The Butterfly Effect Part I

Forgive me for posting again on health care, but a few things have it on my mind of late. Probably most significantly, the congressional vote on HCR is approaching, yet I was also delighted to learn that my specialty society has decided to remain neutral on the HCR plan... As Winston Churchill once quipped: "You can always count on Americans to do the right thing - after they've tried everything else", so too can the same be said of ACEP, my specialty society... At least most of the time. ;-)

We physicians are simply not disinterested observers and I commend ACEP in recognizing this, even it they do not actually recognize this.

Anyway, I want to share a particular tale about events I have been witnessing for many years. And while I realize my interpretations on these events may be very far from a complete 360 degree picture of the truth, still they are as I saw them and therefore an honest attempt to tell a tale the best I can without resorting to extensive research and fact checking. Perhaps someone else (a journalist?) will one day pick up this story and flesh out my obvious omissions and errors. I would clearly be curious to read a fuller account.

My story is about a common tragedy which affects our collective- stroke- and how a glimmer of hope appeared against this curse. But how this glimmer of hope set off an unforeseen butterfly effect which has become my personal parable of the tragedy of the commons mess we call our health care system. This particular story is perhaps most relevant to my home state of Maryland; yet I somehow sense its lessons are illustrative of what has befallen medicine in general. And how complexity can simply beget more complexity, yet more complexity is not always for the positive of anyone involved. A classic tragedy of the commons saga if ever there was one.


A little background may be helpful: strokes are caused by an interruption of blood flow to part of the brain leading to brain tissue death. They are the second most common cause of death and major cause of disability worldwide. They are a VERY big problem for us all.

Further our developed world is seeing more and more strokes as we age and the effects of all these Five Guy's cheeseburger's begin to take their toll on our collective BMI.

Enter a glimmer of hope: a thrombolytic known as tPA.

To simplify things greatly, think of thrombolytics such as tPA as the medical equivalent of Drano. Physicians use thrombolytics to open clogged arteries. tPA is manufactured by Genentech and according to the company's 2008 annual report, thrombolytics brought Genenetech revenues of $275 million for all clinical indications- certainly no chump change but similarly no "blockbusters", to use a little pharm lingo.

... FWIW, the people at Genenetech are entitled to every single dime of that money imo so do not misunderstand where I am going.

In fact, I will stop the Chapter I of my tale here. When you are ready, proceed to Chapter II