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How To Survive A Wildfire: Lessons From Australia

August 25th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips

Tags: Australia, Emergency Medicine, Fire Safety, wilderness medicine, Wildfire

We are still in fire season in the U.S., and with persistent hot, dry and windy conditions, may see quite a few more conflagrations this summer and into the autumn. The fires that can be attributed to human behavior occur for the same reasons year in and year out, whether they are accidental or intentional. So, we will face them, and knowing what to do before they happen can be a prerequisite for survival.

Of course, fires occur worldwide, and there is much to learn from the experience of others. Some months back, there was an interesting commentary in the news during fire season in Australia that pondered the question, “Why did so many die in Australian bushfires?” Here is a paraphrasing of the response:

“Yes this is awful – devastating to the psyche. For Australia, this is bigger than the twin towers and we cannot blame an external agency. Much of it we did ourselves. All over central Victoria, it was the worst fire weather by far that has ever been experienced. Temperatures were above 40 degrees centigrade (105 degrees fahrenheit) for days, there was no significant rain for months, and there were strong to gale force winds straight out of the central desert for days.

It seems that most people who died actually did so trying to flee at the last moment. They died on the open or in cars, especially in crashes along the roads or running into fallen trees. Even before the fires hit, it was so hot that eucalyptus trees were dropping large branches everywhere.

Many who survived in the fire storm did so in prepared or ad hoc refuges and bunkers or inside their houses, leaving their homes only when the houses were burning but the main fire had passed.

The problem was that in some areas the winds were so strong that houses were torn apart by the wind, leaving no option but to be in the open. As usual, many of the injured did not have suitable clothing. For some, the attire of shorts and thongs may have been fatal. The fires were so hot that they melted alloy wheels on cars. Many, if not most, people living in the area at least evacuated their children, and the elderly and sick. Most houses were relatively well prepared for ‘normal’ fires. This is a semi-rural area, so people had water, pumps, mobile and fixed sprays, and plans. The problem was that they had no chance to use them, because everything happened so fast and was so intense.

The area was beautiful-the sort of dangerous beauty that comes from houses situated amongst trees. The area is a mountain ash forest. Many of the trees around the houses are stringy barks and cyprus pines, all of which become explosive in fires. There was ember spotting as many as five miles ahead of the main fire front. The actual fire winds were over 100 kilometers per hour. At times, the main fire front moved at 30 to 40 kilometers per hour.

Some persons commented that one of the most bewildering aspects of ‘Black Saturday’ was the disconnect between the general and, ultimately, prophetic warnings issued by authorities beforehand and the absence of specific information when the fires overwhelmed communities. But really! There is not some celestial fire watcher able to communicate with everyone and tell them what to do! Phones were out, the emergency call (000) was overwhelmed (1800% over normal call volume) and the operators were actually listening to people die without being able to help.

There have been so many extraordinary stories of bravery and good luck, but it is really difficult to put it all into perspective. People everywhere seem to be really quiet and depressed. There is a constant barrage of awful vision on the TV that keeps on reinforcing the horror. Really well known people are dead. So many kids and complete families.”

Key points for those who will one day face the prospect of encountering a wildland fire:

1. The thermal intensity of a wildland fire is beyond imagination. It is far better to be away from the heat than to try to shelter within it and try to survive. Escape routes should not be left to serendipity or improvisation. Anyone who lives in an area that is vulnerable to wildfire should have a plan for when and how to escape.

2. One needs to understand fire behavior, and how to avoid panic. Last minute attempts at self rescue are often marked by tragedy.

3. The wildland-urban interface is growing. The minority of homeowners subject to wildland fire risk have properly cleared their property of remediable fire hazards, and likely are not completely prepared to protect their lives and dwellings.

4. Warning systems are not infallible, and resources are easily overwhelmed. Everyone needs to take personal responsibility for being on the lookout for wildfire, and for his or her response to an encroaching blaze.

5. The aftermath of most natural catastrophes can be as devastating as the event. Entire communities and populations are affected, so we share the responsibility to prevent fires, report them promptly, protect our family and friends, and assist response teams in doing their jobs to suppress fires.

This post, How To Survive A Wildfire: Lessons From Australia, was originally published on Healthine.com by Paul Auerbach, M.D..

High Blood Pressure & Eye Damage

August 24th, 2009 by Toni Brayer, M.D. in Better Health Network

Tags: Cotton Wool Spots, High Blood Pressure, Internal Medicine, Malignant Hypertension, Ophthalmology, Retinal Detachment

*This blog post was originally published at EverythingHealth*

Who’s Taking A Swipe At Physicians Now? AHIP

August 24th, 2009 by Shadowfax in Better Health Network, Health Policy

Tags: AHIP, America's Health Insurance Plans, Attack, Healthcare reform, Physicians

AHIP, the trade group representing the nation’s health insurers, released a study decrying excessive physician charges.  There’s some amazing stuff in there: office visits being billed at $6200, a lap chole being billed at $9,000 (just for the physician’s portion).  Truly egregious, if true — and that’s the qualifier.

The methodology of this “survey” is not really honest.  They cherry-picked an insurance database looking for the highest billed charges for various CPT codes.  Supposedly they “excluded high charge outliers that may reflect billing or coding errors.”   Really?  How on earth, one wonders, could they have concluded that an office visit billed at 5,000% the medicare rate was not an error?  Were there more outrageous charges that were excluded?  Sounds fishy.

Moreover, the survey is promoted as exposing the outrageous fees that doctors charge, when in no way are these fees representative of physician fees.  Physician fees, as any other group of data points, fall into a more-or-less normal distribution.  There’s a median point around which most practices cluster, and the further out you get the fewer physicians that are charging those fees, high or low.  The cited fees are certainly in the 3+ standard deviation tail of this graph, but you wouldn’t know it from the AHIP press release.

They present these outrageous charges as if they are accurate and as if they represented a widespread abuse of consumers by greedy doctors.

The annoying thing about this is that there is a valid argument to be made that the uninsured do face higher fees than the insured.  This is of course more of a factor with the much-higher hospital costs, but physician fees are also higher for the uninsured.  The reason for this is that insurers demand a discount off the standard fee in order to contract with physicians.  This gives physicians an incentive to crank up their fee schedule as high as they can get away with.

So if UnitedHealth comes to me and offers to pay me 75% of billed charges (I wish!), I need to make sure that my fee schedule puts that figure at a level that is going to return a reasonable per-patient compensation.   This is less of an issue nowadays, since most insurers prefer to settle on a conversion factor and contract by the RVU, or as a percentage of the standard medicare rates (110-150% most commonly).  That’s easier for their billing systems to manage.  So there is less incentive for us to keep charges high.  But still, a few insurance plans like to do the old way, and there are occasional patients who are insured but we don’t have a contract with their insurer.  In those cases, we expect compensation in full, and the insurer usually pays some arbitrary sum that they feel is reasonable, with the patient responsible for the balance.

Does this screw the folks without insurance?  Yes, to a degree.  Most of the uninsured don’t pay a dime.  They just throw out the doctor’s bill, along with the much-bigger hospital bill, and we wind up writing it off as bad debt.  Most hospitals, and our practice, will also write it off as charity if the patient asks for it and can show some hardship.  So the uninsured will get a huge bill, but they very very rarely have to pay a huge bill.

The ultimate solution for this “problem” of the uninsured being “overcharged” is not, as AHIP implies, to somehow regulate physician charges, but to eliminate the uninsured.  Get everybody covered under some sort of insurance plan, and this problem goes away.

*This blog post was originally published at Movin' Meat*

Government Insurance & Running Naked Through Storm Risks

August 24th, 2009 by EvanFalchukJD in Better Health Network, Health Policy

Tags: Competition, Government Insurance, Government-run Healthcare, Health Insurance, Obama, Risks

There has been a lot of talk about the way in which a public health insurer would compete against private ones.  As the President put it recently:

People say, well, how can a private company compete against the government?  And my answer is that if the private insurance companies are providing a good bargain, and if the public option has to be self-sustaining — meaning taxpayers aren’t subsidizing it, but it has to run on charging premiums and providing good services and a good network of doctors, just like any other private insurer would do — then I think private insurers should be able to compete.  They do it all the time.

He makes a good point.  But we don’t have to talk about this in theory – we can look at existing state insurance programs to see how they operate.

In states prone to natural disasters like hurricanes, the market for private insurance has become increasingly uncompetitive.  Several state governments have responded by setting up public insurance programs to sell coverage to property owners in their states.  They operate something like private insurance companies – collecting premiums, maintaining reserves, and, importantly, buying reinsurance in the event of a catastrophe that exceeds what they can pay for themselves.

The New York Times reports that a number of the state insurers are thinking of doing something that a private insurer would likely never do: dropping their reinsurance coverage.  It could save hundreds of millions of dollars a year.  But it would expose them to billions of dollars in risk – that they likely would be unable to pay.  The Times calls it “running naked through storm risks.”

Why can they do this?

I suspect that in the event of a bad hurricane that depleted their reserves, these insurers believe they can turn to the state or federal government to cover their losses.  They are acting as if they already have a sort of “free” reinsurance from the government.  Or, to use a modern expression, they are assuming they will get a bail out if something bad happens.

What it means is that these companies aren’t running anything like a private insurer.  By not accounting for the cost of a catastrophe, they aren’t dealing with the real insurance risk they are taking.  As long as a disaster doesn’t happen they save money.  But when (not if) a major hurricane hits, they will be swept away in the storm, leaving the state and federal government – and the rest of us – with the bill.

“It’s typical of governments today to not be willing to make the hard decisions that are necessary to face up to the true risks and the true costs of the policies that they’ve undertaken,” said Robert Hartwig, president of the Insurance Information Institute, an industry group.

The Times says there are some efforts underway to formalize this sort of “implicit guarantee” from the government.  That might be a step in the right direction if it forces everyone to grapple with the extent of this risk.

But what we see with these kinds of insurers is one of the important ways in which public insurers really aren’t the same as private ones.

*This blog post was originally published at See First Blog*

A Young Man With A Congenital Heart Defect

August 23rd, 2009 by scanman in Better Health Network, True Stories

Tags: Cardiology, Cardiothoracic Surgery, Pediatrics, Radiology, Transposition Of The Great Arteries

…in four parts, from Paul Levy’s blog.

It is, says Paul, “From a friend of a friend,” and it starts thus…

My son is sleeping right now…had a rough weekend – his blood pressure dropped, his blood count was decreasing, and he had chest and neck pain. The clinical team adjusted his meds, gave him a unit of blood, and are now trying to figure out what to do next. He is scared and worried and wants so desperately to be “normal” again. He is scheduled for leg surgery this afternoon and then we wait to see what the next steps will be.

While I have a few quiet moments, I thought I’d document the story of how he made it this far….it is a story of extraordinary luck and a fair amount of clinical heroism.

My son was born 17 years ago with transposition of the great arteries (his heart had over-rotated and was pumping in a way that didn’t allow oxygenated blood to move from the lungs to the body and back again) so he had a 9 hour operation at a week old to reconstruct his heart.

…read the rest of part one

…and parts two, three & four.

Here, in my opinion, is the best passage from the entire saga…

My son is receiving absolute top-notch care from the only place in the area that could have saved him, but was by luck, not by any “consumerism” on our part – we didn’t Google “teenage arterial switch survivor with heart attack” or pull up HealthGrades to find the best hospital or doctors to treat him….we have benefited from the kindness and skill of a community of health care providers affiliated with a hospital that was uniquely situated to help him, but the only choice we had in this was what hospital to drive him to.

…

In part 2, we learn the reason for the young man’s sudden collapse…

We learned much later that the problem that caused the heart attack was due to his reconstructive surgery when he was a baby…as he grew and became more active, one of the reimplanted coronary arteries became pinched between the rebuilt pulmonary artery and the aorta….this was an inevitable result of the surgery that saved his life 17 years ago and would have happened at some point – while swimming, riding his bike, walking in the neighborhood, playing lacrosse, or running by himself in the neighborhood as he trained for cross country….so the fourth link – he happened to have his attack while at a school with trainers equipped with an AED, with coaches and parents and teammates right there ready and able to help him. He wasn’t alone….and he was in the best possible place to have his attack (even though he complicated things a bit by having it in the woods and falling down a steep bank)

…

Congenital cardiovascular abnormalities, especially anomalous coronary arteries, are amongst the commonest of causes of sudden cardiac death in athletes.¹ Ramona had posted about a young man who collapsed and died during the Little Rock Marathon in 2008. That unfortunate young athlete had a rare disease of the coronary arteries.

Coronary artery anomalies constitute 1–3% of all congenital malformations of the heart. In approximately 0.46–1% of the normal population, anomalies of the coronary arteries are found incidentally during catheter angiography or autopsy. The etiology of coronary artery anomalies is still uncertain. Maternal transmission of some types has been suggested, particularly when only a single coronary artery is involved. Familial clustering is also reported for one of the most common anomalies, in which the left circumflex coronary artery (CX) originates from the right sinus of Valsalva. Anomalies of the coronary arteries may also be associated with Klinefelter’s syndrome and trisomy 18 (i.e., Edwards syndrome). Cardiac causes for early and sudden infant death include anomalies of the coronary arteries; the Bland-White-Garland-Syndrome may be one relevant cause. Anomalies of the coronary arteries found in children may be associated with other congenital anomalies of the heart like Fallot’s syndrome, transposition of the great arteries, Taussig-Bing heart (double-outlet right ventricle), or common arterial trunk.²

Normal Coronary Arterial Anatomy

Common variants are anomalies with origin from the contralateral side of the aortic bulb. These include an origin of the LMA or the LAD from the RSV or the proximal RCA and an origin of the RCA from the LSV or the LMA. There are four possible pathways for these aberrant vessels to cross over to their regular peripheral locations: (1) “anterior course” ventral to the pulmonary trunk or the right ventricular outflow tract, (2) “interarterial course” between the pulmonary artery and aorta, (3) “septal course” through the interventricular septum, and (4)”retro-aortic course”. Clinically, course anomalies of the coronary arteries are subdivided into “malignant” and “non-malignant” forms. Malignant forms are associated with an increased risk of myocardial ischemia or sudden death and mostly show a course between the pulmonary artery and aorta (i.e., “interarterial”). The most common case is an origin of the RCA from the LSV that courses between the aortic bulb and the pulmonary artery. Anomalies of the LMA or the LAD arising from the RSV with a similar course are associated with higher cardiac risk, too. It is suggested that myocardial ischemia and sudden death result from transient occlusion of the aberrant coronary artery, due to an increase of blood flow through the aorta and pulmonary artery during exercise or stress. The reason is either a kink at the sharp leftward or rightward bend at the vessel’s ostium or a pinch-cock mechanism between the aorta and pulmonary artery. Up to 30% of such patients are at risk for sudden death.²

…

The young man in this story probably had something like this after the surgical correction (Arterial Switch Operation) for TGA…

“Malignant” course of LAD

…a classical malignant course of the LAD between the Aorta and Pulmonary artery.

…

References:

1. Sudden Death in Young Athletes: Screening for the Needle in a Haystack – Free full text article in American Family Physician.
2. Text about congenital coronary artery anomalies and the two figures are from this textbook – Multi-slice and Dual-source CT in Cardiac Imaging.

Start Slide Show with PicLens Lite

*This blog post was originally published at scan man's notes*