on the few. A third party model who must pass on to others the costs of a few. The following is my breakdown of America’s patients, as seen from the door of the hospital room. What kind of patient are you?

Happy’s on a roll. Excellent summation.

We’re All Dead … « WhiteCoat Rants

We’re All Dead … « WhiteCoat Rants
If you believe Michael Cannon’s article “Universal Coverage Kills” at the National Review Online.

It amuses me when people possessing little knowledge of the inner workings of the practice of medicine write articles as if they are “in the know.” Mr. Cannon’s article is one such work.

Nice rant, on point and on target.