Allergies and National Pride

Mr. Johnson came in a few weeks ago with shortness of breath that had been going on for three months and an extremely weak answer to the question, “And what is the medical emergency brings you to our Level II Trauma Center at 2 AM today?” His care was routine, but every now and then when interviewing a patient you come up with a gem. Looking at his chart, he claimed an allergy to American Cheese.

Granted, allergies mean different things to different people. Some people may consider an expected side effect as an allergy. Drugs such as erythromycin and narcotics are known to cause gastrointestinal effects such as nausea and vomiting. Other allergies may be a result of more patient-specific intolerance of the medication at a certain therapeutic level, such as patients who become excessively sleep or dizzy at a certain dose of anti-hypertensive drug but do fine at a lower level. (Interestingly, before drug levels became available some drugs were dosed by side effects. The right dose of digitalis, a drug used for heart failure, was the dose one step lower than the one that made you throw up.) A true allergy is a full-fledged joyride for histamines, mast cells, basophils, and lots of other mediator you’ve never heard of, all heading down the autonomic highway. The patient with true allergy develops hives, shortness of breath, and swelling throughout the body but most dangerously around the lips and tongue that can result in total airway obstruction. And when one has a true allergic reaction to one member of a family of drugs, we will shy away from any of the members of that family in order to avoid precipitating the same reaction with a chemically similar agent. (Knowing this, some of our drug seeking patients manage to have allergies to all but their drug of choice. On the other hand, when they say they are allergic to codeine abut can take the closely related oxycodone just fine, that’s doesn’t add up, either.)

I’ve been accused of sometimes thinking way too much, and so the allergy to American cheese caused me great mental consternation. You just knew he had to be faking this, because everyone is aware that hypoallergenic plastic is the major component of American Cheese (just as velvet is the prime constituent of Velveeta.) So I wondered if he had any problems with foreign cheese? No, he was probably happy to feast on foreign cheese, especially of those countries that failed in their duty to join the Coalition of the Willing. Little pansy countries in Europe that get their cheese not from big strapping corn-fed cows in industrial-strength hermetically sealed dairies but from little scampering goats of questionable manhood that frolic about the hillsides to the sounds of Zamfir and the Pan Flute (“He’s sold more records within the NATO alliance than David Hasselhoff!”).

Yep, that was it. Clearly he despised our country, our government, our way of life, the very foundations of our land. But he was smart: he knew that to air his wrath publicly would put his life in jeopardy, so he subtly declared his hatred of all things good and noble and American (because all three words mean exactly the same thing) through his alleged allergy to our cherished national processed food product. No doubt he was the kind of guy who probably kept saying French Fries when any Real American called them Freedom Fries, the same Real Americans who would also eat Freedom Toast in the morning and ask thier girlfriends to wear lacy Freedom Maid costumes for Halloween. And he had some nerve with that attitude in Daytona. Down here, in the wake of 9/11 there was a joke…no, not really a joke, but a statement of fact…that hitting NYC bought the terrorists time to hide while the media reacted, the government examined it’s options, and a response plan was put intoplace. If they had hit the Daytona 500, all the survivors would have filed out of the track, got their firearms down from the gun rack in the back of the truck, and called two buddies to put three extra can of gasoline and a really big cooler in the bass boat. War’s over.

(Speaking of foreign things, one of my colleagues has made a new rule. He will not see patients with foreign bodies unless the offending object has a green card. And if there’s no green card, he plans to extract misplaced item, enclose it in a box, and ship it back to whatever country it might belong. Which is exactly what we were going to do during my internship to an illegal immigrant who had been in a chronic vegetative state and on a ventilator in Kansas City for over a year. A senior resident, an intern, two students, a Ryder truck, and lots of oxygen tanks...but that’s another story.)

Are We Serious About Health Care Reform?

Doctors get asked from time to time what we think of health care reform. (We also get asked about swine flu, and spend a considerable amount of time explaining that you cannot contract the disease from Sweet and Sour Pork.) I used to try to follow the debate to the letter, but realized it was silly to do so when nobody making the policy actually did, either. So here’s what I understand as of now:

Health care reform was intended to give every American full access to the health care system. It was intended to stabilize or decrease health care costs while enhancing the quality of care. It was intended to reform the health insurance industry, and to make the lives of physicians and other health care providers easier by decreasing paperwork and releasing them from the burdens of unrealistic expectations and medicolegal fear. The net effect of the entire effort was to improve the overall health status of the nation. These are all laudable, important, and urgently required goals.

But so far, what we’ve got is a proposal that forces all Americans not already covered by Medicare or an expanded Medicaid to purchase an “affordable” health insurance policy or face a federally imposed fine. In order to help lower-income families purchase insurance, we will be using government money to support the purchase of polices from the same insurance companies that have been the leaders in denying, restricting and raising the costs of health care coverage so that administrative costs now represent a third of our health care dollar. Yes, we will allow public co-ops to develop insurance plans as well, but these will operate in the same mode as traditional insurance companies and will, in essence, differ only in ownership and profit margins. (In fairness to the co-ops, there is a model that works for them. It’s called Medicare). The out-of-pocket deductibles for low income families purchasing insurance, and the choice of using family dollars to buy insurance or pay a fine likely smaller than in the coverage costs, even with a subsidy? Not even a whisper of a question.

Physicians, of course, will not be finding their workloads eased nor have more time for quality patient care. While all Americans may be insured, the paperwork per patient stays the same, and there is still no relief from the lawsuits that result when the physician is unable to meet the consumer demands irregardless of the quality of care provided. Reimbursement still favors procedures rather than thought, technology instead of counseling, and the drive towards increased specialization and a reliance of testing rather than clinical insight remains unabated. (Oh, wait a minute; there’s going to be a panel. That’ll make it all better.) That is, of course, assuming that these newly enrolled patients have physicians to see them: Many physicians already decline to see Medicaid patients (or see them only when required to do so, as when “on call”) due to perceptions of patient compliance and medicolegal risk. There is no reason to believe a new flood of Medicaid patients will be greeted by enthusiastic doctors and hospitals, and those who do assume the burdens of care will do so facing declining reimbursements despite increased demands for accountability.

Am I missing something?

It seems to me that if we’re serious about health care reform, let’s do it seriously. If the underlying principle is that all Americans should have access to a baseline level of health care, then we should design health care reform as we would any other program that delivers basic services to which everyone should be entitled. If we view health care as a fundamental benefit of living in this country (the question of health care as a “right” or a “privilege” is temporarily shelved for another day), then we need to determine the appropriate level of entitlement, institutionalize it, and provide it without cost to all citizens of the United States. Those who can afford more certainly have the privilege of doing so, but are still responsible for their share of the common good.

The public schools can serve as an example of this precedent. American society has determined that education of our children through at least age 16 (10th Grade) serves a social good of such import that we require all children to receive this benefit. Granted, individual schools may differ in quality, but we have as a collective body decided that every child has a right to an education, and we have institutionalized this right through school statues, infrastructure, and funding sources. Those who opt out of the baseline benefit (sending a child to public school) can choose to do so at their own expense, but are still required to contribute to the general welfare. To make it more plain (and put it in a health context), we have determined that within the United States, every person should have access to clean water for drinking. We institutionalize this belief through laws, regulations, and infrastructure such as sewer pipes and water treatment plants. This baseline level of service doesn’t stop anyone from spending a few extra dollars for a water softener or filter, but those with own systems are still responsible for supporting the public works.

So if we’re serious about health care reform, let’s be serious about it and build reform around the fundamental desires and goals of the effort rather than what can get past the lobbyists. Let’s take the time to determine what clinically represents the baseline level of care that should be expected by every American, and let’s find ways to build in a set of responsibilities for each beneficiary to match the entitlement they’ve been granted. Lets’ change reimbursement patterns to reward primary and preventive care. Let’s revamp he system of medical justice. Let’s invest powerfully in information technology to allow doctors and hospitals to “talk” to each other within a secure framework of patient care.

But let’s not go as far as to restrict health care to a single payer system, thus denying those who can desire and afford further benefits to obtain them. The advent of a public benefit will likely be in competition with private insurance plans, and the latter may lose some business. But it also provides them with an opportunity to streamline their corporate structures, revise and enhance their product lines, adapt marketing strategies to maintain their volume and market share and, in the process, make health insurance truly affordable for all. It seems to me that’s essentially a “conservative,” free market idea that co-exists quite nicely with the more “liberal” agenda. (I believe that the idea I‘m discussing is fundamentally different than a “public option” insurance plan…the difference between a public and a private option coverage is simply a matter of where you send the bucks. Nonetheless, establishing a defined minimum level of benefit for all citizens will likely result in some of the same competitive challenges and opportunities for the private sector.)

Of course, if a fundamental shift in how our system works is not what anyone was actually thinking…well, as Miss Emily Litella used to say, “Never mind.”

She Thinks She's Po!

Someone I know recently described herself as a Teletubbie:

“I’m soft, round, child-friendly, and have a source of perpetual amusement on my torso.”

New Vital Signs

Medical tradition has held that there are four vital signs. They are the pulse count, respiration rate, blood pressure, and temperature. While nobody’s asked me, I presume they are called vital signs because, with the possible exception of popsicles like Walt Disney, Ted Williams, and the crew of the SS Botany Bay (KHHAAANNNN!), one simply cannot be vital without them.

Even now, the measurement and interpretation of vital signs remains one of the most important aspects of clinical care. One of the cardinal rules of Emergency Medicine is that you can’t send a patient home unless you can explain or correct any abnormal vital signs. Vitals signs also serve as the miser’s lab test, a low-tech, no cost indicator of patient status. It is to the detriment of medical practice and art that in our hurry to build volume and bill technology, vital signs are either neglected or cursorily acquired without any of the real-world interpretation encompassed in actual patient observation. Vital signs help to interpret patient complaints; it’s hard to assess a patient who says they have a fever when no temperature was ever taken (an unfortunate side effect of many “no wait” ED triage systems). Similarly, careful assessment of vital signs and matching them with the clinical status of the patient is something technology cannot achieve without human interpretation. It would good to know if the patient is cool and clammy because they’ve just been in the pool or their blood pressure is zero. (Admittedly, that last one was hyperbole. The fact is that when you have no blood pressure, the sweating stops. As does your pulse, your respirations, your ability to think at a level higher than Jessica Simpson, and most other things we associate with life. It's a corollary to that wonderful surgical rule that reads "All Bleeding Stops. Eventually.")

But modern medicine, just like the Value Meal at McDonald’s, is all about more. If four vital signs were good, five must be better. And so about thirty years ago it became popular to add the Glasgow Coma Score (GCS) to the hoary hierarchy of health. In brief, the GCS is a measure of neurologic status based on eye opening, verbal response, and the ability to move the limbs to stimuli. The score ranges from 3 to 15, three being a comatose state and 15 being awake, alert, oriented, and able to say things like "it's important that we engage in constructive dialogue with the Iranian leaders" without laughing (oh, wait..maybe I got it reversed).

The GCS is actually a very cool invention, one about which I have waxed, if not eloquently at least pedantically, in some previous work for jems.com. However, what I’ve always found most fun about the GCS is that if there is no response to a measured parameter, there is a natural assumption that the score should be zero rather than one. It’s nobody’s fault…nothing equals zero in most other facets of life, so it’s a deeply ingrained pattern of behavior. But the GCS doesn’t work that way, which is why from time to time you’ll get a call from a paramedic indicating that the GCS is 0, which as far as I can tell is better than dead.

For the last decade it’s been in vogue to add pain to the list as well. This idea is based on work documenting that physicians often undertreated pain. In addition, pain became one of the criteria by which a patient must receive an emergency evaluation and stabilization exam under the tenets of federal EMTALA (Emergency Medical Treatment and Active Labor Act) legislation. Pain control then became a rallying cry for patient’s rights organizations, often to the extent that the idea of clinically appropriate pain control was turned on its head. At one point during my tenure as Kansas State Health Director, there was even a bill put up before the legislature with a clause that would require physicians to treat a patient’s pain in a manner best determined by the patient, not the physician. That's not a bad idea if patients have terminal cancer, who in my book are entitled to any medication they want. But it's not a good idea if the law is intended to satisfy patient demands regardless of need.

(I could write any number of other pieces on this blog about how we deal with drug seekers, in the ED. I know some of my colleagues get frustrated by them, but dealing with these patients for me is a game of Clue in real time, my own personal version of CSI. There is the part where you do your clinical job, ferreting out behavioral and exam clues as to the true nature and severity of pain; there is the part where you check out the story and gather other background materials through phone calls and old records; and finally there is the moment when you synthesize the data, open the envelope with the cards, and declare the case solved.

I won’t go into great details about how ED docs do this for fear of giving away some of our deductive powers. But let me simply offer this single point of advice: We know where the telephone is and we know how to use it.)

The cunning linguists among you (always wanted to work this line in somewhere) will note that a sign is an objective finding, while a symptoms is a subjective sensation. This definitional problem has led to the creation of a number of pain scales in an attempt to standardize an inherently variant phenomenon.

The most interesting are those that ask the patient to rate the pain on a scale from one to ten. One of these scales notes that a pain level of ten is the worst pain you can imagine. This scale appeals to the philosopher in me. If you can imagine something, then you can imagine something greater, and imagination is by definition infinite. So according to this scale, no pain can ever reach ten, because you could always imagine just a bit more pain than you have, and then you can imagine just a bit more pain than that. It’s the same paradox that has Zeno’s tortoise winning the race no matter how fast Achilles could run and how little the head start.

Then there are the scales that establish ten as the level at which you would do yourself bodily harm to be rid of the pain. If that’s the case, then instead of using drugs for pain relief the most cost-effective way to handle the problem would seem to be an informed consent for euthanasia. (But I hate taking business from Dr. Kevorkian.) The scales that are the most fun are those that establish ten as pain so bad you’re unconscious, because when the malingering patient says to me they have a pain level of 10 I can look at them and say, without judgment or malice, that they’re lying because they’re still talking and not unconscious (in which case you don’t have any pain, right?).

I’ve been thinking about vital signs lately because last week I thought I had stumbled on the Next Big Thing in Vitals. It was The Moan. In the ED one hears a lot of patient noises, and it’s important to be able to distinguish between those sounds which suggest a person in distress and those which indicate your life is about to become difficult. So as the ambulance brought in a young woman whose moans suggested the latter was to be my immediate fate, I wondered if volume, pitch, or frequency of the moan could be used as an index of illness severity. My initial hypothesis was the volume of the moan was inversely proportional to the degree of acute pathology; the louder you yell, the better your lungs and heart and the less likely you are to actually require emergency care. (Actually, when I initially thought of this I wasn’t using such polite terms. My train of thought was less clinical and much more directed at the assumed personality characteristics of the said producer of the industrial-strength holler. But I’m sure you get the drift.)

I ran this idea by a wise, weather-beaten colleague of mine, the kind of guy who doesn't recognize narcotics more potent than two fingers of Jack and an old poster of Farah Fawcett. He quite rightly suggested that moaning in and of itself was a non-specific indicator with poor specificity, sensitivity, and predictive values. (And they say there's no academic talk in community hospitals. Look at all those big words, huh?) He pointed out that many patients have a perfectly valid reason to moan and probably ought to be allowed to do so without fear of labeling. Folks with kidney stones, for instance, should and do moan. People with mangled limbs are not only expected to moan, but have the God-given right to do so. Patients with acute cardiac events may also moan to themselves as they briefly reflect upon their lives (those who rise up out of bed and shout, "Elizabeth! I'm comin', honey!" are a different matter entirely). So if I was going to pursue this line of reasoning and develop a powerful clinical tool, clearly more thought was required.

I started to reflect on other markers that might contribute to my new index of patient non-distress. For example, three weeks ago the ambulance brought us a young woman who was dying. We knew she was dying because she would emerge from her exam room, stride up to the nurse's desk, loudly proclaim “I’M DYING” while asking for pain medication, and saunter back to her room until the next matinee 2.83 minutes later (6 episodes in 17 minutes...yes, it was timed). When I finally had an opportunity to visit with the patient (after seeing two other patients who were not only not moaning, but not breathing as well) I discussed with her that I felt comfortable saying that she was actually not dying because those who usually are often do so quietly and seldom make a habit of getting up and notifying us of their impending demise. So perhaps one of the parameters for my new vital sign should be related to the number of times you walk away from your bed to tell the nurse of your imminent discharge to the celestial floor.

A third thing I want to fit in is the number of previous visits to the ED. In general, those who use the ED more frequently tend to have less severe illness on presentation. (Again I’m using polite language here, although in person I will often ask our “Frequent Flyers” if they’re getting companion tickets for their dozen visits this year alone. But to show you how medicine has evolved, twenty years ago when I started I would ask they were getting Green Stamps.)

By themselves, none of these parameters meets the level of significance needed for a valid clinical measure. We’ve already mentioned that there are entirely valid reasons for moaning, and there are some truly unfortunate people with terrible progressive disease who do require frequent ED visits. So in order to make this work, combining the measures into a single equation seems to have the best chance of providing an accurate measure of patient non-severity. So as of 5:47 tonight, here’s my winning entry:

(Decibel volume of moaning) x
(Nursing desk visits for death proclamations) x
(Number of previous ED visits in past 24 months for same complaint) =
Non-Severity of Non-Illness Index (NSNII, or The "Rodenberg Score")

(You may have noticed that even in the few pieces I've already submitted to this blog, I keep naming stuff after myself. There are two main reasons for this. The first is that, like Beowulf, a large part of me believes the way you survive after death is through the fame you've achieved in life. In medicine, fame is to be an eponym. The other reason is that the only thing that ever actually got named after me was a local EMS prehospital seizure treatment protocol that used rectal valium, a procedure that came to be known as a "Rodenberg ." I would much rather have my name covered with some other form of glory than...ummm...sheizure.)

Like most things in medicine, a few caveats must be kept in mind. The score cannot be applied to children less than 12, because you simply can't choose your parents. (One of the saddest things I know is to see bright and happy little kids in the ED, and then look at their family and realize the child has no chance in life.) And it’s also considered invalid in nursing home patients, because tradition dictates that they be shipped out to the ED every time they roll over in their beds, accidentally pinning the remote under their hip and turning off The Real Housewives of Beverly Hills during shift change. (And there are three shifts each day.)

I look forward to your help with this research effort. Additional contributions are welcome. But it'll still be called The Rodenberg Score. Just so we're clear on that.

The Child Writes a Column

In the Blue Ridge Mountains of Virginia
On the trial of the Lonesome Pine…”

Oliver Norville Hardy, Way Out West, 1937

My son and I have developed a number of Daddy and Boy traditions during our decade together. One of them is movie night, where we select a favorite from our large collection of Laurel and Hardy films. He makes an innovative dessert (usually a base of ice cream with Lord only knows what he throws in there), we eat popcorn and drink Coke, and with any luck neither of us pukes up these culinary creations. Another is the “Nature Walk” (or, as he calls it, “A Fate Worse Than Death”), where the child is forced to troll through neighborhood parks and walking trails in the company of his parent and is encouraged to converse about things in the real world like school and friends and karate class, and is constantly reminded that, dagnabit, some day he’ll be grateful for this time together. I have to ask him about school during these walks, because when I ask him on the phone I’m continually astounded by the fact that he can spend seven hours in a building with hundreds of other children and do absolutely nothing. Here’s how those conversations go:

“Did you do any reading today?”

“No.”

“Did you do any math?”

“No.”

“Did you do any science?”

“No.”

“Did you do any social studies?”

“No.”

“Did you eat lunch?”

“Yes.”

“Did you use any oxygen?”

“Yes.”

“Did you sit on your thumb and spin?”

“No.”

This routine has become so well established in our conversations that now all I have to do is ask, “How was school today?” to hear him say, “Nonononoyesyesno.”

We also have Automotive Song Time, during which I sing spontaneous ditties while driving such as “All Praise to the Father” (Sample lyric: “All praise to the father. He’s better than the rest. All praise to the father. Of dads he is the best.”) while he cringes in the back. One of our newest habits is the Sunday Morning Breakfast, where we head to a local coffee shop and get some cups of hot chocolate while we read the comics and explore the internet. This week it was special selections on You Tube. He showed me the Kittycat Dance. I showed him the video of Peyton Manning from Saturday Night Live. We accidentally opened an email with a very grown-up picture of a young lady from Grandpa. Fortunately, the child has books about the human body at home. Minimal explanations were necessary.

I was showing him my piece on jems.com about soccer, and how I had featured his rear end as a central point of that missive. (For those who missed it, I told the tale of his greatest athletic triumph, making a save in five-year-old soccer when the ball hit his backside.) He thought this was interesting, and then asked if I could write something for him on the internet. I would have been ecstatic if he had wanted to write it himself. For a ten-year old, my son is a brilliant writer, a creative genius in Spider-Man sneakers, and this isn’t just the Daddy talking. He’s won countywide school creative writing contests for his age group, and for ages he’s been dictating ideas and stories to me that I type up for him. For example, several years ago when my brother’s wife was expecting, he created a wonderful gift for my sister-in-law where he asked folks to provide baby advice and then put all the responses in a keepsake album. It seemed logical to me to ask the person in my household who was closest to babyhood (in age, not maturity…that would have been me) what advice he might give. Here are a few excerpts from his list:

Babies are important to take care of.

The might spit out their food, so watch out!

If you treat the baby the way it wants to be treated, then the baby will treat you the way you want to be treated.

Do not feed the baby beer!

Keep the baby away from Lego pieces or they will eat them!

Babies are nice, so do not wake them up when they are napping.

Do not say, “The baby has a beard.”

(And who among us has not wanted to note that the baby has a beard?)

He also got quite frustrated when he read in the newspaper that Pluto was taken off the list of planets. Here’s his unsent Letter to the Editor:

Dear News,

I am mad you say Pluto is not a planet! Pluto was an emblem to me. An emblem of the small kids. I think all of you should get a new job. May I suggest a job selling door-to-door ham? Pluto is important to me. It is my favorite planet! MAKE IT A PLANET AGAIN! I will keep doing this until Pluto is back as a planet! So, I think you should give Pluto another chance. DO IT OR ELSE!

Your protestor,

Brendan Rodenberg

So it was with great fatherly pride, and a desire to avoid work for as long as possible while attempting to hit Level 70 on “Cradle of Rome” (available from Real Arcade.com), that I offered him the opportunity to write a column for jems.com. Unfortunately, he declined with all the politeness and tact that a ten-year-old can muster when asked to do something by a parent whom he is beginning to perceive as flawed in some vital way, but can’t quite put his pre-teen finger on it.

“That’s dumb.“

Hoping for clarification, I asked what exactly was dumb about it. He informed me (in no uncertain terms) that all I write about is medical stuff, and that was boring. He did say, however, that if I really wanted to write something useful it would be about Lemony Snicket, the eponymous author of the series of children‘s books titled “A Series of Unfortunate Events.”

(I should probably note for the record that the reason my boy thinks that all things medical are silly is likely a direct result of the way I‘ve handled the usual childhood emergencies. I suspect that like most of us involved in emergency care, if someone is generally doing well we quickly lose interest. So his experience has taught him that if he gets hurt, I‘ll ask him “Is it bleeding? Is it attached?” If the answer to the first question is no, and the answer to the second is yes…and he‘s able to answer the questions, which means his ABC‘s are intact…and if he stomps his feet and yells, “You ALWAYS say that!“ in my general direction, I know he‘s okay. And we discuss that it’s okay to cry if it hurts, and together march through the house in search of the mandatory band-aid.)

So I‘ve been struggling with ways to link Lemony Snicket to medicine for the past few weeks. I tried to think about how we all make our living off a Series of Unfortunate Events, but that came out too morbid and seemed to be reaching for profundity when there was really none there. I thought maybe the anonymity of Lemony Snicket might represent a parallel to the uncertain nature of who or what is driving the health care system, but no matter how I turned it over in my head or on the page the topic never quite made sense. I even tried to derive an analogy between the main characters in the stories...the Baudelaire children and the Evil Count Olaf…but lost focus when the Count had morphed into Medicare Billing Guidelines and the infant Sunny became a pre-scandal Eliot Spitzer.

And late one night, as I finally gave up, I realized that for me, the failure to write is intellectual death. Most of us have probably run across the Kubler-Ross model somewhere in our training. It’s a five-step scheme for how we react to the prospect of death. In trying to get something to gel, I had gone through all the stages…denial, anger, bargaining, depression, and acceptance. And with acceptance came the idea that sometimes I might need to write about what I tried to do, and not what I did. Even a record of our unfulfilled hopes and aspirations can tell others more about who we are and what we believe than any catalog of diplomas or plaques on the wall.

Maybe I‘ve learned something valuable about futility. Maybe this piece should go into the Literary Hospice, be tucked into a nice warm bed, and given adequate pain relief until it expires of its’ own accord. Maybe futility is a lesson unto itself.

Besides, it’s time to ask the school questions again. Like I don’t know the answer.

(Afternote: This piece was originally written in the Spring of 2008…it’s amazing what one finds on the computer that never got published when digging through the pile of flash drives. Since then, there have been a few changes. The Nature Walk is now tolerated because we have a new Fate Worse Than Death in The Father-Son Bike Ride. And we no longer have Daddy and Boy Movie Night…the movies are still there, but I have made the transition from Daddy to Dad, which I think is the start of the change of the father image from Conquering Hero and Role Model to Annoying Guy with Money and Keys. But the more things change, the more they stay the same. He’s now in middle school…and still does nothing for seven hours each and every day.)

My Modest Proposal

On Decreasing Health Care Costs: A Big Olde Nicotine-Stained Proposal

(With many apologies to Jonathan Swift)

It has come to our attention that writers of better repute than myself have divined that the health care system in our blessed land…England, of course, for by the Grace of Our Lord no other land can be called as such with any sense of the honor imposed by the term…may someday cost our kingdom more than it does today. This hard to believe, for even the best life is worth no more than a pig and a farthing in the eyes of the physic, and is but half a thought in the mind of the Lord. Yet there are those, flushed with the bawdy proclivities and foolishness philosophies of the The French…natural rights, indeed… who predict a time when our colonies might dare to someday be independent and prosperous without the sheltering wings of our generous King, and who say that by the year 2006, should mankind still be upon this earth awaiting the rapture promised to us in the Gospels, that goodly band of rabble across the ocean may spend up to two trillion of their monies on health care each year.

Yet it is easy to recognize why this is so, as we walk about our homes and lands to see that followers of the Way of the Camel put Promethean fire to the tobacco leaves in our mouths; and that the hurly-burly of life, the hiss of the steam engine and the clatter of the coach traffic on the cobblestones streets, has caused many of us to worship at the altar not of the Almighty Jehovah, but at the King of Burger and his consort Wendy. And if we are to consider for a moment what may be next, just as the rebel Franklin talks about sparks from the sky as though they may be useful some day and the scornful idea of independence from their Mother Land…we might only expect these habits to worsen in our midst, until we eat foodstuffs on the advice of white suited colonels, makers of pommes frittes from Alba, and small canines of the new world speaking the Castilian tongue. We will chew leaves on the advice of Red Men and Bears of the North, and smoke products to remind us of fortunate moments at ninepins. Our machines will do our labor for us, and we will have no need for walking or exercise; we will become as a confined boar, growing larger yet losing our ferocity, until we are led meekly to the slaughter. We will develop disease such as the gout, which will make us immobile; we will develop dropsy, and our limbs will swell; we will find Hippocrates’ oncos and carcinos in our lungs, in our voices, in our mouths and noses; we will develop the disease of the honey urine, and lose the feelings in our limbs before the darkness envelops our eyes; our hearts will rise in defiant aggression and slay the body that bore it. The battle will be waged over many long and difficult years, and will cost us. Our purse will be poorer, and the costs will not be borne not only by the sufferer, but truly in every holt and heath.

But as we together lament the state of our wellness, and of our debts in this world and in the world to come, let us note the work of our Dutch colleagues (if such a continental can be called a colleague; still, Our Lord asks us to recognize good in all, even those who are not Loyal Subjects of Our Beloved King) who have used the bones of sheep and the motions of the stars to calculate the costs of living the life we seem destined to lead. They tell us that those who use the leaf of Raleigh and who revel in the kettled fat live less than those whose lives are a smokeless Spratt, but cost less, too. Those who live a more healthy life live longer, and cost more over their years than those who die sooner and quicker.

And so, my friends let us solve our problem in the most pleasant way. Let us smoke and drink, feast and sup, tell tales of humor, sagas of heroes, and legends of woe amidst the leafy haze of aromatic combustion; let us make merry. And let us die, quickly, painlessly, if the Lord grants us favor; but more likely hacking, coughing, suffocating as the malignant masses encases our lungs, or with the tense burden of Atlas falling onto our breasts, manifesting the weight f the world upon our arms and shoulders, giving off the sweat of honest labor as our heart takes that last…beat…beat…

And let us say Amen.

(Van Baal HM, et al. Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure. PLoS Med 2008; 5(2):e29.)

Talking to Myself

When I was a Paid Professional Liberal doing public health in Kansas, every year at Christmas time I would take a week off and work a series of shifts in my “home ED” back in Florida. It gave the folks in the ED physician group a bit of a break around the holidays, I reminded myself that I could still do doctor stuff, and, to be frank, it was the best paying hobby that I know.

Given the changing pace of medicine and of medical practice, it was not surprising that every year there were a few new things to learn. There were new drugs, new lab and x-ray methodologies, and new physicians in the community with whom you’ve never worked. And it was always fun to play that year’s version of Admission Roulette, where the primary care physician is not on-call for himself, but is being covered by someone else; that physician refers you to someone else to admit the patient, and that person referred to is also being covered by someone on-call. Throw a consult or two into the mix, such as in an elderly patient with chronic medical problems needing admission for a hip fracture, and things get even more fun.

It was during one of these vacations that I discovered the newest (and continuing) bane of my existence. It is a particularly savage device known as the Automatic Towel Dispenser. This infernal creation requires you to pass your hand underneath a sensor to generate the provision of a single square of paper the texture of finely pressed chipboard. If, like me, you are one of those people who desires a second sheet because there’s just not enough surface area to soak up all the water in a single piece, you then have to wait until a timing device somewhere within its’ electronic bowels decides you can access an additional square. You spend these ten seconds or so frantically waving your still-dripping hands under the sensor, because you never quite know when it will give you the towel you want. It’s like playing a slot machine where you know you’ll win something, but you’re not sure when or at what cost. Nonetheless, you know it’s important to show some kind of purposeful movement at all times, a committed demonstration of intent so that all who pass by will know, “There is a man who wants a towel.” It drives me bats, partly because of the waste of time (if I see twenty patients in a shift, and the only time I choose to wash my hands is after seeing each patient for the first time, I still spend a minimum of three minutes waving my hands about in a frenetic mode), but mostly because of the indignity of it all. And in some of the patient rooms, the Automatic Towel Dispenser is located immediately behind the counter I tend to lean on while talking to patients. This means that if I get to close to the dispenser, the electric eye assumes I’m frantically waving my hand and sends off a virtually endless stream of towels until I remove my body to the other side of the room.

This is not to say I have any problem with hand washing as a concept. The Austrian physician Ignaz Semmelweiss should be praised daily for his 1847 discovery that deaths from puerperal fever could be virtually eliminated by hand washing between work in the morgue and patient care. That notion led to Sir Joseph Lister’s work on antisepsis and the emphasis on cleanliness in medical practice that benefits us today. As a past-life public health professional, I truly believe that it’s the personal, common-sense things, like washing our hands and covering our coughs and sneezes, that will do more to contain infectious disease than any other policy or program. So when I put on the long white coat and dust off the stethoscope, I’m probably more into hand washing than I need to be. Given where your hands wind up going and what they end up doing in the ED, that’s not a bad thing. But it adds nothing to the clinical effort to just stand around dazed like Amy Winehouse, wringing your hands in despair as you wait for a towel that’s still going to be too small, so you’ll need another. And it’s not like the alternatives are all that bad. If the towel dispenser is the kind that has a crank on it, you’ve got to figure that the last person who used it washed their hands before turning the crank, so the crank should be a contagion-free zone. If it’s the kind where you just reach toward the center of a bulging pile of towels and pull one out, it’s not like you have to caress the entire dispenser before reaching into the slot for that one elusive towel. (Clearly, I have way too much time…and water… on my hands thinking about this. Towel-waiting time is thinking time.)

It’s these sorts of events that make me recognize that I’m just not a technology-friendly guy. While it’s true that I have come to rely on my laptop for writing, e-mail, and Fantasy Football (The Screaming Leemers are now 3-0, while the Vocal Meerkats are 1-2), I’m otherwise pretty clueless about how most of modern life works. For example, last year it was decided that I needed a new cellphone to replace my six-year old model that finally failed to recharge. My problem was to find a phone that did what I wanted it to, which is to make and receive phone calls. A device that does so, however, turns out like failure in Apollo 13 (“Not An Option”). You have to get a phone that has text messaging, wireless capabilities, and multiple permutations of scrolling menus. And that’s just the free one that comes with the service…no upgrades for me. To be fair, I probably shouldn’t be surprised at my lack of comfort with things novel and new. I’ve been accused of failing to recognize that there has been any decent popular music written since 1990. This, of course, is not a case of willful ignorance, but a mere reflection of the fact that with the possible exception of “Love Shack” by the B-52’s (technically released on a 1989 album, but I’ll cut it some slack and round up), the proposition is absolutely true.

What bothers me about the Automatic Towel Dispenser is not that it does what it does. It’s kind of like trying to get mad at a computer game. The game does what it’s programmed to do, and there’s really very little you can do about it. (While I believe this to be true, I am equally convinced that these programs has some kind of sensor in it that detects the tension level in my mouse hand and causes an internal pixie to rub his hands together with glee just before making the screen go dark. The pixie is why my son’s “Bad Words” quarter collection keeps growing every time I play Age of Empires.) The problem, I think, lies with the people who design the systems and those who purchase them. Technology sells, but too often it sells for the sake of technology, and unless the buyer is the user the ultimate consumer is left out. For me, I’m not looking for things to be user-friendly. The towel-dispenser is user-friendly, in that it takes no effort or training to operate. I want them to be user-useful.

Let me give you an example. The hospital I work out added voice-recognition software to their medical records capabilities a few years ago. Voice-recognition software is designed to allow you to dictate your note directly into a computer, and the computer will print out your dictation in real time without the need to go through a transcriptionist. On the surface, it looks ideal. Real-time data can be generated in print and is available immediately for clinical use, or can be stored indefinitely in an electronic format. Clear, legible, typewritten documents lead to more accurate billing and provide medicolegal security. Costs are lower in the long run because you remove the human typewriter in the middle. What could be better?

Technically, nothing. It’s a great premise, and the software indeed does what it’s supposed to do. If you give it words, it will take what it “hears” and put them on paper and in an electronic form for all the purposes just described, and it does a great job at it. And it’s a fairly “user-friendly” format…it takes some time to get used to the system, but the learning curve is not bad. In some ways, it might even be able to speed up the documentation effort; for example, you can program it with a standard exam so if you tell it “lung exam” it will print out a preset response (“Lungs are clear to auscultation bilaterally without wheezes, rales, or rhonchi”).

But it’s sometimes not user-useful. There are times it takes longer to get the system to transcribe your words correctly than it does to simply dictate a chart. The system is said to have a recognition accuracy of 90-95%. That’s really very good for this kind of software. But what it really means in practice is that the system will misunderstand, and transcribe incorrectly, one out of every 10-20 words it hears.

That may not seem like a big deal. For example, let’s look at one the Introduction to the Declaration of Independence with every tenth word removed (starting with word #5):

When, in the course human events, it becomes necessary for one people to the political bonds which have connected them with another, to assume among the powers of the earth, the separate equal station to which the laws of nature and nature's God entitle them, a decent respect to the of mankind requires that they should declare the causes impel them to the separation.

The study of linguistics and human factors engineering tells us that humans are pretty good about filing in the blanks, especially knowing the rules of usage of a particular how language and the cultural context of the communication. But the computer can’t do that, because while it may know some of the structural components of language, it knows nothing of context. So if read at face value, the dictation may seem disjointed at best and confusing at worst.

The other key factor is that for the system to transcribe a word, it has to “hear” it. That is, it has to be able to clearly delineate a word from other speech on either side of the word and from any background noise. In many ways, this is operator-dependent. People who speak slowly and clearly, using short words and brief phrases, have less problem than people like me who tend to talk fast and use lots of punctuation, causing the computer to run words together and transcribe what it thinks it heard rather than what was said. Earlier this week I was asked about a record where the computer had documented that, “A ride was injured by the radiologist,” rather than the intended, “MRI was interpreted by the radiologist.” (To be fair to the machine, this is no different than what we do when we think that Manfred Mann was blinded by the light while wrapping up a feminine hygiene product in the middle of the night, or when we attempt to attribute any lyrics whatsoever to “Louie, Louie.”).

This effect can lead to some pretty funny moments. For example, when I dictate a physical exam, I tend to use the word “cardiovascular,” as in “cardiovascular exam shows there to be a regular rate and rhythm without murmur.” The software has continually interpreted the word as “cremaster.” The cremaster muscle covers the testes, and raises or lowers the scrotum in order to regulate the development of sperm. According to the software, I’ve been listening to scrotums for well over a year, even on women. (Here’s a home experiment for you. The Cremasteric Reflex occurs when you stroke the inner part of the upper thigh and the scrotum and testicle on that side are pulled up towards the groin. Try it with someone you love. This is, of course, to be distinguished from Peter’s Sign, the radiologic finding that on pelvic x-ray, the male member always points to the side of the problem.) And knowing that these things happen, we sometimes set the system up to fail. A few weeks ago I started to dictate some phrases I always thought were funny into the system to see what would come out. “Ball peen hammer” emerged as “balls penis ham her.” (Don’t worry, Risk Management…it’s already deleted).

Fast talkers like me also cause the software to often not recognize shorter words such as articles and prepositions, and for whatever reason when I use the system it tends to leave out the word “no” quite often. This can produce radical shifts in meaning; there is a world of difference in the phrases “patient has chest pain” and “patient has no chest pain.” Some physicians with stronger accents can also cause the software problems, although the program does have the capability to be “trained” to the particulars of an individual over time. But while a human transcriptionist can slow down a tape to listen again to what is being said, and through training and experience has some sense of context, the computer has no ability to do either. And while you could legitimately say there is a responsibility for the physician to go back and check his work, you might also reflect on how much time it would take away from the work of the department to go back and correct by hand every tenth word as well as any unusual phrases like I’ve noted above. So we tend to trust in the software, and use both the known limitations of the program and the clinical context to clarify any confusion.

And then there’s the Law of Unintended Consequences (I could make a joke here about marriage and children, but I demur). The ED where this software was first installed was a busy, noisy place, and the station where the physicians and clerks sat was right in the middle of the floor show. The docs sat on one side and the clerks assigned to work with them sat on the other, and usually there’s a pretty lively back and forth banter as orders are given, phone calls are transferred, and both printed lab work and rubber bands fly across the table. That background noise, on top of the unique sounds associated with the ED and other twenty-four hour establishments such as psychiatric holding facilities and fraternity houses, interfered with the software’s ability to recognize specific words and phrases. However, you couldn’t have a doctor continually leave the ED to go to a soundproofed area. So a glass partition was installed that divided the desk in half, docs on one side and clerks on the other, with some additional extensions that enclosed the physicians from both the front and the sides. That left open the back, which happened to be immediately in front of rooms used for patients whose clinical condition required close proximity to the core of the ED, but were unruly about their visit to our facility. These noises would echo within the canyon of glass, which in turn made dictation even more difficult when the party was really going strong. The dictation effect was irrespective of the fact that it was harder to talk to the clerks over the wall, and sometimes it took a running start to make sure the printed lab work got over the partition when flung at the doctor for review. To counteract this problem, a three-inch-wide slot was cut in the glass so you could order a Big Mac Value Meal and a CT scan of the abdomen and pelvis at the same time. (I will confess that, at the end of a night shift when the caffeine was good for one last burst of creative energy, I actually printed out a sign that said, “Mr. Gorbachev: Tear Down This Wall!” and taped it to the glass.) We have now moved into a newer, and much more tranquil, ED that features modern, state-of-the-art design and mood lighting. Working there feels a lot like being in the booth with Venus Flytrap. It’s just a matter of time before we light the incense and install a lava lamp to liven up the place.

While frustration with systems such as voice recognition software inevitably leads to calls for culpability, in reality this state of affairs is no one’s fault. The system designers and vendors made the system to do exactly what they said it would. The purchasers did not buy the system in order to impose on others. They saw a need and found a way to answer it. The health care system has more silos that Kansas, and it shouldn’t be surprising that a system purchased for the benefit of one part of the system might hurt the function of another.

I’ve been speaking here of a hospital-based system, but the use of technology is exploding within prehospital care as well. And while my example is of an”administrative” use of technology, patient care technology has the same limitations. Point-of-care testing may be technologically feasible, but what benefit is there if the result doesn’t make the paramedic provide a better level of care? If the ultimate user of medical technology is the patient, how do a few extra minutes on scene to use a device add value in an urban EMS system?

The solution to the problem of user-utility is ultimately one of communication. For whatever reason, designers don’t talk to purchasers, buyers don’t talk to users, and users seldom provide feedback to those who build or buy the systems foisted upon them. Agencies and institutions making large capital investments in technology should as a matter of course convene multidisciplinary teams to evaluate the products for not only their ability to get the job done, but to do so in the most clinically effective way. This is especially true when new technologies force changes in established patterns of work between different organizations. For example, while I value electronic EMS records for billing, review, and research purposes, it drives me nuts as a clinician that in many cases I can no longer get a copy of the EMS record from the prehospital crew before they leave the hospital.

So if you’re one of those people who’s developing a new application for health care, ask your friendly neighborhood doctor, nurse, or EMT what it might mean to him. If you’re buying a system, make sure it not only does what you want it to do, but also helps your staff do their job the best way that they can. And if you’re the one who’s had some new device dropped in their lap, accept what the technology is supposed to do and find a way to help it work better. It’s not helpful to rage against the machine unless you actually understand what you’re raging against. And only when the batteries die can you rage, rage against the dying of the light.

(With inadequate apologies to Dylan Thomas, “Do Not Go Gentle Into That Good Night” should be required reading for all. There’ll be a test.)