Emergency Medical Doctor

Scott Gottlieb Gets It Right on Obama Healthcare

EMDoc — Tue, 02 Sep 2008 18:44:00 GMT

Today's Wall Street Journal has commentary from Dr. Scott Gottlieb on the Obama healthcare plan I have been blogging about. He notes how successful Federally Qualified Health clinics have been in Chicago.

"those clinics have been hampered by state and federal regulations that try to promote "fairness" in our health-care system, only to undermine simple, local efforts aimed at genuine reform.

First among these regulations are mandates that require clinics to offer certain health-care services. In many cases a particular mandate can be defended. But the accumulated total makes it harder for some bare-bones clinics to offer any services at all."

As discussed previously, Mr. Obama wants to pull patients from private type insurance into a similarly federally mandated program.

As I have been ranting it is about access to care not insurance or registering in a federal program. Dr. Gottlieb agrees and adds to our reasons why access is the problem:

One big challenge is attracting and retaining skilled medical professionals. Pay is low, and the risks to providers high. Here, Sen. Obama's plan is no help. The Economic Policy Institute estimates that the Obama plan will cost about $1.6 trillion over 10 years. Give or take a handful of billions, funding his plan will eventually mean the same cuts to providers working under programs like Medicare and Medicaid that were used to subsidize other big health-care expansions.

Finally, the Federally Qualified clinics even had built in immunity much like the docs in the military, but recently even some of this protection has been taken away. Certainly, the Democrats do not support tort reform, so what else is there to attract good docs to such a program.

Marie Coco - Health Care Fight

EMDoc — Thu, 14 Aug 2008 18:22:00 GMT

8/12/08 Marie Coco, syndicated columnist with The Washington Post, echoed my sentiments regarding the health care crisis. Mentioning that if it was not for the price of gas, the real estate market crumbling, and the credit and banking crisis, healthcare would be the number one issue.

The reason I like her perspective is because for the first time she and I agree. Quote:

"To say you're going to provide affordable coverage to people is not the same as giving them health care," she says. "Just because you have insurance coverage does not guarantee you access to the care that you and your doctor decide you need. And people with insurance understand that."

This has been the montra of the Democratic platform for decades, and frankly as I mentioned previously in my columns about the McCain and Obama health platforms, providing access to care, not just insurance is lacking. As all of us know, just because you have insurance does not mean you can go to a doc when you want where you want easily.

Emergency Departments - Your Primary Care Provider

EMDoc — Thu, 07 Aug 2008 13:39:00 GMT

In a front page article by the San Francisco Chronicle , they describe a report by the CDC, that reveals what we in Emergency Medicine know all too well. We have become the primary care providers of the community. To quote the article:

"The likely cause is there are just fewer and fewer primary care physicians," he said. "If you were to get the flu and your doctor says, 'Sure, I'll see you in two weeks,' you may not be able to wait. It's hard for even insured people to get quick appointments and be seen quickly."

The study over 10 years from 1996 to 2006, reveals that the number of uninsured has increased by 5 million in that 10 year time frame, while the number of ED visits has increased by 32% from 90 million to 119 million visits. At the same time the number of emergency departments that have closed dropped by nearly 5%. This puts added pressure on existing emergency departments and hospital systems. I would add that those closings also do not necessarily mean more money for hospitals as most hospitals are losing money on nearly every ED visit or admission.

To quote Dr. Billy Mallon, current California ACEP Chapter president:

""The main problem with ER overcrowding is I can't get the admitting patients out. I can't get them to the ICU, to the operating room or to the wards," Mallon said.

He said people who lack access to other care options contribute more to overcrowding than patients who rush to the emergency room in nonemergency situations. "

Ahhh, finally what I have been saying all along. The Obama, McCain camps and all these other state universal health care plans that are being tried have it wrong. It is not about being insured, it is about having access to care. Insured patients cannot get access to their primary care doctor or their orthopedist or their dermatologist or their gynecologist so they are going to where they know they can get the care they need....the country's emergency departments.

So how can this be solved?

The primary care specialties need incentives to attract students. Why would a medical student select internal medicine, family practice or pediatrics, put in long hours and hardly make a living , when they can be in a surgical specialty that may pay them 400-500% more and have a better lifestyle. With the aging population the demand on ED's and hospital admissions will increase, so while it is easy to say we need to cut Medicare programs now, we will pay the price in the future. Hospitals need more dollars to have capital expansion projects in areas of need. What will Atlanta do if Grady hospital closes? Will everyone move out of Atlanta?

The state of our health care system is a shambles, to say the least. I would say it is a "crisis". In as little as 5 years time, I predict the system will completely collapse, meaning every ED and every hospital will be beyond capacity everyday, not just a couple days per week as it is now. The next presidential administration and congress needs to grab the bull by the horns, and get it fixed or what will develop is a system of the haves and have nots. Smart industrious healthcare administrators will start cash only hospitals and clinics that those that can afford will go to primarily and the rest will suffer in s system with little access and poor quality care. ( I won't even mention what could happen if there is a major terrorist event or natural disaster.)

McCain's Health Plan for America

EMDoc — Fri, 01 Aug 2008 18:25:00 GMT

Senator McCain's Health Care plan says that the problem with healthcare is that it is too expensive and that there are 47 million who are uninsured.

The McCain plan wants it to be easier for families to get the insurance they need. This will be done with a tax credit of $2500 for individuals and $5000 for families. You choose the insurer and the money from the credit goes directly to them. I would prefer to have the credit go directly to me and let me put it in a Health Savings Plan.

He plans on expanding the benefits of health savings accounts.

The plan then goes on to a number of ways to lower the cost of healthcare, which includes tort reform of some kind. Tort refrom is the only issue not present on Mr. Obamas plan, otherwise the plans closely mirror one another.

So to summarize, both candidates offer some form of a move to socialized government controlled medicine. Is this really what we want as a nation? Time and again we have seen the inefficiencies of Medicare, Medicaid and Social Security. Neither addresses the issue that is really at hand and that is access to healthcare. Hospitals and healthcare providers need to be paid for the services they provide, if the plans do not pay adequately then hospitals and health care providers will not participate. Those who can afford to , will pay out of pocket to get the care they need and those who become part of this government run madness will be forced into a system that will be more stagnant than the one we have now.

Barack Obama's Plan for a Healthy America

EMDoc — Tue, 29 Jul 2008 16:31:00 GMT

I wanted to devote some time to my thoughts on the presidential candidates' healthcare plans as they are currently written. I will start today with a review of the Obama plan and then in a subsequent entry the McCain plan.

To quote the Obama plan:

"...the Obama plan will save a typical American family up to $2500 every year on medical expenditures by:

Providing affordable , comprehensive and portable health coverage for every American;
Modernizing the US health care system to contain spiraling health care costs and improve the quality of patient care; and
Promoting prevention and strengthening public health, to prevent disease and protect against natural and man-made disasters."

Wow, that sounds great, this is certainly something every American would want, but let's look at this a little more closely.

So how will every family save $2500 dollars per year? The Obama plan tells us how:

Health IT investment, which will reduce unnecessary spending in the system that results from preventable errors and inefficient paper billing systems.
Improving prevention and management of chronic conditions.
Increasing insurance industry competition and reducing underwriting costs and profits, which will reduce insurance overhead;
Providing reinsurance for catastrophic coverage, which will reduce insurance premiums; and
Making health insurance universal, which will reduce spending on uncompensated care.

I certainly agree with investing in IT and all of its benefits, but its upfront costs are huge. He says he would invest $10 billion a year over 5 years to cover this, he ventures this would save $77 billion per year once implemented. Not sure where the $10 billion dollar per year number comes from, but this seems low to me. Improving prevention and management of chronic condition will be done by mandating coverage of smoking cessation programs and cancer screenings and by emphasizing to Americans that they should live in a "healthy environment that includes sidewalks, biking paths, and walking trails; local grocery stores with fruits and vegetables;" and "Obama will increase funding to expand community based preventative interventions to help Americans make better choices to improve their health." Whoooo, that is a whole lot of fluff.

The 3^rd way was to lower overhead for insurers. Last time I checked the insurers were making record profits, do you really think that lowering their overhead will make them pass that savings on to the working man.

It is not clear from the plan how providing reinsurance for catastrophic coverage will reduce premiums for all of healthcare. If an American only has catastrophic coverage then aren't they missing out on all the great preventive measures in the plan that are going to save so much?

Finally, making insurance universal, my favorite. This will reduce spending on uncompensated care. This will be a new plan like the one Senator Obama has called the Federal Employee Health Benefits Program (FEHBP, needs a fancier sounding abbreviation). This sounds like Medicaid to me, which as you know, very few physicians and other medical providers participate in. So where will patients go for their care? Your emergency department.

Another issue is "Reforming medical malpractice while preserving patient rights...Barack Obama will strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance." Funny how he does not seem to understand that the price of malpractice is not the issue, the number of wasteful lawsuits against hospitals and physicians is the issue. The plan also will work to reduce physician error. Unfortunately, error is not why patients enter litigation; bad outcomes whether the doctor did anything wrong or not is the reason.

And finally, the most important part of how the plan will be paid for, besides on the backs of the small business owner, is "by allowing the Bush tax cuts to expire for people making more than $250,000 per year, as they are scheduled to."

Any takers....

ACEP Seattle

EMDoc — Tue, 21 Aug 2007 23:33:00 GMT

Well the ACEP Scientific Assembly is coming up in October. You had better hurry and register now, Seattle is a fun city and everyone wants to be there, especially after the New Orleans convention last year. It is a chance to recharge your emergency medicine batteries, see old and new friends and have a great time. It is a time to elect new board members. This year I think Mike Gerardi from New Jersey is the right man for that job. He brings an energy for our specialty that is hard to find.

It is also a time to think about making a donation to the Emergency Medicine Foundation. This is a nonprofit group founded by emergency physician to raise money and garnish grants for research solely in our specialty.

So see you in October.

4 Hour Antibiotic Window Little Effect on Survival in Pneumonia

EMDoc — Wed, 01 Aug 2007 12:41:00 GMT

Most docs have recognized the ridiculous science behind the Quality rules requiring antibiotics in Community Aquired Pneumonia within 4 hours of arrival at the hospital. Finally, there is a study from our home NJ Medical School in Newark, NJ that reveals that giving antibiotics in the first 24 hours has little effect on survival. The study found that despite increasing the number of patients that received the antibiotic in 4 hours over 3 years there was no change in survival.

While it intuitively makes sense that we should give antibiotics in a timely manner for pneumonia, the science behind the quality of measuring it is flawed and should no longer be measured.

Busting Some Myths About Dying

EMDoc — Fri, 06 Apr 2007 18:13:00 GMT

The National Safety Council put out the odds of dying from injury based on 2003 data. I recently reviewed this very interesting data and thought it was time to break some myths. The media typically makes a big deal about shark attacks, alligator attacks, death by guns in the home, air crashes, etc. These are the big ticket items to get attention and ratings.

What is the reality?

Here are the top causes of death and the odds of dying from them:

Cause Odds of Death

Heart Disease 1:3.6

Cancer 1:4.5

Stroke 1:15

Lung disease 1:20

Accidents 1:22

For example 1 out of 15 people will die from a stroke. But more specifically let's look at some stats based on the lifetime risks of dying from various types of accidents. Let's start with Transportation related risks:

Pedestrian 1:626

Bicycle 1:4919

Motorcycle 1:1020

Car occupant 1:237

Pick-up or van occupant 1:900

Heavy transport vehicle 1:8480

Bus 1:104,113

Train 1:156,169

Streetcar 1:1,874,34

Well this all seems to make sense, the larger and heavier the vehicle the less likely you are to die. The exceptions being a street car which I always thought of being more like a heavy bus which is extraordinarily unlikely to result in death, and being a pedestrian being safer than being an occupant of a car. I guess it all depends where you walk. But you say wait EMDoc, everyone says air travel is pretty safe, and it is, with odds of 1:5051. Not however better than a bus, train or streetcar. Why Greyhound and Amtrak are not capitalizing on this I have no idea.

There is often discussion about how dangerous it is to have firearms in the home. Opponents of the right to bear arms would say that they might accidentally misfire and kill someone.

Unintentional Firearm Discharge 1:5134

Assault By Firearm 1:314

I think this justifies my having a firearm to protect my family who has a much greater chance of killing me than I do accidentally killing myself or one of my family members.

Most towns require fences around your pool that are a minimum of 4 feet tall, anyone could hop over them, it is a joke. What's the real risk of drowning:

Bathtub 1:11,289

Swimming Pool 1:7278

Natural Body Water 1:3060

Last time I looked 4 foot fences were not required around the oceans, lakes and streams, but you have more than double the chance of drowning there. And if you did not notice you are safer in a bus, train or streetcar than in your own bathtub!

And to those of you who continue to believe that using illegal drugs like heroin and other psychedelics is okay, your odds of dying is 1:406, making it nearly as risky as walking down the street. Sadly, death from complications of medical and surgical care is 1 out of 1313. A number that in my mind I should always be trying to improve during my clinical practice. Going to your doctor should never be more dangerous than riding in a bus in my mind.

There is so much more interesting information at the National Safety Council site so go check it out....in the meantime I've got to run off to a shift, I think I'll catch the streetcar.

SoundMatters MAINstage HD - Surround Sound Home Theater Without The Wires

EMDoc — Mon, 02 Apr 2007 23:27:00 GMT

Recently, I had a small room that I wanted a surround home theater in but did not want the need to run wires to rear surround speakers. So I checked out the Yamaha YSP-800 and the Polk Audio Sound Bar. The Yamaha was the better of the two for sure, but at $800 and the need for an additional amount of money for a subwoofer this was way over budget. I had heard the SHARP SD-SP10 with new Dolby virtual 1.1 was pretty awesome but it has yet to land in the US from Japan, although I did see one on eBay but again the budget numbers did not meet.

Then I found the Soundmatters MAINstage HD. This is a small box about the size of a cable TV box that can sit on the TV itself or above it or below it. It has 80 watts, and 3 speakers, left, right and a woofer. I opted for an additional SONY SAW2500 10" 150 watt sub for $100; this brought me to $500 dollars for the system well within budget.

The sound from this little box is really amazing. I have been tempted to open it and take it apart to see how the richness of the sound is actually accomplished. Sound from CD/mp3 is as good as some more expensive Cambridge Soundworks speakers I have, and the virtual surround it good enough to make me think someone is sneaking up behind me in a scary movie. The remote allows volume, bass and input control, as well as a "dialog" button that focuses spoken word towards you allowing the volume to be lowered. This is handy when other are sleeping while you are watching sports or news late at night. It certainly is not as good as a hardwired surround home theater, but for a small room it is excellent. It has coaxial input and digital optical input for Dolby digital sources (it does not support DTS). So you can hook up the digital cable box, the DVD player and have a full system ready to go.

So again, this is great for a small room where running speaker wires is difficult or just ugly, if you had a bigger room I would go for one of the Yamaha units.

EMDoc Gets a Facelift

EMDoc — Fri, 30 Mar 2007 23:58:00 GMT

Well, those of you returning to my site will see that we have had a major facelift. The color scheme is better. The whole format is easier to navigate and to use. I have the easy ability to publish photos. The comments sections are more controlled so hopefully there will be no more spam.

A big kudos to my buddy DonXML for helping me get this done!

What Is The Cure For Overcrowding?

EMDoc — Mon, 05 Mar 2007 17:27:00 GMT

So you say overcrowding is an issue at your hospital. Your ED is regularly filled with admitted holds (patients admitted to the hospital waiting for beds, for those non-emergency affiliated readers). Your emergency nursing staff is burdened with inpatient care that they are not familiar with providing and/or documenting. Your ED docs are forced to see patients in hallways, lobbies, ambulance bays, waiting areas, wherever space allows. It is a highly inefficient, demoralizing and undignified way to provide care. Your patients are very unhappy. You are unhappy. Weekdays maybe you get some beds but Fridays and weekends are filled with staff call-outs, and having to close units. Do you have a headache yet?

So what is or are the solutions? Well, there is no magic pill. The Vicciellio concept is one: place the admitted holds one on each unit in the hallway upstairs on the floors. While this has been accepted by many state departments of health, it is put to little practical use by hospitals. Nursing unions do not like it, and short of forcing the issue by taking a patient up to a floor yourself and leaving them in a hallway against your administrations wishes, risks your job and probably your groups contract.

So what else? Well you could try and push for state legislation to provide disincentives for hospitals that continue this practice. This would take a while, in our state it could take years. So is it possible to fix the overcrowding situation? Yes (in this case I am an optimist). No one person however, is capable of making this drastic change. It involves changing the hospital culture to recognize that the ED for many places is the front door for their admitted patients, and therefore the ED should be treated as one of the hospital’s best customers. It involves every department of the hospital making sure the ED and floors have staffing and supplies they need to operate at full capacity 24 hours a day, or at least at peak volumes hours, compared to the current 9am-5pm model that most hospitals operate under now. For instance, if a low risk patient is placed in 24 hour observation on a Friday night to receive an MRI during the stay but your MRI unit is closed on Saturdays, then you won’t get the patient out in time. Money will be lost. It involves pushing your medical staff to recognize their own inefficiencies. Rounding once per day on inpatients is not enough. Patients need to be discharged as soon as possible, waiting until the next morning is no longer an option if they are ready to go at 5pm the day before. Case managers, social workers in the ED watching admitted patients from the ED to discharge is a necessity. Nursing homes must accept discharged patients at least 12 hours per day, I say 7a-7p, not just until 4pm, like many practice. If your hospital does not have a VP of quality along with a VPMA then you are behind. Finally, the ED docs, and nursing need to have a central reporting structure within administration. The time for nurses in the ED to only report to theVP of nursing and the docs to someone else is over. Our goals as docs and nurses in the ED are the same. There needs to be a commitment from administration to make this work at all levels; they need to acknowledge that admitted holds are not good for patient care. Finally, you need metrics. Measure every aspect of the patient moving through the entire hospital; from the time they walk through the ED to the time they are discharged. We need to look for prediction models of staffing, volume and throughput. Do you know what happens 24 hours after your hospital’s length of stay increases by 0.5 days? I don’t, but I would bet the number of holds in my ED will be going up. Imagine if you could staff for that ahead of time. Well there is a lot to swallow here. Our hospital is striving for many of these points, and I will keep you abreast of how the process proceeds.

Emergency Department Crowding

New Jersey Emergency Deparment Overcrowding/Surge Capacity

EMDoc — Mon, 19 Feb 2007 22:12:00 GMT

NJ ACEP in an effort to push overcrowding and surge capacity to the forefront recently held a townhall meeting/press conference on the topic. This was through a grant from national ACEP.

The event was featured by the following press agencies:

The Record, NJ 101.5 radio and a letter to the editor in the Star Ledger, among others.

Highlights included the recent IOM report and the ACEP National Report Card, where NJ has received an A for quality medical care, an F for malpractice issues and C+ for patient access. The link will bring you to the site and you can see how your state ranks.

A recent article in the Annals of Emergency Medicine highlights the national scene and NJ plight even farther. For instance, 2 NJ hospitals are moving out of the local residential communities and to the major highway corridors. Is this a way to get out of the overcrowding situation? Is this purely to allow ambulances faster easier access or is it a way for them to avoid the burdens of charity care patients whom may not be able to easily get from their residential communities to the highway location? Interesting concept, not sure if it will hold to bear.

Gardner's Gate

EMDoc — Mon, 19 Feb 2007 21:38:00 GMT

Well, I am happy to see that the American College of Emergency Physicians is doing all it can to keep up with evolving technologies. From having our council meeting with wireless connections and live web presentations to now the addition of blogging.

Yes, they now have the Gardners Gate, hosted by Dr. Angela Gardner, Secretary/Treasurer and member of the Board of Directors of ACEP. The blog is full of interesting and timely information about what is happening in emergency medicine and in ACEP. If you get a chance go check it out.

A Message From Above

EMDoc — Sun, 01 Oct 2006 01:35:00 GMT

I was having a bad day, a small squabble at home, I hit a curb with my car, the usual B.S. and politics at work, it was morning, etc. I was starting to feel better, made an appropriate apology, but still a little aggravated, (none of which is good for my borderline blood pressure). I was walking from my office and saw a worker in the hospital. I see this worker almost daily. I say hello, sometimes he says hello sometimes he doesn't. Sometimes he looks at me sometimes he doesn't. He is older than I and reminds me of my father-in-law who past away a few years ago... Irish, built like a horse. Well today I saw him multiple times and he was working hard, so besides saying hello, I said, “Boy, they sure have you working hard today.” With that he stopped what he was doing and began talking to me, quite pleasantly how he loved his work, even though some people thought less of him for it. How it made him a good living. How he provided for 3 daughters, who went on to be very successful. All of this without really looking right at me, and sort of talking out loud rather than to me directly. He then said he was very thankful for all he had, and he knew I was too because of the work I did and suddenly looked me right in the eye, touched my arm with his big rough hands, and quietly said, “You need a gratitude list.” He then winked, looked away, and said, “Thank you.”

At first, I did not think a whole lot of this, but as I walked away I felt a chill in my neck, and thought was this man telling me something more. Even more, I saw him again later, and said hello again, and he hardly acknowledged my existence as had been my experience in the past. So was this my imagination recognizing that I was having a weak, vulnerable moment and reading into something more than a simple conversation or was it something more. I have friends who tell me they have experienced things they cannot explain. As a physician, I have seen many people live who should have died and died that should live. I usually can explain or rationalize these things and if I cannot I do believe that God no matter what I do has the ultimate power over my life. Was He speaking to me through this gentleman? While I have never heard the term 'Gratitude List', I am starting one now.

Once Again Technology Fails

EMDoc — Thu, 10 Aug 2006 18:57:00 GMT

The other day I saw a patient with abdominal pain. The patient had the pain for some time. They had a CT scan of the abdomen at an outpatient radiology facility the day before. I asked if she knew the result, and she said, “No, but can't you just pull it up off of your computer?” The answer of course was “No.”

This statement should turn the world of information technology on its head! When I answered “No.”, she replied, “Well, I know you can access the records from my personal doctor.” I said, “With all due respect, it is a Saturday night, how would I do that? I doubt your doctor's office is open.” Her reply in a very frustrated way, “ You mean you honestly don't share all your computer information with him?” Again, “No, nor any other doctor in the area for that matter.”

So here a layperson, whose current job is working as a cashier in a supermarket, sees everyone with wireless phones, broadband internet access, satellite TV, has the ability to view and pay her bills online thinks it would be safe to assume that this should occur at every level in business and especially in healthcare where a life may hang in the balance.

As mentioned in my previous blog entry this is a widespread issue that is frankly strangling the business of medicine. Reports to look at why something like length of stay is long are impossible to generate since there are 3-4 different systems that look at all the data and none of them speak to one another. Well, now I'm frustrated, I've blogged about the same topic 2 posts in a row, granted they were far apart, I've got to find another pet peeve.

Physicians and Computers, Gaps Remain

EMDoc — Fri, 09 Jun 2006 16:36:00 GMT

This article per Reuter's reveals something that I am not surprised about. Physicians especially in their privat offices are not using computers to document patient records, write prescriptions or to track patients' routine preventative care. Working at a facility where in the Emergency Department we do use all computerized systems I would find this hard to live without. I can sit at my workstation, see every patient in the department, view their chief complaint and triage note(when completed), view their prior visit history , including all the old history and physicals, lab results, etc. I can order all my tests and view new and old plain xrays, CT Scan and ultrasounds. I can also access the internet to see this sight and my toolbox, as well as view email, and anything else the hospital doesn't filter out. Granted this near utopia I work in is paid for by the hospital.

But what is the solo practitioner or small group internist to do financially to pay for these things when their is really little monetary incentive. Sure you could argue that with a prescrition writer, less mistakes will be made, and that better office charting could protect you in a lawsuit. But the internists, family practice and pediatricians still have pretty reasonable malpractice rates so this doesn't help much. Finally, there is the “it is good for my patients'”argument. Again, when the upfront cost come right from your take home salary this too is hard to swallow.

Unfortunately, this lack of technology is prevalent across all fields in medicine. Those of you in the technology field would think that the paramedics who come to your house could easily download all the information about your care in the field to the hospital when you arrive. Nope, doesn't happen. You would think that most information from the hospital could easily be sent right to your doctors office anutomatically. Nope, doesn't happen. If you order a medication in the hospital, and it is the wrong dose or frequency, someone will notice, not always.

So to all of you techies out there, we need open architecture systems that are easily adapted and customized to our needs and can quickly speak to one another through a common language (XML?), and finally this needs to be affordable to the masses (think Microsoft Office for every aspect of healthcare). We as the customers are tired of technology that is rammed down our throats , forcing us to change our processes to work around it!

healthcare technology open source architecture

ION iTT USB Turntable

EMDoc — Thu, 08 Jun 2006 02:19:00 GMT

Finally got the ION ITT USB turntable that I have been looking for months. Originally, saw it on the Gizmodo blog almost a year ago. Then could find it on a number of retail sites but it was always sold out. Finally, found it available on the Circuit City site.

It is a regular turntable that can play via RCA plug through your regular system but also a USB plug that when plugged into your computer and using the supplied Audacity software allows you to record your vinyl. You can choose to record a whole side of an album then breakdown each cut or record one cut at a time. It can then be edited, cut, chopped, equalized and have most hiss and pops removed. When it is all cleaned up you can convert the Audacity file to an MP3 and have permanent digital files of all your vinyl. I have played with it a few times with some 45’s, and it works well. The sound quality is pretty good with the cartridge that comes with it. I am sure if you were a hi-fidelity aficionado you would want to upgrade the cartridge, but this was good enough quality for me.

ION USB Turntable Vinyl Records

French Press Coffee

EMDoc — Thu, 08 Jun 2006 01:52:00 GMT

Well in my continued quest for the best cup of coffee, a colleague caught my interest explaining how he only makes coffee with a French Press. Well, I went out to get one. Found one for about 15 dollars at Target, nothing fancy but works well. Amazon has the same one on the attached ad. Did not have any whole beans at the time so through some Maxwell House Slow Roast in the container, filled with near boiling water, stirred, waited patiently for 4 minutes, pressed the plunger and voila, one of the best cups of coffee I have every had. The press retains all the oils, and richness that the coffee can offer.

As a result I have also rediscovered the Porto Rico Import Company in NYC. They have great weekly and monthly deals on whole bean blends. I prefer the City Roasts, and the Mocha Java and Northeast blends are very good. On sale they are as little as $3.99 per pound. This week their Vienna Columbian is on sale for $3.99, $5.99 for decaf. Give them a try.

French Press coffee

ACEP Leadership and Advocacy Conference

EMDoc — Wed, 07 Jun 2006 18:10:00 GMT

Attended this conference a couple weeks ago, and as usual it is probably one of ACEP’s most interesting conferences. There are great talks on the current politics facing our college and then of course visits to your representatives on Capitol Hill. This year the NJ chapter was able to hit each senator and congressional office for the entire state where we pushed for HR 3875 The Access to Emergency Medical Services Act of 2005. As a result of all the efforts by ACEP we were able to sign more co-sponsors to the bill in hopes that now it may be brought up for discussion. The bill and its accompanying senate bill have the 3 main points:

Emergency physicians and other physicians providing care to the uninsured in emergency departments would be extended the same liability protections as Public health Service officers (Federal Tort Claims Act)
An additional 10% payment would be authorized for emergency care provided to Medicare beneficiaries.
Hospitals that promptly move admitted patients from the emergency department to their definitive hospital destination would be rewarded with incentive payments of an additional 10%.

It may not be perfect but hopefully, it can be brought to committee for further discussion and changes.

By the way Washington, DC is rapidly becoming one of my most favorite cities visit. The conference was at the Grand Hyatt, which is in the best location, central to almost everywhere you would want to go and there is a Ruth's Chris Steakhouse right around the corner.

Capitol Hill American College of Emergency Physicians

Bird Flu - A Real Epidemic

EMDoc — Mon, 01 May 2006 19:22:00 GMT

I am not concerned about bird flu at this point. I think most of it is media frenzy. Yes there have been 100 deaths worldwide from it, but how many people die from the flu in the US. The graph below gives a percentage of those who die from the flu/pneumonia in the 2005 season. (It is difficult to pull the two diagnosis apart epidemilogically.) About 8.5%. If you just say that 1 million people had the flu last year, which is a very low number considering there are nearly 300 million living in the US, then 85,000 people died from flu or pneumonia in that year. So you see bird flu is really just a small time virus at this point. Could it mutate and get worse, of course, even then, how come there have not been the epidemics of the past in the last 50-75 years? Could it be that healthcare is better, people get vaccinated, they take care of their underlying medical problems, they are treated with antibiotics if they develop a bacterial infection on top of the flu, etc.

We should be spending a lot more money on effective vaccination strategies and basic preventive medicine then wasting massive efforts of preventing bird flu. I could be wrong...time will tell...I feel like Kentucky Fried.

Geico Rates Drivers By Education and Job Status

EMDoc — Tue, 21 Mar 2006 17:57:00 GMT

Is this fair? So Geico actuarials are out there rating their customers based on level of education and job status. They feel that this correlates with some decreased level of auto accident risk if you have received a higher level education and hold a job. Is this wrong? Apparently, NJ Assemblyman Neil Cohen thinks so and to solve it, as is always the case in New Jersey, you introduce legislation to limit what businesses can do. Then they wonder why few large businesses and corporate headquarters stay in this state. As Mr. Hoy points out Geico is out to make money by limiting risk. Of course they could be wrong with these stats and lose money and have to raise rates, and then their customers would have the option to find another insurer. Their customers also have the right to go to another insurer if they feel that this rating system is unfair. I am sure they also rate people by how old they are, whether or not they are married, have children, the type of car they drive and any accidents or summonses they may have had in the past. Does that sound discriminatory? You see it is all about statistics, if people who drive Mustangs have more accidents than those who drive Civics, then the Mustang drivers have to pay more to balance the risk. If the statistics bear themselves out then why shouldn't Geico be aloud to do this or any car insurer for that matter?

My question is why can’t malpractice insures do similar by rating prior malpractice cases? If you are named in case, even before it is brought to court and a determination of guilt is made your malpractice premiums go up. If you are named in a case and the case is dropped, your premiums go up. It is ludicrous. Why can’t the actuarials rate the risk based on the merits of the case, if the case is dropped there is very little or no risk, if a physician loses a case then the risk would be higher, but even then the individual case risk should be weighted individually. I know I am living a pipe dream, perhaps I am even smoking the pipe, but it would be fair to the customer….the physicians.

Geico NJ Auto Insurance Medical Malpractice

iPods In The Workplace

EMDoc — Mon, 13 Mar 2006 19:36:00 GMT

Has anyone noticed the overabundance of people wearing iPods while they are working? In fact I even witnessed a nurse in my ED wearing one while she was working. I really did not know how to react. Turns out she isn’t the only one and staff have been reprimanded for it. Now don’t get me wrong, I do not have a problem with people listening to music in the workplace. In fact, I also do at my workstation. My workstation is away from patients and I keep the volume down so only I or someone standing just outside can hear it. But to do it in an open public forum, the fishbowl of the ED is just not appropriate when we are supposed to be concentrating on saving lives. I have even seen a neurologist doing rounds wearing one.

Perhaps it is me, maybe I am not adjusting to the change of the generations behind me, and then again I could take full advantage of this and open a hearing aid store.

iPod

Benzocaine - The Sky Is Falling!

EMDoc — Thu, 23 Feb 2006 18:04:00 GMT

Once again the alarmists at the FDA are going forward and giving a good drug a bad wrap. This time it is benzocaine, a topical anesthetic, that is especially useful to anesthetize the inside of the mouth and throat before introducing a tube into the airway or the stomach. Simply put it makes the procedure more comfortable for the patient. The problem is the FDA puts out this advisory about a known complication of using benzocaine called methemoglobinemia. They state that due to this warning the Veterans' hospitals are pulling benzocaine from the shelves. This sounds pretty bad....but it is not!! Quote:

The FDA has received adverse event reports involving benzocaine sprays together with symptoms that probably indicated methemoglobinemia in the patients. It is important to note also that these cases were received over a period of many years and this is an uncommon adverse event.

Key point; this is an uncommon adverse event. From a risk management point of view I must stop the use, or if I do and something happens I will be hung by the trial lawyers. So because some overzealous practitioner used too much of the stuff and caused this complication, the rest of us who use these drugs properly are under greater scrutiny should we use it and literally are forced to stop using this helpful drug! Thank you FDA, my tax dollars have been well spent helping you try to make up for your blatent inadequacies of the past.

benzocaine FDA methemoglobinemia

Batman Versus Osama!!

EMDoc — Thu, 16 Feb 2006 23:46:00 GMT

I have always been a big Batman fan; from the hokey days with Adam West in the 70's to the modern day “Batman Begins”, but now the Caped Crusader is ready to fight terror wear it has begun. Batman will be hunting down Osama bin Laden and whoopin his butt! Although, the DC Comics release has not yet been announced I cannot wait.

If movie rights are made I hope the direction goes to Christopher Nolan who directed “Batman Begins”. IMHO this was the best Batman movie ever. If you have not seen it you need to buy it, rent it or borrow it as soon as possible. Even Mrs. EMDoc enjoyed it, and she never likes any movies like this...she may like it because Liam Neeson is in it but that is for her to comment on not me.

Without spoiling it, the best part of the movie for me is when Bruce Wayne is finding all the toys and gadgets he will use while fighting crime.

Batman Osama bin Laden

Pertussis - Coming Back

EMDoc — Thu, 16 Feb 2006 02:40:00 GMT

Recently, I was made aware of a case of Pertussis in my area. Now I had read about a resurgence in Pertussis in adults and young adults, but have not actually seen or perhaps recognized any. Typically young adults and adults have a milder form of the disease or are relatively asymptomatic. They are still very contagious and the bigger concern is that they will spread it to unvaccinated children or only partially vaccinated adults. The biggest concern is infants who if they get it can get be overcome with life threatening bacterial pneumonia. From the CDC, 51 of 56 Pertussis related deaths were in infants less than 6 months of age and 42 of those were less than 2 months of age.

Fortunately, if recognized early enough the disease is easily treated with macrolide antibiotics such as erythromycin. For more information check the CDC website.

Pertussis