Doomed to Failure

My initial impression of President Obama's healthcare plan is one of suspicion laced with grave concern and sprinkled with disdain. Surely he must realize that expanding Medicaid is not providing universal healthcare - Medicaid patients are turned away from many (most?) outpatient facilities already because the reimbursement rates are so low that each patient is a money-loser for the practice. I'm suspicious that he's using this plan as a token gesture to claim that he's fixed the uninsured problem. Guaranteeing coverage does not guarantee access, particularly when that coverage is pathetically insufficient. Even raising reimbursement to Medicare levels would still leave many patients without access to healthcare.

Another of his proposals is to eliminate Medicare payments for patients who are re-admitted to a hospital within 30 days of their last discharge. Like many liberal ideas, this sounds good in theory; if patients were appropriately treated the first time, then they should not require readmission for at least another month, right?. Improving the quality of care is a worthy goal, but when one's initial assumption is wrong then the conclusions will be wrong too.

A noncompliant dialysis patient, for example, may miss a couple of his outpatient treatments and present to the ER with life-threatening hyperkalemia (elevated potassium) or pulmonary edema (fluid in the lungs). Some of these patients don't go to their dialysis centers at all, they just come to the ER when they can't breathe. Instead of admitting these repeat offenders to the ICU, our incentive will be to dialyze them emergently in the ER and discharge them after several hours of critical care. That's good for ER docs (cha-ching!) since we can run up huge critical care bills on Medicare's tab, but not so good for the long line of patients in the waiting room who have discovered that they can't get an appointment with a doctor because nobody takes their newly-provided Medicaid.

Medicare patients, by definition, are either old, sick, or both, so they are more likely to require frequent admissions. When grandma has a TIA ("mini-stroke") 27 days after her last admission for pneumonia, the hospital's (and any on call physician's) incentive is going to be to discharge her from the ER rather than admit her to the hospital for an uncompensated megaworkup. So the ER docs stuck in the middle will do an 8-12 hour TIA workup with Neurology consultation in the ER, further backing up the waiting room. I could go on and on, but these examples should suffice. Patient care will suffer under this plan, and costs will not be reduced.

Other Obama initiatives like "Expanding the Hospital Quality Improvement Program" and "Improving Medicare and Medicaid payment accuracy" are just JCAHO-like regulatory mandates and excuses for payment denials which will not increase access to care in any way whatsoever, but will definitely make it harder for hospitals to stay in business. This plan is simply bureaucracy at its worst. My plan is better.

UPDATE: More concerns from Buckeye Surgeon and Dr. Whitecoat, great reads both. And 911doc reminds us that socialists were trying the same crap decades ago.

On Needing Eyeglasses

I've noticed some decline in my visual acuity for quite some time now, but as with most inconveniences, one makes allowances and carries on. Thanks to some poor planning with my FLEX account, I discovered that I needed to spend a big pile of cash on either my teeth or my eyes within the next month or else donate the funds to people who I've never met and whose very existence I hypothetically despise. Since I've already spent a bundle to fix my teeth in the past couple of years, the eye exam was a logical choice.

I was secretly hoping that my vision wasn't so bad after all, but I was only fooling myself. I could barely read the 20/30 line, and the benefits of correction were immediately obvious. So it seems that the second half of my life will be spent looking through corrective lenses. Maybe they'll make me look more distinguished or at least hide the bags under my eyes.

Coming soon: "On needing a cane"

A Pitibull Situation in Chicago

Shadowfax has been following the case of the child in Chicago who was attacked by a Pit Bull and discharged from the ER without his apparently severe facial lacerations being closed. This post started as a reply but got too long, so here it is.

Delayed wound closure, even of a dog bite to the face, is not necessarily unethical and in some cases (heavy contamination, lack of specialist availability, delayed presentation) is itself the standard of care. Referral of uninsured or Medicaid patients to county facilities is not unethical either, and in many situations is the only reasonable option available. More and more physicians are refusing Medicare, Medicaid, and the uninsured, so there is no guarantee these patients will be seen when they follow up as an outpatient unless they go to a county facility.

It's the combination of these two issues that is controversial. Activists are using the drama of an "untreated" disfiguring attack (on a child!) to advance their socialized medicine agenda, much like their ideologues use the "unfairness" of foreclosure to advance their Socialist goals.

While it's tempting to blame Michelle Obama and the hospital policies she reportedly helped design, this particular disposition was made in the trenches by an ER doc, not in the upstairs offices by a committee. Not having seen the wounds, it's hard to comment on the propriety of the decision, but I will say that it's becoming increasingly difficult to have Plastic Surgeons come to the ER to repair wounds, much less to have them admit these patients. The days of "if a patient requests Plastics, then they get Plastics" are becoming but a fond memory.

I've personally had to suture several uncomfortably complex wounds I would have much rather had a specialist fix because the specialist just wasn't going to come in. "Just do the best you can to get it together, and I'll see them in my office," they say. We wield the "last resort" of requiring their presence via EMTALA with caution, because if we use that weapon injudiciously we might find ourselves out of a job. So we do the best we can and move on to the next patient.

There are few wounds that *have* to be fixed right away and even some gaping disfiguring wounds with flaps hanging about can technically be approximated, bandaged, and cosmetically fixed later. Is this the type of care that I'd want for my own son? No, but I pay for my own son's medical care. This controversy isn't about wound care though, it's about indigent care. Everything is politics.

The Obesity Epidemic

Are there contributing factors other than overeating and lack of exercise? Some interesting theories here, including viruses, microwave ovens, air conditioning, and artificial sweeteners.

via Conservative Grapevine

Duck Hunt Made Easy

From the comments: "The weapon of choice for the zombie apocalypse."

Get Rid of Your Medical Insurance

It makes good economic sense for many people to dump their medical insurance. For those who rent apartments and ride the bus, it doesn't matter if their credit rating gets destroyed by a collection agency or three, so there is no reason they need to pay for their EMTALA-mandated emergency medical visits. They should save that money to buy their prescriptions (and staples like food, cigarettes, and booze).

Those middle class folks stuck in homes they can't sell in the depressed housing market and resigned to driving beat-up old cars during the Obama recession aren't looking at taking out a loan in the near future anyway, so they shouldn't worry about their credit rating either. They should use the money they save by dropping medical insurance to help make their next mortgage or car payment. Heck, they might have enough left over for a big screen TV, or at least an iPhone.

Worried about paying for college? The "rich" don't qualify for school loans anyway, and the poor have guaranteed loans and grants from the government. No need to worry about bad credit when the worse off you are, the better your chances for help. Living in a nanny state has its benefits....enjoy them.

Screw the insurance companies, the hospitals, and the doctors. Demand your right to free healthcare. You've got more important things to spend your hard-earned money on.

Symbolism and Irony

Obama coins are like his presidency - not the change many had hoped for.

via Gateway Pundit

I am the Wolf

I solve problems.

I've had an interesting variety of patients lately. That's the best part about my job - dealing with the unexpected. A sudden life-altering event has occurred, and a frightened family fears the worst. They seem to think their adrenaline should be contagious, that we should all be as frantic and scared as they are. They don't understand that my adrenaline only makes me think faster and more clearly. Outwardly my demeanor never changes, except that I might dispense with some of the usual pleasantries.

If I'm curt with you it's because time is a factor. I think fast, I talk fast and I need you guys to act fast if you wanna get out of this.

But I don't get scared and I'm not going to run around in circles wringing my hands and crying. Just answer my questions quickly, do as I say, and I'll fix your problem for you. That's what I do - I solve problems. With people.

That's thirty minutes away. I'll be there in ten.

Oh yeah, I also drive real f***ing fast, so keep up.

Take the What Pulp Fiction Character Are You? quiz.

Tough Guys

I can't get it to embed for some reason, so you have to go here.

The Stinger

Cervical spine injuries cause about 6000 deaths and 5000 new cases of quadriplegia per year. These well-known consequences of a "broken neck" usually mean that patients with these injuries are brought by EMS crews to the ER already taped to a rigid and uncomfortable backboard with a stiff cervical collar preventing any movement of the spinal column until we can "clear" them of a dangerous fracture or subluxation.

Not everyone with a neck injury calls 911, however, and some of them walk in themselves. Such was the case of a high school football player whose coaches thought had suffered a "stinger" during a game. After a tackle, he developed neck pain and numbness to the left arm. He left the game and fortunately didn't return, but his parents were concerned enough to bring him to the ER afterward.

When someone walks into the ER on their own power, our clinical suspicion for serious injury is sometimes reduced. I can only assume this is why he wasn't immobilized in triage. When I entered the room, I found him sitting upright in a wheelchair in mild distress from pain, still wearing his sweaty football uniform but not his helmet. He appeared to be holding his head very still so as not to move his neck at all. He was exquisitely tender to the lower midline of his posterior neck. He was slightly weak in his left upper arm but had normal grip strength.

I immediately placed him in a cervical collar and we carefully laid him down on a backboard. I skipped the X-rays and sent him straight to the CT scanner, where he was found to have a burst fracture of C4 and some injuries to the posterior elements of C5.

In Texas it's hard to tell a teenager and his family that he'll never play football again, but the good news overshadowed the bad: after his surgery he left the hospital 3 days later with no neurological deficit whatsoever, one of the luckiest patients I've ever seen.

Quote of the Day

Sorry about the dearth of medical posts, I haven't had the BUMA lately. But this quote is simply delicious:

"Here's a question for (Tom) Daschle : When you amended your taxes and coughed up about $140,000 in back taxes plus interest, did you feel like you were stimulating the economy as much as you would have if you had spent that money yourself?"

And for that matter, did you feel more patriotic?

UPDATE: It gets better. A LOT better: "A penny saved is a penny earned! Especially when you save it by not paying your taxes."



via Instapundit