Friday, November 8, 2019

My fall and later rise.

On August 8 I was injured in a major bicycle accident which required surgery. 

My wife and I go to the Edmonton Folk Festival every year.  I have only missed 3 festivals since 1995.  Since moving to our current home in the West End, we have usually ridden our bicycles.  It is 12 km each way on quiet roads or paved trails.  This means riding home in the dark or twilight.  

We went as usual this year for the Thursday evening concert.  We left a little late, wanting to avoid the line-up to get in.  We don’t do the tarp run.  With only two of us we can usually squeeze in between tarps.  We arrived, got our weekend wristbands, bought a program and walked up the hill, finally finding a good place to place our tarp.  We then went to the beer garden and had one beer each.  It was a sunny humid day.  “Are you going to have another beer,” my wife asked.  “No”, I said “lets go have dinner.”.  We both ate Ethiopian food sitting on the grass.  The first act which we weren’t interested in was already playing on the stage.  We then walked back to our tarp where we watched the second and third acts, both of whom were quite good.  It was my plan to leave after the third act and miss the final act.  The festival is 4 days and you have to pace yourself.  Plus we could see the weather deteriorating to the west of us.

We walked back to the bike lock up to pick up our bikes.  It had rained a lot over the previous days and there were swarms of mosquitos and I got quite a few bites before we left.  We cycled thru Cloverdale and took the pedestrian overpass and then started cycling west along the trail.  As we passed the Riverboat area, a wedding party was just dispersing.  The first flashes of lightening were showing to the south and west.  We kept on, my wife riding ahead as usual.  To get home we had to cross the Saskatchewan river via the Low Level Bridge.  This meant going on the underpass under the bridge in order to cross on the correct side of the bridge.  

There is a small downhill going to the underpass.  As I started to descend, I ducked my head as I always do going under bridges.  I thought to myself, I don’t have to do this, there is lots of room.  I could see my wife ahead almost at the other end of the underpass.   There was a bright lightening flash.  That is the last thing I remember.

I do remember going into a dream state.  I first dreamed I was back at the bike lock-up, then that we were cycling on River Valley road (about 1 km away and where we were heading).  Next I was awake on the ground talking to my wife.   I was bleeding from my face.  I remember saying I could ride home but my wife told me I had to go to the hospital which as I became more with it made more sense.  My wife called a taxi and quite quickly one came.  It was a minivan so we threw my bike in the back and I got in.  My wife decided to cycle home and drive to the hospital.  I was bleeding moderately heavily, she gave me the blanket we had sat on to put over my face.

I was starting to be more alert.  I realized I had facial fractures.  My teeth were pushed back in my mouth.  I figured I might had a skull fracture and maybe even be bleeding intracranially.  At points in the short taxi ride I felt drowsy but forced myself to stay awake.  We shortly arrived the University Hospital ER.  The fare was about $15, I gave the driver $20, given that I had probably bled over his cab.  He really was a nice guy who was quite concerned about me.  He brought my bike to security in front of the ER, who I remember were generally disinterested in looking after it.

I then went to triage.  There was one person in front of me.  When it was my turn, I explained what had happened.  I was then sent to register and then directed to the waiting room.  This was quite full and I had to squeeze into a chair between two people, holding the blanket over my bloody face.  

In the 10 or so minutes in the waiting room I was able to reflect at what I had done to myself and what effect it might have on my life.  I figured I had knocked out my front teeth.  I most likely had facial fractures, possible some neurosurgical problems.  I had been knocked out.  I was going to need surgery  I was not going to be able to work for an as yet unknown period of time.  Given that I had a head injury would I even be able to go back to work.  Would I be able to or want to ride a bike ever.  Would I be able to play the saxophone?  (I actually thought that).

I was eventually summoned into the back where I was taken into the trauma room with its resuscitation equipment, radiolucent bed and overhead X-ray (keep in mind I had been sent back to the waiting room by triage).   I remember the nurse who walked me back as very kind and compassionate.  Not at all like the ER nurses I used to work with, or read on Twitter.  An IV was inserted, blood was drawn and X-rays were taken.  A very nice ER doc came in trailed by a medical student.  He went thru as thorough trauma assessment including rolling me over.  They gave me ketorolac for pain and to my surprise it actually worked (they promised I could have something more potent if necessary).   I shortly went over to CT to have facial and head CT.  “Aren’t you going to look at my neck?”, I asked.  The ER doc explained that I didn’t have any neck pain and had walked in.   Makes sense.  The techs in CT were also really nice and professional.  After CT I was moved back to another area of the ER.  Somewhere in that time my wife had arrived, having ridden home.   

I lay in the cubicle for a couple of hours.  I was fully awake and was aware that I was most likely out of major danger.  My wife had brought my phone which she had taken from me at the accident scene.  I had the prescience to email and cancel an appointment I had the next day.  At some point we looked at my helmet.  I’m not sure how it came with me.  It was broken at the front, which made sense with the facial fractures. We tossed it in the garbage.  I feel a little bad about this.  It is an inanimate object but it did save my life and while I had only had it for a couple years, it had sat on my head for some pretty epic kilometres of biking.

My GP had signed me up for the patient portal so I could legally look at my blood work.  I started getting emails in the ER telling me I had blood results, which I was able to log in and see. 

Eventually the ER doc came and told me that I had no intracranial problems but had multiple facial fractures.  He had phoned plastics who would see me the next morning.  I could go home.

Oh and do you mind if the student sutures your only facial laceration.

I sutured lots of facial lacerations as a student so I said it was okay.  He somewhat clumsily set up the suture tray, injected local and put in a few stitches.  I noticed that rather than instrument tying he was hand tying each knot.  We chatted while he was doing all this.  He was from Victoria like me but we went to different high schools (a generation or so apart).  The ER doc came back and asked if I wanted something for pain.  I said I preferred Percocet over Tylenol 3 and I found a rare ER doc with a triplicate pad, so I got a prescription for 30 and 5 tablets to go.  My wife got my car from parking and picked me up in front of the ER and she drove me home.

Because of the swelling I was told to sleep with my head elevated she set me up on the couch in my office with lots of sheets and towels to keep the blood off.  I didn’t sleep.  Too wired, too worried about the intracranial bleed I was sure I had.  I keep on telling myself, you had CT of your brain, everything is okay.  I had Percocet but was scared to take it.  Eventually around 0600 I went back to my own bed and slept on a couple of pillows until about 0900 or so when my wife woke me because it was time to go back to the ER.

We checked into the ER again and told them that we were meeting plastics.  We were directed back to the waiting room.  This was quite full and the only seat was next to a disheveled “gentleman” stinking of cigarettes and possibly alcohol.  At one point he bought a cellophane wrapped sandwich and tossed the wrapper on the floor.  A burly man sitting kitty corner to us wearing a Boston Bruins ball cap yelled at him to pick it up and I thought I was going to have a ringside seat to an ER fight.  Infrequently, people were summoned into the ER to be seen.  To be honest most of them didn’t look very sick.  It was sickest people who seemed to be ignored including the young lady moaning and holding her abdomen.  

After about an hour a junior plastics resident came down to see me.  He did a more thorough exam than the ER did.  He looked somewhat unimpressed at my sutures from the last night.  He said he would talk to his chief resident.  Back to the waiting room where more or less the same crowd were still sitting there.  A couple of hours later I met a more senior resident who told me that I would be admitted to hospital for surgery the next day but could go home over night on a pass.  I was told to wait to see the chief resident, who came down later with the staff surgeon.  I was quite relieved to see the staff surgeon.  I had worked a lot with him when I worked at the centre of excellence.  He explained that I had quite bad facial fractures and what he would do to me.  He said that he could do my case in his elective time the following Wednesday but recommended that we try to get it done over the weekend on call.

Before I could go home however I had to be admitted to my bed so I could go out on pass so I had to wait another hour or so in the waiting room which was becoming old.  First I was told that my bed was ready but they were waiting for a porter.  I asked if I could just walk over there but was told it wasn’t allowed.  Finally a porter arrived and we walked towards the ward.  She got lost and I had to guide her to ward, where I was admitted and then sent home.  My wife showed up with a milkshake and we drove home.

I was really tired by this time and I remember falling asleep sitting upright watching the football game on TV.

The next morning we got up bright and early and went to the ward where I was shown my “bed”.  My “bed” was what they called an “overcapacity” bed which meant it was a stretcher in between two beds in room designed to have two beds.  (Apparently they have not figured out how to put bunk beds in hospital rooms),  Both my room mates were long term residents of the plastics ward.  I was told that I was likely to be the second emergency case done at around 1000.  Around 0900 a nurse came into start an IV for the OR.  I have been out in the sun a lot this summer and my hands were little leather-like, as well while I had tried to drink lots, I was a little dry.   She failed, as did the 2 nurses who tried after her.  The third attempt struck a nerve and I got a shock down my arm.   I got a little cross.  I was sick of my little bed so I wandered out to the lounge in the atrium.  Out there one of the plastics residents came but to tell me that I was further delayed but she at least bought a glass of ice water and a nurse bought a glass of juice.  For the rest of the afternoon I alternately read, looked at my phone and occasionally wander around the atrium.  At around 1600, I was getting a little tired so went back to my “bed” and actually was able to go to sleep.  Someone tried to get me to eat supper but I told her I wasn’t supposed to eat.  At 1800, a nurse came out and told me that my surgery was cancelled that day.  I was a little relieved.  Based on my experience I was looking at a 6 hour surgery and I wasn’t enthusiastic about coming back after midnight after facial surgery.  My wife came and picked me up and we went to Booster Juice and then home. On the way home, the ward phoned me and told me that they thought I could get done first if I came in a 0615 Sunday am.  

We showed up at 0615 the next day and I went back to my “bed”.   It quickly became apparent that I wasn’t going to be first on the list.  Around 1100 a plastics resident told me that I might get done later in the day.  I told him I preferred to wait at home and could get back to the hospital in 15 minutes if necessary so I went back home.  Later in the afternoon I was advised that because of 5 transplants being booked they wouldn’t be doing me on Sunday and could I come back Monday am.

No doubt the Centre of Excellence was busy Saturday and Sunday but I have worked enough weekends to know how the emergency slate is gamed and nobody wants to follow a 6 hour plastics case.  To his credit and my detriment, my surgeon wasn’t very good at this gaming.  It is difficult to argue about transplants, although they never seem to be an emergency between 0800 and 1700 Monday thru Friday.

I was figuring this all out.  Monday am I phoned the ward and told them that I was staying home and they could call me when my case was booked.   Later Monday I got a phone call telling me that there was no chance I would get surgery on Monday but I was now booked in elective time Tuesday afternoon.  This was a bit of a relief.  I now knew more or less when I was going to have surgery.  I had gotten use to the way my face was, I wasn’t having much pain, I had Percocet and was enjoying my diet of milkshakes, smoothies and beer.  

I went back to the plastics ward Tuesday.  Maybe they felt sorry for me, but I now had a private room with a window.  A nurse came in and put an IV in my antecubital fossa.  I waited reading a book I had started and checking my emails and Twitter.   Some time after noon, two porters showed up with a stretcher and I was off to the OR.

Aside from colonoscopies I have never had a general anaesthetic.  Aside from having had 5 days to think about this, I had some reasons to be anxious.  It had been 13 years since I worked at the CofE and the anaesthetic department had turned over quite a bit.  I knew as a facial smash I might be a difficult intubation.  And then there was the impending 6 hour surgery.  I told myself that from my point of view I would be asleep the whole time but I was still nervous.    I worried about coughing on the tube, nausea and pain.  As we got into the OR I looked for nurses I knew from before.  I was wheeled into their receiving area where a nurse interviewed and checked my chart.  A nurse who used to work at my hospital came in and talked to me which I appreciated greatly.  (I occasionally see someone I know waiting for surgery and go over to talk to them; I never realized how appreciated it is).

After a while, first the surgeon and then the anaesthesiologist came to talk to me.  I had never met the anaesthesiologist although she told me she had trained in our program.  She told me that I would be intubated nasally.  I had figured that with maxillary fractures, I would be getting intubated orally but I guess they have to be able to look at the alignment.  The surgeon had told me that I probably wouldn’t but might be wired shut at the end.  I wondered how I would respond to waking up like that.  

I was pushed into the room.   I could see the scrub nurses setting up.  My CT scan was on the viewbox but without my glasses I couldn’t make out details (not that I could with glasses).  Lying supine, I saw my anaesthesiologist pushing the Glidescope into the room.  That should have made me feel anxious but at that point I wasn’t caring much and I figured she was just being safe.  I had told her not to modify her usual technique for me.  She told me she was injecting  midazolam.  I had had midazolam before for colonoscopy and know what a potent amnestic it is.  I knew I had a few seconds of consciousness left.  I remember about 20 seconds.

Seeming seconds later, I was in the recovery room.  I was extubated.   I couldn’t believe how awake I was.  I had a little pain but no nausea.  I looked at the clock and it was just after 1900.  That took a while, I said.  The nurse asked if I wanted something for pain and I said yes.  She gave my 0.6 mg of hydromorphone and told me I had gotten 2 mg in the OR.  What seemed shortly after I was told that I was going back to ward.  When I looked at the clock however it was after 2000.  Being pushed back to the ward, I saw my wife waiting for me in the hall.  I was so happy to see her.


I looked a little like Ali after the Joe Frazier fight

I was finished surgery but was not out of the woods yet.   There had apparently been problems with my nasal intubation and both nostrils were clogged with clot.  Not withstanding my nose bleed they still gave my low molecular weight heparin (but said I couldn’t have NSAIDS).   The intermittent compression machine they put on my legs kept me awake as well.  I really didn’t feel that tired however after my general anaesthetic.   The IV infusion pump periodically alarmed as well.  

Morning came and the plastics housestaff came in, the 3 residents I had already met plus 2 medical students.   One of the residents told me I had been a difficult intubation.  Apparently because of my size, (6’5”) a regular ETT barely gets from my nose to the vocal cords.  This presumably explained the nosebleed.  They said I could go home after a CT of my facial bones and that the IV could come out.  The anaesthesiologist had put another IV in my saphenous vein (I do that too sometimes) which was affecting my mobility.  I decided to disconnect the IV.  There was an extension with a needleless connector so I just unscrewed it.  The pump was still running.  I know how to shut off an IVAC pump but I figured it might wreck the charting so I called the nurse.  A nurse came fairly promptly and I got a lecture about not playing with the IV.  The same nurse came back about 10 minutes and apologized, saying she didn’t know I was an anaesthesiologist.

A breakfast tray arrived with a muffin and a box of bran flakes. It had now been about 5 days since I had eaten anything solid. “They expect me to eat this?”, I thought.   I soaked the bran flakes in milk and gingerly ate them and the muffin which I broke into small pieces.  I really didn’t feel like eating but I knew if was part of my recovery. 

Later in the morning I went over to CT by wheelchair.  The CT techs were so pleasant and that scan took about a minute.  A CT scan when I was a resident took about 30 minutes.  Then back to the ward.  A friend who still worked at the CofE came over to visit, we chatted along with my wife who had arrived from home.  I was told that my CT scan was read and was okay but the surgeon wanted to see me.  I was getting a little tired of my room so we walked out to the atrium where we bumped into him and he gave me some final instructions. “You really are in hurry to get out of here”, he said.  “Sorry,” I said, “I hate this place.”  A little ungrateful perhaps because overall they had been so good to me.  I think what I meant was I want to get home and start getting better.

We drove back about 15 minutes to my house.  I was still suffering the effects of the concussion and the general anaesthetic.  Everything was moving so quickly, I didn’t think I would have been able to react to it all.

The next few days seem a blur.  I am not the busiest person but now I was in enforced inactivity, my only job was to get better.   I spent most of the next 4 or so days reading, looking at my I Pad and having random naps.  A few times I went out in the car with my wife.  Things were still moving to  fast for me.  The first two nights I really didn’t sleep.  This was probably the effect of the anaesthetic and possibly also due to the dexamethasone I had been given.  The second night home, I became obsessed about a peri-operative MI.  I remember thinking, “I am going to die tonight.”  I had Zopilcone but was scared to use it, my face was still swollen, my nose was plugged and I was worried about obstructing.  Later I started using the zopiclone which gave me a deep sleep for 3 hours after which I slept fitfully often until 0800 or 0900.  

Eating was still painful and I didn’t have much of an appetite.  My wife cooked some delicious meals for me that I could eat on my soft diet.  I regret I didn’t appreciate them more because they were really good.  The surgeon had left wires in my mouth in case he had to wire my jaw (he didn’t have to) and one of them was irritating my gum. 

On Thursday after surgery my brother phoned me.  My 90 year old mother had been taken to the hospital with abdominal pain.  I talked to the ER doc in Victoria and it appeared that she had perforated her colon.  I knew that this would be fatal and I told him to just keep her comfortable.  I wondered about flying to Victoria to “say goodbye” but I knew I was in no shape to travel.  Maybe if my surgery had been done on the Saturday like it was supposed to have been done.  My mother died on Sunday.  The team in Victoria did as good a job as they could trying to keep her comfortable but with the peritonitis she must have had along with her dementia, it must have been a horrible 3 days for her before she finally died.

I did visit my mother in late July and was able to spend a few hours with her.  I tried to comfort myself that I had said my goodbyes but I still regret not being able to see her one more time.

On Saturday my wife suggested that we go and visit where I had crashed 9 days earlier.  We went to the farmers market first.  I still had a lot of facial bruising.  As it happened we ran into someone I knew so had to explain what had happened.  We then drove to the other side of the Low Level Bridge, parked and walked across.  I wondered if I would get anxious returning to the site but I felt okay.  Almost immediately looking at where I had gone down, I could see why.  The pavement was rutted and broken off at the right side of the trail.  I must have hit the edge of the trail where it was broken and slammed down hard.  I felt a little better.  I don’t remember the impact but had always worried that I had done something stupid and that was why I crashed.   Now I felt a little angry that the city could leave a busy paved trail in that condition.



The scene of the crime.


By Monday one of the wires which was digging into my gum was really starting to bug me.  My surgeon had told me that he would be on vacation but that I could contact the on call plastics thru the hospital switchboard.  I figured however that would just result in being told to go to the ER and wait and frankly I had spent enough time in the ER.  I thought about asking one of the plastic surgeons at my hospital to look at it.  Wednesday morning I woke around 0600 and had a revelation.  The plastics house staff round at 0600, I could phone the ward and ask to speak to them or leave a message.  I did that but the nurse I talked to was very protective of the doctors although I did get him to take a message.  He did have a good suggestion, dental wax.  I googled dental wax and sure enough London Drugs carried it.  I finally felt good enough to to drive and headed over there just after opening and picked up some dental wax.  Later in the morning one of the plastics residents called me and said my surgeon, who it turned out wasn’t yet on vacation , could take out the wires in the surgery clinics.  I did this later in the afternoon.  At the clinics I met a nurse who had worked in the Pain Clinic years ago when I was at the CofE and we got to chat a bit and I got the wires removed except for the ones holding my upper incisors in.

It was Tuesday that I finally woke feeling almost normal.  It was a beautiful late summer day and I knew I wanted to go for a walk.  That morning I walked with my wife and the dogs down into the river valley to the zoo.  Walking along the dirt path beside the river was such a healing experience.  We had coffee at the coffee shop outside the zoo before walking home.  This involved a climb out of the river valley and I was relieved that my conditioning hadn’t suffered much.  We did this walk every day for a few days.  I started looking at the step counter on my phone and tried to make the 10,000 step maker every day.

My work in chronic pain had made me aware of the risk of PTSD after an accident I had so almost as soon as I got home from hospital I called the medical association’s Physician and Family Support line and got an appointment with a psychologist.  Because it was the summer I wan’t able to get in right away but did get an appointment for Thursday.  I drove down to the office just off Whyte Avenue.  I was feeling really good.  I was out of the woods, I was going for walks every day and was driving again.  The psychologist and I sort of talked for about 30 minutes when it was clear that I was doing pretty good.  I sort of apologized for wasting his time.  Apparently getting knocked out so you don’t remember anything is a good thing.  On the way home, I stopped and bought a new bike helmet.  

I went to the Eskimos football game the following day Friday.  It was not a very good game and my wife and I left in the 4th quarter.  It was dark when we left.  I park at a nearby hospital where I have reciprocal parking privileges.  Driving home in the dark with the traffic and the bright lights brought back memories of my taxi ride to the hospital just over 2 weeks earlier.  A cyclist wearing dark clothes and no helmet crossed the road in front of us and this upset me for some reason.  Maybe I wasn’t as good as I had made myself out to be.

It was around then that my wife noticed some redness in the skin around my nose.  It looked a bit like a skin infection.  I figured there was a plate underneath.  I have of course seem some horrendous post-surgical infections and had views of my face sloughing off.  By then we had gone down to the dacha in Canmore to see if some mountain air would pick me up.  Fortunately there was a walk in clinic open on the Sunday so I went there shortly after opening time and saw a doctor who it turned out was a former next door neighbour.  I was started back on antibiotics.  (When I saw my plastic surgeon later, he didn’t think I had an infection but told me to finish the prescription).

Gradually recovering, the question was when exactly could I go back to work.  I had been told it would take 3 weeks to recover.  After two weeks I felt a lot better but I still had some facial swelling.  As it had turned out, I injured myself with 2 weeks of vacation left.  Worst vacation ever.  (We had planned to take in the Salmon Arm Roots and Blues festival the following weekend but obviously didn’t go.)

I was supposed to work the week before Labour Day and be on call 3 times over the Labour Day weekend.  That obviously wasn’t going to happen.  My colleagues really pitched in and all my work slots were filled within a few hours of me posting that I wouldn’t be able to work.  It turned that because of a family problem with another anaesthesiologist we were short staffed the week before Labour Day.  I actually volunteered to work.  My offer was prudently ignored.

Eventually I decided that I would do my scheduled work the Tuesday after Labour Day.  I am self employed, as they say, I have to eat what I kill.  I have significant savings so I could probably have stayed out longer.  It was more that I felt I was ready and was worried about losing my skills if I stayed out longer.  I was already taking most of October off, if I missed September that would be a long time off.  That was in addition to all the time I had taken off in the summer.

I had suffered a big knock to the head and I was worried about cognitive effects.  I keep on going over drug doses in my head and imagining scenario and what to do.  I felt I was ready cognitively.

My first day back was a single all day flap.  That was great for me, just 1 IV to start, 1 airway and then a lot of sitting.  I got thru that.  The next day was a urology list with about 8 cases and I sailed through that.  I was back.

I have more or less recovered now.  I still have some facial numbness and I will need dental work on my front incisors, hopefully only being capped.  My teeth are a little mis-aligned and chewing is still difficult.  A pleasant side effect of not enjoying food as much was a 15 lb weight loss.  After the surgery my face was numb and dysesthetic, so I didn’t want to shave.  I now have a beard and my wife even likes it.

I still think how fortunate I was.  If I had not been wearing a helmet I may likely have died. The transplant unit was across from the plastics unit and I think how bits of me could have been living across the hall in other patients.  I was glad I was riding with my wife; quite often I have ridden home from the Folk Festival alone.  I am glad I didn’t have to rely on the kindness of strangers.

And what about the Canadian Healthcare system?  Sure I had to bunk with 2 other people in a room designed for 2 and I waited 5 days for surgery.  But I got seen in the ER right away, I had 2 CT scans and I major surgery and the only things I paid for was $20 for the taxi and a few dollars here and there for OTC meds.  What a great system and yet politicians and sadly quite a few doctors want to blow it up.  Shame on all of you.

And I remember how nice everybody was to me, the emergency nurse, the emergency physician, the CT scan staff, plastic surgeons, the floor nurses and of course the anaesthesiologist and the OR staff.  Sometimes in my career when I was tired, busy or frustrated I haven’t been the  nicest to patients and I regret that now.

I really have to thank my surgeons.  I like to make fun of surgeons but the care I got from the whole team was fantastic.

I have to thank my anaesthetic colleagues who are the greatest colleagues anybody could ask for.  I had to miss work during the summer and was on call on a long weekend.  In Edmonton we have a very short but nice (not this year so much) summer and people gave up days off in the summer for me.  And they picked up every day within hours of it being posted.

And of course my wife.  She was so calm in the face of what was a really serious injury.  She let me recover slowly with no demands.  There were times when I just wanted to be left alone and she did that too.  And of course the great food, from the smoothies before surgery to the delicious soft diet food after.

Monday, April 29, 2019

The Board

I trained as a medial student and intern in 3 different labour suites, caserooms whatever you
The unifying feature of caserooms was the The Board.

While The Board slightly varied between sites, there were constants.  The patient’s name, attending physician, Gravida and Parity, gestation and dilatation.  There was usually room for other info such as pre-eclampsia or VBAC.  It was such a valuable source of information for seeing what was going on and predicting workload.  The Board when I was junior was a blackboard with chalk.  Lately it is a whiteboard.  Such a low tech but effective way of communications.

At Vancouver General Hospital which did OB in the early 1980s, the medical students had to keep The Board up to date, which meant constantly having to bother the nurses about what the dilatation was (they didn’t tell you when they did vag exams, because you might want to do it yourself, which after all was one of the reasons you did an OB rotation) lest you get yelled at by  the crabby soon-to-be-former OB resident.  

When I came to my current medium size Catholic hospital 13 years ago the board had become more streamlined than what I remembered.  Dilatation and gestation were not charted, but it at least had the patients name, attending physician, gravida and para.  They also wrote a big E next to the patient if there was an epidural.  Very useful for anaesthesia when you came in on call.  

Something as effective and elegantly simple as the board was bound to come to an end of course.

Several years ago, I was called for an epidural and looking on the board saw that her last name was 3 letters long.  I went into the room but noticed she had a different name more than 3 letters long.  Back to the desk I went.  No I was told the 3 letters are the first three letters of her name which for privacy purposes we are now only allowed to use.  I rolled my eyes and did the epidural.  Of course as I commented many people nowadays have 2-3 letter last names, plus it is highly likely that you will have 2 people in labour at the same time who share the first three letters of their last name (McDonald/McDowell. Chan/Chang).  Other people whose opinion counted more than mine must have weighed in because they started putting on the full name again.  

About two years ago I got called for an epidural.  At our site they never tell us the patient’s name only the room #.  “Room 5 wants an epidural” they tell me.  I walked past The Board and noticed that the patient had the same last name as one of the obstetricians.  Of course when I walked into the room the patient had another name.  It turns out that for privacy now they were now only posting the name of the doctor on The Board.  Twice as it turns out under patient and under physician.  

The day before yesterday I walked onto the ward and The Board had shrunk to about 1/3 of its size.  “Why is The Board smaller?”, I asked.  “Its an accreditation standard, “ I was told.  I am not sure why it should matter at all to the accreditors but apparently it does.  The Board is now literally tiny.   Whereas you used to be able to stand back of the nursing station and read it, you now have to go right up to it.

This presumably is in the name of privacy.  My mother always told me if you had nothing to hide, you didn’t need any privacy.  I wonder how many patients really cared about their names being flashed up on The Board.  People after all pay to put birth announcements in the newspaper.  Labours are live-Tweeted, Facebooked and Instagrammed.  Plus I am sure in the past if people wanted the anonymity, they were accommodated with a pseudonym.  And if you’ve figured out that your husband’s mistress is in labour at this hospital you can probably find out which room she is labouring in.

At the same time, we actually have made labour a group activity.  It is not unusual to have multiple family members in the room, or hanging around the hallways (usually talking outside the call room) while the mother is in labour.   I frequently have to ask for all but one of them to leave when I do the epidural.  (As department head, I had to deal with a complaint about one of my colleagues doing just that).  My father on the other, even if he had wanted to, was not allowed to see any of the births of his 4 children, which may explain why I grew up so messed up.  

And there is the issue of depersonalization.  I seem to remember during my OB rotations that I actually knew the patient’s name.  Now most patients are referred to by their room number.  I even find myself writing the room number on the patient label I collect for billing so I can tell them apart.


Of course in the 21st century we could have replaced The Board with something electronic that might even be an improvement but I’m not holding my breath on that

Why I stopped subscribing to my local newspater.

The Edmonton Journa didn’t publish my letter but I have a blog:

My wife and I cancelled our subscription to the Edmonton Journal.

Since moving to Edmonton in 1992, we have subscribed to your paper.  I remember it as an excellent paper with balanced coverage of local, national and international news and issues.  The large Saturday and Sunday editions were a true joy to read,  taking several hours.

Over the last few years, the quality of the paper has declined, there is no longer a Sunday edition and the size of the paper has decreased to the point where the flyers deposited in our mailbox along with the paper are often  larger in size.  In addition the national and international news and opinion section has been outsourced to the National Post.  

Worse was the behaviour of the Journal during the election and in the run up to the election.  On at least two occasions the UCP was allowed to buy full page ads on the front page of the journal giving the impression that this was news not advertising.   During the election various PACs were allowed to buy full page ads in the news section of the paper.  In addition the Journal endorsed the UCP which is really not surprising although disappointing.

I realize that papers depend on ad revenue to survive and am not naive enough to expect that advertisers and owners of newspapers will always agree with me.  I realize that their coverage of news of their editorial opinions will always subtly reflect the bias of the owners and advertisers.  I have always enjoyed reading the other point of view if only to mentally rebut it (and occasionally agree with it).  The Journal in the past has always presented a diversity of opinions and tried to present both sides of the story.  It is clear however that the promotion of a single agenda is now being blatantly pushed not only in editorial content but also in the way that news is being presented.  This is reflected in the Journal ignoring certain stories and by presenting opinion as news.

For the past few years, I have noticed that the Globe and Mail’s coverage of Alberta and Edmonton issues is more thorough and balanced than that of the Journal.  The Journal has now become a newspaper which features the worst aspects of the Edmonton Sun and National Post. Quite frankly most days, now I find myself going straight to the comic section which is actually still quite good.

I have read newspapers since shortly after learning to read.  As I mentioned above, I still find the Globe and Mail to be a high quality source of information and entertainment.  Recently while visiting Victoria, I read the Times-Colonist and was thoroughly impressed with quality of the journalism.

Newspapers have been observed to be under siege with competition from the internet and other platforms.  I have always preferred to read a paper and I suspect that a significant number of people do not read newspapers any more not because of the internet but because the content in newspapers has become so awful.  


Tuesday, April 9, 2019

Sometimes you write a really good letter but don’t send it.

About a year ago I applied for a licence in my neighbouring province (where I was born, went to school and worked for a while).  This was an interesting experience  which I should blog about some time.  The caper was in addition to having to get a criminal records check, having to be fingerprinted.  This was because apparently a sex offender has the same birthday as I do.  

I quixotically phoned the agency, knowing that it wouldn’t change anything but I needed to yell at someone on the phone.  They were very polite; it was like I wan’t the first person and I went down to my local police station and good fingerprinted.  Interestingly enough, so many people need to get fingerprinted now that our police force has a free standing office which does nothing but fingerprint people.  

And I wrote this letter. 

“Thank you for your letter and for the time your two employees took trying to explain it on the phone.  It is nice to know that I am not suspected of being a sex offender.

For your information, I was born in British Columbia, grew up, attended medical school there and practised medicine there.  I have practised in Edmonton since 1992 and have been at my current hospital since 1996.  I have lived in my current house for over 10 years.  I have paid both federal and provincial income taxes as well as property taxes.  I have a drivers licence.  I recently renewed my passport for 10 years. (I provided a notarized copy to the CPSBC).   I have a Nexus card.  It is my understanding that every year I have had criminal records check through the CPSA.  I also had one when I got a visa to go to Rwanda to volunteer teach.   I show up in Google searches of my name.  It is not like I have hiding for the past 40 or so years.

I accept however the possibility that during this time, I may have lived a double life involving nefarious activities under another name leading to my acquiring a criminal record.  It is also possible that I continued to work and raise a family while incarcerated.  An alternative explanation might be that I used my time while incarcerated to learn how to construct a time machine which I used on release to travel back in time and create a new identity.

Seriously I think that people who exploit the vulnerable especially those who abuse children are the lowest form of humanity and if by getting fingerprinted, I could prevent one such incident of abuse, I would happily get fingerprinted every day.  The truth is that this policy is not about protecting the vulnerable; it is a make work project for the public safety industry and a cash cow for the RCMP and local police forces.  Even the nice lady who spoke with me on the phone acknowledged that this policy has resulted in a huge increase in the number of staff needed to maintain it and one wonders how many nurses or police officers could be employed with the money necessary to employ these people.  The other and more concerning issue is that policies like this are primarily designed to give the appearance of doing something about the problem rather than actually doing anything about it.


It further needs to be noted that saying, “we’re only enforcing policy” is a somewhat empty excuse when you are the ones who made the policy.  It also sounds very much like “we are only following orders”, an excuse that was deemed invalid around 1945.”

Monday, January 7, 2019

Do I feel guilty about getting drunk the day my father died.

While I'm not  necessarily proud of going on the wine tour on my father's last day on this earth, I am not ashamed also.

Would I have been ashamed if in an alternate universe, he had not broken his hip but rather had had a huge myocardial infarction or stroke on that day while I was out wine touring. 

As I said, it still bothers me that he died alone but I got to see him the week he died and spent a lot of time with him during his last two years alive.  I would rather remember him as he was when he was younger because the last two years weren't really that great for him or for us for that matter.

While anaesthesia doesn't get involved in end of life very often, I did do general practice for 3 years and also anaesthesiologists get to do 6 months of internal medicine so I saw my share of death watches where the entire family assembles around the bed of a dying parent or grandparent in various stages of awareness and pain.  Overall, I didn't get the impression that anyone, patient or family got any comfort from the practice.

Friday, January 4, 2019

Thoughts on my father's death.

My father died last June 2.  He was 94 and it shouldn't have been unexpected.   As I was to find out, it was still difficult.

I go on a few medical and teaching missions nowadays.  In 2011, I went with CASIEF to Rwanda for 4 weeks (a total of 6 weeks away between pre and post-cations).  My parents were pretty old by then, so I believe  I told them, if something happened while they were away, I was not coming home.  Therefore every time I visited and left my parents it was like I was saying goodbye forever.

Between placing my parents in various levels of care over the past 2 years I have been visiting about every month, which is more than I saw them when I was attending university in Vancouver, a ferry ride away.

Anyway I was on my way to the Canadian Pain Society meeting in Montreal.  On arriving in Montreal, I turned on my phone and my brother had texted me to tell me that my father had fallen and broken his hip.  We were still in the airport.  "Do you want to fly back?" asked my wife.  No, I said, it won't make any difference.  He will have surgery in the next couple of days which he may or may not survive and whether I am there or not will not make any difference.  And besides I had said my goodbyes.  I kind of had the sense that this was it.  He was going to die within a couple of weeks or it would be the start of an inevitable downward decline.

After some consideration, I decided that after returning to Edmonton, the Friday, I would fly to Victoria on Saturday to visit Saturday and Sunday.  I had a busy next week planned.  A medicolegal in Calgary on Monday, Pain Clinic in Grande Prairie Tuesday and Wednesday , a medicolegal in Vancouver. Thursday and one in Kelowna on Friday.  Now I could have cancelled all this but really it really wouldn't have made any difference would it?  I phoned the ward regularly during the week I was in Montreal.

So I flew out to Victoria Saturday am, rented a car and went straight to the hospital.  My father had had surgery by then.  I never ever learned whether he had a hip pinning or a hemi-arthroplasty or whether it was a GA or spinal.  He was in a private room and was pretty delirious.  He did recognize me.  It was very interesting because in between bouts of delerium he actually made sense and was talking about politics which he loved doing.  He had a bundle of newspapers which he clutched tightly, not letting the nurses take from him.  I also went and visited my mother.   She kept on asking where he was and I kept on telling her he had broken his hip.

I visited again on Sunday.  The nurses said he had had a bad night and he was lying in bed but recognized me.  I spent a little time with him and then drove back to the nursing home to see my mother. I asked the staff at the nursing home if it would be okay to bring her over.   I had mixed feelings about this.   She was already not terribly able to walk even modest distances and I would have to park and walk over to the hospital with her.   The other thing that worried me was what I would do if she refused to leave my father's bedside.   Nevertheless, I took her, we walked slowly over to the hospital and up to my dad's room.  By this time the nurses had hoisted him into a chair and he was in a deep sleep.  We say there for almost half an hour, my mother and I.  At one point my father opened his eyes but didn't seem to recognize us and went back to sleep.  After half an hour, my mother said, "that's not my husband is it?" and we left, stopping for coffee and a snack at the coffee shop in the lobby.

I returned my mother to the nursing home and spend a little time before leaving.  I had a flight in the late afternoon and so had lots of time.  I could have visited my father again but I thought what difference really would it have made.  I figured he had survived the first few days of injury and surgery, the delirium would resolve and he would be eventually starting a long (and most likely futile) rehab program.

I later flew to Calgary, then to Grande Prairie, to Vancouver where my wife met me and then to Kelowna where I had a medicolegal Friday.  My son lives in Kelowna and we had planned to spend Saturday in Kelowna and leave in the evening.  My son works Saturday so we couldn't visit with him that day but took him and his girlfriend out to dinner Friday.

My wife suggested we do a wine tour Saturday and we found a taxi driver who did private tours and who would take us to the airport afterwards.  We were just on the way to our first winery when my brother phoned me.  My father was apparently now septic from at UTI with decreased blood pressure.  He gave me the pager number of the hospitalist.  I paged her and she phoned back right away.  By that time we were outside of our first winery.  She confirmed what my brother told me, I confirmed his resuscitation status and suggested that if he didn't respond to modest amounts of fluids not to do anything.

We went into my first winery.  "I hope you don't think," I said to my wife,"I am being callous by tasting wine when my father is most likely dying."  She didn't think so.

Wine tours are really just an excuse for getting drunk during the day and we did that quite happily and I am may have even forgotten about my father.  At one point our driver suggested we visit a craft brewery which we did.  Outside the tasting room, my phone went off.  It was the hospitalist.  My father's blood pressure was now worse, falling to as little as 40 systolic.  I told her that I understood and that he would probably die.  I then phoned my brother and told him, I didn't think my father would live out the day.  I am not usually good by the way at predicting deaths.

For some reason I decided to taste a flight of beers and I ordered them and took them out to table outside.  Then it hit me, my father was going to die.  I started crying.  People were looking at me.  I got myself together and then tasted my craft beer.  Why waste it. 

We finished our tour and went to the airport.  We flew to Calgary.  At the Calgary airport while waiting for my plane to Edmonton, I phoned the unit.  The nurse said my father was hanging in there.

Sometime while I was in the air between Edmonton and Calgary my father died.  My brother left a message on my phone which was on airplane mode.

It doesn't bother me that my father died.  He was 94 and had never adapted to nursing home life or my mother's dementia.  He had a great life including 33 years of retirement on a comfortable pension.  It does bother me that he died alone although I don't know that it would have made any difference or whether in his last hours he would have even noticed the company.  I don't know what goes on in peoples minds while their body is shutting down; I hope that during the hours he was unconscious before he died, he was having visions of his childhood in Sussex or meeting my mother for the first time.

My father requested that he not have a funeral.  Some people I talked to thought that it was weird and that we should have something but we didn't.  My brother got him cremated which is what he wanted.  I assume he has the ashes.

I went to visit my mother a few weeks later.  The staff had told her that he had died but of course she forgot this after getting quite upset.  She of course kept on asking me where he was.  I told her over and over he was resting.  At one point she said, "What is he resting from?".  "Arguing"  I replied because that is what he loved to do and she actually laughed.  When I went into my mother's room the book "Silk Roads" was on table in her room.   I gave that book to my father the previous Christmas.  He like to read in my mother's room.  I really enjoyed the book.  I hope he got far into it.



Wednesday, December 26, 2018

How I Stopped Worrying About Giving Up Chronic Pain

I decided last March to give up chronic pain.  I blogged about it.  I am now down to my last few clinics.  I had continued to agonize about whether I was making the right decision.  Until last Friday’s clinic.
The last pain clinic before Xmas is always interesting.  People bring in baking, candy and occasionally liquor.  (I have for years thought about asking them to donate to charity instead but this of course presupposes they would even give me a gift.). On the other hand it is a littler busy and you end of dealing with a lot of prescription faxing because people need early releases or realize their prescription is going to run out over Xmas.
Three things on an otherwise good day just pissed me off.
  1. One of my patients has been going to the local block shop where she has been getting blocks.  I have no idea what type of blocks or where because they never send me reports.  I may have referred her there, it wouldn’t matter, they hardly ever send me their consults.  Anyway she told me she was getting rhizotomy and she had been told to take 2 weeks off after it.  Then the capper.  She brought her disability form which they had told her to have me fill out.  I was a little shocked and told her I didn’t fill out those forms.  I told her to take them to her family doc, which I am not proud of.  I should have told her to take them back to the block shop. She left disappointed, maybe angry.  Probably the last time I will see her.
  2. Next I get an email from my PCN pain clinic pharmacist. Another patient had a rhizotomy at the same block shop.  This time I had referred her there.  This made her pain worse rather than better.  Funny how nobody doctors or patients considers that that might happen when you apply radio frequency current with a large needle.  Anyway the block shop was refusing to prescribe any analgesics.  After initially refusing myself on the basis of “you break it, you buy it”, I thought better and faxed in a prescription for hydromorphone.  If you think that this is just a problem with one particular block shop; actually this is the best block shop  It is mostly physiatrists, they actually examine patients.  Just about everybody gets a block though.  Did I mention her family doc has taken 14 days off over Xmas with nobody covering her practice?
  3. Later that day a patient I see sporadically came in.  He has a very complex pain and psych history.  So his psychiatrist decides this is a good time to wean him off all but one of meds.  Yes this includes narcotics but also included a lot of psych meds.  Surprise, surprise his pain is worse and I am supposed to sort this out the Friday before Xmas when I’m going to retire in 3 months.  “Did you tell this to your psychiatrist, “ I asked.  Turns out he had seen the psychiatrist 2 days earlier but they had only talked about his mood.  I suggested that he go back to his psychiatrist and ask to go back on his meds.  As if this is going to happen before January.  I have nothing against deprescribing, I think it is good idea sometimes as long as you are prepared to admit when it isn’t working.  I know there are 2 sides to every story and his psychiatrist might have had a very good reason to want to wean him off.  I of course don’t know because he never bothered sending me a copy of his notes.  And he can’t say he didn’t know I was involved in his patient’s care, because I sent him a copy of my last progress note.  I could try to phone him except that in 25 years I have never gotten through on the phone to a psychiatrist nor has one ever returned my calls.  Not to mention it is Friday, Friday before Xmas.

Hey I know that disability forms are a pain to fill out and most of us think if a patient tells his employer he needs time off, they should within reason believe them.  I also know that our colleges and people like David Juurlink have made the prescription of narcotics dirty.  The point is when you accept care of a patient you should take responsibility for their disability forms and for the complications of your treatments.  You should also communicate with your colleagues.

I thought that I was giving up chronic pain because I had lost my compassion.  In fact I now realize that it is the whole medical environment that has finally.  Not administrators, EMRs or lack of resources.  It’s the whole “not my problem “ attitude that has malignantly affected medicine.  Every week some patient tells me about their latest interaction with a physician, it could be their family doc or a specialist, and I think of how ashamed I am to be a physician.  To be fair, there are some doctors who give their chronic pain patients excellent care, with whom it is possible to work with.  The thing is, that these doctors are now so uncommon that they stand out.


So I will mostly be spending the rest of my career working almost exclusively with surgeons.  I have written and thought a lot about surgeons, some of it in jest.  Surgeons are economic with the truth, a little arrogant, tardy and make me work when I would rather not.  But...surgeons give a shit about their patients at least for the time under surgery and frequently for a few days before and after their operation.