Maggie's Farm

Everybody should get some CPR training, with regular refreshers. You never know when someone is going to go down at the supermarket, in church, at the movies, in a parking lot, or at a baseball game. Be the person who knows what to do.

In the tension of the moment, it's hard to think straight unless you are in an ER with support and help. And people collapse all the time, usually for minor and relatively benign reasons. But sometimes it's an arrhythmia, or a heart attack-related arrhythmia, and, if so, it's your chance to try to save a life as long as you aren't too far from definitive help. In the wilderness, forget it. They're a goner if they quit breathing. CPR is a temporary thing.

Online CPR certification here. (with sound). It's best to practice it with a dummy, though. I have only had to perform this once in a non-medical setting. A rainy, cold, wet parking lot. She survived, but with mild brain damage from hypoxia (the cause of her collapse and subsequent respiratory failure was a ventricular arrhythmia of unknown cause). And I cracked a rib or two, but that hardly matters when someone is "trying to die," as docs call it.

I had a friend who went through a hell of a time with a pulmonary embolism (a very common life-threatening and commonly life-ending event in all ages) four days after a flight from Rome to New York. I would have thought that the stats were higher, but it appears that the occurrence of deep vein thrombosis (clot formation, in this case usually in the legs, which, when they get loose, are carried to the lungs) is only doubled during travel of four hours or more - whether car, plane, bus, etc.

The solution might be a baby aspirin, but best is to keep those legs moving a bit instead of sitting immobile for long trips. Get up, walk around, stop the car and walk in a circle, whatever. Or just twitch your legs restlessly the entire trip, as if you had ADHD. That will help prevent this terrible problem.

I do not post often enough, so I am grateful that Bird Dog keeps me on the Soros-sponsored payroll.

Our worthy and self-sacrificing editor emailed this piece to me from Stumbling and Mumbling, a pleasantly cantankerous economics-oriented Brit blog. Apparently the Brit NHS has a euphemistically-named "National Institute for Health and Clinical Excellence," (does that sound like something out of Brave New World?)whose job is to decide what treatments the government will pay for with your tax dollars. They try to apply cost-benefit analysis to your problem.

Of course, such a process necessarily politicizes medical treatment by making every treatment, and every disease, a political football, with the loudest voices and the squeakiest wheels and the most pathetic stories winning out. And also turns every person into an expense item on a spread sheet, thus making it cost effective for everyone to die promptly without burdening their neighbors, at the precise moment when they cease to generate tax revenue. Citizens become, in essence, farm animals on a government plantation.

The potentially-fatal flaw in democracy is that people can vote themselves "free" stuff, because there is no end to that childish wish. But with each "freebie," there is a loss of autonomy, of self-reliance, of adulthood, and of freedom.

American patients are accustomed to have their problems insulated from government cost-benefit committees. They are accustomed to freedom, which can cost a bit more. And if they require low-cost or free care, they can go to any clinic they want, almost everywhere in the US. I work in one, for nothing, in Providence, one day a week, and have done so for 20 years - but you have to prove that you are poor. You may not take advantage of our good intentions. And if you sue us, you can, should, and will, go to hell.

Well, that was a digression from the point at Stumbling that I wished to highlight. He noted that no other government "programs" are subjected to cost-benefit analysis, except for medical treatments.

Now, you just have to wonder, why might that be?

I have faith that, in general, Americans will never sell their freedoms for a bowl of lentils.

To a Fat Lady Seen From the Train

O why do you walk through the fields in gloves,
     Missing so much and so much?
O fat white woman whom nobody loves,
Why do you walk through the fields in gloves,
When the grass is soft as the breast of doves
    And shivering sweet to the touch?
O why do you walk through the fields in gloves,
    Missing so much and so much?

Frances Cornford wrote that - the charming form is called a triolet.

Our editor asked me to comment on Dr. Helen's piece on fat people. As a doctor, I tend to be a "Do as I say, not as I do" sort of guy. I smoke cigars and I am pleasantly, or some might say prosperously, or some might say, grandfatherly, well-fed.

When patients of mine are seriously overweight, I tell them straight out. The word fat does not bother me. I have a model in the waiting room of five pounds of adipose tissue designed to get a reaction. It is disgusting.

As someone who did my share of general surgery earlier in my career, I can tell you that fishing through gallons of yellow adiposity, getting your gloves so greasy you cannot hold the scalpel, is no damn fun. If you are fat, and saw what you look like under the skin, you would be horrified.

Another complication recently published is that obesity makes it more difficult to make a diagnosis. It's called "study or exam limited by body habitus."

However, I also understand that the flesh is weak, and that staying in youthful shape after 45 is no mean feat. It takes work and discipline, and the evidence that it leads to longevity or health is minimal. However, being in good shape adds a lot to quality of life. On the other hand, being obsessed with health is for the crazies.

Plus there is the vanity factor: few guys will look at a fat girl, and no gals will look at a fat guy - unless he is rich or powerful. But, at some point, unless we are narcissists, we accept reality and don't care all that much.

Final word: If you are too fat, I will say that. And, if you care, I will tell you how to deal with it. But your life choices are not my problem, beyond that: your doctor is not your Momma, nor is he/she responsible for your health. Your health is in your hands, and God's, and nature's. My only responsibility is to give you advice as your friend, and to try to help you when you get sick.

As a guy who has been in practice for many years, I have no doubt that doctors' decisions are the reason American medical attention is as expensive as it is.

However, what Kling in his excellent and important piece at TCS omits is the extent to which such decisions are driven by patients and their families. Most patients, offered the option that "this might help," opt for it. And the docs go along with it, even if the statistical gains are marginal to none. In other words, they replace their measured judgement with the "consumer's" choices. "Doc, do everything you can." I see it every day, and have done this countless times myself.

And why not, if someone else is paying the bill? Do we love outselves too much? Or do we want to believe in magic? (Also, bear in mind that the physician ordering your test or procedure makes no money from that.)

As a consequence of "consumerization" and litigation, the band of "elective" procedures and tests shrinks ("elective" used to imply that Major Medical insurance would not pay for it), while the band of the routine expands, including the marginal, the useless, the "heroic," the hopeless, the experimental, and the optional. Many extremely expensive cancer treatments would be on that latter list, plus allergy "treatments," plus even routine annual physicals which I believe are a waste of time and money - my list would be quite long, and I could easily annoy every medical specialty.

In the good old days of medical authority, before people came up to you and said "I read on the internet that there's a doctor in Arizona who says...", physicians were capable of carrying the burden of making good decisions for their patients. And when folks were ready to go, we let them go: we would never treat pneumonia in the ICU in Alzheimer's patients. That is not rationing - that is sane decision-making. And we all pay the bill.

Thus American medical care is more expensive, but minimally more effective, than other places: we spend our extra money on the margins, and on terminal patients, where outcome is not meaningfully affected. A classic example comes to mind: Mickey Mantle, with metastatic lung cancer and dying, gets a liver transplant for his cirrhosis. I doubt a physician recommended that, but they probably did say it was an option, and he said "sure." It probably gained him a couple of weeks of torture and misery, in the hospital.

Kling considers all of the possible causes for medical costs, and concludes:

That leaves (D), with its radical suggestion that America's culture of medical practice is at fault. I arrived at this conclusion as an economist, looking at the data that contradicts the alternative hypotheses and also at a variety of studies, cited in my book, that show little relationship between health care outcomes and the supply of medical services.

Since writing my book, I have come across the work of Nortin Hadler, an MD who, coming from a very different direction, arrived at the same conclusion that I did about America's medical culture. In 2004, Hadler published The Last Well Person: How to Stay Well Despite the Health-care System

Hadler takes on many popular forms of health care in America, from alternative medicine to colonoscopy screening to anti-cholesterol drugs to heart bypass surgery. In his iconoclastic view, all of these therapies have benefits that are too small in terms of either statistical significance or common sense to warrant widespread use (he qualifies this by saying that certain narrow target populations do in fact benefit from these approaches).

Hadler steps on some very sensitive political toes. Americans want to hear that our doctors "save" men with prostate cancer. Hadler sees it is a common, slow-acting ailment that can be left untreated (there is a less-common variant that is more dangerous). We want to believe that talk-show hosts who scold people to get mammograms, watch their cholesterol, and submit to the indignities of colonoscopies are doing the public a service. Hadler argues that we should take a more stoic attitude toward the risks that we face.

Please read the whole thing.

From Kevin, MD:

Do you have Adult ADD? Take this quick test:

1. Do you sometimes get up to get something out of the refrigerator while watching TV?

2. When reading a technical text or doing homework, do you sometimes wish you were watching The Sopranos, or going to bed, or going out with friends?

3. When you have a huge pile of bills and paperwork, do you think "Aw, shit"?

4. Have you ever clicked "OK" or "I Agree" or "Next" on a website without reading all of the information?

5. When you are supposed to be focusing on something tedious, do you ever think about sex or other kinds of fun?

6. Have you ever opened a box from the bottom instead of the top?

7. Have you ever used a digital camera without memorizing the manual first?

8. Have you ever had trouble finding your keys?

9. Have you ever stared out the window, thinking "I'd rather be fishing?"

10. When you are online, do you move from site to site without spending at least 15 minutes perusing Maggie's Farm in detail?

If your answer is "Yes" to one or more of these questions, you definitely have ADD. See a doctor immediately before it gets worse.