And I Should Know This... How?

I still haven't blogged my bill for having my appendix removed, because I've been waiting to tie down the bill itself. The hospital I chose was in-network for my health plan, but I'm getting a bill for a little under $800 for the ER services.

So, it turns out that while the hospital is in-network, the doctor in the Emergency Room is not. The doc is not employed by the hospital, but instead is essentially a consultant.

How I'm supposed to figure that out I have no idea. How I'm supposed to find an in-network ER doctor during an emergency I have even less of an idea.

Back when I was a consultant, tax law requires that if I work a certain number of hours for one employer I cannot claim self-employment or consultant status as that would essentially allow corporations to evade employment costs. I wonder if this applies to ER doctors?

Do ER docs work at multiple hospitals, multiple employers?

But still, my main point is that I chose a hospital that is in my health plan's network, but the ER doctor is not being paid by my health plan because she's not in their network. Hence, I have a bill for $900.

How the heck am I supposed to avoid that?

It's an EMERGENCY room. I had appendicitis. I assumed once I was past the front desk and my health card had been entered into the system and approved as a method of payment, that my care was going to be provided by in-network staff. Why should I believe any different? How could I possibly choose which doctor attends to me in the ER?

And had I known or found out, what should I have done? Gone to a different hospital?

I received two bills from the generically-named billing company and I thought I was safely ignoring them, that my insurance would figure it out and kick in at some point. Now I'm getting collection threats which prompted me to follow up and find out that the health plan considers this doctor out of network.

This is the same insurance company that paid the $16,000 appendectomy bill no questions asked, but they won't pay the doctor bill that was submitted for service on the same day as the operation.

Make sense?

Nope.

And people ask me why I think it's important to bring transparency to health care...‎ Full story...

Quality Surgery, Guaranteed!

It's almost sad that this is newsworthy, but a hospital in Pennsylvania has elected to stop charging people for fixing it's own mistakes.

In other words, if the hospital cuts off the wrong leg or causes you an infection and you require additional treatment *because of the hospital's wrongdoing*, they'll fix it free of charge. I know. It sounds CRAZY right? Anyway, hit the link for the Times article.

How come Pennsylvania always seems to be at the front of these sorts of things? I think it must have something to do with the high Welsh population... all that common sense must permeate somehow :o)‎ Full story...

Guest Blog: Open Source and Primary Care in the US by Timothy Cook

Tim Cook, a vocal proponent and leader of open source in the health care IT space and owner of possibly the most impressive list of achievements in the FOSS-meets-HIT space, managed to stumble across a post I made a while back about the National Health Information Network. Even though he was apparently having a much more interesting Christmas than I was, he took the time to drop me a note which led to the guest blog below. Thanks Tim!

Back in March 2007 Jaz-Michael King posted about open sourcing the National Health Information Network (NHIN). There are success stories regarding using open source as part of some trials being done with NHIN record locating such as the Mendocino HRE as well as others.

But, as Jaz pointed out in December 2007, Regional Health Information Organizations (RHIOs) are struggling more because of lack of "Information" as opposed to lack of funding. If they could get the information into the systems then the funding would take care of itself.

So the root problem lies in; why can't we collect the information? Virtually all primary care clinics have computerized billing systems. The problem is that billing information is not rich enough to really provide the content and context needed for longitudinal patient care.

The real solution is capturing information electronically at the point of care. That information can then be used for many purposes including driving the billing systems and decision support.

The reasons that US primary care clinics have not adopted electronic health/medical record applications is because of the economics of doing so. Just the licensing of these applications can run into the tens of thousands of dollars. There are several open source alternatives that carry no license fees. However, the real costs of implementation of these systems include so much more than just licensing. Books such as "Computerization and Going Paperless in Canadian Primary Care" (ISBN-13:978-1857756234) detail these processes and expenses. It can easily take up to 24 months to transition from paper to electronic medical records. This is expensive in terms of not only training but in temporary reduced efficiency.

But, even if a clinic forges ahead with an implementation and they are successfully converting from paper to electronic; who gains? In a 2004 View Point paper by the American College of Medical Informatics (J Am Med Inform Assoc. 2005;12:13–19. DOI 10.1197/jamia.M1669.) they identified some primary reasons for the failure of the health information technology market in the US. Two major ones are:

1) Misaligned incentives. Simply, the people being expected to pay for EHR systems are the ones gaining the smallest percentage of pay back. payors and employers have by far the most incentive to see EHRs implemented.

2) Lack of true interoperability standards. In order for payors and employers to gain their maximum benefits, the systems must be able to communicate semantically correct patient information using open standards. In order to be capable of communicating semantically correct information, they must first be able to STORE semantically correct information. I believe that this is a bigger problem than the health informatics community realizes.

Longitudinal patient information is arguably one of the most temporally and spatially complex information sets known. Certainly GIS and others are complex as well but the science of medicine and therefore healthcare is constantly changing creating a moving context. To understand how to treat a patient the healthcare provider needs to be able to understand what has worked as well as what hasn't worked in the context of what was known about the patient and the treatments available at any point in time. This creates an environment of very complex data relationships. If any one of those relationships are broken then the semantic context of the data is lost and now there is a loss of information. Data items need to be bundled and stored as a complete unit of understanding for them to constitute information. Once broken apart into separate data items they are much like Humpty Dumpty.

Open information exchange specifications have been proposed such as the Continuity of Care Document (CCD) but again it isn't really an electronic health record model.

The openEHR specifications ( http://www.openehr.org ) are an object-oriented information model based on over 15 years of research and implementation experience designed specifically as an electronic health record information model. The openEHR specifications provide an opportunity to avoid the Humpty Dumpty data fracture. Through the use of "two-level modeling", openEHR specs describe a solid reference model enhanced by archetypes that bundle data items into an contextual information packet. These information packets can be transported between systems without loss of semantic context. I believe that vendors, proprietary and open source, would do well to examine the openEHR information specifications for use as the basis of their systems.

Use of a common information model will open the door for payors and employers to see their benefits unfold as patient information can be exchanged maintaining its semantic context. I project that this will reduce healthcare costs, improve quality of care and improve patient
satisfaction in the processes of care.

Timothy Cook, MSc
Health Informatics Research & Development Services
LinkedIn Profile: http://www.linkedin.com/in/timothywaynecook
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I Am Deformed

I've been having some annoying shoulder and neck pain lately which I've been attributing to rugby and like all good Welsh rugby idiots, I've figured if I ignored it it would go away eventually. Ah well.

After a month of wincing I finally decided to see someone about it, but really didn't want to go the whole doctor/surgeon route. So I went to a chiropractor.

I will document my experience over the next few months, which I'll start here by talking about the first visit.

My first note on arrival was that it was pretty much like a doctor's office, girls behind the desk, a bunch of chairs, some magazines. Everything was more naturopathic though, the magazines were all granola types.

After my insurance card was inspected, I was taken to a back room with a massage table device and a computer. A tech came and ran two scanning devices up my spine, one for "nerve imbalance" and the other for "muscle problems".

As she scanned, a graph was being spat out onto the computer monitor, with varying amounts of red and green spiking away horizontally from my spine. She told me this was a significant amount of "nerve imbalance" which I asked what that meant.

She said it meant my nerves were imbalanced, which I politely told her I had understood as much... what did that *actually mean*?

She looked at me quizzically and replied no-one had ever asked her that before.

Anyhoo, the chiropractor came along and told me what was actually going on physiologically, and after a few pokes and prods declared I likely had a straight cervical spine as opposed to one that curves away from your head. He X-rayed me and said no, was wrong. In fact my spine curves in exactly the opposite way it's supposed to, it curves forward.

I took this as proof positive that I am in fact a lot more cro-magnon than most would believe.

So I am currently in therapy, I have had two cracky popping things done to me that have made me feel better, and I have a silly-looking device I have to lie down, strap my head into, and inflate. It sounds funner than it is, believe me.

I will collect up the bills and post them here when I have a few for review. For now, the chap has been extremely forthcoming with information and does not hesitate to answer any of my myriad questions.‎ Full story...

About Bleedin' Time

So it looks like the 29 BILLION dollars' worth of research funded by the NIH will finally be open access to the public that paid for it in the first place...

The Washington Post covers this nicely so I won't go into too much detail, but long story short, we pay taxes, government funds research, research gets published in journal, journal costs $500 a year if you want to read the results.‎ Full story...

Medical Myths

Cool little article from BMJ about common myths that persist, even in the doctor's office.

• People should drink at least eight glasses of water a day
  
• We use only 10% of our brains
  
• Hair and fingernails continue to grow after death
  
• Shaving hair causes it to grow back faster, darker, or coarser
  
• Reading in dim light ruins your eyesight
  
• Eating turkey makes people especially drowsy
  
• Mobile phones create considerable electromagnetic interference in hospitals.

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RHIOs Need Data Not Dollars

GovHealthIT reports on a Harvard study that finds that RHIOs across the USA are failing abysmally. Well duh. Regional Health Information Organisations can only function if and when they have regional health information to organise. Imagine building Google before the Web. Or Facebook before E-mail. That's what we're seeing happen now, and the feds STILL refuse to speak up.

Two systems that work that I think shine a light on how to build a national health network are the Internet and the credit card clearing system. Neither of these systems were written into law, neither came from new taxes, yet somehow they seem to work and sustain themselves.

The calls for funding RHIOs get louder and louder, yet these people HAVE NO DATA to share.

I have a few thoughts:

Incent adoption of electronic health records NOW. We don't need RHIOs, we need records.

Understand that successful implementation of EHRs will REDUCE REVENUE for those people implementing. REIMBURSE THEM.

If we build the data, the network will take care of itself.‎ Full story...

Doctors, Plans, Doctors, Plans...

In an almost humourous move physicians today released a report card of their own: a report card ranking pay-for-performance plans in Minnesota. Coming from the very people who have been staunchly defending themselves against public reporting, this could seem a little tit-for-tat counter-intelligence style of guerrilla physician warfare, but the details are pretty cool.

The Minnesota Medical Association reviewed nine P4P programs and declared the system to be inconsistent, forcing docs to work to nine different tunes. Much of the problem lies in the fact that the health plans themselves don't have a standard way of measuring quality performance, which leads to docs having to chase their tails trying to meet performance objectives.

On a side note, I see again the concern that docs who treat "sicker" patients are unfairly measured as these populations should lead to risk adjustment for the physician.

I don't know about you, but if a medical society is willing to posit that Doctor A treats sicker people than Doctor B, I suggest that instead of grading Doctor A on a curve, we take the medical society at their word that Doctor A is not achieving good outcomes and get his "sicker" patients a better doctor who can actually handle the extra effort required.

If they're sicker, surely they should be getting better-than-standard care, not risk-adjusted average care? Call me crazy...‎ Full story...

I Told You So

"Have them take it out, it's not even necessary". Amidst all the appendixotic shenanigans of this year, people kept reciting this to me. "The appendix is vestigial". "The appendix is useless". "You don't even need it".

Now, I'm not a god-fearing man. I don't subscribe to creationism and only slightly less non-subscribing to evolution. I live in the here and now, and if my body saw fit to grow an appendix then dammit it's there for a reason. I dodged having the thing removed for a long time over this.

Apparently it's where all the good germs live (Science Daily).

So, in some form of anti-Jaz spite contest, the medical community held back on letting the world know what the appendix is for until I had mine removed.

Bah.
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The-Paris-site: Comments That Rang Clear

The-Paris-site: Comments That Rang Clear....9/27

Interesting story about a blog that is being sued by a hospital. The blog is posted to anonymously, and the hospital is claiming defamation.

I don't know enough about the story to comment, but it brings up something I have to tell a lot of people far too often: there is no anonymity on the Web.

There is a perceived anonymity that has long been inherent thanks to free E-mail accounts, nicknames, forum IDs and the like. If you want to sign up as hotgirl22 or professor55 you're free to do so, but using the Internet requires that you identify your machine. From there, everything you do is tracked.

Every thing you do on the Internet bounces through routers all over the country. You request a Web page and that request goes from your machine to maybe 30 locations, all capable of logging the request. At a minimum both your ISP and the server you requested from will store your information for some time.

Now, for the most part, no-one cares who you are and you can skate through all sorts of Internet life as hotgirl22 or professor55 for years, but the second someone starts to care you should know that someone, somewhere probably knows who you are.

You purchased Internet access with a credit card. You provided a secondary E-mail address. You bought something. You signed in at the library.

There is no anonymity on the Web unless you're prepared to work very hard to obtain it.

Whether or not you have a right to anonymity on the Web is another discussion, but when your mediocre attempt at anonymity falls flat simply because you logged on under an assumed name, don't think for a second you'll be able to preserve your secret.‎ Full story...

New York Regional Health Care Report Card Goes Live

I know, I've been quiet. It's been a while since I posted, and here's why:

First and foremost, I have been buried in data all summer, getting this report card out. More on that in a minute.

Secondly, I determined to take some time to myself this year, so I've taken a slew of short camping trips to spend time with my son, do some fishing, sleep in a tent and generally get some of the city out of me.

Thirdly, I finally had my appendix out after my third and final bout with appendicitis.

So, now it's out. It's online at http://www.nyshaf.org/hcrc and I'd like to take this post to explain how I think it can be used, what purpose it serves, and talk about some of the data involved.

The report card is split into two main sections, HMO and Hospital. In both sections the report is split up by groups of measures that can viewed side by side, some quality, some patient experience, some cost.

One of the main problems with public report cards is that the health data is so complex and so arcane it's practically useless to the lay consumer. Sometimes a lower score is better. Sometimes a higher score is better. Sometimes the score is a percentage, sometimes a range. Sometimes it's a vague statistic definition, such as "not significantly worse that the national mean".

Another big problem is the tendency to predetermine what "good" is, and then try to communicate that top the viewer. Health care providers may say that high quality is paramount, cost is irrelevant. An HMO may say that the best care is given by better high quality, low cost providers. Some people think high volume is a good thing, other's don't. The list, and the permutations are endless.

Finally, the overarching goal is to present as many of these public reports as possible in a single space in a single format. For this year's report we've combined 25 publicly available reports which you'd normally have to obtain from 25 different sources.

So I set about trying to determine how to take all these kinds of different data and represent them in a singular fashion that would be easily and quickly comprehensible, without implying a judgement or a ranking. More than one reporter asked me "which hospital is the best?" My answer is always another question: best at what?

One hospital may be the world's best for cancer treatment; is that where I should go for a scheduled C-section?

There is no best hospital, there is no best doctor, no best surgeon, no best HMO. But there *are* providers that are better for you and your individual needs than others.

So, goals set: translate complex data analysis into visual nuggets of qualitative information, and allow the user to narrow down the qualities and measures that matter to them.


What you see above is one category of HMO data. More detailed information is available with a click or two, but at a glance you can see that for customer service one HMO stands out as being highly rated, three are more or less average, and one has some issues.

At least, I hope you can see that. If not, I just wasted a year.

So how can a consumer use this report card?

Example 1: Heart Attack

I have never heard of anyone having a heart attack and stopping to consult report cards on where they think they should go.

However, once you're in the hospital, your loved ones can consult the report to see how well the facility you ended up at is faring at providing quality treatment. If anything stands out as worrisome, bring it up with your doctor.

Further, several of the measures apply to the care you receive after your emergency treatment. Medications prescribed at discharge for example, including aspirin, as well as smoking cessation counselling.

Mortality rates for heart attack are relatively flat, everyone is going to be pretty much "as expected". If your hospital shows up red for mortality, bring this up with the hospital staff.

You may be looking at a co-pay or even worse, you're uninsured. Use the average charges bill to get an idea of how much the stay will cost you or your employer. You can also see the average length of stay for a heart attack patient, and if it's shorter or longer than you think is right, raise this with your physician.

The overall point is that the level and standard of care can and will vary from hospital to hospital, and nowhere is perfect. It pays to be informed, and remember you are your best advocate.

Example 2: Choosing an HMO

Some employers will offer you a choice of two HMOs. If you or your partner has an ongoing condition such as asthma, have a look at which of the two HMOs available seem to be more on the ball for that condition. Then check out the customer satisfaction ratings for that HMO.

If you don't have a choice and your HMO plan scores poorly, then use that as a reminder to make sure you get the care you need by advocating for yourself. Have a look at the care provided by other HMOs and demand that same care from your primary physician.

If you have children, compare the two youth sections. In my county, only one HMO has all green for appropriate youth care.

Example 3: Appendicitis

I have a bit of personal experience here. I had the symptoms of acute appendicitis for a few days, and finally went to the ER after the symptoms didn't go away. i was a little atypical, and was in little danger of perforation, but nonetheless you may be able to do what I did.

I looked at the five hospitals nearest me, and compared the length of stay for an appendectomy, the surgical infection prevention score,a dn the price.

I'm price-sensitive even though I have good health insurance. The company where I work pays for the health care I receive, and the last two years have seen a steady increase in both the company cost as well as my family rate contribution to the plan. Further, all my co-pays went up significantly this last year.

Because health care is so often paid for with invisible dollars it can feel a bit like Monopoly money, you never see it, you never worry about it, you get a long, arcane bill that you never have to worry about. However, I know that if I can get an appendectomy at hospital A for $10,000 less than hospital B, I just saved the company money. Saving the company money puts more dollars in the kitty for my next pay raise. And being relatively young and by all accounts rather stoic, I'd rather have the cash up front than ploughed into a pool for a rapidly greying employee population.

In my county, appendectomy hospital bills range from $7,000 to $30,000.

Let me repeat that.

In my county, appendectomy hospital bills range from $7,000 to $30,000.

That's before the surgeon's and anaesthetist's bills.

I actually placed more importance on finding a hospital that had a low average length of stay with good surgical infection scores. I wanted somewhere under $15,000 with three or so days stay on average.

The hospital I chose actually had a poor score for timely antibiotics, so instead of choosing a different hospital, I questioned the staff when my first antibiotics were given and ensured I was less than an hour from surgery.

Example 4: Mother to be

Some women search for hospitals that are less inclined to perform a C-section. In my county, the C-section rate varies from 17% to 34%. That's double the rate. For primary caesareans, the rate goes as low as 11% at a hospital that also shows a high rate of vaginal births after C-sections, clearly a hospital that can help you have a natural birth.

Others may choose the scheduled C-section route, and look for a hospital that performs a good number of the procedure. You can compare the number of times the procedure was performed in a year at all your local hospitals, as well as the surgical infection prevention scores.

Looking to get home quickly after the surgery? Some hospitals have you stay for three days, others for five.

--

In my next post I'll go into more detail about the different data sets including the different kinds of measures available, where we get the data from, and how accurate that data is.

In the meantime, I am very interested in hearing from anyone who has used a public report card similar to this one in a real life situation. Was it useful? Did it complicate things? Did you bring anything up with your doctor?

Finally, if you wish you had similar resources in your community, consult www.abouthealthtransparency.org/ and click your state. You can also check out www.consumerhealthratings.com/
‎ Full story...

Appendix Ultimatum

So, the old appendix flared up again, as of course it should. Same symptoms as before, it was evident what was coming. I left work, drove home, and prepared for my first hospital stay.


(Quick reminder for the uninitiated: I visited Hospital A in February with symptoms of appendicitis, waited six and a half hours in the E.R. until giving up and going home. I then visited Hospital B the next day and had the most awful day I've had in quite some time, culminating in me being seated on a gurney two corridors away from the E.R. outside the isolation room where a guy with full-blown tuberculosis and his wife were wandering in and out of isolation back and forth in front of me complaining of the heat. I've had a dodgy appendix for quite some time. Read the full story in all it's glory here.)

I gathered a book, a change of clothes, and the average length of stay for the five hospitals closest to me - not including hospitals A and B from my prior sojourns. I then had a good night's sleep in my own bed, and mentally prepared to lose myself to the system for a few days.

I saw that my hospital of choice had lower than desirable scores for infection prevention, so I made a note to bring it up when antibiotics first appeared.

My plan was to hit the 8 a.m. shift change, but my subconscious desire to not go to the hospital had me pacing the living room until nine, so I didn't get to the hospital of choice until ten. Nonetheless I was triaged within 12 minutes and was seen by a doctor within another 15.

Emergency Preparedness

The E.R. proper was impressive; clean, lots of open space, certain areas were labelled - such as the asthma section. The doctor who saw me was amazingly friendly, very informative, listened and heard the story of my history with appendicitis and it's atypicality. I drank the stuff you need before going for an MRI and was confirmed to be suffering from appendicitis by around 3 p.m.

I was told that I'd be admitted to the E.R. and therefore settled in for the wait.

It should be noted that this whole time I was in my regular clothes. No gown. Clothes. I cannot begin to describe the difference compared to sitting in Hospital B in February all day in a gown.

I was in the E.R. up until around 7 p.m. During the entire day, I felt like I was in a place that was very aware of its patients. My E.R. doc was fantastic. Checked on me every once in a while, I received regular updates about my status. Around tea-time the learner doctors began arriving one after the other to poke and prod.

I was given a form to sign that acknowledged I had received various forms and information. I asked for the said forms and information, but was told I would receive it the next day. After a brief exchange of dry sarcasm, I elected to shut up and sign the release, making a mental note to see when the information actually arrived.

It was given to me two days later.

As the reality of surgery became more and more present, I asked the learner doctor surgery chap who was taking all my details down about how I could remove my appendix home with me. While it may seem odd to some, I am part of a large group of people who actually want to keep their hands on the bits that come out of us. I asked earnestly about my ownership of my slated-for-removal organ, and even offered to go halvsies on it so that pathology could have something to look at. I asked two different surgery doctors to check on this for me, I never got an answer nor did I see those doctors again.

Slowly, as my status was swinging from profitable E.R. visitor to run-of-the-mill appendectomy last thing on a Friday night, I became less of a customer and more a vocal cadaver.

Special Ops

Looking back, the thing that really peeves me is that no-one ever told me what was going to happen *after* the surgery. I did not know I was going to be shaved "down there".

I did not know I was going to wake up with tubes up my nose and another down my throat into my stomach. I did not know there would be metal staples in me. I did not know I would spend the night in a recovery room full of other people.

None of this was impossible to deal with, but knowing it beforehand would've made waking up after surgery a whole lot easier.

Seems to me that pre-op I should be given a one-page handout along the lines of "Appendectomy for Dummies" that covers what they're about to do and what things will be like after.

One page. A couple of paragraphs. That's all I'm asking. I don't want half an hour with a very busy surgeon stroking my hand and reassuring me. Just give me the handout.

So I woke sans appendix. The operation took longer than expected as my appendix was reluctant to leave, for which I feel proud in a silly way. The surgeon chap, when trying to impress upon me how aberrant my appendix was, exclaimed "that was one ugly appendix", at which I was offended in a silly way. It was twisted around and clinging on, he described it as having to "peel it off out of there".

The first 24 hours were simply uncomfortable as I had this pipe down my neck. I finally made it to a room, where I experienced my first real time in a hospital bed.

Overall, the stay was great, everyone was polite and friendly. The only real grumble I have is that the surgeon was very obviously agreeing to anything I asked like "please take this pipe out of my stomach" or "let me eat some ice chips" but he had no intention of doing so, which he could have just said so instead of trying to placate me.

For example, he told me the pipe could come out within the hour, left the room and gave no such order. This happened three times, all the while he actually wanted the thing in there about 36 hours. He told me this after it was removed, along with why it had to be in there for so long in the first place.

Information I could have really used, say, 36 hours ago.

Feed Me

Due to my atypical presentation, the guy wanted me in hospital for four or five more days. I worked really hard on walking around, looking healthy, and passing gas "back there". Given that I chose the hospital based on their apparent ability to kick people out relatively quickly, I felt I should give it the old college try. The surgeon really wanted me to stay in, but after talking to the resident who was visiting me, the surgeon came by eventually and checked me out. Again, I really felt listened to, like what I was saying was relevant, that I knew my limits and capabilities, I knew my body, and I felt like I would recover better at home. I was passing gas "back there", I was walking around unaided, I was peeing like a racehorse. The guy let me go home, albeit reluctantly and with many cautions about when to come back if such and such happened, but the point is they listened to me and let me go home.

Either that or someone googled me and figured they should let me go before I caused a scene

By the by, why is the no Internet in hospitals? I worked every day checking E-mails, I would have loved to do some research on recovery from appendix surgery, check the rugby. I was reduced to working on my phone which is mind-numbing after any decent amount of time. Get some wi-fi people! We'll pay for it, don't worry, you can bill it to the room just like the TV.

Three days later, when I was becoming ready to kill the next passing orderly for a tub of strawberry jelly, the senior resident for the day, after having asked me about 15 times if I was passing gas "back there" agreed to let me get some "clears", code talk for jelly, stock and tea - which in American means Jello, broth and... tea.

UK jam, US jelly
UK jelly, US jello
UK stock, US broth
UK broth, US chunky soup


I was so concerned that these orders wouldn't be passed on I ninja'ed the "Nil P O" (no food by mouth) sign above my head and removed it to the wastepaper basket.

That lunch time I received a tray with two jellies, a bowl of beef stock, a cup of tea and a bread roll which certainly doesn't seem clear to me but I wasn't about to give it back.

Never has a bowl of beef-flavoured water tasted so good. Three days without food is cruel and unusual in my book.

Nailed To The Door

All in all I'm glad the appendix is out, I wish I had it at home, and the hospital experience was middling. The E.R. was truly great. Everything else was vanilla. Maybe it all comes down to who's on duty that day. I don't know. I know I'm writing a letter to the E.R. doc and her boss to say thank you, they really exemplified everything I want to see when I'm in the E.R., I couldn't have been happier or more pleased with the care.

The only truly awful moment came on my third night when a roaming minstrel was allowed onto the floor and he minced from room to room with his guitar taking requests and singing to the patients. It was bad in a comedic, wincing kind of way.

I half hoped he'd break a string so I could make a luthier reference, a joke I'd been crafting for just the right moment, but the chance never came.

Ah well, it was a stretch anyway.








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