Sideline Money, Sideline Docs.

Talk to an investment guy, talk to a real estate gal, talk to a banker and you will hear that there's scads of money 'on the sidelines' pending the election. Conventional wisdom amongst most of the money folks is that a Romney win will be a quick and clear signal for people to invest again in the private sector. I hope it's true. It feels true.

But there is something no one is talking about, and that's the 'sideline doctors'. Every single physician in this country is watching this election with keen interest. For many it will be the deciding factor in whether they practice to retirement or they retire early and cut back on work  (under Obamacare).

Academic physicians are the only ones I have met who are consistently FOR Obamacare. The ones who will be honest with me are scary statists, and I would dearly love to punch them in the nose. It is, I think, the only thing they would understand.

So just like with investments, real estate, and finance in general, medicine also has TONS of it's resources now 'on the sidelines'. Hard to plan for the future when you don't know what the rules will be. Hard to start a practice, much less build one, when you aren't sure what Obamacare will mean to your bottom line. Hard to commit to the hardest profession in the world when it might mean that you work for a government flunkie (with a G.E.D.) reading from a manual, and lecturing you about compassion and diversity. Again, punching in the face seems one's only option here and doctors are averse, as a rule, to going to re-education camps.

In all seriousness. If Romney wins and Obamacare is scrapped then I predict the following.

1. The impending doctor shortage will be averted by physicians choosing to continue practice, or return to practice. Also, applications to medical schools will boom.
2. Research and development of new treatments and drugs will take off.
3. Many who are now choosing to become Physician Assistants may reconsider and go to medical school.
4. The left will have a seizure.

Because of # 4 above and because there is a large portion (20% ?) of citizens and illegal aliens who will continue to favor beer, cigarettes, and cell phones over health insurance,  I think Romney will have to replace it with something.

But that something, while it will no doubt have it's problems, will not turn the great American health care system into the N.H.S., or Brazil.

Go Mitt

Scooping the New York Times

It used to be that scooping the New York Times by a few hours would make your career. Now scooping them by years means Jack-squat. It used to be that promising what you knew you couldn't deliver was political suicide. Let's hope it still is.

Who knew it took ten years to train a doctor? Who knew becoming a doctor was a daunting, expensive, and often thankless task? Who knew EMTALA and Obamacare would wreck our system? Hint!!! Not the New York Times. 

And Paul Krugman is still a pantywaist shill.

Supreme Obamacare Eve (Blast from the past)

Witness the genius of Obamacare. A repost from 2009.

Government Health Care Update

The official wait time in my region for bilateral total hip arthroplasty at the VA is one year. Bone on bone, walking with a walker, end stage arthritis. One year. Seems like the VA has surpassed both Canada and the UK in a very short period of time. The rest of us to follow shortly. Yay!

D.F.A.S. and the Nine Cirlces of Hell

A tribute to DFAS. One of the most efficient and excellent government agencies to ever come down the pike. Some say they have passed even the DMV in their excellence.

This is a love letter to you DFAS. I love the process. I love how you have managed to have computers make decisions for you! Skynet is definitely aware (to hear you tell it). Wow, I didn't know we could do that yet!

And I love it, absolutely LOVE IT that the pay mistake was my fault. I can't figure it out yet, but I'm working on it... I don't pretend to operate on your level of superhuman logic.... but one must try. Hell, I can't do Calculus, but at one point I could do a little of it....

I am also pleased that you have decided to dock my pay in accordance with the money I stole from the government. Every paycheck a different number. What are you trying to tell me? I can't figure it out, but when I do I expect a moment of clarity, an epiphany even, that will, no doubt, change my life.

As a result of this process which is, evidently, still ongoing, and has taken ten months to this point, I have become a more dedicated worker for you. I am going to start paying lots more attention to process and to systems for they never fail. And human reason, well, we all know what happens when that is let out of it's cage. My charts are going to reflect my newfound love of process... just you watch DFAS!! I SWEAR!

And, since this wonderful learning opportunity started for me, I have become much more interested in organizational charts, and, I do believe, I have found the master chart created by Dear Leader which shows exactly you fit into the wonderfully wonderfully wonderful government. I would come personally to your underground bunker (wherever it is) and hug you all for this lesson that I have received. It is definitely worth every bit of the fifteen thousand dollars. How could I put a price on the kind of wisdom YOU have granted me??

So I must ask you D.F.A.S., did I pull the correct organizational chart? The one under my signature? I think I see you guys squarely in circle eight. Keep up with what you are doing and I have no doubt you can move down quickly.

Forever loyal, forever yours, forever grateful. And if you are looking for new employees might I suggest looking up a certain 'CannedAm', she, no offense intended, could run your entire agency right now.

Your Humble Servant,
Drone

"Buck" and Modern Medicine

Buck Branaman  is a genius. And the movie "Buck" is worth watching over and over. It's a movie in which you will meet a man like many who chose medicine WANTED to become. Mr. Branaman is one of the worldwide experts in horse-training and he's much more than that, he's probably the best human psychologist I've seen in a long time.

Now the thought struck me while watching one particular part of the film that Mr. Branaman would have quit his profession long ago were it not for the fact that people who seek his services do not compose a huge voting block and, as far as I can tell, pay him for what he does. Some actually save money for years to go to his clinics. Wow.

I can picture the moment when the government decides that all horses have a right to Buck Branaman's time and expertise, pass laws about how he may go about delivering his service,s and how he may be reimbursed. It's going to be the same day that he retires. I mean the way he treats the owner of the renegade Stud-Colt at toward the end of the film is not only a HIPAA violation, it is very POOR customer service, will generate a complaint, and the poor woman's money will have to be refunded.

EXCEPT... EXCEPT!!! The woman herself was grateful for the upbraiding she received and said, after, and through some tears, "He's right.... he's right.... I do have problems I need to fix and the horse is only one of them."

So I'm picturing myself saying something similar in the ER, "No sir, I am not refilling your pain medicines, you have problems which you are covering up by taking them and you are lying to me in order to try to get them from me, now, I can either call the cops on you right now, or I can help you find the help you need, but I am NOT refilling your narcotics."

For me, another job lost. But, thankfully, not for Buck Branaman.... not yet at least. Sometime after EHTALA is passed by congress.

Amazing Discovery

Working on the periphery of a military hospital has been wonderful. I have been able to hide very well, and, at the same time, have been able to do some good medicine (a lot of ortho stuff, derm, and some infectious disease) pretty much on my own. Folks tell me I'm doing a good job so I'll believe them. But it has been nothing short of revelatory to have to deal with the docs they have staffing their "ER". Most are civilian contractors and most of them either don't care, or are incompetent, or both.

Example: patient with chest pain, abnomal EKG, and blood pressure of 190/110. Discharged home after initial set of markers negative.

Example: patient with high fever, headache, neck stiffness. Discharged to follow up in clinic after shot of toradol and CBC.

Example: patient with shoulder pain, pulsatile in nature (absent injury) and pain radiating to hand. Discharged to follow up after shot of toradol.

Patient one ended up getting stented three days later, luckily, without infarcting. Patient two had, drum-roll, meningitits. It was viral. He lived.

Patient three has a tumor in his axilla. He will probably live for a while. It took us a month to get the MRI that diagnosed him.

Lovin' me some government health care. Hopefully I'm one of the good guys in a very crappy system. So here's the amazing discovery... in a system which is highly regulated and top heavy with administrative lackeys the care delivered tends to be, well, a piece of shit. This came as a great shock to me as it will to you I'm sure.

This isn't Russia is it?

Congratulations Tennessee. Your state government, "TennCare" specifically, has just invited a large portion of it's board certified Emergency Physicians to pull chocks for greener pastures. You see, TennCare, doomed from the start on the principle that the problem with socialism is that eventually you run out of other people's money, has now run out of other people's money (for the Nth time), and is now coming to take more money from the doctors providing care.

With the stroke of a pen, legislators have defined out of the "emergency medical condition category" about 2,000 medical diagnoses (like tuberculosis)... They have been kind enough to write these conditions down so we will know ahead of time that we will be reimbursed $25 if we diagnose a patient with one of these conditions. The document is 220 pages of single-spaced, small-font SHIT.

This article laments that many providers will simply stop seeing TennCare patients. No doubt they will. But in the ER, and at the one where I occasionally guest-star... There is no option to stop seeing TennCare patients. It would abrogate federal law under EMTALA... And you try turning the "non-emergency" cases away... You better be 100% right pal or you are going to jail, or court, or both.

And once again, nowhere in the debate, is there ANY discussion about what recipients of their neighbor's largesse need to do to DESERVE this entitlement. What's that? They are deserving because they are disabled, poor, old, infirm, or unemployed? Okay, and how many TennCare patients, each year, are able to improve their circumstances enough to come off TennCare? What incentive is their for them to do so? None? So you kick of the kid with cerebral palsy because he's costing TennCare too much money? Wonder if the TennCare administrators are making some
sweet jack... My bet is yes, they are, and they all talk and talk and talk, but they don't do CPR.

I tell you who IS incentivized right now... All my colleagues in EM in Tennessee... Incentivized to leave the state. Let the legislature argue how to get three Emergency Physicians to cover 100 departments. I know, let's staff the ERs with independent mid-level practitioners. That will save a lot of money. Hey docs, how many times are you going to take this before you stand up and shout or simply walk away?

And somehow this applies, but I'm too tired... Enjoy.

EMTALA-Obama, Impacting Now....

Never know what you will run into on those two day drives to the beach... Here, we run into the future of American medicine. Cheers.

What Can I Add? Nothing! I See Nothing! (updated 2/24)

The Canuck's know the deal. Obama is increasingly becoming a person who would be better pictured with a riding crop and a monocle.

Happy Happy Joy Joy!

(Colonel Klink played by Werner Klemperer, and the series produced by... drum roll please... Bing Crosby)

Through the Looking Glass

Alice Delafleurs

Casablanca News/Ministry of Truth

Bobby Lee Smith, in a rage fueled by his fundamentalist Christian beliefs, went on a murder spree at Fort X today killing 13 people and wounding at least thirty. Crisis counseling teams from Washington are, as we speak, en route to the area, and the FBI has arrested all known acquaintances of Mr. Smith and has taken his family in for questioning.

President Barack Obama quickly called a national press conference to press for passage of his national health care initiative, stricter gun-control laws, and to condemn this act as a hate crime. He also stated that Mr. Smith's church would be shut down "until further notice", and expressed his "strong belief" that Mr. Smith's murder spree was not a random act of violence, but rather an "expression of the fundamental tenets of his religious beliefs which are openly anti-American". Mr. Obama also hinted that Mr. Smith might be sent to the Guantanamo Bay detention facility until his trial by military tribunal.

Mr. Smith is a registered republican and is rumored to have visited Idaho recently, where right-wing hate groups including the Aryan Nations and the American Nazi Party, have been known to have been organizing for years. His personal emails, made public on our main site, show a rigid belief in the christian 'god' and a desire for 'justice'. He also is a NASCAR aficionado.

Candlelight vigils will be held tonight across the country. At the vigils a petition will be presented by A.C.O.R.N. to push for gun-control legislation, and to ask congress to indict former President Bush for his weak record on gun-control, and for his militaristic bearing which may have given some impetus to Mr. Smith's rampage. You may sign this petition at our main website also.

Unfortunately the government may have some road-blocks to a quick conviction at trial as Mr. Smith is a diagnosed 'paranoid schizophrenic', but a Harvard psychiatrist, speaking off-the-record (and on condition of anonymity) said the following. "Mr. Smith certainly seemed to be paranoid in the days prior to the shooting, but his emails do not seem to be these of a true schizophrenic, rather, they seem to be the writings of a man obsessed with military culture and angry that he could not enlist in the Army due to his 'diagnosis' ".

Mr. Smith's actions recall those of Timothy McVeigh, the so called 'pro-life' movement, the Salem witch trials, the Spanish Inquisition, and the crusades,... the common thread is impossible to ignore. Mr. Smith committed the murders with weapons stolen from a neighbor. The neighbor has been arrested.

In a tragedy such as this one does tend to question one's opposition to the death penalty, but the question 'why' seems to have already been answered.

msilatipaC

I just worked my last shift in the ER, and I had an epiphany.

I have been living and working, for many years now, in a system which is the reverse of capitalism. Suffice it to say that because of federal law we can no longer say 'no' in the ER. Over many years this little nugget has passed into the public mind and those who would be barbarians absent a strong police presence are punishing us with no disincentive.

Unfortunately, our inability to say 'no' is now known by all the other services in the hospital, all of which (with the exception of the Hospitalists) CAN, in fact, say 'no'. Even the good old clinic docs know it and have, just today, bent me over a barrel and had their way with me. Example...


FP or IMed Doc: Hey it's Dr Beeper here... I'm sending you a patient by ambulance who needs to be admitted for something... I think they have ischemia or heart failure or babesiosis... Could you tuck them in to the Hospitalists for me?

Me: Did you call the Hospitalist, sir?

FP or IMed Doc: No.

Me: We will be happy to take care of it for you sir (per script handed down from on high).


And it is with this epiphany that I bid a way-too-late adios to the meat-grinder otherwise known as the ER. I'm done, and I do not suffer under the delusion that my problems are that important to anyone else. They are clearly not. However, when you consider that America is 50,000 boarded EM physicians short TODAY, my problem, in this particular case, will inevitably become yours. Here's how...

The hospital at which I now work is a gem. It is a community hospital with almost every specialty represented. We are a great facility. As a consequence of this, outlying hospitals have decreased their ER capabilities and out-of-county ambulance services now don't bother stopping at the local band-aid station anymore- they just drive to us. Sometimes they call ahead. Here's what's needed to bypass bumfoodle's ER... a patient request.

Now, as I leave this great facility, the ER is perpetually swamped with sick patients and not-sick patients, our hospital is often full and we end up transferring the patients from 50 miles away another 75 miles to whatever facility has beds. The beds are drying up there too.

Why is this? Because a bloated, parasitic host of administrators and paper shufflers are making a good living off our backs... can't run a hospital now and not be letter perfect with the huge governmental regulatory tome which can no longer be bound in a single large metropolitan area phone book and has to be stored on a 160GB hard drive. It is also because ER care for many is, de facto, FREE.

This is the reverse of capitalism, which would, were it allowed to function in health care, make it possible to turn a profit practicing medicine without the smoke and mirrors (and also have the salutary effect of helping people understand about taking care of themselves and get even a rudimentary knowledge of medicine). But profits are evil I'm told.

Grandma is still the best doctor around for normal illnesses, but everyone now thinks that everything is deserving of emergency care up to and including EMS transport across county lines for a toe bruise.

For all of you aspiring physicians, mid-levels, and nurses out there... you DO have job security, but you do not have any chance, by being excellent, of making an excellent wage or building an excellent business. They are coming with the long knives for all of you.

Twenty years ago they used to tell you in school to play sports but to have a backup plan because your odds of making a living playing sports were very slim, but I am here to tell you to lighten-up your academic pursuits... get out on the golf course or the basketball court or the football field. Pick up that electric guitar... move to Hollywood and do movies. Tinker in your basement and invent a better mousetrap. These are the last places in today's America that excellence is rewarded, and, professional sports will always be rewarded because we have become a nation of pantywaists, and pantywaists need their heroes and will not begrudge them their millions.

Adios. I will continue to blog from a place where, when I see a sick patient, I will pick up the phone, make a call (or maybe not), and send them to the ER.

The Good Old Days of American Medicine

The 'good old days' for doctors in America were the seventies. But let's talk about the 'good old days' for patients in America. They are right now and they are about to end. 

The good old days for patients have been at the expense of American doctors and nurses and paramedics for thirty years now, and because of EMTALA, Medicare, and gutless politicians and physicians. Group politics, super. See ya later individuality and achievement.

After Obama 'fixes' medicine my life will be easier and I will make more money for less work and with capped liability to boot! I will take some pleasure in pointing this out to all of you muddle headed liberal do-gooders and earth mothers out there, but not too much, because I will pull out a lot more 'pronouncment of death' forms. These patient encounters are easy and there's no risk and I get paid, so cool. You just have to make sure the patient is really dead, and this is only occasionally difficult. Here's a story about what will not happen anymore. 

You will not be an 80 year old smoker who has been struggling to breathe for two days and when you call 911 they will not get there right away. You will not be rushed to the hospital with lights and sirens blaring and you will not be thrust in front of me at 4am with a heart rate of 220, curiously the same as your systolic blood pressure, and I will not, then, do the following...

I will not run into the waiting room to find your family (after shouting out, IV, nitro drip, cardiazem 25 IV, morphine 4 IV, set up RSI, pacer pads!) to find out if you have a living will (you are too far gone to do more than scream and breathe).

Through their tears they will not tell me to 'do everything'.

I will not then run back into your room, pulling a few techs and nurses with me and do the following...

I will not give you 20mg of etomidate followed by 25mg of succinlycholine and slide an 8.0 tube into your trachea and hook you up to a vent.

I will not then push about 50mg of propofol on you before shocking you with 100 Joules of synchronized electricity to get you out of your atrial flutter with aberrancy, and will not rush you to the scanner to make sure you are not dissecting a thoracic aortic aneurysm or pushing against a massive pulmonary embolus.

I will not, after you come back from scan, have a brief moment to look in your eyes (as the propofol has been momentarily stopped), and apologize to you for intubating you (as it seemed like you didn't want me to do it, but I could not trust you (at the brink of death and without documentation) to make a good decision), and have you nod your head to me and try to thank me. 

I will not then send you to the ICU where, in spite of your continued smoking habit and lack of insurance or money, some of the finest critical care physicians I have known will, in all likelihood, succeed in getting you out of the hospital, back home, and comfortably smoking. They will lose money in the endeavor (and sleep and time away from family), but that's what they do now.

Instead, when you call 911, you will get a recording or be put on hold. If you make it past the call screener you will be rushed to the hospice where you will die in a haze of morphine. But, and here's the good part, it WILL be 'free' (and I will be free to take a nice nap on the overnight shift).

Swine Flu Ado Sends Biden Into Hiding

Fear not, Mr. Vice President, you need only touch the hem of his garment (OR wash your hands OR calculate the odds of your family being infected OR not spout-off about something of which you are ignorant... Well, maybe it would be best to just shut up all the time like you had been doing so as not to mess with the cool vibe man).

Early in the 1900s polio and flu killed Americans by the tens of thousands and we, as a country, survived and prospered in spite of it (and with great courage). We also found a cure for polio and developed the flu vaccine.

8 years ago terrorists killed 3,000 in an inferno in NYC, and we got stronger and prospered in spite of it, and with great courage. And in spite of the fervent quasi-prayers from the libs our troops have won victory on the battlefield in Iraq. Depending on the R.O.E. per our current CinC, we may also do so in Afghanistan.

What a sad, miserable state we have come to when a flu outbreak in Mexico causes our Vice President to tinkle on himself. What's Joe Biden wearing today? Depends.

Look out Usama! The media's wish fulfilment fantasy will shortly become farcical, and that may be when we save ourselves from the fatal banality pandemic which will otherwise conquer.

*I'm adding the text "100% organic swine flu cure" and "100% natural swine flu cure" and "swine flu protective mask" to find out how many new hits we get because of it and therefore whether to remain nearly hopeless or to be somewhat hopeful about our country. Also, see poll upper right.

* And after a heavy slap to the wrist...

Tarheels Romp Through 'The Dance'

As my favorite basketball team was winning a game en route to the national title this is what I was doing. I have never seen overwhelming sepsis take a patient from me like this. This case would be a 'Grand Rounds' case at about any teaching hospital, but instead it happened in my little ER on a warm spring night.

When you let yourself get to 428 pounds as a 21 year old you have made some choices that will impact you for the rest of your life. In this case the impact was a sudden death in spite of everything we could do. We worked on her for about thirty minutes longer than the MECCA would have because we could. Academically speaking the last thirty minutes was futile. But we had met the family and we had seen the tears and we did not want to let her go even though we all knew.

When you become very ill and you have chosen to forgo health insurance you are in big trouble (in spite of EMTALA). Not only are you less able to see a physician when you first get ill, but just by me telling your story to a receiving facility over the phone it becomes obvious that you do not have insurance and the availability of ICU beds is mysteriously effected. The only cure for this is for the government to pass SUPEREMTALAHIPAA which will prohibit description of the patient in any way when transferring from one facility to another. Any information given might lead one to a correct inference about insured status. It will go like this...

ME: "I have a patient for you".
RECEIVING FACILITY: "Okay."

In all fairness the die was cast long before I saw this patient. She ignored her symptoms for too long and got to us a few hours too late and even the MECCA could not have saved her at this point. Her girth made central lines impossible even with ultrasound guidance. We could not even Doppler a femoral arterial pulse. And within a few hours it was all over, the last minute of CPR pictured here with 10 ER personnel trading turns trying to get enough blood out of her heart to perfuse her brain.

All of us in the room bit our nails to the nub as we watched all our interventions fail; gorillacillin IV, fluids wide open, pressors that would make you or me bleed inside our brains... dopamine, levophed, neosyneprhine, epi... failure. Then asystole, then PEA, and a dead heart on the ultrasound. No movement... not even the flutter of a valve, and all our puncture sites pouring blood while the extremities clotted off and she bled into her gut.

Go Tarheels. They were clearly the best team this year.


* picture altered from original

Michigan Court Lays Groundwork for Medical Collapse

Understanding that the right to sue is not the same thing as a victory in a lawsuit why in God's holy name would anyone choose a career in medicine knowing this? I actually have no problem at all with this ruling as long as all doctors are provided with a functional crystal ball (and training on the same so as to ensure faultless interpretations). Congratulations to the federal appeals court in Michigan, you have earned the coveted title of official MDOD fucksticks.

EMTALAEMTALAEMTALAEMTALA Duh.

Please read this.

So here's a cherry example of what happens when the government sees a problem in the private sector and tries to fix it by passing a law. I witnessed this in action in my military days. One summer, when the medical students on a military scholarship were rotating through various hospitals in the military system, a student was killed in a traffic accident en route to their clerkship. The military then decided that no medical students would be allowed to drive to their summer clerkships. Good solution, wouldn't want anything dangerous to happen to someone in the military. Cars are dangerous.

So did the kid need his lip fixed? Maybe. That's really not the point. I don't have pictures and I wasn't there so I can't comment, but choosing NOT to close a dog bit to the lip or to opt for delayed closure is at least reasonable. The teaching changes every few years and I will close most dog bites, but not all.

Both our national colleges fell for this hook, line, and sinker. What a bunch of pussies. How can you say that this boy didn't need treatment immediately? Here's how... This kind of repair, evidently done by a plastic surgeon, would be impossible outside a large city as large cities are the only places where you can get one 'on call'. You might get lucky and be at a hospital with OMFS (oral-maxillofacial surgery) or a game ENT, but right from the get go this is a hot potato of liability for any doc that chooses to close this wound. Do you want to suture his lip with an angry mom watching your every move knowing that the wound, by definition, has a high likelihood of infection? I don't. So not everyone in the country would have this procedure available at the drop of a hat and that's not fair. What to do... What to do?? I got it! Let's pass a law guaranteeing access to a plastic surgeon 24/7 anywhere in the US. Awesome! Problem solved. Next? This governing thing is so easy.

I can see it now. An angry mom, justifiably so (but angry at the wrong person), not getting what she wants that very instant for her child. An angry mom convinced she and her son are the victim of the 'wallet biopsy'. In fact, I would wager a lot of money that had the mom NOT been a person of color that she would not have succeeded at the second hospital. If the lip was torn to shreds it would be beyond an ER doc to fix it properly and if it was torn to shreds there is no 'emergency' here... the child was referred for definitive closure at a later date. So what's the problem? The appearance of an EMTALA violation.

EMTALA, the law that killed American medicine. The law which, if it were applied to say, grocers, would read, "Thou shalt give food away to anyone in your store who claims to be hungry or you will be fined and may lose your license to sell groceries and if we are really mad we'll throw in a lawsuit too."

The law which the average Joe on the street has finally figured out. The law that gave us this bit of ridiculousness. The law that killed my profession by making it an endless parade of entitled (mostly) faux-misery. The law that makes otherwise apparently very bright people say something like the following...

...ACEP's Dr. Gardner said emergency physicians must consider not only legal obligations but also moral and ethical responsibilities to the patient. "Every action we take as emergency physicians should pass the 'Aunt Betsy' test: 'Is it good enough for your Aunt Betsy?' " she said. "If not, I don't think it's something emergency physicians should be doing."

Or this from a physician whose other job is to outlaw guns in every home and who oversees the chaos and failure at Atlanta's Grady hospital...

The danger is that patients without private insurance often do not have access to care elsewhere.

"If we don't see them in the emergency room, they will not get the care they need, and some of them will come back much sicker," said Dr. Kellermann, professor and associate dean for health policy at Emory University School of Medicine in Atlanta, Georgia. "Most of my colleagues are unwilling to not treat [low-acuity] ED patients if they do not have reasonable assurance that the patients have someplace appropriate to go."

Okay, I'll play with your hypotheticals Drs Gardner and Kellerman. My Aunt Betsy is a non-compliant diabetic, alcoholic, child abuser who films and distributes child pornography and just took 8 hits on the crack pipe. She was bitten by one of her thirty attack dogs which she does not properly keep, and her lip is 'tore up'. The family can't wait for her to die. She has cost us all countless hours of misery and countless dollars hiring lawyers to keep her sorry ass out of jail. So yes, it is "good enough for Aunt Betsy".

As to Dr. Kellerman, well, I sure would like to save the world but right now I'm just trying to make it through another year in a high acuity ER with 30% payors, 30% admissions, and 50% 'shoulda gone somewhere else and didn't need the ambulance and wont pay a dime.'

But back to Aunt Betsy... Fifty Al Qaeda fighters, wounded in battle with the USMC, somehow manage to get to your ER. All require surgery. What do you do? Ten escaped convicts who just murdered your security guards? Charles Manson with a heart attack? Hitler? Satan? I am comforted that I now have an answer and will simply think of "Aunt Betsy." There's a fine line between clever and stupid.

Practicing Emergency Medicine as Dr. Gardner would have us practice also would lead to the following (as long as we are throwing out hypotheticals). People will get the message that there's no downside to walking around uninsured. There's no need to budget for it. All you have to do is call 911 or go to the ER. If you don't get what you want then threaten or scream and ultimately you might just need to go down the street to the next ER. "The government" is paying for it so it's free. Also, if you feel you are were treated poorly (with the wealth of medical knowledge that you have acquired by studying in your off-hours) then you can call one of those lawyers on those billboards and sue. You might just hit the jackpot. Then, ER physicians, castrated, will quit mid-career and leave a gaping hole in coverage across the United States, and hospitals will close or 'reorganize' so as to avoid the money pit. Oh wait, that's what's happening now.

Not Freddy Kreuger

So on a warm day after a snowstorm a nice sled ride would have been a great thing, but, not appreciating the degree or direction of the slope, a young lady, wearing jeans and a t-shirt, went rocketing into the trees and raised her left arm to protect her face from the trees. Good thing too or this injury would have been absorbed by the facial tissue.

Twenty years ago a plastic surgeon would have been called and would have been happy to come in and fix this as, on first blush, it looked like this might have needed a skin graft. However, there are no plastic surgeons outside academia now who will take ER call because if they did they would lose money with every call.

An Orthopedic surgeon would have been obligated to fix this were there an underlying fracture or tendon injury, but there was not such an injury.

A Vascular Surgeon or Hand Surgeon would have been obligated to fix this if there had been a major vessel injury or a laceration involving any of the hand or finger extensors, but there was no such injury.

Enter meatball surgeon, your local ER doc. I did not want to fix this myself because I knew that if I did I would be out of the game for at least an hour and that the wound would likely get infected from all the foreign debris in it, but I was the only one who would touch it.

We numbed the area widely and used a mechanical lavage device (a glorified 'squirt gun' called a 'pulsevac') to get as much crap out of the wound as we could. Then I cut out a bunch of dead tissue and dead skin (debridement) and did the best I could. Not pretty.

The patient did not fill their antibiotic prescription and the wound did get infected. I heard this from the plastic surgeon who was kind enough to follow up this injury. But all that happened was that he had to pull a few sutures and drain some pus.

Insurance? No.
Money? Apparently only enough for a sled.
Sutures? I don't know, about 100.
Bill? To you! Thanks.

The Lack of a Liberal Arts Education

I do not know the author of this piece in EP Monthly and bear him no personal animosity. The fact that it was published at this time seems to me to be an alarm-call about what is to come with our health care system.

A friend of mine has written a rebuttal, and has been rebuffed in his attempt to get it published, so I am including it below in full.

Notice, if you will, that Dr. Hochfeld demonstrates a few things in his apparently dispassionate plea for a government fix. The two that strike me are the logical fallacies that run throughout, not the least of which is an amateurish and shallow view of what a 'right' is and what a 'right' means in this country, but moreso, the fact that if one does not accept his initial premise, that 'basic health care is a right for all' that the rest is pap.

I do not accept his premise and neither does the good doctor below. Dr. Hochfeld's 'solution' to our 'crisis' would have been lauded by Marx himself, but this doesn't appear to bother him or those who responded favorably to his proposal. It is unconstitutional on it's face, also, apparently not a big deal for the author or for our president-elect.

I weep for the people of this country as Che-Guevara-esque portraits of Obama are being posted in the hip cafes of this great land. We are witnessing the birth of a cult of personality. Without further ado, I present my friend, Dr. Tarkovich, a boarded EM physician with a tour in Afghanistan under his belt and a knowledge of history and logic that destroy Dr. Hochfeld's arguments like Oprah destroys a doughnut.

I want to comment on Dr Hochfeld’s article on health care reform, as I see some major flaws with his reasoning. I think the problem that most people have when trying to solve the high cost of health care in this country is that they have trouble stepping outside of the current paradigm. Free market health care would not work within the current system, but where is it written that the current system cannot be changed?

First of all, people do not have a right to health care. Dr Hochfeld claims that “access to basic health care is a right,” but then goes on to say that certain physician services are included in that right. There is no way that a person can have a right that infringes on the rights of other people. These are called positive rights, and are morally flawed. A person can have a negative right- the right to be free from harm by another person, but health care requires that other people provide goods and services. If I have a right to health care, the doctors, nurses, pharmacies, and drug companies will have to give me their product and service for free, which infringes on their right to be compensated for their labor. What do you want to do to people who refuse to give away their work for free? Steal money from them in fines? Put them in a cage? Once you force someone to work for free, that person has become a slave, which is prohibited by our Constitution. Claiming that people should have a right to health care is akin to saying people should have a right to food and therefore all restaurants and grocery stores must give their products and services away for free. Is the government going to pay for these things? How will they ration those dollars and determine who is deserving? Will they also throw money at another commission with a top-heavy bureaucracy? What if a physician does not want that money with all those strings attached? Is he or she free to make those decisions, or is the doctor forced to provide that service on penalty of being fined or jailed? The socialist system cannot work without threats of violence. Am I the only one who finds that troublesome?

Dr Hochfeld makes the argument that the suppliers of health care have too much control over the demand. I agree with him, and this is where the free market could take over. Why does it cost $800 for someone to come to the ER for an uncomplicated broken arm or laceration repair? Why can’t someone spend 6 months to be trained in simple procedures and make a living in his or her own private clinic? No, there is no medical degree being given, but they can let the free market determine if they are doing a good job. They have a great incentive in that they will go out of business if they do shoddy work. Before you suggest a regulatory body to oversee this industry, think about how much the costs will go up to fund the bureaucrats in this endeavor. We are trying to keep costs down, and the free market is very good at that job. I am sure these people would be happy to receive $50 for minor cuts and breaks, and they could even use dangerous drugs like: lidocaine, tetanus boosters, and cephalexin. We have a monopoly on services in this industry, and the free market cannot exist without competition. What would hospitals do to compete with this new sector? They would have to lower prices. If a person wanted a thorough physician evaluation, he or she could choose to pay more. Much in the same way you decide what to eat for dinner or what type of television to buy, cost plays a role. People make decisions about their health based on cost all the time (types of food, cigarettes, alcohol, saturated fats, etc).

Additionally, Dr Hochfeld proposes a system with a salary cap for specialists. This is akin to complete socialism without allowing market forces to determine salaries. Karl Marx’s “labor theory of value” says that value is determined by the amount of work required to produce a product, not the consumer demand. This fallacy means that a surgeon who labors for six hours and finally removes an inflamed appendix should get paid more than the adept surgeon who removes it in 30 minutes. Guess which doctor will have more consumer demand and be worth more money in the free market? When we try to fix things with central planning, we are marching down the same road that caused the downfall of the USSR. No central body can ration health care dollars because no one can predict market pressures and respond to consumer demands as rapidly or as efficiently as the free market. In order for our system to work in the free market, we would have to remove the current restrictions that allow for monopoly privilege of physician services. Dr Hochfeld claims that he is looking for a way to make physicians work harder; the answer is competition.

Pharmaceutical companies are also hampered by FDA restrictions, which make them take almost 20 years to get a new drug approved. They in turn have to charge ridiculous amounts of money for their product to recoup these costs and strategically hold off on releasing medications until they have exhausted the prior one. For those of you who will argue that this is for safety, I urge you to look at the number of drugs that came to market and were later found to be extremely harmful. What is wrong with publishing data and allowing physicians and patients to decide? Are we too stupid to make those decisions? How long would a drug company be in business if they produced a drug that harmed many people? No one would buy his or her product and the owner could be held liable in court as well. When was the last time a member of the FDA got sued for approving a drug that was harmful?

Finally, on the issue of care for those who need it and can’t afford it, I bring up the absurd notion of “charity.” We are all human beings, and most of us in this line of work have compassion. Personally, I donate a large amount of money to charities every year; charities that I feel do an excellent job. For those of you who think the government is the best charity to handle this endeavor, look at how carefully they handle your money and how efficiently they produce things like new roads and highways. Do you want more “evidence-based” medicine like blood cultures in uncomplicated pneumonia? (Hopefully the sarcasm came through in those comments). The free market would do a much better job of caring for sick people than our current socialist system. Wouldn’t it be great PR for a hospital to have an entire charity wing? I think a doctor would acquire many more patients when it became known that he or she spent even one day per month doing free care. Of course, the legal system would have to be drastically revamped in my world, but that is a topic for another time.

When the system you propose requires that you use a word of violence like Tsar, it is time to rethink that system.

My Medical Holiday

Having been on the giving side of the medical equation 18 months longer than was good for my sanity I have decided to take a little back.

I just flew up to northern Montana where I went hiking and crossed into Canada. I then hired a 'coyote' to smuggle me back into the US. I dropped all my IDs and money in an envelope in Moose Jaw, Saskatchewan and mailed it back to my home address. I purchased a bottle of fine Canadian Mist whiskey and hit the road with my escort to Minot North Dakota. Wow, was I a drunk asshole.

As agreed upon when I hired my 'coyote' he dropped me just outside Minot and punched me in the face and called 911. In relatively short order the fine paramedics arrived and found me head- injured and slurring my speech. Without any ID and with me only being able to say, "It hurts, eh?" I was able to stay a few days in Minot General courtesy of the U.S. taxpayers.

Of course, since I kept having "seizures" and pain and remembered I was allergic to toradol, motrin, tylenol, phenergan, and reglan, they have been dosing me with dilaudid and valium and feeding me to my hearts content. They also went ahead and fixed my deviated septum which made me snore and has been bothering me for some time and which was made a bit worse by the well-delivered punch.

Since my case of amnesia is not resolving I'm working on getting the nice docs in Minot to airlift me to the Mayo for a thorough Neurology evaluation. I think I will be able to make my way back through the specialty hospitals (as I will continue to present protean manifestations of rare diseases requiring, again, lots of good drugs... Hell, maybe they will bring in 'House, MD'?) to near my hometown where I will leave AMA from the hospital around midnight, and walk home after two or three weeks of a fine holiday. Thank you all for paying for my vacation, and thanks, EMTALA.