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No One Knows What the Future Holds

Early on, I started getting direct messages from friends and acquaintances asking what to expect when COVID19 hit our shores. How bad would it be? What should we do? Most often --once school and then other life started to close down -- how long will this last? 

I explained then -- and continue to explain today -- that this is a new and different disease and we are just learning as we go. We are learning how to treat it, how it spreads, how to recognize when it will be benign and when it will kill.

We don't know.

We react and act and our reaction and actions change what happens next. 

We cast about for someone to tell us what we want to hear. 

Between the Internet and Cable TV, we have grown accustomed to experts on tap, with a ready reassurance or a dire warning. So much so, that when they tell use that they don't really know, we feel that can't be true. There must be someone with a crystal ball. 

Enter the grifters, conspiracy theorists, end-times prophets and pundits to fill the void. 

As Mark Lilla writes in the New York Times, however, we don't know what the future holds:

"The pandemic has brought home just how great a responsibility we bear toward the future, and also how inadequate our knowledge is for making wise decisions and anticipating consequences. Perhaps that is why our prophets and augurs can’t keep up with the demand for foresight. At some level, people must be thinking that the more they learn about what is predetermined, the more control they will have. This is an illusion. Human beings want to feel that they are on a power walk into the future, when in fact we are always just tapping our canes on the pavement in the fog. 
A dose of humility would do us good in the present moment. It might also help reconcile us to the radical uncertainty in which we are always living. Let us retire our prophets and augurs. And let us stop asking health specialists and public officials for confident projections they are in no position to make — and stop being disappointed when the ones we force out of them turn out to be wrong.

A day in the ER fighting COVID19

Great storytelling of a doctor who fought Ebola and is now fighting COVID19 from AJ+


EKG Interpretation by ... Ortho?

Sure you passed your ACLS class --barely -- but your specialty area doesn't deal with electro-physiology all that much and you have a hard time remembering what all those EKG rhythms mean. 

@TCKMed on twitter had a great thread to ... um .. help. 

Okay, that was easy, how about ... 
Let's slow this down ... 
Now it gets confusing, hang on ... 
 Danger ...

Now things get seriously ... anoying? 

Ummm ... crash cart squiggles?
The Final Squiggles!



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

No One Knows What the Future Holds

Early on, I started getting direct messages from friends and acquaintances asking what to expect when COVID19 hit our shores. How bad would ...