A Bleg.

cover.

I have a new book out on Kindle that is now published. It is called “War Stories: 50 Years in Medicine.”

I’ve been working on this for 20 years and kept having to revise it as I would put it down and then go back to it after ten years. I finally decided to rework it and publish it two years ago. My students were reading the draft on my laptop while I was editing so maybe it will be interesting.

It is a memoir of patients. They are all patients’ stories that I have tried to describe accurately and to describe what we did then. Sometimes I screwed up and I tell those, too. Sometimes we did the best we could and we now know better. Some of these cases are still hard to explain.

Two of them, in the chapter on Melanoma, are about young women who developed major melanoma metastases years after the primary was excised but when they had become pregnant. The melanoma went wild in pregnancy, in one case ten years later. In the other, three years after I had removed the primary, she developed extensive metastases while pregnant. She refused abortion and I thought it would cost her her life. In both cases the melanoma vanished after pregnancy ended. In one case, the woman, last I heard, was free of melanoma 25 years later. The other was free ten years later. The medical literature says pregnancy has no effect on melanoma. Neither ever became pregnant again.

Another case is an example of the only supernatural near-death experience I have ever heard.

The book starts when I began medical school in 1961 and describes experiences with patients, including my summer working with schizophrenic men in 1962. I have a series of stories about patients I saw as a student and sometimes intersperse stories from later that are about similar cases and events. One that is amusing, I guess, is about my very first pelvic exam, on a 40 year old prostitute who had just gotten out of prison and enjoyed it thoroughly. I had a dozen student nurses as witnesses. I do have some biography in it but try to keep it to minimum.

After the first eight chapters, I go on to residency and then finally to private practice. I continued to teach and there are a few of those stories. There is a chapter on ethics including my thoughts on euthanasia and “benign neglect.” Toward the end of my career, I started and ran a trauma center in our community hospital. I also did a fair amount of testifying in court in both trauma cases and some civil cases where I testified for plaintiffs and for defense. I consider it a compliment that Kaiser Permanente had me testify for their defense even though I had also testified against them.

Anyway, the book is on Kindle and I hope somebody is interested. It has some similarity to my medical history book, which I plan to do a Kindle version of once this one is launched. In this one, I spend some time explaining the diseases in a way that I used to explain to patients and I still do to students. Without some basic understanding, most of these stories would not make sense and I hope the explanations are not too dull. If so, all comments are welcome. If anyone likes it, feel free to post a review on Amazon. Two reviewers from the first book in 2004 told me to let them know if I did another one and I have contacted them.

If anyone wants to discuss the book here, feel free to add comments.

Obamacare = Medicaid

emergency

I have been interested in health care reform for some time and have proposed a plan for reform. It is now too late for such a reform as Obamacare has engaged the political apparatus and sides have been taken. The Obamacare rollout was worse than anticipated and it was hoped that the Supreme Court would have mercy on the country, but that didn’t happen and it has been the law for two years.

What has it accomplished ? Well, the forecast drop in ER visits hasn’t happened. It also didn’t happen in Massachusetts when that plan took effect.

Wasn’t Obamacare supposed to solve the problem of people going to the ER for routine medical problems? We were told that if everyone had “healthcare” — either through the ACA exchanges or through Medicaid expansion — people would be able to go to their family doctors for routine care and emergency rooms would no longer be overrun by individuals who aren’t actually experiencing emergencies.

As it turns out, Medicaid patients can’t get appointments with physicians.

“America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately,” said Michael Gerardi, MD, FAAP, FACEP, president of the ACEP.

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Why Gruber has to lie

The left does not do economics. They do politics and elections and lying to get past the “stupid voters” but, when pressed, nothing they do qualifies as numerically or mathematically sound. Social Security worked until everyone found the queue and until Congress raided the trust fund in the 90s.

Obama and the Democrat leaders knew that Hillary made enemies of the insurance companies in 1992. The insurance companies funded devastating TV ads with “Harry and Louise” that cost the Democrats Congress in 1994. Therefore, they had to do what was necessary to get the insurance companies “inside the tent pissing out and not outside the tent pissing in” in Lyndon Johnson’s immortal words.

Insurance companies have considered health insurance a loser for 25 years now. What they prefer is becoming “Administrative Service Organizations” which administer self funded health plans by employers.

Corporate benefits include- organizing/ negotiating health insurance, group dental, STD, LTD, life, etc.

The plan the Democrats came up with, with Gruber’s help, was to make the government the funding entity and pay the insurance companies to run the program. That way everybody is happy, except, of course, the taxpayer. The taxpayer does not like tax increases which would be needed to pay the bills. Therefore the taxpayer has to be fooled.

The excise tax on high-cost health plans was among the many fees and taxes proposed as offsets to help slow the rate of growth of health costs, particularly premium growth, and finance the nationwide expansion of health coverage. When the Affordable Care Act was signed into law in March 2010, its coverage provisions were estimated to cost more than $900 billion over the next decade, from 2010 to 2019, and were to be paid for by fees and taxes on both individuals and businesses. At the time the health reform bill passed, the excise tax on high-cost plans was estimated to raise roughly $32 billion in revenue over the next decade, or by 2019.

Without the taxes to pay the bills, the whole plan collapses. At its base, Obamacare is Medicaid for everyone. The employer mandate has been, contrary to the text of the law, postponed as the flaws in implementation appear. If it were to be enforced, there would be a revolution. Basically, Obamacare will destroy the health care plans of the 85% of the population who are satisfied with what they have to enroll everyone in a new program that approximates what Medicaid does. The reason for this is that our betters in Washington have decided that we spend too much on health care. That may even be true. One way to deal with this would be to use a market-based approach that resembles how health care was paid for 60 years ago. I have previously discussed how this worked and how it might be restored.

Today, the vast majority of Americans get health insurance as a benefit from their employer. How this developed has been discussed at length and began during World War Two. In 2008, John McCain proposed a possible way to disconnect employment, alleged to create “Job Lock” but he lost the election. A hostile analysis of his proposal is here. The McCain campaign’s description is here.

What became Obamacare is the work of the Democrat staff of Congress when the Democrats had filibuster proof majorities in both houses. The election of Scott Brown in a reaction to the impending passage of the health plan forced them to rush the bill through without amendments before Brown was sworn in January 2010.

The taxes to fund Obamacare were hidden as “fines and penalties” until exposed by the Supreme Court in its 2012 decision on the constitutionality of Obamacare. All penalties are now taxes. The largest are on employer-funded plans.

The funding from employee plans is called “The Cadillac Tax which is an excise tax on employer plans that exceed the benefits of Medicaid. The “exchange plans” are increasingly looking like Medicaid, especially in the narrow networks of providers, as doctors are now called.

As health coverage expands to tens of millions of Americans–through Medicaid expansion in states and the new state health insurance exchanges that will soon begin selling individual health coverage–some Americans with employer-sponsored health coverage are seeing their benefits decrease.

One of the most significant, and controversial, provisions of the Affordable Care Act is the new excise tax on high-cost health plans proposed to both slow the rate of growth of health costs and finance the expansion of health coverage. The provision is often called the “Cadillac” tax because it targets so-called Cadillac health plans that provide workers the most generous level of health benefits. These high-end health plans’ premiums are paid for mostly by employers. They also have low, if any, deductibles and little cost sharing for employees.

If this is ever implemented, the Medicaid-for-all nature of Obamacare will become obvious. That’s why it will not happen. The fundamental premise behind Obamacare is not viable. That is why it will fail and the numbers do not add up.

Gruber can’t say this. All he can do is obfuscate.

Ebola is now acknowledged to be airborne.

I was just going to add another comment to my previous post on whether Ebola can be airborne but comments are now closed. The CDC has now changed its guidelines on transmission. I linked to Patterico because he has a good post on this. The guidelines are out now as public knowledge.

“If you are sniffling and sneezing, you produce microorganisms that can get on stuff in a room. If people touch them, they could be” infected, said Dr. Meryl Nass, of the Institute for Public Accuracy in Washington, DC.
Nass pointed to a poster the Centers for Disease Control and Prevention quietly released on its Web site saying the deadly virus can be spread through “droplets.”

Why is this stuff coming out in drips (sorry for the pun) like it was Benghazi ?

“The CDC said it doesn’t spread at all by air, then Friday they came out with this poster,” she said. “They admit that these particles or droplets may land on objects such as doorknobs and that Ebola can be transmitted that way.”

I won’t duplicate any more of Patterico’s post as he has been on the case nearly as long as I have.

As for the idiot nurse from Africa who defied authority about quarantine and is suing, she has more trouble today.

Maine state police were stationed outside the home of Ebola nurse Kaci Hickox Wednesday as Gov. Paul LePage said he was seeking legal authority to force the “unwilling” health care workers to remain quarantined for 21 days.

The 33-year-old nurse, who has shown no symptoms of the deadly virus, arrived in Maine on Monday after being forcibly held in an isolation tent in New Jersey for three days under that state’s strict new law for health care workers who have recently treated Ebola patients in West Africa.

There is actually little risk as she is a CDC Epidemiology Fellow with little contact with patient care.

She is also a lefty Obama supporter.

It turns out that Kaci Hickox is a registered democrat and Obama supporter who works for the CDC. “The nurse currently quarantined in New Jersey is an employee for the Centers for Disease Control and a registered Democrat with a history of left-wing advocacy,” reports GotNews.com.

The CDC Epidemiology Fellowships are http://www.cdc.gov/eis/index.html not patient care positions.

EIS officers are on the public health frontlines, conducting epidemiologic investigations, research, and public health surveillance both nationally and internationally.

She has an number of published papers on epidemiology that are statistical studies, not clinical care.

Is Ebola airborne ?

Ebola has become an uncontrolled epidemic in Africa. I have previously posted on Ebola.

UPDATE: A new CDC report has now been provided on precautions. Somebody is worried. The document, itself, is here (pdf)

Now, we are going to send 3,000 military personnel to Africa to help. I sure hope none of these US people are infected. They did not volunteer for this and the training to protect themselves will take time.

Now the German epidemiology community has concluded that Liberia and Sierra Leone are lost.

Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Hamburg told DW that he is losing hope, that Sierra Leone and Liberia will receive the neccessary aid in time. Those are two of the countries worst hit by the recent Ebola epidemic.

“The right time to get this epidemic under control in these countries has been missed,” he said. That time was May and June. “Now it will be much more difficult.”
Schmidt-Chanasit expects the virus will “become endemic” in this part of the world, if no massive assistence arrives.

With other words: It could more or less infect everybody and many people could die.

This, of course, is from a German site and our own CDC is unwilling to say it.

For Sierra Leone and Liberia, though, he thinks “it is very difficult to bring enough help there to get a grip on the epidemic.”

According to the virologist, the most important thing to do now is to prevent the virus from spreading to other countries, “and to help where it is still possible, in Nigeria and Senegal for example.”

Of course, it is already in Nigeria.

In the balance therefore, the probability is that the virus is not airborne — yet — but it is more dangerous than its predecessors. This would account for its ability to slip through the protocols designed for less deadly strains of the disease. It’s not World War E time, but it’s time to worry.

And: This may be a new strain with more virulence.

The results of full genetic sequencing suggest that the outbreak in Guinea isn’t related to others that have occurred elsewhere in Africa, according to an international team that published its findings online in the New England Journal of Medicine (NEJM). That report was from April 2014.

Now, we have more news. From 2012, we know transmission in animals may be airborne.

While primates develop systemic infection associated with immune dysregulation resulting in severe hemorrhagic fever, the EBOV infection in swine affects mainly respiratory tract, implicating a potential for airborne transmission of ZEBOV2, 6. Contact exposure is considered to be the most important route of infection with EBOV in primates7, although there are reports suggesting or suspecting aerosol transmission of EBOV from NHP to NHP8, 9, 10, or in humans based on epidemiological observations11. The present study was design to evaluate EBOV transmission from experimentally infected piglets to NHPs without direct contact.

The study of this potential explosive development showed:

The present study provides evidence that infected pigs can efficiently transmit ZEBOV to NHPs in conditions resembling farm setting. Our findings support the hypothesis that airborne transmission may contribute to ZEBOV spread, specifically from pigs to primates, and may need to be considered in assessing transmission from animals to humans in general.

Now we have more articles appearing about this.

The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air. You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.

If the New York Times is publishing this, somebody is worried.

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