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Friday, September 25, 2015
Thursday, September 24, 2015
Wednesday, September 23, 2015
Public Health Issues in Central Valley of California: Thousands not receiving State Aid for Water
Drought has 14 communities on the brink of waterlessness
Parkwood's last well dried up in July. County officials, after much hand-wringing, made a deal with the city of Madera for a temporary water supply, but the arrangement prohibited Parkwood's 3,000 residents from using so much as a drop of water on their trees, shrubs or lawns. The county had to find a permanent water fix.
Parkwood is one of 28 small California communities that have since January cycled onto and off of a list of "critical water systems" that state officials say could run dry within 60 days. Amid the drought that is scorching the state and particularly the Central Valley, the State Water Resources Control Board decided this year, for the first time ever, to track areas on the brink of waterlessness.
"It's a sign of how severe this drought is," said Bruce Burton, an assistant deputy director for the board.
Public Health Issues in Central Valley of California: Thousands not receiving State Aid for Water
MedicineBall is the new Moneyball | Jordan Shlain MD | LinkedIn
MedicineBall is the new Moneyball
Jordan Shain, M.D. published a futuristic vision for patient centered medicine. The bottom line is the patient becomes not only the recipient of health care but an active collaborator.
Vocal patient advocates insist on patient involvement in the review of complications. It is the current mantra and politically correct statements of the media, at social events, on social media and cocktail parties.
What do the rest of the patient and doctor community really think? That is an unknown. It leads to a conclusion that this course is all well and good.
Without careful analysis this is much like a non blinded study the results of which may be open to question.
Most providers have long been involved in peer review. It has been part and parcel of American Medicine for decades. It may not be a uniform standard practice. Peer review at an academic medical center is much different than that in a small hospital. Patient collaboration may be very important in that setting as part of a regional quality assurance organization. The devil may be in the details.
A poor outcome may result in a medico-legal event. The evidence produced may introduce a new feature in law suits. Malpractice incidents may rise or fall.
Propublica, in a seminal article, 
These meetings are among peers and colleages, in strict confidence, to share mistakes as a mechanism of improving. The Institute of Medicine in their acclaimed report, 
complication rates. The new paradigm in payment: Your income will be dependent on your outcomes. Incomes = outcomes.
Data holds a key; a very important one, however it does not hold the key. Participatory humanism plus data does.MedicineBall is the new Moneyball | Jordan Shlain MD | LinkedIn
Tuesday, September 22, 2015
TrialMatch Aims To Ease The Pain Of Clinical Trials Recruitment | TechCrunch
Are you in the Game ?
Will I help Someone Else ?
TrialMatch Aims To Ease The Pain Of Clinical Trials Recruitment | TechCrunch
Thursday, September 17, 2015
Primary Care Telemedicine A Key New Care Channel | EMR and HIPAA
Primary care medicine and your 'family doctor' may soon be a smartphone or tablet pc.
The rules and regulations governing health care are changing rapidly as state medical boards have fallen behind and are struggling to keep up with the HIT revolution.
Telemedical treatment has been a tantalizing possibility for many years, for reasons including a failure of health plans to pay for it and too little bandwidth to support it, but those reasons are quickly being trumped by the need for quick, cheap, convenient care.
In fact, according to research by Deloitte, 75 million of 600 million appointments with general practitioners will be via telemedicine channels this year alone.
While one might assume that this influx is coming from traditional primary care practices which are finding their way online, that doesn’t seem to be the case.
Instead,a growing number of entrepreneurial startups are delivering primary care via smart phone and tablet, including Doctor on Demand and HealthTap, which offers videoconferences with PCPs, and options like Healthcare Magic and JustAnswer, which offer consumers the opportunity to get written responses to their healthcare queries from doctors.
Whether or not these methods are HIPAA Compliant is still open to question.
Primary care doctors going into direct primary care are also joining the primary care telemedicine revolution; a key part of their business is based on making themselves available for consultation through all channels, including Skype/Facetime/Google Hangout meetings.
To date, most of the thinking about telemedicine have been that it’s an add-on service which is far to one side of the standard provision of primary care. However,with so many consumers paying out of pocket for primary care — and virtual visits typically priced far more cheaply than on-site visits — we may see a new paradigm emerge in which victims of high-deductible plans and the uninsured rely completely on telemedical PCPs.
Rather than being merely a new technical development, I believe that the delivery of primary care via telemedical channels is a new form of ongoing primary care delivery.
It will take some work on the part of the telemedicine companies to sustain long-term relationships with patients, notably the use of an EMR to track ongoing care. And telemedicine PCPs will need to develop new approaches to working with other providers smoothly, as coordination of care will remain important. Health IT companies would be wise to consider robust, unified platforms that allow all of this to happen smoothly.
Regardless, the bottom line is that primary care telemedicine isn’t an intriguing sideline, it’s the birth of a new way to think about financing and delivery of care. Let’s see if traditional providers jump in, or if they let the agile new virtual PCP companies take over.
Primary Care Telemedicine A Key New Care Channel | EMR and HIPAA
Monday, September 14, 2015
Why your Physician is Not as Well off as You Think
This post is meant for two groups of people
1. Medical Students
2. Patients
It's not easy being a doctor. Not only will you work long hours, and in today's world of shrinking reimbursement, and regulatory constraints there will be a finite limit on your income. Unless you began financial planning while in late college or early medical school, you have realized the slippery slope you are now on. Depending where you are you may decide it is not worth it financially to become a physician and bear the responsibilities you will face. In fact after all is said your net spendable income for many years. may not be more than a good accountant, nurse, or plumber/electrician.
The debt you accumulate may be equivalent to a mortgage on a small to moderate home. Real estate is also an asset, it can appreciate over the terms of your payout on your medical school debt. Medical school debt is just a liability. And it will affect how you may borrow after graduation.
A medical degree is no longer a ticket to financial freedom or success. With it comes significant liabilities for medico-legal insurance, rising overhead, and burdensome regulatory and licensing mandates.
You will be required to participate in many non-reimbursable duties, and I do not mean charity patient care, but hospital committee meetings and post graduate medical education which also consumes a portion of your income, and time away from your business (seeing and caring for patients.)
And like in so many other businesses federal and state regulations have grown enormously, intruding into medical affairs where no sane person would go, without much concern and no liability for poor outcomes due to restrictive regulations.
If all of the above has not dissuaded you from our noble profession then you may be fit to become a
physician.
How to Get Rid of Your Med School Debt
1. Medical Students
2. Patients
It's not easy being a doctor. Not only will you work long hours, and in today's world of shrinking reimbursement, and regulatory constraints there will be a finite limit on your income. Unless you began financial planning while in late college or early medical school, you have realized the slippery slope you are now on. Depending where you are you may decide it is not worth it financially to become a physician and bear the responsibilities you will face. In fact after all is said your net spendable income for many years. may not be more than a good accountant, nurse, or plumber/electrician.
The debt you accumulate may be equivalent to a mortgage on a small to moderate home. Real estate is also an asset, it can appreciate over the terms of your payout on your medical school debt. Medical school debt is just a liability. And it will affect how you may borrow after graduation.
A medical degree is no longer a ticket to financial freedom or success. With it comes significant liabilities for medico-legal insurance, rising overhead, and burdensome regulatory and licensing mandates.
You will be required to participate in many non-reimbursable duties, and I do not mean charity patient care, but hospital committee meetings and post graduate medical education which also consumes a portion of your income, and time away from your business (seeing and caring for patients.)
And like in so many other businesses federal and state regulations have grown enormously, intruding into medical affairs where no sane person would go, without much concern and no liability for poor outcomes due to restrictive regulations.
If all of the above has not dissuaded you from our noble profession then you may be fit to become a
physician.
How to Get Rid of Your Med School Debt
Medical Schools Teach Students To Talk With Patients About Care Costs : Shots - Health News : NPR
In 1969 while I was completing an internship in general medicine I remember examining very ill patients who were starting on the never-ending conveyor belt of testing, and treatments, study after study, and some treatments that were very painful in the face of a poor prognosis or outcome. The Intensive Care Unit was a point often of diminishing returns of investment of time and money.
During the 1960s not much was made of cost, either by attending physicians, doctors in training, or hospital administrators. There were no HMOs, or managed care. Medicare had just begun in 1963 and had not yet fueled medical inflation.
Although not a high priority issue at the time I would think and ask question, "what are we doing to this patient" The 'primum non-nocere' theme did not seem to apply to financial or family concerns.
After a life-long career in medicine I now know that not only does the patient have the disease (especially if chronic, such as diabetes, heart disease, cancer or a multitude of others) the family also 'suffers' directly or indirectly. The patient may become disabled, lose employment and suffer severe financial setbacks that will involve an entire nuclear family.
The effect of a hospitalization ending in short term or long term disability will impact financial capability to purchase interim COBRA coverage, or even insurance in the long term.
Medical curriculum has changed. Courses in health information technology, multiculturalism, prevention, nutrition have become standard faire in additon to the overwhelming facts in science and medicine. Now add the economics of medicine, and not just as a 'theorectical' macroeconomic theory, but also as a microeconomist talking face to face with a patient and/or family member.
The depth of knowledge which a good physician should be aware, run the gamut from medi-caid, medicare, and the affordable care act.
Medical Schools Teach Students To Talk With Patients About Care Costs : Shots - Health News : NPR
During the 1960s not much was made of cost, either by attending physicians, doctors in training, or hospital administrators. There were no HMOs, or managed care. Medicare had just begun in 1963 and had not yet fueled medical inflation.
Although not a high priority issue at the time I would think and ask question, "what are we doing to this patient" The 'primum non-nocere' theme did not seem to apply to financial or family concerns.
After a life-long career in medicine I now know that not only does the patient have the disease (especially if chronic, such as diabetes, heart disease, cancer or a multitude of others) the family also 'suffers' directly or indirectly. The patient may become disabled, lose employment and suffer severe financial setbacks that will involve an entire nuclear family.
The effect of a hospitalization ending in short term or long term disability will impact financial capability to purchase interim COBRA coverage, or even insurance in the long term.
Medical curriculum has changed. Courses in health information technology, multiculturalism, prevention, nutrition have become standard faire in additon to the overwhelming facts in science and medicine. Now add the economics of medicine, and not just as a 'theorectical' macroeconomic theory, but also as a microeconomist talking face to face with a patient and/or family member.
The depth of knowledge which a good physician should be aware, run the gamut from medi-caid, medicare, and the affordable care act.
Medical Schools Teach Students To Talk With Patients About Care Costs : Shots - Health News : NPR
A Doctor at His Wife's Hospital Bedside
I became moved to share my story with my readers by an article published in the NY Times. The similarity is uncanny and while the details are different, the theme is the same.
My last blog, A Doctor at His Daughter’s Hospital Bed - The New York Times describes an episode where the physician is present in hospital when his daughter is critically ill and dying.
Because the hospital system is so dysfunctional he takes matters into his own hands to treat and save his daughter from dying due to septic shock. Our medical communication system lags greatly with the necessity of real-time communication and to manage the increased number of transactions.
Old habits and patterns of behavior die hard, and not just in the health sphere. Health communication and health information technology are still not optimized. In many cases the old way of doing things has just be digitized, not really transformed.
The transformative changes will come as a result of physicians, software developers, and professional businesss managers working, thinking and creating the new model.
About 15 years ago my spouse suffered a severe bowel obstruction from a cecal volvulus. Her abdomen became distended in one hour as if she was 9 months pregnant. She was rushed to a nearby small busy hospital emergency room. The hospital was in an area of less affluence than the surrounding resort community. It was a less than sought after hospital my most physicians in the area. At that time the development of managed care was in HMOs with restrictive physician membership.
I knew many of the physicians who worked at this hospital. Shortly after arriving, it was determined that she was non-transferable, and in critical condition. There were no physicians available on our particular managed care plan. Other than the physicians who were present in the emergency room, there were no surgeons availble.
Fortunately for our family one surgeon (a recently trained trauma surgeon was in the emergency department. The staff pointed out that she could not be admitted due to not having an admitting physician.
Time was ticking by and her condition was worsening rapidly. The only physician available was the critical care surgeon, and though on duty as the emergency room doctor realized the nature of the situation. She took the responsibilty of admitting her and scheduling a new doctor to immediately assume responsbility for the emergency room.
She ordered the staff to prepare for the surgery, and to transport my wife to the operating room. The staff again balked, however the surgeon overruled the nurses, and administrators. By this time several hours had elapsed. She had arrived at the ER at about 7 PM and it was now 11 PM.
On the way to the operating room blood was drawn, several portable X-rays were done. Not all the lab results were ready by the time the incision was made. The operation took about two hours.
As a physician I already knew the gravity of her situation, even if the operation were successful.
As I waited, nervously thinking about our family of three sons, one of who had cystic fibrosis Dr Y appeared in scrub suit, to reassure me.
I went to the recovery room where I waited several hours. Dr. Y. appeared, and asked, "Did you know your wife is pregnant ? The pregnancy test did not come back until after the surgery began.
In a case such as this it really doesn't effect the immediacy of the problem at hand.
Her post-operative course was stormy, with fever, shock, respiratory distress and
Despite her critical illness she was not admitted to an ICU but rather to a regular surgical floor, where nursing was less intensive.
Over the course of several days she spiked fevers and became weaker. She had a tachycardia, and severe abdominal pain. I thought she belonged in the intensive care unit. and requested that she be transferred. There was a discussion about her not meeting the 'criteria' for transfer. I protested, and they 'compromised' by assigning an aide to stay with her through the nite. I was working nearby and had an office full of patients. It was close by and I could be back in five minutes. She was so ill she was delirious, and not aware of her surroundings. I needed to get some rest. Our children were in the care of friends.
I returned a bit later to find she was not much better, and began raising 'h', calling the chief of staff, the hospital administrator, and anyone who would listen. She was transferred shortly later. Her delirium conttinued in the ICU, taking 24 hours to resolve. As the situation evolved it turned out she had a large pleural effusion, and a subphrenic abcess above the spleen under the left diaphragm.
After two weeks of IV antibiotics she had recovered well enough to be discharged. She was however on IV nutrition, forbidden to eat. We went home. About a week later she developed pain and a draining abcess in her lower abdomen. We rushed her again to the emergency department where her surgeon examined her. Her bowel had ruptured, and she was developing an entero-cutaneous fistula.
This time I was wide awake enough to insiste she be transported to a university hospital, about 65 miles away in a metropolitan area.
There she was well attended and in a surgical ICU where intensive antibiotics were administered by IV and into her abdomen directly, The cultures grew methicillin. resistant staphylococcus aureus. At the time there were few alternative antibiotics, save for some very toxic ones.
Eventually she went home after four weeks. The good news was that the fistula was closing. She was discharge and remained NPO and on TPN for six more months at home.
Is there a moral to this story ?
Be involved with your loved one's care in hospital, ask questions, ask for second opinions,
Don't hesitate to ask to be transferred to another hospital. In some hospitals there is an unwritten theme of not saying anything disparaging about a fellow physician.
We were locked in to where we were since no one would order a transfer due to her unstable condition.
We were grateful that the trauma surgeon had accepted her, and she seemed totally dedicated and committed to my wife's welfare. It was a bright spot in a very frightening situation.
.
My last blog, A Doctor at His Daughter’s Hospital Bed - The New York Times describes an episode where the physician is present in hospital when his daughter is critically ill and dying.
Because the hospital system is so dysfunctional he takes matters into his own hands to treat and save his daughter from dying due to septic shock. Our medical communication system lags greatly with the necessity of real-time communication and to manage the increased number of transactions.
Old habits and patterns of behavior die hard, and not just in the health sphere. Health communication and health information technology are still not optimized. In many cases the old way of doing things has just be digitized, not really transformed.
The transformative changes will come as a result of physicians, software developers, and professional businesss managers working, thinking and creating the new model.
About 15 years ago my spouse suffered a severe bowel obstruction from a cecal volvulus. Her abdomen became distended in one hour as if she was 9 months pregnant. She was rushed to a nearby small busy hospital emergency room. The hospital was in an area of less affluence than the surrounding resort community. It was a less than sought after hospital my most physicians in the area. At that time the development of managed care was in HMOs with restrictive physician membership.
I knew many of the physicians who worked at this hospital. Shortly after arriving, it was determined that she was non-transferable, and in critical condition. There were no physicians available on our particular managed care plan. Other than the physicians who were present in the emergency room, there were no surgeons availble.
Fortunately for our family one surgeon (a recently trained trauma surgeon was in the emergency department. The staff pointed out that she could not be admitted due to not having an admitting physician.
Time was ticking by and her condition was worsening rapidly. The only physician available was the critical care surgeon, and though on duty as the emergency room doctor realized the nature of the situation. She took the responsibilty of admitting her and scheduling a new doctor to immediately assume responsbility for the emergency room.
She ordered the staff to prepare for the surgery, and to transport my wife to the operating room. The staff again balked, however the surgeon overruled the nurses, and administrators. By this time several hours had elapsed. She had arrived at the ER at about 7 PM and it was now 11 PM.
On the way to the operating room blood was drawn, several portable X-rays were done. Not all the lab results were ready by the time the incision was made. The operation took about two hours.
As a physician I already knew the gravity of her situation, even if the operation were successful.
As I waited, nervously thinking about our family of three sons, one of who had cystic fibrosis Dr Y appeared in scrub suit, to reassure me.
I went to the recovery room where I waited several hours. Dr. Y. appeared, and asked, "Did you know your wife is pregnant ? The pregnancy test did not come back until after the surgery began.
In a case such as this it really doesn't effect the immediacy of the problem at hand.
Her post-operative course was stormy, with fever, shock, respiratory distress and
Despite her critical illness she was not admitted to an ICU but rather to a regular surgical floor, where nursing was less intensive.
Over the course of several days she spiked fevers and became weaker. She had a tachycardia, and severe abdominal pain. I thought she belonged in the intensive care unit. and requested that she be transferred. There was a discussion about her not meeting the 'criteria' for transfer. I protested, and they 'compromised' by assigning an aide to stay with her through the nite. I was working nearby and had an office full of patients. It was close by and I could be back in five minutes. She was so ill she was delirious, and not aware of her surroundings. I needed to get some rest. Our children were in the care of friends.
I returned a bit later to find she was not much better, and began raising 'h', calling the chief of staff, the hospital administrator, and anyone who would listen. She was transferred shortly later. Her delirium conttinued in the ICU, taking 24 hours to resolve. As the situation evolved it turned out she had a large pleural effusion, and a subphrenic abcess above the spleen under the left diaphragm.
After two weeks of IV antibiotics she had recovered well enough to be discharged. She was however on IV nutrition, forbidden to eat. We went home. About a week later she developed pain and a draining abcess in her lower abdomen. We rushed her again to the emergency department where her surgeon examined her. Her bowel had ruptured, and she was developing an entero-cutaneous fistula.
This time I was wide awake enough to insiste she be transported to a university hospital, about 65 miles away in a metropolitan area.
There she was well attended and in a surgical ICU where intensive antibiotics were administered by IV and into her abdomen directly, The cultures grew methicillin. resistant staphylococcus aureus. At the time there were few alternative antibiotics, save for some very toxic ones.
Eventually she went home after four weeks. The good news was that the fistula was closing. She was discharge and remained NPO and on TPN for six more months at home.
Is there a moral to this story ?
Be involved with your loved one's care in hospital, ask questions, ask for second opinions,
Don't hesitate to ask to be transferred to another hospital. In some hospitals there is an unwritten theme of not saying anything disparaging about a fellow physician.
We were locked in to where we were since no one would order a transfer due to her unstable condition.
We were grateful that the trauma surgeon had accepted her, and she seemed totally dedicated and committed to my wife's welfare. It was a bright spot in a very frightening situation.
.
An emergency physician stops at a roadside accident. He finds out he's not needed.
This blog post was carried in The Health Care Blog. THCB is the oldest, most active #hcsm blog. It features outstanding blogs and is produced by KevinMD
Although Dr. Edwin Leap posits he is not needed at these accident scenes, in my opinion he has a skewed point of view, as an emergency physician somewhat jaundiced and perhaps naturally 'burned out' after a long successful and ongoing career in emergency medicine.
Let me tell you a story. On a long stretch of highway in a desert I happened upon a catastrophic accident involving three vehicles in the middle lane of the I-10 freeway. I was with my family, my wife and three sons (ages 10-15). Traffic was speeding through the area at about 80-90 miles/hours. We were the first to arrive on the scene. The actual accident was visible to us as it occured. I quickly intellectualized events and objectively decided to not stop and go on to our destination.
My spouse who used to be a nurse confronted me and said 'Stop and see what you can do". Under threat of being divorced I complied. She, a nurse, and is a much better 'caregiver' than I could ever be. Nurses really do care, not just how to care or be a caregiver. She has a need to 'care' As a physician I have a need to diagnose and treat (only one half the equation of a true healer).
Fortunately I listened to her.
I stopped and realized I was a 'first responder'. From the side of the freeway I could see three bodies in the middle of the freeway. It was a dangerous situation for anyone. I stood there on the side of the freeway waiting for a break in traffic. I immediately called 911
The EMT's arrived in less than 4 minutes. Fortunately although we were in a relatively isolated stretch of freeway a regional California Higway Patrol Station was less than two miles away. It included as squadron of fireman/emt's.
As they arrived they cut off traffic (3 police cruisers, roar onto the freeway and get ahead of the cars coming down the road.
One proceeded ahead to the accident scene to coordinate their plan. I was duly impressed, and glad I did not run into the freeway to help ( A dead me couldn't do much)
There were three people on the highway. Going from best to worst was a very pregnant (full term) woman who was concious but drifting in and out of conciousness. The second was an elderly gentleman who had been thrown out of a vehicle landing on the side of the road. The third person lay in the median divider, crumpled head and neck twisted 180 degrees, large gash from front to back on the top of her skull, blood coming out her ears, nose and mouth. Her chest was crushed, she had no vital signs or reflexes with fixed, dilated pupils.
The police and EMT's asked if they should begin CPR.
The unfortunate lady was dead and the chances of a successful resusication were meager. Besides the severitiy of blunt traume, a nearly open skull wound, and full cardiac arrest compounded her no chance of survival.
I instructed them to forget her and be attentive to the pregnant lady and the roadside victim. My assessment was she had a living baby, her vital signs were good...she had not yet gone into shock, and she had a live baby ( I happened to have my stethoscope in my car) The uterus was quite tense....labor had begun.
I hailed down one of the on the scene highway patrol officers and told them to get a helicopter immediately....Again good fortune. The CHP station was about 1 minute from the accident site, and the helicopter was there. Both sides of the freeway by now were closed down. As the helicopter descended they asked me what hospital to take her to. There were three in the area, and having been on the staff at all three I chose the level 3 emergency department. She was at the emergency department in about five minutes.
What did I do ? Nothing and everything.
By the way I am an ophthalmologist for the past 25 years. I was a general medical officer in the Navy from 1969-1971 during the height of the Vietnam conflict about the time of the 'Tet Offensive. You millenials will have to 'google' that one.
I ran a Navy MASH unit and I knew how to triage....as does Dr. Leap. I did general practice for five years prior to specializing. This scene brought me back to that time. While I did not physically perform I was able to triage and organize priorities which gave confidence to the first responders who do not have authority to make life and death decisions about CPR, administering oxygen. There immediate response is to treat unless told otherwise by a licensed M.D.
I think it was 'The perfect storm'......a good one with incredible timing and combination of EMTs police, and perhaps me, although I won't claim it.
Had I been five seconds earlier I would have missed it and been unable to respond at all.
I am not at all critical of Dr. Leap. He is far more qualified than I in the subject of emergency care.
No one can second guess these situations. There is no 'preferred practice pattern'..
As for me, my 3 kids were in the car.....they saw it all, and came to their own conclusions about the accident. They were late to the birthday party, but will never forget what happened, and that I did stop to render aid.
I still don't really know what they thought at the time. None of them chose to follow in my footsteps as a physician.....their career now is computer science and engineering.
How the world changes !
An emergency physician stops at a roadside accident. He finds out he's not needed.
Although Dr. Edwin Leap posits he is not needed at these accident scenes, in my opinion he has a skewed point of view, as an emergency physician somewhat jaundiced and perhaps naturally 'burned out' after a long successful and ongoing career in emergency medicine.
Let me tell you a story. On a long stretch of highway in a desert I happened upon a catastrophic accident involving three vehicles in the middle lane of the I-10 freeway. I was with my family, my wife and three sons (ages 10-15). Traffic was speeding through the area at about 80-90 miles/hours. We were the first to arrive on the scene. The actual accident was visible to us as it occured. I quickly intellectualized events and objectively decided to not stop and go on to our destination.
My spouse who used to be a nurse confronted me and said 'Stop and see what you can do". Under threat of being divorced I complied. She, a nurse, and is a much better 'caregiver' than I could ever be. Nurses really do care, not just how to care or be a caregiver. She has a need to 'care' As a physician I have a need to diagnose and treat (only one half the equation of a true healer).
Fortunately I listened to her.
I stopped and realized I was a 'first responder'. From the side of the freeway I could see three bodies in the middle of the freeway. It was a dangerous situation for anyone. I stood there on the side of the freeway waiting for a break in traffic. I immediately called 911
The EMT's arrived in less than 4 minutes. Fortunately although we were in a relatively isolated stretch of freeway a regional California Higway Patrol Station was less than two miles away. It included as squadron of fireman/emt's.
As they arrived they cut off traffic (3 police cruisers, roar onto the freeway and get ahead of the cars coming down the road.
One proceeded ahead to the accident scene to coordinate their plan. I was duly impressed, and glad I did not run into the freeway to help ( A dead me couldn't do much)
There were three people on the highway. Going from best to worst was a very pregnant (full term) woman who was concious but drifting in and out of conciousness. The second was an elderly gentleman who had been thrown out of a vehicle landing on the side of the road. The third person lay in the median divider, crumpled head and neck twisted 180 degrees, large gash from front to back on the top of her skull, blood coming out her ears, nose and mouth. Her chest was crushed, she had no vital signs or reflexes with fixed, dilated pupils.
The police and EMT's asked if they should begin CPR.
The unfortunate lady was dead and the chances of a successful resusication were meager. Besides the severitiy of blunt traume, a nearly open skull wound, and full cardiac arrest compounded her no chance of survival.
I instructed them to forget her and be attentive to the pregnant lady and the roadside victim. My assessment was she had a living baby, her vital signs were good...she had not yet gone into shock, and she had a live baby ( I happened to have my stethoscope in my car) The uterus was quite tense....labor had begun.
I hailed down one of the on the scene highway patrol officers and told them to get a helicopter immediately....Again good fortune. The CHP station was about 1 minute from the accident site, and the helicopter was there. Both sides of the freeway by now were closed down. As the helicopter descended they asked me what hospital to take her to. There were three in the area, and having been on the staff at all three I chose the level 3 emergency department. She was at the emergency department in about five minutes.
What did I do ? Nothing and everything.
By the way I am an ophthalmologist for the past 25 years. I was a general medical officer in the Navy from 1969-1971 during the height of the Vietnam conflict about the time of the 'Tet Offensive. You millenials will have to 'google' that one.
I ran a Navy MASH unit and I knew how to triage....as does Dr. Leap. I did general practice for five years prior to specializing. This scene brought me back to that time. While I did not physically perform I was able to triage and organize priorities which gave confidence to the first responders who do not have authority to make life and death decisions about CPR, administering oxygen. There immediate response is to treat unless told otherwise by a licensed M.D.
I think it was 'The perfect storm'......a good one with incredible timing and combination of EMTs police, and perhaps me, although I won't claim it.
Had I been five seconds earlier I would have missed it and been unable to respond at all.
I am not at all critical of Dr. Leap. He is far more qualified than I in the subject of emergency care.
No one can second guess these situations. There is no 'preferred practice pattern'..
As for me, my 3 kids were in the car.....they saw it all, and came to their own conclusions about the accident. They were late to the birthday party, but will never forget what happened, and that I did stop to render aid.
I still don't really know what they thought at the time. None of them chose to follow in my footsteps as a physician.....their career now is computer science and engineering.
How the world changes !
An emergency physician stops at a roadside accident. He finds out he's not needed.
Friday, September 11, 2015
Health Reform: House Can Sue Administration
Implementing Health Reform: House Can Sue Administration Over ACA Cost-Sharing Reduction Payments (Sept. 10 Individual Market Update)
Following the SCOTUS decision that the ACA meets constitutional standards, the House of Represenatives (Republican majority) continues it's course of amending or repealing 'Obamacare'
On July 30, 2014, the House voted along party lines to file a lawsuit challenging the President. Twice private counsel that it hired to bring the case resigned, but the House finally succeeded in engaging Jonathan Turley, a conservative professor at George Washington University, to file the action.
The legal situation becomes complex in regard to the constitutionality of certain portions of the Affordable Care Act.
In a Republican dominated House of Representatives another attempt is being made in regard to the legalitiy of the ACA subsidies funded out of the general treasury.
Background
This lawsuit originated in an attempt by the House of Representatives to hold President Obama responsible for what it views as abuses of presidential power. Since 2010, the House of Representatives has been held by a substantial Republican majority. The House has been at loggerheads with the President on many issues, but in particular on health care reform. The House has voted over 50 times to repeal the President’s signature policy initiative, the ACA.
Frustrated by the difficulty of implementing an incredibly ambitious and complicated law, and by the unwillingness of Congress to help by adopting technical amendments, the administration has on a number of occasions acted unilaterally to make adjustments it believes to be necessary to implement the law. It has also interpreted the law differently than the House. The House has taken strong exception to what it perceives as actions in excess of presidential authority and in violation of the law. In 2014, the House decided to call upon the judiciary to aid it in its disputes with the President.
The Issues
The complaint, filed on November 21, 2014, focused on two issues: the decision by the administration in 2013 to delay the implementation of the employer mandate for a year, and the funding by the administration of the ACA’s CSR payments, arguably without an explicit appropriation.
The ACA offers low and moderate-income Americans premium tax credits to help make insurance affordable. These are offered through the tax system and are funded through a permanent appropriation for tax refunds.
The CSRs are obviously not free. The ACA requires the Treasury to reimburse insurers that reduce cost sharing for eligible individuals and families as they are required to do. This reimbursement is made on a monthly basis. The House, however, claims that Congress failed to include an explicit appropriation in the ACA to cover these costs, and has not appropriated funds to cover the cost of the CSRs since the ACA was adopted. Indeed, as Judge Collyer notes, the administration requested an appropriation to cover the CSRs in 2013, which was never acted on. (The administration claims that it decided no appropriation was needed).
The Constitution provides at article 1, section 9, clause 7: “No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law . . . .” The House claims that since no money has been appropriated for the CSR payments, they are unconstitutional.
This is not a trivial matter. If the CSR payments to insurers stopped, the insurers would still be legally required to reduce cost sharing—at a cost of $5 billion this year and $136 billion over the next ten years without reimbursement. Burdened with this cost without reimbursement through the CSR payments, many insurers would cease to offer marketplace coverage. Those that remained would have to raise rates dramatically to ensure solvency. Although much of the increase would be covered by the premium tax credits for low-income individuals, higher-income enrollees could face unsustainable increases. This could well put the marketplaces into a death spiral, where healthy people would drop coverage leaving only high cost patients behind.
Judge Collyer’s Opinion
After the filing of the case, the administration moved to dismiss the complaint for lack of standing. The plaintiffs, on the other hand, moved for a judgment in their favor on the legal issues. Judge Collyer asked the parties to first brief the motion to dismiss, and the September 9 decision addresses this motion.
Her opinion is long and very technical. She focuses on three issues:
- Does the House have standing to challenge the administration’s actions (that is, has the House been injured in a particular way by those actions)?
- Does the House have a legal basis for its claim?
- Is the House’s claim justiciable (that is, appropriate for resolution by a court)?
Judge Collyer rejects all of the administration’s responses to this argument. When money is spent without an appropriation, the House as an institution is injured in a particular way not shared by the public as a whole, or even by an individual member. The dispute is not about implementation of a law, but about the constitutional role of Congress. Although Congress has its own means of enforcing its will, this does not bar it from resorting to the courts in constitutional disputes.
The case will certainly be decided ultimately by the D.C. Circuit, perhaps by the Supreme Court. In the meantime, however, insurers that participate in the marketplaces will be subject to considerable uncertainty, and if there is anything that health insurance markets do not need now, it is uncertainty.
A win for the House would not mean that the ACA is unconstitutional, as would have been the case had the NFIB litigation succeeded; or even that the ACA would have to be amended, as would have been the case had King v. Burwell succeeded. It would merely mean that Congress would have to appropriate funding for the CSRs to function. The appropriation process is a perpetual battleground, and this year’s is shaping up to be as bad as ever. In the end, this would merely become one more appropriation for the administration and Congress to fight over, and one more reason why the fate of the ACA might turn on who is in charge of the next administration.
Summation
Even with less than 18 months left in President Obama's tenure in the White House, Republicans continue to chip away at the ACA. If the Republicans maintain a majority in the House of Represenative, and re-capture 1600 Pennsylvania Avenue it is almost certain that there will be significant changes to the ACA.
This however will create more havoc in unwinding the gordeon know of the ACA.
The ACA is mostly about health insurance reform and several peripheral issues such as payment reform, the establishment of Affordable Care Organizations, all of which may be exclusive to themselves. Some of the goals of the ACA are to make health care more affordable. This has yet to be determined in the short term.
Proponents of the law claim the cost savings are already significant. Others would point out that the infusion of significant public funds have allowed the ACA to work.
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