Thursday, March 22, 2007

Dog Days

Everybody, say hello to Denver Pickles!

The dog, the legend, here he is...

He would love to jump out of the screen and into your lap, if you'd only let him...He won't bite, he doesn't pee in the house (well, um, usually), and he's an adorable wiggle-butt and snuggle-puppy.

It's Denver Pickles!

Wednesday, March 21, 2007

We don't care how they do it in New York, and apparently the feeling is mutual

I caught a glimpse of the NBC Nightly News last week and was surprised to see a feature story about Dr. Persharon Dixon, a pediatrician who left Atlanta to work with the local community health center here after the storm. The health center has her riding around in a mobile van, a rather ingenious setup. The van and her work is sponsored by the Children's Health Fund out of New Yawk.

The broadcast gave me a peculiar feeling of pride, revulsion, and anger.

Only the first emotion is directed at Dr. Dixon. I've met her, and she's a wonderful woman and pediatrician, very sincere and caring. I have nothing but good things to say about her.

The latter two emotions I reserve for the Children's Health Fund.

A mobile health van is a good thing. A community health center is also a good thing. But so are local pediatricians. I don't claim to know the timeline or organization of CHF's involvement with healthcare on the MS coast after Katrina, but I do know this: CHF sure as hell never called me. Not to ask what I thought the kids might need, not to ask how CHF might integrate into the existing health structure, not even how we might work together.

All right, Dr. Scott: be reasonable! They have no obligation to call every pediatrician on the coast. You are a private practice, they hooked up with a non-profit. Besides, they're here helping out, just be grateful and appreciative!

First, there aren't that many pediatric practices on the coast. Here in Hancock County there are three pediatricians, and one of them already works for the community health center. How hard would it have been to pick up the phone and call the other 2 pedi's here?

Second, and more importantly, good intentions are no excuse for arrogance, particularly when intruding on someone's home turf. The CHF has a press release which notes that Mississippi already had pathetic medical care before the storm, and a shortage of primary care physicians. That may be true, but not on the coast. Me and my colleagues are not ignorant back-woods hicks who need us a little edumacation from the big city experts. We need help, not competition. Yes, we can learn from CHF's experience, but they can also learn from ours.

And so, once again, the locals continue to toil for (what somedays appears to be) naught while the out-of-towners grab the attention. "Look! Look at what we are doing for these poor Mississippi children! Look how we are helping when no one else will!"

Go ahead, call it sour grapes. I know I have it coming. But when the spotlight leaves, will the local providers leave also? Having exhausted our resources, with no outside help for us, what will happen then? I hope CHF has a fleet of those mobile health clinics ready, because that's all that may be left for health care on the coast.

Thursday, March 15, 2007

Tweaking

"We should meet. And we will meet. But I'm in the middle of a project that needs...tweaking."
--Joe Fox (Tom Hanks), "You've Got Mail"

The accountant is perusing my tax information, perhaps as we speak. But Dr. Scott has still been quiet and neglecting his blog.

I am in the middle of a major project that needs...tweaking.

Actually, two projects. One is a conference next month. I have been invited to speak about Katrina. I had a talk already prepared, it just needed updating. Then the conference organizer asked if I would prepare a second talk as well. So now I am dividing my talk in two: the first, as a "general interest" for pediatricians and spouses and invited guests, tells the Katrina Story from the days before August 29 through the present (and the future). It describes my personal experiences, as well as what the community as a whole has faced (and continues to confront). And I thank y'all for giving me the impetus to put Katrina Story in writing (even if a meager 7 chapters so far); it has been great rehearsal and even better organization for my scattered thoughts.

The second talk will now be about the medical lessons from Katrina: the illnesses, injuries, and environmental hazards after the storm (including, but not limited to: "Katrina Cough," MRSA, mosquitoes, black widow and brown widow spiders, and formaldehyde in FEMA trailers), the mental problems (PTSD, depression, anxiety, and "Katrina Brain"), and...for the first time anywhere...a critical look at long-term healthcare delivery in a disaster area.

I'm getting psyched just thinking about it, but I've got a couple of work-heavy weekends ahead in preparation for this.

I mentioned a second project. That one is actually far bigger and more important. But I am not at liberty to share the details with you at this time. Soon. It needs...tweaking. A lot of tweaking. Sorry to tease you like this, dear reader, but when I reveal my secret you will understand all. For now, I just wanted to let you know that you have not been forgotten; I've just been preoccupied with other matters of importance.

TTFN.

Tuesday, March 6, 2007

Death and Taxes


Yes, the blog has been quiet recently. I spent last week (especially the weekend) gathering receipts and whatnot for my accountant. It took many many hours, to which my wife asked, "if you've spent this much time already, why not just finish the tax form yourself?" To which I replied:

1. I don't know enough about depreciation, nor the items that may have been depreciated over the last 2 years.
2. I'd feel more comfortable handing it over to the accountant (transfer of responsibility).
3. I've got more important things to deal with right now.

Now I have to find a way to pay for the taxes. And that was another thing I did this past weekend: signed the final paperwork on my SBA loan. (This is the "Death" part.)

I am now owned by the SBA. Or rather, in a few weeks, my house will be. The SBA requires they be listed on the mortgage and deed. They also need receipts to verify all money has been used "appropriately." On the last, I pointed out that the loan is "payback" on money that was spent over a year ago. Still: no receipts, no more money. And if I get any future insurance settlements related to Katrina, it gets applied against the SBA loan. None for me.

It took 18 months to get to this point. And all so I can get 4% interest on a 30-year note.

I realize the government is trying to limit fraud and to make sure that the money is spent only on replacement needs caused by disaster. But, consider this:

At the same time I completed my SBA application - October 2005 - I went to my local bank for a "GO Loan." These were special short-term Katrina-zone loans issued by banks, with no interest, but they were due in 6 months. The GO Loan had a two-page application. I was approved, and received $25,000, in about 2 weeks.

While the SBA officer was very helpful and friendly, the SBA as an organization brings to mind the worst of sadistic bureaucracies. It makes the IRS look like a model of efficiency and kindness. There has GOT to be a better way to get money to people. And don't forget, we're talking LOANS, not GRANTS. Why couldn't the local banks handle this, just like they did the GO Loans? Just a thought.

Meanwhile, I need to think how to repay the SBA Loan, which is paying my taxes, which are the price I pay for starting and continuing my practice on the Gulf Coast. My, don't I feel privileged being here right now.

Monday, February 26, 2007

Tourists, Go Home

Ever since Katrina passed through, tourists have been coming here by the carload and busload to see the devastation. On the whole, I've been a supporter of this idea of "disaster tours" or "disaster pilgrimages." As much as you might read or see of Katrina, I assert that words and pictures simply cannot convey the total experience. In order to fully understand Katrina, you must experience its aftermath first-hand: the 360-degree immersion, the assault on all your senses, the mind-numbing sight of block after block of debris and destruction. Even at this late date, 18 months after the storm, most outsiders would be shocked at the extent of what has not been done, and the further publicity of such can only help.

Besides, this event has become part of history, and it's only natural that people will want to come and bear witness, to tell their friends and family, just as crowds flocked to Ground Zero in New York City in the months after 9/11.

All the same, this is not a sterile museum exhibit, or an isolated preserve. People live here. People work here.

About once a week I'll be driving home, and a car ahead of me will stop. In the middle of the street. And people will step out and gape and start taking pictures.

Other times cars will creep along Beach Boulevard at less than 10 miles per hour.

Please, people! I wouldn't drive like that if I came to visit your town!

Yes, by all means, come and see the devastation for yourself. Contribute your dollars to the local economy while you're at it. But is it too much to ask that you obey basic driving rules? We've been through enough already. If you're going to come and visit, at least show some respect for the people trying to live semi-normal lives here. Not stopping in the middle of the street would be a great start.

Thursday, February 22, 2007

Katrina Story, Chapter 7: Damage Assessment

We drove through the National Guard checkpoint and turned left on Highway 90, towards my office and the hospital. On the corner we caught a glimpse of the K-mart parking lot, now known as "Camp Katrina." Survivors and volunteers alike had congregated here and proceeded to take over the lot, which was now populated with RVs, campers, and tents.

The tire store in front of the K-mart looked like it had collapsed in on itself; the glass was smashed and the metal garage doors were caved in. Along the road, store signs were either down or the plastic blown out, leaving gaping rectangles. Some stores had their roofs torn off or fallen inwards.

We continued down Highway 90 and arrived at my office. The building looked largely intact from the outside, even though its neighbor had lost its metal roof. I peered in the waiting room and saw chairs and tables intact, on the ground, if not in the exact position where they had been 1 1/2 weeks ago.

I unlocked the front door and was hit by an overwhelming smell of mold. Wallpaper in the hallway was warped and buckling, and part of the hallway wall had actually given out, exposing the flooring store next door.

Picture my office as basically one long hallway. From the waiting room, the hallway went down the left side of the office. First room on the right was the reception and business office, followed by three exam rooms, and then my office, which was also the break room, which had a back door to the outside. The lab was across the hall from my office.

The reception/business office was trashed. Ceiling tiles had collapsed to the floor, covering a desk and bookcase with grey foam on the way down. The flood line was three feet off the floor, just above the desktop computers, laser printer, flatbed scanner, telephones, and all other electronic equipment. A horizontal file, which had been completely submerged, wouldn't even open anymore.

The exam rooms originally had white vinyl floors, but now they were just a thick brown-grey, covered with muck. The exam tables had also been submerged, and water still remained in the drawers. I couldn't even enter the third exam room; presumably a chair had floated between the exam table and the door, blocking the way.

In the lab, the refrigerator had tipped over on its side. Vaccine vials were strewn across the floor. But as I entered the back office, I realized the office had saved the worst for last.

The back bookcase, which previously held my medical textbooks, was now half-full, as its contents were strewn around the room and up the hall. My desk was tipped up at an angle, with a book somehow wedged under one corner. Whatever had originally been on, and on top of, my desk, was now also on the damp floor. The break room refrigerator had floated out of its corner into the middle of the room. The office server, placed up on the nurse's desk, was neatly covered with water, muck, and even dried leaves and grass.

I tried to open the back door to let in fresh air, but it wouldn't budge. On further inspection, I saw the back door had been wedged out of its frame. I wondered if a looter had tried to break in to the office. I then took a closer look at the door between the back office and the hallway. The door, including frame, had been torn out of the wall and was lying at the end of the hall. No looter did this. I realized the storm surge must have built up outside the back door, until it was breached; then the flood waters came in with such force, like a burst dam, that it swept books off the shelf and pushed the inner door completely aside, before tossing about the refrigerators and furniture.

I set to gathering a few basics, knowing that we had limited space in the car and had yet to visit the house. Salvaged from this first trip: office spirometer (purchased two weeks before Katrina, never used on a patient), cash box contents, damp office files (receipts, contracts, personnel papers), hard drives from desktop computers, and the office computer server. The latter weighed eighty pounds and drained water when we lifted it, but I hoped against better judgement that something might be salvageable--perhaps, if nothing else, the hard drives? Besides, if the drives were even remotely intact, they might have recoverable patient medical data, and I couldn't risk that information falling into the wrong hands.

We got back in the car to drive next door, to the hospital.

What used to be a hospital now looked like a military base. Army green tents covered the front lawn, and a black metal fence surrounded the entire military-hospital complex. On the road, a wooden sign painted green had a red cross letting people know that this was where they could get medical care. National Guardsmen milled about or walked to and fro. We drove up near the ER entrance, where we faced another guard post and more soldiers with M-16s. After producing my hospital badge, we were waved through and pulled up to the ER itself.

The waiting room had become a warehouse, where both donated and pre-existing supplies were being organized into neat stacks and piles. Here was the sterile gauze, there were boxes of gloves, that's the place for diapers and baby food. Extension cords snaked through the ER and the hallways, running from generators to construction floodlights. I found the hospital administrator in his new "office," a dark nook of the ER that used to be the staff lounge and library. He was talking to the head of maintenance on a two-way radio, hopeful that Mississippi Power might be able to restore electricity to the hospital this afternoon.

As it turns out, the hospital had not closed, but instead remained open during the storm. By the time they tried to evacuate some of the sicker adults, the storm was upon them and ambulance transports were no longer running. The wind ripped open a ventilation duct during Sunday night, but otherwise the building did fairly well until Monday morning, when the storm surge arrived. The first floor hallway became a stream. Then the generators flooded. As the water level continued to rise, the staff started evacuating patients up to the second floor, in the dark, in the heat and humidity.

After the storm, the worst was yet to come. Within a few hours, a steady stream of survivors began making their way to the ER. A nurse described it as a scene straight from "Dawn of the Dead," with an advancing horde of staggering, dazed people. Many had physical injuries: cuts, bruises, scrapes; others were trying to find food and water, though the hospital barely had enough for its own personnel. Some just wanted to be checked out after their ordeal. The makeshift ER ended up seeing 800 people in the first 4 days, before the federal Disaster Medical Assistance Teams finally arrived. Only then did the hospital close its doors and the brave, battered staff go off shift.

Needless to say, the hospital was in no shape to reopen anytime soon; the CEO thought it would take at least a month before even the basics could be provided. I asked about office space, since mine was completely unusable, as was just about every other building in town, and it might be two months or more before electricity and running water was restored. He said that FEMA might be providing the hospital some portable trailers in the next few weeks, perhaps by the start of October, and that the hospital would allow interested doctors to use the temporary space. I also learned that FEMA does not provide trailers directly to doctors; apparently, we are considered the same as any other small business, and our services are not essential to the community, no more than the local burger shop or clothing boutique.

Now we had some timeframe and direction: a hospital-provided trailer, in early October. This would be my new office.

Before I left the hospital, passing stacks of donated medicines arrayed in the ER, I realized I probably had some intact samples back in my office. The administrator said, "yeah, I don't think we went in your building." What did that mean? In the first few days after Katrina, the police and National Guard broke into some offices to commandeer medicines and create a small stockpile at the hospital. It was decided that the meds could better be kept safe, and distributed as needed, under appropriate supervision, at one central facility--which now happened to be also under armed guard. I should note that some offices stored not only antibiotics or cholesterol meds, but also controlled substances: painkillers, Valium, and similar.

We offered to add my meager pediatric samples to the pharmacy, since I wouldn't be distributing them anytime soon. We ended up collecting five boxes worth of medicines, all above the flood line, untouched and usable.

Outside the ER a truck from the Florida Department of Health was unloading bags of ice.

We walked back towards my office, about three blocks away. Just outside of the hospital grounds I saw a multicolored foot-long shard of hard plastic that looked vaguely familiar. It was a fragment of my office sign that had originally been by the road, perhaps 1/4 mile away. It was the only piece of the 4 x 6 foot sign I would ever find.

Monday, February 19, 2007

Jurisdynamics

The other day I received a blogosphere welcome from Jim Chen, Dean of Law at University of Louisville. Lest you think I routinely have friends in high places, I first made an "Internet connection" with Professor Chen through his blog, Jurisdynamics.

I don't remember exactly how I stumbled across his site, but I've found it to be incredibly insightful and thought-provoking on, among other things, the law as it relates to disasters. The site is actually about "the interplay between legal responses to exogenous change and the law's own endogenous capacity for adaptation."

Huh?

That sounds pretty heavy, but my interpretation (and I hope Dean Chen or his colleagues will correct me if I'm wrong) is that Jurisdynamics deals with the law's application towards, and evolution around, a rapidly changing and complicated society. Since we can't expect any single judge, lawyer, or lawmaker to be an expert on the many developments in technology, computers, communications, complex nonlinear systems, medicine and healthcare, even sociology and mathematics, we need to make sure that the legal system can be flexible enough to accomodate new situations. After all, at the risk of getting classically philosophical, what is the purpose of law, if not to serve the good of common society?

So Jurisdynamics is nothing if not interdisciplinary. But it's also fairly down-to-earth. You won't see (many) obscure Latin phrases, high-falutin' references to so-and-so court cases, and such. It's about ideas; it's about practical concerns. It's not concerned with impressing anyone; it is concerned with exploring issues.

And though I've never personally met the man, I get the impression that Jim Chen is much the same. Go to the site and peruse his CV: Fulbright Scholar; Harvard Law School; clerk for Justice Clarence Thomas; visiting professor in France, Germany, and Slovakia; 91 published papers or chapters; and now, dean of a law school. I stand in awe of this man's accomplishments in his field. But look at the papers he's written: the titles are full of witty cultural references: "A Vision Softly Creeping," "Come Back to the Nickel and Five," "Midnight in the Courtroom of Good and Evil," and my favorite, "The Sound of Legal Thunder: The Chaotic Consequences of Crushing Constitutional Butterflies." (Five points to the first reader who correctly identifies that last reference!) And I get the impression he has great respect for the English language, not as a crude tool for hammering out papers, but as an art form, as an elegant vehicle for complex thoughts.

I see Dean Chen and his CV and his intellectual curiosity and breaking boundaries, and I can't but help to admire him. That is what I aspire to, professionally speaking. That is one reason I want you to check out his blog. (Note: I say "his" blog, but in giving credit where it is due, I want to point out that Jursidynamics is not a solo effort, but rather the collaborative work of an exceptional cohort of scholars.)

The other reason? If you have any interest in Katrina, the failed response, and the stumbling recovery, you need to keep up with his site. It won't go into every breaking news item--just the important ones, and how the law can either help or hinder current and future efforts.

Friday, February 16, 2007

It's All In Your Head

I realize that making fun of Scientology's take on mental illness is an easy and cheap shot (much like Tom Cruise himself nowadays). Still, a patient yesterday reminded me of just how laughable/misguided/disgraceful such a denial is. For the few of you who don't already know, Scientologists believe all mental illness is curable through sheer willpower and exorcism of personal demons (the latter on multiple levels), and therefore they proclaim psychiatrists to be frauds who like doping up kids for money.

Of course, Scientologists believe the gospel according to L. Ron Hubbard, a hack sci-fi writer who invented a religion based on the evil space warlord Xenu and the "thetan" spirits that inhabit our bodies. Or something like that. No, really, look online if you don't believe me. Doesn't sound like they're in any position to judge the mental fitness of anyone else.

Anyway, without divulging too much detail, yesterday I saw a six-year old who was depressed. WAY depressed. Not like "I feel sad." More as in, "I hate everybody. Everybody is mean." Sitting on the exam table quietly, looking down, not cracking a smile, for the entire 30-minute visit. Mom says he's been like this every day for 2-3 weeks now, doesn't even want to play his video games.

So, Tom Cruise, want to try to clear his thetans? John Travolta, do you believe you can make this kid happy again?

It's fair to say, without being judgmental, that this is not normal for a six-year old boy. It also doesn't take a clinical psychologist to realize that there is something acutely screwed up in his brain chemistry. Adults with major depression will remind you that their condition is not simply a "bad mood:" it's more like being taken over, becoming physically and mentally incapable of rising above. Yes, there are many factors converging here: his home and family environment, his intellect and inherent ability, his experiences around Katrina. But none of this accounts for why a six year old boy would act like this for 2 weeks straight.

He needs to see a psychiatrist. Pronto. Unfortunately, there are none around here. I'm not averse to prescribing meds myself, when appropriate--but antidepressants are tricky. Last year the FDA became concerned about a few case reports of teenagers becoming agitated and even suicidal while on antidepressant medications (specifically, "SSRIs" such as Zoloft, Paxil, and Prozac). The FDA mandated a "black box warning" and urged extreme caution. So us pediatricians (already being told by many insurance companies that psychiatry was "not our area of specialty" and therefore not a reimbursable office visit) didn't want the extra liability, and we stopped prescribing SSRIs ourself, and referred all depression to the child psychiatrists.

Of course, the vital statistics released last month revealed a double-digit percentage increase in childhood suicides last year. Gee, who would have thought: if you don't give people antidepressants, they become--wait for it--depressed, and depressed people are at risk for being--wait for it, again--suicidal?

The perfect storm: politics, legal liability, and ivory-tower academics. But until the FDA decides to rescind that black-box warning, I'll be in BIG BIG trouble for any adverse effects from SSRIs that occur on my watch. I picture the malpractice lawyers licking their chops like ravenous wolves.

The mom assures me that she will watch and notify immediately if the child becomes a danger to himself or to others. In the meantime, we've spent 2 days trying to find a child psychiatrist (thank goodness he's not on Medicaid, or we'd be really screwed). We may have one an hour away, if we're lucky, who might be able to get him in one month from now (and mom will have to pay cash because she hasn't yet met her insurance deductible). And I guess he'll just have to suffer through it until then.

Monday, February 12, 2007

It's Mardi Gras Time!



The Waveland Krewe of Nereids held its annual Mardi Gras parade yesterday. For those of you not from the Gulf Coast, Mardi Gras is a BIG DEAL here. The Waveland parade may not be anything like you find in New Orleans, but it did have 80 floats, and it is one of the more family-friendly parades on the coast.

Afterwards, the streets looked like a giant pinata explosion, with colored beads and trash and smashed cups strewn everywhere. They're still cleaning it up as we speak, and by tomorrow it will be just another memory--but one of the happier ones as of late.

Friday, February 9, 2007

Pandemic Panic

Amidst the hoopla over the Gardasil (HPV/cervical cancer) vaccine this week, one news item largely overlooked concerned OSHA and the CDC issuing more pandemic flu guidelines. In the event of a severe pandemic, children would be largely quarantined; no school, no daycare, no spreading the nasty little hobbitses...er, I mean, flu viruses...until the pandemic started to abate.

By itself, that sounds prudent. Past studies have shown children to be the principal "vectors" for spreading the flu. Interrupt transmission by keeping them away from each other.

I'm curious if anyone on the federal level has considered the economic consequences of this. As a med school professor used to say, "if this is true, what does this imply?"

No school or day care means teachers and day care workers out of work, possibly for as long as 2 months. Parents will need to take off work themselves to care for their children. And parents' employers will no longer be able to function. Even if we prevent the flu from causing widespread death (which is very optimistic), the US economy would basically crash.

Has our government considered how they would bail out millions of small businesses? Pay for massive unemployment benefits? Would public employees still be paid?

On a personal level, what will happen to healthcare? Will I basically shut down my pediatric office for 2 months? Will I temporarily confine my practice to check-ups and children without fever or respiratory symptoms? Will I only allow one child in the office at a time? Will I leave my office to staff the ER? Note that none of these options leave me with a financially viable practice. After Katrina, I don't have any more financial reserves. A two-month shut-down--or even a slow-down--would most likely cause me to go under without state and federal assistance.

The devastation from Katrina will be repeated, but this time on a national scale. I'm not talking about the physical destruction; I'm referring to the economic fallout. The fact that we have still failed to address the Katrina recovery makes me very, very scared that pandemic flu would be far, far worse.

Have a nice day. >:)