#3: Politics, Parasites and a Proof of Principle

sully-with-blood-drops2

Now that Max Baucus and Senate Finance have finally pushed their bill out of committee, there are at least five legislatively viable approaches to healthcare reform floating around on the Hill. (Also see this, but quickly, it’s all getting dated even as I write.) Given the current political picture, there’s every reason to believe that Congress will push through some sort of healthcare reform legislation, perhaps before the end of the year.

President Obama will sign it, and I’d like to think that he’ll be holding his nose when he does so. That’s because the bill he gets is almost certain to be at least 50% fecal matter by weight.

Oh, sure, there will be a lot of laudable stuff in the final bill. It will cover more people by making healthcare coverage more affordable, it will possibly put something remotely resembling a leash on the for-profit insurance companies, it will probably mandate EMR (which I consider to be a Good Thing) and, most importantly, it will demonstrate an incredibly important proof of principle: health care reform is actually possible.

Remember, a huge array of powerful actors were dead set against any reform at all, right from the git-go– extremely well-monied and reactionary interests, people who don’t know the difference between a pneumonia and a blister, who would be perfectly happy to let you die in the street if it saved them a dollar on their taxes, the kind of folk who are generally in it for themselves and eat their young.  The fact that anything even got out of committee, given the carefully staged town hall outbursts, gazillions spent on disinformation, and hysterical bull**** about “death panels,” is something akin to a legislative miracle.

So yeah, the final bill will have a lot of reasonably tasty stuff in it. It will also be at least 50% excrement. And what happens, exactly, when you mix tasty stuff with excrement?

Still, I’m one of those guys who likes to think that the glass is only half full of crap, and there is a glimmer of hope that the complex, corrupt, mysterious and intensly Kabuki-like process of legislative reconciliation now underway will actually improve on the bills that have come out of committee.

I also play Mega Millions on a regular basis. (I won $3 this morning, woo-woo!).

But hey, there’s always next time (see Proof of Principle, above). And so, for next time, and for the Mega-Millions part of me who hopes against hope that something useful will come out this time, I humbly offer, in all its glorious simplicity, Sullydog’s Overriding Principle for Meaningful Health Care Reform.

Ready, Nancy? Harry? Barack? Lewalski? I know you’re reading this.

Brace yourselves.

Here it comes.

Don’t spend health care money on people who don’t do health care.

That’s it. That’s all there is to it. And from a physician/patient perspective, it really makes a lot of sense. It’s really just a polite way of saying that parasites are very bad for you and must be exterminated without mercy. Huge segments of the health care economy are parasitical, sucking resources out of the system without giving a damn thing back, except increased costs, perverse incentives, and toxic administrative burdens. If a new health care system were to put even a few of these helminths out of business, that would be a prime indicator that something had been done right.

Just to be clear, I’m not talking about people who run hospitals and clinics, critical administrative and support personnel–although truly meaningful reform would reduce the need for administrative support. It takes a lot of people to do billing and wrangle with HMOs. No, I’m talking about the real bloodsuckers, the people who line their pockets with American healthcare dollars and don’t actually do anything to promote or support patient care–people who, in fact, weaken the entire system and put our patients in jeopardy.

There are plenty of barnacles on the hull of US healthcare, but two groups deserve special attention. I don’t think I’ll get any argument from most people on the first genus of tapeworms that should be in our crosshairs: malpractice lawyers.

Now, from my tone, you might prematurely surmise that I’m hostile to all malpractice lawyers, or that I think the medical malpractice tort system is a bad thing in and of itself.

So, just to be sure there’s no mistake, that nobody misconstrues what I’m saying here, let me just clarify by saying that you would be absolutely right. That’s exactly what I’m saying.

This is a destructive, malignant, greed-based industry that has been capitalizing on human suffering and sucking the life out of our health care system for quite long enough. The entire enterprise deserves to leave skid marks on the bowl. Our medical malpractice tort system does not improve the quality of care, does not justly redress errors, has been a principle driver of increased waste and costs, and has poisoned the art of clinical decision-making almost beyond recognition. Other, more rational, more effective, and more just alternatives are readily at hand to mete out justice and provide compensation and care for injured patients. These are not opinions, they are facts, and they constrain malpractice attorneys, as a class, with a direct and categorical moral duty to find a way to serve the public interest rather than harm it, as they are doing now. They can do this by evolving into homeothermic chordates and working on new methods for just and proportionate patient redress, or by devoting their skills to another branch of the justice system. Or they can remain in an evolutionary cul-de-sac, in which case we should force them to trade in their pin stripes and Porsches for a nice shelter and a soup kitchen. Either will do. If health care reform puts thousands of ambulance chasers (and malpractice insurers, and professional expert witnesses, and various and sundry other vermin) out of business, I will not shed one bitter tear. They’re bloodsuckers.

The second superfamily of parasites that needs to be exterminated make up that vast, vile and suffocating biofilm known as the Health Insurance Industry. It’s time to don hazmat suits and go to work on these guys.

A lot of sturm und drang has erupted over the now-moribund prospect of a Public Insurance Option, much of it having to do with such a public program’s ability to insure more Americans at less cost by undercutting premium margins and exploiting unfair advantages (such as lower marketing costs) over for-profit insurance. Horrors! These “unfair advantages,” it is said, would gradually suck all the oxygen out of the insurance market, and ultimately put HMOs and other private health insurers out of business.

Really? Wow. When can we get started?

Let’s review the physiology and life cycle of a typical member of the species insurances profitales parasiticus, shall we? This loathsome creature spawns in that celebrated, dog-eat-dog, Darwinian space known as the Market, which is a great ecosystem for predators and even for wary herbivores, but a really shitty environment for sick people. Once it has affixed to a host (also known as a policyholder), it will feed on premiums until the host sickens, is injured, or is weakened by lack of employment. At that time, the worm detaches and scurries away as fast as possible, to search for another victim while its decimated erstwhile host is consumed by the various scavengers and saprophytes of the Market (and the malpractice tort system—an excellent example of synergistic parasitism).

That’s it. That’s how this whole system works. For-profit insurers collect premiums from policyholders. That’s their blood meal. If they can keep it in their belly, they get nice and fat and rich. And the only way they get to keep it is by limiting or, better yet, denying compensation when somebody gets sick. Think about that: they’ve already got your money. The fundamental incentives of the free market mandate that they keep as much of it as possible. As private corporations, it is in fact their duty to their stockholders to keep as much of it as possible–no matter how sick you are.

There is just no getting around it: anybody who has private health insurance places their insurance company in an immediate fiduciary conflict of interest the minute they get sick or injured. That’s because the duty to compensate the patient’s care is at direct odds with the duty to maximize profits. And that’s how we end up with a system like the one we have now–a system in which the insurance marketplace is supposed to provide coverage, but the overriding economic incentives of the insurance marketplace are to deny or limit care. It’s perverse. It’s immoral. It’s evil.

Of course, if Congress cared whether something was perverse, immoral or evil, we’d be living in a different world. Instead, let’s focus on the fact that this system doesn’t work, that it leaves millions without access, and that it’s also stupid and wasteful, because it means that billions of dollars a year are spent lining the pockets of an industry that doesn’t actually provide health care–people who actually deny health care for a living.

It’s so simple. Don’t give healthcare money people to don’t do healthcare. What’s so hard about that?

Why do we put up with a system that’s dysfunctional and wasteful and immoral, just because it makes a lot of people insanely rich and powerful?

Oh. Yeah, right. Never mind, don’t answer that. I’m off to buy another Mega-Millions ticket.

Jonathon Sullivan, MD is an emergency physician in Detroit, MI

A1.2

Question of the Week

What is the initial ED treatment of symptomatic carotid artery dissection? What is the reason?

Initial treatment of symptomatic carotid artery dissection is unfractionated heparin, used to prevent thrombus formation on the injured endothelial surface and thereby to prevent embolization

Thank you for participating in this week’s Question of the Week.  Please check back soon for the next question.

Q1.2

Question of the Week

What is the initial ED treatment of symptomatic carotid artery dissection? What is the reason?

Please submit your answers to the questions in the “leave a reply” box or click on the “leave a comment” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s Question of the Week.

Hand Case Discussion 1.2

Hand Icon

Presented by: Jeff McMenomy, MD

CC: “My finger hurts.”

HPI: A 56 year-old right hand dominant male with history of type II diabetes mellitus presents with complaint of progressively worsening right index finger pain and swelling.  He says symptoms began about 6 hours ago.  He denies any trauma to the finger.  He complains of pain with any movement of the finger and states that he has exquisite pain whenever the finger accidently bumps against an object.  He has never had finger pain like this before.  This patient denies any fever or chills.

Past Medical History: Diabetes mellitus type II, hypertension

Past Surgical History: Tonsillectomy and adenoidectomy as a child

Family History: Positive for diabetes and hypertension; negative for heart disease or stroke

Social History: 10 pack-year smoking history, quit 5 years ago; denies ethanol or illicit drug use

Allergies: No known drug allergies

Medications: metformin, hydrochlorothiazide

Physical Exam:

Temp 36.8,     HR 92,     BP 140/91,     RR 18,      O2 Sat 98% on room airConstitutional: Alert and Oriented x 3, nontoxic-appearing

Musculoskeletal:

Right index finger is uniformly swollen and held in partial flexion.  This finger is exquisitely tender along the flexor surface and tenderness extends proximal to the flexor surface of the hand over the second metacarpal. The right index finger is only mildly tender over the extensor surface and there is no tenderness elsewhere on the hand or over any of the other fingers.  Patient has exquisite tenderness with passive extension of the right index finger but only mild tenderness with passive flexion.  There is mild erythema over the flexor surface of the right index finger which does not extent to the rest of the hand or to any other fingers.  There is no palpable fluctuance.  Patient is able to actively flex and extend at all joints of the right index finger, including the distal interpahalangial joint when this joint is isolated.  He does, however have pain with these movements.  There is no pain or deficits with active flexion or extension of any of the other fingers of the right hand.

Radiographs: Three-view x-ray of right index finger and hand shows soft tissue swelling of right index finger but no fracture or dislocation

Questions:

1.  Given this patient’s presentation, which of the following possible condition is of greatest concern?

a.  Dorsal finger soft tissue abscess with surrounding cellulitis

b.  Felon

c.  Flexor tendon tenosynovitis

d.  Herpetic whitlow

e.  Traumatic rupture of flexor tendon

2. What is the definitive treatment for the condition of greatest concern in this patient?

a.  Bedside nail bed repair, splinting, and arrange for follow-up in hand surgery clinic

b.  Bedside repair of ruptured tendon and arrange for follow-up in hand surgery clinic

c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

e.  Local incision and drainage of abscess with gauze packing strip and follow-up in 2 days for wound check and removal of packing gauze

f.  Prescription for oral acyclovir, hand hygiene recommendations, and primary care follow up

3. What is the most common organism isolated from such lesions?

a.  Herpes simplex virus type 1

b.  Herpes simplex virus type 2

c.  Neisseria bacteria

d.  Pseudomonas bacteria

e.  Staphylococcus bacteria

Answers:

1.  c.  Flexor tendon tenosynovitis

The most concerning condition consistent with this patient’s signs and symptoms is flexor tendon tenosynovitis.  The classic description of flexor tendon tenosynovitis involves Kanavel’s four cardinal signs, all of which are present here.  There are: tenderness over the flexor tendon sheath, uniform swelling of the involved digit, pain with passive extension, and a semiflexed resting position of the involved digit.  Such infections are most commonly caused by penetrating trauma but commonly patients do not recall any trauma to the digit.

2.  c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

Early recognition of this condition and evaluation by a hand surgeon for prompt operative intervention is essential.  Delay in recognition and treatment may result in loss of use of the involved finger and possibly the involved hand.  All patients must be admitted to the hospital and IV antibiotics should be started promptly.

3.  e.  Staphylococcus bacteria

Staphylococcus is the most common bacteria isolated in such infections and antibiotic coverage should cover this organism.  If MRSA is suspected, vancomycin may be administered.  Neisseria gonnorrhoeae should be considered in all patients with suspicion for sexually transmitted infection and is a possible hematogenous source, especially in patients with no history of penetrating trauma to explain the source of infection.  Ceftriaxone may be considered in such patients.

References

JA Marx, et al. (2006). Rosen’s Emergency Medicine: Concepts and Clinical Practice, Sixth Edition. Philadelphia: Mosby Elsevier.

JE Tintinalli, GD Kelen, JS Stappczynski. (2004). Emergency Medicine: A Comprehensive Study Guide, Sixth Edition. Chicago: McGraw-Hill.

RG Hart, DT Uehara, MJ Wagner. (2001).  Emergency and Primary Care of the Hand. Dallas: American College of Emergency Physicians.

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.

Hand Case 1.2

Hand Icon

Presented by: Jeff McMenomy, MD

CC: “My finger hurts.”

HPI: A 56 year-old right hand dominant male with history of type II diabetes mellitus presents with complaint of progressively worsening right index finger pain and swelling.  He says symptoms began about 6 hours ago.  He denies any trauma to the finger.  He complains of pain with any movement of the finger and states that he has exquisite pain whenever the finger accidently bumps against an object.  He has never had finger pain like this before.  This patient denies any fever or chills.

Past Medical History: Diabetes mellitus type II, hypertension

Past Surgical History: Tonsillectomy and adenoidectomy as a child

Family History: Positive for diabetes and hypertension; negative for heart disease or stroke

Social History: 10 pack-year smoking history, quit 5 years ago; denies ethanol or illicit drug use

Allergies: No known drug allergies

Medications: metformin, hydrochlorothiazide

Physical Exam:

Temp 36.8,     HR 92,     BP 140/91,     RR 18,      O2 Sat 98% on room airConstitutional: Alert and Oriented x 3, nontoxic-appearing

Musculoskeletal:

Right index finger is uniformly swollen and held in partial flexion.  This finger is exquisitely tender along the flexor surface and tenderness extends proximal to the flexor surface of the hand over the second metacarpal. The right index finger is only mildly tender over the extensor surface and there is no tenderness elsewhere on the hand or over any of the other fingers.  Patient has exquisite tenderness with passive extension of the right index finger but only mild tenderness with passive flexion.  There is mild erythema over the flexor surface of the right index finger which does not extent to the rest of the hand or to any other fingers.  There is no palpable fluctuance.  Patient is able to actively flex and extend at all joints of the right index finger, including the distal interpahalangial joint when this joint is isolated.  He does, however have pain with these movements.  There is no pain or deficits with active flexion or extension of any of the other fingers of the right hand.

Radiographs: Three-view x-ray of right index finger and hand shows soft tissue swelling of right index finger but no fracture or dislocation

Questions:

1.  Given this patient’s presentation, which of the following possible condition is of greatest concern?

a.  Dorsal finger soft tissue abscess with surrounding cellulitis

b.  Felon

c.  Flexor tendon tenosynovitis

d.  Herpetic whitlow

e.  Traumatic rupture of flexor tendon

2. What is the definitive treatment for the condition of greatest concern in this patient?

a.  Bedside nail bed repair, splinting, and arrange for follow-up in hand surgery clinic

b.  Bedside repair of ruptured tendon and arrange for follow-up in hand surgery clinic

c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

e.  Local incision and drainage of abscess with gauze packing strip and follow-up in 2 days for wound check and removal of packing gauze

f.  Prescription for oral acyclovir, hand hygiene recommendations, and primary care follow up

3. What is the most common organism isolated from such lesions?

a.  Herpes simplex virus type 1

b.  Herpes simplex virus type 2

c.  Neisseria bacteria

d.  Pseudomonas bacteria

e.  Staphylococcus bacteria

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.

A1.1

Question of the Week

Q:  Hypersensitivity to what two foods is a contraindication to using propofol?

A: Soybean oil and egg lecithin are components of the emulsion that contains propofol.  Hypersensitivity to these components or the drug itself contraindicates use of the drug

Thank you for participating in this week’s Question of the Week.  Please check back soon for the next question.