Tuesday, October 25, 2016

End of Life

Image result for barbarian invasions movie
The final scene from the movie "The Barbarian Invasions"

A year or so ago courts in Canada ruled that people have a legal right to what was then called assisted suicide and is now called physician assisted death but what is what used to be called euthanasia.  They gave the government a year to come up with a law.  Our former Tea Party government diddled around with this and it fell on our new government to come up  with a law.  The law they have come up with is predictably unpopular with both sides of the argument which some people would interpret as that it must be a pretty good law.

I generally disapprove of whatever you call it but as soon as you make arbitrary statements, all the what ifs come into play and these issues are rarely black and white but are rather shades of grey. I could expound further on the ethical issues but all kinds of other people who are able to use terms like beneficence and non-malfeasance and actually understand what they mean are already expounding in the medical and lay press. 

I work in a Catholic hospital.  While the Catholic church has historically had no qualms about killing heretics, Muslims, Jews, or Protestants; the idea of ending the suffering of somebody with a terminal condition seems to stick in their craw.  This is problematic because our sister hospital has 95% of the palliative care beds in the region.  We are assured by our medical director not to worry because most of the PAD will be delivered in the patients' homes because apparently  in the universe he lives in, patients still die at home.

This does give me an opportunity to muse about my experience with end of care.

The concept of euthanasia is not by the way a new one.  I remember having a discussion of it in Grade 10 English class of all places

Anyway as an intern I was towards the end of 8 unhappy weeks on Internal Medicine when we had an unfortunate patient admitted to our service in the evening.  This poor man had been otherwise well until a few days ago when he developed back pain and as we like to say, his bone scan lit up like a Christmas tree.  He had some type of untreatable cancer in his bones and he was deteriorating rapidly.   Now no death is really a good death but we could say that he had had an active life almost up to the end, unaware of what was going on in his bone marrow and that by presenting late in his disease, he was spared weeks of chemotherapy hell.  I doubt he or his family saw it that way.

The medical resident (actually a second year family practice resident) told the patient and his family that there was nothing that could be done and that we would keep him comfortable with morphine until the cancer took it's course.

That was when one of his daughters yelled, "what you are talking about is euthanasia!" and ran out of the room.

Nowadays that would generate an ethics consult, a palliative care consult, a week of chemo and possibly an ICU stay but in 1983 we didn't do that so he got IV morphine which was a relatively new concept then.  Instead of just running an infusion or having the nurse give the med IV (the patient might die?) the intern had to inject 10 mg of morphine every 4 hours.  That meant every 3rd night that was me.  On a q4h schedule, that meant a midnight and 0400 injection.  Generally you were up and around at midnight but at 0400 you were generally trying to catch a few minutes of sleep.  After almost 2 months on 1 in 3 call you would sell your mother for a few extra minutes of sleep.  As it happened I was on call on the above patient's last night on earth and after the midnight injection, I asked the nurse if she might consider a sc injection.  (From a pharmacokinetic point of view, sc injections would give a more steady state morphine level, which I should have thought of).  She of course laughed in my face and at 0400 the page came, I went to the bedside, she handed me a syringe which I injected slowly and went back to bed.  At 0500, I got the page to pronounce death.  "Aren't you glad you got up to give him that injection IV instead of sc", the nurse said.  "What the hell was in that syringe you gave me,"  I replied.

The second episode was early or late in my career as a rural GP.  It was my first weekend in a small BC interior town and I was on call.  Friday night I got a call about a patient with ALS who was at home.  I made a house call and listened to his chest and he had pneumonia.  The one thing I remember was that he was watching the playoff hockey game and I remember thinking, "too bad he's not going to find out who wins the Stanley Cup this year."  Funny the things you think.  I prescribed some oral antibiotic and went home to watch the rest of the game.  Sunday evening I got another call and made another house call and he was really in a bad way.  I called the ambulance which took him to the hospital ER and I could see that he was not going to survive the next few hours.  At the same time his wife seemed quite adamant that everything be done which left me in a dilemma because everything that I had been taught told me that you don't ventilate ALS patients ever.  I called his family doctor who worked in the same clinic at home because I figured he knew the family well and could come in an talk with them.  "Oh" he said, "Do you need help intubating him?".  I muttered something like I didn't really think intubation was appropriate and besides we didn't have a ventilator at our hospital.  Anyway it looked like his wife wanted everything done so we called in a nurse, loaded him up in the ambulance and sent him to the referral hospital an hour away by road.

I talked to the nurse, who went with him, later and she said that they almost intubated him at the referral hospital before they realized that he had ALS and he died shortly after.

I think about how better the whole case could have played out, how he could have died at home surrounded by his family or at worst in the local hospital surrounded by his family instead of spending the last hour of his life in an ambulance.   He might have even been able to watch a little
hockey.

His wife came in the next week to see me and I told her how sad I was that her husband died and she shot me a look that said, "Fzck you" and asked for prescription for Valium which I gave her.

Shortly after that I decided rural (or for that matter any) general practice wasn't for me so I went in the anaesthesia where we don't have to deal with end of life issues except of course for the six months of IM I had to do which had some really interesting end of life issues, one of which I blogged on years ago.

Somewhere along the line the whole euthanasia debate got hijacked by the concept of "passive euthanasia" which was if you didn't try every single futile treatment, that was the same as giving someone a massive overdose of barbiturates or whatever.  So over the past 25 years we now have end of life patients in ICU, or getting futile surgical procedures.  One third of the beds in our ICU are dedicated to ALS patients now.

Anaesthesia is in fact quite often involved in end of life care as I will outline below.  This scenario or something similar is not uncommon.

Granny is dying of colon cancer at home.  She has been seen by the palliative care team and is doing great until she develops a bowel obstruction.  Instead of taking her to the hospital with the palliative care unit, where they know her, she gets taken to another hospital.  There the ER doc or the internist calls the surgeon who without seeing the patient agrees to do a laparotomy/enterostomy.  The patient is told she is having a quick general anesthetic where she will have the obstruction relieved by a small incision.  She is seen in the receiving area by the surgeon and you for the first time.  In the OR, of course the tumour is stuck to the abdominal wall and bleeds, or the surgical resident perforates the bowel and all of a sudden cachectic Granny has an incision from her pubis to her xyphoid and the you know she is not going to breath post-op.  You could call ICU but you can already hear the peals of laughter from them when you ask for a bed.  So you take her out to recovery on a ventilator and the recovery room nurses are really pissed off at you. (The surgeon is meanwhile telling the family that she is being ventilated because of the anaesthetic.)

The bottom line here is that other people on your behalf made promises they didn't have to keep, she was just having a quick case, she wasn't going to die today.  Had you seen her, you may have said otherwise but you weren't invited to the discussion.

The other issue is that Granny is a DNR or whatever you want to call it (we have a very complicated Goals of Care document in our region).  Technically you can just turn off the ventilator and watch her struggle for minutes to hours until the hypoxia/hypercarbia trigger the final lethal arrhythmia.  You could even sedate her a bit.  Nobody really wants to see that though. I've turned off the ventilator on organ donors enough but somebody that you talked to an hour so ago?  Not sure about that one.

The other scenario is the pathologic fracture and the ensuing tumour embolus.

This is not to say that either patient shouldn't get surgery.  A bowel obstruction or a pathological fracture can be pretty incapacitating.  The issue is that in that population there is a high risk of death or requiring ventilation post-op and this is something that needs to be discussed with the patient and their family and never is.  Granny for example might elect for an NG tube and a lot of morphine or a radiologist might be able to do something percutaneously.

When I was on the admin dark side, some people came to our Medical Advisory Committee to discuss the above Goals of Care document.  I took the opportunity to express my concern about these scenarios and the fact that we are never invited to these discussions.  "Yes, that is a problem," said the nice lady and went on to the next question.

The final issue is that having decided it is okay for doctors to kill people under circumstances how do we actually go about it.  Because as I blogged in respect to Capital Punishment it is really hard killing somebody when you really want to.   I mean those of us who do "monitored sedation" know how easy it is to make somebody apneic and occasionally cause a cardiac arrest but when you really want to kill somebody it may not be as easy as you might want.

As I understand currently the practice would be to administer large doses of oral barbiturates.  20-30 years ago getting barbiturates was easy.  About half the population were on them as sleeping pills.  We even gave them to pregnant women.  If you gave somebody a months supply of Seconal you usually gave them enough to kill themselves.  Now if I order a lethal dose of a barbiturate, the pharmacist is probably going to ask some questions.  He may even refuse to fill your prescription. (A significant number of pharmacists refuse to dispense the morning after pill, presumably these people may have some opinion on euthanasia)     That plus in some provinces barbiturates are on the triplicate prescription program.  Assuming that you have gone thru the proper procedures for physician assisted death, you won't necessarily get in trouble but you may get hassled.

Of course getting somebody who has a swallowing problem or who is drifting in and out of consciousness to swallow all those pills is going to be a little difficult.  That is why probably a lot of euthanasia is going to be intravenous which has its own issues because IV access is not that easy as I find out once a week or so. 
  
The other issue is that a lot of the euthanasia candidates are going to be narcotic tolerant which means you are looking at bigger doses.  Dose is a problem because you can give a huge dose and still not kill somebody.  (I remember a story in medical school which I hope is an urban legend about somebody who took a huge dose of horse tranquillizers and woke up days later on the stretcher on the way to have his kidneys harvested.)   I have a friend who is now a retired anesthesiologist in Holland who tells me of GPs coming to the OR to "borrow" some pancuronium and everybody knows what they intend to do with it.

Looking forward into our brave new world of legalized euthanasia or physician assisted death (because why use one word when you can use three) who is going to be doing the killing?

I think a lot of doctors are already thinking, I'm just going to call anaesthesia, they have all kinds of cool drugs and besides we already blame them when somebody dies.  I think most of the leaders in anaesthesia are trying to keep a low profile lest more people think that way which is too bad because we as a specialty should be part of this debate.

There are the evangelical physician advocates of PAD who are already active and will probably do a good job of it  although there are not very many of them.  Knowing doctors as I do too well, I predict the following scenario.

We have socialized medicine in Canada which means that doctors who euthanize patients will expect to be paid.  This means that a generous fee will be negotiated, because this has been mandated by a court decision provincial governments will pay whatever is demanded.  This means a certain class of doctors, who we all know, are going to realize that they can make a killing out of killing people and it is they who are going to be doing most of the PAD.  




I am (or I guess I am not) a leading physician of the world.

Image result for hippocrates

This fellow had a similar experience to me and blogged on it.

In case you are interested in becoming a leading physician of the world, here is the website.

I am not sure how I got into this but it may have been while wasting time on  Linked In or I may have responded to a random email.  I must stop doing this.

Anyway I got a phone message today, informing me that they had reviewed my information and I was now a leading physician of the world, as long as I phoned the toll free number they left me.  I had a hole in my clinic and so I phoned the number and after some time on hold, I talked to a lady who went over all my information and asked me some questions, like to what did I attribute my success.  I am not actually certain whether I am in fact successful or what I attribute any success.  I suspect being born white, and English speaking, into a middle class professional family at a time when University tuition was affordable had a large amount to do with it.

As the clock ticked away on the phone call, I was beginning to wonder how an organization devoted to the noble cause of identifying the leading physicians of the world supported itself.  I soon found out as the nice lady started asking my about whether I wanted the platinum or diamond plans and the costs of these.  I realized what I should have know all along that I was being scammed.  I therefore told the nice lady that while 10 minutes ago, I had not been busy, I was now busy and that perhaps she could email me the info.  She didn't want to do this and so I hung up on her so never got to hear about the gold plan like my cardiology colleague, let alone the silver or bronze plans which no doubt exist.

Anyway I have failed again to grasp the brass (or was it platinum or diamond) ring and will have to content myself with being an ordinary physician.

The Demedicalization of the Caesarian Section.

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First off, I am not in favour of natural childbirth.  I am interested in history so when I visit places that have a history, I occasionally visit graveyards.  I am always struck by the number of young women buried next to a newborn baby, because the mother and baby died in childbirth.  In Cuba when this happens, the baby is buried with the mother between her legs.  This is natural childbirth and if we want to accept mothers and babies dying as a natural occurrence, we should embrace this. 

Having said all this in my lifetime the Caesarian Section rate has gone from 20% to 30% with very little decrease in maternal or foetal morbidity or mortality.  It is at the same type well documented that materanal morbidity is increased with caesarian section versus vaginal delivery.

I was on call recently and did quite a few sections which gave me some time to reflect on this.

We do almost all our sections under regional nowadays.  This is a major change from when I was a resident where the majority of Caesarian Sections were done under general.  We would always see the patient the night before and try to convince them to have their section under epidural which was how we did them then.  Now patients are told by OB they are having their section under spinal and it is very rare to have a patient demand a general (some "experts" in OB anaesthesia think we now do too few GAs).  Sections under general anaesthetic were always a major stressor at least as a resident and even as a junior staff.  The patient would be awake in the room, the OR team scrubbed and the belly prepped and draped.  You would pre-oxygenate the patient and the nurse would apply cricoid pressure after which you would inject a pre-set dose of pentothal followed quickly by succinylcholine.  You would then attempt to intubate the patient, this was made difficult by the fact that you had to work with the drapes and one hospital where I trained made things especially difficult by insisting on using the ether screen.   ("Fortunately ", we didn't have a pulse oximeter for most of my residency; it was probably when we and the OB saw how low the sats went that regional began to be pushed more aggressively.)  The pregnant airway is as we are all told more difficult and I shudder to think of giving GAs to the BMI 60 patients we routinely see now for sections.  The fact that a significant number of these GAs were in the middle of the night or you had had to drop everything and rush up to do it added to the stress.

As I mentioned sections are now done exclusively under regional and it must be at least two years since I did a GA section.  After we put in the spinal or top-up the epidural, the patient is draped, the block tested and then the father is invited to come and sit at the head of the bed.  This is not always the husband/father, it could be the mother, a sister or a friend.  I remember on occasion having two people in the room but I suspect infection control has blocked that. Under regional, the sections are little more relaxed as there is not the race to prevent baby from getting some of mom's general anaesthetic drugs and in 5-10 minutes we have a baby.

This is when what I call the "love-in" starts.  Everybody's IQ drops about 20 points, everybody coos how beautiful the baby is, the father is invited over to the bassinet to cut the cord, photos are taken etc.  Our hospital now does skin to skin.  Such a beautiful and special moment.  Except.....

The mother still has a large abdominal incision and a big hole in her pregnant highly vascular uterus.  There is still the matter of getting the placenta out which may or may not be easy.  And there are little issues like amniotic fluid emboli and pre-eclampsia.  Further the OB is probably going to exteriorize the uterus which means that means that your patient is going to get nauseous and if the block is the least bit patchy, uncomfortable.  She may also get hypotensive from the spinal and from the blood loss.  In other words, your patient is not out of the woods and may need your attention still.

This happened to a colleague of my a few years ago.  I don't remember exactly what happened but he felt he needed some help with the patient and so asked for assistance from one of the nurses.  The love in was still in process and the nurses ignored him accidentally or intentionally.  This lead to him raising his voice (his version) or yelling (their version) and he got written up and had his wrists slapped.  I wasn't there and only heard his version so I can't really comment.

This is a difficult issue to discuss because a Caesarian Section is life saving for the mother or the baby in some circumstances.  Just how often is the question.  Certainly not 30% of the time.  A lot of women really wanted have the perfect labour and delivery and push out their baby and when in their best interests we have to section them, they may feel that they have failed and we don't want to reinforce this.  At the same time we read about the "too posh to push" mothers who chose to have a section rather than even attempting vaginal delivery.  There are probably variants of this and I imagine discussions going on in the OB office where the prospective mother states her concern about the difficult labour of her sister, friend or mother and states that if things look like they are headed that way, she wants a section.  I am not sure whether these discussions happen, I strongly suspect that they do and a significant number of "failure to progress" or "non-reassuring tracing"  sections are as a result of these discussions.

The demedicalization of the Caesarian section, benefits mostly the OB who no longer feels guilty (assuming they are capable of that) when she does a questionable section, because she wants to get back to her office, go for dinner, not have to hand off the patient etc, doesn't have to worry about depriving the mother of a wonderful birthing experience because after all a section is a birthing experience with mom awake and the father or whoever invited to participate.  

My argument is that by making the Caesarian Section less medical, more routine and more pleasant we are making it too easy and maybe we need to find some type of balance.  Not holding my breath on that.

Tuesday, September 13, 2016

First Do No Harm

There was recently an article published in a leading newspaper, referring to opioids, entitled "First Do No Harm".  I have discussed is this in the past and may again in the future, however the use of this adage struck me. 

I first heard this adage way back in medical school referring to anaesthesia and the fact that anaesthesia contradicts this principle.

In fact when the urologist discovers after the patient is asleep that the patient passed the stone already or the orthopod after the patient is asleep realizes that maybe he should have examined the patient or at least looked at the X-ray  and all the patient needs is a cast, I reassure them.  "Anaesthesia is good for you", I tell them.  I hope this makes them feel better but  most surgeons have no conscience anyway.

The fact is in medicine that we are constantly exposing patients to harm in the hope that we will make them better.   We are in effect betting the ill effects of a treatment versus the likelihood of helping the patient.

The House of God had it down with rule XIII:

THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

This of course isn't always in the patient's best interest either although is probably in their best interest more often than we think.

For example how often do you hear an doctor justify a procedure or test by saying, "I didn't no what else to do" or "Well I had to do something".  I have been guilty of this back when I was in general practice, in the pain clinic and quite often in anaesthesia when things are going south, how often do we try something random which we know probably won't work.  

Here's some questions to ask yourself.

1.  Based on your assessment is the patient going to die within the next few hours without treatment?
2.  Do you have any idea of what is going on and will either the test you order help make the diagnosis or does the procedure or treatment at least have a reasonable chance of stabilizing things.  

But speaking of aphorisms, what about the Hypocratic Oath.  A patient advocate asked me about this oath a few months ago in connection with an op-ed he was going to write.  

"First", I explained to him, "Many doctors, including me, have never taken the Hypocratic Oath."  Some schools have an elaborate oath taking ceremony.  My school didn't.  Am I a worse doctor for that?  "Secondly, " I went on, "there are multiple versions circulating including a modern version."  
"Thirdly", I pointed out, "Many of the things proscribed in the Hypocratic Oath are actually part of medicine, like cutting for stone, administering noxious substances (chemotherapy, anaesthetics) and abortion (controversial but still part of medicine). ". 

The Hypocratic Oath also has things like treating your teacher(s) for free.  We have socialized medicine in Canada and I work in a city where I didn't train, but that doesn't mean I would be interested in treating pro bono the 100 or so physicians who taught me.

About 20 years ago, I bought a handsomely bound of the "Aphorisms of Hypocrates" which now sits in my bookcase along with some of the other handsomely bound historical books from the same series.  And I read the Aphorisms.  I can tell you that if you practised in the Hypocratic fashion, it is a question of who would get you first, the licensing body or the lawyers.  I often wonder why we place such importance on the thoughts of somebody who practised over 2000 years ago.  I do like reading the history of medicine if only because seeing how wrong prominent physicians were in the past, puts into the context the modern practice of medicine. 

I think we need to spend less time worrying about doing no harm and more time stopping using outdated and irrelevant aphorisms.

Monday, September 5, 2016

Things that make my work worthwhile

My wife just read my last blog post.  "You sound like a crabby old man" she said.  Well for a number of years I worked with a lot of crabby old men (and a few crabby old women); sadly or not many of them have retired and there is a niche that needs filling because just as mosquitos and wasps are important parts of the ecosystem, COM just might be an essential part of the OR ecosystem.

About 2 years before I left of CoE, things were at a low point and morale was horrible in our department.  While the causes were at least to me pretty obvious, the solution was to hire a consultant to find out what was wrong.  I am not sure whether our department or the hospital paid for it.  Anyway those of us who wanted to meet with him were allowed a one on one meeting which I enthusiastically signed up for.  As most people who are earning $400 an hour are, he was quite pleasant.  So for about 30 minutes I detailed everything I thought was a problem with the operating room, the surgical service and the anaesthetic department.  At the end of this rant, he asked me, "why do you still work here?".   I thought about it and said something to the effect that I had been there for 10 years, I knew the place, I liked most of my co-workers and that I really hoped that things would get better.  I didn't say that I wasn't really sure I could get a job anywhere else, that the case mix at the CoE was so different from other sites that I wasn't sure that I could handle a different case mix and that I realized that the grass was not necessarily greener elsewhere.  A report which I never saw was duly produced, some minor cosmetic changes were temporarily introduced, things continued to get worse and I decided that maybe in fact I could handle the case mix at another place and that the grass was greener elsewhere.  

The one thing I remember about coming out of the meeting with him, was how good I felt having let it all out to somebody besides my poor wife.

But there are all lot of things about my work that make it all worthwhile.  Not in order of importance by the way.  

1.  The sight of my hospital in my rear view mirror at the end of the day.  (Okay it gets better.)
2. Being part of a team.  Sometimes we don't feel like it but we are part of a team and we can't function without each other.  That doesn't mean we always get along or have to get along but it is great to work towards a common purpose every day.  It is great when for example we get a heavy urology list and we all work through it together, finishing on time or when we all work together on a really sick or dying patient.  
3.  OR nurses.  I have worked with these men and women for 30 years now counting my residency.  I still find it incredible the way they can handle multiple surgical instruments, and complex electronics flawlessly, anticipating the surgeons' next moves.  On call I find it amazing that the same team of nurses can flawlessly go from a complex Ortho case, to a general surgery case and then to a urology case all with radically different equipment and requirements.   Or if I ask for a piece of equipment I maybe use once every 3 years, they can usually find it.
4. The jokes.  OR humour is probably the funniest and most inappropriate humour around which is why I can't give any examples.
5.  Patient contact.  We don't get much of it in anaesthesia but we get more than we are given credit for.  I really like talking to patients pre-op going over their history and explaining things.  I know I am sometimes brief and perfunctory.  I even like the stupid patients or the ones who clearly aren't paying attention to me.
6.  Hitting the sweet spot.  The time when every thing goes right, when you ask the patient to open his eyes as the dressing goes on and he does; and he seems comfortable and not nauseated.  Or when you get the spinal first pass.  Doesn't happen every case or it wouldn't be special.  
7.  My co-workers.  I already mentioned the OR nurses.  I get to work with a great group of anaesthetic colleagues and while the only time we get to work together is when the shit is hitting the fan, I really appreciate the support and cameradery we have.  Sure the surgeons really piss me off sometimes but I  do know that some of the stunts they pull are done with the patient's best interest in mind.  I should also mention all the other nurses, techs, clerks and orderlies I work with most of whom are great to work with. 
8.  Recovery.  Should have mentioned these nurses earlier.  Doesn't get the glamour of places like ICU, but the way these nurses can anticipate problems, pick up problems early and move quickly when the shit hits the fan is positively amazing.  They have saved my ass so many times.
9.  Being an anaesthesiologist.  Within a month of my residency starting, I knew this is what I was born to do.
10.  My lifestyle.  OK the surest way not to get an anaesthesia residency is to mention that we have a good lifestyle.  But we do.  No start up expenses, low overhead, fixed start to the day, when you are finished for the day you are finished for the day.  Easy to work part-time.  Sure there are specialties that have a nicer lifestyle but we have the satisfaction of doing a good job while we are at work.

Sunday, September 4, 2016

Things that really bug me

Some of the people at work complement me on my relaxed laid back demeanour.  I would rather they complemented me on how intelligent and handsome I am but I have to take whatever complements I get.   Under that calm exterior lies a smouldering pit of resentment.  

Let me air my grievances.

1.  Electric beds.  Not electric OR beds, but I will get to those.  I am talking about the electric beds from the ward.  It does make sense to reduce the number of times patients are transferred and so some patients go to and/or from the OR on these beds.  Except, these beds are never at the same height as the OR bed which means plugging them into an electric outlet.  Of course they come with ridiculously   short power cords (short enough not to reach the wall but not short enough to not trip over) which means finding an extension cord so that they can be plugged in.  Did I tell you most of the beds in our hospital now have two plugs both of which have to be plugged in, so now two extension cords.  Aside from the fact that we really don't need two more things to trip on in the OR there is a potential electrical hazard here.  When I was a resident we had to learn about electrical safety and it seems that by law most devices in the OR are elaborately grounded to prevent shock to the patient and staff.  And apparently if you use an extension cord, this exposes the patient to micro or macro shock.    (Like I said, I learned about electrical safety, I didn't say I understood it.).  Oh and the new beds come with a piercing alarm which goes off if the bed is unlocked while plugged in, like for example when you are pushing it towards the OR table so you can move the patient.   

A lot of this could be fixed if the beds came with batteries which our OR beds do and which the hospital beds in the hospital in Ecuador where I sometimes work do (the floor nurses would still forget to charge it) or if they allowed the option of manually raising and lowering them without plugging in the bed.

Electric OR beds I for the most part like.  I miss strengthening my legs pumping up the table.  I don't miss wrecking my back bending over to crank the handle.  The only problem I have is with the surgical princesses who insist on moving the bed up and down side to side every 5 minutes.  Cuts into my phone call, Internet and of yeah monitoring the patient time.

2.  IV poles with more than 4 legs.  Space is limited in the OR.  OR tables are rectangular as are beds and stretchers. This means that the right angle of the IV pole with 4 legs fits in nicely against these objects saving space during cases or when you are taking the patient to recovery room or ICU.  Life was good the universe was in balance.  25 years ago the first 5 legged IV poles appeared.  Now they seem to have taken over.

Sadly this picture is typical.  Look at them:  three  5 legged poles (and in the background a lonely 4 legged pole)

Proponents of these claim they are less likely to tip over.  As we all know, if you load enough infusion pumps, blood warmers etc onto on of these, they can and will tip over especially if you add a urology size bag of fluid or two.   They will tip over most likely because some clumsy oaf like me trips on the legs.  And suggesting that adding legs makes them more stable shows a lack of knowledge of geometry because as I learned in Grade 7, three points define a plane which is why for centuries milk maids use three legged stools because they don't tip over.  Not to mention tripods.

3.  Infusion pumps.  Okay I use infusions all the time and would hate to go back to the situation like when I was in medical school where nurses counted drips to figure out how fast the infusion was going.  (My wife when she re-certified for nursing had to learn about drip counts; "nobody does that anymore," I told her.). I certainly don't object to having some medications run thru infusion pumps and I can see that in fragile patients and children, making sure they don't get too much fluid is important.

What really bugs me is the 20 year old with the fractured ankle who comes down with his IV running through an infusion pump.

And do they have to be so freaking complicated.  This is the 21st century.  I am a PC guy but when I got my i phone, I had it figured out and running within minutes.  Why do we now have to have hour long inservices on these pumps before we can use them.  Do people not realize that this is inherently dangerous?  Nowadays when an ICU patient comes down with 10 of these running, I usually try to ignore them, occasionally starting my own IV line.  This would be fine except the ICU nurses always set the VTBI (volume to be infused) to a low number so it will run out during the OR and the alarm(s) will go off forcing me to deal with it.  I think they do it intentionally.  

And can they trust people?   Why is everything locked up.  We got new PCEA pumps for OB recently.  We actually got to play with them at rounds before they went into service and liked  them (not that it would have made any difference if we hated them, they were already bought).  So a couple of weeks ago I decided I would use it on a patient, the pump was now inside a plexiglass locked case which not only made it difficult to read the screen but required a key which the nurses took 10 minutes to find.  Plus in addition to a key to lock the case, there was a second different key on the pump which the nurses also had to find.  

Do they actually think malicious relatives are going to turn up granny's infusion?

4.  This:
If you are concerned about your diet, just don't eat the doughnut or the muffin.  Don't just eat the top of the muffin or cut out half or, as somebody  in the above pictures did,  2/3 of the frigging doughnut.  Because despite all the lectures and posters on hand hygiene,  I know where your hands have been and  the type of person who would do this to a muffin or doughnut is the type of person who doesn't wash his hands, so you think I or anybody are going to eat the fraction of pastry you left behind?

4.  People who drink but don't make coffee.  You know the scenario.  You drop your patient off in recovery, see your next patient and in the remaining 5 minutes before they call you, head to the OR lounge for a coffee to warm you up and keep you awake for the next case.  Except there is no coffee left.  You look around the lounge and just about everybody has full cup so...one of them took the last coffee and didn't bother making another batch.  You could (and probably will) make another batch but you know this is going to be the time when your room turns over quickly.  Making coffee is not difficult.  Most of you went to medical school.  It doesn't take that long.  If you drink the last drop of coffee making another fzcking batch.  OK?

This by the way also applies to the first person in the lounge in the morning.  If you drink coffee, make the first pot.  Don't just sit there and when I arrive ( and I am never first) say morosely, "there's no coffee."

This applies to medical students, residents and sales reps who drink our coffee.

5.  Arm boards.  You would think by now they would have designed an arm board that attaches and detaches easily from the OR table?

6.  Residents, medical students.  Okay I was both a medical student and resident at one time, but I was much smarter, cooler, and hardworking.  Plus less klutzy.  This applies mostly to surgical staff.  I figure by now I have spent a year of my life watching students and residents painfully close incisions.  This applies to anaesthesia as well although our residents are way better and now the only medical students we see are thinking of applying to anaesthesia so actually know something.  Actually we at our place see residents so infrequently that largely I would just rather do my room by myself thank you very much.

Fellows are by the way just as bad and quite a few fellows clearly decided to do the extra year of training because they forgot to learn how to operate during the previous 5 years.  For some of them no amount of training is going to ever make them into surgeons.  

7.  The constant gaming of the "emergency list".   I know we can't just restrict our after hours work to life and limb threatening cases but when you can predict your on call workload based on what surgeons are on call things have gone too far.  Maybe things haven't changed , maybe I am getting older and crabbier.  Most of my 5 years as dept. head, I spent fielding phone calls:  from the anaesthesiologist on call complaining about what the surgeon(s) had booked; from the surgeon demanding that I call in a third anaesthesiologist to do the "emergency" case he had booked 4 days ago that had now been bumped by a real emergency.  

Wednesday, August 10, 2016

More idiocy from Infection Control

A couple of recent experiences on call thanks to our tireless infection control department.

A few months ago a patient presented for surgery.  A year ago she had Vancomycin Resistant Enterococcus.  This was cleared and she had negative cultures.  So she presents in the ER requiring emergency surgery, can't remember what, maybe a hip fracture.  Whoever did her history and physical noted that she had VRE.  Had can of course be present or past tense.  Notwithstanding her negative cultures on goes the yellow gown and we have to go into full paranoia mode in the OR.  Before the case, I ask the charge nurse, "can't we just call infection control and explain and get the isolation precautions lifted?".  No of course because it is the weekend and infection control doesn't work on weekends.  Silly me.

To our credit both the surgeon and I ignored the precautions which means there are probably multiple incident reports floating around.

Next a month or so ago the charge nurse informs me that the surgeon has booked a cholecystectomy.  But.... the patient has been to a hospital outside of Canada and by hospital policy has to be treated as a possible antibiotic resistant carrier.

So I am trying to imagine in what third world hell-hole she found herself in hospital.

Answer:

Phoenix Arizona.