Wednesday, July 29, 2009

Insensible Losses

I weigh about 190 pounds. That's equal to about 85 kilograms.

To figure out the appropriate hourly fluid replenishment for a (basically) healthy 85 kg patient just lounging around in the hospital we follow the 4-2-1 rule, which is that for the first 10 kg we supply 4 cc per kg per hour, the next 10 is 2 cc per kg per hour and then 1 cc per kg per hour for the rest of the weight. So 40 + 20 + 65 = 125 cc per hour.

This means that a basically healthy 85 kg guy (like me) loses around 125 mL of fluid from urine and insensible losses (think sweating, respiration, etc) per hour.

Over a 25 hour period that amounts to a nice figure of 3,125 mL or 3.125 Liters. Think about it - that's a huge water debt. A big bottle of soda is only 2 Liters of fluid.

People don't drink enough before a fast and it's dehydration far more than hunger that makes them feel like crap.

So drink well and have a meaningful fast.

Tuesday, July 28, 2009

Healthcare, Oh Boy

So I was asked recently to publish my views on the ongoing healthcare debate facing this country. I’m not sure why my views are so sought out given that I have some obvious vested interests in the issue, but regardless it is a topic of interest to me and I haven’t blogged in awhile so this is a good topic to rebreak the ice on.

To be clear, the issue at hand is the concept of a broad-covering government sponsored ‘insurance’ plan essentially modeled after similar programs like Medicaid for the poor and Medicare for the elderly to include anyone else who doesn’t fit into either of those titles. And apparently there are a whole bunch of Americans who are set in just that fix – 47 million is the number which gets thrown around, but just who are these 47 million Americans?

From the US Census Bureau:

Did you know that nearly 18 million of them are people from households that make more than $50,000 a year, i.e. people who could afford insurance but opt otherwise? And 8 million or so are between the ages of 18 and 24?
Did you know that around 10 million of these uninsured are not citizens of the United States, i.e. those who would not be covered by any of the public options being bandied around Congress anyway (and even should they be covered)?
Did you know that about 25% of these uninsured are estimated to already be eligible for existing public programs?

Now these figures likely overlap a bit, but you can pretty easily see that 47 million problems have been cut in at least half, if not more. Do ~20+ million truly uninsurable American citizens require an entire reformation of the system or are there some obvious and simple tweaks we could make that would absorb them into what already exists? Could we do that without costing (likely far more than) a trillion dollars over ten years? Hmm...

It has also been suggested by ‘objective’ assessments of medical care provided by different countries that the United States offers healthcare at about as good quality as Iran, or something to that effect. By counting things like average life expectancy and infant mortality and comparing them to some European nations, it appears that the US comes far inferior. But what these same comparisons fail to realize is that it’s isn’t just healthcare that determines those figures. Americans tend to also be generally more unhealthy in their simple daily diets and activities than those other countries – this alone could leave the statistics showing a reduced life expectancy in America. And unlike in Europe, Americans are far less likely to abort imperfect fetuses and far more willing to try and save premature babies – thereby leading to higher reports of infant mortality.

Additionally, US News and World Reports writes “[I]t's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates.”

Now, putting that all aside for now, I’d like to discuss a couple of philosophical problems I have with the idea of these semi-socializing welfare programs in general. The key thing to always keep in mind with welfare programs is that they sound nice and kind, but there ain’t no such thing as a free lunch. See, it’s a great political ploy that works again and again and again whenever it’s tried since not only do politicians get to play the moral high ground by offering the people free healthcare, for example, (as they oppose the opposition which clearly prefers that people die without treatment) – they also get to offer them free stuff! And what electorate can resist the idea of free stuff with the moral superiority package? But it ain’t free – somebody has to foot the bill.

Historically, those who were mandated to pay for the peoples’ insurance were the general taxpayers as they funded Medicaid, Medicare, SCHIP and so on – all unrestrained entitlements that are bankrupting this country. But also corporations and small businesses had to supply their workers with expensive health benefits which was a cost passed simply onto the consumers (ie the American people) and made American products completely uncompetitive on the international markets (which is also part of the reason why the United States is no longer an industrialized nation). And who has recently been suggested to pay for this newest gift to the American people? The middle class, of course. But how smart do you think it is to continue taxing the most productive segments of society – in a recession no less! - to sink money into the least productive? At a certain point, those smart people are going to realize that their hard work and ability is no longer working for them, but against them as they sooner and sooner hit marginal returns on their EARNED rewards. Better for them to work 30 hours a week and keep $150,000 than to work 60 hours a week and take home $200,000, eh? From where then are any of these programs going to be funded? Thus you should be not shocked at all to find that European per capita GDPs tend to be 25% less than America’s.

And despite what people clamor on and on about, healthcare is NOT a right. You cannot have a right to a service that someone else provides. Rights are natural things that surround the idea of personal freedom which others ought not interfere with. You have the right to life, liberty and the pursuit if happiness, but you don’t have the right to impose your will on a medical professional to treat you since that would enslave him and take away his rights. Free people trade value for value and you have the right to pursue professional care of your health through peaceful interactions. Doctors are not serfs and will not put up for long being government property.

Now, with even all of that said, the key thing to recognize is that financially the US healthcare system sucks. The U.S. healthcare system costs double what other countries cost with largely comparable end results. Even though nations with socialized medicine have a degree of rationing – so do we, TODAY. Sure, it’s not the government largely doing the rationing (though it obviously is in part as any Medicare recipient is well aware) but is it better when private insurance companies do not cover everything or have restrictively high premiums? In America we don’t ration by first come first serve, we ration by ability to pay. Better? And even though we don’t have a well organized socialized system, we still mandate that anyone coming in to an ER will be seen and treated – which is essentially the way the government eventually picks up the tab for the uninsured. The uninsured have no provisions for regular visits and simple meds to keep them in health so they show up to the Emergency Room when disaster eventually strikes, costing the system way more than regular upkeep would. So we effectively already have socialized medicine in America, we’re just paying for it ass-backwards.

The solution? I favor the gradual removal of all of these government-sponsored entitlement programs and a return to individual payment for medical care. Way better than any fraud-infested bloated bureaucracy or even any profit-driven corporation, the best person to take care of your own expenses is you. If you’re paying, little doubt you’d pay attention to the reasons for every proposed test, little doubt you’d seek the generic drug when you’re told it works as well as the more expensive new one, little doubt you’d not want to overload the system with minor complaints, little doubt you’d take a measure of responsibility for your own care and know your own history so that your doctor at the new hospital doesn’t need to redo a whole slew of the same tests you got at the hospital in your old town. This reality plus a healthy charity mentality in medicine is the way to go. Healthcare should be recognized as a charity of high regard – millionaires should endow hospitals and individuals can help others in their community. Doctors too should be willing to take a certain number of pro bono cases, since after all, they can afford it now that they are actually receiving the money they billed from their regular patients.

But since this is never going to happen, is a broad covering government insurance option the worst idea? Perhaps not. If creating it removes our other non-afforded entitlement programs then it may be well worth it. But will it end up being the same kind of bloated bureaucracy, with waste and fraud being hallmarks of government involvement - most probably. My prediction: it will happen eventually - it will cost a ton of money, be moderately effective and significantly rationed which will lead to the existence of a two-tiered medical coverage system. People who have private coverage will want to stay private while everyone else will be grouped in the new program. It won’t change medical care all that much but will possibly lead to simpler medical billing for many Americans. Economically we'll get by but with people far less willing to share their earnings charitably (like it is in Europe, charity is a rare gift) and our grandchildren will be the ones still paying the interest on our out of control spending today.