Our entire hospital booted up a new Electronic Medical Record (EMR), from top to bottom, we are now an Epic facility. Today was my first shift in the ER after go-live, which was Saturday. Holy smokes, what a project it was to get it up and running. This system now runs everything in the hospital, from the ER to the OR to the wards, to the business and billing function, stocking, housekeeping, nursing, RT/PT/OT, social work -- EVERYTHING. And we went live with a "big bang," all at once.
The good news? It went, if not perfectly, very well, and certainly better than expected. There were no major issues, which was a huge relief since the programming team was frantically building critical elements until the day before go-live. It's really disconcerting to sit with tutors three days before the event, ask how to order labs, and be told, "well, this is how you'll do it, but you can't do it now since that module is still in development." But to their credit, they got it done and it works.
The bad news? Not too much, other than the fact that the system is massive and really, really complex. This makes the learning curve super steep, and the impact on operations during the first week has been substantial. We have lots of support, with tutors and specialists standing by our elbows guiding us through each workflow, but every simple little thing takes forever as you're learning it.
How complex is this system? Just my interface, and I am but one provider of many classes, has by my count at least 15 different screens I interact with, and each screen has dozens of widgets and elements I need to operate. Worse, the behavior of each widget isn't always consistent from one context to the next. There are multiple ways to get some common tasks done, which is nice, but it's so easy to get lost in all the menus, windows and panes. It's pretty overwhelming, and mistakes can be frustrating to undo.
And I'm an eager adopter, a computer savvy guy. For me to be completely on overload, I pity some of the less nerdy folks working in our hospital.
I don't want you to think I'm down on this system. I loved our old EMR, Picis, because it was super elegant and simple and easy to get stuff done. This is much more intricate, which is a big challenge to learn but -- I think -- will be more powerful once I get it mastered. I can see myself being much more efficient than I was before within a couple of months. I hope.
For those who are interested, we have the ASAP module with the Notewriter function, but my off-the-cuff reaction is that Notewriter is utter crap and I don't think I'll ever use it. I've constructed a H&P skeleton with a lot of datapoints auto-populated from the chart and I am using Dragon dictation. The current release of Dragon seems much more accurate than older ones I have used, and there were Dragon experts there giving us lots of tips & tricks to really take advantage of the shortcuts available.
For example, I can order meds & labs verbally, and even common lab panels, using the mic. I can also drop in a standard age/gender/complaint specific physical exam with three words. (IMPORTANT: proofread/edit the output to make sure it's appropriate for the actual patient!) Also, I've made a slew of medical decision making notes with links that pull in personal/clinical data from the chart for common situations.
So it's a powerful tool, and I may wonder how I ever got by without it in a year or two. But for now, my head is spinning and I've gotta go lie down.
[EDIT: The de-identified screenshot was provided by the nice folks at Epic.]
Our entire hospital booted up a new Electronic Medical Record (EMR), from top to bottom, we are now an Epic facility. Today was my first shift in the ER after go-live, which was Saturday. Holy smokes, what a project it was to get it up and running. This system now runs everything in the hospital, from the ER to the OR to the wards, to the business and billing function, stocking, housekeeping, nursing, RT/PT/OT, social work -- EVERYTHING. And we went live with a "big bang," all at once.
The good news? It went, if not perfectly, very well, and certainly better than expected. There were no major issues, which was a huge relief since the programming team was frantically building critical elements until the day before go-live. It's really disconcerting to sit with tutors three days before the event, ask how to order labs, and be told, "well, this is how you'll do it, but you can't do it now since that module is still in development." But to their credit, they got it done and it works.
The bad news? Not too much, other than the fact that the system is massive and really, really complex. This makes the learning curve super steep, and the impact on operations during the first week has been substantial. We have lots of support, with tutors and specialists standing by our elbows guiding us through each workflow, but every simple little thing takes forever as you're learning it.
How complex is this system? Just my interface, and I am but one provider of many classes, has by my count at least 15 different screens I interact with, and each screen has dozens of widgets and elements I need to operate. Worse, the behavior of each widget isn't always consistent from one context to the next. There are multiple ways to get some common tasks done, which is nice, but it's so easy to get lost in all the menus, windows and panes. It's pretty overwhelming, and mistakes can be frustrating to undo.
And I'm an eager adopter, a computer savvy guy. For me to be completely on overload, I pity some of the less nerdy folks working in our hospital.
I don't want you to think I'm down on this system. I loved our old EMR, Picis, because it was super elegant and simple and easy to get stuff done. This is much more intricate, which is a big challenge to learn but -- I think -- will be more powerful once I get it mastered. I can see myself being much more efficient than I was before within a couple of months. I hope.
For those who are interested, we have the ASAP module with the Notewriter function, but my off-the-cuff reaction is that Notewriter is utter crap and I don't think I'll ever use it. I've constructed a H&P skeleton with a lot of datapoints auto-populated from the chart and I am using Dragon dictation. The current release of Dragon seems much more accurate than older ones I have used, and there were Dragon experts there giving us lots of tips & tricks to really take advantage of the shortcuts available.
For example, I can order meds & labs verbally, and even common lab panels, using the mic. I can also drop in a standard age/gender/complaint specific physical exam with three words. (IMPORTANT: proofread/edit the output to make sure it's appropriate for the actual patient!) Also, I've made a slew of medical decision making notes with links that pull in personal/clinical data from the chart for common situations.
So it's a powerful tool, and I may wonder how I ever got by without it in a year or two. But for now, my head is spinning and I've gotta go lie down.
[EDIT: The de-identified screenshot was provided by the nice folks at Epic.]
The genesis for the idea of denying payment for nonemergency ED visits is frequently traced to the research of John Billings, a professor of health policy at New York University. In the early 2000s, he developed an algorithm that used discharge diagnoses to identify ED visits that are "ambulatory care sensitive." In his view, ambulatory care-sensitive visits fall into one of two groups: those that are "primary care treatable," meaning that the problem could safely be managed in a doctor's office, and those that are "primary care preventable," meaning that the visit might have been averted if care had been provided sooner. An uncomplicated lower urinary tract infection would be considered "primary care treatable." An asthma flare-up would be categorized as "primary care preventable." Unfortunately, policymakers have generally misinterpreted Billings's findings. The fact that many ED visits could be managed in primary care settings does not mean that such care is available. In fact, Billings himself asserted that high rates of ED use for ambulatory care-sensitive conditions are a strong indicator of poor access to care -- not poor judgment on the part of patients.
I couldn't have said it better myself. Which, I suppose is why I'm writing here and he's writing in NEJM. One other nugget I wanted to expand on -- Kellerman writes:
Perhaps the Authority's actions will encourage Medicaid beneficiaries to forgo nonemergency ED visits and instead forge enduring relationships with primary care providers.
This is an important point that goes beyond access to care -- note the words "enduring relationships." That's a pretty huge element of primary care. I've been with my PCP for a dozen years. (Oddly he was medicine chief resident in my university when I was a 3rd year med student, in a university 2500 miles away. Life is weird.) The family practitioner who delivered me was still my doctor when I got accepted to medical school. These relationships are enduring and that's a big part of why they are so valuable. They are also a big part of why med students go into primary care.
Now our community has decent access to primary care. It's not great, but I am sure it's better than some places. We have a large and reasonably well-funded network of Community Health Centers (many of which were funded by Obama's ARRA and ACA, but that's another topic). They're overburdened; the demand exceeds their capacity, but they do good work with limited resources. Unfortunately, the doctors there are not well paid, many are doing public service to get loan forgiveness, and they tend to come and go pretty frequently. They have decent access for acute care, again, they do their best, but most urgent visits get shunted to an urgent care area staffed by mid-level providers, not the regular medical staff.
Commonly enough, I see CHC patients in the ER with, as Dr Kellerman calls them, "ambulatory care sensitive conditions." Cutting the BS, these are trivial things to go to an ER for. Cough/URI. UTI. Flu. Medicine refills. A rash. Back pain. We all know the non-emergency crap that fills our ERs, and despite ACEP's dishonest PR claims, it's a hell of a lot more than 7% of ER cases.
So why do these patients come to the ER instead of accessing their established primacy care doctor? They do have them, so what's the issue? Well, I make it a point to ask them, politely and non-judgmentally. Part of it is my curiosity, and part is to encourage them to actually go there in the future. The answers I get generally fall into about three distinct categories:
Anxiety
Access
Absence of Relationship
Anxiety is straightforward enough: "My baby (18 months old) had a fever and a cough and I'm an 18 year old single mother and I was worried." Fair enough. Access is also a common issue: "I called the clinic but they didn't have any openings." Again, I can't argue with that. But I have been surprised at how often the reason patients give for bypassing their PCP and coming to the ER is that they don't feel like they have a relationship with an actual person: "Every time I go there I see someone different."
This is actually huge, and commonly overlooked. I go to see my doctor because I like him and trust him, and he knows me. If I had to go to a clinic where I'd never see the same person twice, well, the added value of that over an ER is nil, and on top of that you have to call and get and appointment and wait for the appointment, while the ER is just "drop in convenience." From the perspective of the patient, especially a medicaid, "cost-insensitive" patient, I can see why they come to the ER.
I don't know what the solution is. I don't see more money coming into the care-for-the-indigent tier of our two-tier health care system, and as more patients come onto medicaid in coming years, I can only assume the access barriers and the depersonalization of the CHC system will worsen before it gets better.
We'll be here to see them in the ER. Hopefully the state won't punish us by refusing to pay.
The genesis for the idea of denying payment for nonemergency ED visits is frequently traced to the research of John Billings, a professor of health policy at New York University. In the early 2000s, he developed an algorithm that used discharge diagnoses to identify ED visits that are "ambulatory care sensitive." In his view, ambulatory care-sensitive visits fall into one of two groups: those that are "primary care treatable," meaning that the problem could safely be managed in a doctor's office, and those that are "primary care preventable," meaning that the visit might have been averted if care had been provided sooner. An uncomplicated lower urinary tract infection would be considered "primary care treatable." An asthma flare-up would be categorized as "primary care preventable." Unfortunately, policymakers have generally misinterpreted Billings's findings. The fact that many ED visits could be managed in primary care settings does not mean that such care is available. In fact, Billings himself asserted that high rates of ED use for ambulatory care-sensitive conditions are a strong indicator of poor access to care -- not poor judgment on the part of patients.
I couldn't have said it better myself. Which, I suppose is why I'm writing here and he's writing in NEJM. One other nugget I wanted to expand on -- Kellerman writes:
Perhaps the Authority's actions will encourage Medicaid beneficiaries to forgo nonemergency ED visits and instead forge enduring relationships with primary care providers.
This is an important point that goes beyond access to care -- note the words "enduring relationships." That's a pretty huge element of primary care. I've been with my PCP for a dozen years. (Oddly he was medicine chief resident in my university when I was a 3rd year med student, in a university 2500 miles away. Life is weird.) The family practitioner who delivered me was still my doctor when I got accepted to medical school. These relationships are enduring and that's a big part of why they are so valuable. They are also a big part of why med students go into primary care.
Now our community has decent access to primary care. It's not great, but I am sure it's better than some places. We have a large and reasonably well-funded network of Community Health Centers (many of which were funded by Obama's ARRA and ACA, but that's another topic). They're overburdened; the demand exceeds their capacity, but they do good work with limited resources. Unfortunately, the doctors there are not well paid, many are doing public service to get loan forgiveness, and they tend to come and go pretty frequently. They have decent access for acute care, again, they do their best, but most urgent visits get shunted to an urgent care area staffed by mid-level providers, not the regular medical staff.
Commonly enough, I see CHC patients in the ER with, as Dr Kellerman calls them, "ambulatory care sensitive conditions." Cutting the BS, these are trivial things to go to an ER for. Cough/URI. UTI. Flu. Medicine refills. A rash. Back pain. We all know the non-emergency crap that fills our ERs, and despite ACEP's dishonest PR claims, it's a hell of a lot more than 7% of ER cases.
So why do these patients come to the ER instead of accessing their established primacy care doctor? They do have them, so what's the issue? Well, I make it a point to ask them, politely and non-judgmentally. Part of it is my curiosity, and part is to encourage them to actually go there in the future. The answers I get generally fall into about three distinct categories:
Anxiety
Access
Absence of Relationship
Anxiety is straightforward enough: "My baby (18 months old) had a fever and a cough and I'm an 18 year old single mother and I was worried." Fair enough. Access is also a common issue: "I called the clinic but they didn't have any openings." Again, I can't argue with that. But I have been surprised at how often the reason patients give for bypassing their PCP and coming to the ER is that they don't feel like they have a relationship with an actual person: "Every time I go there I see someone different."
This is actually huge, and commonly overlooked. I go to see my doctor because I like him and trust him, and he knows me. If I had to go to a clinic where I'd never see the same person twice, well, the added value of that over an ER is nil, and on top of that you have to call and get and appointment and wait for the appointment, while the ER is just "drop in convenience." From the perspective of the patient, especially a medicaid, "cost-insensitive" patient, I can see why they come to the ER.
I don't know what the solution is. I don't see more money coming into the care-for-the-indigent tier of our two-tier health care system, and as more patients come onto medicaid in coming years, I can only assume the access barriers and the depersonalization of the CHC system will worsen before it gets better.
We'll be here to see them in the ER. Hopefully the state won't punish us by refusing to pay.
Andrew Sullivan fumes over the fact that the price of healthcare continues to go up despite the fact that utilization is not, and concludes that healthcare providers (generally hospitals and doctors) are "rent -seeking." The allegation here is that doctors and hospitals are jacking up the prices for services simply because they can, because they (we) enjoy a monopoly on the provision of healthcare and are able to set rates as we see fit.
There is a grain of truth to this logic which makes it an appealing argument. Part of my job is to fight with insurance company executives for the highest possible reimbursement. It's always, as the euphemism goes, a "spirited discussion." Sometimes I win and get more money, sometimes not. In my state, and in my experience, there's been a balanced power dynamic where neither the payers nor the providers enjoy significant leverage over the other. There are, however, many states where payers have de facto rate-setting power, and there are some markets in which certain providers, due to their size or cachet, are able to drive these negotiations towards outsized reimbursements.
But what of Andrew's central allegation? Is this, as the puts it, "The Great Healthcare Rip-off"?
I don't think so, at least not in the sense that we are using whatever leverage we enjoy to create outsized profits. Healthcare is a low-profit business. According to the AHA's Trends in Hospital Financing, the typical hospital's operating margin hovers between 2-4%, and about a third of hospitals run a negative operating margin in any given year.
Point is, that if hospitals do have price-fixing capabilities, they're certainly not using them to pad the bottom line. At least, not very effectively.
Similarly, physicians' income does not seem to be positively affected by this market power. Last time I looked at the raw data was in 2008, when I found that for the previous decade physicians' income had been flat-to-declining compared to inflation. I haven't seen any evidence that that trend has changed, and a quick glance at BLS data doesn't seem to show a spike in doctors' income.
So again, across the industry, I don't see evidence of profiteering. If anything, healthcare providers are just frantically trying to offset the losses from the economic downturn and reductions in public insurance reimbursements.
The DaVinci robot. It's the coolest, got-to-have medical gadget of the decade. It does minimally invasive surgeries, particularly pelvic surgeries like prostate removal. And it is awesome. Check out this video of Swedish Hospital neurosurgeon Dr James Porter as he makes a paper airplane the size of a penny with the DaVinci:
As a gadget guy, I get the allure of such a toy, and the promise is exceptional. All the other hospitals in our area got these, at a cost of a couple of million dollars each, and the urologists at our hospital demanded that our facility purchase one also. If we didn't, they worried, we would be at a competitive disadvantage and would lose cases to regional rivals. Despite the relatively lower case volume and lack of a business case for the investment, they got their wish and we have the gadget too.
So the medical market is dysfunctional in a unique way: competition increases costs. This turns the laws of economics on it head, since in most other industry, increased competition drives prices down, not up. See: Walmart.
Which brings us to the other big reason that US healthcare is so damn expensive. Physicians continue, over and over, to do procedures like DaVinci prostatectomies, like knee arthroscopies, like lumbar diskectomies, like coronary stenting for stable angina, like MRIs for low back pain, and many more, despite the fact that they have not been proven to be more effective or in some cases have been proven to be ineffective or harmful!
Of course, it's hard to convince someone that a procedure doesn't work when their income depends on their not understanding that fact.
So, returning to Andrew's thesis -- is American healthcare a "rip-off"? Yes, in the sense that the market is broken and full of perverse incentives and inefficiencies, and yes in the simple sense that we pay twice as much as the rest of the world and get no more value from that extra investment. But no, not in the sense that physicians and hospitals are deliberately maximizing their monopoly powers to realize excess value.
*Disclaimer: yes, I know the data is conflicting, and am very skeptical of the industry supported data showing benefit, given the huge profits the device manufacturers are making. Suffice it to say the technology is controversial, and that the enthusiasm for its adoption far exceeds any reasonable demonstrated cost-benefit ratio.
Andrew Sullivan fumes over the fact that the price of healthcare continues to go up despite the fact that utilization is not, and concludes that healthcare providers (generally hospitals and doctors) are "rent -seeking." The allegation here is that doctors and hospitals are jacking up the prices for services simply because they can, because they (we) enjoy a monopoly on the provision of healthcare and are able to set rates as we see fit.
There is a grain of truth to this logic which makes it an appealing argument. Part of my job is to fight with insurance company executives for the highest possible reimbursement. It's always, as the euphemism goes, a "spirited discussion." Sometimes I win and get more money, sometimes not. In my state, and in my experience, there's been a balanced power dynamic where neither the payers nor the providers enjoy significant leverage over the other. There are, however, many states where payers have de facto rate-setting power, and there are some markets in which certain providers, due to their size or cachet, are able to drive these negotiations towards outsized reimbursements.
But what of Andrew's central allegation? Is this, as the puts it, "The Great Healthcare Rip-off"?
I don't think so, at least not in the sense that we are using whatever leverage we enjoy to create outsized profits. Healthcare is a low-profit business. According to the AHA's Trends in Hospital Financing, the typical hospital's operating margin hovers between 2-4%, and about a third of hospitals run a negative operating margin in any given year.
Point is, that if hospitals do have price-fixing capabilities, they're certainly not using them to pad the bottom line. At least, not very effectively.
Similarly, physicians' income does not seem to be positively affected by this market power. Last time I looked at the raw data was in 2008, when I found that for the previous decade physicians' income had been flat-to-declining compared to inflation. I haven't seen any evidence that that trend has changed, and a quick glance at BLS data doesn't seem to show a spike in doctors' income.
So again, across the industry, I don't see evidence of profiteering. If anything, healthcare providers are just frantically trying to offset the losses from the economic downturn and reductions in public insurance reimbursements.
The DaVinci robot. It's the coolest, got-to-have medical gadget of the decade. It does minimally invasive surgeries, particularly pelvic surgeries like prostate removal. And it is awesome. Check out this video of Swedish Hospital neurosurgeon Dr James Porter as he makes a paper airplane the size of a penny with the DaVinci:
As a gadget guy, I get the allure of such a toy, and the promise is exceptional. All the other hospitals in our area got these, at a cost of a couple of million dollars each, and the urologists at our hospital demanded that our facility purchase one also. If we didn't, they worried, we would be at a competitive disadvantage and would lose cases to regional rivals. Despite the relatively lower case volume and lack of a business case for the investment, they got their wish and we have the gadget too.
So the medical market is dysfunctional in a unique way: competition increases costs. This turns the laws of economics on it head, since in most other industry, increased competition drives prices down, not up. See: Walmart.
Which brings us to the other big reason that US healthcare is so damn expensive. Physicians continue, over and over, to do procedures like DaVinci prostatectomies, like knee arthroscopies, like lumbar diskectomies, like coronary stenting for stable angina, like MRIs for low back pain, and many more, despite the fact that they have not been proven to be more effective or in some cases have been proven to be ineffective or harmful!
Of course, it's hard to convince someone that a procedure doesn't work when their income depends on their not understanding that fact.
So, returning to Andrew's thesis -- is American healthcare a "rip-off"? Yes, in the sense that the market is broken and full of perverse incentives and inefficiencies, and yes in the simple sense that we pay twice as much as the rest of the world and get no more value from that extra investment. But no, not in the sense that physicians and hospitals are deliberately maximizing their monopoly powers to realize excess value.
*Disclaimer: yes, I know the data is conflicting, and am very skeptical of the industry supported data showing benefit, given the huge profits the device manufacturers are making. Suffice it to say the technology is controversial, and that the enthusiasm for its adoption far exceeds any reasonable demonstrated cost-benefit ratio.
Grandmaster is a remarkable person, to put it mildly and with a great degree of understatement. He survived the Battle of Okinawa as a young child and endured much deprivation in the years to follow. He chose to dedicate his life to the study and preservation of the traditional Okinawan martial arts as a young man and continues to do so. He has been a 10th degree black belt for 25 years! He is, it seems, as old as the hills and as enduring. He is pushing 80, but still as tough as nails. Standing a diminutive 5'0", he can toss young men about like rag dolls, despite the fact that they have 12 inches of height, 60 lbs, and 50 less years of age on them. And his bones are so dense that blocking his punches feels like smashing your forearms into a cement wall.
Age is beginning to take a little toll on him: his kicks are no longer any higher than his waist, and workouts of longer than two hours are taxing. Still, I can only hope to be in as good shape when I am 80.
We also benefitted from a great degree of personal instruction from Kaicho. The man is amazing with the fluidity and precision of his movements, and his discerning eye which will spot (and correct) a student's most subtle flaws -- a slight misalignment of this hips, say, or a strike which arcs in an inaccurate angle. The legend is that in all his years of competition in karate tournaments he was never once deducted a point, except one time when he forgot his belt. When he enrolled in tournaments, the other competitors would drop out. Having the opportunity to observe him up close, I believe it.
This weekend we worked on kata (traditional forms) and some sport kata (forms adapted for tournaments), as well as fighting drills and tuite (standing grappling techniques) and time with traditional martial arts weapons. This in addition to a great deal of conditioning work and body toughening.
We shared a lot of sweat and bruises. Sometimes it seems as if nothing in the words is as funny as watching a close friend writhing in pain as Grandmaster demonstrates a particularly agonizing maneuver on him. And a few minutes later, it is your turn to experience the pain as you become the tackling dummy. Afterwards, you rub your wrists or neck or wherever the technique was performed, and all you can do is laugh. But it's a gift as well: once you've had a joint lock performed on you, you will never forget how it works and how to apply it yourself.
A weekend of karate -- inspiration from the great masters and comradeship with our fellow students. Good times.
And if you see me walking funny in the ER tonight, you'll know why.
Grandmaster is a remarkable person, to put it mildly and with a great degree of understatement. He survived the Battle of Okinawa as a young child and endured much deprivation in the years to follow. He chose to dedicate his life to the study and preservation of the traditional Okinawan martial arts as a young man and continues to do so. He has been a 10th degree black belt for 25 years! He is, it seems, as old as the hills and as enduring. He is pushing 80, but still as tough as nails. Standing a diminutive 5'0", he can toss young men about like rag dolls, despite the fact that they have 12 inches of height, 60 lbs, and 50 less years of age on them. And his bones are so dense that blocking his punches feels like smashing your forearms into a cement wall.
Age is beginning to take a little toll on him: his kicks are no longer any higher than his waist, and workouts of longer than two hours are taxing. Still, I can only hope to be in as good shape when I am 80.
We also benefitted from a great degree of personal instruction from Kaicho. The man is amazing with the fluidity and precision of his movements, and his discerning eye which will spot (and correct) a student's most subtle flaws -- a slight misalignment of this hips, say, or a strike which arcs in an inaccurate angle. The legend is that in all his years of competition in karate tournaments he was never once deducted a point, except one time when he forgot his belt. When he enrolled in tournaments, the other competitors would drop out. Having the opportunity to observe him up close, I believe it.
This weekend we worked on kata (traditional forms) and some sport kata (forms adapted for tournaments), as well as fighting drills and tuite (standing grappling techniques) and time with traditional martial arts weapons. This in addition to a great deal of conditioning work and body toughening.
We shared a lot of sweat and bruises. Sometimes it seems as if nothing in the words is as funny as watching a close friend writhing in pain as Grandmaster demonstrates a particularly agonizing maneuver on him. And a few minutes later, it is your turn to experience the pain as you become the tackling dummy. Afterwards, you rub your wrists or neck or wherever the technique was performed, and all you can do is laugh. But it's a gift as well: once you've had a joint lock performed on you, you will never forget how it works and how to apply it yourself.
A weekend of karate -- inspiration from the great masters and comradeship with our fellow students. Good times.
And if you see me walking funny in the ER tonight, you'll know why.
I can't believe we are still having this conversation. Really, it kind of makes me sick. I've been beating this dead horse for five years now, but I guess it's worth saying again.
And I'd like to expand on their points a little bit.
What the ER does (because federal law says we have to):
Examine every patient who walks or rolls through our doors.
Screen for life-threatening disease or other conditions which present an imminent threat to health and bodily function.
Provide necessary stabilizing care for the above.
What the ER does (because we are nice people and like helping patients):
Treat minor injuries and acute but not life threatening illnesses.
Treat exacerbations or decompensations of chronic illnesses.
What the ER does not do:
Provide comprehensive, integrated, longitudinal health care.
Provide screening and health maintenance services.
Manage chronic illnesses.
Provide guaranteed access to subspecialty care.
So, if you come in because you are pooping blood and it's serious enough that something needs to be done to stop the bleeding, you're in luck! We can do that. But if, say, you come in because you're tired and I notice that you are slightly anemic with a very low-grade lower GI bleed from your as-yet-undiagnosed colon cancer, well, that's unfortunate. Because I will be sympathetic, and I will tell you that you need to go get a GI doctor somewhere to agree to scope you, and good luck with that if you are not insured. Maybe you live in a county with a hospital for the indigent who can do that for you in six months, if you've the fortitude to stick with it through the byzantine process it will take for you to get into their clinic. Hopefully, they'll diagnose you before it metastasizes. But I'm going to give you a piece of paper and send you home. Regretfully, I should add. I care, but I can't give you the care you need in the ER.
Alternatively, if you come in with an acutely blocked and inflamed gallbladder, I can get you to the OR for a surgeon to take it out before you get septic from it. Yay us! If, however, you have the seventh attack of excruciating pain from an uncomplicated gall bladder attack, that's a pity. I can make you feel better and send you home with a piece of paper. Maybe you'll get lucky and it'll get bad enough that someone has to take care of it.
Further, if you come in with a hangnail and I notice that your blood pressure is sky-high, I may be able to give you a short-term prescription for a blood pressure medication. But I can't manage it forever through the ER (though some patients try), and unless you get into a family doctor's office to get it taken care of properly, I'll see you again in a few years when you have your heart attack/stroke.
So, Thank You, Sarah and Aaron, for making this important point yet again. Let us all scream it from the rooftops. The ER is for Emergencies. That's what the "E" stands for. We're a backstop -- the option of last resort, the societal safety net. We are not the venue for universal health care, and I wish that for once and for all that policy makers (largely the conservative sort) would get that through their heads.
I can't believe we are still having this conversation. Really, it kind of makes me sick. I've been beating this dead horse for five years now, but I guess it's worth saying again.
And I'd like to expand on their points a little bit.
What the ER does (because federal law says we have to):
Examine every patient who walks or rolls through our doors.
Screen for life-threatening disease or other conditions which present an imminent threat to health and bodily function.
Provide necessary stabilizing care for the above.
What the ER does (because we are nice people and like helping patients):
Treat minor injuries and acute but not life threatening illnesses.
Treat exacerbations or decompensations of chronic illnesses.
What the ER does not do:
Provide comprehensive, integrated, longitudinal health care.
Provide screening and health maintenance services.
Manage chronic illnesses.
Provide guaranteed access to subspecialty care.
So, if you come in because you are pooping blood and it's serious enough that something needs to be done to stop the bleeding, you're in luck! We can do that. But if, say, you come in because you're tired and I notice that you are slightly anemic with a very low-grade lower GI bleed from your as-yet-undiagnosed colon cancer, well, that's unfortunate. Because I will be sympathetic, and I will tell you that you need to go get a GI doctor somewhere to agree to scope you, and good luck with that if you are not insured. Maybe you live in a county with a hospital for the indigent who can do that for you in six months, if you've the fortitude to stick with it through the byzantine process it will take for you to get into their clinic. Hopefully, they'll diagnose you before it metastasizes. But I'm going to give you a piece of paper and send you home. Regretfully, I should add. I care, but I can't give you the care you need in the ER.
Alternatively, if you come in with an acutely blocked and inflamed gallbladder, I can get you to the OR for a surgeon to take it out before you get septic from it. Yay us! If, however, you have the seventh attack of excruciating pain from an uncomplicated gall bladder attack, that's a pity. I can make you feel better and send you home with a piece of paper. Maybe you'll get lucky and it'll get bad enough that someone has to take care of it.
Further, if you come in with a hangnail and I notice that your blood pressure is sky-high, I may be able to give you a short-term prescription for a blood pressure medication. But I can't manage it forever through the ER (though some patients try), and unless you get into a family doctor's office to get it taken care of properly, I'll see you again in a few years when you have your heart attack/stroke.
So, Thank You, Sarah and Aaron, for making this important point yet again. Let us all scream it from the rooftops. The ER is for Emergencies. That's what the "E" stands for. We're a backstop -- the option of last resort, the societal safety net. We are not the venue for universal health care, and I wish that for once and for all that policy makers (largely the conservative sort) would get that through their heads.
Usual disclaimers about the validity of the underlying database apply, but overall I can't disagree with their findings. Privately insured kids who go to the ER are more likely to receive diagnostic tests or interventions than those who are uninsured or on public insurance (i.e. Medicaid/SCHIP). The study authors, wisely, refrain from making sweeping statements about the cause of such disparity. Which doesn't prevent the media from leaping to conclusions, and going right for the salacious ones:
Emergency departments are required to treat everyone who comes through the doors, but that doesn't mean they treat everyone the same way.
Insurance coverage may play a major role in the kind of care a young patient receives, according to a study published in the most recent edition of The Journal of Pediatrics.
ARRRGH!
No, no, no, no a thousand times, no. The implication here is that the ER discriminates inappropriately, either undertreating indigent children or overtreating insured children. This is not what the study says. It is, I hasten to add, a valid question, worthy of research. Bias based on socioeconomic status is a real factor in medicine, well documented, and should be looked into. But if you look at the very abstract of the study in question, it concludes: "It is unclear whether these patterns represent appropriate utilization."
The problem is that the database does not allow the researchers to account for the different characteristics of two very different populations presenting to the ER. The acuity of the uninsured children is much lower, generally (in fact, the paper affirms that the triage acuity of the uninsured group was significantly lower). In large part this is because the access to primary care for kids on Medicaid is very poor-to-nonexistent, so they substitute the ER for a PCP, visiting with very minor illnesses and well child exams at a far higher rate than privately insured kids. So you would expect a lower rate of testing in the underinsured group, because they are not the same as the privately insured kids, who have good access to pediatricians, and tend to come into the ER when they are sicker and more in need of tests.
To properly evaluate whether insurance status leads to inappropriate disparities in treatment, it would be necessary to acuity-match the two populations. The one element in the cited study that roughly does so is in the comparison of the care provided to admitted children, and in that subgroup, there was no difference in the amount of tests provided. This is not surprising, since the admitted kids are by definition the sickest and most likely to require tests and interventions. More important, if you are looking for disparities in how kids are treated, is to compare matched groups of discharged children with comparable presenting complaints. but this study, due to the limitations in the data source, cannot do that.
The study authors are remiss, in my opinion, in under-recognizing the actual acuity differences in the two groups. That they chose to headline their own study with the disparity in treatment with barely a mention of the patient-specific factors is leading and invites readers to draw conclusions which are not warranted.
Usual disclaimers about the validity of the underlying database apply, but overall I can't disagree with their findings. Privately insured kids who go to the ER are more likely to receive diagnostic tests or interventions than those who are uninsured or on public insurance (i.e. Medicaid/SCHIP). The study authors, wisely, refrain from making sweeping statements about the cause of such disparity. Which doesn't prevent the media from leaping to conclusions, and going right for the salacious ones:
Emergency departments are required to treat everyone who comes through the doors, but that doesn't mean they treat everyone the same way.
Insurance coverage may play a major role in the kind of care a young patient receives, according to a study published in the most recent edition of The Journal of Pediatrics.
ARRRGH!
No, no, no, no a thousand times, no. The implication here is that the ER discriminates inappropriately, either undertreating indigent children or overtreating insured children. This is not what the study says. It is, I hasten to add, a valid question, worthy of research. Bias based on socioeconomic status is a real factor in medicine, well documented, and should be looked into. But if you look at the very abstract of the study in question, it concludes: "It is unclear whether these patterns represent appropriate utilization."
The problem is that the database does not allow the researchers to account for the different characteristics of two very different populations presenting to the ER. The acuity of the uninsured children is much lower, generally (in fact, the paper affirms that the triage acuity of the uninsured group was significantly lower). In large part this is because the access to primary care for kids on Medicaid is very poor-to-nonexistent, so they substitute the ER for a PCP, visiting with very minor illnesses and well child exams at a far higher rate than privately insured kids. So you would expect a lower rate of testing in the underinsured group, because they are not the same as the privately insured kids, who have good access to pediatricians, and tend to come into the ER when they are sicker and more in need of tests.
To properly evaluate whether insurance status leads to inappropriate disparities in treatment, it would be necessary to acuity-match the two populations. The one element in the cited study that roughly does so is in the comparison of the care provided to admitted children, and in that subgroup, there was no difference in the amount of tests provided. This is not surprising, since the admitted kids are by definition the sickest and most likely to require tests and interventions. More important, if you are looking for disparities in how kids are treated, is to compare matched groups of discharged children with comparable presenting complaints. but this study, due to the limitations in the data source, cannot do that.
The study authors are remiss, in my opinion, in under-recognizing the actual acuity differences in the two groups. That they chose to headline their own study with the disparity in treatment with barely a mention of the patient-specific factors is leading and invites readers to draw conclusions which are not warranted.
I always thought the story of Abraham and the binding of Isaac was one of the creepiest and most horrifying stories of the many creepy and horrifying stories in the Bible. I mean, think about it. At the behest of some supposed supernatural being, Abraham is prepared to truss his child like an animal and slit his throat:
Abraham took the wood for the burnt offering and placed it on his son Isaac, and he himself carried the fire and the knife. As the two of them went on together, Isaac spoke up and said to his father Abraham, "Father?" "Yes, my son?" Abraham replied. "The fire and wood are here," Isaac said, "but where is the lamb for the burnt offering?" Abraham answered, "God himself will provide the lamb for the burnt offering, my son." And the two of them went on together. When they reached the place God had told him about, Abraham built an altar there and arranged the wood on it. He bound his son Isaac and laid him on the altar, on top of the wood. Then he reached out his hand and took the knife to slay his son.
That's messed up. The fact that it was God's funny little joke and Isaac wasn't murdered doesn't really redeem the story.
I think this is so repugnant because it runs counter to humanity's deepest instinct, to love and care for our children. It's appalling to consider that abstract notions regarding the dictates of a probably nonexistent deity can over-ride this fundamental human impulse, to put the life and welfare of your child above all else.
I was musing on this after a recent case I saw in the ER. A young man, barely old enough to drink, well, went out and got drunk, as young men do. He was involved in a dispute of some sort involving drugs and was administered some street justice. He came in to me quite ill indeed. He had stab wounds to the chest and abdomen, as well as an actively bleeding deep cut to the left arm extending up over the deltoid and into zone 3 of the neck. The paramedics reported a large amount of blood loss at the scene, and his arm wound was still bleeding heavily on arrival.
The resuscitation went very well, considering the injuries. He was intubated and thoracostomied in a jiffy, and I tacked together that big arm wound in a temporizing fashion to stanch the blood loss. But clearly, he was going to need to get to the OR pretty soon. His hematocrit dropped dramatically after fluid resuscitation and he was showing signs of shock so we began to prepare for transfusion.
It was around that time that his parents showed up and informed us that the patient was a Jehovah's Witness and would not accept blood products under any circumstances. Even if that meant his death. They were adamant on this point even after I explained that we were not in hypothetical territory any more -- that his injuries were quite life-threatening and the blood loss might be the factor that caused him to die. They were firm and well-prepared and even showed us a piece of paper signed by the patient, fairly recently, expressly refusing blood transfusions.
Now I will parenthetically note that this young man was not so observant a Jehovah's Witness that he wouldn't go out and get drunk and use drugs, so I wonder whether he would have been willing to rescind that refusal were it his own life on the line. But he couldn't speak for himself, so I was bound to obey the parents and his expressed wishes.
As it happened, he got lucky. He had a very rough course in the OR and post op. He definitely would have been at less risk and probably would have suffered less disability had he been transfused. Thanks to a very skilled OR team and our hospital's exceptional blood-conservation program, he pulled through.
The parallel between this case and the Genesis story is pretty apparent, I should think. They're both equally abhorrent. I'm more appalled by my experience, actually, since a) it really happened and wasn't some myth of dubious factual provenance and b) the parents who were willing to allow their son to die did so in the context of modern education, societal mores, and with all the tools of moderns medicine at their disposal. Yet they valued some abstract, imaginary fantasy of the afterlife and their idiosyncratic reading of scripture over the real, actual living, breathing son whom they had loved and nurtured for two decades. That's just sick, and it made me feel sick to be complicit in their withholding of care to their son.
Yes, I understand the legal and ethical obligations I am under as a physician, and I obeyed their wishes. But I do not respect them; in fact I hold them in the deepest contempt.
I always thought the story of Abraham and the binding of Isaac was one of the creepiest and most horrifying stories of the many creepy and horrifying stories in the Bible. I mean, think about it. At the behest of some supposed supernatural being, Abraham is prepared to truss his child like an animal and slit his throat:
Abraham took the wood for the burnt offering and placed it on his son Isaac, and he himself carried the fire and the knife. As the two of them went on together, Isaac spoke up and said to his father Abraham, "Father?" "Yes, my son?" Abraham replied. "The fire and wood are here," Isaac said, "but where is the lamb for the burnt offering?" Abraham answered, "God himself will provide the lamb for the burnt offering, my son." And the two of them went on together. When they reached the place God had told him about, Abraham built an altar there and arranged the wood on it. He bound his son Isaac and laid him on the altar, on top of the wood. Then he reached out his hand and took the knife to slay his son.
That's messed up. The fact that it was God's funny little joke and Isaac wasn't murdered doesn't really redeem the story.
I think this is so repugnant because it runs counter to humanity's deepest instinct, to love and care for our children. It's appalling to consider that abstract notions regarding the dictates of a probably nonexistent deity can over-ride this fundamental human impulse, to put the life and welfare of your child above all else.
I was musing on this after a recent case I saw in the ER. A young man, barely old enough to drink, well, went out and got drunk, as young men do. He was involved in a dispute of some sort involving drugs and was administered some street justice. He came in to me quite ill indeed. He had stab wounds to the chest and abdomen, as well as an actively bleeding deep cut to the left arm extending up over the deltoid and into zone 3 of the neck. The paramedics reported a large amount of blood loss at the scene, and his arm wound was still bleeding heavily on arrival.
The resuscitation went very well, considering the injuries. He was intubated and thoracostomied in a jiffy, and I tacked together that big arm wound in a temporizing fashion to stanch the blood loss. But clearly, he was going to need to get to the OR pretty soon. His hematocrit dropped dramatically after fluid resuscitation and he was showing signs of shock so we began to prepare for transfusion.
It was around that time that his parents showed up and informed us that the patient was a Jehovah's Witness and would not accept blood products under any circumstances. Even if that meant his death. They were adamant on this point even after I explained that we were not in hypothetical territory any more -- that his injuries were quite life-threatening and the blood loss might be the factor that caused him to die. They were firm and well-prepared and even showed us a piece of paper signed by the patient, fairly recently, expressly refusing blood transfusions.
Now I will parenthetically note that this young man was not so observant a Jehovah's Witness that he wouldn't go out and get drunk and use drugs, so I wonder whether he would have been willing to rescind that refusal were it his own life on the line. But he couldn't speak for himself, so I was bound to obey the parents and his expressed wishes.
As it happened, he got lucky. He had a very rough course in the OR and post op. He definitely would have been at less risk and probably would have suffered less disability had he been transfused. Thanks to a very skilled OR team and our hospital's exceptional blood-conservation program, he pulled through.
The parallel between this case and the Genesis story is pretty apparent, I should think. They're both equally abhorrent. I'm more appalled by my experience, actually, since a) it really happened and wasn't some myth of dubious factual provenance and b) the parents who were willing to allow their son to die did so in the context of modern education, societal mores, and with all the tools of moderns medicine at their disposal. Yet they valued some abstract, imaginary fantasy of the afterlife and their idiosyncratic reading of scripture over the real, actual living, breathing son whom they had loved and nurtured for two decades. That's just sick, and it made me feel sick to be complicit in their withholding of care to their son.
Yes, I understand the legal and ethical obligations I am under as a physician, and I obeyed their wishes. But I do not respect them; in fact I hold them in the deepest contempt.
Last year, 13 Americans died during running races, and another eight while competing in triathlons. While those numbers might seem troubling, the deaths are attributable mostly to the booming popularity of endurance sports--13 million Americans enter running races each year, and 2.3 million compete in triathlons. But the rising participation and the proportional death toll--especially in cases like Hass's--highlight the need for quality medical care at these events. And usually that care comes from volunteer doctors.
At least it used to. More and more doctors are refusing to donate their services, and it's for one frustrating reason: they can't get medical-malpractice insurance. Most doctors' insurers typically won't issue one-day policy riders for sporting events, and race organizers haven't stepped up to offer alternative coverage. After the 2008 Ironman World Championships, volunteer medical director Franklin Marcus famously resigned because race organizers had refused to offer coverage
I've run into this myself, and it can be a really tricky issue. The problem is that this is a place where Good Samaritan laws and "duty" overlap in a way that's murky at best and damaging at worst.
For those not familiar with this aspect of malpractice law, here's a ten-second primer. In order to be liable for malpractice, three things need to be present: 1. A duty to treat 2. A breach of that duty (commonly thought of as "standard of care") 3. A harm resulting from that breach
So when a patient rolls into the ER, as the ER doc who has agreed to be present for emergency cases (or as a surgeon who has agreed to be on call, etc) the duty is implicit. Also, of course, when there is a pre-existing doctor-patient relationship that duty is satisfied. But what of the "man on the street" situations? If I am walking down a street and see someone keel over, I'm under no obligation to render assistance (in most jurisdictions). I have no duty to treat. In theory, that means that I could render aid without any risk of being sued, and in order to encourage physicians to render aid in such situations all 50 states have passed so-called "Good Samaritan laws." They vary from place to place, but they generally immunize a doctor from malpractice barring recklessness or willful and wanton negligence should they render emergency assistance.
The problem is that this usually only applies when you have no duty to treat. So if I am at a (not at all hypothetically) karate tournament with my dojo and I see a contestant injured, I can provide first aid without fear of malpractice. But if I am asked in advance to be the "tournament doctor" then it becomes a murkier issue, because then I am acting as an agent of the event and its organizers and as such might meet the definition of "duty to treat." This raises a whole secondary set of concerns -- are the facilities and supplies adequate to treat injured contestants, can I pull an athlete who wants to continue, etc. Some locations extend Good Samaritan protections to doctors who act as volunteers without expectation of compensation. Others do not. Most organized athletic events have some sort of liability insurance, but that would probably not cover a physician's professional liability, and smaller events (say, a recreational kids' soccer league or a local karate federation) don't have the resources to get their own med-mal policies.
So this puts the doc in an uncomfortable situation. We want to support the local organizations, whatever they may be, but you have some tough choices to make. You can go "naked," without insurance, which is not unreasonable in most cases since the actual risk of injury, let alone getting sued is very low in most activities. But for some sports, the risks are higher, and many doctors are too afraid of getting sued to run that sort of risk. So then you are left begging your insurer for a rider allowing you to do this or begging your skeptical partners to make this an underwritten part of the group's policy. The cost for this sort of coverage is trivial, and in fact some insurers will give it for free, but some insurers and some groups won't allow it at all. It varies a lot by specialty. Ortho docs, in my experience, tend to be much more invested in local athletics (if nothing else, it's good business!) so they are more comfortable viewing this as a necessary and reasonable business expense. Pediatricians, too, since there are so many kids' sports leagues and the serious injury rate is so low. Your mileage may vary.
It was nice to see in the linked article that malpractice coverage is becoming more available (and at a very affordable price of $60 per doc). Hopefully that will become the standard for event liability insurance in the future.
Last year, 13 Americans died during running races, and another eight while competing in triathlons. While those numbers might seem troubling, the deaths are attributable mostly to the booming popularity of endurance sports--13 million Americans enter running races each year, and 2.3 million compete in triathlons. But the rising participation and the proportional death toll--especially in cases like Hass's--highlight the need for quality medical care at these events. And usually that care comes from volunteer doctors.
At least it used to. More and more doctors are refusing to donate their services, and it's for one frustrating reason: they can't get medical-malpractice insurance. Most doctors' insurers typically won't issue one-day policy riders for sporting events, and race organizers haven't stepped up to offer alternative coverage. After the 2008 Ironman World Championships, volunteer medical director Franklin Marcus famously resigned because race organizers had refused to offer coverage
I've run into this myself, and it can be a really tricky issue. The problem is that this is a place where Good Samaritan laws and "duty" overlap in a way that's murky at best and damaging at worst.
For those not familiar with this aspect of malpractice law, here's a ten-second primer. In order to be liable for malpractice, three things need to be present: 1. A duty to treat 2. A breach of that duty (commonly thought of as "standard of care") 3. A harm resulting from that breach
So when a patient rolls into the ER, as the ER doc who has agreed to be present for emergency cases (or as a surgeon who has agreed to be on call, etc) the duty is implicit. Also, of course, when there is a pre-existing doctor-patient relationship that duty is satisfied. But what of the "man on the street" situations? If I am walking down a street and see someone keel over, I'm under no obligation to render assistance (in most jurisdictions). I have no duty to treat. In theory, that means that I could render aid without any risk of being sued, and in order to encourage physicians to render aid in such situations all 50 states have passed so-called "Good Samaritan laws." They vary from place to place, but they generally immunize a doctor from malpractice barring recklessness or willful and wanton negligence should they render emergency assistance.
The problem is that this usually only applies when you have no duty to treat. So if I am at a (not at all hypothetically) karate tournament with my dojo and I see a contestant injured, I can provide first aid without fear of malpractice. But if I am asked in advance to be the "tournament doctor" then it becomes a murkier issue, because then I am acting as an agent of the event and its organizers and as such might meet the definition of "duty to treat." This raises a whole secondary set of concerns -- are the facilities and supplies adequate to treat injured contestants, can I pull an athlete who wants to continue, etc. Some locations extend Good Samaritan protections to doctors who act as volunteers without expectation of compensation. Others do not. Most organized athletic events have some sort of liability insurance, but that would probably not cover a physician's professional liability, and smaller events (say, a recreational kids' soccer league or a local karate federation) don't have the resources to get their own med-mal policies.
So this puts the doc in an uncomfortable situation. We want to support the local organizations, whatever they may be, but you have some tough choices to make. You can go "naked," without insurance, which is not unreasonable in most cases since the actual risk of injury, let alone getting sued is very low in most activities. But for some sports, the risks are higher, and many doctors are too afraid of getting sued to run that sort of risk. So then you are left begging your insurer for a rider allowing you to do this or begging your skeptical partners to make this an underwritten part of the group's policy. The cost for this sort of coverage is trivial, and in fact some insurers will give it for free, but some insurers and some groups won't allow it at all. It varies a lot by specialty. Ortho docs, in my experience, tend to be much more invested in local athletics (if nothing else, it's good business!) so they are more comfortable viewing this as a necessary and reasonable business expense. Pediatricians, too, since there are so many kids' sports leagues and the serious injury rate is so low. Your mileage may vary.
It was nice to see in the linked article that malpractice coverage is becoming more available (and at a very affordable price of $60 per doc). Hopefully that will become the standard for event liability insurance in the future.
The availability of basic health care varies radically from place to place across the nation. To the left of the vertical slider bar, counties outlined in orange had no doctor's office in 2009, according to the Census Bureau. Clark County, Mississippi, for example, had a population of over 17,000 but no doctor's office, while Manhattan had a doctor's office for every 500 residents. The map to the right shows the relative availability of primary health care providers by county. Enhanced access to health care is key to improving the health of Americans.
The availability of basic health care varies radically from place to place across the nation. To the left of the vertical slider bar, counties outlined in orange had no doctor's office in 2009, according to the Census Bureau. Clark County, Mississippi, for example, had a population of over 17,000 but no doctor's office, while Manhattan had a doctor's office for every 500 residents. The map to the right shows the relative availability of primary health care providers by county. Enhanced access to health care is key to improving the health of Americans.
Ah, the life cycle of a blog: from posting every few days, to multiple posts a day, to posting every couple of weeks. Is "Movin' Meat" on its way to permanent hiatus? I don't know any more than you do. Recently my free time has seemed to be consumed by work, the kids, karate, and when I have time to play on the computer, I seem to spend more time on Twitter. In any event, I'm not hanging it up, and I do intend to keep posting, at least as often as I have something to say and some time to thoughtfully present it.
To make up for the recent radio silence, I offer you this true anecdote from last weekend which qualified me for my twelfth Dumb Guy Award:
I used to have a perfect 40-year track record of never accidentally setting the house on fire. Unfortunately, I can no longer say that is the case. My Lou Gehrig-like streak has been broken.
So, we have dogs. (Relevant.) If we leave food on the counter for more than a minute or two, it becomes dog food. Also, the damn cat. So both Liza and I have a longstanding, almost automatic habit that as soon as we are done eating, all food is immediately covered or otherwise put away. Sometimes when we have pizza or some otherwise largish dish, Liza would put it in the oven to keep the critters away from it. I have objected to this practice on the grounds that I think it's unsanitary to leave unrefrigerated food out and also because from time to time I turn on the oven and it starts smoking and I pull out the charred ruins of yesterday's dinner. In fact I have ... discussed this with Liza a few times. (I was going to say that I have yelled at her for it, but one does not yell at Liza if one wishes to keep one's ears.) At any rate, it was a pet peeve of mine, and we have discussed it. And since those discussions, it has been a fairly uncommon thing to have leftovers in the oven any more.
The other night, we had pizza, as we usually do on Friday nights -- movie night at the Shadowfax homestead. (Relevant.) Last night, Liza and Son #2 went to the Sounders game, which is soccer. Son #1 had his friend Ethan over for a playdate/sleepover, and I was of course minding the two girls as well. I was absorbed in a complex task on the computer, and Liza had thoughtfully gotten a frozen bakable platter of Mac'n'Cheese rather than abandon the children to my tender ministration, by which I mean neglect. After Liza left, I turned on the oven to preheat and went back to the computer room, immediately forgetting about the oven. A few minutes later, Son #1 shouts that something smells like smoke. I ran to the kitchen to be confronted by thick black smoke pouring out of the vent on top of the oven. I hit the fan, deactivated the oven, and opened the door to see large sheets of flame shooting out.
From the pizza boxes. Which I personally had put in the oven and forgotten.
A lot of things started happening at once. All seventeen smoke detectors in the house started going off at ear-splitting volume. The kitchen started filling with smoke VERY quickly. The little girls started freaking out at the noise and the smoke. I realized that this was not the sort of fire you can beat out with your hands or a cup of water; it was in fact growing as I watched it. I remembered where the fire extinguisher was (in the cabinet next to the oven), retrieved it, and pulled the safety pin. I aimed it at the flames and squeezed the trigger.
Now, I will pause here to note that I have never before discharged a fire extinguisher. I had only a vague idea of what happens when you do. You point it at the fire, FWOOOSH, magic smoke happens and the fire is out. Simple, right? I did not know (and was not really thinking about it deeply at the moment) that the magic smoke is in fact a very very fine white powder, ejected under high pressure into a very confined space. To say that the mess it left was catastrophic would be an understatement. "Unholy" would be a better description of the results. A huge cloud of white dust billowed back from the oven and covered my face and every single surface in the kitchen.
I peered into the oven through the haze, and saw that the boxes were no longer burning. I retrieved them, still smoking faintly, and set them on the counter by the window. I noted then that there were still (or again) decent sized flames shooting out of the oven. I am guessing that some of the pizza or box had adhered to the roof of the oven, but I don't know. FWOOSH again, another huge backblast of white particles and the fire in the oven was out. Unfortunately, the pizza boxes on the counter had managed to re-ignite themselves and were shooting flames about four feet up. Another brief blast of mystery white powder all over the counter and sink and wall and cabinets, and the pizza boxes were once again downgraded to smoldering, with a few flickers of flame. I realized the fat in the cheese of the pizza (there was quite a bit left) was going to be really hard to put out, and the extinguisher was nearly spent so I picked up the boxes and ran out back. The air from running caused the flames to flare up in my face quite dramatically. Perhaps the white powder covering my face protected me from serious burns; we shall never know. I pitched the blazing boxes onto the back lawn and went back inside to contemplate the smoky, snowy ruin of our kitchen.
The good news was that we now had a fire-free house, which is a something of a luxury when you really consider the alternative. The bad news was that the smoke was thick in the air, burning my eyes, the girls were sobbing uncontrollably, the fire alarms were shrieking, and the oven was a horrible mess I didn't even want to think about. Son #1 was a champ at this point, rounding up the girls and consoling them and keeping them out of my way. I ran through the house opening each and every window. It was 44 degrees, so soon the girls were crying *and* shivering. The smoke upstairs was so thick it was actually sobering. Way up in the playroom it was so dense I was coughing and my eyes were tearing. I couldn't turn off the fire alarms, but they shut themselves off after a few minutes. Slowly the smoke began to clear.
I surveyed the damage. Nothing serious, really. Just a huge mess, and nobody hurt. So a victory when it comes to kitchen fires. Son #1 and Ethan came down and started writing their names in the dust that covered everything. I sent them away when they started to pour out water to create paste. Teagan lectured me in her "important" voice about the big big fire that we had in the oven.
Outside, on the lawn, the pizza boxes burned prettily.
I sent Liza a text, and got the following, concerned, supportive response:
I poured myself a big glass of wine, for courage, and set to the cleanup. THREE HOURS with the shop vac, all the while enduring insightful commentary and overt taunting from my nine year-old son. He truly has the genes of a champion taunter, and I think he felt entitled since he continued to watch the girls for me. Ethan was reserved and polite; a nice kid. But he looked at me with an air of quiet disdain, which is a painful sense to get from a kid. After a while I noticed that the dogs were trying (OF COURSE BECAUSE THEY ARE DOGS) to eat the still-smoking remains of the pizza on the lawn, so I had to go out and deal with that. I surrendered and gave them all the blackened pizza that wasn't actually hot to the touch, which they ate greedily, because they are dogs. I slipped on the wet wood getting back on the deck and nearly broke my leg, catching myself just in time. Shaking a weary fist at the sky, I went, defeated, back into the house.
When Liza got home, she was actually quite understanding and did not beat me up at all, beyond noting that the place smelled (and smells) like a campfire. She was very complimentary at the cleanliness of the kitchen, which bore almost no sign of the disaster. With a childlike sense of wonder, she surveyed the rest of the house and noted how far the white dust had spread (all the way to the kids' bedrooms, the wet bar, the front room, pretty much the entire house. Son #2 was disappointed to have missed the excitement. I got quietly drunk and went to bed; the boys stayed up till 3AM giggling.
So I now hereby claim the title of DUMB GUY as is my right and my due until such time as Matt or some other guy commits an act of idiocy.
I will say in defense of my Dumb-ness that while anybody can make the careless mistake of turning on the oven without checking it, the fact that I had many times berated my loving wife for her habit of putting the boxes in there, and then proceeded to do the same damn thing myself qualifies me for the willful stupidity element of the award, with bonus points for irony. And the consequence of the mess and the humiliation in front of my son and his friend certainly meets that criteria.
Ah, the life cycle of a blog: from posting every few days, to multiple posts a day, to posting every couple of weeks. Is "Movin' Meat" on its way to permanent hiatus? I don't know any more than you do. Recently my free time has seemed to be consumed by work, the kids, karate, and when I have time to play on the computer, I seem to spend more time on Twitter. In any event, I'm not hanging it up, and I do intend to keep posting, at least as often as I have something to say and some time to thoughtfully present it.
To make up for the recent radio silence, I offer you this true anecdote from last weekend which qualified me for my twelfth Dumb Guy Award:
I used to have a perfect 40-year track record of never accidentally setting the house on fire. Unfortunately, I can no longer say that is the case. My Lou Gehrig-like streak has been broken.
So, we have dogs. (Relevant.) If we leave food on the counter for more than a minute or two, it becomes dog food. Also, the damn cat. So both Liza and I have a longstanding, almost automatic habit that as soon as we are done eating, all food is immediately covered or otherwise put away. Sometimes when we have pizza or some otherwise largish dish, Liza would put it in the oven to keep the critters away from it. I have objected to this practice on the grounds that I think it's unsanitary to leave unrefrigerated food out and also because from time to time I turn on the oven and it starts smoking and I pull out the charred ruins of yesterday's dinner. In fact I have ... discussed this with Liza a few times. (I was going to say that I have yelled at her for it, but one does not yell at Liza if one wishes to keep one's ears.) At any rate, it was a pet peeve of mine, and we have discussed it. And since those discussions, it has been a fairly uncommon thing to have leftovers in the oven any more.
The other night, we had pizza, as we usually do on Friday nights -- movie night at the Shadowfax homestead. (Relevant.) Last night, Liza and Son #2 went to the Sounders game, which is soccer. Son #1 had his friend Ethan over for a playdate/sleepover, and I was of course minding the two girls as well. I was absorbed in a complex task on the computer, and Liza had thoughtfully gotten a frozen bakable platter of Mac'n'Cheese rather than abandon the children to my tender ministration, by which I mean neglect. After Liza left, I turned on the oven to preheat and went back to the computer room, immediately forgetting about the oven. A few minutes later, Son #1 shouts that something smells like smoke. I ran to the kitchen to be confronted by thick black smoke pouring out of the vent on top of the oven. I hit the fan, deactivated the oven, and opened the door to see large sheets of flame shooting out.
From the pizza boxes. Which I personally had put in the oven and forgotten.
A lot of things started happening at once. All seventeen smoke detectors in the house started going off at ear-splitting volume. The kitchen started filling with smoke VERY quickly. The little girls started freaking out at the noise and the smoke. I realized that this was not the sort of fire you can beat out with your hands or a cup of water; it was in fact growing as I watched it. I remembered where the fire extinguisher was (in the cabinet next to the oven), retrieved it, and pulled the safety pin. I aimed it at the flames and squeezed the trigger.
Now, I will pause here to note that I have never before discharged a fire extinguisher. I had only a vague idea of what happens when you do. You point it at the fire, FWOOOSH, magic smoke happens and the fire is out. Simple, right? I did not know (and was not really thinking about it deeply at the moment) that the magic smoke is in fact a very very fine white powder, ejected under high pressure into a very confined space. To say that the mess it left was catastrophic would be an understatement. "Unholy" would be a better description of the results. A huge cloud of white dust billowed back from the oven and covered my face and every single surface in the kitchen.
I peered into the oven through the haze, and saw that the boxes were no longer burning. I retrieved them, still smoking faintly, and set them on the counter by the window. I noted then that there were still (or again) decent sized flames shooting out of the oven. I am guessing that some of the pizza or box had adhered to the roof of the oven, but I don't know. FWOOSH again, another huge backblast of white particles and the fire in the oven was out. Unfortunately, the pizza boxes on the counter had managed to re-ignite themselves and were shooting flames about four feet up. Another brief blast of mystery white powder all over the counter and sink and wall and cabinets, and the pizza boxes were once again downgraded to smoldering, with a few flickers of flame. I realized the fat in the cheese of the pizza (there was quite a bit left) was going to be really hard to put out, and the extinguisher was nearly spent so I picked up the boxes and ran out back. The air from running caused the flames to flare up in my face quite dramatically. Perhaps the white powder covering my face protected me from serious burns; we shall never know. I pitched the blazing boxes onto the back lawn and went back inside to contemplate the smoky, snowy ruin of our kitchen.
The good news was that we now had a fire-free house, which is a something of a luxury when you really consider the alternative. The bad news was that the smoke was thick in the air, burning my eyes, the girls were sobbing uncontrollably, the fire alarms were shrieking, and the oven was a horrible mess I didn't even want to think about. Son #1 was a champ at this point, rounding up the girls and consoling them and keeping them out of my way. I ran through the house opening each and every window. It was 44 degrees, so soon the girls were crying *and* shivering. The smoke upstairs was so thick it was actually sobering. Way up in the playroom it was so dense I was coughing and my eyes were tearing. I couldn't turn off the fire alarms, but they shut themselves off after a few minutes. Slowly the smoke began to clear.
I surveyed the damage. Nothing serious, really. Just a huge mess, and nobody hurt. So a victory when it comes to kitchen fires. Son #1 and Ethan came down and started writing their names in the dust that covered everything. I sent them away when they started to pour out water to create paste. Teagan lectured me in her "important" voice about the big big fire that we had in the oven.
Outside, on the lawn, the pizza boxes burned prettily.
I sent Liza a text, and got the following, concerned, supportive response:
I poured myself a big glass of wine, for courage, and set to the cleanup. THREE HOURS with the shop vac, all the while enduring insightful commentary and overt taunting from my nine year-old son. He truly has the genes of a champion taunter, and I think he felt entitled since he continued to watch the girls for me. Ethan was reserved and polite; a nice kid. But he looked at me with an air of quiet disdain, which is a painful sense to get from a kid. After a while I noticed that the dogs were trying (OF COURSE BECAUSE THEY ARE DOGS) to eat the still-smoking remains of the pizza on the lawn, so I had to go out and deal with that. I surrendered and gave them all the blackened pizza that wasn't actually hot to the touch, which they ate greedily, because they are dogs. I slipped on the wet wood getting back on the deck and nearly broke my leg, catching myself just in time. Shaking a weary fist at the sky, I went, defeated, back into the house.
When Liza got home, she was actually quite understanding and did not beat me up at all, beyond noting that the place smelled (and smells) like a campfire. She was very complimentary at the cleanliness of the kitchen, which bore almost no sign of the disaster. With a childlike sense of wonder, she surveyed the rest of the house and noted how far the white dust had spread (all the way to the kids' bedrooms, the wet bar, the front room, pretty much the entire house. Son #2 was disappointed to have missed the excitement. I got quietly drunk and went to bed; the boys stayed up till 3AM giggling.
So I now hereby claim the title of DUMB GUY as is my right and my due until such time as Matt or some other guy commits an act of idiocy.
I will say in defense of my Dumb-ness that while anybody can make the careless mistake of turning on the oven without checking it, the fact that I had many times berated my loving wife for her habit of putting the boxes in there, and then proceeded to do the same damn thing myself qualifies me for the willful stupidity element of the award, with bonus points for irony. And the consequence of the mess and the humiliation in front of my son and his friend certainly meets that criteria.
Eva V is the daughter of some very close friends of mine. Her dad is a pediatrician and her mom is a pediatric oncologist, so kid's health and kid's cancer are topics with which she is very familiar. Her dad has participated in the St Baldrick's fundraiser for pediatric cancer research for the last several years, and this year Eva has decided to shave her head in support of pediatric cancer as well!
She is ten years old, and I've got to hand it to any ten year old girl who's brave enough to go bald for this cause.
So if you are someone who's inclined to support the St Baldrick's Foundation against kid's cancer, or if you just want to support a brave young girl, then by all means please wander over to her donor page and toss her a couple of bucks!
Eva V is the daughter of some very close friends of mine. Her dad is a pediatrician and her mom is a pediatric oncologist, so kid's health and kid's cancer are topics with which she is very familiar. Her dad has participated in the St Baldrick's fundraiser for pediatric cancer research for the last several years, and this year Eva has decided to shave her head in support of pediatric cancer as well!
She is ten years old, and I've got to hand it to any ten year old girl who's brave enough to go bald for this cause.
So if you are someone who's inclined to support the St Baldrick's Foundation against kid's cancer, or if you just want to support a brave young girl, then by all means please wander over to her donor page and toss her a couple of bucks!
The earliest memory I have of having music of my own was this album. I was maybe eight (?) and my older cousin gave me this and also Simon & Garfunkel's "Bookends." They were real vinyl, of course, and I can still sing all the songs from both by memory.
Lest you think my cousin was a bad influence, by the time I was twelve, he took me to see the Clash live and later, PIL. Whether that was a good thing or bad, I let you be the judge.
The earliest memory I have of having music of my own was this album. I was maybe eight (?) and my older cousin gave me this and also Simon & Garfunkel's "Bookends." They were real vinyl, of course, and I can still sing all the songs from both by memory.
Lest you think my cousin was a bad influence, by the time I was twelve, he took me to see the Clash live and later, PIL. Whether that was a good thing or bad, I let you be the judge.
My family includes four of the 49.1 million uninsured people in the United States. I've comforted myself that we couldn't afford private insurance, which we can't, but at least we were all relatively healthy and never seemed to have problems. [...]
But recently my mindset has become affected by our position. I tell my kids not to do things that I certainly enjoyed doing as a kid, like don't climb high on trees, run a little slower on the trail, watch out for roots and stones! It's not just the usual parental concern either. I'm consciously thinking "oh my god, I cannot afford to fix them if they get broke!".
This is the luxury gap between the between the 20% of nonelderly americans who are uninsured and the rest. The luxury is, of course, being able to just walk into a doctor's office and see them at the appropriate times. It is easy to discount this minority since most are at or near the poverty line. But many of the uninsured are like myself and just can't seem to make the numbers work for a family of four each month by adding on private individual (i.e. non-group discounted) health insurance. [...]
By Tuesday we weren't left with any choice. My son had just gotten out of a bath and though he wasn't cold, his hand and his feet were blue. I'd never seen it like that before. My wife laid it down and we were going to the Urgent Care. We all got dressed and heading over there early. He was miserable, crying in pain cause he couldn't get enough oxygen. We were scared that we might have waited too long. [...]
Most of the uninsured in this country aren't lazy, freeloading hobos who don't wanna work. They span a wide variety of demographics. As a 30 something, white male with advanced college degree who works full time as a self-employed consultant and writer are you surprised that I cannot afford health insurance for my family? In fact, the majority of uninsured are in my age range and are full or part time workers earning incomes above 100% the federal poverty level.
The good news is that his son got better. The bad news is that his care was a couple of orders of magnitude more expensive than it might have been if they'd had better access to care, and that his son's life was put into jeopardy by their necessary reluctance to seek out care. Adding insult to injury is that this family will probably have any financial reserve they possess wiped out by what should have been a minor illness.
And these aren't dirty cigarette-smoking, cell-phone buying scumbag poor people who deserve their fate (the caricature of the uninsured found most typically on libertarian blogs). This guy holds an advanced science degree and this family is firmly in the middle class. They're just unlucky enough to have to buy non-group plan insurance in the pre-ACA marketplace.
The ACA -- if it goes into effect -- will mitigate this. The health insurance exchanges will regulate individual health insurance plans, guarantee that no person or family will be rejected due to prior history, and make it easier for families to shop for and purchase insurance. The subsidies will make insurance more affordable on a sliding-scale basis. Bringing everybody (or nearly so) into the system will make insurance cheaper for all of us.
The ACA isn't perfect. At best it's a start. There may not be death panels, but there's plenty there not to like. You've got the mandate (for the record, I'd be fine with ditching the mandate if there were another effective method to encourage healthy people to buy in -- lock-out periods or late-entry penalties or what have you). There's no public option to force insurers to compete honestly. ACOs may not do anything to bring down costs. But for Kevin Zelnio and his family and the many other families in similar situations, who desperately want insurance but cannot afford it, ObamaCare provides them with a ticket to enter into the system. It's a pity that it's gotten so polarized that we can't move on and get to work on fixing deficiencies, improving what we've got, rather than refighting the scorched earth campaigns of 2009.
My family includes four of the 49.1 million uninsured people in the United States. I've comforted myself that we couldn't afford private insurance, which we can't, but at least we were all relatively healthy and never seemed to have problems. [...]
But recently my mindset has become affected by our position. I tell my kids not to do things that I certainly enjoyed doing as a kid, like don't climb high on trees, run a little slower on the trail, watch out for roots and stones! It's not just the usual parental concern either. I'm consciously thinking "oh my god, I cannot afford to fix them if they get broke!".
This is the luxury gap between the between the 20% of nonelderly americans who are uninsured and the rest. The luxury is, of course, being able to just walk into a doctor's office and see them at the appropriate times. It is easy to discount this minority since most are at or near the poverty line. But many of the uninsured are like myself and just can't seem to make the numbers work for a family of four each month by adding on private individual (i.e. non-group discounted) health insurance. [...]
By Tuesday we weren't left with any choice. My son had just gotten out of a bath and though he wasn't cold, his hand and his feet were blue. I'd never seen it like that before. My wife laid it down and we were going to the Urgent Care. We all got dressed and heading over there early. He was miserable, crying in pain cause he couldn't get enough oxygen. We were scared that we might have waited too long. [...]
Most of the uninsured in this country aren't lazy, freeloading hobos who don't wanna work. They span a wide variety of demographics. As a 30 something, white male with advanced college degree who works full time as a self-employed consultant and writer are you surprised that I cannot afford health insurance for my family? In fact, the majority of uninsured are in my age range and are full or part time workers earning incomes above 100% the federal poverty level.
The good news is that his son got better. The bad news is that his care was a couple of orders of magnitude more expensive than it might have been if they'd had better access to care, and that his son's life was put into jeopardy by their necessary reluctance to seek out care. Adding insult to injury is that this family will probably have any financial reserve they possess wiped out by what should have been a minor illness.
And these aren't dirty cigarette-smoking, cell-phone buying scumbag poor people who deserve their fate (the caricature of the uninsured found most typically on libertarian blogs). This guy holds an advanced science degree and this family is firmly in the middle class. They're just unlucky enough to have to buy non-group plan insurance in the pre-ACA marketplace.
The ACA -- if it goes into effect -- will mitigate this. The health insurance exchanges will regulate individual health insurance plans, guarantee that no person or family will be rejected due to prior history, and make it easier for families to shop for and purchase insurance. The subsidies will make insurance more affordable on a sliding-scale basis. Bringing everybody (or nearly so) into the system will make insurance cheaper for all of us.
The ACA isn't perfect. At best it's a start. There may not be death panels, but there's plenty there not to like. You've got the mandate (for the record, I'd be fine with ditching the mandate if there were another effective method to encourage healthy people to buy in -- lock-out periods or late-entry penalties or what have you). There's no public option to force insurers to compete honestly. ACOs may not do anything to bring down costs. But for Kevin Zelnio and his family and the many other families in similar situations, who desperately want insurance but cannot afford it, ObamaCare provides them with a ticket to enter into the system. It's a pity that it's gotten so polarized that we can't move on and get to work on fixing deficiencies, improving what we've got, rather than refighting the scorched earth campaigns of 2009.
