Tuesday, July 20. 2010
 Medicine has always abounded with quackery, and placebo effect is real. Hope springs eternal...
However, when tax dollars are expected to pay for it, it's another matter: Europeans Cast Critical Eye on Homeopathy.
In a free country, folks are welcome to buy their own quackery if they want, on their own nickel. Most docs privately think of Chiropractic as quackery, but the Chiropractors have a lobby in DC, and I believe there is a legal injunction against MDs terming chiropractors "quacks" in public. They sometimes do help people with sore backs. I am just imagining the debates about whether federal guidelines will include crystal therapy and massage therapy.
American medicine itself has little intentional quackery, but many treatments which are of dubious value. For examples, futile treatments for terminal cancer, or those $15,000 treatments for "Chronic Lyme". Thus far, in America you can pretty much get whatever medical treatment you want regardless of its usefulness for you. Problem is, others are usually paying for it.
My prediction is that government-controlled medical care will be determined by politics and, to some extent, politically- or bureaucratically-oriented docs. That is not good medicine.
Good medicine is individualized, not based on statistics.
Friday, January 29. 2010
Cardiocerebral resuscitation (CCR) is a new approach to patients with out-of-hospital cardiac arrest that has been shown to improve rates of neurologically intact survival by 250%--300% over the approach advocated by the 2000 American Heart Association guidelines. And EMS systems can realize these improvements without having to buy a single new gadget or device.
People try to die all the time, in church, in parking lots, in supermarkets. Here's the new method to try to save them from the Grim Reaper:
Friday, September 4. 2009
Medical technology has confused the simplicity of death. One quote from the piece at New Atlantis:
...as long as the ventilator remains, that body does not look like a corpse. It remains warm, like the living, and the organs continue to do the work they have always done, albeit with the assistance of chemical interventions. Most significant and most challenging, from the point of view of common sense, is the fact that the heart still beats. The injury to the brain has destroyed the centers in the brainstem that regulate breathing—thus the perpetual need for the ventilator. But the heart of an animal—even one profoundly injured—has its own “inherent rhythmicity,” its own originative source of motion. This means that heartbeat and circulation have no absolute dependence on the brain in the way that respiration has. The heart, without any input from the brain, can continue to beat as long as its own tissue is intact.
The characteristic puzzle of the total brain failure condition, then, is this: the body remains warm and pink as blood courses through the vessels; the vital organs continue performing their work; but the human being as a whole, permanently unconscious and permanently and profoundly disengaged from his surroundings—eyes closed, making no response to pain, making no effort to breathe—seems something short of alive.
Thursday, September 3. 2009
Regular readers know how much I love Stats. Peter Donnelly is wonderfully fun here: How Stats fool Juries. I don't think the lawyers understand the stats either, but you can in a few minutes. (H/t Bird Dog via the Right Wing Prof)
Monday, August 31. 2009
 People hate it when I burst their bubbles about eating habits, but facts are facts. Everybody likes to imagine that they can control their health by what they eat, but there is no real evidence for that unless you are starving to death or fat as a pig. (Ordinary American fatness has minimal health effects, but major aesthetic effects).
Here are some real facts for readers who fuss about their food. In my view, unless you are on a serious diet, anybody who fusses overly much about what and when they eat has an eating symptom. Harmless enough, but a symptom.
(Everybody has his share of neurotic symptoms. It's human.)
I will say it again: the only reason to fuss with your food is to make it taste good - and to stay skinny and fit so you look good, have endurance, and do not offend others with your unpleasant appearance.
Hey, honey. Get that beer man over here. I need a cold one or two to go with my Sabrett's.
Friday, August 28. 2009
The women of the world owe a giant debt of gratitude to Hungarian physician Dr. Ignaz Semmelweiss.
Mocked and ridiculed by the experts, he was correct that puerperal fever, which killed many mothers, was somehow spread by doctors and nurses who did not disinfect their hands.
The germ theory of infectious disease had yet to be explained in the 1840s, but he was a practical doc, not a theorist.
Wednesday, August 26. 2009
- Should you take an aspirin, or a baby aspirin, daily or every other day to reduce your risk for nasty cardiovascular events (heart attack, stroke)? Check it out. As I once mentioned here in the past, all male docs I know over 40 take a baby aspirin daily.
- Middle-aged women get Frozen Shoulder. Know what it is? It's not an excuse to avoid vacuuming, doing the dishes, or sex. It's a nasty thing.
- Also, I recently heard a talk about ADHD. There is a strong association between ADHD and Social Phobia, which I thought was interesting. However, it's confusing because ADHD is such a confusing pattern of symptoms since it is so commonly combined with other diagnosable problems: bipolar disorder, anxiety disorders, depression, conduct disorder, antisocial personality, etc. It's a mess of a diagnosis.
Friday, August 21. 2009
Obesity is probably decreasing in the USA. What changed (in 1998) was to change the definition of obesity down to 30 lbs. overweight, thus adding millions to the "obese" column.
There's no way somebody 30 lbs overweight (by whatever standard is used) is what people consider obese. 30 lbs overweight is "plump," pudgy," or, as they used to say, "sleek" or "prosperous-looking." In women, "matronly."
In fact, being 30 lbs overweight has no ill medical effects at all. The aesthetics of it are, of course, highly subjective.
Tuesday, August 18. 2009
 Bremelanotide. It's a nasal spray, works quickly. Looks like it can be bought online.
Is it a party drug, or a medical drug? I do not know. Haven't tried it yet, personally, but I probably would if only for my educational purposes...
All of the late middle-aged docs I know are "scientifically" curious about it. It is said to be the only true aphrodisiac. If it has no serious side effects, I can see this drug leave Oxycontin in the dust on the black market.
Not everybody, for sure, is fully satisfied with his or her sex life, unless young and in love.
All doctors know this: The "Preventive Care" Myth from Krauthammer.
Preventive care is expensive, and has a very low yield. Things like mammograms do not exist because they are cost-effective: they exist because people want them.
Friday, August 7. 2009
When somebody collapses and stops breathing, make sure you remember how to do CPR. Just make sure you don't do it to some person who simply fainted, because you can be sued if you break a rib. Legal protection for Good Samaritans in the US is fading fast. Still, every citizen ought to know how to do this.
I have had to do it twice, once in a parking lot and once in church. One lived, one died.
Saturday, August 1. 2009
Hanson at Overcoming Bias posts the graph below from the British Medical Journal. It says they looked at 2500 treatments, so I suspect this isn't just medicines. I'd like to see the list to determine whether it only included standard treatments like antibiotics for pneumonia or stents for coronary artery blockages, or whether it includes things like homeopathy and massage therapy.
I don't know what to make of the Terra Incognita of the 46% of "unknown effectiveness." I want to see the details.
Saturday, July 25. 2009
Michelle:
Health and Human Services Secretary Kathleen Sebelius tried to reassure citizens in New Orleans this week that Obamacare bureaucrats will make sound medical decisions for all Americans. She failed. Under the government-run plan, she promised, a team of health care experts will recommend what should be covered: “I think it would be wise to let science guide what the best health care package is.”
I guess it didn't occur to her that doctors know some science - and they also know something else: they know their patient. No two patients are alike. People do not want an "approved treatment protocol" - they want to work it out with a doc who is working for them, and is not a de facto civil servant. I think what Sebelius means is not "science": she means a board of cost-containing medical efficiency experts.
However, I do not think anybody wants a government to have that sort of power. Governments create omnipotent monopolies.
It's one thing for a private medical insuror to tell you they don't cover in vitro fertilization, and another for the government to tell you that you cannot have it because "science says" that it's not cost-effective. In the former case, it's a freely-entered association, as Milton Friedman would say, and if you want the in vitro badly enough, you can save your pennies and get one. Furthermore, I'd much rather make an appeal to a private biz than to the government.
We suspect that the government wants two things: 1. To get more folks on the Government Plantation and, 2. To control Medicare costs. Re the latter, the O might be right that it may have been unwise for his Grandma to have a hip or knee replacement when she was dying from cancer - but he is correct that 80% of medical costs occur in the final year of life. However, unless somebody has terminal cancer or something comparable, how do you know it's somebody's final year of life in advance?
Another related issue is the equating of "health care" (a dumb term) with medical insurance. I suppose with the high costs of medical technology and hospital treatments, those costs are out of reach for the average person (which is why we buy cheap catastrophic, ie high-deductible medical insurance) but, for most purposes in life, a regular office visit for a bad sore throat or a camp physical doesn't cost very much at all, while an ER visit for your bad sore throat can set you back $750.
We agree that it is foolhardy for anybody who is not wealthy - especially for a family - to carry no catastrophic major medical insurance, because bankruptcy sucks. We also think it is foolish for people to expect insurance to cover every office visit: the whole point of insurance is supposed to be that you hope you never need it.
However, years of Medicaid (for the poor), Medicare (which pays for everything, at low rates), union-driven medical benefits and work-related medical benefits have produced a sense of entitlement and, we would argue, have driven up the cost - and the quality - of medical treatment in the US.
What is the right role for government in medical care? We don't know, and we don't trust anybody who says they know. Fact is, government already controls much of it via Medicare, Medicaid, and now SCHIP. It has been incrementalism at work, with the long socialist view. One thing we do know is that fewer and fewer Docs want to accept Medicare, and few ever accepted Medicaid except for charity clinics and inner city Medicaid mills staffed by foreign medical graduates.
Why do so many Docs opt out of Medicare? Because of the paperwork requirements and the unsustainable rates of reimbursement. When people get a doctor's bill, they often forget that it's not a bill for his time: it's a bill for his rent, his machines, his two nurses, his insurance coder, his bookkeeper, his receptionist, his staff's benefits, his malpractice insurance, etc. Your local Internist and Pediatrician is not getting rich on $65 office visits these days. In fact, they are struggling.
No, the big costs are tests, some medicines, hospitalizations, cancer treatments, dialysis, the ICU, etc. The big ticket items - and those costs are not compressible. They can only be rationed if costs are to be cut. We do not think those costs should be cut, because we believe that such decisions are a matter of personal choice and freedom and, as they always say, "All you have is your health." Or your disease, as the case may be.
We wish we knew the right answers to all of these issues but, despite the problems, we will say one thing: With the best, most innovative and most available medical care in the world, one must be extremely careful about messing with it. Freedom is always messy. We re-link Cardinal at Tigerhawk's defence of American medicine.
From another point of view, a quote from an annoyed Vanderleun's Who, Whom?, which reiterates our Roger's thoughts about The Plunder Economy:
Who—whom?" Who shall be forced to give up the health care that they like (most Americans), and whom shall receive health care they (supposedly) ain't got -- for free -- at a cost to everyone else of trillions in dollars and immeasurable quantities of freedom and privacy and security.
Who (shall give)? You and hundreds of millions of others. Anyone who has a job, or makes things, or owns things that can be taxed. And then have a fee for this or that levied (for the common good). And then taxed again.
Whom (shall receive)? The poor shall be marched to the front of the line; their ragamuffin children with protruding bellies on their shoulders for the photo-op. But right behind them will come.... the slackers, the lazy, the whacked-out, the grifters, the hustlers, the useless, the career recipients of endless government hand-jobs, the hard-core unemployable, the 17% of crack whores that do not work for the government, and a few million others that form the hard, adamantine core of Obama's and the Democrats' aptly named "base."
"From each according to his ability, to each according to his needs," is what's going on here. Except this time the add-on is "Even if you don't need it or want it, because little Susie the crack whore does. P.S. We're gonna slip in some language to pay for her abortion too, just because it will piss you off."
That is a bit cold, Mr. V.
Written by The B and BD together.
Monday, July 20. 2009
Dr. Bob has penned a definitive essay on the topic of preventive medicine. It's all true, and all docs know it. One quote:
One big-picture aspect of this huge transformation in American health care which seems to be receiving little or no attention is its heavy emphasis on preventive medicine. We have been hearing for some time about how preventive medicine will save substantial sums of money and thereby make the overall health care system far less costly. Of course, such rhetoric has an enormous appeal at a surface level — after all, if you can prevent diseases, you certainly don’t need to spend money to cure them.
Who could argue with this?
But this innocent-sounding, simplistic Trojan horse will prove deadly for American health care, and end up empowering the bureaucrats and politicians who will, in fact, gain the most from this change in direction.
Read the whole thing.
Saturday, July 18. 2009
 It looks like we are on the subject of health freedom today. What I have observed over the past ten years is that people increasingly equate insurance coverage with medical care. That's sad.
In my view, it's a pathologically infantile sense of entitlement when people expect others to take care of them. Sad, indeed when Americans can afford their cars and car insurance and computers and iPods and cell phones etc. but expect somebody else to pay their bills if they get sick.
My view is that every responsible adult needs cheap catastrophic medical coverage - what used to be called Major Medical, with the deductible of your choice. Budget into your life the costs of your kid's broken arm and annual $120 camp physical - or don't have kids. If there's a big problem, the Major Medical will cover you. Like if you have a heart attack, break your back falling off a ladder, or if your kid gets shot in the eye with a BB gun.
I want to know what the Dems want to cover with their grand plan to "reduce" medical costs:
Will they cover Reike, massage therapy, homeopathy, acupuncture, chiropractic, crystal therapy, therapeutic touch, late-term abortion, breast enhancement, plastic and cosmetic surgery, hopeless chemotherapy and radiation therapy, eye movement therapy, light therapy, Chinese herbal medicine, hypnosis, social workers, bunion removal, in vitro fertilization, elective Psychoanalysis, alcohol rehab, penile implants, heart transplants, high colonic cleansings, liposuction, ingrown toenails and toenail fungus, Native Indian Soul Renewal, and liver transplants?
And do you want politicians making these decisions for you?
Me? I want the government 100% out of medical care and medical choices, because they have no idea what they are doing. No more of a clue than they know how to run GM - or the corner candy shop. I know what my private family policy covers. I chose it, I pay for it, and it's cheaper than the family's car insurance.
What the heck does the government have to do with these decisions, anyway?
Friday, July 10. 2009
 There is no convincing evidence that "healthy eating" - whatever that is (eating "organic" vegetables?) - or a "healthy lifestyle," eg exercising daily or whatever - has any beneficial effect on your long-term medical future.
Those things might - or will - make you feel better, happier, and more functional, and nobody likes to carry 30 lbs. of unecessary lard around with them, looking like a muffin-top or worse. Nothing to do with health, though. And that is why "Lifestyle Medicine" is quackery which has been foisted on a credulous public.
One quote:
...it’s little wonder, then, that the results of every major randomized, controlled clinical trial of healthy eating and lifestyles to date have been ignored, downplayed, or explained away... or their benefits greatly overstated. As incredible as it seems, they have failed to demonstrate significant benefit in preventing chronic diseases of old age, like the big three diabetes, heart disease or cancers, or in living longer. Nor has any healthy eating intervention been credibly shown to give everyone a government-approved BMI.
Other than avoiding smoking and substance abuse, and taking our medicines, our fates are sadly not in our hands.
Carpe diem: every day could be your last.
Tuesday, June 23. 2009
The main reason Americans spend more on medical care is not about life expectancy - it's about two simple things: quality of life, and the trial lawyers.
(American life expectancy stats are also pulled down by the numbers of premies and babies with terrible abnormalities we attempt to save.)
First, in how many countries can you get a shoulder repair or a new knee or hip in a week? Annual screening colonoscopies and mammographies? Guys with advanced ALS on home ventilators? And how many countries generate the new treatments that the US does? (We do 90% of them. For a recent dramatic example, see this via Insty.) We all wear out and die, but there aren't many countries where my 83 year-old Mom would be playing tennis with her new shoulder, hips and knee, her synthetic mitral heart valve, her pacemaker, her cataract surgeries and her hormone replacement. She calls herself The Bionic Mom. She is willing to die, but while she is alive she wants to live: play tennis, work in her gardens, go to the ballet, sit on her volunteer boards, cook for my Dad, and go to Europe every August. What is that worth in $ terms? Of course they are on Medicare, but they would gladly buy private insurance instead.
Re the trial lawyers, where else in the world do you get a $7000 work-up if you walk into the ER with a migraine headache? Where else in the world do obstetricians pay $350,000/year in malpractice insurance because the law permits suits for bad results, not just practice errors (like amputating the wrong leg)?
If something needs fixing, it's the latter, not the former.
George Will put it this way:
The president characteristically denies that he is doing what he is doing — putting the nation on a path to an outcome he considers desirable — just as he denies any intention of running General Motors. Nevertheless, the unifying constant of his domestic policies — their connecting thread — is that they advance the Democrats’ dependency agenda. The party of government aims to make Americans more equal by making them equally dependent on government for more and more things.
That, plus power, is what it's all about. As the Cube puts it:
The main question of the day is, can Americans afford NOT to adopt socialized healthcare? Everyone knows that the individual will never take the necessary steps; it is up to the State to do it for us. In a vital decision like this, do we really need to depend on the vote of emotionally underdeveloped conservative segments? Those incapable or unwilling to acknowledge the moral superiority and the ethical progress of the more socially advanced Europeans, do not deserve a right to vote. Voting rights shall be taken away from them, as well as their medicine. One cannot expect a society to prolong the lives of its useless, degraded elements at its own peril.
I need to squeeze in here somewhere the fact that members of Congress and the government would keep their own generous private medical plans, and not be subject to government control.
Monday, June 22. 2009
I majored in Statistics in college (with a minor in English Lit), but my stats sophistication is a bit rusty now. But it's not so rusty that I do not raise my brow at any latest stats reported in medicine, or especially in Psychiatry - and especially genetic studies.
As Gene Expressions points out, it's partly because a p-value of 0.05, commonly used in such studies, is unrealistic for these things. It's straight out of How to Lie with Statistics, which is essential reading for all high school students.
As the man says, if there is a genetic serotonin link with trauma and depression, it has yet to be proven.
In his second post on the topic, Why are most genetic associations found through candidate gene studies wrong? he makes the key point:
For nearly all diseases, reproducible associations have small effect size and are only detectable when one has sample sizes in the thousands or tens of thousands (for many psychiatric phenotypes, even studies with these sample sizes don't seem to find much). The vast majority of candidate gene association studies had sample sizes in the low hundreds, and thus had essentially zero power to detect the true associations. By the argument above, in this situation the probability that a "significant" association is real approaches zero. The problem with candidate gene association studies is not that they were only targeting candidate genes, per se, but rather that they tended to have small sample sizes and were woefully underpowered to detect true associations.
While I find the field of behavioral genetics to be as fascinating as anything else in this world, I always read the latest gene-behavior studies with the highest skepticism. (Do I think real Bipolar Disorder has some provable genetic underpinning? Yes, I do, even though I do not think it has been adequately proven yet. But not much else genetic in Psychiatry has been adequately proven in my view. Schizophrenia maybe, IQ almost certainly, but possibly not homosexuality, or depression, or alcoholism.
The trick to getting papers published is to run your numbers so they show something. It's not rocket science if you know how to do it: just look at the climate studies. (Even Einstein fudged his math. He happened to turn out to be right, though, as far as we know today.) Science is about hypotheses, not Truth.
Wednesday, June 17. 2009
No good deed goes unpunished.
Well, that is surely not always true, but with the economic downturn, the charity medical clinic at which I volunteer one day per week has seen a sharp upturn in lawsuits against us Docs and the clinic this year.
The medical defence lawyer we have now engaged (we have had no complaints or suits for 10 years until January 2009) tells us that we should now regard each patient as a potential enemy. (Our clinic's founding Christian philosophy is to regard every patient as a friend and neighbor.)
He tells us that our notes must be guided by the principle of CYA (your notes are legal documents, not medical reminders as we had thought) and that every decision a doc makes contains some basis for a suit in the hands of a hungry lawyer because all medical decisions are judgement calls and every situation is unique.
He also told us that recessions tend to see more suits against doctors because more folks are looking for cash, and much more so in charity settings. Plus the tort lawyers are hungry too - but they always are. He also advised us to refuse to treat any patients with substance abuse histories for our protection - other than alcohol.
He actually said "Do not be kind. They will screw you whenever they decide to." He has been around the block a few times.
I do not like this at all. A Psychiatrist/Psychoanalyst cannot do the job under such conditions. Furthermore, I can not and will not endure any relationship in my life without mutual trust. I am considering resigning (even though I was one of the founders of the place) and finding some other outlet for my charity. Maybe prison work, where you can safely begin with the assumption that everybody is a liar and cheater and working the system - and take it from there.
My position on the Board, plus my volunteer time (all unpaid) doubles my legal liability. I just want to do my best, tithe and double-tithe my time, and avoid hassles that do not fit into my life - and legal fees that I cannot comfortably afford.
And no, I would never work for ObamaCare. Never. I did not go into medicine to be a government employee. I went into medicine to work for my patients, doing my best, with no intention of looking out for lawyers.
Tuesday, June 9. 2009
It's tough for doctors because we are often held responsible for people who either do not want, or do not accept, our help and advice. But, as long as their name remains on our rolls and as long as we persist in trying to be constructive, the lawyers can get us.
I have been burned several times by keeping them on the rolls in the charity clinic, only to be sued by them eventually for not doing a better job "taking care of them." What? I am not a professional mother and I do not "take care of" anybody. I am a doctor, not a caretaker and, despite the modern lingo, not a "care-giver" either.
Like all doctors, I try to work with my patients - and do not take care of them, or I to try to bring them around to where I can work with them.
If I were more self-protective, I would not even try and would just say "I cannot help you. Good bye," but that is not my medical tradition. My medical tradition is that you are a friend to your patients, whoever they are.
Novalis presents such a case. More practical docs than I am would just throw them out of the office. However, after being punished and hassled legally several times by going the extra mile, my heart grows harder.
Indeed, good deeds often are punished and yes, it does lead to some bitterness especially when it is performed on a charity basis. I have never been sued or hassled by a private, self-paying patient.
Wednesday, May 27. 2009
Via Tiger at Althouse, Mary Roach (author of Stiff) with video on orgasms from fetus to death.
Friday, May 8. 2009
Another reminiscence from our shrink friend Nathan about his days in the Indian Health Service -
 A limp and a death among the Lakota Sioux marked my first day at Eagle Butte, devoid of eagles and buttes. Two days’ drive from Chicago, I am greeted from afar by John Running Horse, he dipping and rising like a Venetian gondolier, waving aloft what from afar seemed to be the plaster sculpture of a leg. Up close, it is.
Before I could stop completely, John Running Horse lay one hand on the open window of my red Fiat 128, bowed in head and cast, asked, “You the new doc?” I was. “Put this thing on again”; hands me the cast, then points to his gondoliering leg. I park and head in.
The Indian Health Service had told me that there were two docs; arrive Sunday.
But, by Sunday, Dr. K. had been flown out with her atrial flutter to be cardioverted eighty miles up the road to Mobridge; Dr. L. was riding shotgun with a mother in active labor also to Mobridge. No docs in Eagle Butte.
I wrapped a new cast on John Running Horse’s right leg and asked as I did so -- dipping plaster rolls in warm water, smoothing them first around, then smoothing downward along the fracture to make it seamless -- how his old cast got cut off. Itched, he said; cut it off himself, as he unsheathe his James Black/Musso pattern S-guard bowie knife. White plaster still dusted its curved Stainless steel back tip and brass quillion; hadn’t even wiped it clean.
I told John Running Horse that his skin would itch again after a few days; dried skin flakes. I found a metal coat hanger, bent it straight and showed him how he could insert it within the cast to scratch itches. He found this marvelous; made a special leather sheath for it to hang from his belt. Later, he returned; brought a water color gift; painted himself on his horse; he wearing Sioux gear. In his right hand, born aloft like some victorious banner is not a leg cast, but his Winchester Model 1894 lever-repeating rifle -- the gun that won the West, the weapon of choice for the Rifleman of TV.
Continue reading "A Limp and a Death"
You used to just plain peter out at 68 or 79 or 93 but, after 1951, the law changed and some Doc had to make up a cause to put on the death certificate. A proximate cause, plus additional lines to fill in for contributing causes/underlying causes of death. (Imagine what that change did to disease stats!) More many more little-known facts about death.
Old time Docs knew that people died when they got old and rickety or had a bum ticker or some nasty growths. You plumb wear out eventually, and it is just a matter of which internal doohickey crapped out first. It was considered sort-of natural, and not a medical issue.
And, when folks died, they either said "They died" or "They ascended to their Maker" or "Went to their eternal reward." They did not say "They passed" (what a strange expression - passed what? New Agey-sounding, isn't it? Took a pass on more life, or what? Passed into the Spirit World?) or "passed away," as the relentlessly euphemistic funeral home people used to say. Like they aren't dead: they just sort of floated away past the 7-11 and the Pontiac dealership and the Pizza Hut to somewhere else.
Maybe to the lovely Mall in the Sky.
Tuesday, April 28. 2009
 The news mills are ginning up yet another medical crisis storm these days in an effort to pave the way for gummint medical care by the same good folks who run the DMV and the post office. They seem to imagine a problem with cost, access, and insurance. Maybe we are a nation of crybabies, because we have the best medical care in the world with which to pamper our so-called precious selves.
It's time we got beyond that self-love, and cared about the Greater Good. I have a few simple, rational, Utilitarian solutions.
Cost: Cost is driven by technology and modern pharmacology, cancer treatment, crocks (people obsessed with their health), gomers ("gomers go to ground"), and futile, guilt-driven end-of-life treatment for annoying old or sick relatives. The cost of American medical care can be dramatically reduced by forbidding all cancer treatment other than Oxycontin and at-home 10-gallon morphine pumps, all medical treatment for those over 57 (the children are our future!), all CT and MRI scans, all blood tests, and all medicines other than friendly, holistic, herbal organic ones. No more vaccinations - they cause Autism. No more antibiotics - everybody knows that they make people sick. Eliminate Dermatology (just stay out of the sun, people). Eliminate Opthalmology (bad eyesight is from masturbation - it's your own fault). Eliminate Psychiatry (mental illness is socio-political mind control). Eliminate Urology (do you want a #3 gauge tube stuck up your urethra?). Eliminate Surgery - it is physical assault on comatose victims. Eliminate Neurology - it's just nerves.
Access: Doctors are like waterfront trade unions: they limit their numbers to keep their payments high enough to join country clubs, to buy boats, and to take vacations. My idea: anybody who gets a C or better in Organic Chem is automatically admitted to a government medical school. Lots of good, caring people are weak in math and chem and bio and stuff, but that's who we need more of. My medical school flunk-out rate was 18%: what a waste of talent. Plus there are too many Jews and Asians in medicine anyway, and too few people of color or of gender identity diversity. So, with this increase in the numbers of docs, fees could go down to $5 per office visit and the docs who don't like it can open dry cleaning shops, cigar shops and wine shops like they do in Canada.
Insurance: Medical insurance is a dumb idea. Why expect your neighbor to pay your medical bills when they will be so low under my plan anyway? They will be cheaper than your garbage pick-up, your newspaper subscription, your cigarette costs, your car payment or your monthly payment for your big screen TV. (Did you ever notice how nobody complains about the cost of their TVs, computers, or Life Insurance?) Or just save your money if you want and die quietly without complaint, dude, and make space for the next generation. Too many people on the planet and, let's face it, life isn't all it's cracked up to be anyway. A vale of tears and toil, a tale told by an idiot, full of sound and fury, signifying nothing. What's the big deal about death? Didn't your parents teach you that life is a bitch?
Friday, April 24. 2009
Our shrink friend Nathan, who has completed Aliyah in Israel, sends this reminiscence of his days working for the Indian Health Service, doing general practice including surgery and obstetrics - and anything else that was needed. Old-timey medicine.
Before replacing the sloughed skin on Mrs. R's arm, I had to find out why her forearm was raw to the muscle. New here among the Sioux, I am surprised to learn that my colleagues (and one ancient Roman Catholic always fiddling with her rosary) hadn't checked this elderly, chunky widow's blood sugar: diabetic, sure enough, never diagnosed. So, first things first: stabilize her blood sugars, treat the diabetes, and give proper antibiotics (for anaerobes and aerobes -- they missed this too), then when you see the shiny, glimmer of healthy tissue margins, go for a skin flap transplant.
The pharmacist was my surgical assistant; he was the brightest of the bunch, from N'orlins, La before the Flood, he couldn't get into med school, he said, but he was smart, hard-working and pleased to assist. He also ordered special hickory chips from N'orlins, La. to barbecue and made his own roux. It was then that I learned I loathed ochra, that slimy matrix it exudes.
Then how to unskin a lady was not to be straightforward as it was at the University hospital where I studied. The surgical suite -- well-endowed -- had not been used for years; surgery was sent eighty-miles up-road to Mobridge to the White hospital; none done here, except deliveries (which too often evolved into C-sections who had to be sent, ambulance screaming, up to Mobridge. One trip, the eternally-soused obstetrician kept his fist in the mother's vagina to keep the baby from popping out.
To unskin a forearm means to find a donor site from the inner thigh. Anesthesia needed for this and there was no anestheiologist, no nurse-anesthetist, even in the 1970's. I do double duty. First, a lumbar block to numb the donor site; second, a brachial plexus block -- in the armpit -- to numb the recipient, the naked forearm. Lumbars I had done many of: babies with possible meningitis; Southside Chicago girls in active labor, with no prenatal care and needing an urgent C-section. But, brachial plexus block was a never-done for me; remembered the anatomy, the complex twistings and routings within that armpit, like some noodling of telephone wires beneath the city streets, but never stuck a needle there. The night before surgery, I bone-up on my Netter's anatomy and hit the spot square-on the next day in the O.R.
Before hitting the OR, I had done several days debriding of the sloughed wound: fresh it must be to transplant the sod of skin. In the OR, flipped on her side, I slid into the vertebral space between L4 and 5; a bit lordotic pull by the nurses and I had a clear tunnel in. Then, flapped on her back, Mrs R. was ready. The thigh well scrubbed, Betadined, aproned, an oval hole isolating the site. Instruments we had. The strange loopy-scalpel to slice just-thick-enough epidermis and a touch if dermis to both "take" to the new site, yet leaving some dermis to heal-over the thigh; something like a large cheese knife the instrument looked. Forearm next. Her arm flung up like some lop-sided angel wing, I probed left-handed with two gloved fingers, then slid the massively long needle --- like from the cartoons -- in between the stretch of skin. Wait. Wait. Numbness without paralysis in the arm. First, a touch on the skin (for sensitive fibers); then a pinch with a forceps (for the pain C-fibers) and success.
 Laying the layers onto the site is much like laying sod; carefully, side by side, the edges trimmed to the wound shape. The "root" growing will take on its own, a pressure bandage holding the skin sod in place. A fine lawn it will hopefully be; like sodding around a putting hole -- it should look good and cover the ground. And after five or six days of brief peeks, it looks darn good.
But, Mrs. R. wants a pass to leave early. There will be a Sundance ceremony with several initiants, including, I learn later, Russel Means, wanted by the FBI for shooting three men on Rosebed reservation, down south. I explain, I plead in fact, that she can't rotate the arm; she must stay in hospital a week or so until we know healing has happened. Mrs. R. has donated two buffalo for eats at the ceremony and insists, politely, quietly, firmly, that she is going. Wakantanka, the Sioux god whose voice one hears shushing through the Black Hills, will protect her. She invites me.
Being invited was one thing; getting in another. I and Debby were the only washichus, white men, attending. While this was a Lakota Sioux ceremony, it had become politicized; other tribes, mostly the more militant ones, as far away as the Navajo, had sent "guards": thick-armed toughs with long, greasy black hair and their image of mean on their faces. The fellow who greeted us -- we had the red Fiat 128 in South Dakota -- commanded us out. A face like a slab of steak with two eyes embedded, he frisked me; looking for drugs and guns, he said. His compatriots searched the tiny Fiat's baggage, checked under the carriage, beneath the seats, glove compartment. When he turned to frisk Debby, I told him firmly, no way: I would turn around and he could explain to Mrs. R. why I was not admitted. Her name was a key to the lock that was his harshness. We were passed through.
I did not expect to be the only Washichu; thought other docs would be invited; learned later that my do-gooder colleagues who come to save the Indians are not so welcome. Already, I had dispensed with making morning rounds with them, as I tired and was irritated at the "religion" they spouted at bedside; told them I needed to round earlier.
We formed a large circle. Formed is not quite right. A circle was somehow formed by the few hundred there, centered by the cottonwood from which leather strops hung. Each strop was anchored with a bone hook -- from what animal I don't recall, perhaps antelope. The six piercees entered; I'm told by Mrs. R. that they had purified themselves in the wild for several days with fasting and water. The hooks are pierced into the pectoral muscle, not the skin, to hold more firmly; one on each side. as the men leaned back against the leather thongs, faces skyward, Cubist, uptilting tits were formed: this manly ceremony giving rise to a touch of woman. A moaning or humming was emitted by them by these men; also those in the circle, as the men stomped sidewise about, a dance they called it, in a hypnotic slowness. A timeless quality it felt.
Near the end, several men appear with massive shallow wooden bowls, face us in the circle and pass around the dried buffalo donated by Mrs. R.
She is called to near the center. A peace pipe is to be given to her for her generosity. As some chiefly type raises the pipe, his arms extended, palms upward, I realize, a touch shocked, that she will now rotate her arms upward to receive the peace pipe with both hands. I feel a belly clutch: will she tear the stitches?
Mrs. R. looks back at me afterwards; tosses a smile of reassurance. Thanks to Wakantanka the skin is fine, she explains.
One weekend, we go to the Black Hills, find a cabin, rest outside beneath a sky filled with more stars than I have ever imagined. I feel a sense of annoyance as I hear the rush of what sounds like highway traffic just beyond the ridge. Ridge top I look: no highway; it is Wakantanka speaking through the black pine.
It was the only time He has ever spoken around me.
Top photo: Sioux war party, 1870s?
Middle photo: Sioux warrior
Lower photo: Sioux village
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