WhiteCoat

Yet Another Patient Dies Waiting For Emergency Care

Michael Herrera, who founded many Tex-Mex restaurants across North Texas, went to the Parkland Hospital emergency department after a golf game. He was having severe stomach pains.
Unfortunately for Mr. Herrera, 270 other people also checked into the Parkland Hospital emergency department that day.
Mr. Herrera waited 19 hours for care and still had not seen a doctor when he went into a cardiac arrest and died.
Mr. Herrera was uninsured and Parkland Hospital is reportedly the only hospital in the Dallas area to provide care for patients without insurance (I do not know this to be a fact, but am stating this due to several comments in the comment sections of the articles below).
Here are some other articles about the story from Dallas News, Pegasus News, Fort Worth Star Telegram, and WFAA.com from Dallas/Fort Worth.

Still think funding for emergency care is unimportant?
Still think socialized medicine and “free” care is the way to go?
We’re going to see more and more people die waiting for care until our lawmakers increase funding for emergency care and create a system that provides adequate reimbursement to medical providers while protecting everyone from jackpot justice.

More ED patients, less available EDs, more medical providers getting fed up with practicing emergency medicine. Hospitals trying to stay afloat by limiting care to indigent patients.

First it’s Beatrice Vance
Then it’s Esmin Green
Just today, Kevin MD linked to another story about Brian Sinclair who died in Winnipeg after waiting 34 hours to be seen in a Canadian emergency department. See another version of the story here.
Now Michael Herrera is dead.

Think about this question when you enter the voting booths this November:

How many people have to die waiting for medical treatment before our elected leaders address funding for medical care?

We’re getting what we pay for.

It is sad that some people are getting it sooner than others.

Boy am I glad I’m a doctor.

Picture credit here

UPDATE SEPTEMBER 30, 2008
An autopsy showed that Mr. Herrera died from complications due to diabetes, heart disease, and morbid obesity.
“I would suspect that with his presentation, he would have been attended to and sent home,” said Dr. Ron Anderson, president and chief executive officer of the Parkland Health and Hospital System.

32 Responses to “Yet Another Patient Dies Waiting For Emergency Care”

  1. crankylitprof says:

    While this is certainly a tragedy, and the 19-hour wait time is ridiculous, I have to ask…

    If he founded several restaurants, and had the $$ to play golf, why the Holy Righteous FUCK didn’t he have money for health insurance?

    Or was he one of those, “I’m healthy so I don’t need it” types.
    Or was he a “EMTALA guarantees they have to take care of me, so why out out the cash?” types>

  2. SeaSpray says:

    That is so sad…and frustrating. We think it could never happen to us…but what if?

    I admit I don’t know what either candidate is proposing to improve health care. I thought I heard Obamas was health care for everyone…is that the socialized program? But I don’t know that as fact.

    And I don’t have a clue what McCain is proposing.

    What do you docs think? Which plan is better?

    Too bad it can’t be the best of both worlds combined into one stellar health plan for all. And docs are fairly paid and reimbursed and there are no long waits for surgeries, procedures and ERs..oops my faux pas..EDs :)… and no one loses their home over escalating medical bills.

  3. mottsapplesauce says:

    SeaSpray,
    I’m not 100% sure on this, but I believe Obama wants to try to make insurance more affordable for everyone, and I think part of his plan is to make it mandatory for children to have coverage–don’t know how he plans to make that happen though.

    I believe part of McCain’s plan is to overturn Clinton’s law of forcing employers to offer coverage for their employees, but again I’m not sure what other plans he has in mind to take place of what already exists. I haven’t been following either of them lately, with all the financial chaos in the news these last few days.

  4. My apologies for dialoging with your commentators, but this level of “not knowing” — ummm — it IRKS me. A good place to begin, applesauce and seaspray, might be here:

    http://www.webmd.com/election2008/comparecandidates

    Any pertinent googling of the terms will bring you more details, as well. And if applesauce can point out those employers “forced” to offer benefits to their employees, well, we can all dust off our résumés…

    No apologies necessary. The biggest reason I put these posts up here is to stimulate dialogue. Thanks for the link!

  5. samwrites2 says:

    Wow, anyone from Dallas should know better than to go to Parkland.
    But even then, how bad does it HAVE to get to prompt reform? Hey, can we get $700 billion over here aimed at health care?
    And what about Michael Jr., 10 without a dad?
    One more reason I’ll go homeless before I go without health insurance.
    -Sam

  6. Nurse K says:

    Obvious, WhiteCoat, but EMTALA means every emergency DEPARTMENT has to provide care to the uninsured, including any and all emergency DEPARTMENTS in Dallas.

    Actually, EMTALA only requires that the hospital provide a “medical screening exam” that is reasonably calculated to uncover any “emergency medical conditions.” If no EMC exists, then EMTALA doesn’t require that a hospital render care at all.
    In an attempt to stop hemorrhaging money, hospitals are now starting to perform their screening exams and, if no EMC exists, are asking for payment before a patient sees a physician or receives treatment for non-emergency conditions. Perhaps that is what the comments were all about.

  7. I hate to be cynical but I strongly suspect that intervention from leadership regarding healthcare policy and funding will make things worse, not better.

    I sure hope I’m wrong though. I’m the only RT in a 125-bed emergency room because we had to tighten the budget, and I know the doctors, nurses and other allied health people are feeling the pressure just as much as I am. It would be great to see a practical and functional solution so that I don’t have to have a 125-bed assignment all to myself every damn day.

  8. SeaSpray says:

    Thank you Bianca.

    Obviously, I could have looked it up. Thanks for saving me the trouble. :)

    Still wonder what the docs think.

  9. Nurse K says:

    Completely random, but today, there was a nurse who’d worked in Kenya in our ER and she was saying that in Kenya, she worked in a 20-bed ER which saw 400 patients per day and no one got care unless they could pay up front (exceptions were made for people who were on the verge of death). She said that on a *daily basis* people died in her waiting room. The reason they could see 400 patients per day, of course, was that the work-ups weren’t all 5-hour megaworkups for everything.

    Yes, I obviously know about MSEs and all that, Whitecoat. I guess I misunderstood the comments. Hopefully, this dood’s “stomach pains” would have caused an EKG to be ordered which looked crappy which would have lead to a pretty full stabilization, including cath lab (assume the stomach pains were an anginal equivalent) and admission.

  10. mottsapplesauce says:

    Bianca,
    I appreciate the link you provided. Both candidates possess positive ideas for healthcare reform.

    However, let me re-address what I meant to convey in my first message. I didn’t mean to put Clinton’s law in a negative light. His law was one of the best things he ever did in office, IMO. I would probably be one of the millions of uninsured if it weren’t for Clinton. My employer is one of the ones ‘required’ to offer benefits to employees…maybe that’s a better term. I might not know the logistics behind it, but I’ll chalk that up to ignorance, since I didn’t have a full-time job until Clinton was already in office, so I’m not at all familiar with what laws, if any, were in place prior to that. Before I was diagnosed with an auto-immune disease, I’ll readily admit that I never bothered to learn about healthcare & political issues. The upcoming election is very important to me, but as I said, I haven’t been following the campaign trail as much lately, because I’ve had other issues in my life that take precedence for the time being. If that irks you, well..sorry, but you can at least feel good about educating an ignoramus like me. I already know who I’m voting for, BTW.

  11. Teresa says:

    Clinton’s law was one of the worst things he ever did in office. It makes it more expensive for employers to hire employees, reducing jobs available for people. And worst of all, it makes health insurance harder to obtain.

    We desperately need a law that forbids employers providing health insurance; at a minimum, we need to stop allowing employers to deduct the costs of providing health insurance. This is one of the seminal events (when employers started providing health insurance) on the long decline of our health care system.

    People like you, applesauce, should not be denied insurance because you have an auto-immune disease. But forcing employers to provide insurance to you is NOT the right way to go. We need a system where people can buy their own insurance, even with pre-existing conditions, and are encouraged to do that before they become seriously ill. By tying insurance to employers, freedom for Americans is greatly reduced in many ways, and health insurance becomes more difficult to acquire.

  12. marcia (2) says:

    Teresa, if insurance is divorced from employment, as McCain would like, there’d better be more than a measly $5,000 tax credit offered to off-set the lost benefit, or there will be fewer insured people than there are now. Wait and see. He’s also talking about deregulating the insurance industry, which has too much power over doctors and medical decisions as it is. If you think deregulation is a good idea, just take a look at what it did to Wall Street.

    We had to buy an individual policy when we owned our own company (there was an additional policy available through the employee lease-back firm we used, but the coverage sucked), and the premiums for a family of five are extremely expensive (over 1k/month, usually, with a long lapse in coverage for pre-existing conditions). The $5,000 premium is only marginally realistic for a young, healthy couple. Everyone else will end up spending more out of pocket for healthcare, which most of us can’t afford, which means the government or hospitals will end up eating more bad debt, or people will be denied needed care.

    I’d like to think we can come up with a better solution than that.

  13. SeaSpray says:

    I just always assumed if you worked full time for a company that insurance was automatically part of a benefits pkg… way before Clinton came in office.

    We were without insurance for one year in our marriage and we could not afford the COBRA payments at that time. Thank God we did go back on the plan when he returned to work!

    I always looked at a good benefit package as money in the bank along with the paycheck… and certainly helps determine who you will want to work for. :)

  14. ERP says:

    Sad. What is up with Parkland being the only hospital in the Dallas area to serve uninsured? Are all uninsured transferred there if someone presents to another ER?

  15. marcia (2) says:

    I agree, SeaSpray, that a good benefit package should be an important consideration when looking for employment. But think of the economy we’re in right now.

    When unemployment is high, employers have more latitude to offer skimpy packages because they know people are desperate for jobs or job security. A bad economy actually incentivizes (I don’t believe that’s a verb, but I’ve seen it used before!) companies to cut back on costs in this way.

    Also, young people are less likely to take advantage of employer-subsidized insurance, because many believe they don’t need it and would rather have the extra cash in their pockets. That’s an incentive for employers to hire younger workers–even those who do sign up for benefits cost less.

    Small companies, which make up a large portion of employers in the U.S., have difficulty affording benefits, period. Most of them don’t offer 401Ks or retirement plans, although this used to be a common perk (not so many years ago); I suspect most would drop insurance coverage if it wasn’t a requirement.

    Even if insurance benefits remain optional, only those employers who care about attracting top talent will bother to offer it. Companies with “disposable” employees (Wal-Mart comes to mind), will choose to reabsorb the expense in order to enhance their profit.

    The only time employers will feel compelled to offer benefits is when: the supply of labor is substantially lower than the demand; a government body requires it; or they want to attract employees with special skills (doctors would probably still be covered, IOW).

    If McCain gets his way, I really believe it’s going to be disastrous for the public and healthcare providers alike. We may reach a point, as with the financial market, where the only available solution becomes some form of socialism.

  16. Teresa says:

    Teresa, if insurance is divorced from employment, as McCain would like,

    Sorry, but I don’t know what McCain’s plan is, and I’m not interested in the political aspects of this discussion. I am interested in FIXING THE PROBLEM. I don’t care who supports what.

    We had to buy an individual policy when we owned our own company (there was an additional policy available through the employee lease-back firm we used, but the coverage sucked), and the premiums for a family of five are extremely expensive (over 1k/month, usually, with a long lapse in coverage for pre-existing conditions).

    There is the absolute best example I can think of against employer-provided insurance. More of these kinds of laws will simply make health insurance even MORE unaffordable by anyone not employed by a big corporation. What are you thinking? Is it your idea that everyone should have to be employed by mega-corporations? There should be no small businesses or start-ups?

    I guess you’ve never spent much time working for a big corporation. I have. I have no interest in seeing big business bureaucrats control even more aspects of this country. Once employers are the only source of health insurance, you’ll get exactly what they wish to provide. You want coverage for things not on their plan? Tough. Once private policies have been eliminated, through bills like Clinton’s, big business will control exactly what will be paid for through insurance coverage.

    We were without insurance for one year in our marriage and we could not afford the COBRA payments at that time.

    You couldn’t afford the COBRA payments, so you think having employer-provided insurance, which causes insurance rates for the unemployed to be higher, is a GOOD thing? That isn’t logical.

    I always looked at a good benefit package as money in the bank along with the paycheck… and certainly helps determine who you will want to work for.

    Not everybody wants to work for someone else. You are obviously thinking only of yourself. There are other people out there who would like to start their own business or retire early or something, and if you get your way, that will be harder, if not impossible, for them to do.

  17. marcia (2) says:

    If you live in the U.S., and you don’t care what the Presidential candidates’ positions are on healthcare policy, you are crayzee. Do you think bloggers are going to determine the solution? No. We are going to get whatever Congress decides we get, and if the Presidential party and Congressional majorities are congruent, it will most likely be decided during the next administration. If you don’t bother to research the issue, please don’t vote.

    You said: I guess you’ve never spent much time working for a large corporation. I worked for one of the largest retail conglomerates in North America for nine years. I was paid well, had excellent insurance benefits, including dental and vision, as well as a 50% matching 401k plan, up to 6% of my annual salary, which I took full advantage of. It was great. So I really don’t see the point you’re trying to make here about large corporations.

    As far as small companies go, did you miss the part where I said we owned our own company? It was small. We were able to offer insurance benefits because we used an employee lease-back firm that negotiated reasonable group rates (based on having lots of other companies also using their services) for our employees. It didn’t cost nearly as much out of pocket as if we bought coverage for the business directly.

    Nevertheless, the insurance offered little more than catastrophic coverage. So we opted to purchase an individual policy for our family. That was doable for us because we owned the company and had the income. It wasn’t doable for our employees, because, although we paid fair wages, they still didn’t earn enough to pay 1k/month for insurance alone.

    Not everyone wants to work for someone else. That’s true. Work for yourself, and you’ll find that your option is purchasing an individual policy that lacks the discounts involved in being part of a large risk pool. You’ll pay a lot more for the privilege of working for yourself, especially if you want coverage for pre-existing conditions.

    I think, before you accuse people of thinking “only of yourself,” you should do your homework and find out how much it would cost to insure your family or yourself without subsidy or shared risk. Your assertion that “if you get your way, that will be harder, if not impossible for them to do,” is complete BS.

  18. SeaSpray says:

    You said it better than I ever could have Marcia.

    Teresa – We had some catastrophic things happen legally and financially that year. He was not able to work that year…actually 20 months and insurance premiums were a luxury we could not afford. My husband’s employer pays a lot more for our premiums and we still pay a hefty premium bi-weekly for our insurance.

    Unless there is a significant reformation of insurance prices/coverage… it would not be feasible to expect employees in lower paying jobs (and I don’t even mean minimum wage)to be able to afford high insurance premiums. I think a hardworking, contributing and devoted employee deserves to be compensated with benefits …OR…be paid a HIGHER wage so they CAN afford the insurance. But even then…you don’t have the group rates of a corporation.

    “You couldn’t afford the COBRA payments, so you think having employer-provided insurance, which causes insurance rates for the unemployed to be higher, is a GOOD thing? That isn’t logical.”

    It isn’t logical to think everyone that can’t afford to pay for a solo insurance plan shouldn’t be covered under a corporation group plan if they are working there. Following through with your logic… then because of small businesses and desired early retirement…no one should be covered under a company insurance plan.

    So its better to add all the millions of hard working people to the uninsured list (because they can’t afford solo coverage)with the unemployed population?

    Socialized medicine anyone?

    At least the working people are still CONTRIBUTING their work effort to the corporation and hard earned DOLLARS to the corporate plan. Workers are still responsible for their insurance premiums. It isn’t a FREE ride!

    A lot of places get around having to offer benefits by only offering part time positions. I have worked in those positions because it was more important for me to be with our sons. And I waived insurance benefits, because the premiums were expensive at my hospital job and because I had my husband’s insurance.

    Again…my point is health insurance premiums are expensive.

    Besides…employers have been offering insurance benefits for as long as I can remember and I am guessing before that. You can bet…that if important to me… I will be seeking out the employer with the best benefits package when I return to work.

    “You are obviously thinking only of yourself. ”

    Are we not responsible to look out for ourselves? Do YOU care if I have health insurance?

  19. SeaSpray says:

    PRESIDENTIAL DEBATE TONIGHT…YAY! :)

  20. mottsapplesauce says:

    They’re actually televising it at some of our local eateries here. Nothing like downing some hot wings & beer while you watch a presidential debate….

    Back to WC’s original post, it scares me that events of this nature will continue to happen. I shudder at the idea that you, me or anyone could be another victim. I pray that no matter who wins the election, that healthcare reform be one of the top priorities. The biggest challenge is finding a solution that works.

  21. SeaSpray says:

    That sounds like fun MottsA. :)

  22. mottsapplesauce says:

    One more point Theresa, sorry to keep re-hashing the subject, but I believe Clinton’s law does not force employers to
    ‘provide’ insurance, it requires them to ‘offer’ insurance. There is a BIG difference. Also, I believe it is based on the NUMBER of employees you have. The laws are required to be posted by your employer in a visible area. So, I’m going to read them again, & will correct myself if I’m wrong.

  23. marcia (2) says:

    Yeah, you’re right. I think the magic number is 25 employees, if I remember correctly.

  24. CR says:

    We’re going to see more and more people die waiting for care until our lawmakers increase funding for emergency care and create a system that provides adequate reimbursement to medical providers while protecting everyone from jackpot justice.

    Hospitals are posting record profits (2006) and you want the government to provide more funding? Why is that?

    Averge CEO pay vs. average worker pay, over the last 30 years, has gone from 5 times average worker pay, to 250 times average worker pay. Where is all the money going? To CEO’s. So where is the problem?

    And to boot, these financial CEO’s are just screwing up the system.

    CNN
    Nice graph

  25. [...] by GruntDoc on October 2nd, 2008 Yet Another Patient Dies Waiting For Emergency Care « WhiteCoat Rants Mr. Herrera waited 19 hours for care and still had not seen a doctor when he went into a cardiac [...]

  26. [...] Yet Another Patient Dies Waiting For Emergency Care Posted on October 3, 2008 by coptermedic From White Coat Rants: [...]

  27. [...] White Coat Rants makes a tear well in our eye with his post detailing the idiocy produced when committees morph into bureaucracies and then into government oversight entities. And this all for the sake of money shuffling and vote buying. Outside of the academy, Medicine is dying, patients are dying, and doctors are the whipping boys of the moment. Check this one out too. [...]

  28. Ariel says:

    The solution is HSA with hiogh-deductible cathastrophic insurance. Also, as others have said here, “mandated” employer-insurance is a disaster. Not only has it pushed up prices for everybody, but it has also removed ANY insight into costs and responsibility for own wellness.

    I am a fresh Family Medicine graduate and just working as locum right now. There is no way I will be playing the game of working for medicare or insurance companies where some BS in healthcare “adminsitration” is telling me what I get paid for or not or what tests my patients can get.

    I plan to work a few years locums, ER coverage and possibly at some cruise-ships, but eventually I will join the ranks of cash-based primary care docs. Hopefully Obama the almighty doesn’t “mandate” that doctors treat anyone for free in the meantime. Well, one can always find something else to do. I could pick up a job right now at a fitness center making about 80K. No Fridays, no calls, no lawyers, no medicare/government BS.

    Guys, wake up!! The primary care crisis is REAL and don’t expect government to fix it.

  29. Lola says:

    Here’s an interview on NPR/Fresh air with a guy who explains the difference between McCain’s health care plan and Obama’s.

    http://www.npr.org/templates/story/story.php?storyId=93975730

    He saw problems with both plans–didn’t think they made economic sense. McCain wants to raise taxes on employers who offer insurance, so costs will be passed on to employees. Consequently the cost of health insurance will go up for anyone who is working now, and evidently it will go up far more than the $5,000 tax credit McCain is offering.

    This would be of some benefit to me at present–I’m paying through the nose for individual coverage now–but would reduce the value of getting insurance through an employer. And yes, costs for insurance through an employer are considerably less, because you are part of a pool. On your own, you may–or may not–be able to get medical insurance. But insurance companies have an army of clerks and gatekeepers whose job it is to make sure that getting treatment or getting reimbursed is impossible.

    Of course, if you’re not making enough to pay for insurance, you’ll just wind up trying to get treatment at the emergency room and the cost will be picked up by the taxpayer. :-)

    Wake up, guys–taxpayers are already covering health care costs for the uninsured. And health insurance companies are very, very profitable. It will cost us less in the long run to cover routine and basic care for everybody up front, before it turns into a crisis. I’m so tired of fighting insurance companies. I’d take the Canadian system any day.

  30. ERdocDFW says:

    I trained in the ED at Parkland and let me clarify a few myths here:
    1) Parkland is a great hospital. It’s a busy county facility, but compared to some county facilities elsewhere in the country Parkland is above average. The ED is crowded every day and 270 patients in one day is not unusual for the Parkland ER.

    2) EMTALA mandates that any ER has to care for people who show up regardless of ability to pay. This is true for every ER in the country. Parkland is the only county facility in Dallas, but I can assure you other hospitals are also taking care of the uninsured, since this is mandated by law, and they are not all being transferred to Parkland as someone suggested.

    3) Nothing in the story I have read suggests there was any wrong done by the ER staff. Without being able to look at his triage note and vitals, it’s difficult to know a lot about the situation. But according to one article he had a chronic hernia and was having some discomfort. People come to the ER for a lot of non-emergent things such as reducible hernias. He may not have been ill appearing, could have had a normal exam, and normal vitals. You just never know. Also could have been an atypical story with a myocardial infarction.

    4) People go into cardiac arrest every day—some at home, some at work, some at the hospital. He could have had a sudden cardiac event completely unrelated to why he was in the ER to begin with. It happens. You just never know. What if he had been seen by a physician as soon as he hit the door? He could have had an appropriate workup based on his history and physical, been sent home and then died at home. May not even be related to why he was there to begin with. Sometimes despite the best and most efficient health care in the world, people die and there is nothing that anyone can do to predict—or prevent–it from happening.

  31. [...] recent blogs have discussed or linked to articles about patients who have died in ED waiting rooms. Thanks to SymTym for some other examples – from [...]

  32. defendUSA says:

    Again, I am late to this dicussion, but I have to pose a question. I keep hearing, reading that there are 47 million people uninsured. And nobody asks why, they just accept that number. Do you know how that number is arrived at? Health care costs have been on the rise since the 70’s. What about the number of “uninsured” who choose to be that way? Yes, some do it because they cannot afford it, but others who are uninsured are those who believe youth is on their side and they would rather have that fancy new car. What about the wealthier set who can pay out of pocket?

    The Census Bureau performs two surveys using two distinct methodologies in order to determine the level of insurance coverage that exists in the United States. The first is the Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) which asks about health insurance coverage in the previous year. It is conducted via questionnaire each year and is the basis for the 46.6 million uninsured figure that is the basis (without rounding) of the uninsured figure most frequently referenced by those demanding that something must be done. The other survey, less widely known, is the Survey of Income and Program Participation which attempts a more comprehensive review of coverage availability.

    What do these surveys mean? Well let’s consider the ASEC survey first. It determined that 84.1% of Americans were covered by health insurance in 2005. Assuming that this figure has not changed or, as is more likely, improved along with the overall economy, at least 252 million people are covered by some type of health insurance at present. It helps to put that 47 million figure in perspective.

    But the story doesn’t end there. The Census Bureau concedes that the ASEC survey significantly underreports actual levels of insurance coverage and, even to the extent that the data is useful, it more likely reports the maximum number of people without insurance at a given time rather than a real picture of who has been without coverage for any material amount of time during the examination period. It is the alternative measure of insurance coverage that is the more accurate assessment and it places the level of insurance coverage in this country in the vicinity of 92%, which would place the number of uninsured people in the United States somewhere closer to 24 million.

    There is a difference between the coverage people have and the actual access to health care. If lack of insurance equates to lack of care, the percentage of people who died would be higher. For example, how many people who pay for health care are stubborn enough to ignore aches and pains because they hate doctors and don’t seek care? By the same token, how many of the uninsured are just as stubborn and how would universal health care solve that? The short answer is that it won’t.
    And, someone above commented about having to pay for their own insurance. My husband left a job to do his own thing. COBRA was rip-off central. It would have cost me 1800 a month. I went in search of other insurance. I got a 5 million dollar per use policy with a 2500k deductible for a family of six and it cost me $485 per month. My husband was the only one with a ‘pre-existing’ depression dx. There was a 500 rx plan, which was met and then they were paid for as part of the deductible.

    My personal belief is that the current system works much better than Britain, Canada. Hawaii tried it and now the program is bankrupt. In Britain, my Army pal, an ex-pat, waited 3 years for a back surgery and by then, too late. He also was forced to wait 4 months to begin treatment for cancer. Why do Canadians come here for surgeries? Take off the blinders and stop thinking that things are greener on the other side. They really aren’t. Britain is moving toward privatization again and in Canada, so too, the private clinics are coming out. Our sustem is far from perfect, but it beats the hell out of every other Country.

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