Medical News

Imagine Congress passes the “There Is Such a Thing as a Free Lunch Act” (TISFATLA). The law is simple and well-intentioned: No American should go hungry during the workday. Therefore, any restaurant that chooses to remain open between 10:30 a.m. and 3:00 p.m. must provide a nutritious lunch, defined as at least 500 calories of balanced food (protein, vegetables, whole grains, etc.) to anyone who walks in and requests it, without regard to their ability to pay, insurance status, or how many times they’ve eaten there that week.

Restaurants aren’t completely cornered. They can still raise prices on breakfast and dinner, seek government subsidies, reduce portion sizes, shorten hours, or even close during lunch. But they must serve first and ask questions later, or face steep fines (tens of thousands of dollars per violation) and possible loss of their operating license.

What Happens Next?

Immediate effects: Lines snake around the block. Demand surges because the price at the point of service is zero. Office workers, students, tourists, and predictably frequent diners treat the restaurant as their new daily cafeteria. A tiny fraction of “super-users” (maybe 1–2% of customers) begin consuming 10% or more of all free lunches. One motivated individual might rack up 20–30 meals a month. Why stop? It’s “free.”

Restaurants respond as any business would: they raise breakfast and dinner prices sharply to cover losses, cut quality, shrink portions, and reduce staff. Some simply stop serving lunch altogether, shrinking overall supply and making the remaining spots even more crowded. Wait times balloon to an hour or more. Working people who can’t stand in line during their short break go hungry—not because they lack money, but because the queue rations access.

The Government’s “Solution”: More Rules

Instead of admitting the law created perverse incentives, policymakers declare the problem is “greedy restaurants” exploiting loopholes. So Congress and regulators respond with layer after layer of new rules to “fix” the distortions:

• Restaurants must now document every free lunch with detailed nutritional logs, customer affidavits of need, and proof that the meal met exact caloric and macronutrient guidelines.
• They have to submit monthly reports to a new federal “Lunch Equity Commission” showing how many free meals were served, to whom, and at what cost.
• To prevent “abuse,” restaurants must implement a national “Lunch Eligibility Verification System” that cross-checks customers against a government database— but they still must serve first and verify later.
• New mandates require “culturally appropriate” options, allergy accommodations, and sustainability standards for ingredients.

Complying with this exploding regulatory thicket isn’t cheap. Restaurants now have to hire entire new departments of billing specialists, compliance officers, nutrition auditors, and paperwork clerks just to navigate the rules and avoid ruinous fines. These added administrative costs get passed on through even higher dinner prices, smaller portions, or reduced service quality. Some smaller restaurants simply give up and close.

The result? The original promise of “free lunch” has morphed into a vast, expensive bureaucracy that employs more people pushing paper than actually cooking food. Meanwhile, lunch lines remain long, quality has declined, dinner prices have skyrocketed, and fewer restaurants are willing to stay open during the mandated hours. Everyone begins complaining that the nation’s “restaurant system” is broken. Why, in Europe, people just walk in and buy lunch without waiting!

The EMTALA Parallel Is Striking

This cycle is not hypothetical, it’s exactly how EMTALA and the broader healthcare regulatory regime have evolved. A hospital shows up with a possible emergency? Screen and stabilize first, payment questions later. When uncompensated care piles up and emergency departments become overcrowded with frequent flyers (a small group of patients driving a wildly disproportionate share of visits and ambulance runs), the response isn’t to revisit the zero-price mandate. Instead, we get more rules: ever-stricter documentation, quality metrics, electronic health record mandates, billing codes, prior authorizations, and compliance layers.

Hospitals and physician groups respond by hiring armies of coders, billers, compliance staff, and administrators. U.S. healthcare now spends roughly 25–30% of total dollars on administrative overhead — far more than in most other countries. That bureaucracy doesn’t deliver care; it manages the distortions created by mandates, price controls, and third-party payment systems. The original goal of helping people in genuine need gets buried under mountains of paperwork, while costs keep rising and access problems (long waits, boarded patients, specialist shortages) persist.

The Deeper Lesson

When someone tries to use jury duty, court-appointed lawyers, or judges as justification for forcing doctors and hospitals to provide “free” healthcare, they’re missing (or ignoring) this dynamic. The justice system obligations are narrow constitutional protections against government abuse of its own punitive power. EMTALA-style mandates in medicine are open-ended entitlements that conscript private resources and then breed ever-more-complex regulation to manage the inevitable shortages and abuses.

There is no free lunch, just as there is no free healthcare. Every attempt to create one through mandates simply shifts the costs (to paying customers, taxpayers, or future patients) and grows a parasitic administrative class that feeds on the resulting complexity. The compassionate impulse to help the needy is better served by increasing real supply: more doctors, fewer barriers to entry, price transparency, and targeted aid, rather than layering on rules that make the system slower, more expensive, and less responsive to actual human needs.

The problem is one of intelligence. How do you create more doctors, nurses, and other medical personnel without lowering standards? Medicine (and advanced nursing) is cognitively demanding. It requires high fluid intelligence, strong working memory, pattern recognition, and the ability to integrate massive amounts of complex information under pressure. Multiple studies put the average IQ of physicians around 120–130 (roughly the 90th–98th percentile of the population). That’s not an accident or a gatekeeping artifact; it’s what the work demands. You can’t mass-produce doctors the way you can produce more Uber drivers or retail workers without either lowering standards or hitting the natural limits of the talent pool.
There are ways to increase the number of health care workers, and we can discuss that in a later post.

In case you are wondering, this post was written because of this guy:

People are guaranteed a right to an attorney if charged with a crime. That's another man's labor.

Rights are what society decides they are.

— aeon (@AeonCoin) April 14, 2026

The left loves to tell everyone how the US needs to have “free” healthcare, you know, like they do in Canada. Let me illustrate why that’s bull hockey.

I was at work, and a man brought his 17 year old son in, after the son fell off of his dirt bike a week before, injuring his shoulder. X-ray showed no broken bones. The dad asked if we could see any tendon or muscle damage, and we informed him that an x-ray can’t see that, he would need more testing. At this point, it is no longer in the scope of emergency care. The doctor and I advised them they would need to go to the child’s doctor’s office to get an order for an MRI, because only an MRI could see with that kind of detail.

The dad then asked if we could write the order for the MRI. The doctor explained that ER doctors can’t write an order like that, because the doctor writing an order for tests has to be the same doctor who treats the patient’s conditions exposed by that test. The man explained that the child’s doctor wanted him to have an MRI. So we asked him why he doesn’t get his own doctor to write the order. Even if insurance won’t pay for it, it’s only about $200.

We are from Canada and are returning home in the next couple of days. I can’t believe you won’t just give me an order. This is ridiculous, not only do we have to pay almost $300 for this ER visit, you can’t even write us the order to get the MRI. Now you want us to pay for a local doctor and pay $200 for an MRI? The health care system here in the US is so broken.

We asked, “If you can get it done for free back home, then why don’t you get it done when you get there?” His reply was gold:

We specifically came here to the US get an MRI because there is a year long wait for one back home. We tried to get one at the place down the street, but the MRI place said we need a doctor’s order. All I need is an order from a US doctor so we can get one while we are here in the states.

That’s the state of Canadian healthcare. It’s free, but you can’t have any. Rather than wait, this dad bundles his kid up, flies to the US, then trashes our medical care because it won’t do it now, and won’t do it for free.

Nursing is a great job because it’s a large tent. There are jobs for nurses both in and out of hospitals. I can’t speak for out of hospital nursing because I don’t have any experience whatsoever, but in hospital there is a hierarchy, and it’s the same in nearly every hospital, to the point that memes are made about this.

Nursing has a definite pecking order. Let me say that each nursing specialty is needed, but some nurses do have a more strenuous pathway than others. Remember that nursing is filled with mostly women (about 65% female) and women are some catty, backstabbing bitches. It makes for some very cat-like behavior, and not in a good way. No, in a “mean girls” way. The bullying and competition is pretty fierce. Women are simply vindictive, conniving bitches.

You have your inpatient nursing- medical/surgical (called med-surge), and these nurses staff the oberservation and general patient floors. Generally, med-surge nurses care for the least complicated patients, and they tend to be the least skilled nurses in the hospital. I’m sure that will piss some people off, but that’s just how it is. Because the patients are low acuity, nurse/patient ratios are 1:6 or sometimes as high as 1:8.

A step up from that is cardiology, oncology, wound care, those sorts of specialties. Nurses in these areas are very good within their specialty, but don’t generally know a whole lot outside of it. Again, they are needed, and a great example is that I suck at wound care, so not slamming anyone. The nurses in this area are usually ratioed at 1:4 or 1:5.

Above the general floor nurses are your step down units- PCU, CVPCU, those kinds of units. These nurses handle patients that are more complicated and require more care. For that reason, ratios are usually 1:3 or 1:4.

The next level up in the inpatient nurses packing order is the ICU. The nurses in this unit generally consider themselves to be the cream of the crop. There is a bit of a superiority complex here, and a good bit of it is well deserved. ICU nurses are well known for being very detail oriented and for having OCD. Every IV line is carefully labeled with color coded stickers. The ICU nurse knows everything there is to know about the patient: the name of his kids, his dog, his favorite color. They have time for that, because the nurse patient ratios are frequently 1:1 or 1:2, so they spend the entire 36 hour workweek with 1 or 2 patients.

Then there are outpatient nurses. PACU (post anesthesia care unit) nurses take care of patients who have just come out of surgery. After that the patient either gets admitted to an inpatient unit, or goes home. Also surgical nurses, endoscopy nurses, and the like. The nurses here are fairly specialized, and most of them work M-F 9-5 jobs. Other nurses refer to these types as “princess” and the shifts they work are called “princess shifts.”

The emergency department. The nurses here are known as being “cowboys” who don’t follow the rigid rules the rest of the hospital’s nurses have to follow. They have one overriding goal- stabilize a patient, then send them to an inpatient unit. Everything else- bathing the patient, changing their clothes, and other nursing tasks just don’t get done. ED nurses also tend to think of themselves as being the best of the best, and act like those routine tasks are beneath them. For this reason, inpatient nurses generally don’t like ED nurses.

If anything goes wrong in an inpatient nurse’s area, the nurse will initiate a “rapid response” or “CAT” call, and the response team will come to help them out. Some hospitals use ICU nurses as the response team, other hospitals use ED nurses.

As you can imagine, the rivalry between ICU and ED nurses can be rather intense, med-surge nurses feel (or are looked down upon) as being inferior, and the entire hospital feels like it is at war with one unit, shift, or zone being at war with all of the others. Some temporary alliances are formed, mostly when one unit teams up with another to take a third unit down a peg or two.

Yes, nursing is filled with a bunch of infighting that is mostly caused by having several hundred women in the same building, all wearing the same outfit, and about 1 in 5 of them is menstruating at any given time. It’s like being in a building full of rabid honey badgers.

All shift long, it’s “day shift is lazy,” or “Night shift didn’t do anything last night,” then you hear “Med-surge nurses are idiots,” or “Those ICU nurses are stuck up bitches,” and the old reliable “The ED nurses didn’t even bathe this patient and put him in a gown before they sent him up.”

Older nurses take great pleasure in screwing with younger ones, for no other reason than flexing their pecking order muscles. It’s so bad that every nurse hears an old adage while they are in school: “Nurses eat their young,” meaning that the level of bullying of new nurses by old ones sends many a young nurse off to cry in the bathroom.

It’s especially difficult when you are a man that just doesn’t like playing those kinds of bullshit power struggle games, and also has the nasty habit of calling things like you see them. It’s been a difficult skill to learn, biting my tongue. I still struggle with it frequently. I’m old enough that I don’t play those games, and I tell people to fuck off. That’s when your attacker then plays the victim card and uses their victim status as a weapon.

My first experience with this was in nursing school, when a fellow student began bitching at me and calling me stupid, and I told her to shut the fuck up. I almost got kicked out of school after she went to the instructors and told them I was racist and sexist. For the rest of school, that woman (who also happened to be black) organized a “Hate on Divemedic” club amongst the other students and staff members of her own demographic.

If you get the feeling that I don’t like most women in the workplace, you would be correct. They spend more time setting up tribes, posturing, backstabbing, and putting on makeup than they do actually caring for patients. There is a lot less of that kind of bullshit in the ED, simply because we are too busy to have time for that shit. Let there be some down time, and the ED starts with it too.

It’s exhausting.

I got a message from a reader who is a nurse, talking about my last work post. The gist of it was “be careful making enemies of HR and training folks, they will screw you over.” You know what, that is 100% correct, nurses like that will find a way to get back at you. The difference now is that I am close enough to retirement that I just don’t care.

This is for my medical readers, a little pearl from critical care in the ED. This was a case I recently had in my care. Look at what decision making goes into critical care:

A patient presents with acute severe dyspnea consistent with hypertensive acute decompensated heart failure (flash pulmonary edema).

Initial Assessment:

Respiratory:RR 40/min with sternal retractions. Severe air hunger despite NIV. EtCO₂ 31 mmHg (hyperventilation, not ventilatory failure). SpO₂ 100% on NIV. Cardiovascular:HR 120 bpm BP 218/184 mmHg (marked sympathetic surge / afterload crisis)

Clinical interpretation:The patient was not hypoxic and not retaining CO₂, but was in extreme sympathetic overdrive with excessive work of breathing and anxiety worsening pulmonary congestion.

Intervention

Continued noninvasive ventilation (NIV). Morphine 2 mg IV administered as a targeted adjunct for refractory air hunger and anxiety. Reassessment (15 minutes post-administration)

HR: 95 bpm RR: 18/min BP: 142/72 mmHg SpO₂: 96% (clinically acceptable). Work of breathing markedly improved; patient calmer and tolerating NIV.

Teaching Points

Air hunger in acute heart failure is often driven by pulmonary congestion and sympathetic activation, not hypoxia alone. EtCO₂ of 31 mmHg confirms hyperventilation and preserved ventilatory reserve, reducing concern for opioid-induced CO₂ retention. Low-dose morphine (2 mg IV) in this setting blunts excessive catecholamine response, reduces central perception of dyspnea and panic. It produces mild venodilation, which lowers preload/afterload, and improves tolerance of NIV without suppressing respiratory drive.

Why this was appropriate: Although the use of morphine in heart failure is an old therapy that has been largely discredited in modern studies, it was appropriate in this case. NIV was already in place (airway support maintained), continuous monitoring, including EtCO₂, was available. The dose was anxiolytic, not sedating, and the primary threat was sympathetic storm, not respiratory failure.

Key Teaching Pearl

Morphine does not treat heart failure and can actually be harmful in many cases, but in rare, carefully selected patients, low-dose morphine can interrupt a life-threatening sympathetic–dyspnea feedback loop when NIV alone is insufficient.

Practice Implications

Morphine should not be routine in acute heart failure, consider only when:

• Severe air hunger persists despite NIVEtCO₂, which indicates hyperventilation (not CO₂ retention)
• Blood pressure and monitoring allow safe administration
• Always pair with definitive therapy (NIV, BP control, diuresis)

My charge nurse disagreed, saying all HF should be treated with nitroglycerine and loop diuretics. That’s simply blind protocol adherence. The doctor and I disagreed with that, to the patient’s benefit.

Bottom Line

This case illustrates that physiology-guided, low-dose morphine when used judiciously and with monitoring can be a safe and effective adjunct for refractory air hunger in hypertensive acute heart failure, reinforcing the importance of individualized clinical judgment over reflexive protocol avoidance.

This article in the Daily Mail had me shaking my head. This is night and day from the US system.

• They called EMS. It took EMS an hour and 28 minutes to arrive.
• When they got to the hospital, the ambulance had to wait 30 minutes to offload their patient
• There was a Four hour wait to see a doctor who ordered a CT scan
• Another hour to get the CT
• yet another hour to get the results and confirm that the woman had had a stroke

My iPhone log tells me I called 999 at 10.51am. My mum was finally settled in a bed on a ward at 1.30am the next day. All in all, it had indeed taken almost 15 hours between me reporting the symptoms of a stroke in my mother, to her receiving the correct care for it.

At the end of it all, they had to pay out of pocket to see a private specialist. The issue is that by then, it is too late and the damage from the stroke is mostly permanent. Free healthcare, my ass.

Now let’s contrast that with the US:

• Here in the US, an ALS ambulance arrives in 10 minutes or less 80% of the time (that is the standard). Still, the average 911 call to arrival at the hospital is 36 minutes in the US.
• From hitting the door, patients have 10 minutes to see a doctor.
• 15 minutes to see the stroke team. (every nurse in my ED is certified by the NIH as a stroke team member)
• Door to CT time is 25 minutes.
• Door to results of the CT being reported is 45 minutes.
• Door to needle time (time from entering the hospital until receiving clot busting drugs) 60 minutes.

My hospital beats every one of those metrics. The times I have given tNK or tPA were less than half of that. When someone with these symptoms enters our facility, the CT is done as quickly as we can move them to the CT room. The doctor and the ED stroke team are nearly instant. Our door to needle time is 27 minutes, on average.

The drugs must be given within 3 hours of symptom appearance or they simply don’t work very well, although some studies suggest that there is SOME benefit in getting the drugs up to 24 hours after symptoms appear. Time is brain.

Now tell me how cool it is to have ‘free’ healthcare.

Ron DeSantis is taking heat for a statement that he made. He said that people under age 50 largely don’t need health insurance. He is correct. People under age 50 are healthier than those over 50, and their premiums largely pay the freight for those who are older and sicker.

Our nation’s healthcare system gets crapped on a lot. Even though the United States has only 9% of the world’s doctors and 3% of the world’s hospitals, half of the innovation in healthcare of the entire world is being created right here in the United States. We are punching far above our weight class:

• New drug development: The US was responsible for the development of 43.7% of new molecular entities (NMEs) and has seen a surge in new drug approvals.
• Biotechnology patents: U.S. firms filed nearly 38% of global biotechnology patents from 2015–2020.
• Research funding: The US accounts for a significant share of global medical and health R&D, at around 44% of the world’s medical research funds.
• Clinical research: The US leads the world in the number of active clinical trials, supported by its advanced infrastructure and large population.

There are plenty of people who would slam the US medical field because of costs, then drag out statistics claiming that the US lags the world. In many cases, those statistics are misleading. For example, the US says that a child is stillborn if it dies before birth, but some other countries will count a child as stillborn if the child dies up to 30 days after it is born. This is important, because this means a 29 day old infant who dies does not count towards infant mortality. For that reason, use health statistics with a healthy grain of skepticism.

This means that the chief reason for claiming the US healthcare is trash is that it can be expensive. After all, we always hear about how Canada has better healthcare because it is free. Of course, you have to wait weeks to get something as simple as a CT scan or an MRI, while here in the US you can get a CT scan in less than 10 minutes, and an MRI can be done in a matter of hours.

So why do things here cost so much? Let’s use my recent trip to the emergency department as an example. My itemized bill showed that I received 5 bags of normal saline over a 12 hour period. The charge for this was a total of about $11,000. This seems a bit high for 5 liters of salt water, mostly because it is. Take a closer look, and you see a couple of things:

The saline is charged out at $35 per liter. That’s not TOO unreasonable. Then you see that there is an additional charge of about $900 per hour for “monitoring while fluid replacement is taking place.” This is how hospitals pad the bill. They give you a couple of liters early, then run in what is called “maintenance fluids” at a rate of 50 ml per hour. They then bill you almost a grand an hour for that nurse monitoring you while you got those fluids. It’s just a way that the hospital pads the bill, because that nurse is also billed to you as part of the daily room charge. They also bill $50 a day for cardiac monitoring, plus you get billed for every doctor who even glances at your chart.

Of course, insurance companies see right through this, and they refuse to pay. The hospital knows this, and in fact they plan on it. The hospital has an agreement with the insurance companies, and they actually only collect about 35% of what they bill out, on average. The hospital’s total average costs are usually equal to about 31% of what they bill. That 4% difference is the hospital’s profit.

In my case, the entire visit to the hospital was billed out at $43,000. Out of that bill, my insurance paid $2,500, I paid about $700, and the rest was simply waived away. The full bill of $43,000 is what they bill to those poor suckers that don’t have insurance. The hospital knows that what they did for me was in no way, shape, or form worthy of $43,000. The insurance company knows it, too. In fact, everyone involved knows that no one is actually going to pay that much.

Why, then, do they do it that way? Because that is what the insurance companies want. They want medical expenses to be so high that people pay for insurance out of fear. That’s the problem with US healthcare. Not the care, not the cost, but the insurance companies scaring people into buying their products through punitive pricing models.

The answer then isn’t to have more people insured- it’s to get insurance companies out of the equation, or to at least prohibit hospitals from charging the uninsured more than 20% over what insurance companies pay. Market forces will then take care of the rest. It isn’t a problem with healthcare, it’s a problem with insurance companies. If the hospital can turn a profit on what they pay the insurance company, they can turn a profit on 20% more than what the insurance company pays. There is no legitimate need to charge the uninsured 1,400% more than the insured.