A polite suggestion to the makers of uninterruptible power supplies (UPSs) everywhere

Dear UPS makers,
Thank you for making some really excellent products. My home has products of varying sizes made by several of your manufacturing colleagues, and they generally do a terrific job of protecting my sensitive electronics from the occasional power flicker.

I write, however, to ask you very nicely to QUIT with the dang BEEPING NOISES in your otherwise useful devices. The power has been out in my palatial abode for nearly three hours now, and I’d get some sleep were it not for the incessant hooting from self important UPS gadgets.

Yes, we know the powers’ out. The loss of the fans, AC, and lights was quite enough a clue. No need to rub in our “lives in the stix” factor. No need for inanimate devices to keep us awake telling us “hey, the power is still off”.

Nobody wants, or needs, these alarms. They were sold to you by the Vast Alarm Conspiracy. Done alarming every single thing in the hospital they went to you: flattered, you bought into their “your products’ intended function deserves attention” mantra. You were lead astray, I tell you.

I implore you, as a man losing sleep while ranting into an iPhone, Stop It. Stop with the alarms.

Thank you, and a quiet good night, from everyone someday,


Kevin, M.D. – Medical Weblog: The Happy Hospitalist: All for one and none for all

Kevin, M.D. – Medical Weblog: The Happy Hospitalist: All for one and none for all
The Happy Hospitalist: All for one and none for all
The following is a reader take by The Happy Hospitalist.

All for one and none for all. That is the state of the current government program called Medicare. The entitlement program that threatens the financial security of our nation. On March 25, 2008 the Boards of Trustees released their Annual Report of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. In this 43rd edition, the Trustees note a government program covering just over 44 million people at an expense of $425 billion dollars during 2007. That equates to approximately $10,000 per beneficiary.

The Medicare Crisis has the potential to kill this economy, and something has to give.  Read the whole article: it’s well written, it’s a good prescription to avoid the oncoming disaster train, and there’s essentially no way it’s going to happen.

Too bad.  We’re all going to pay for this, literally and figuratively.

HHS Secretary Pats Self on Back for Having a Blog

As quoted in Congressional Quarterly:

The ever-evolving blogosphere is now helping to shape the health policy debate by allowing more interaction between the public and policy makers, said Department of Health and Human Services (HHS) Secretary Michael O. Leavitt , a blogger himself.

Leavitt, who launched his blog on the HHS Web site in August 2007, said his entries follow a range of topics, from day-to-day experiences, to his thoughts and decisions surrounding health care issues and policies.

People can post comments on his blog, which Leavitt said has provided valuable information.

“There have been times when someone has made an argument to me that I found compelling that I am sure began to mold and shape my thinking,” he said during a Kaiser Family Foundation event Tuesday.

Blogging can be a “very powerful engine for public policy setting,” he added, citing a recent HHS blog established to advance a summit on pandemic flu. He said the pandemic flu blog was a “wild success” in terms of being able to communicate with active “flubies” on the issue.

Note, this appointed Bureaucrats’ evidence of the power of medical blogging is that he has a blog and that people can leave comments.  That’s laughable on its face, and the hubris underlying is truly impressive.

Any evidence he’s read any other medical blog?  No.  None.

This is unimpressive by any standard.  Emarrasing, really.

amanzimtoti: Third world aid

amanzimtoti: Third world aid
Third world aid
We recently had an American delegation from PEPFAR (the United States President’s emergency plan for AIDS relieve) visit our clinic. I didn’t stick around for the circus because preceding the visit a list of demands was given to the clinical manager. Now PEPFAR isn’t even one of our major sponsors – from what I understand the money they’ve given us was just enough to put up some shelves in our pharmacy. Don’t get me wrong, we’re grateful for any donations, but if you’re going to give money for a worthy cause, you should do it out of the goodness of your heart, not so you can make them jump through hoops for you.

Ugly Americans.

Black Box Warnings now Officially Useless

FDA to Add Warning to Antibiotics – WSJ.com
July 9, 2008; Page B7

WASHINGTON — The U.S. Food and Drug Administration will seek to add strong warnings about the risks of tendon rupture associated with a class of antibiotics used to treat bacterial infections.

The FDA wants to add black-box warnings, the strongest warning the agency issues, to a handful of drugs, including Bayer AG’s Cipro and Johnson & Johnson’s Levaquin. The move comes six months after the consumer group Public Citizen sued the FDA to require the agency to add black-box warnings to the drugs.

Serious reports of tendonitis and tendon rupture continue to increase with use of the drugs, prompting the FDA to ask companies to add the stronger warnings, the FDA said in a posting on its Web site Tuesday. Such ruptures most frequently involves the Achilles tendon, but also include ruptures of the shoulder, hand, biceps, and thumbs.
(emphasis mine)

Black box warnings used to be for very serious, life-threatening problems in drugs.  Now tendonitis and tendon rupture are life threats, or are so serious they warrant a Black Box?  The elevation of known, well-documented drug side effects to Black Box status dilutes its meaning, and will ultimately require the formation of a new class of warnings.

Tendon ruptures aren’t benign.  Neither are infections.  Name me an antibiotic that wouldn’t rate a black box under the criteria used on the flouroquinolones, then wonder at what’s happened to the FDA.

Dr. Schwab, ER Bloggers, and Conservatism

Alerted by Kevin, MD today, I find that Dr. Schwab (Surgeonsblog) has decided to label ER Blogs, and bloggers as mindlessly conservative, and apparently unenlightened.  (Oh, plenty of disclaimers are sprinkled throughout, so you know he’s not actually talking about anyone, just everyone).

First thoughts: somewhwere Shadwofax has his lower lip stuck out just a bit, and this might be what made Graham pack it in.


So.  Fisking is what I seem to do best in these situations, so I shall.

… And yet. Reading some ER blogs — not all, and by no means all the time — I find the vitriol off-putting. The derision. And the take-no-prisoners attitude — the downright hatred, so it often seems — toward “liberals,” suffused throughout. (Not to mention a similar attitude, quite often, toward their own clientele). I love political give-and-take; most of my work-colleagues politicked far to my right, yet we had enlightening and stimulating, good-hearted arguments. But reading some ER blogs, unlike any other category in the healthosphere, is like listening to Rush Limbaugh or Ann Coulter. It’s a polemicist’s playground.

Well, that’s rich.  I so tired of the lockstep leftist blather on Dr. Schwabs’ blog I eventually just stopped reading it.  A polemicists’ playground?  Read the sentence preceding that one, and see if you can find the disconnect.


In case you’re ever wondering if a blog writer is a fevered leftist, just wait for the following to appear in a blog post:

I’ve had my moments of moral muttering, liberally laced with haughty holiness. I consider George Bush the worst president we’ve ever had (and no, Mr. Bush, history will not vindicate you). But I’ve never called him “a bucket of spit.”

It’ll show up, appropos of nothing whatsoever.  They think it’s normal to interject their BDS into everyday life and any blog post.  Really.  It’s astonishing.

Nor do I kiss off all conservatives as some sort of existential threat. (Some, of course. But not the whole group.) Physicians are, in general, a conservative bunch. But they’re also educated; enough, you’d think, to have left their minds at least slightly ajar.

I have an open mind, but to paraphrase, not so open that my brains fell out.  I am reasonably well educated, I take my time making decisions when I have the time, and have come to the conclusion that the government isn’t the answer to every problem.  My personal politics skew more libertarian, but here’s the thing: NOBODY CARES what I think politically.  That’s why, excepting politics about medicine, I leave it out.

His ending:

Maybe it’s an inevitable corollary: working in an ER turns people. Another possibility: people who lean loudest to the right are the ones who choose the job in the first place. Or perhaps (with a couple of exceptions) it’s just that the rightward ER docs blog, and the leftward ones go home and tie-dye.

Get it?  If you’re conservative, you’re “turned”.  Perhaps some introspection and insight are needed on the part of the blogger.

Another thing I find amusing

CNN has used this graphic before, and though it bugged me, I let it go.  Since I have a blog and nothing to say, I’ll point it out so it’ll bug you, too.

This graphc:
reverse Lead II

The EKG tracing in the photo is backward (meaning it reads incorrectly from left to right, which is the convention).  There’s nothing particularly interesting about it, but it’s backward, and it gets my (unpleasant) attention every time.

So, CNN, I’ll be glad to review your medical graphics, for an entirely reasonable fee. Or get someone else to do it, but please do so.

Brand new federal requirement: NPI needs to match IRS data

Really, it’s like they don’t want docs to use the Government system…

Brand new federal requirement: NPI needs to match IRS data
Brand new federal requirement: NPI needs to match IRS data
Healthcare IT News
By Diana Manos, Senior Editor

WASHINGTON – Just when doctors thought things couldn’t get much worse, experts say, the Centers for Medicare & Medicaid Services has thrown another wrench into the already difficult transition to using National Provider Identifiers.

According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.

I read to there, and thought, ‘well, that’s not entirely unreasonable’.  What an idiot I am.

According to billing experts, this is a disaster waiting to happen. Every aspect of the data must match, including the exact spelling of names, the use of initials and even blank spaces in the data. The slightest discrepancy could send Medicare claims back to the drawing board.

Aah.  So, Medicare issues a NPI, which isn’t checked against the IRS name, then retroactively and apparently without notice announces they’re not going to pay for work already done in good faith, over yet another clerical gotcha, in which they were complicit.  Breathtaking, the hubris.

After a year-long contingency period, the use of NPIs was required by CMS as of May 23. Both before and since that deadline, doctors have had difficulty getting paid due to a host of complications with CMS and clearinghouse systems, experts say.

Cyndee Weston, executive director of the American Medical Billing Association, said the IRS matching requirement “has blindsided the whole industry.”

I might actually join the AMA if they said ‘no more’ to this crap.  Unfortunately, I suspect they’ll hold their hat in their hands, appoint a commission, and say pretty please.

Bait & Switch.  They’d never dare pull this crap on lawyers.

The humor behind health care reform – Medical Economics

Dr. Leap is getting even more famous!

The humor behind health care reform – This doctor’s tongue-in-cheek rallying cry is steeped in undeniable truth. – Medical Economics

I was buried in a sea of charts when a colleague joined me in the physicians’ lounge. We joked about our frustrations with paperwork and patients, while somberly agreeing that medicine’s in a bad way and physicians are more and more dissatisfied.

At the same time, we recognized that many of our problems are self-induced, stemming from doctors’ tendency to ignore fundamental truths. So I set out to compile a list of what we need to remember—truths that often go unnoticed while physicians utter empty words about professionalism, duty, and healing.

The Protestant Reformation began with Martin Luther’s theses. I’m not Luther, and my “undeniable truths” may not be nailed to a church door. But they could be the stirrings of a healthcare reformation.


Go, read, and comprehend!

Transfers due to Incompetence

Recently, I and my colleagues have taken a lot of transfer calls that have, as their basis, professional incompetence.  Allow me to explain, and then to ask a question.

We’ll get a call from an ER doc with a patient who’s stuck in the middle of a situation: their ED patient has an emergency requiring specialty treatment, they have a specialist in said speciality, but said specialist ‘doesn’t feel comfortable / hasn’t done in years’ the procedure the patient needs, so we’re called to get the patient to a specialist that’ll take care of them.

As a description I’ll tell one bowdlerized tale to give the flavor: patient with an open femur fracture.  Sending hospital does have an orthopedist on call, but “s/he only does spines, and they doesn’t feel comfortable doing this”.  (This happens with virtually all specialties, I’m not singling out ortho, just using them as an illustration of a general problem).

So, yes, medically we can take care of this patient, and medically we accept the transfer; when I talk to admin, I make sure they know all the facts, and then I make sure we do the right thing for that patient, and that’s to bring them to us.

Here’s my question: besides an EMTALA complaint (which the hospital reportedly files a lot of, and reportedly come to nothing), is it time to start reporting this level of professed incompetence to certifying boards?  I would presume a Boarded Orthopedist would be able to take care of an open femur fracture as part of both routine training and certification (and I’d bet they’re credentialed for that procedure at their hospital); if they then profess incompetence in caring for that injury, wouldn’t their certifying board like to know?

What say you, physicians?  Report, yea or nay, and if not, why not?

The wreck of the good ship, EMTALA at edwinleap.com

The wreck of the good ship, EMTALA at edwinleap.com
EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986. For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons. Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath. It is, in fact, one of the largest unfunded mandates the US legislative branch has ever gifted on its subjects.

Dr. Leap, speaking the Truth.  Read it.

An engineer’s guide to cats

Hat tip: Black Triangle » Blog Archive » An engineer’s guide to cats

WSJ Health Blog : Report: U.S. Wastes More Than Half of Health Spending

Health Blog : Report: U.S. Wastes More Than Half of Health Spending
Health care isn’t exactly known for its efficiency, but a new analysis from PricewaterhouseCoopers puts the value of the waste sloshing around in the system at a whopping $1.2 trillion a year.

That’s right. Trillion–with a T. The findings of the firm’s Health Research Institute suggest that up to that much “wasteful spending” could be going on, more than half the $2.2 trillion spent on health care in this country.

PwC arrived at that estimate by pulling together a lot of previous research and performing its own analysis. Still, the particulars are a bit vague, with some large ranges.

A lot of the waste is attributed to some favorite bugaboos of efficiency advocates, including ineffective use of information technology ($81-$88 billion), claims processing, ($21-$210 billion) and defensive medicine ($210 billion). Medical errors cost $17 billion and badly-managed diabetes is tied to $22 billion.

Frankly, I’m surprised the ‘defensive medicine’ slice isn’t higher. Read their blog entry for the rest of the story.

From my worm’s eye view of the health system there’s absolutely no reason for me, as an individual physician, to try to decrease healthcare spending. Oh, I’ll make it a point to prescribe generics whenever possible, I’ll gently try to talk people out of xrays they don’t need but want, but that’s about it. There are very powerful forces aligned to prevent anyone or anything from denying even the most futile or insane healthcare spending.

The Ottawa Ankle Rules are but one example. Every ED sees patients with ankle sprains, and some need xrays (but up to 35% don’t, at least in Canada). When I was with the USMC, where I could tell patients ‘no, you don’t need an xray, you have a sprain’ I taught and applied the Ottawa Ankle Rules, and was reasonably proud I wasn’t sending a constant stream of sprained ankles to the xray department for normal xrays to be taken. I mentioned this effort to one of the ED physicians at the base Naval Hospital once, and his response surprised me: “Please don’t do that. When they are off duty they come down here to get an xray of their ankle”. So, applied science and physical exam, with an explanation (I had a lot of time per patient then, and very little equipment) didn’t do it, they went around the system to get an xray. Whay? Because they wanted an xray. There’s an addiction to tests and tech in US medicine (on both sides of the equations, I’ll grant), and it’s not healthy for the patients or the pocketbook.

Nobody I know in the US even tries to apply the Ottawa Ankle Rules in civilian hospitals. Refuse to do an unindicated test? Are you bananas? The patient will insist on “Talking to your boss”, will call the patient advocates’ office, etc, and the incentives are very clear: just order the test, no matter the lack of utility.

Fortuantely organized medicine has stopped sending the message that physicians need to be the gatekeepers of healthcare spending, since there is no backup for those doctors and decisions that would do just that: deny useless tests and futile care. Ask the HMO’s how their rationing care to try to prevent escalations in cost (and save money on their healthcare on the cheap model) went over with the public, the same public that was supposedly aware that for a lower cost they were going to have to have less control over the “I want it all, now” healthcare that’s the norm in this country.

The current system is a prescription for indulgence and waste on a colossal scale. The only way to reign in the explosion of spending in this country is rationing of some sort: Free markets will ration based on ability to pay; single payor will ration based on refusal to pay and a blizzard of paperwork for everything. There is no free lunch, and we’re spending money we don’t have on tests and treatments we don’t need.

We have met the enemy, and he is us*.

Update: About the PWC report; I’ve read it, and am underwhelmed. Here’s the methodology (page 3 of the report):

About the research
As part of its preparation for the 180º Health Forum, PricewaterhouseCoopers’
Health Research Institute (HRI) interviewed more than 20 health industry and
government executives who will be participating in the forum sessions. The
forum is dedicated to change in healthcare. Reviewing the waste in health
spending was viewed as an appropriate starting place for discussing how to
restructure incentives, investments and priorities. In addition to interviews,
HRI reviewed more than 35 studies about waste and inefficiency in healthcare
and commissioned a survey of 1,000 U.S. consumers to get their views on
what constitutes waste and inefficiency in the system.

So, it’s a series of opinions with very nice graphs. As documentation of conventional wisdom it’s first rate; as a scientific critique, less so.

Pilot’s gun discharges on US Airways flight

Pilot’s gun discharges on US Airways flight 12:14 PM | Local News | News for Charlotte, North Carolina | WCNC.com | Top Stories

CHARLOTTE, N.C.– A gun carried by a US Airways pilot accidentally discharged during a flight from Denver to Charlotte Saturday, according to a statement released by the airline.

First, I’m betting they had to take the plane out of service to clean up the cockpit.

Accidental discharges (mistakes in weapons handling and safety) (which is not “the gun just went off”: that doesn’t occur) happen eventually to everyone who handles weapons enough. The very very experienced range masters where I go will confess to accidental discharges, and do so to educate how their mistakes occurred and the lessons they learned. (These lessons invariably wind up being ‘get your finger off the trigger, and don’t let yourself get distracted’).

Most AD’s are non-events in the permanent-damage category, though I can certainly see how the cockpit of an aircraft would provide dozens of chances at a bad outcome. I wonder if the TSA and the airlines have a procedure that covers this? Probably it is ‘land safely, let’s talk about it on the ground’.

I was aware of the cockpit armed pilot program (or whatever its Orwellian name is), and thought it a good idea. Given the frequency of AD’s I still think it’s a good idea, but confess I hadn’t given weapons handling accidents much thought. Now I will, and here’s something else to get the flying public a little more anxious.

Update: Pilot suspended, from the armed flight deck officer program, and from fight status.

When Nations Act Like Adolescents

I read this on CNN:

Russian bomber buzzes U.S. aircraft carrier – CNN.com

WASHINGTON (CNN) — American fighter jets intercepted two Russian bombers, one of which buzzed a U.S. aircraft carrier in the western Pacific over the weekend, U.S. military officials told CNN Monday.

One of them twice flew about 2,000 feet over the deck of the USS Nimitz Saturday while another flew about 50 miles away, officials said. Two others were at least 100 miles away, the military reported.

U.S. Defense officials said four F/A-18A fighter jets from the Nimitz were in the air.

The Russians and the U.S. cartrier did not exchange verbal communications.

First, they’re Bears, and turboprops aren’t pure jets. CNN should know better, but apparently don’t.  This isn’t the first time they’ve gotten something basic wrong.

Second, on reading this, it strikes me this is very much like kids taunting adults, sure in the knowledge that adults will act with restraint while they ‘show the man’ their power.  If the Russians thought for a second we’d shoot them down they wouldn’t take such a deliberately provocative action, but a) they’re impotent, know it, and it bugs the heck out of them and b) they can count on the US ‘adults’ to not shoot them down for acting out.  Restraint is the hallmark of the modern warrior, popular opinion to the contrary.

Impotence and strength aren’t always what they seem at first glance.