Brown vs. Board of Nursing

January 21, 2010

Timothy Noah is right. I still may not  feel entirely confident that I know how to use the word ironic correctly, but I think this one’s got irony written all over it, probably in the blood of the uninsured. For those of you who don’t know, Massachusetts is the only state in the country with near-universal health coverage, which was achieved by legislation enacted in 2006. The Massachusetts legislation passed under the stewardship of then-governor Republican Mitt Romney. Jump to three years later, when Obama’s pushing health reform on a national level, and one of health reform’s champions, Democratic Senator Ted Kennedy (from… where else? Massachusetts, duh), dies a politically untimely death in  August 2009. Now here we are in the new year, and Republican  Scott Brown, a  Mass. state senator,  just won Kennedy’s vacant seat in a special election. Brown is the first Republican to occupy the seat in like a billion years or something. As a state senator, he supported health reform for Massachusetts, but now as a United States senator, he opposes national health reform. The voters of the only state with universal health coverage sent a man who opposes health reform to the Senate. The irony of the circumstances, the irony of the timing, the bizarre message this sends… well, I’m at a loss. I’m sad. The watered-down, public option-free, anti-abortion, pro-insurance company, pro-Big Pharma version of heath care reform that the Dems worked so hard to pass in both the House and the Senate may never reach the president’s desk, thanks to an unfortunate death and a fateful election. Even in its flawed state, I wanted that legislation to pass. I really did. Now it probably won’t, and I just have to be sad.

Yet some things still retain the power to make me glad. Check out this sweet article from Kaiser Health News, authored by Dr. Lavizzo-Mourey, president and CEO of the badass Robert Wood Johnson Foundation. The article argues that nurses have the clinical expertise, the patient advocacy background, and enough of the public’s trust to reshape health care for the better, but we lack positions of political influence. So, my dear nurse friends, I hope this inspires you to live up to the public’s high opinion of you. I hope this means you’ll think about organizing and bombarding your senators and representatives over the health reform issue. I hope this means you’ll run for city council, apply for Ph.D. programs, join hospital boards, join nursing organizations, go to law school, and first and foremost, take what you’ve learned at the bedside with you. I know many of you will argue against ever leaving the bedside… after all, patient care is why you became nurses in the first place. I’m not saying everyone in our field needs to start climbing the ladder and grubbing for power.  But I do think that part of patient care is lifting your gaze from the bedside, looking out the dirty hospital window and seeing inequities that either prevent millions of people from ever reaching a much-needed hospital bed or trap countless others in their hospital beds, unable to shake the chronic diseases of our civilization. So although you are desperately needed at the bedside, and much appreciated by your colleagues and your patients, I do believe that most bedsides at least come equipped with a cheap-looking hospital phone from which you can call your senators and representatives and tell them why the both the bed and the bedside are such difficult places to be these days. Don’t forget to dial 9 first.


I Heart Nurses, ER edition

December 10, 2009

I’m about to tell you a deep dark secret of the medical world, so keep this on the D.L, deal? Ready? Ok. Here we go. (Deep breath.) Ok. (pause). Alright. For reals this time. Ready? Ok. 1, 2, 3, go!

Whether or not they are willing to admit it, almost every health care worker, no matter what age, what gender or what specialty, has an inferiority complex concerning emergency department folk. Even if we are happy in our own specialties, tending to premies in Newborn ICU or sullen teens at the STD clinic or emotionally-bereft family members of patients new to hospice, we all kinda secretly wish we could hop on top of the gurney and crack open the chest of a trauma patient. We want to wield that crash cart with ferocity, slam that first intraosseous needle into a veinless drug addict, and deploy enormous volumes of morphine with swagger. We want the badass ER nurses to accept us into their shit-talkin’ clique and the testosterone-pumped docs to meet us at the bar for a round of shots and dirty stories after our shift.

Of course, this is all part of a fantasy that doesn’t really exist. ED docs are not always manly, handsome superhumans–the best ED doc I know is a sweet, soft-spoken hispanic lady. And not all ED nurses are fiery redheads like my friend Lisa, although I have noticed that emergency nurses are, in general, bitchy and hilarious and a blast to hang out with. But many of them are cranky burnouts or sweet older ladies or hardworking fathers. There’s also techs and secretaries and paramedics and terrified students and lab people and pharmacists and transport guys and the people who restock the supplies and a few naked, disoriented patients from the other wards wandering around, too. But in reality, ED patients are not all gory traumas and massive MIs and outrageous injuries, and they are certainly not all quirky but lovable or touching characters. For the most part, ED patients at a big teaching hospital like ours are drunks, drug seekers, unfortunate people without insurance, and hysterical parents of children who have the sniffles. Now, I am not saying that our ER does not see some crazy shit. They have gunshot wounds and MVAs and hanta virus and bones sticking out of limbs and blown valves and all kinds of stuff. But these cases are relatively few compared to the constant onslaught of non-emergency cases and substance abusers. And this type of inappropriate usage of the ED is one of the reasons why ER waiting rooms become a holding cell for desperate people who have been waiting 6, 10, sometimes 14 hours just to see a doctor. It’s a shitty situation, and nobody’s happy. And that’s the real reality, the reality that keeps most health care workers out of the ED, mindful that the fantasy isn’t worth the stress of a system in peril.

Inappropriate usage of the emergency department is a complex problem with multiple etiologies. Many people without access to insurance are forced to use the ED for primary care. Other people cannot wait 2 months for an appointment with their own primary care provider. Plenty of people do end up going to their primary care provider’s office, at which point they are sent directly to the ER by a nervous provider who would rather take extra precautions than be sued. Plenty of people are just unaware of alternatives like urgent care. People with avoidable chronic illnesses such as diabetes or heart disease have scary flare-ups that send them to the ER on an annoyingly regular basis. And other people just don’t know that a cough and a runny nose are not life-threatening, since health education leaves much to be desired in this country. Social services also leave much to be desired in this country, which means emergency rooms get to babysit people who would be better off in a comfortable shelter or a treatment program.

All this overflow adds up to a miserable experience for people who really are experiencing severe, urgent or life-threatening problems. It adds up to waste and burnout. Even if people receive excellent medical care at the ER, they leave pissed and dissatisfied because of long waiting times, poor customer service, and high out-of-pocket expenses.

If you are unfortunate enough to wind up in a busy ER, make sure you pack a blanket and a pillow. Bring your iPod and some snacks. If you have a laptop, bring that too, since most ERs now have wireless internet and you can use the time to google your symptoms and diagnose yourself. Unless your guts are spilling out all over the place, don’t expect to be seen right away. My apologies for that. The thought of people waiting stresses me out, and that’s one of the toughest realities that ER people must constantly confront.

Even given what a hot mess the emergency department is, I still cling to the fantasy of hot doctors and kickass nurses and crazy medical cases. The reality of the situation makes these people even more remarkable, since they deal not only with the ugliest medical disasters, but also with the ugliest snags in the health care system. It’s quite a burden to shoulder, and some shoulder it more gracefully than others. In either event, I hope that political, social, cultural and economic factors eventually converge to help ease the load and restore the ER to its rightful place among the medical specialties: emergency medicine.


Shine, Perishing Republic

November 6, 2009

I’m sure that today’s headlines will mature into fodder for tomorrow’s brilliant Woody Allen film-cum-social commentary on love and happiness within the larger misery of the human condition –I mean, I can picture the scene where Cate Blanchett, impersonating Woody Allen, throws her hands in the air while exasperatedly pondering the absurdity of an American military psychiatrist opening fire on a crowd of U.S. servicepeople, killing a dozen and injuring scores more. How do these things happen? How are we supposed to receive, process, and reflect this information with our subsequent behavior, our ability to keep going and to find meaning in the broken world that surrounds us? Somehow methinks Cate Blanchett’s character will learn to love in the end, will accept the yin with the yang, will realize that for every violently deranged gunman, there are a hundred sensitive, kindly bloggers out there trying to make the world a better place. But meanwhile, back here in non-movieland, the forces that be continue to tiptoe around the fact that military suicide rates are climbing, and active and veteran servicepeople are at substantially higher risk for committing suicide than civilians (Kuehn, 2009, JAMA, 301(11), 1111-1113). As per violence, even the DOD admits that domestic violence against spouses of servicepeople is “a problem.” Unfortunately, data on rates of military suicide, homicide and other noncombat-related violence is hard to come by: searching CDC, NIH, PubMed, PsycheInfom, CINAHL and PMC databases didn’t yield much. Kuehn (cited above) determined suicide rates by extracting data from general CDC surveillence reports. I couldn’t find anything specific to the military. If you’ve got a source, lemme know!

Mental health is a hot topic for military PR right now, and the rising rates of active-duty and veteran violence and suicide has them Army boys sittin’ around scratchin’ their balls asking, “why?” That’s right. The NIH, the Army, and $50 million in taxpayer money are teaming up to investigate why soldiers commit suicide!!! Don’t get me wrong: I theoretically support suicide research and figuirng out why it happens. But in the case of  young men and women participating in and subjected to extreme violence, I think the answer is a little bit self-evident. Still, okay, okay, it’s good to study factors that protect servicepeople against suicide, because if we know what the protective factors are, we can keep asking “non-suicidal” people in the service to do our dirty work in intolerable environments without worrying that they’ll just kill themselves first. Ok, maybe that’s pessimistic of me. Maybe we’ll use the knowledge to screen for mental illness and treat suicidal ideation, or change military policy to accomodate those prone to suicide or mental illness (uh, yeah right). Or we can pile “protective factors” onto those at risk for suicidal ideation. Like how some of the first meth addicts were military pilots who were given meth in order to protect them against combat fatigue.

Today’s other headlines weren’t the counterbalancing pick-me-ups I’d hoped they’d be. Anti-abortion, anti-immigrant democrats (forgive my extreme ignorance, but I didn’t know there was such a creature) may jeopardize health reform, and H1N1 vaccines magically reached Wall Street before other needy clinics. Hey, you people who think the “honor system” is alive and well in the medical industry: I have already seen H1N1 vaccine go to members of non-priortitized groups, because someone asked nicely or somebody knew somebody or somebody was a VIP or whatever. I have objected, but some providers seem to be of the opinion that a little bit off the top won’t hurt. My most esteemed government, next time you can keep your honor system and instead hold providers accountable for each and every dose of vaccine you ship to them.

FYI: Hoarding of the swine flu vaccine isn’t just a domestic issue. It’s projected that there will be about a billion doses for the world’s six billion people.

Looking at today’s headlines makes me shake my head, and I can only borrow the thought of a visionary born a century before me (no, not Woody Allen): Shine, perishing republic.


The Gatekeepers

September 18, 2009

Though I typically role-play only within the privacy of my own home, I thought we’d try a little exercise here on SEMI. Lets pretend that we’re presented with a group of starving people. Why are they starving? I don’t know. Pick a reason. Ok, let’s go for broke here. Maximum emotional impact. Extreme example. They’re starving because they are in a concentration camp, duh!

“I want to help!” you say. “Let’s get these people some food!” A group of your friends agrees. You go about trying to devise a way to get these poor starving folks some food.

“We’ll give them money, and they can go out and buy food,” offers somebody. Another person points out that, unfortunately, even with all the money in the world, these people will still be burdened by a lack of access to food, seeing as they are, uh, confined to a concentration camp. Not a lot of food providers around these parts.

“Ok, let’s distribute food directly to them,” counters someone else. Someone in your group objects, claiming that they believe your group is too inept to perform such a task yourselves.

As a group you mill over various ways of providing the people in the camp with money, food, and access to food for a while before another person in the back raises his hand and jumps up and down excitedly. “Oh, I got it! I got it!” he shouts. You recognize him. Wow! It’s Republican Senator Grassley from Iowa.”Let’s give money to the people RUNNING the concentration camp! They seem like they know what they are doing! Then people in the camp can apply to these wonderfully organized, efficient camp managers for food!”

This proposal receives robust support from the camp managers. Your group of friends cuts a check to them, and everyone goes home.

Is this a poor way to illustrate Sen. Grassley’s proposal mentioned in today’s Washington Post?

“Some Senate Democrats, along with a key moderate Republican, Sen. Olympia J. Snowe (Maine), are now discussing ways to increase assistance for individuals and families who could face premium costs of up to $15,000 per year by 2016. Sen. Charles E. Grassley (Iowa), the ranking Republican on Baucus’s committee, is suggesting government assistance to insurance companies to help them control premium costs.”

Maybe. Is it extreme to compare insurance companies to Nazis? Sure, I suppose. I don’t know. The Nazi/Hitler analogies have been rampant of late, so I’m just jumpin’ on the bandwagon here. But in this case, many people have died from treatable conditions due to denial of coverage. Could this perhaps be because an insurance company’s existence is predicated upon taking money and keeping it?

Another choice quote from todays WaPo article:

Obama sought to ease concerns among young adults, who are now among the least likely to purchase health insurance, but who would be required to do so under the Baucus plan. Healthy 20-somethings are key to successful reform, because their payments to insurance companies would offset the costs of care for older adults.

You know, this is really funny. Like how young workers would pay into social security to offset the costs of all the old folks collecting social security? Except now the young people, like me, get to cushion a private company’s profit margin so that they can continue denying the claims of old or sick people. Fantastic! So here’s my open appeal to old people:

My dearest Old People,

I understand that, through no effort of my own, I am young. I understand that being young furnishes me with responsibilities towards those older folks who built the world in which I am living today, and as such are no longer young. I am prepared to accept this responsibility. But couldn’t I just give y’all the money directly, or couldn’t I just pay taxes and work a job in which I directly care for old and sick people like I’ve been doing for the past five years?

Smooches,

SEMI

P.S. My most precious Old People, I eagerly await your reply.

By the by, I can’t wait to live in a world where we all spend 20% of our income on goddamn “health care”:

For families buying insurance through the exchanges, the expenses are likely to mount even more rapidly, the CBO said. For example, a family of four making $78,000 would face insurance premiums of 13.9 percent of income, or $10,800, in 2016. Add deductibles and co-payments, the cost could rise to $15,300 — just under 20 percent of income.

Note: even a family of four that does not access health services even ONCE during the year is still legally obliged to pay almost $11k for insurance.

So we’ve heard the financial projections on the Washington side: this plan costs about $800 billion over ten years, it doesn’t add to the deficit, and amending the plan will naturally result in a higher price tag. But what about the financial projection for insurance companies and other “industry leaders”? I can’t wait to hear about their third-quarter earnings following enactment of this legislation.


Maxed Out

September 17, 2009

If the very best thing that can be said about your piece of legislation is that it (hopefully) does not add to the federal deficit, I’d say you probably failed to do your job and protect Americans from the ravenous pockets of private insurance execs. In fact, you led your flock to the slaughterhouse by mandating that they purchase health insurance (is this even, like,  constitutional?) while failing to provide a public option or even reasonable subsidies. Though expansion of Medicaid and insurance industry regulation are laudable, the rest of the legislation, including major cuts to Medicare reimbursement, lame insurance cooperatives, and forcing people to give up to 13% of their income to insurance companies, seems pretty  disgusting.

As one of the coveted uninsured, I suppose I’ll be going to jail when I refuse to pay the fine for failing to acquire insurance, because I’ll be damned if I give my money to an industry that has demonstrated its capacity for pure evil time and time again OR a spineless government that spoon-feeds the insurance companies 30 million new customers without providing a viable alternative. The Washington Post notes that Uncle Sam expects to help pay for this program by collecting 50 BILLION dollars from penalties imposed on individuals who don’t purchase mandatory insurance. In other words, the Baucus bill would rather collect $50 billion by fining people who are already unable to afford insurance than by imposing additional taxes on filthy rich people, or even by collecting revenue from a well-run public option (though I admit the notion of revenue from such a program may be wishful…nay, delusional, thinking.) If I’m missing something here, please, enlighten me. Until then, grow a pair, Washington. Then we can talk.