Archive for June, 2009
The mouth of Sauron
Posted by redlinedoc in Uncategorized on June 21st, 2009
I’ve had my bouts with American cars and probably won’t buy another for some long time.
The first was with GM diesels. In the late 70’s there was a gas crisis and my dad decided that the best way was to go diesel. The local dealer sold not one but two impala diesels. One never worked all that well costing before its well earned retirement 0.72 cents per mile. The dealer never really got it right, going through one battery after another. Finally the car spit out its transmission parts, the torque of the engine far greater than the transmission design. The dealer offered to repair the transmission splitting the difference so that ‘no one would get hurt’… 1300$ would be my share. I went to the local transmission fixit place who completed the entire repair, 340$. Ahh well. The war of the batteries continued burning out one battery then another, the dealer only charging me the 75$ swap charge each time. Finally the dealer fessed up; he was only and oils and lubricant’s fixer for diesel and had no idea what was going on. Several weeks later the car gave a groan, spit out many parts on the ground. I gave the car to the local trade school. They could not understand why I would give them a car with a working radio.
I swore off GM.
Recently I read that GM had made a V-6 2.8L engine with a firing order 1-2 3-4 5-6. The crankshafts reliably cracked around 30K miles. The solution. Wait. Most of these cars have only 5oK warranties. Hmmmmmmmmmmm.
Some years later I buy a Chrysler PT cruiser. I did the research which suggested that the repairs were more than average. Little did I suspect it was a plan on the part of Chrysler. I got a plan with the car which included oil changes. The oil change guy at the dealership must not have been part of the dealership plans. He never saw the leaky high pressure lines and in doing the oil change managed to rip another line under the car.
Some time later, my mechanic, not at the dealership, goes to change the timing belt, a necessary repair. To do this requires complete disassembly of the right side of the car. Success. But now it needs adjustment. The plate to adjust this is located directly behind the front motor mount. One of the local dealerships suggests “cut it off and weld it back” REALLY!
None of that is as pertinent as the words from the leadership at Chrysler. As they were marching down the road to bankruptcy, one of their fearless leaders, who no doubt will be reinstalled and highly bonused and paid by the American taxpayer in the name of saving his job, announces that “we put a bad engine in that car (the PT Cruiser); but, we’re not making them anymore”.
Words of comfort, direct from the mouth of Sauron!
You’ve been turfed!
Posted by redlinedoc in Commentary of the times, Medicine, Universal HealthCare on June 21st, 2009
More of my patients are being turned away at the gates every day. Often they need advanced care which we at the primary care level can’t give them.
I have always felt that we were most lucky, we are a smallish state and have a training institution and hospital which are owned and operated by the state. This hospital should be seeing the those at the fringe, those in great need. For many years the hospital was located in the center of an immigrant community. In the 70’s it relocated to a suburban location, very upscale. At first there was a bus to take people from the community but that quickly was quashed. Now it takes two busses and a local jitney at the heath centet, about 2.5 hours, to get there. Not much of a barrier.
Patients going to his greater facility of learning often encouter trolls at the gates. Trolls? Admission to this center of ‘much higher learning’ requires the proper insurance, not some of the lower paying kinds that our patient’s possess. When they call, the answer is frequently, call back when you have better insurance.
A few weeks ago, after some harsh notes from our facility, several well dressed physicians show up to try to make arrangements to expedite the admission of our patients into the gleaming tertiary care facility, state owned and supported. To show magnanimity one of the docs takes out a card with driving directions and some special parking near his clinics. There is muffled laughter as we tell him that the majority of our patients don’t drive nor own cars. He’s a bit culturally disconnected.
Lest you think that this is peculiar to the country estate hospital, the in-city institutions answer similarly.
Recently a patient shows on a Friday afternoon, all hunched over, the Groucho Marx walk, right upper quadrant pain, rather classic gallbladder symptoms; a surgical problem. She is referred, complete with small note from the doc, and ambulance transported to the in citty emergeny room to prevent her from having to find transport. The attending physician there concurs but adds the diagnosis ’shitty insurance’ and instead of wheeling Senora Patient to a holding area for surgical admission, gives her back a note with the names of two surgeons in the area saying she needs urgent and immediate care. She of course calls those offices only to find that neither surgeon participates with her insurance. Quel suprise! Monday morning, quite more hunched over she comes back to our primary care clinic, sicker, with the note and no scar. A nasty note and a phone call, she’s retransported and admitted for care. This is a good outcome?
With all the ballyhoo about insurance companies participating in health care, and contrary to their every present advertisements that ‘they take care of you’ we need remember that there’s a profit motive totally separated from any health provision. The recent squealing and wheezing from the health insurance companies and their paid compadres in government about the death of health care should we use single payor or government sponsored health care is quite self serving, serving only their investors.
The only investors in Medicare are we the users. Its far from perfect. It has a 5-8 percent overhead, unmatched anywhere in the insurance industry, even with draconian plans which provide and income source for the insurance companies not safety nor security for their policy holders.
We need to re-direct our efforts and energies toward providing a comprehensive Medicare type system. A single payor system will insure fairness. I see no reason why the private companies can’t compete for business as they do in every other country with single payors. Lets see them for what they are, trolls at the gates.
Death by insurance –
Posted by redlinedoc in Medicine, Universal HealthCare on June 21st, 2009
Yesterday I lost another, friend. Death by insurance read the certificate, or so it should have. Geno was a kind fellow, gentle soul, never made lots of money but found himself suddenly underemployed, a polite term for being older and getting paid for fewer than 20 hours a week, then finding there is no health insurance
Ok, you think. Let this guy pull himself up by the bootstraps. He did. He got a second job. Still no insurance. Then he got Diabetes. Oops. Its not quite like a third job because you pay them instead of getting paid. You work harder. The doc says you should have less stress. Ok. I’m working a job to pay the insurance and another to pay for food, now I have to pay rent because the diabetes job just doesn’t bring in enough.
Oops.
Now you can be on state sponsored insurance, some of the time. You feel really terrible. He did. He worked all his life and was always responsible. Now he’s a ward of the state and working. He gets headaches. He’s not feeling well. One day he falls. He goes to a doctor but they can’t see him because his limited HMO insurance wants him to see a doctor 40 miles south. He bucks the system but there are not many alternatives.
Finally he gets an appointment with neurology. He has a grade 4 astrocytoma; not a good prognosis. Although he has insurance for this and has coverage, because of his limitations (he has memory lapses and poor focus) after the tumor is primarily removed, he often forgets to take his medications or takes them improperly. Insurance has no use for home visits.
He slips. He has difficulties. The secondary job is history. The primary job lays him off. He’s now totally on the HMO. They say he’s ok free living. He has slips and fall. He’s ok free living. He forgets his medications. He’s ok free living. He asks for assist but they say he’s not elegible on this cheaper chicken HMO insurance.
He died yesterday. Now the HMO is off the hook. No more insurance payments. No doctor visits. No Gene. Seems like a good system. Death by insurance.
Lest you think this is an isolated incident -
Two years ago a friend of mine, a retailer, sucessful in business but a small retailer, began to have urinary tract pain. He had no health insurance because at more than 1500$ a month it was more than he could afford. Additionally, that amount was for catastrophic insurance, you see, as a child he’d had bladder problems and every insurance company pro-rated him. Finally he gets insurance. He’s had, what he thinks, is a bladder infection. Its been so severe that occasionally he sleeps in a bath tub with warm waters. Small catch. There’s a 90 day waiting period.
He goes to his doctor who, as he’d suspected, sends him to urology. They want to examine his bladder and because of prior difficulties with anatomy need to do this in a hospital. There’s this 90 day thing. We wait. He’s more comfortable but of course not better.
The bell rings. Its a bladder tumor. They biopsy – perhaps benign, although most are not. It is benign it seems. But theres a second troubling spot next to it. Not benign. The tumor is resected, he starts chemo and radiation and everyone is hopeful. There are all sorts of limits to this insurance policy he has – so greater exploration, whole body films and the like, aren’t done.
Two months forward, he’s a bit dizzy and falls. There is an ominous cracking sound in his neck. There’s a baseball sized tumor there. Now we do more work up. Its a metatastasis. Alas it was a death knell. When removed and the neck repaired a shower of tumors widely spread show up. After an enormous fight he choses to let go.
No more store. No more employees. No more friend. These tumors when seen early are frequently non-fatal. With time the outcomes are more dire.
Death by insurance.
Forever?
Posted by redlinedoc in Uncategorized on June 3rd, 2009
I am reminded that forever is a limited term. How so?
Some years ago a tile fellow did some work in a bathroom. I said at the time ” Perhaps we should use mud (concrete)?”
“Naaah,” he replied, “use the mastic, it will last you a lifetime….”
About three years later, through no fault of mine, he dies. Shortly there after the tiles came loose on the wall — prompting the question — whose lifetime?
Some many years later I bought a product a car remote, guaranteed for a lifetime of use. The thing had troubles but the installer was local and very helpful with the twists and vagaries of the system. About 90 miles from home one day, the system failed, on a Saturday afternoon. About the same time an ex of his walked into his shop, double taps him in the head leaving him quite dead. The local dealer folds. But– not to worry this is a national franchise. Uh huh. A year later, no service, no ability to fix it and no ‘other dealer’ willing to work with it, I ripped it out of the car to solve a panoply of problems. Lifetime hmmmm.
And yet once more into the breach. I find myself drawn to an automobile. Its comfortable. Consumer’s report says that it has some repair problems but I chose the engine and model with fewer. You guessed it Chrysler. As I’m listening to the litany of demise from the mouth of marketing at Chrysler – he says “we put a bad engine in that car. We knew it but it sold well. We’re not making it any more.” Ahh yes the full circle. Not only NOT forever but not even partially.
I always liked the City on the Edge of Forever on StarTrek. But even there she dies. Its not forever.
Dead chickens. No eggs.
Posted by redlinedoc in Commentary, I never saw THAT coming on June 2nd, 2009
I was recently reminded that leaving weasels in the hen house gives you a result. Alas, its dead chickens and no eggs. Why chickens?
Our economic (heaven forfend czars) have been running in and out of the hen house. I had proposed, and I’m not a gory fellow, that perhaps a few heads-on-pikes outside Lehman Brothers might have curtailed the mad stealing that goes on. Yes, I’m a victim too.
Each day I read of the glorious rounds of in the front out the back door dealing at the SEC with Larry Summers or the folks at Chrysler or GM who revel in the bailout, glory in bankruptcy. A few days ago the VP of Chrysler said in effect sorry folks we made some lousy cars, like the PT Crusier, it had a lousy engine but they sold!…. and I an owner of one of those lumps of clay! There is some chutzpah in the GM folks managing NOT to take any responsibility for anything. Its the fault of unions, economy, dealers, stockholders, manufacturers of parts but no no no not GM. They didn’t make cars that didn’t run, engines that failed for obvious reasons, cars that fell apart nearly on the lots, no no no not them. Its someone else’s fault. Those same donkeys are going to be rebuilding the same cars but with our monies. What a way to go. Take a risk. Do a lousy job. Get a bailout! Hmmm is there a DD-285/7448 that -=I=- can get to fill in for my share?
Indeed all the folks are all white-washed now. Not to worry. Stole a few million in pension funds from old folks to gamble away with 100:1 odds? Didn’t see it coming? Naah not to worry Mr Weasel, here are the keys.
So what. They’re old. They didn’t need the eggs anyway.
Disposable people
Posted by redlinedoc in Uncategorized on June 2nd, 2009
I have a window on a wonderful new construction project in the North End of Hartford. We who work here know that this city and this part of this city are the 3rd poorest in the United States! Anything new and beautiful is a welcome treat.
I watch the construction part by part, fascinated by the exterior work which is still proceeding rather industriously, sealing windows, sealing the roof and more. I’ve seen all sorts of jack lifts and long boom devices to get the workers up close and personal. The other day I’m watching as this fellow is in one of the scissor lift self movers, no helmet, no restraining strap, no eye protection, no respirator jack hammering out concrete dust (clouds of the stuff) from a groove to be used in the roofing array. As a medical professional I think, hmmm
Disposable people.
Whats with Tzars?
Posted by redlinedoc in Uncategorized on June 2nd, 2009
We seem, in the US, to have come to love our Tzars. To be sure the Russian’s also loved their Tzars, to death.
Why is it then that we love them so? We have a car Czar, a Drug Tzar. Czar this and Tzar that. Its the same intellect that brought back ‘crusades’. Perhaps the most monstrous human losses were suffered in the crusades expeditions from West to East, jihads of an earlier time, most all doomed to failure.
So, why Czars?. The Russian’s loved their Czars, hated them and in the end they killed not only the Czar but his children, childrens children, household workers, horses and anyone who could pronounce the name. So why are WE in love with Czar’s for drugs and Czars for cars? Given the mounting success of the war on drugs (actually a war on the American people, but more of that later) and the apparent success of the Car Czar (bankruptcy of the two of the three major US car manufacturers), we seem to be approaching the Russian ideal.
I’m old enough to remember Nikita Khruschev
Nikita Khrushchev pounding his shoe at the UN
declaring they (USSR at the time) would bury US. (yes yes its double entendre). We recognized at once the value of shoe pounding and within a few years here we are, appointing Czars.
The Jews of the Pale, knew well that the Czar was no friend but as with all things they had blessings for everything. Teyve in Fiddler on the Roof coughs up a blessing, ” God bless and keep the tzar — far away from us!” Indeed.
As of old, Czars were not elected, nor even chosen by some lady emerging from the lake with a flaming sword, but chosen. We insulate them from possible rational commentary. New sources flock to them for information. As of old, they stand apart.
Failed health, failed heathcare.
Posted by redlinedoc in Medicine on June 1st, 2009
I write this entry as a physician working with in the system, having been in it for more than 30 years and watching the steady transfer of medical decision making away from the hands of physicians and into the hands of the payors, not the patients.
I’ve written elsewhere about this but a recent episode brings the inadequacy and hopelessness of the current system home.
A friend (not patient) develops some urinary bleeding. He calls. I suggest, doctor (and give him some names). There is a bit of a glitch. He’s a retailer but doesn’t have enough employees (small store) to qualify for group insurance and his individual rate is enormous. He waits.
He goes to the emergency rooms. They give him antibiotics and painkillers. They tell him ’see his doctor’.
He waits.
He goes back to the emergency room. A note here. Emergency rooms are wonderful places for stopped hearts, lots of bleeding, run over by a bus. Emergency rooms are inappropriate places for continuity of care. He has no doctor. He pays out of pocket. He sleeps in the bath tub while the insurer waits 60 days from initiation. We protect our insurers, their stockholders.
It is now 15 months since the first symptoms.
Sadly, my friend has a bladder tumor, which at first appears to be non-malignant, but on closer examination is. No problem. These things are radiation sensitive. He goes for radio therapy and 6 weeks after discovery of the primary tumor (and excision) he falls, rushed to the hospital for a much larger spinal (neck) mass which has eaten at his spine. This too is radio-chemo sensitive.
Alas the removal of this tumor unleashes a string of others… and now there is no friend. He is waiting to die.
So, who done it? I’m not sure that early detection or regular physician visits would have altered this outcome; however in his early 50’s his chances would have been much improved. There is no primary care physician involved, it’s all specialists. As a sub specialist I realize my narrow view screen, my imperfect mirror for my patients; however, I do implore them to find a primary care physician (rapidly becoming a rare specie) to help them navigate the tricky flumes and waterways of our so-called system.
I do know that I have lost a friend. The community has lost a resource, and we are all, in Dunne’s words – ’send no one to know for whom the bell tolls; it tolls for thee” lesser for this.
As a trained physician I know we all have our time, yet all of us in the healing arts fight death. I feel that the unseen co-conspirator here was an uncaring, blovinated system. By denying coverage to some we diminish us all.
Heads on pikes
Posted by redlinedoc in Commentary of the times on June 22nd, 2009
It seems its a day of good news bad news. The good news seems to be that the boys at Goldman Sachs are snuffling at the trough and ready to suck up those great well deserved bonuses for having put us in the worst recession since the 30’s perhaps worse than that. I fear that we missed an opportunity for heads on pikes. I’m not ordinarily a gory sort of fellow; however, if a few of those egregious folk had their heads up along the boulevard perhaps fewer of these guys would be snorting at the trough so soon. Its a sign that regularion has lost and that we as a nation have or will loose big time now that the game is a foot and the money is liberally flying around again.
It makes me wonder in some ways what the big call is for CEO’s. I hear one company after another looking for the most expensive CEO guy they can find. I have no problem paying for success. Its the paying for the failures. United Airlines, General Motors, Chrysler, Hewlett Packard — each of those men and women walked away handsomely endowed with bonus and super bonus and stock options. As each of these companies tanked and drew down the economy we threw MORE money at CEO’s. I’ve yet to see cat skeleton’s around full cat food bowls. I believe if we all went to reasonable executive pay and said NO MORE! that indeed CEO’s would be paid proprionately and reasonably. Perhaps we should make the CEO take some of the risk (not with fako securities from the board but with his own monies. Perhaps, as in days of yore, CEO’s should bear a percentage of risk and win-lose with the company.
Danny DeVito, ever a mirror for the times, did it well with ‘Other People’s Money’.
The Harvard business school recently announced that they might teach business ethics to their grads. What a concept! Such things as stealing from old ladies is wrong, wiping out the life savings of people and towns is poor for future business, and the future. My son said that if once in a while if the inchoate mob, those who lost nearly everything, had an opportunity to be in a closed area with the hedgies and mutualaholics who ground their savings from real to immaginary numbers that much of this would be object lesson.
But then, that’s pretty gory.
Heads on pikes. Not a lot. Just a few. Some in Wall Street. Some on K Street. Some along the mall. Sobers the crowd and makes us remember that there really are people who are responsible. Until then, its still “Buddy can you spare a (discounted) dime.”
bonus, business+ethics, CEO, Chrysler, Danny+DeVito, ethics, executive+compensation, General+Motors, Goldman+Sachs, Havard, Hewlett+Packard, other+peoples+money, risk, United+Airlines
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