Why I won't be wearing a poppy again this year

One of the highlights of elementary school was getting the free poppy that was passed out every year. Back then they were made of felt and were a whole lot better than the plastic ones passed out today.

Poppies "celebrate" the deaths of Canadian soldiers in the First World War as celebrated by the poem "In Flander's Fields" by Dr. John McCrae a physician who died shortly after writing this poem. I can still recite most of this poem from memory (but I can't remember where I left my keys). Every year in November poppies are given out for a donation by Royal Canadian Legionaires and Army/Navy/Air Cadets. Not wearing them is, certainly for someone in the public eye such as a politician or other figure, a major faux pas.

I haven't however worn one since university. Not because I forgot to get one, not because I always stab myself with the pin, not because of the cheap plastic or that I always seem to leave them on the coat I am not wearing.

I first got a little disgusted at an event that happened years ago. At the ceremony in Ottawa, a group of women wanted to lay a wreath in memory of women who were raped during war-time. A little strident but we must also remember the number of civilians who suffered during the war as well. These women were physically restrained by a group of veterans from laying the wreath.

Remembrance Day was started as a day to remember how awful war really is in the hope that we would not have another one. Some people say that it was the horror of the first world war that lead politicians in Britain and France to appease Hitler in the years running up to WW2. Those of us who study history would say that WW2 was probably inevitable and whether or not Hitler was appeased only affected how early or late the war would have started. In fact probably not just a few British, French, Canadian and American politicians and businessmen actually liked what Hitler was doing until what he was doing threatened them.

When I was young most of our fathers had actually served in the second world war. My father did although he fixed radios at various airfield in Canada. Quite a few WWI veterans were still alive. These veterans marched silently on Remembrance Day in memory of their colleagues who died and in the hope that more would not have to die. Unfortunately as we get farther and farther away from wars as devastating as the First and Second World Wars, Remembrance Day has moved from a solemn remembrance of the horror of war to a celebration of war.

Over 100 Canadians have died in the war in Afghanistan propping up a government that oppresses women, Christians and ethnic minorities. Any criticism of this war is answered by the usual reply of, " Do you want those brave soldiers to have died for nothing". It is hard to answer this except to reply that yes indeed they have died for nothing and that maybe we should get out before more die for nothing.

I had a lot of hope for the 21st century. I really felt that we would find a way of solving problems in a way that didn't involve killing people.

I think I'll be forgetting to get a poppy next year.

Unnecessary medical testing

White Coat has a post about unnecessary medical testing

He challenges us to find examples of unnecessary medical testing.

Just off the top of my head:

1. Electrolytes unless the patient is in renal failure, on diuretics or steroids, or has been vomiting or has diarrhea.

2. PT/PTT unless the patient is on Coumadin, or you are suspecting liver failure or sepsis.

3. MRI of the back or neck for chronic pain unless there are leg or arm symptoms.

Stupid People

An acquaintance of mine recently started work at the phone advice centre for our health authority. This service allows patients to call 24 hours a day and speak to a nurse who will triage according to protocols and give advice. This hopefully avoids some ER visits while getting some people who need to get into the ER right away into the ER right away.

She has been quite frustrated with just how stupid people appear. She feels that by tolerating their stupidity she is "enabling" them.

This of course reminds me of when I first started out doing locums as a family doctor. I was on call for a large clinic. They had a lobster party that night and even though I was on call for the group, they suggested I come out after the evening clinic as on call meant for the most part answering phone calls. At some point in the evening I had to call a patient who had called the answering service. I had already spoken to her earlier that day. One of the doctors overheard my end of the conversation and remarked when I hung up, "They don't teach you how to talk to stupid people in medical school do they?"

How true.

Both my parents were professionals and highly intelligent. I grew up in a middle class/upper middle class neighbourhood and went to a really good school. From junior high on academic and non academic students were segregated into different classes. I hung out mostly with the academic kids. I then went to university and on to medical school. Now some of the people I knew in University and Medical School weren't the sharpest knives in the drawer but we didn't have to deal with them except maybe to laugh at the stupid questions they asked during lectures.

Maybe I am a little dense but it wasn't until my internship that I noticed that there was this large underclass of people who didn't grow up with well educated parents, go to nice schools let alone university. These people showed up with complex problems that required some work on their part and some insight into their condition. And back then and now I still have a hard time putting a complex problem into simple words that can be understood.

Before the advent of pre-assessment clinics and screening, we saw most patients the night before their surgery and a few days pre-op in a pre-assessment clinic. When I worked at the CofE, just about every patient presenting for inpatient surgery was about to have some type of terrible horrendoplasty. I would sit there, try to make sense of their usual complicated medical history, and then try to explain the anesthetic aspect of their care including the epidurals, art lines, central lines and the possible ICU stay they were about to experience. I tried to go slowly. After all this, I would ask if they had any questions. Inevitably they asked one or more of the following three questions:
1. What time is my surgery?
2. How long will my surgery last?
3. Am I going to see my surgeon today? (I started replying, " I don't know, I'm not his secretary" until a patient complained about this.)

As a resident, when we did elective C-sections we actually used to give patients the choice between regional and general (as opposed to now where the OB tells them they are having a spinal). I actually overheard a person say, "Well if he doesn't know what is best, how am I supposed to decide". So much for informed consent.

Stupidity should not be confused with the absence of education nor does education guarantee the absence of stupidity. Stupidity is not just endemic in patients, it has infiltrated the system. Much of the administrative policy over the last 20 years has either been malicious or stupid. I think stupid. I used to think most internists and pediatricians were intelligent people who just lacked common sense. I know just think most of them are just plain stupid. I have already on this blog said what I think about surgeons. And yes, we have stupid anaesthesiologists too!

Anesthesia Shzt List

I read an interesting post on Great Zs blog.

I have only once said I would refuse to work with a surgeon. It was at the centre of excellence when a thoracic surgeon could not be located after his resident got into some significant bleeding and we had to find another thoracic surgeon. I wrote a letter to my chief. This lead to a staff meeting that turned into a lynch mob, the surgeon was disciplined by adminstration, but continued to work for a couple of years after before going on "leave" from which he has never returned. I did work with him about six months later and he was quite cordial.

There are lots of surgeons who I prefer not to work with; if for example I am asked if I will stay late to do their emergency, I generally decline. For some surgeons late is any time after 1200.

In a community hospital where I used to work we all knew that certain anaesthetists hated certain surgeons and vice versa so whoever was assigning the list didn't assign them in the same room unless he was feeling particularily evil.

We all of course have surgeons we would like never again to have to work with:

Dr. Tardy

He not only is late for his first case but is late for every case of the day. This means you either stay until 1800 to finish his list or his last case (and he always books his longest case last) is cancelled which means you go home at 1300 losing income and quite often witnessing a nasty scene between him and the nurses. Dr Tardy has not figured this out.

The teacher

He loves to teach. This means he lets his residents or even medical students do much of his cases. This "teaching" consists of mostly of him leaving early to presumably do something else while his resident closes. He never compensates for this in his booked times. This means his list usually runs late (see Dr. Tardy). The teacher's enthusiasm for teaching rarely extends to anaesthesia residents. Plus one can only take so much teaching, after a while it becomes repetitive and you realise that The Teacher doesn't really know that much, he just repeats what he does know over and over.

Dr. Pottymouth.

I am not one of those people who is easily put off by swearing. I swear a lot, I actually enjoy swearing. As my scout master told me, it is not the word but how you use it. We had a cardiac surgeon at the CofE who went into what people called F-Tach. It took two anger management courses forced on him to cure him of this affliction.

Dr. Angry

Lets say a surgeon has two OR days a week and is angry for both of them. He works for 30 or years so think of the number of days in his life he is angry. Is there anything that makes him happy? If what I trained 5-6 extra years for made me angry, I might reconsider things or perhaps it just might make me more angry.

Dr. Whiny

A slightly more benign and passive-aggressive version of Dr. Angry. He just whines all day. Nothing is right with him.

Dr. Nightowl

This guy loves to operate after hours. Nuff said. You wonder why you are always up all night with him and not with the other surgeons who presumably see the same emergency patients. It may be something to do with afterhours premiums. In case emergency doesn't supply him with work, Dr. Nightowl usually gets patients on his wait list to show up in emergency so he doesn't have to waste time on activities like spending time with his family while on call.

Dr. Perfect.

Every thing about this guy's professional and personal life is beyond reproach as you will hear for the entire day. Of course you are screwing up his perfect case just by being there. In addition to the platitudes you will hear him reciting to everybody who has no choice but to listen, you will of course hear about his perfect children, his perfect car and his perfect vacation.

Dr. Fingerpointer

A cousin to Dr. Perfect. Every complication is someone else's fault usually yours and he will point that out in ways ranging from conversions in the doctor's lounge that you overhear, and that are told back to you, to sneaky progress notes that of course you never read but are part of the chart forever. He occasionally will confront you personally and quite often will write a letter to your chief. Dr. Fingerpointer is quite often a vascular, thoracic or urologist; all specialties that by the nature of their work or patient population get bad results. They have not accepted that.

Dr. Slowhand

Some surgeons are slow because they are meticulous. Most of us don't mind because we hope we or our family get such good care. For the bulk of slow surgeons the old slogan "First you get good, then you get fast" comes to mind. This of course usually results in the cancellation of Dr. Slowhand's last case (see above). Quite often Dr. Slowhand is not the most punctual person.

Dr. Knowitall

Dr. Knowitall is an expert on everything. This includes anaesthesia, and Dr. K is always ready to give you helpful advice on how you should be conducting your anaesthetic. Dr. K. will also hold forth on just about any non-medical topic, as well as medical topics outside his narrow area of specialty. Woe to you if you actually try to challenge Dr. Knowitall.

Dr. Powderkeg

At least Dr. Angry is angry all the time and Dr. Whiny whines all the time. With Dr. Powderkeg you can see it building up all day and you are just wondering when the shit is going to hit the fan and who is going to be on the opposite site of that fan.

I Knew a Terrorist

Some people I knew as a child, teenager or young adult went on to become famous. Three people I knew a bit played in the NHL, I knew two future cabinet ministers, and one concert pianist. Some other people while less famous have had successful and practical lives.

But I also knew a terrorist.

His name was Brent Taylor and he was a member of the Squamish Five. You can read the links.

I'm not saying Brent and I were good buds. He probably didn't even know I existed. He was a year ahead of me in school. I first learned of him in Grade 8 when I started Junior High. He was in Grade 9. He was a good athlete, was on most of the school's sports teams and was on the students council. I think he held the provincial triple jump record in his age class at one time. I believe I played at least one rugby game with him. Our rugby team was pretty desperate and he was a good athlete.

By the time I got to High School in Grade 11, he was in Grade 12. His hair was now much longer than it had been before and he had grown a beard. I would have said he looked like Jerry Garcia but I didn't know who Jerry Garcia was then.

He went on, I went on and I had completely forgotten him until I heard of the arrest, subsequent trial and conviction.

Why is all this significant.

In Canada because of the "war on terror", a number of innocent (or not yet proved guilty) Canadians have been held without trial, sent to third world countries like Syria to be tortured or have not been allowed to come home. While there are varying levels of suspicion, from the accounts I read in the paper, the compelling reason for treating these poor individuals as they were or are being treated is that, they knew, were seen talking to, or were related to someone who actually had some connection to terrorists.

I have this recurring thought; Brent Taylor is being roughly interrogated and asked about who his accomplices are. He names the biggest nerd he can remember from school, me. And I am off to Syria.

As a postscript there was another student who went to the same school, a little younger also named Brent Taylor. I bet every time he tries to enter the US he curses his namesake.

Fertility Treatments

I was a little late in reading our national medical journal and so came on this editorial.

Essentially the editorial recommends as way to prevent multiple births from fertility treatments (thus shutting down half the reality TV shows) that the procedure should be covered in Canada. Currently prospective parents wanting in vitro fertilization treatments have to pay for the procedure. Because the procedure is expensive, in order to improve the odds multiple embryos are implanted. The hope is that only one will survive to babyhood. Often as we read from the tabloids more than one and in some cases many more than one survive.

Now as the editorial says, there is a significant risk to the mother with multiple gestations. Further as the editorial points out:

Perinatal mortality is 4-fold higher among twins and 6–9-fold higher among triplets. Complications such as cerebral palsy are 3–7 times more common among twins and 10 times more common among triplets. 4 When these complications occur, it is the public health care system that bears the cost while the parents and children bear the grief.

I have two perfect children so I can be smug. I can't really feel the anguish of a couple who is unable to conceive and how empty my life would be without my kids (empty of early morning hockey, school concerts, expensive hobbies?).

The bottom line is however, what are these infertility specialists thinking? Any other specialty who had an elective procedure which could predictably worsen the life of the mother and children would probably be under investigation by licensing bodies, the government and the press. While I hope most infertility specialists entered that subspecialty with a goal of enriching the lives of infertile couples by providing them with children, I suspect a lot of them are Ob-Gyns who at some point in their residency realized that delivery babies in the middle of the night really sucks and they should find a nice well paying subspecialty with good hours. Very few of these infertility specialists actually deliver the babies they implant.

And why is the procedure costly. Part of it is the cost of the infertility drugs. Why are they expensive? Is it the cost of production or is it because some economist with the pharma company calculated that that was the amount that desperate couples were prepared to pay. Another is the private fee that the doctor collects. Again based on what the market will bear rather than any relativity to what other doctors earn for work of similar complexity.

Public health care in Canada was introduced by Tommy Douglas an NDP premier and later national leader of the party. When the NDP government in Ontario decided as a cost cutting measure, that they would no longer cover fertility treatments (one reason was the observation that couples on the wait list conceived as frequently as couples under treatment) there were editorials about how Tommy Douglas was rolling in his grave at the violation of the right to public health care. Tommy Douglas who started out as a Baptist Minister would have no doubt frowned on test tube babies.

Somebody else pointed out years ago that a screening program for clamydia would markedly reduce the rate of infertility and would be a whole lot cheaper.

The whole issue that nobody wants to address is that there are two many damn people on the planet already. If we are going to maintain our standard of living while not exhausting our food and energy we are looking markedly reducing our fertility rate not creating new octomoms.

What I Did Last Night on Call

I spent about 5 hours doing a bowel resection for cancer of the recto-sigmoid.

Why was I doing this "elective" case on call?

The patient has quite severe lung disease (industrial exposure and smoking) with CO2 retention, requires home oxygen and even with the O2 he can basically walk from his bed to the bathroom but not much farther. The cancer was asymptomatic but had been picked up during screening for anemia. He had been canceled once because of no ICU bed and now one had opened up.

Fortunately we weren't very busy so the second call person didn't have to hang around long and there were no cases to follow.

The poor fellow is now residing in ICU on a ventilator and hopefully will be weaned off over the next few days although I have my doubts.

The "bottom" line is that rectal cancer while undoubted not a nice way to die, it is unlikely to kill him before his lung disease so why did we even bother?

But of course I am only an anaesthesiologist.