Monday, August 31, 2009

It Will Take More Than a Band-Aid to Fix Health Care (Marin IJ)

Last month, we had a disastrous family discussion on health care reform. Our pre-school-aged participant clutched a box of princess Band-Aids and suggested she had the solution. When I told her that we might need to ration those Band-Aids, she asked me if I was a “social-er-list.” Another participant, aged six months, tried to eat my insurance card and then, when I took it away, wailed incessantly. I was discouraged, because what I had hoped would be a thoughtful exploration of how we might keep health care costs from bankrupting our children, turned into a cacophony of distraction.

This scenario, as you might have guessed, was imagined rather than real. But on the national stage the distraction is all too real and it’s threatening to turn an important discussion into a circus. So, in the interest of informing the debate, I’d like to offer several (general) observations from the point of view of an emergency physician.

*Reform, in some form, is necessary. Our current health care expenditures are out of control and are a major economic threat. Even if you are satisfied with your own medical coverage, the bloated health system still puts you at risk in myriad ways. These risks include retiring into a bankrupt Medicare system, across-the-board cuts in social services, and a sluggish economy with sluggish 401Ks. Most people, on all sides of the debate, understand this.

*There is fat to be trimmed. Emergency care is an excellent example – when patients come to the emergency department (ED) for health conditions that could otherwise be treated in a clinic (medical office), the care that they receive is expensive and sometimes unnecessary. When a non-emergency is treated in the ED, there is rarely additional benefit to the patient, just additional cost (to the patient and the system). In my own research into over a million Northern California ED visits, my co-investigators and I found that 48% of ED visits were for conditions that clinic docs could have seen at lower cost, and with less waiting time. As a whole, there may be at least 30% fat (i.e. unnecessary or excessive costs) in the current system.

*All citizens should have access to health care, but also should be active participants in their health and the public health. Residents of Marin County are, generally speaking, knowledgeable about their medical histories and I cannot over-emphasize how this improves their care when they need to come to the ED. Citizens elsewhere are less familiar with theirs – and this is a problem – for them and the system. As for public health, by definition we are all in this together and there are simple things you can do to contribute; practice good hygiene, limit how much you pollute and (as scary as it might be to some), get your children vaccinated.

*Insuring more people will not, in and of itself, decrease the strain on EDs. Research shows that recipients of public insurance are significantly more likely to use EDs than those with no insurance – in the case of Medicaid, nearly four times more likely. This means that we can expect that any reform that insures more patients will most likely also result in more ED visits. This should give policy makers pause – especially given that the nation has seen the closure of over 1,000 EDs in the last fifteen years while visits have increased by over 20% (to 119.2 million in 2006). Already, our community EDs are strained with overcrowding and poorly equipped to handle a public health crisis – like a potential swine flu epidemic. If we add more coverage to patients, we can expect more unnecessary ED visits and further overcrowding. Unless, that is, there is both: 1) a concerted effort to improve access to primary care providers and 2) the inclusion of some incentives that encourage people to choose clinic care over ED care for non-emergent conditions.

*Some sort of tort (medical malpractice) reform is a must. Overuse of medical testing and so called “defensive medicine” may not be as big a part of the problem as some would lead you to believe, but it is definitely part of the problem. Health reform which purports to control costs but doesn’t control torts is not honest health reform. In California, we have a law that caps pain and suffering damages in malpractice suits – such legislation should be in place nationwide. Otherwise, the trend, evident in states such as Florida, wherein certain specialists, like obstetricians, refuse to take call due to risk of litigation will just worsen.

Regardless of what happens this month or next, the health reform discussion is not going away anytime soon. If a bill gets passed, its success or failure will likely lie in the details of implementation. If it doesn’t get passed, we will just be putting this issue off for another four to eight years. Either way, I for one am rooting for a substantive discussion. And maybe a princess Band-Aid too.

*Dr. Dustin Ballard is an emergency physician practicing in Marin County and the author of "The Bullet's Yaw: Reflections on Violence, Healing and an Unforgettable Stranger." His Medically Clear column appears every other Monday. The opinions expressed in this column are his and do not necessarily reflect the views of affiliated organizations or funding agencies.

Friday, August 21, 2009

Step off the ladder, before you get hurt (Marin IJ)

When I visit a house that I’ve never been to before, I can’t help but notice its danger zones. I guess my morbid awareness of hazards is a byproduct of the years I’ve spent working in the Emergency Department (ED). Walking up a sloped driveway (such as my own), I envision an elderly woman falling as she attempts to roll the garbage bin to the curb. Climbing a stairway that lacks a handrail, I imagine how a small misstep could result in a ten-step somersault. Entering a foyer with a glass coffee table, I remember a patient who sat on such a table while sleepwalking – and ended up with a foot-long triangle of glass lodged in her bottom. In the kitchen, I look suspiciously at the cheese slicer, bagel knife and garbage disposal. Out back, I cringe at the power tools – a nail gun, skill saw, and metal grinder. It’s not that I am paranoid, it is just that I have seen too many home projects gone awry – hands nail-gunned to 2x4s, fingers precisely amputated by skill saws, and bits of metal wedged in eyeballs by projectile-inducing grinders. But, danger lurks everywhere and we can’t live our lives afraid of everything. As Johann von Goethe once wrote, "the dangers of life are infinite, and among them is safety."

So while it is not instructive to excessively preach about prevention, there is one common backyard tool that really gives me the shivers, and this I must share with you. The ladder. Ladders are simple and useful objects in most situations, but they are also disasters waiting to happen. Nationwide, based on data from the United States Consumer Product Safety Commission (CPSC), there are approximately 170,000 ladder-related visits to EDs each year, including over 150 deaths. Based on a statistical analysis of the CPSC data published in the American Journal of Preventive Medicine, the rate of ladder injuries has increased by fifty percent since 1990. Here are a few things about ladder-related injuries that may not surprise you; they usually occur at home (a non-occupational setting), they are frequently related to improper positioning or support and/or over-extension of the ladder, they most frequently involve men, and their severity increases dramatically with the increasing age of the victim and the height of the fall. With this in mind, there are some folks who just shouldn’t be using ladders – elderly folks taking the medication Coumadin (warfarin), drunk or otherwise intoxicated people, and anyone with balance or equilibrium problems. For the rest of us, I have some simple advice.

These are common sense tidbits from the CPSC:

*Straight and extension ladders should be set up at about a 75-degree angle and should extend at least 3 feet over the roofline/working surface.

*Make sure the weight supported by your ladder does not exceed its maximum load rating (this includes you and your materials).

*Metal ladders conduct electricity so you should use a wooden or fiberglass ladder when working in the vicinity of power lines or electrical equipment.

*Be sure all locks on extension ladders are fully engaged.

*Keep your body centered between the rails of the ladder at all times and avoid leaning over to one side or the other.

*Do not use a ladder for any purpose other than that for which it was intended (i.e., ladders should not be used as a play structure for little Jimmy).

And, from my own clinical experience, I’d like to add the following helpful hints:

*If you are going to climb a ladder, leave the chainsaw behind. Unless you are a professional, chainsaws and ladders just don’t mix. I treated one 80-year-old gentleman who was on a ladder, trimming some branches, when he lost his balance and fell. Either on the way down or on impact, I’m not sure which, his chainsaw collided with his neck, dissecting it like an anatomy lesson. Remarkably, he survived (albeit with significant disfigurement) but if the chainsaw had cut another centimeter or so deeper his major blood vessels would have been severed…I do hope that he subsequently retired both his chainsaw and his ladder.

*Placing a mattress 15 feet below your ladder is not adequate protection from a fall – especially if you are 85-years-old. A colleague of mine has a neighbor who liked to clean the gutters on his two-story house and felt entirely safe doing so because of the mattress he placed on the ground beneath him. Apparently, this gentleman carefully considered the direction in which he was most likely to fall and placed the mattress accordingly. Luckily, he retired the ladder before he had a serious fall; that mattress would not have prevented a broken hip or cracked skull.

So, next time you pull out the ladder for a weekend project, take a moment to consider if you will be using it safely and, perhaps more importantly, whether you should be using it at all.

Monday, August 10, 2009

Parental Deception that Goes too Far (Marin IJ)

History is ripe with foolish medical therapies. Bloodletting, mesmerism, and “colonic irrigation” enemas are just a few of the well-intentioned but potentially harmful treatments that have lost both favor and credibility. Unfortunately, new ones are always there to take their place. Take, for instance, a product launched last year named Obecalp – a pill designed to deceive children. Now, as the father of an opinionated four-year-old, I know that creativity is a crucial part of parenting. When my daughter squawks at the idea of walking to pre-school, I ask her to be Dora the Explorer on an important mission. Or, if the living room floor is completely covered with crayons and Groovy Girls, I tell her about the “messy monster,” who absconds with toys that are not neatly put away. Fibbing to children is an ancient technique perfected by generations of parents who have explained “There is no more ice cream,” “Yes, sweetie, someday you can have a pony,” and “Of course Santa Claus can fit down the chimney.” But while I am not above the occasional white lie that prevents an 8.0 trembler on the meltdown scale, I (and many others) draw the line at Obecalp. Last May, the New York Times reported that a chewable, cherry-flavored dextrose (sugar) tablet would be marketed to parents as a placebo treatment for children. A placebo is an inactive drug that works based on a patient's belief that it will make him or her better and Obecalp, as you may have noticed, is the word “placebo” spelled backwards. The idea behind Obecalp was to market a chemically inert alternative to painkillers such as Tylenol (acetaminophen) and Motrin (ibuprofen). Bottles of 50 tablets were to sell for $5.95 and because they didn’t contain active ingredients they could be sold as over-the-counter dietary supplements. The concept, according to inventor and mother of three, Jennifer Buettner, was to design a pill with “the texture and taste of actual medicine so it will trick kids into thinking that they’re taking something. Then, their brain takes over, and they say, ‘Oh, I feel better.’” A useful trick, perhaps, and with a website tagline of “Invented by a Mommy!” some financier must have thought Obecalp was going to be a sure bestseller. Actually, it was just a bad idea. Even in a highly medicated society like ours, a fake drug for children was a line most parents were not willing to cross. Now, let’s be clear; the placebo effect does exist and it can be powerful. There are certain situations where, after parents and a physician discuss it, a trial of placebo treatment makes sense. For example, some pediatricians recommend that the parents of a child with ADHD try a week or two of placebo before starting a potentially harmful medication like Ritalin. But, we already live in a pill-for-every-problem culture. Remember when many obese Americans opted for Fen-phen rather than diet modification and exercise? Some of them ended up with pulmonary hypertension rather than skinny jeans. By encouraging our children to a pop an Obecalp for every sniffly nose, tickly throat, or bruised ego, we would be reinforcing this mindset. And even worse, we would be substituting a pill for parental creativity and attention. When I was a boy, my mother turned me into a vegetable and fruit-chopping machine through a simple technique – extreme flattery. I was led to believe that I, and only I, was capable of delicately slicing pineapple. If we left it to someone else, our fruit salad might not make it to the table. When I finally realized that I’d been duped for years, I was somewhat perturbed, but mainly impressed – my mother had found an effective way to keep me out of trouble and save herself some time. The lesson was duly noted for later use. A year later, the Obecalp website is still active, but the product has not found its way to the local drug store. My inquiries to the “Invented by a Mommy!” e-mail address were met with cyber silence. Thank goodness. The idea of substituting a sugar pill for ingenuity wasn’t going to do our children any good in the long run. Just thinking about it leaves a bad taste in my mouth.