Reagan Republicans hated OSHA–no surprise

With a hat tip to Dave Farber’s ip list:

Here’s a nice Labor Day story.

In 1980, the last year of Jimmy Carter’s administration, the Occupational Health and Safety Administration (OSHA) commissioned a series of three 30-minute films about worker safety. These were real pro productions, with Studs Terkel as narrator on two of the productions. In 1981, Reagan appointed 36-year old Florida construction executive Thorne G. Auchter, who proceeded to systematically dismantle the agency. Evidently, the 3 films disturbed Thorne greatly, because OSHA issued a recall, threatening to withhold OSHA funds from any organization that did not return their copies of the films, which were promptly destroyed.

But, a few union officials defied the ban and "stole" copies so they weren’t able to be returned. Over the years, they would occasionally show them to their troops, using the fact they banned as a way to get them to watch the films, which have important messages about worker rights and workplace safety. But, aside from these bootleg showings, the video disappeared.

Public.Resource.Org got a note recently from Mark Catlan, a health and safety expert for one of the unions for the last 28 years (he actually started working for the union the year the film came out, and remembers his education director stealing a copy out of his office so it wouldn’t get returned). A year ago, Mark decided the world needed to see these films, so he found 16-mm canisters and made them available to us to transfer to DVCAM and then disk.

Making their public debut after 30 years are "Worker to Worker," "Can’t Take No More," and "The Story of OSHA."

Link to YouTube

Link to the Internet Archive: 

Carl Malamud <>

Can VoIP survive Congress?

So should emergency physicians hope that VoIP does not survive Congress so that California could better fund its emergency services? Yesterday I pointed to the California Medical Socieity’s President’s proposal. Today, Congress wants to preserve the subsidy for rural and low income “plain old telephone service” (POTS).
The Wednesday, July 7 hearing, “VoIP: Will the Technology Disrupt the Industry or Will Regulation Disrupt the Technology?” should open a small window on this policy making process.
It seems intuitively more reasonable for subsidy to accrue to the same business rather than across businesses. Not that telephone taxes haven’t funded wars, but at least the present subsidy goes to deliver telephone services to more users, not EMS.

California Medical Association President Supports Emergency Services Ballot Initiative

The initiative would add a 3% surcharge to residential and mobile phone bills (free registration required)

Much as I’d like to see support to “help bail out” emergency departments, trauma centers and emergency doctors I don’t think taxing communication services is a good approach, particularly as Vonnage Wins One suggests that we may not have plain old telephone service (POTS) to kick around for much longer as a tax base, or at least that is if we want a modern communication infrastructure; a social good at least as important to our society as emergency health care.

Mobile Lawyer arrives at the ER

imgp0291_2I arrived at work Tuesday, May 4 for an early meeting and found this truck parked outside of my ER in physician only parking.

imgp0292_2Our security staff chased him from the physician parking, but he spent the rest of the day camped on the corner diagonally opposite the ED. I guess it must work or they wouldn’t be doing it.

So this is what has happened to two grand professions in a world where capitalism has triumphed over common sense.

The Tsunami: Neither Hasten nor Postpone Death

The Centers for Disease Control reports that 8.7% of all ED visits in 2001 were by patients aged 75 and older.[1] At Maimonides Medical Center 16% of our patients fall in this age group. Though I’m a “baby boomer” and he’s not, Daniel G. Murphy, MD, MBA (Hofstra Business School, May 2003) our Vice-Chair and Medical Director for nearly eight years has given much more thought than I to this theme. So let me turn this month’s column over to Dan.

Perhaps I use too many metaphors explaining my thoughts, but one bantered about in Boston this October at various Quality Improvement and Patient Safety Section, Geriatric Section and Benchmarking Alliance meetings during the recent ACEP Scientific Assembly needs sharing among us:

“A tsunami is coming!”

For years, we have worked hard to make our emergency departments more efficient. Best practices, data driven CQI, customer service, error reduction, computerization, decision support, streamlined bed control and standardized peer review processes are just a few of the successful efforts and new paradigms. It’s a good thing too, since the role of emergency departments in America grows more crucial and more burdened annually.

But a tsunami is coming, already visible on the horizon, presaged by choppy and rough surf today (crowding), and it may wipe us out before we retire. The tsunami is the aging ‘baby boomer’ generation and emergency departments and hospitals are (to complete the metaphor) the coastal villages lying directly in its path. It provides a dispiriting backdrop for today’s EM CQI tinker. Input may soon overwhelm a process already lamenting its inability to transfer admitted output (inpatient boarders).

One way to prepare for and assuage this impending disaster is to reconsider how we die in America. We need to die better, with our families, perhaps at home, with no one doing chest compressions and no one putting a tube down our throat. Hand holding, praying, crying and feeling is much better. We just need a major culture change and then implement better end-of-life education and better communication.

I know the following: a) more of my patients are very close to or at the end of life, b) emergency departments and hospitals are horrible places to spend the end of one’s life and c) we do a poor job of caring for patients and guiding families at the end of life.

We need to help identify that point in a person’s (person, not patient) life where there is more value and reward in focusing on planning, comfort, dignity, family and ritual. Life is a terminal condition. Palliative care is a desirable choice for almost all people at some point prior to death, whether it is hours, days, weeks or months before their final breath.

In the July-August 2003 SAEM newsletter, Drs. Quest and Abbott summarized the World Health Organizations definition of palliative care.[2] :

• Active, total care of patients whose disease is not responsive to curative treatment.
• Control of pain and other distressing symptoms.
• Address psychological, social and spiritual problems.
• Achieve the best quality of life.
• Affirm life and regard dying as normal.
• Neither hasten nor postpone death.
• Offer a support system for patients to live as actively as possible before death and to help families cope and then bereave.

But what can we do in the emergency department? The nursing home keeps sending them. The families can’t handle it! There is little expertise and ability at home. Sometimes there seems to be little end-of-life expertise in the nursing home. By the time the dying elder is in the ER, the opportunity for privacy, tranquility and even dignity are lost. If we don’t ignore you, we may intubate you! Our comfort with natural death and dying is notoriously fragile in the ER. We will almost certainly stick some tube into an orifice. It’s our nature.

Some of us in the United States are comfortable with impending death only when paperwork is current and pristine. The documentation includes ‘do not resuscitate’, ‘do not intubate’, other advanced directives, living wills and health care proxies. Is the need for certified, renewed and impersonal contracts reflecting some difficulty of the American healthcare system to connect with our patients at the humane and primary care levels? Do we fail to see the forest, only some frustrating tree, confounded and frightened by medico-legal risk?

As Mildred Solomon, EdD[3] and Linda Kristjanson, PhD[4] explain of the Australian healthcare system, “Long-term relationships between general practitioners, patients and families, coupled with the existence of palliative care services, solve many of the communication problems that, in the United States, advance care directives are intended to ameliorate. Once the decision to accept palliative care is made, people accept that certain things won’t happen, the resuscitation matter dissolves, and patient, family and health care team address each end-of-life question, such as tube feedings or the use of antibiotics, as these issues arise.” Kristjanson continues, “You know your patient, the relationship is very individualized, thus an advanced directive would be seen as a legalistic document that would be incongruent in the context of the relationship.”

Such holistic, generalist, and humane approaches are unusual where we practice. Indeed, too many elders seem to have a neurologist, cardiologist, podiatrist, cardiothoracic surgeon and dermatologist, but no one who takes responsibility for the care of the person instead of an organ system. I witness nursing home admission procedures where patient-physician relationships that have endured decades are terminated just as end-of-life planning is most crucial. As long as our federal healthcare reimbursement model encourages procedures instead of humane, generalist care, form will follow finance and poorly integrated, intrusive and wastefully expensive end-of-life care may predominate.

But I ask again, what can we do in the emergency department? What can we do as emergency physicians?

I believe that our contribution could be significant. We are, after all, generalists. We are capable of seeing the big picture and treating or palliating every sort of ailment and organ system. Are there desired end-of-life services that we are uniquely qualified to provide? Perhaps there is a significant pre-hospital or ED need and market eager for our care, advice and skills.

In the House of God,[5] the term GOMER was first publicized. How ironic to consider the phrase as prescient, desirable and sophisticated. Look out to sea. A tsunami is coming. There may still be time to build an adequate sea wall and save the village. If we work hard and fast, we will just get bumped around and wet like we always do.

[1]McCaig, LF and Burt, CW: National Hospital Ambulatory Medical Care Survey: 2001 Emergency Department Summary in CDC Advance Data from Vital and Health Statistics. No. 335, June 4, 2003.

[2]Quest TE and Abbott J for the SAEM Ethics Committee: Palliative Care and the Emergency Physician: Finding our Way. The SAEM Newsletter XV(4): 14, July-August 2003.

[3]Solomon MZ. Why are Advance Directives a Non-Issue Outside the United States? In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 13-18.

[4]Kristjanson L. Advance Care Planning in the Australian Context. In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 43-46

[5]Shem, S: The House of God. Dell, 2003

Heard Bruce Schneier

imgp0153_cropped2Heard Bruce Schneier speak in the Kohn Lecture last evening at the 92nd Street Y.

Schneier’s five steps to security analysis make sense to me and I enjoyed his examples. The five steps:
1. What assets are you trying to protect?
2. What are the risks to those assets?
3. How well does the secuirty solution mitigate the risks?
4. What other risks does the security solution cause?
5. What costs and trade-offs does the security solution impose?

He was wonderfully clear about the trade-offs in security, but a bit blurry on threat and risk at times despite his efforts to avoid conflating the two. Nonetheless, I was a bit disappointed by the rigor in the discussion. I suppose I’m lamenting the substitution of the political for the technical in the lecture though Schneier was quite clear that he’s not running for office. I’ve not yet had the chance to read the entirety of the book, Beyond Fear, in which from what I’ve already read he’s clearly more technical.

Still, Schneier is not addressing risk as conceptually nor as thoroughly as Peter L. Bernstein does in Against the Gods, The Remarkable Story of Risk which takes a historic, mathematical and conceptual view of risk, ultimately discussing risk in modern financial market terms. While not directly on point to Schneier’s discussion in terms of security, nor operational risk as I conceive of it from my time in the field in EMS, Bernstein’s historical, mathematical and conceptual discussion would enrich strategic planning in the entire emergency management field.