The Ether Way

But every word has music in it.

In a recent interview for the new York times, William Shatner was challenged to defend his acceptance of even trivial roles. He replied, "but every word has music in it"

I understand that. For me, every anesthetic is a poem and a puzzle. Sometimes it's about saving a life. More often, it's simply about leaving somebody feeling well  enough to eat lunch after their carpal tunnel.

It may be a case I've done hundreds of times, with a technique I've used for decades. Those cases are like comfortable old songs that I sang with my kids over and over when they were small, and still sing for myself when I think (hope) no one is listening.

It may be a chaotic trauma, all of us struggling to bring some order to the pandemonium of grotesquely disrupted anatomy or maybe it’s a big burn patient, leaking their life's fluid away through hideously charred skin, or no skin, the underlying fat and muscle obscenely exposed, like an anatomy class corpse, jarringly wrong. Those cases leave me unsettled, sometimes for a while.

On good days, I practice anesthesia in a state of grace. My step is light. I feel the little “snick” as my
epidural needle pierces the ligamentum flavum, on to a beautiful release of air from a glass syringe which was just a millimeter ago a bouncing shock-absorber. Two minutes later, the suffering mom-to-be, who was previously involuted with pain, looks into the father’s eyes and squeezes his hand, and they both smile.

Other days, I can’t seem to thread a 20ga angiocath into a vein the size of an LA freeway. Every patient wakes up combative and disoriented. 10 hours is an eternity. Thank god some days anesthesia is difficult, lest I begin to take it all for granted. (or take my hard won skill for granted?)

For it is a gift  and a privilege to be able to do something I am good at, which has meaning for me and for others around me. Something necessary. Something real. To hold a hand, make reassuring eye contact, stand vigil (well, sit mostly) and manipulate (mysterious) consciousness. Fighting pain, defending my patient from the vicissitudes of life and the necessary suffering of surgery.

I ask my junior associates how they are, and they say, "living the dream." I think "amen to that" although I know they are being facetious. That makes me sad for them, because it smacks of “quiet desperation,” and although anesthesia is a wonderful calling, it’s a really tough job, for reasons that every anesthesiologist understands... you better love it, or you're gonna hate it.

 

But every word has music in it. My satisfaction is trying to reach that music.”

Thank you, Mr Shatner, for reminding me.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anesthesia, the internet, and the future...

I've just returned from the ASA where I participated on a Panel discussing "Anesthesia, the internet, and the future" with three talented co-panelists; Vivek Moitra, Micheal Woo, and Bill Hanson. Bill discussed Penn's implementation of the Electronic ICU at Penn. Vivek talked on using the internet as an anesthesia intellectual resource, and Mike discussed the nuts and bolts and ethics of video posting. I presented on  social networking tools and the evolving clash between the new technologies and existing societal laws, structures and values. In this post I will provide links to some of the resources I follow to keep up.

I have had twitter and facebook acconts for quite a while; in my digital practice, twitter is actually the more interesting. Facebook is cluttered with too many games and inducements to random interaction amongst the friend cohort. But then again, I'm not 17.

When last I talked on social networking tools, in 2008,I concentrated on potential anesthesia applications. This year I discussed the internet and society. The first place I would direct the interested  is to Clay Shirky's lecture at Google Headquarters ("Schoogle") which can be found on you tube. This is the lecture accompanying his first book, Here Comes Everybody. It's simply spectacular. Clay is now affiliated with the Berkman Center for the Internet and Society at Harvard.

danah boyd (she does not capitalize her name) is another thinker on the societal ramifications of the social web, with more of a focus on age based psychology. She is also now affiliated with Berkman, and is a social media researcher at Microsoft Research New England. You do not have to drill very deep to pull in the broader range of thinker/talkers from these three links. I would particularly direct interested parties to the schoogle lectures; I have yet to watch one that wasn't fascinating.

I will post more on my talk in the next week or so, but I wanted to get these resource links up for any interested parties.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mirage Care

73 accused (a foreign criminal enterprise is alleged).

2,900 stolen identities. Birthdates, social security numbers.

118 phantom clinics in 25 states.

Preposterous patterns of care that are not even remotely plausible.

Completely fictional physicians. How does this happen? Seriously.

163 million dollars.

I bet the paperwork was perfect, and would have passed a RAC audit with flying colors.....

You can't make this stuff up.  No one would believe it except for the inconvenient truth that it happens to be true (or allegedly so).

Is anyone more confidant the the Gummint can administer health care on a larger scale?  They cannot even prevent massive fraud in the portions of the system they administer now. While I doubt that there are larger frauds out there, it is likely that there are an even larger number of more smaller scale operations. It is entirely possible that smarter perpetrators would be harder to detect and even more difficult to apprehend.

Ugh.

http://news.yahoo.com/s/ap/20101014/ap_on_bi_ge/us_medicare_fraud_arrests

 

Show Me The Money! Or why talk of waste, fraud and abuse devolves into more friction for practitioners at the sharp end.

Waste, Fraud & Abuse. To hear Politicians talk about it, you’d think that the world of medicine is rife with it. After you read some of the stories below, you might wonder whether there are any honest doctors or hospitals. Some recent news items, coupled with some older stories, are fodder for reflection on this hot topic.

First, while it is widely accepted that government programs are often inefficient, it is not widely acknowledged that some of them invite fraud and abuse. Medicare, more than any other US government program invites fraud. Why? Because the government writes checks to people and companies that it does not directly employ to provide service to recipients who are also not in its employ. While most of the checks it writes are small in government terms, some are large. In almost all instances, the government has no ability to ascertain what service was rendered. Worse, due diligence is conducted with the imagination and initiative of…. the government. What this means is that due-diligence is almost exclusively about paperwork, which in turn, invites massive fraud.

There’s this recent story, which is simply astonishing:

http://news.yahoo.com/s/ap/20100717/ap_on_he_me/us_medicare_fraud_arrests

94 people. 250 million dollars plus. That’s a lot of money. If the allegations are true, then some very greedy doctors have made wads of money. How? By prescribing and delivering physical therapy (which has no enduring tangible trail) fraudulently. The pay for each treatment would be modest, but the number of treatments at issue is massive. There are also alleged bogus bills for equipment and even procedures.

Even if you worked very, very hard, it would be hard to honestly generate the amount of billing alleged in this news item:

http://www.fiercehealthcare.com/story/chicago-mds-accused-fraud/2009-02-02

In this story, a single cardiologist is alleged to have billed in excess of 13 million dollars for ICU care. The story lacks specifics that make it hard to analyze for plausibility; it doesn’t mention the timeframe over which the billing took place (1 year? 7years?), nor does it mention whether this practitioner was engaged in other clinical work. Still, it’s hard to generate a scenario that could explain away this level of billing for a single practitioner. Readers note: the news item leads us to believe that at one point this physician had collected millions in billing.

Payment is for service rendered. In principle, it is for the service. In practice, it is for the paperwork. Submitting impeccable paperwork will reliably generate payment. The government audits paperwork because it can, and because it can do so cheaply. Good practitioners generate good care and mediocre paperwork. Many struggle to get paid for the honest work they do. In contrast, perpetrators of massive fraud generate no care and high quality paperwork. There are legends of huge sums paid to hospitals that never existed, operated by criminal conspiracies of physicians, office staff, and experts in medical billing. It is likely we don’t read about this much in the news because it might make the problem worse. The first news item above makes the scope of the problem clear: the feds have to pay people to go and see if there is actually a business providing the service represented at the address listed!

The dictum for practitioners is ‘If it isn’t documented, it didn’t happen.’; the dictum for perpetrators of massive fraud is: ‘if you document it, they have to prove it didn’t happen.’ 

Here’s an old story, also from Chicago:

http://articles.chicagotribune.com/1999-12-21/news/9912210114_1_medicare-scam-plea-agreement-civil-cases

http://openjurist.org/156/f3d/784

http://www.encyclopedia.com/doc/1N1-10848766A29A60E0.html

The story, if true, is outrageous. The government is defrauded of 28 million dollars, and the defendant gets 3 years in prison. Worse, if all the relevant financials are contained in the news item, he’s millions ahead. How many? Who knows? We know how much restitution was ordered, but my guess is that only the defendant knows how much money he really collected. It wouldn’t surprise me if the difference is substantially higher than the newspaper item documents. Longer sentences are handed down for much smaller sums with regularity. Going to jail sucks, but there is no question that medicare fraud combines great payout and low risk for bold, competent criminals.

Medicare is not the only federal health care program plagued by allegations of massive provider fraud. This recent story is distressing because it suggests that not only can you run from the law, if you run long enough, you can drop off their radar:

http://www.twincities.com/wisconsin/ci_15599431?nclick_check=1

So how much of this is happening? No one knows. Worse, fewer people care than you might think. Why? Because outright fraud is not where the money is. For the feds, the real money is making providers accept lower payments for services, rendered, and increasing the obstacles that patients/providers have to actually generating care. This last sentence from the first item says it all:

In 2008, authorities required all medical equipment providers in Miami to apply for new certification, hoping the paper hurdle would deter scammers. The number of claims dropped by $1.6 billion.

Does anyone think that there was that much fraud in Miami? No way. If there was, the FBI would have invaded. Nope. 1.6 billion is a LOT of money, way more than the sum of all of the fraud discussed above, and it’s just from Miami. We don’t have data, and thus we can’t know for sure, but my guess is that most of the equipment providers decided that it wasn’t worth the expense to apply for the new certification and simply got out of the medicare business. Fine for them, but this abrupt contraction of providers likely generated significant hardship for medicare patients. Similar strategies to pay less, make it harder to provide and obtain care, and increase the friction associated with generating care are on their way.  They're going to make the administrative burden of providing care in any environment more difficult, and it is likely that they will do little to stop the kind of brazen fraud discussed above.  In spite of the headlines about fraud, most of the savings from pursuing ‘waste, fraud and abuse’ is going to come from providing less and paying less. Ignore what the bureaucrats and politicians say. In this case, the numbers don’t lie.

Perioperative Stent Management

We have our medical students in the neuroICU make informal 15-30 minute summaries of issues relevant to our patients.  We had a patient in our unit who had complex back surgery but had an indwelling drug eluting coronary stent that had been in place for several years.   This is the summary provided which I reproduce here with permission of the student:

Perioperative Stent Management

Carter Clement, UPenn Medical Student  April 23, 2024

 

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (Fleisher et al)

 

1) Balloon Angioplasty

-Healing takes ~2 wks & surgery has high risk of thrombosis in this period

-Increased risk of restenosis after ~8 wks

 

2) Bare Metal Stent (BMS)

-Endothelialization takes 4-6 wks & greatly reduces risk of thrombosis

-Dual antiplatelet therapy (DAT, ASA + thienopyridine) should be given during this period (usually x 4 wks)

-ASA alone should be continued beyond this period 

-Thienopyridine effects persist ~1 wk after drug is stopped, so surgical risk persists in that time

 

3) Drug Eluting Stent (DES)

-Well established risk of late thrombosis (up to 18 months) because drug elution prevents endothelilization

-DAT x 12 months, then ASA only

Other Perioperative Considerations:

-Generally, consider continuation of DAT beyond recommended time frames if high cardiac risk

-Consider continuation of DAT during surgery when possible, especially if:

    -High cardiac risk & low bleeding risk

    -Urgent surgery is necessary before the recommended non-surgical period has expired 

(Exceptions: high risk surgeries such as neurosurgery - weigh risks and benefits on patient-to-patient basis)

 

Long Time No Post

Both Mitch and myself have been consumed with the stuff of life, and have been remiss in posting for a while now.  This post is an attempt to at least call attention to a variety of follow-up stories from themes of the past.

First, the NHS continues to struggle with its own unique combination of limited resources and externally mandated 'performance' or 'quality' targets.  This combined with a variant of a civil service mentality, combined to produce this report:

http://news.bbc.co.uk/2/hi/health/8531441.stm

Secondly, the NHS, chronically short of resources and funds, is doing what every other under-funded government run service is doing: reducing service at a time when demand is surging.  This kind of action can only occur when supply is uncoupled from demand, as is the case when the government budgets health care in an annual funding cycle.  The NHS has long wait-lists for almost every kind of service.  Reducing capacity in the face of such demand is.....

http://news.bbc.co.uk/2/hi/health/8610173.stm

http://news.bbc.co.uk/2/hi/health/8590710.stm

The story of the computerized medical record there has become surreal.  Original launch date: 2006.  Most recent launch date: 2015.

http://news.bbc.co.uk/2/hi/health/8543328.stm

As importantly, as the BBC story points out, there is little or no transparency to these decisions by the NHS.

The NHSis increasingly a political football.  Is this a vision of our future?

http://news.bbc.co.uk/2/hi/health/8343340.stm

http://news.bbc.co.uk/2/hi/health/8570822.stm

http://news.bbc.co.uk/2/hi/health/8614684.stm

And for those of you that ponder such things, the ratio of managers to beds continues to climb:

http://news.bbc.co.uk/2/hi/health/8587122.stm

Think about it: an 84% increase in managers over a decade where hospital beds contracted significantly. I guess it is worth noting that the NHS is almost certainly THE largest employer in England, with more than 2% of the population employed directly by the NHS!

Change of subject: Is this really an accident?

http://news.bbc.co.uk/2/hi/uk_news/8613791.stm

20 organs might not seem like a huge number, and there is no doubt that dozens of recipients benefited from this glitch, but make no mistake: if this were not the result of a software failure, the only question would be: who is going to jail?

The electronic health record continues to produce news, but not in the ways that its proponents hope:

http://spectrum.ieee.org/riskfactor/computing/it/more-hurdles-appear-in-us-electronic-health-record-adoption

Finally, as is often the case, authors of fiction see the world more clearly than we do.  I have carved this delightful quote:

In “The Hostile Hospital,” from the Lemony Snicket “Series of Unfortunate Events” books, the three young orphans at the center of the story visit the fictitious Heimlich Hospital, where Babs, the head of human resources, asks them if they know what the most important work done in a hospital is.

“Healing sick people?” one of the children asks innocently.

“You’re wrong,” Babs growls, silencing the children. “The most important thing we do at the hospital,” she continues without flinching, “is paperwork.”

from this story:

http://www.nytimes.com/2010/04/08/health/08chen.html?ref=health

For practitioners, the new era of reducing 'waste, fraud, and abuse' heralds documentation requirements so onerous that they might drive many to leave the practice of medicine. 

You Know If It You See It! On The Justice's Advice and Conflict of Interest

 

I just published an opinion piece.

 

Kofke  WA:  Disclosure of industry relationships by anesthesiologists:  Is the conflict of interest resolved?  Curr Opinion Anesthesiology 23:177-183, 2010.

 

I was asked to write this and undertook a fairly detailed overview of the literature on the topic.  We use the word “literature” loosely as there is little real data and lots of heart-felt opinion, verities, and dogma; depending on who you read.

 

Medicine is full of examples of people so egregiously conflicted as to astound and produce umbrage.  The top examples:

 

1.       The widespread practice among orthopedic surgeons to “consult” for companies that make the implants they put in patients.  These aren’t little consults.  In quite a few cases the consult fees were in the million(s) dollar range; certainly more than or approximating their clinical income.  Well, these weren’t consults; they were overt bribes in my opinion.  The feds got wind of it and put some controls on the practice through a plea agreement that includes a quantitative listing of company consultants and their fees on their web pages.  This underscored the importance of quantitation in disclosure, a key point of my review.  One defense is that the docs disclosed they were consultants for these companies.  However, I doubt the patients knew their docs were “on the take” for millions.  The amount matters.

 

2.       Docs have been retained by companies to either do research or just consult.  One outcome of such relationships has been the practice of the company writing an article and then asking the doc, for a fee (amount seldom disclosed) to sign off on the content and take authorship credit with the true author not acknowledged.  Disclosure of support is usually acknowledged but not the amount.  This is ghost writing. 

 

The same thing goes on with speakers’ bureaus.  The give the speaker their canned slides and the speaker presents them, acknowledging support, but without quantitative disclosure.  I did this until they made me give the canned talk.  After I refused to do that invites to talk dried up.  I miss the money though, got $1,750 per talk for ESP Pharma.  They try to launder the money by having an education company administer the talks, but the outcome is the same as is the real source of the money.

 

These examples and other such obvious inappropriate practices has led to McCarthy esque backlash with some advocating no interaction of academic centers with industry or that journals not accept industry-supported research for publication.  There are lots of good arguments as to why this is overreacting.

3.      However the extreme to which this can go can lead to scandalous unforeseen consequences as uncritical editors (suckers!) accept without question any article critical of COI practices. 

 

Hirsh published an expose of the August JAMA in Mayo Clinic Proceedings.  The JAMA authors were highly critical of Merck’s ghost writing practices.  This was a very serious and significant article.  Well, it turns out that the authors should get the Pulitzer for unbridled  ribald hypocrisy in medical fiction writing disclosures.

 

 Undisclosed in their article focusing on COI was their own COI, namely that they were themselves consultants for attorneys involved in litigation against Merck!!  Astounding IMHO.  Even more astounding is the almost comically outrageous consulting fees they received:  up to $25 million.  Now, I suggest, the amount matters and this is an undisclosed conflict  with a sum of money that surely impacts on the content of what these authors wrote in JAMA.  Certainly biased work.

 

Between these extremes are a continuum of COI issues which are summarized in the three tables in the article and they are paraphrased here:

 

Table I:  Industry funding of Research

 

              Good Things about it include:

 

·                    Breakthroughs in therapy.

·                    Profit motive drives innovation.

·                    Contract income supports university mission.

·                    Faculty career development is supported.

·                    Create preliminary data for NIH grants.

·                    Attract foreign investment

·                    Development of experts through supporting their involvement in a research area.

 

  However, bad things include: 

 

·                    The emphasis on development of “me-too” drugs means a lot of industry support isn’t driven by innovation but rather market share concerns.

·                    Research is really supported by marketing budgets.

·                    Phase 4 studies are really a marketing means to familiarize docs with new drugs (the company doesn’t care if the research is published).

·                    Research consulting fees can be so excessive as to be kickbacks (bribes) which affect what the consultant (expert) says and writes.

·                    Equity/patent stakes in a company can constitute enormous sums that must induce bias,

·                    Ghost writing, and  ghost speaking

·                    Bounties for per subject research subject recruitment biases entry criteria and can invalidate results.

 

Table II reviews good and bad of industry support of education.

 

            Good Things include:

 

·                    There is a need to get the word out about new things that are available.  Note Steve Shafer’s article on Critical Thinking recounts the issue of a gadget with high grade evidence (but Zilch marketing) for better CPR has not achieved widespread use.

·                    While educating about a product or drug spin off education on related physiology and pharmacology is common.

·                    CME costs less to participants making funds available for other virtuous activities.

·                    Experts can be supported to provide education.

 

Some of the bad things about industry support of education:

·                    Funds come from marketing budgets, reflecting the primary intent of the activity from the sponsor’s perspective.

·                    Speaker pay or financial stake in the sponsor’s success may be enough to guarantee bias.

·                    Junkets to resorts and vacation sites pervert the real intent of the activity while garnering a tax-deductible vacation for speakers and attendees.

·                    Speaker bureaus control what speakers say… “ghost-speaking”.

·                    Involvement of a speaker in a speaker’s bureau gets them out and about enough to become known as an expert who then morphs into a key opinion leader who gives national lectures and writes guidelines. (Grouse)

·                    Ghost writing by industry employees or contractors guarantee bias.

 

Table III overviews industry funding in clinical practice

 

            Good Things include:

 

·                    Timely updates on new products can be provided by industry representatives.

·                    Industry representatives can be a helpful resource for safe introduction of a product into clinical practice.  We see this lot in surgery.

·                    Drug samples can help those who cannot afford them.

·                    Drug samples can allow for low cost evaluation of a drug by a patient and his/her physician

 

Bad things about industry influence in clinical practice include:

 

·                    The primary mission of an industry representative is really to augment company revenue.

·                    Shadowing programs (paid) involving industry representatives can offend patients.

·                    Gifts induce, implicitly, reciprocation.

·                    Kickbacks and bribes happen, but rarely, I think.

·                    Direct to consumer advertising bypasses physician expertise. (My hospital does it too!)

·                    Drug costs seem excessive when viewed in context of lavish drug company profits.

·                    Free samples get patients hooked on expensive drugs.

·                    Free meals are used as a ploy to gain access to docs and develop highly-valued personal relationships with them.

 

So what is a doc to do?  We are just surrounded by these sales pitches and are recurrently subjects of marketing ploys.  There are good spinoffs but also risks of bias of which we all must be wary.  So we should look for disclosures of support by industry and weigh that as we analyze the veracity of what is presented.  Is knowing that enough?

 

No!

 

In my opinion, the amount matters.  I believe disclosures should also include the amount of money, time, and resources made available to a potential instrument of bias.  This instrument could be your doctor, teacher, or reporter of research findings.  Exorbitant support will produce bias.  How do you define exorbitant?  It’s like The Supreme Court Justice Steward said about porno…you know it if you see it.

 

 

 

My Favorite References on COI

 

Angell M. The truth about drug companies. How they deceive us and what to do about it.

New York

: Random House; 2005.

 

Stossel TP. Divergent views on managing clinical conflicts of interest. Mayo Clinic Proc 2007; 82:1013–1014.

 

 Stossel TP. Regulating academic-industrial research relationships: solving problems or stifling progress? N Engl J Med 2005; 353:1060–1065. Stossel TP, Stossel TP. Has the hunt for conflicts of interest gone too far? Yes [see comment]. Br Med J 2008; 336:476.

 

Hirsch LJ. Conflicts of interest, authorship, and disclosures in industry-related scientific publications: the tort bar and editorial oversight of medical journals. Mayo Clinic Proc 2009; 84:811–821.

 

Lanier WL. Bidirectional conflicts of interest involving industry and medical journals: who will champion integrity? Mayo Clinic Proc 2009; 84:771–775.

 

 Lo B, Field MJ  Conflict of interest in medical research, education and practice.

Washington

DC

: Committee on Conflict of Interest in Medical Research, Education, and Practice;

Institute

of

Medicine

.

National

Academy

of Sciences. National Academies Press; 2009.

 

Shafer SL. Critical thinking in anesthesia: eighth Honorary FAER Research Lecture. Anesthesiology 2009; 110:729–737.

 

Toland B. Are doctors getting fees or ’bribes’? Pittsburgh Post-Gazettecom Business [Newspaper] 2007 November 7, 2023 [cited 2009 July 30, 2009; newspaper article]. http://www.postgazette.com/pg/07311/831621-28.stm.

 

27 Grouse L. Physicians for sale: how medical professional organizations exploit their members. Medscape J Med 2008; 10:169.

 

Willyard C. Physicians fight back against disclosure rules. Nature 2009; 460:556–557.

 

Bringing Resuscitation into the 21st century, or Seeing is Believing...

I do a fair amount of trauma anesthesia. An important part of trauma bay resuscitation is a quick and dirty transcutaneous ultrasound evaluation; Heart, pleural space, liver, spleen, bladder.

 Fifteen years ago, one of my partners had a patient develop pulseless electrical activity (PEA)  in the middle of an ortho case. (Well, actually, the story is so old that the patient developed what was then called electro-mechanical dissociation, EMD; same thing, different era…)

Anyway, she dropped a TEE (we were in a mixed cardiac practice), diagnosed a saddle embolus, the patient’s chest was opened, thrombectomy was performed, and he survived  (not without  a stormy course, of course.)

 I recently was discussing ACLS with a young cardiology colleague, and we were both discussing the ACLS “cookbook.” We were talking about  the least-common-denominator limitations of the ACLS system, and pretty quickly fell onto the usefulness of echo in sorting out PEA.  Virtually all the  non-metabolic etiologies of PEA (and tachycardia/hypotension) are amenable to echo diagnosis, and the windows required are not particularly difficult to grab; it’s basically a ventricular view. We’re not looking to diagnose aortic stenosis here. And an echo is instantly confirmatory (or not!) of asystole or v-fib. Ever see a v-fib which proves to be a lousy ecg signal with what is in fact, PEA with a beating, empty heart? I have.

There are a few implications of this discussion, some theoretical, some tactical.

First, my anesthesiology colleagues resent having to maintain ACLS certification; as one of them put it, “it’s like making a master chef take remedial sauce-making every two years.” I am such a "master-chef'," and I couldn’t disagree more, for three reasons.

First, I have seen too many codes botched by “bread-and-butter” anesthesiologists over the past two decades to harbor any illusions about the “master chef” designation of anesthesiologists a decade or more out of training. Many of them are right there, but some of them are not.

Secondly, ACLS is about a team approach to a high-tempo crisis. The team expects certain behaviors from the leader; if the leader does not fit her management style into a response pattern expected by the conditioning of the team, confusion and disorganization are the consequence. Especially with the young generation of clinician nurses, they need explanations to be comfortable, and once you have established your familiarity with the standard therapies, they will accept variation with brief explanation. I am reminded here of innovators like John Coltrane,  whose extraordinary trail blazing virtuosity was validated by his equally extraordinary command of the the traditional ballad-bebop forms. You gotta start from terra-cognita on your way to terra-nueva (we’re leaving out terra-incognita here…)

Finally. Things change. Aloha, bretylium and procainamide, welcome, Amiodarone. You can't ell the players without a program.

But I digress. I feel strongly that we ought to have a simple echo (like a sono-site; there is a great subcostal view to the right here) available at EVERY code, and the team ought to be trained to get the

windows that tell you what you need to know to diagnose the mechanical causes of PEA. It’s time. There are no disposables, so it’s a one-time cost. If you are being fussy about sterility, a sandwich bag with a tie-wrap, or a transderm-type occlusive sticky  will do.  I suppose you could have the ultrasonography team respond to every code as an alternative. But that seems like overkill, and in any case, crowds the room. It's time to do the (inevitable) validation work with and without. After all, an artist is only as good as his tools...

Seeing it from Both Sides

As the debate over health care reform waxes on, both sides have turned up the rhetoric, and moderate or reasonable voices on either side are being shouted down and lambasted.

On the Pro-Reform side,  there is this recent commentary from Don Wycliff in the Chicago Tribune:

http://www.chicagotribune.com/news/opinion/chi-oped0903wycliffsep03,0,2484870.story

He astutely points out that the federal government is already deeply engaged in providing or facilitating health care for millions of US citizens. His list includes the following entities, all of which would have to be eliminated to get the federal government ‘out’ of health care.

    - Medicare

    - Medicaid

    - VA health care

    - Military Health care

    - Indian Health service

    - the Surgeon General

    - the CDC and the NIH.

 A few observations:

- I’ve already written a substantial amount about the failures of the VA system, and how remarkably disinterested anyone appears to be in fixing them.  The current movement is no exception: there is no discussion of fixing the problems that everyone admits plague the VA system.  Veterans with the means to do so obtain their care elsewhere.  If the VA is a barometer of how the feds will deliver health care, then the results are cause for concern, not optimism. Also concerning is that there is little discussion from either side about fixing the VA. We owe it to our veterans to do vastly better, regardless of how the current debate goes.

- Medicaid is not entirely a federally run program ,it is administered locally by the states, and has generated a patchwork quilt of coverage that verges on ridiculous.  The hospital where I work is located near the Indiana border, and is the closest tertiary care center for the hundreds of thousands of people who live in nearby Indiana.  We can care for their insured, but not for their Medicaid.

- Medicare is a big bite, too big for this post.  Let’s just say that as Medicare demands more and pays less, care for medicare patients is going to be increasingly difficult to obtain.

- The Indian Health Service is worthy of its own post, but I am unlikely to ever get around to generating it.  The spectrum of people who provide care for the IHS includes some of the very best doctors I have ever met, to doctors who cannot obtain any other employment.

 - The NIH provides little care, and the CDC almost none at all.  Both represent enormous public good, and very worthwhile outlays of federal tax dollars.  While libertarians represent that the free market would create both entities if the feds did not; the fact that nothing resembling either one exists in any other country makes me certain that this contention is absolutely wrong.

On the other side of the debate is this break down of the numbers by Dennis Byrne, also published as a commentary in the Chicago Tribune:

http://www.chicagotribune.com/news/opinion/chi-oped0825byrneaug25,0,7272374.story

First, the commentary on this one, which is posted below the article itself, is fairly typical of the partisan bomb-throwing that has been going on.  The president may have wanted honest discussion, but this topic has provoked both sides to talk at each other, not to each other.

Byrne’s numbers:

- 46 million uninsured, of them:

    - 9.5 million illegals

    - 12 million eligible for some sort of government program, but have not bothered to sign up.  Given the nature of government bureaucracy, this is unsurprising.

    - 9.1 million people who are between jobs and temporarily uninsured.

    - 7.3 million families with an income greater than $84,000/yr

    - and finally, about 8 million working poor, without insurance.

First, if we’re not going to cover the illegals, we shouldn’t include them in the count.

Second, the 7.3 million families with an income of 84k or higher are either living as a free people should be allowed to, or a group of free riders who should be made to pay or play.

Third, the temporarily uninsured are truly uninsured. For almost everyone who is unemployed, the cost of continuing their employer sponsored health plan would consume their unemployment benefit.  If they want to eat, they cannot continue their health insurance.

Fourth, make it easier for those eligible to sign up for the government programs that already exist.  Be warned: doing this will increase the expense of these programs.  Interestingly, if this number is correct, Obama could generate health care for most of these people with a minimal investment in supporting and expediting their enrollment.  This would not require an overhaul in the system, but would require the money to care for an additional 12 million people.

Fifth, understand that the real issue here are the 8 million working poor and the 9.1 million between jobs.

Finally, there are ways of controlling health care costs that have not yet been incorporated into the language of any of the bills under consideration:

http://townhall.com/columnists/HughHewitt/2009/09/04/without_tort_reform,_it_isnt_health_care_reform_--its_a_plaintiffs_lawyers_protection_act?page=1

 Mr Hewitt is correct and very clever to have thought of this.

Brits throwing Granny Under the Tram?

A century-and-a-half ago, give or take a few years, a clinical/philosophical battle raged around the issue of surgical anesthesia. A school of thought, the "heroic" school, asserted that no morbidity or mortality was justified for the mere alleviation of pain and suffering, and they plainly rejected ether or chloroform on that grounds. Citing scripture and asserting a belief that pain was necessary for healing, they nevertheless gave way before a utilitarian understanding that the advantages of surgical anesthesia were worth some risk, and a relatively high risk it was. While anesthesia enjoys a mortality rate of probably 1:250000 now, in 1850 it was probably more like 1:300 give-or-take.Over the decades the same utilitarian calculus has been worked countless times for every therapy, from antibiotics (anaphylaxis! Stevens Johnson syndrome!) to elective cholecystectomy (bleeding! infection! Death!). A weighing of risk versus benefit.

In this case, The Liverpool Care Pathway, a protocol for providing comfort to patients who are judged by their caregivers as being close to the end-of-life, has been indicted as theoretically precipitating untimely death. The indictment is anecdotal opinion, but is reasonable in its concern; that the withholding of nutrition and hydration, and the administration of narcotics and sedation for the amelioration of pain can provoke death in a patient who in fact might not have otherwise died near term.How does this differ from the decision to extirpate an otherwise healthy 35 year old's gall bladder, based upon their colicky intolerance of mexican food, knowing that there is a distinct, if rare, incidence of death? Well, I suppose one could argue that the 35 year old is able to give informed consent, although I have yet to believe that any lay patient understands the risk of pulmonary embolus or common duct ligation. 

Could it be the relative imminence of death inherent in the decision to withdraw support? If so, then the issue is merely one of popular lack of understanding, since nothing is quite so dramatically imminent as a saddle pulmonary embolus in an otherwise healthy 35 year old.

Or are we uncomfortable because they are potentially "burying their mistakes" beyond the reach of oversight by virtue of the very nature of the intervention (or withdrawal thereof).

Or is it that there is an insidious dual-agency conflict here, with the care team acting as an economic agent of the state, callously inducing health care efficiencies by knocking off granny a couple of days, (or weeks?) early. Well, maybe. And maybe, the anecdotal warning of the experts is just that; a warning that one must be particularly careful about diagnosing futility prior to instituting self-fulfilling care plans. As they say in drowning resuscitation, the patient is not dead until they are WARM and dead, as a reminder that hypothermia can mask a survivable situation. And just maybe in turn, that warning was grasped by a controversy-hungry newsperson, preying upon the public mistrust of impersonal beaurocracy to gin up a little newsProbably it's all of the above, but the question remains, do the benefits of not forcing the dying to linger in suffering outweigh the risks of early death for the few who might have lived a little longer, or supersede the concern that compassionate facilitation becomes hard-hearted sacrifice for the "public good." 

 I'm with Ross Douthat in his recent op-ed on "slippery-slope"-ism in euthanasia. (And the Liverpool Care Plan certainly is euthanasia though late term euthanasia it may be.) On my list of likely slopes to slide down, the euthanasia-as-cost savings risk is pretty far down my worry list, Sen Grassley and citizen Palin notwithstanding.