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I Think it's going to rain today

I woke up with this song in my head.
This morning I realized it is Friday the 13th of March. Back in the ER tonight.

After a week of summer weather.

Woke up to rain.

Last night was a tipping point I think. People in the United States started to realize that -- regardless of whether they personally got sick -- the next few weeks or months were going to be disrupted. It was the cancellation of major sporting SEASONS -- not just events. The statewide school closures that likely got people's attention. On the way home from school yesterday, my 15 year old daughter said "it feels like this dystopian novel I read at the start of the year."

She said she felt that the coming days would be historic -- something that she would look back on and say that she remembered living through it. The weight of events, piling up one upon another on all of our minds.

This morning, Amy and I went to buy groceries after dropping our daughter off at school. A typical payday morning routine for us. Early morning shopping means empty stories and so we like getting what we need and getting back home before the rest of the world gets out the door. This morning, the stores were packed, but people were patient and courteous. Their smile and kindness reassuring, but I saw a lot of husbands out filling carts with lists from their wives. "Why am I buying bottled water?" asked one. "We have water at home, we never drink bottled water." Another complained that he thought it was all just a big hoax, his cart filled with supplies.

My daughter remarked on this too. Just like in the novel, she said, people fall into three categories -- those that worry and prepare, those that don't believe anything will happen and those that panic and act irrationally.

I've been in the medical field for 15 years, so I don't tend to panic. It doesn't accomplish much and burns energy that could be spent on other things. I also think in worst case scenarios -- because that has long been part of my job. A job I return to tonight.

I have plans to limit the spread to my family. Changing out of scrubs and decontaminating at work -- something I always do anyway. I even have our little camper prepared to go if I need to self-quarantine at home.

I go back to work tonight.

I work with a vulnerable population and I expect to see bad outcomes.
Additionally I worry about the stress all this will cause to compound things. Car accidents in busy grocery store parking lots, domestic violence and abuse. Quack cures that do more harm than good. Despair and the diseases that follow on from despair.

Randy Newman wrote "I Think It's Going to Rain Today" back in 1963 ... wrote it for someone else to sing. It is one of his most covered songs, recorded by dozens of acts in the 60s adn 70s. 

"The music is emotional – even beautiful – and the lyrics are not. The honest truth is the song bothered me because of the darkness."

Human kindness is overflowing.

And I think it's going to rain today.



Think Fast: Understanding Stroke

When I was in nursing school, a friend of mine was walking out of a class when he suddenly couldn’t speak, his left arm and leg stopped working.
There were other students all around him, but they didn’t recognize what was happening and they kept asking him what they should do. Because the blood was cut off to a part of his brain that controlled speech he couldn’t tell them.  He knew that it was an emergency -- that they needed to call 911 and get help, but he couldn’t tell them.
He was in his second year of nursing school. He knew he was experiencing the symptoms of a stroke.

A stroke is a life threatening emergency and an life altering event.
Recognizing the signs and symptoms of stroke and understanding the importance of getting help fast can make a world of difference for you or someone you know.
It is estimated that every 40 seconds someone in the United States has a stroke. According to the Center for Disease Control, stroke is the leading cause of long term disability in the United States and it kills more than 140,000 people a year - that is one out of every 20 deaths. While risk of stroke increases with age, more than one third of people hospitalized after a stroke were younger than 65 years of age. Risk also varies by race, ethnicity and gender. More women than men suffer strokes and stroke kills twice as many women each year as breast cancer.
So what is it?
A stroke occurs when the flow of blood is interrupted a part of the brain. You might have also heard the more technical term CVA Cerebral Vascular Accident. It can occur from bleeding, but it is much more common for a stroke to be caused by a clot that blocks the blood supply to a part of the brain. So called ischemic strokes account for 87 percent of all strokes.
Because different parts of the brain control different parts of our body, often stroke symptoms appear as a problem on one side of the body. Often patients will have a facial droop, weakness, numbness or even paralysis on just one side of the body. It can start suddenly and when it does start, time is of the essence. The sooner the patient gets care, the better chance of restoring blood flow. The CDC reports that patients that receive care within the first three hours often have much less disability than those who delay care.

The American Heart Association has developed the act FAST campaign to emphasize what to look for.
  • Facial Droop on one side.
  • Arm drifts downward when raised.
  • Speech is slurred
  • Time is critical - call 911 immediately.

Because most strokes are caused by a clot in the brain, hospitals can give clot-busting medications to break up the clot, but these medications are only effective within a few hours of the start of the stroke.
Moreover, if the patient is bleeding in their brain, those clot-busting medications can make the problem much much worse. So a CT scan looking for bleeding must rapidly be performed before any medication is given. Cut off from its oxygen supply, brain tissue can die and leave permanent damage, so every second counts in getting oxygenated blood flowing again.
Ocean Beach Hospital’s medical staff train to respond quickly to help a patient presenting with symptoms of a stroke. Our hospital works with Providence’s telestroke system so a remote neurologist can examine the patient in the Emergency Room using a direct video connection. While we make sure that all happens as quickly as possible, it all takes time - so it is important to recognize the stroke symptoms and call 911 to get help immediately.
There are other, less common symptoms of strokes that occur in different parts of the brain. A sudden headache or loss of vision can be the first sign of a stroke. An inability to speak, or understand language in a fully awake patient can mean a clot in the part of the brain that controls language. That said, the vast majority of strokes have symptoms that only affect one side of the body.
Sometimes the stroke symptoms may occur and resolve without medical intervention. These are called “mini-strokes” or TIA - Transient Ischemic Attacks. TIAs are strokes but temporary. However, they shouldn’t be ignored because they are highly associated with strokes that cause permanent damage. Don’t delay calling 911 hoping the symptoms just go away.  TIAs are warning signs for a full blown stroke.
It is important to note the time that the stroke symptoms started. Paramedics or nurses may ask when was the patient last seen normal -- this time is what we use when the start the clock ticking for the clot busting medications.
There are a number of factors that increase our risk for stroke. High blood pressure, high cholesterol, diabetes, lack of physical activity and being overweight all put you at increased risk.
An irregular heart rhythm known as atrial fibrillation can also increase the risk of stroke. Smoking -- particularly when combined with pregnancy or oral contraceptives -- greatly increases the risk of stroke. Excessive drinking and recreational drugs also increase stroke risk.
Effort to raise awareness have been working. According to the American Stroke Association, stroke mortality rates have decreased 39 percent from 1999 to 2016 and awareness of the need to call 911 at the first symptoms of a stroke has doubled since 2012.


Ed Hunt is an Emergency Room nurse at Ocean Beach Hospital.


It's the Prices, Stupid

There are a lot of problems with the US Healthcare system that prevent the ideal capitalist model from transferring its invisible-hand efficiencies to make us all well at minimal cost. 

The most obvious problem is people rarely price-shop prior to purchasing healthcare services. Moreover, even if they did, no one knows how much anything costs

Instead, a parasitic multilayered economy has evolved around the confusing and wasteful billing systems. Costs vary wildly based on insurance negotiations, not quality or efficacy. 

Now California wants to control prices directly - using the Medicare payment rate as a baseline. Proposed legislation would employ a nine member comission to set hospital charges and doctor fees.

It would be sort of a back door way to achieving the same effect of a single payer healthcare system, writes Vox's Sarah Kliff.

This system would be similar — but not quite the same — to something we usually call all-payer rate setting, where the government doesn’t run all the health care insurance plans but does tightly regulate the prices they charge. 
All-payer rate setting essentially shares the same goals of single-payer: It aims to increase efficiency and reduce insurer overhead in the health care system. Single-payer does this by eliminating private plans for one government plan. All-payer rate setting gets there by setting one price that every health insurer pays for any given medical procedure.
What's interesting is that this is not a new idea. Apparently Maryland has been using a sort of all-payer rate setting for years under a federal waiver. It is the only state currently doing so, but other states tried it in the 1980s.  That said, countries like Germany and Switzerland also use all payer rate setting to keep costs under control.

Why does setting one price reduce costs? Studies have found that a the same procedure may vary in cost by thousands of dollars based on the size and negotiating skill of the insurance carrier. This creates an inefficient system that requires a whole sub-economy of billing clerks and subcontractors just to figure out what to charge for each procedure.

Single-payer health care systems save money in two ways: reducing administrative costs and increasing the bargaining power of health insurers. This is true of all-payer rate setting systems, too.
Healthcare prices are rising at the fastest level in years, California's proposed legislation may be once politically feasible way to try and reign those prices in.

Required Reading:

All Rate Payer Setting: Back Door to Single Payer? 
California's Ambitious Plan to Set Healthcare Prices


Stories of Those We Carry: Green Glasses

The sun was out - rare this far north on an early spring day.

Visiting cousins from someplace else, you walked along the beach collecting shells and letting sand get between your toes.

Letting the cold water exhilarate your young skin to life.

As late afternoon passed, you and your cousins, 11 and 13, wandered down the beach away from the rented house in the dunes.

At some point the undertow saw your brown 12 year old ankles and pulled you out to sea.

Your cousins heard you struggling in the water, ran to get help, but could not find the unfamiliar house among the unfamiliar dunes.

Finally your cousin knocks on a stranger's door.

Sirens, boats and helicopters race to search the waters, but you are already on the beach.

Too cold to be dead when the paramedics find you.

We know at that when someone goes into the frigid spring surf, they are not coming here to this little hospital.

They are not coming here alive.

The radio crackled with desperation.

The little hospital emergency department is so full that I have to move a patient out of a room to prepare for your arrival.

Your departure.

Still 30 minutes up the beach, code three.

CPR in progress.

You arrive stripped naked and wrapped in blankets, yet somehow your green framed glasses are still on your face.

The paramedic bleeding salt in this dry suit.

Saltwater in his eyes.

Sand sticking to your brown skin.

Needle in the bone of your left leg.

Wires and tubes.

You are almost warm enough.

It is hard to work, silent, knowing.

I turn and find your father and cousin 13 are being brought into the room.

They sit in chairs in the corner, watching us with empty eyes.

The doctor bends on one knee in front of your father to speak to him, but your cousin must translate the words.

Your cousin had run into the water at first.

He ran heroically, up the beach.

He had screamed your name as they searched.

His voice is steady and slow as he tells your father what he already knows.

Because I have no words of comfort in any language for a father in this situation.

I close your eyes.

I bring your green glasses and hand them silently to your father.

They remind me of my daughter -- the same age -- and the glasses that she wears.

There is only one of me.

A father of a 12 year old girl.

A nurse in a rural emergency room.

I have to close the curtain on this room and its silent sobbing.

I have to meet the next ambulance as it arrives at the door.


When I read about #thosewecarry on twitter, this is the case that came to my mind. One of many, that I carry. Read more at or follow The Haunted One on twitter at @thosewecarry


The fragmented US Healthcare system wastes billions just trying to collect bills.

Because the US healthcare system is a mess, it requires armies of people just to figure out who pays what. Those hours and hours of work are a tax on the system, making every interaction more expensive, according to a study recently published in the journal of the American Medical Association.  

The unnecessarily complex, fragmented, and inefficient system of billing, coding, and claims negotiations in the US health care system employs enough people to populate small nations," the pair wrote in an editorial that accompanied the study.
There is no apparent reason for this, they argued. Outside the healthcare industry, it might take about 100 full-time workers to collect $1 billion worth of bills. But when doctors are involved, it takes "an astounding 770 full-time equivalents" to collect the same amount of money, they wrote.
"The process of moving money from payer to hospitals and physicians in the United States consumes an estimated $500 billion per year," they continued.
Read it: 


If you think we are prepared for a pandemic, think again.

We are in one of the worst flu seasons in recent decades with thousands of Americans dying every week and the Trump Administration is proposing huge cuts to health care access, spending and public health. 

Indeed, Republican efforts to cut access to healthcare -- affordable healthcare -- for every American put us on the path to a deadly global pandemic. 

AS reported by Futurism, The Director of the World Health Organization Tedros Adhanom explained: 
The threat of a global pandemic comes from our apathy, from our staunch refusal to act to save ourselves — a refusal that finds its heart in our indifference and our greed.
“Universal health coverage is the greatest threat to global health,” Tedros proclaimed. As the audience shifted in their seats uncomfortably, he noted that, despite the fact that universal health coverage is “within reach” for almost every nation in the world, 3.5 billion people still lack access to essential health services. Almost 100 million are pushed into extreme poverty because of the cost of paying for care out of their own pockets.
The result? People don’t go to the doctor. They don’t seek treatment. They get sicker. They die. And thus, as Tedros explained, “the earliest signals of an outbreak are missed.”


The Myth of Islands

An Island is a lie.

On my way to work, I drive along Willapa Bay and pass by the two Islands that can be seen from the mainland. Long Island crowds just feet from the highway that hugs the shore. Heavily forested it stretches away to the horizon, appearing as solid shoreline. Long Island holds a grove of ancient forest and in days past was inhabited with settlements. There is a ferry landing just off the road that used to bring trucks back and forth across the narrow thread of water that separates it from the rest of Washington state.

A little farther on is a defiant little islet several hundred yards from where the tourist pass by on their way to the beach.. The US Geographic survey named it Round Island back in 1858. Locals call it Baby Island. Its shoulders’ hunched and spiked with snags and cedar that burl in the winter storms. Only a few acres of brush and trees, it appears a picturesque myth centered in the waters of the bay. Steep rocks rising from the silver gray waters and lonely alone.

We like to think of ourselves as islands, as individuals, as ecosystems wholly within ourselves. We like to believe that our actions affect no one beyond our ragged shore. We like to believe ourselves surrounded by waters isolated from the world outside. We like to think ourselves individuals, the center of our own solar systems -- centered yet separated by time and space from mothers, wives, children and friends who dip into our orbit for time only to swing away again.

It is easy to feel alone.

It is easy to think that our actions do not shatter the mirrored water that flows around us, yet the decisions we make ripple out into the world.

We see it in politics, where the temptation is to live and let live, assuming no responsibility for the community, the state, the nation or the world.

I hear it all the time. I’ll take care of myself, do what I want, and it won’t affect anyone else. If other people make bad choices, can’t access health care or mental health services or run out of money when they are too old to work, that’s their problem. It won’t affect me.

Yet it does.

I work as a nurse in an emergency room. It is the front line of the consequences of bad choices.
I meet a lot of people who until that moment thought that they were islands. Many thought their decisions affected no one but them and them alone.  Some have long suffering loved ones at bedside, others have long since burned those bridges to the mainland. Perhaps they justified this as a way to limit that damage they caused, or perhaps the connection was never very good in the first place.

If not family and friends, there are always the professionals -- the police officers, EMTs, nurses, doctors and socials workers -- who crash in waves trying to make a difference until the last breath.

Every wave recedes taking a little away from the beach and leaving a little of itself behind. Yet, the ocean itself is not unchanged.

I have watched as addiction destroys families and devastates public resources. I have seen suicide shatter communities. I have seen health care professionals struggle to make a difference in the face of increasing needs and decreasing resources.

I have seen doctors and law enforcement officers that I worked with take their own life.

Studies have shown that nurses experience depression at twice the rate of the general population. Doctors have a suicide rate that is at least twice that of the general population and that rate is even greater for female physicians. The stresses come from long hours, increasing work loads and the crushing expectations of health care systems that are always demanding more and paying less. Unfortunately, few seek professional help.

So too some of the stress comes from our own expectations. Physician Pranay Sinha, in a 2014 essay entitled “Why Do Doctors Commit Suicide?”  in the New York Times explained it this way:

“There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel the need to project intellectually, emotional and physical prowess beyond what we truly possess. We masquerade as strong and untroubled professionals even in our darkest and most self doubting moments. How, then, are we supposed to identify colleagues in trouble -- or admit that we need help ourselves?”

Individual strength, resilience  and freedom are cultural virtues in our nation.Yet we achieve most when we come together and recognize our connections and that through those connections our individual decisions have repercussions on the world around us.

This far north the tides are impressive - a dozen feet in sea level change can drastically alter your perspective in a few hours time. When the tide is low, the water drains out of old Shoalwater bay and Round Island is exposed as connected to mainland by mudflats that the unwary may be tempted to walk across.

Drain away the oceans that appear to separate us, and you will find underneath the connections that tie us all together. 

What we do and say and how we act affects those near and far.

How we treat each other and how we take care of ourselves matters.

If you think you are an island, just wait until low tide.


This essay was originally written for the The Daily Astorian and published on 4/29/2016.

I Think it's going to rain today

I woke up with this song in my head. This morning I realized it is Friday the 13th of March. Back in the ER tonight. After a week of s...