ED treatment of acute back pain - what's missing and why

[There's something messed up with how Scribefire and Blogger are formatting this post, but for the life of me I can't fix it! So, there are no real paragraphs. I'm going to forego use of Scribefire with FF3 until I sort this one out.]

I had the 2nd ambulance ride of my life recently.The ambulance was overkill. Four strong bodies, duct tape and a door would have been more appropriate, and cheaper too.

Alas there was no intermediate alternative. I was unable to stand or crawl with mere ibuprofen and canes, and that becomes a problem over time. Since nobody will prescribe narcotics and valium over the phone this left me with only one route to medical care -- a back board.

The ED got adequate control over the back spasms with modest doses of IV valium and morphine [1]. I was a pathetic sight hobbling out of the ED on two canes to lie flat in an emptied van, but six hours later, after continuous ambulation, I walked a mile without difficulty using a single cane as a psychological aid. I was on the way to rehab. [2]

I'll have a bit more to say in a later post on the pointless cost of this episode vs. the intelligent alternative, but this particular post is about three very simple things that the ED didn't do. I had them covered myself, but without them I'd still be in the hospital.

So these interventions matter. The important question is why did I have to take care of them?

Now I think I was the guest of a quite good rural ED, and I felt feel confident that ER doc who took care of me seemed confident and competent (and comely too!), so I suspect these are common omissions:

• a cold pack and a neoprene waist belt to provide continuous cold therapy to the acutely spasmed back
• two canes to enable ambulation
• a urinal to enable sleep at home
• (see more here)

The urinal is key for the first day or two at home, yet I had to keep reminding the staff that it needed to go with me.

The ED had no canes, but I could never have done my pathetic totter out of the facility without them. They did have a walker I could test my gait with, but a walker isn't designed to support body weight while in motion. They didn't think to train me on how to use a cane (I knew how), but any significant back pain requires days of cane use. (If your acute musculoskeletal back pain doesn't require a cane, do you really need an ED?)

Continuous cold therapy during the acute episode is an key part of most therapeutic recommendations. I realize reactions differ, but cold therapy is essential for me. I had to bring my own neoprene cold pack belt, and I had to request ice (they had no cold packs).

In the end everything worked, but acute back pain is hardly a rare ED event. Why didn't they have the key ingredients in place?

I'd like to see someone do a survey article on what percentage of EDs provide these 3 items on discharge, in addition to whatever else they do:

1. local cold therapy (an ace wrap and an Rx for a neoprene belt would do - total cost $4)
2. canes with usage instructions ($10 each at Walmart - crummy but effective)
3. a disposable urinal for men (free, since you keep the one you use in the ED).

My guess is that less than 10% of EDs meet this standard, and the result is a horrendous waste of money nationally.

So why hasn't the study been done? If it has been done, why aren't payors making these steps a part of their quality measures used to justify reimbursement? If this stuff isn't in the standard ED guidelines, then we have an even more interesting set of "why" questions.Understanding these "why" questions would tell us a lot of interesting things about health care and where money is spent.

[1] The cognitive effect of the "morphine" was so modest I wondered if it was saline placebo (which would have been fine really -- anything that works!). I think they were just doing small incremental dosing

[2] Once the pain is under some control, and improvement has begun, the rehab process has a certain appeal. Every day actions are a bit like mountain climbing, with the same need for concentration, precision, and planned motion. Also, the same sense of risk with error. It appeals to a certain twisted mind.

Philip Carter summarizes the Senate torture report: affirms use of Stalin's regimen

Phillip "Intel Dump" Carter, now writing for the Washington Post summarizes the Senate report on torture techniques used at Guantanamo Bay...

The Genesis of Torture - Intel Dump - Phillip Carter on national security and the military.

Yesterday, the Senate Armed Services Committee released a 63-page set of documents that illuminates how the Pentagon developed, selected and approved its list of coercive interrogation techniques for Guantanamo Bay.

As Joby Warrick reports in today's Post, the documents clarify the role that the CIA (and senior government officials such as DoD General Counsel William "Jim" Haynes) played. "If the detainee dies, you're doing it wrong," CIA lawyer Jonathan Friedman proclaimed in a working group meeting that led to the development of this DoD memo on approved interrogation techniques...

It's the best short summary I've seen. A few take-away points:

1. After 3 years of acquiescence, the uniformed military finally began to rebel.
2. The report only deals with Guantanamo, we don't know what techniques were used elsewhere. The US outsourced torture extensively, we bear full responsibility for what was done in foreign prisons on our behalf.
3. This will be a significant part of future war crimes trials.
4. The sources I read have felt that the regiment we use was based on Korean and Soviet torture designed to produce on-demand confessions. The Senate report confirms this.

Global warming: what you can do ...

Technically, it's not worth bothering with wall warts and light bulbs. If you buy a new car it makes sense to get something like a Honda Civic.

Otherwise ...

Ask Pablo, Global warming | Salon Life

... So to recap: Pester your local, state and federal politicians, eat less meat and make your home more energy efficient...

Of these, the first is most important.

Which brings me to where I disagree with Charlie's Diary. Yes, technically the light bulb and wall wart fuss is a waste of time better spent opposing GOP candidates, but humans aren't technical animals. Fussing about florescents fosters a culture that can support about a carbon tax, and it helps make global warming something a politician can campaign on.

So don't mock the the folks who worry about "vampire" appliances. They are making it possible to elect and support the politicians who will make the real changes.

The Last Lesson

Narrative comics from China's recent earthquake. Including The Last Lesson.

Via Fallows.

Journalists like politicians that make them feel smart

It makes sense. Bush II isn't as dumb as he acts (he doesn't have that excuse), but he seems dumb to journalists. They feel good about that.

McCain, even without dementia, has the same feature.

Grasping Reality with Both Hands: The Semi-Daily Journal Economist Brad DeLong

...The number of mulligans that America's press corps gives John McCain is truly remarkable. I'm becoming increasingly convinced that it's because he doesn't threaten them--just as George W. Bush doesn't threaten them. By contrast, Bill Clinton and Al Gore and John Kerry and John Edwards and Hillary Rodham Clinton and Barack Obama are scary-smart, in the way that my ex-boss Alicia Munnell once spoke of Lloyd Bentsen: 'It only takes fifteen minutes before it is very clear why he is the Secretary of the Treasury and I am the Assistant Secretary.' That seems to provoke a reaction from many journalists...

Minneapolis is 9th on the top 10 bike city list. St Paul is ?

I'm surprised Minneapolis is only #9. I think they missed a heck of a lot of trails. Two or three of the other "cities" are barely towns, and Boulder is a college town for Pete's sake.

Montreal is a great town, but there's no chance it's a better biking place than Minneapolis.

Of course St Paul, the other half of the Twin Cities, is probably #20. Shame on my city! We need to put together a St. Paul pressure group and start making some progress.

Bottom line, adjusting the list for reality and eliminating towns, Minneapolis is genuinely the 3rd or 4th best biking city in America*. The real rivals (winter-free Portland has it easy) are far more expensive places to live, and Montreal* requires a change in citizenship.

Going by Gordon's Law (ye may know a city by its bike trails) Minneapolis is absolutely a great place to live, and Saint Paul, after all, is only a ten minute bike ride away.

* In the original version of this post I unfairly disparaged Montreal's bike network based on old data. Yesterday we completed a road survey (kids on strike) of part of the network, and Kateva and I sampled a stretch. It's a good bit more extensive than when I last checked, and it's tough to compete with Montreal's attractions. So, I admit, Montreal moves ahead of Minneapolis.

More on the US torture program, and preparing for the war crimes trials

Yes, more on torture. This is part of my duty as an American citizen. McCain would do his best to silence these stories. For now, they're coming out.

A NYT article that's ostensibly about the post-torture interrogation of KSM also tells us more about how the torture program came together ...

Inside a 9/11 Mastermind’s Interrogation - Series - NYTimes.com

.... In its scramble, the agency made the momentous decision to use harsh methods the United States had long condemned. With little research or reflection, it borrowed its techniques from an American military training program modeled on the torture repertories of the Soviet Union and other cold-war adversaries, a lineage that would come to haunt the agency.

It located its overseas jails based largely on which foreign intelligence officials were most accommodating and rushed to move the prisoners when word of locations leaked. Seeking a longer-term solution, the C.I.A. spent millions to build a high-security prison in a remote desert location, according to two former intelligence officials. The prison, whose existence has never been disclosed, was completed — and then apparently abandoned unused — when President Bush decided in 2006 to move all the prisoners to Guantanamo...

Yes, "apparently abandoned". I suspect we'll hear more about that prison. Such things find a use.

The groundwork is being laid for what, if it takes place, will be the trial of the century. The war crimes trial of George W. Bush, Donald Rumsfeld, Condeleezza Rice and their colleagues may yet come to an iPhone near you sometime in the next twenty years ...

Update 6/24: The story is probably a deceptive plant. Makes sense that the torture was more entangled with the "good cop" routine than the NYT tells us.

Wiretaps are legal now

It's good to note these things.

This Modern World - It’s Repentin’ Time in Heaven:

....here’s Sen. Kit Bond of Missouri this morning, explaining why Congress is making it legal for giant telecoms to wiretap us: "When the government tells you to do something, I’m sure you would all agree that I think you all recognize that is something you need to do."

We need a new American tradition.

Every time a traditional protection of the citizen is removed, we should have a national moment of silence.

Is this the right thing to do? The Cost of Havoc will continue to fall for the foreseeable future. There is an argument for reducing the freedom of citizens in proportion to the cost of this freedom. (Torture? No.)

This is a grave choice though, and it should be made with great thought and much discussion. It should be accompanied by greater oversight of government, strengthening the adversarial roles of the three branches, and greater penalties for incompetent and malign leadership.

We're not having those discussions, so this vote is a grievous thing.

Please don't vote for McCain. He is more, much more, of the same. If you can't manage to vote for Obama, vote for a libertarian.

Why blogs rule - Krugman on oil speculation

An example of why blogs rule. Krugman, responding to comments, makes a side comment on recent congressional testimony on oil speculation:

Calvo on commodities - Paul Krugman - Op-Ed Columnist - New York Times Blog

...Some correspondents have asked me what I think about the Congressional testimony of Michael Masters, who told a Senate subcommittee that “index speculators” — institutions that buy commodity futures as an investment — are responsible for the price surge.

The short answer is that I think his testimony is just stupid...

Topical, yes. Direct, rather. Informed, definitely. It's like a vastly smarter, faster version of radio commentary, but it's on demand, linkable, searchable and readable.

I love this stuff.

Oh, and oil speculation? I think it's a dumb term. I wish commentators would divide "speculative" pricing into psychological (futures contracts driven largely by uninformed human psychology) and fundamental (futures contracts based on expectations that demand for "light sweet crude" will exceed supply).

In August I will deliver my eagerly awaited judgment on the contribution of fundamental vs. psychological price projection to oil and gas prices.

An astounding series on mental health disorders

I'm visiting family in Montreal, and the Globe and Mail came with the room today.

I've read the G&M before. It's a duller version of the Wall Street Journal, without the journalism. I didn't expect anything.

So I really was astounded by their special series on mental health: Breakdown: Canada's Mental Health Crisis.

The title is misleading, there's nothing particularly Canadian about the stories. The portrayal of schizophrenia (let us honor the Bigelow family) and David Golbloom's review of the mission of the Mental Health Commission of Canada are among the best writings on mental health I've seen anywhere.

The G&M has excellent journalists. I never suspected.

Canada's imperfect health care system gets knocked by people who don't read outcomes research, but it's vastly better than the America's non-system when it comes to delivering services to the underclass*. Canada is also quite good at "commissions"; Canada evolved the endless commission as an alternative to civil war. So the Mental Health commission may have an impact both in Canada and the US:

...People living with mental illness have the right to obtain the services and supports they need. They have the right to be treated with the same dignity and respect as we accord everyone struggling to recover from any form of illness.

The goal of the Mental Health Commission of Canada is to help bring into being an integrated mental health system that places people living with mental illness at its centre.

To this end, the Commission encourages cooperation and collaboration among governments, mental health service providers, employers, the scientific and research communities, as well as Canadians living with mental illness, their families and caregivers...

The world changes in the strangest ways. Decades of slow progress, regression and failure, then suddenly the world flips about. And that's just "gay marriage".

Progress does happen. We may be entering a new cultural model of cognition, cognitive disability, and cognitive variability.

* In defense of America, Canada has nothing like the Americans with Disabilities Act. There are things Canada could learn from the US.

PETCO goes down - pet food seizure

I wonder how much of this re-energized FDA activity comes from a Democratic House and Senate:

PETCO pet food seized after federal warrant issued | L.A. Unleashed | Los Angeles Times

...At the request of the U.S. Food and Drug Administration, U.S. Marshals seized all FDA-regulated animal food susceptible to rodent and pest contamination. The products violated the federal Food, Drug and Cosmetic Act because it was alleged in a case filed by the United States Attorney that they were being held under unsanitary conditions...

No more PETCO visits for us, but of course we don't know if the competition is any better.

The Mundaneum

I demand an investigation.

I demand an inquiry.

I want to know why the %$!$ I've never heard of the Mundaneum Project ...

The Mundaneum Museum Honors the First Concept of the World Wide Web

...Using 3 by 5 index cards (then the state of the art in storage technology), they went on to create a vast paper database with more than 12 million individual entries.

Otlet and LaFontaine eventually persuaded the Belgian government to support their project, proposing to build a “city of knowledge” that would bolster the government’s bid to become host of the League of Nations. The government granted them space in a government building, where Otlet expanded the operation. He hired more staff, and established a fee-based research service that allowed anyone in the world to submit a query via mail or telegraph — a kind of analog search engine. Inquiries poured in from all over the world, more than 1,500 a year, on topics as diverse as boomerangs and Bulgarian finance.

As the Mundaneum evolved, it began to choke on the sheer volume of paper. Otlet started sketching ideas for new technologies to manage the information overload. At one point he posited a kind of paper-based computer, rigged with wheels and spokes that would move documents around on the surface of a desk. Eventually, however, Otlet realized the ultimate answer involved scrapping paper altogether.

Since there was no such thing as electronic data storage in the 1920s, Otlet had to invent it. He started writing at length about the possibility of electronic media storage, culminating in a 1934 book, “Monde,” where he laid out his vision of a “mechanical, collective brain” that would house all the world’s information, made readily accessible over a global telecommunications network.

Tragically, just as Otlet’s vision began to crystallize, the Mundaneum fell on hard times. In 1934, the Belgian government lost interest in the project after losing its bid for the League of Nations headquarters. Otlet moved it to a smaller space, and after financial struggles had to close it to the public.

A handful of staff members kept working on the project, but the dream ended when the Nazis marched through Belgium in 1940. The Germans cleared out the original Mundaneum site to make way for an exhibit of Third Reich art, destroying thousands of boxes filled with index cards. Otlet died in 1944, a broken and soon-to-be-forgotten man.

After Otlet’s death, what survived of the original Mundaneum was left to languish in an old anatomy building of the Free University in the Parc Leopold until 1968, when a young graduate student named W. Boyd Rayward picked up the paper trail. Having read some of Otlet’s work, he traveled to the abandoned office in Brussels, where he discovered a mausoleum like room full of books and mounds of paper covered in cobwebs....

How did this all go missing? Twelve million index cards? Everyone just forgot about it?

What else from this era has been forgotten? (For relatively modern variants, see these links).

Mega drive 2008: the newest innovations

We're doing one of our family mega-drives. Thousands of miles with 1 dog, 3 children, 2 adults, one van.

It works. Better than a reasonable person would expect.

Each time we do this there's some technology variation. This year we had two.

First of all, we got the video iPod to output video to our shockingly reliable $200 car video "system". This would have worked years ago if I'd tried harder (or bought a custom video iPod cable), but Apple didn't distribute much kid vid. I would have had to rip my own video. Too much trouble!

Now Apple sells "Ben 10" and similar TV for $2 an episode, a small price for auto peace. We put Tom and Diane's iTune's gifts to good use.

Three year old technology, so this one was about the content.

Our second innovation was 3G Net Access with Emily's Blackberry browser. Between Saint Paul Minnesota and Escanaba Michigan Emily asked Google (I drove) about the location of Liverpool and three other topics:

• Rib Mountain, Wausau, Wisconsin: The mountain/hill rises mysteriously from flat land. It's a final remnant of the 1.9 billion year old Penokean mountains, and the 2nd downhill ski resort in America. When I see it I imagine a colossus of the new earth, a tower far greater than Everest. Now all that remains is this rock, the broken heart of the ancient mountain. Once a century it beats "I was".
  
  
• Chippewa Falls and Seymour Cray: How the heck did Cray, a certified eccentric genius, persuade a team to follow him from Minneapolis to Chippewa Falls? How good was Cray that Control Data built a lab for him on land he owned? (Very good, of course.)
  
  
• The Yellowstone Trail: America's first northern coast-to-coast motoring road, the fruit of a small group of South Dakota entrepreneurs. I can't tell from the web site how much of this trail can be followed today.

We couldn't continue our data tourism into Canada, the long distance data costs are prohibitive. So all of this was from a few chance encounters in a single day's drive.

My iPhone to come will have a GPS. It will learn what I am interested in. Soon, when I travel, it will strike a bell each time I pass near these sorts of things.

Our next car trip will be even more novel.

PS. Another drive related observation. The UK academics that grace Melvyn Bragg's In Our Time program don't know squat about economics. What gives? Is it forbidden knowledge over there?

That which does not kill me is not torture

At last we understand why the Bushies say they don't torture people:

BBC NEWS | Americas | US interrogation debate detailed

... John Fredman, then chief counsel to the CIA's counter-terrorism centre, argued during the meeting that torture 'is basically subject to perception'.

'If the detainee dies, you're doing it wrong,' he said...

We've killed several detainees, so even by the Bush standard we do torture.

If they hadn't died though, no torture.

A clear cut standard.

Understanding net neutrality – Imagine Amazon owned the post office

Net neutrality is

Network neutrality - Wikipedia, the free encyclopedia

…  a principle that is applied to residential broadband networks, and potentially to all networks. A neutral broadband network is one that is free of restrictions on the kinds of equipment that may be attached, on the modes of communication allowed, which does not restrict content, sites or platforms, and where communication is not unreasonably degraded by other communication streams

How can we explain why the Net Neutrality discussion is important?

Imagine that there was no UPS and no Fedex. USPS only. There’s only one shipping service in this world.

Now imagine that Amazon owned the USPS.

Now you understand.