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.

Wednesday, September 5, 2018

First days of medical school

With getting older comes all sorts of anniversaries.  I started medical school 40 years ago today.

There were the prelims of course, getting the letter of acceptance sometime in June, writing back to accept their offer and I believe there was a deposit cheque involved.  There was also a trip over to Vancouver to pick up the microscope they said we had to buy.  I quit my summer job a week early much to my father's distress; everybody except him thought I needed a little time before starting medical school.

Starting was simpler than for some.  I had been at UBC for 3 years of undergrad already; I only applied to one school and planned to be either starting medical school or finishing off my degree.  I had a room in the student residences.  My friends had got a house off campus; I preferred to have the familiarity of residence and the ability to roll out of bed and walk to my classes instead of dealing with traffic or buses.

My recollection is I went over by bus and ferry on labour day.  At UBC the week after labour day was registration week, a week of drunken debauchery before classes started the following week.  No registration week for the medical school.  Classes started the day after labour day.

So it was on September 5, 1978 that I found myself in a lecture theatre in the Woodward Building sitting in my usual seat at the back, looking around wondering if I knew anybody in my class.  As people filed in, I recognized a few faces from lectures and labs and even somebody I didn't know all that well but had gotten drunk with a couple of times.  I had a negative opinion of what I thought would be my future classmates.  I expected a serious, hard working, cut-throat group of people.  I expected the next 4 years to be a busy, hard and socially very boring time.  (The summer before I started I was introduced to a visiting fiance of a co-worker as a medical student.  "Oh," she said, "I know a few medical students....I don't like any of them."  Great, I thought I've known you for a minute and you've already insulted me.)

Negative thoughts notwithstanding it was an exciting time, the culmination of three years of undergraduate always with a goal of getting into medical school.  We were welcomed by the Dean who informed us that we were the chosen people and welcomed us to the great fraternity of medicine.  We were then registered, and photographed.  I am not sure whether we had further classes that day.  There was a trip to the bookstore to pick up all the texts they said we needed, including the anatomy trilogy written by our Professor of Anaesthesia.  I also bought an ugly short white lab coat.

I went to the Pit (the student bar at UBC) that night and ran into my old friends and got little drunk which meant starting my first anatomy lab the following day with a bit of a hangover, which I would not recommend but I survived the day.

Thursday afternoon was the useless touchy-feely course we took in first year and we were divided into groups of 8.  The 8 of us sat in the room and some older adult asked us to tell the group something about themselves.  It was a round table and the talk started to my right so I got to talk last.  That was not good.  The first 6 had all had incredible lives, attending schools overseas, volunteer work and they all knew exactly what kind of doctor they wanted to be (and that kind of doctor was not an anaesthesiologist or a general practitioner).  Fortunately the person to my left, turned out to be a down to earth person, with an ordinary life, actually from Victoria although from a different high school.  Then I told my boring life story and we went on to something else.

Later that Thursday we had a tour of VGH lead by 4th year medical students who seemed so incredibly cool, followed by a party in the Medical Student Lounge on 10th avenue.  This party was by tradition put on by the second year class who had survived first year.  They were, as I later learned, by UBC standards an intense group.  Talking to them was somewhat anxiety provoking as they told us about the amount of work we could expect to do in first year (which was mostly true) followed by telling us that second year was worse (which it wasn't).  This was very depressing but  we had Friday morning off and the beer was cheap, so I got to have a few and made some friends in my class and I remember in the early morning a bunch of us heading off to Bino's on Broadway for pancakes before somebody drove me back to the campus.  This was to be the first of many drunken parties in medical school. 

Friday afternoon the first week was our 3 hour Biochemistry lecture and I was most impressed when Dave, my new dissecting partner loudly announced that the lecture would be continued in the Pit.  It just happened to be the night of the second Ali-Spinks fight which was on the big screen and it was great to see Ali regain his title.  Between that and running into my old friends, I think I closed the Pit down.  Medical school was not looking bad.

First year was heavily weighted on Anatomy with 3 or more dissection labs a week, along with a histology lab and 2 hours lectures 3 days a week.  It became apparent that most of us were in grave danger of failing anatomy if (or even if) we didn't work our buns off.  This was memorization of trivial details on a scale none of us had ever encountered.  It was, I am sure, humbling for all us, accustomed to being at or near the tops of our classes to have to shift into survival mode.  The whole stress of the situation seemed to bring everybody together perhaps in the same way basic training brings together soldiers.  We spent so much time together in those days as we all had same lectures and same labs.  We usually ate lunch and had coffee together, and frequently drank together.  People started inviting the whole class to house parties. 

Our class was the largest ever at UBC with 88 students.  There were supposed to be 100 but they weren't able to expand the anatomy lab to fit that number (which may have been galling to the 12 people who found themselves left on the waiting list the day after Labour Day).  Also a first we had 33 women which was most ever at UBC.

I think back now on how little I knew of what was ahead.  I knew nothing of details like specialization, certification exams or what was involved in being on call.  I had no idea what an anaesthesiologist was.  The only one I was aware of was the morose Australian on MASH, who always seemed to say, "Oim losing 'im Hawkeye".  Looking back it is interesting of how little we were prepared for the world we were going to go into  or that in which we live today.

I believe all but two of our class graduated although it took some more than 4 years.  One poor fellow failed anatomy and the summer supplemental anatomy course and was turfed.  The other developed schizophrenia in second year which was fascinating but depressing to watch.  We all went away to internships, did locums, residencies, settled down in various parts of country, a lot of the class eventually washing up in the lower mainland.  We had a 5th, 10th, 15th, 20th and 25th anniversary.  Only about 40 people attended our 25th anniversary in Vancouver, surprisingly given the number who lived in the area.  Nobody bothered organizing a 30th or 35th (maybe they did but didn't invite me).  Two of my classmates work in my city.  I used to see one, a neurosurgeon, a lot when I worked at the Centre of Excellence.  The other a psychiatrist, I last ran into over 10 years ago.   At least 3 of our class have died including my good friend Dave and also Phil who was in my dissecting group.  (The fourth member of our dissecting group, contacted me a few months ago on LinkedIn and introduced herself as the other surviving member of our group.)

40 years on now, I can just look back to the excitement, the fear and the relief of those first days in medical school.

Sunday, March 25, 2018

Leaving Chronic Pain

Sometime last month was my 25th anniversary of my first pain clinic.  I was at the Centre of Excellence, and the person doing the Pain Clinic went on to better things.  The Professor told me I could do the Pain Clinic until they found somebody smarter than me to do it.  Problem was there was nobody smarter or stupider and 25 years later here I am, although not at the CofE.  I should have had a party, moreover somebody should have thrown one for me.

A couple of weeks ago, I gave notice that in March 2019, I will be giving up most of my chronic pain practice and become a more or less full time anaesthesiologist  again.  Like many decisions there was no “last straw” moment, it was a series of small things.

One reason is that despite everything we complain about, being an anaesthesiologist is a pretty good gig, if only for this reason.  When you see the hospital in your rear view mirror at the end of the day, unless you are on call, you know you are finished.  No phone calls from the ward, patients, pharmacies or other doctors.  If for some reason you want to go on a long vacation, you don’t have to arrange coverage and you know that you won’t spend your first two weeks back, putting out all the fires that started while you were away.

I have been pretty good about setting boundaries and have a great colleague who covers me when I am gone.  Patients expectations about availability are less too, I get a lot fewer calls now.  Still I have voicemail and a fax which go to my email which I check even on vacation and the hospital switchboard has my cell number.   I could ignore them because switchboard is supposed to know when I am away and my voicemail greeting usually says I am away and who is covering but I still feel guilty, even when the problem is not one of my creating.  For example I spent a great deal of time on my 60th birthday dealing with a patient who had messed up big time.  I did this after the pharmacist from the PCN pain clinic emailed me to say he needed urgently to speak with me.  Okay why was I checking emails on my birthday?  Because that’s what I do.

I met a pain specialist from another centre about 10 years ago at an anaesthesia meeting.  "I'm thinking of going back into anaesthesia", she said, "I want to retire soon and I can't handle the demands of my patients."  Sounded strange at the time; most people give up anaesthesia and the call involved to do chronic pain, I almost did a few years ago.  This encounter did plant the germ of this idea in my head.

The biggest thing however is that I realized a few months ago that I have lost my compassion.   I no longer have patience for people who won't try do anything to help themselves, I no longer want to hear about problems that I have no way of solving.  90% of my patients are good people who try do everything possible and I have a treatment that might help them or is helping them.  Like most things in life, it is the other 10% that take up most of my time, that leave me feeling drained at the end of the clinic.  I don't want to be seen as blaming patients for their misfortune, its just that quite a bit of the time I have nothing to offer and don't really want to hear about it anymore.  So often I want to say, "YOU have a problem, what are YOU going to do about it?"

Pain medicine and medicine in general have changed over the last 25 years that make it less attractive to practise.  25 years ago most of my patients had a family doctor, moreover they had a family doctor to whom I could make recommendations that they would follow.  Now when I get a referral, I get the sense that the family doctor has washed his hands of this patient.  That is of course if the patient has a family doctor and a significant number don’t.

Paradoxically we have way more physicians doing chronic pain than 25 years ago.  This should make it easy.  It doesn't.  25 years ago, I was almost always the first person to see a patient.  Now quite often they have already seen one or more chronic pain specialist.  Quite often they are still seeing someone else (I saw a patient a few years ago who was seeing 4 other chronic pain doctors; she was quite disappointed when I told her I didn't think there was any point in my following her as well).   This would be nice if I actually had the records from their previous doctor so I could see if I had anything else to offer but that is the exception not the rule.  Moreover some of my colleagues have developed boutique-type silo practices where they offer single modalities, usually interventional treatments.  Quite often the patient is still getting these treatments but the expectation is that I will prescribe medication for them.  Or one of my colleagues has started them on some toxic cocktail of multiple classes of drugs that I am supposed to unravel and continue.   And with all this expertise floating around we should be able to work together in the patients' best interest?  What universe do you live in?

So why don't I, as somebody suggested, just carve off the parts of chronic pain practice I enjoy and forget about the rest?  If only it was so easy to tell in advance who was going to be easy and who wasn't.  And the easy patient of course so easily becomes the hard patient.  I have for the last few years been more selective in screening out referrals and in my new consults so that I am accumulating fewer patients I know I can't help with the resources I have available.  But I have never been comfortable telling a patient that just because I can't do some lucrative procedure doesn't mean I can't try to help you.

It is hard to talk about chronic pain without mentioning the opioid crisis or epidemic whatever you want to call it.  I still prescribe opioids for chronic pain, although not in the industrial doses some of my colleagues prescribe.  So far I have escaped scrutiny from our medical licensing body.  Every quarter I do get a list of patients who are over the recommended dose which I read with some interest.  Talking however to some of colleagues who have undergone scrutiny and have had to pay 10s of thousands of dollars in  "costs" of the investigation or fees to attend remedial courses scares me a little bit.  I am less than 5 years from retirement, slowly building up my nest-egg.  I look at some of my patients and think, "is patient X, the hill I want to die on?"

And of course with increased scrutiny from the licensing body, a significant number of referrals I get are dumps of patients who have gotten onto these industrial doses not to mention a number that are doing well on a reasonable dose and the expectation is that I will take them over in my solo part-time practice.  Which of course I do because I am an old school doctor, who doesn't want to see patients go through narcotic withdrawal.

Narcotics still confuse me and I have no idea what the right answer is.  I have mentioned above, that I have reluctantly acquired a number of patients on whopping doses of opioids.  Most of these people seem to look okay.  Their function like most chronic pain patients is not the best although I periodically find somebody who is actually working.  Most of them are quite happy on the massive doses they are taking; they don't want to see a psychologist or attend a rehab program and they definitely don't want to come off their meds.

On the other hand I read a lot in the medical literature and on Twitter (where I get most of my medical info now) about all the bad effects of narcotics, and there is no doubt that there is some truth in all of this.  The question is where is the balance because as somebody who follows a lot of patients on narcotics, clearly some of them benefit greatly from them with little or no adverse effects.  Further I have seen a number of ugly cases of forced weans that ended up in my clinic.  Our Workers Compensation board has recently become evangelical about weaning off opioids, at least once a month I have to spend 20 or minutes consoling a distraught patient who has been told they have to go to a clinic in a city 3 hours away to be weaned off their meds.  They all think I have some magic clout with WCB.

Just something I don't want to be bothered with anymore.

In fact these patients are the most difficult for me to abandon.  I hope to transfer those with understanding GPs back to their GP.  Some of the complicated ones I am referring to some of my colleagues and my colleague who is taking over my clinic time will take over some.  Our licensing body told me that as long as I gave them 3 months notice, I had no obligation at all to arrange follow up.

Chronic pain still confuses me.  I still don't know what causes back pain or neck pain.  I could be one of those people who says, "yes it's definitely your facet joints and every three months I will inject steroids into those joints or maybe just burn the nerves"  but I know its not that simple.  So I end up offering what I think might work, usually in my case trigger point injections and an antidepressant but feel like an idiot for doing so.  I should be telling them to exercise and lose weight, like that will ever happen.

Patients often ask me about some bizarre symptom they are having.  "Is this normal?"  they say.  "No", I reply, "it is not normal but it is not unusual."   I have learned that patients have these symptoms, they are real; if they're making it up, that too is pathology worthy of treatment; and that in most cases I can only guess at the psycho-physiological mechanism behind it.

The lack of  supportive infrastructure is another factor.  I usually go to a pain meeting once a year where I hear presentations from psychologists and physical therapists and I come home excited and ready to help my  patients.  That is until I try to refer and find that my patients can't afford any of this and the very few practitioners in the public field have exclusion criteria that effectively excludes all my patients.  Long ago at the CofE one of my colleagues came back from his Pain Fellowship (at Boston College, not Harvard as he now tells everybody) to join me in practice.  "Where," he asked me, "do I refer somebody for inpatient rehabilitation?"  I was polite and supportive.  I didn't roll on the floor laughing.  I told him that no such program inpatient or outpatient existed and that he better learn to live with that.

Periodically we get to meet with our regional admin.  They usually tell us how much they support what we are doing and then we don't meet again.  A couple of years ago when I last got invited, I was a little punchy.  "Are you going to be giving us more resources, " I asked, "because if you aren't I really have no interest in attending any more meetings".  And I didn't.  It is not just not having new resources, it is not being able to access existing resources that bugs me.  And it just galls me to see all the new programs that have sprung up for chronic diseases while we have been told there is no more money for chronic pain.

Things are a little better now, we do have self management programs and also some exercise programs.  Thing is, these are all by self-referral and the likelihood of the passive fix-me-now pain clinic patient phoning the number and driving across the city (because they are never central) to attend one of these programs is close to zero.

Anyway, while I sometimes lie awake at night wondering if I am doing the right thing, blowing up 25 years of practice, I told somebody I was retiring (from chronic pain) and it felt pretty good.  Maybe somebody will throw a party for me.

Monday, December 18, 2017

Getting Older

My father once told his grand daughter, my niece that he was not really old, he was just older.

We are all getting older.  I celebrated my 60th birthday this summer.  This was a quiet celebration as have been most of the previous 59.  That is what happens when you have a summer birthday.  I did take a lot of time off this summer and went on two fabulous bike tours, so I guess I did have a nice birthday.

My parents are also getting older.  My father is 93 and my mother 88.   My father retired at 61 although he did some consulting after.  My parents had a very active retirement (although my mother as a housewife may not have noticed any retirement).  They traveled quite a bit; driving all over BC, Alberta and the Western US.  They also visited us quite a few times when we lived on the East Coast.  They toured Europe and Britain.   My father kept on gardening and with the extra time on his hands his garden became more elaborate.

They were however getting older.  One by one their siblings died until I have only one surviving aunt.  My father started to develop all the health problems, prostate cancer, atrial fibrillation (diagnosed by his urologist, most likely a publishable event), cataracts and an abdominal aneurysm repaired electively.  He also developed significant osteoarthritis in his knees which for some reason his family doctor didn't want to refer him to ortho for.  By the time I did the doctor thing and got an orthopod I knew to see him, all the above problems had presented and the orthopod prudently declined to operate.  My mother however remained in fairly good health and was with it.  While her mother died of TB in the 1930s, she had aunts on both sides who lived well into their 90s so I was anticipating a long life for her.  As my father became more and more crippled by his osteoarthritis, she became more and more his legs.

My parents continued to live in the house that they had lived in since 1960,  This was a single story house with a finished basement.  My mother cooked as cleaned as she had all their marriage, my father worked in his garden and did the yard work.  A few years ago, my mother disclosed to me that she wasn't sure that they could handle the house but that my father loved his garden and didn't want to move.  The garden was becoming smaller and less elaborate and shortly after his 90th birthday my father decided that this was his last garden.  They were getting a little help thru homecare and through Veterans Affairs.

Meanwhile my mother who suffered from macular degeneration, developed what might have been retinal detachments (I don't know for sure, the opthamologist wouldn't return my calls).  Last spring she told me, she could no longer read.  My mother loved to read as do I.  I felt very bad for her.

I had started visiting my parents every couple of months a few years ago.  I no longer had all the weekend sports and it didn't seem that expensive to fly to Victoria any more.  It was a nice trip, I would stay in a hotel and visit all my favourite places.  We would go out for dinner and my mother usually cooked lunch and occasionally dinner if I was leaving later on Sunday.

Last June (2016) I visited my parents and had a very nice visit.  My mother made us lunch and on Sunday because I had a later flight, she made a nice Sunday dinner.  She was at that time having the vision problems but the house was clean and they were nicely dressed.

I came back in August.  Again everything seemed okay.  I arrived mid morning, we had tea and then my mother made lunch.  We went out for dinner on Saturday.  Sunday I drove them out in the country and we went to a nice restaurant for lunch.  I was flying home around supper and told them I would eat at the airport on the way home.

So it was that around 1500, having tea my mother said to me, "you know if you had more education, you could get a better job".  Hey I know I'm just an anaesthesiologist.  She then asked me where I lived and who I was married too.  Thinking back over the weekend, I began to suspect she had not known who I was all weekend.  I left feeling somewhat shattered.

Monday I phoned home hoping to talk to my father. My mother answered the phone, recognized my voice and we talked for a few minutes before I was able to talk to my father.  He confirmed that she had been acting like that for some time now.  I contacted my brothers and one of them who had visited earlier in August, confirmed that she had been acting like that when he visited.  He also revealed that she had been falling over as well.

Concerned about (but secretly hoping it was) a subdural, I phoned her family doctor, got a locum told her the story and the locum was able to arrange a CT scan in uncommon speed for a GP.  This was normal except for atrophy.

A family meeting was convened with two of my brothers and me.  My parents or rather my father agreed that it was time to move to some type of facility.  My father has a good pension and they had considerable assets so a private facility was available for them
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I am not going to go in detail all of what has gone down in the last year except that it was about 10 months that I never again want to experience.   My mother now lives in a "reminiscence unit", which is a locked ward for patients with dementia and a tendency to wander.  Reminiscence is a nice euphemism for a place inhabited by people who can remember events from the 1930s but can't remember the names of their children or what you told them 5 minutes ago.  My father as of a couple of weeks ago lives in the same building on  a different floor.  He is allowed to visit my mom but can't take her off the unit.

As it happened just over 6 months ago, we got a phone call that my mother in law was in the emergency with back and leg pain and not really able to walk.  Again not going into all the nuts and bolts of what went down but she is now in a nice facility in Burnaby having moved out of her condo.

Life as my father or maybe it was somebody else observed doesn't come with a users manual and I have learned more about getting older than I ever wanted to.  In no particular order.:

Seniors care is very expensive and somebody is making a lot of money off it.

My parents are currently spending between $10 and $20K a month for the rather nice place they are currently living.  My mother in law who had much less assets was after some time eligible for subsidized care.  However when we first placed her in her first assisted living facility she had to pay a significant extra amount of money to have someone dispense her medications and bath her.  This is despite the fact that the person providing the service is probably getting paid the minimum wage for the time spent providing the service.  This is also the case for the nice people who look after my parents.  There is a RN in their building but I suspect she is getting less than she would be getting by working in a hospital.a

Not all nursing homes are created equal.

I of course should have known that that.  We found a nice seniors home for my parents in their neighbourhood with a room available within 6 weeks.  My wife, then I suddenly realized that this was totally not the right place for my mom but the wheels were in motion and so that was where my parents went.  We told the administration right up front my mother's mental state realizing we might sabotage the move and to their credit they were very accommodating especially for a for-profit facility. 

There are in fact multiple levels of care, which overlap and some are available in the same building some are not.  Researching this was very complex.  This may mean divorce by nursing home.

There are of course public and private facilities to consider as well.  It is interesting that in Canada, everybody gets treated equally in the healthcare system (not really) but that where and how live as senior is so dependent on your income or what programs you are eligible for.

Staying in your home might be important but a lot of people can't do it.

The mantra since I was in medical school has been to keep seniors in their homes and we go to elaborate lengths to do this, not necessarily sometimes in the best interest of the elder or their support people.  My father really wanted badly to stay in his house which complicated things incredibly and my brothers and I (most me) tried to figure out scenarios where both my parents could stay in their home.  My parents are quite well off, money would not have been an object; however on thinking things over there was no way they could have possibly stayed in their home, even with the best of help.  This did not stop me from feeling like I had let the team down.
My mother in law on the other hand was an inpatient and it became clear that she could not go back to her condo.  She was eligible for subsidized care, however when we approached people about that we were advised that she could not go directly to subsidized care from hospital; she would have to go home first, fail her trial of home care and then go to subsidized care.  We had the means to put her in a non-subsidized care facility from which she was able to apply to the lovely subsidized care facility she currently lives in.  Had she not had the means to go into a private facility, however she might still be involved in a Mexican standoff where they say she has to go to her home but she can't possibly go to her home.  I am pretty sure that scenario is being played out in lots of hospitalized seniors.

Rather than being pro-active the system is set up for seniors to fail.

Even 30+ years ago when I came out in practice, they were talking about the silver tsunami although they may not have had such a catchy name.

In Canada we have socialized medicine, every person has a health care number, almost every person has some contact with the health care system, every person pays income tax or receives some form of government assistance, a great deal of seniors pay property tax.  In other words there is a huge repository of demographic information available.

So why are we  so surprised every time we have a senior with failure to thrive?  Why do we wait for seniors to end up in an acute care bed or the ER.  Why aren't we proactive?  It is quite likely for example that if I hadn't visited my parents that particular month, nobody would have realized just how far my mother had declined.  Sure, you can say the family should have some responsibility.  This ignores the reality that living in the same city you grew up in is the exception not the rule and that the children of seniors are mature adults who have jobs, look after their own kids and not infrequently have health issues of their own.

When I was department head, I had to attend Medical Advisory Committee meetings.  Most of those meetings involved various members of the administration telling us about the crisis of seniors in the ER or on the hospital wards.  Once I piped up, something to the effect that why don't we look upstream and try and prevent these people from ending up in a place they and we don't want them to go to.  Nice idea, said someone in a suit and we went on to the next topic.

What about geriatricians.  Geriatricians exist.  The problem is they largely work in hospitals where they see people who have already failed the system or in hospital clinics where after being on a long wait list you can get assessed.  Not out in the community putting out fires like they should be. 

Family docs?  Both my parents had pretty good family docs.  The problem is that it is very difficult providing the type of care seniors need in a fee for service system, while looking after the rest of your sick and not so sick patients.

Not everybody ages at the same rate.

I sort of knew this but visiting my parents in two different seniors' home brought it home to me.  The seniors' population is a heterogenous group with very different needs.  Closer to home, this means that a couple may not age at the same rate.  My mother for example doesn't recognize  me, my father's mind is still as sharp as every.  This leads to the phenomena of divorce by nursing home where because of different care needs a couple cannot stay in the same facility.  My parents are lucky enough to now live in the same building but in different rooms on different floors.

Even individuals don't age at the same rate.  I was astonished by the precipitous decline in my mother's mentation even though she may have been hiding it well.  The swift decline form a fully functioning individual to something way less than that, constant catches family and the healthcare system off guard.  It shouldn't.

A week or so ago, a pain clinic patient asked me if I was going to retire.  "Not right now", I said, "but I just turned 60 and things can change in a hurry."

Have I  learned anything from this?

My parents' generation largely didn't deal with this because people died at younger ages from infections or from heart disease or cancer for which there were fewer treatment options.  Therefore faced with their own fragile longevity they have no idea what to do because they never had to deal with elders in the same predicament when they were young.

I am starting to learn and hopefully plan my own senescence. 

Firstly, I  assume that at some point I will not be able to drive.  By that time I  will probably lack the insight into this so it is better to quit well before I am forced to.  This also means living in a place where the services are within walking distance (which  also might be a problem) or that there is good public transport. 

I am  going to need medical services.  I have a good family doctor.   For the rest of you, this means if you don't have a family doctor, you better get one who is a lot younger than you.  Preferably one who isn't an idiot and who works more than 3 days a week.  When choosing what town I am  going to live in, I now have to factor in what medical services are available locally.  This is important if I want to retire overseas as I often threaten to do.

There is of course planning my  home and will I be able to live in it in the future.  Better figure out how you are going to climb those stairs when you have generalized osteoarthritis or heart disease.  The necessary renovations are going to cost money and despite what my financial advisor tells me, I know I am going to have less of that in retirement.  I joked when visiting seniors homes about, "see you in 10 years" but maybe it is more realistic to go into a home when you want to, not when you have to.

There is of course the whole advanced directive thing.  I am pretty health right now and barring metastatic cancer or something like ALS I would probably like a little CPR.  Problem is that by the time I shouldn't be getting a little CPR or the related trimmings, I may not have the insight.  Better discuss this with somebody sensible now.  Make sure they are prepared to advocate for you because there are quite a few doctors out there who are prepared aggressively treat you, based on their religious belief, hospital policies or the irrational fear of  being sued.

In closing

As my parents started to push 90, believing that longevity is genetic, I rejoiced in my potential long life. 

Not so sure about that now.




Thursday, May 11, 2017

You break it, you buy it


I saw 4 patients that morning.  2 of the patients were young men who were cancer survivors.  Unfortunately combinations of surgery, radiation and chemotherapy have left them with disabling neuropathic pain, which in both cases prevents them from working.

Naturally if you read the progress notes from the Cancer agency you will read glowing, back patting descriptions of the success of their cancer regimen.  Both men are going to survive.

The problem is that both of them have severe pain, and nobody really wants to address it.  Despite what you may read in the American and sometimes in the Canadian media, cancer patients actually get quite good care in Canada with a huge infrastructure of nurse practitioners, social workers, psychologists and patient navigators.  If you are dying of cancer, you will go into a similarly endowed palliative program.  This is as it should be; when my cells start acting in an antisocial fashion, I want it all there for me.

If you are "cured" of cancer however you enter the dismal world of the Canadian healthcare system with its waiting lists and silos of care.  Unfortunately if you have chronic pain nobody really wants to take ownership of you, least of all the oncologists and surgeons who caused the problem in the first place.  This usually leaves it to chronic pain "specialists" like me who are stupid enough to still want to see these patients.  We are usually not talking about narcotics here although that is what they frequently need; anticonvulsants or antidepressants are often effective but I frequently see a patient who has gone for the 18 months or so my wait list is, without trialing them at all.

When you think about it, it takes a special kind of sociopath to leave a patient in pain as a consequence of their treatment, (even if they did save the patient's life) and not feel responsible to at least do something to try and help the patient or at least direct him to someone who can.  Back surgeons are of course big offenders in this regard.

Working in my other life as an anaesthesiologist I see the other face.  As I work in a big city hospital, in what could sometimes be seen as tertiary care, a lot of the work we do in OR, is as a consequence of surgery done at other sites, usually out in the country, often by somebody who had no business doing that complexity of surgery but also alarmingly from within the city.  I often pity my general surgery colleagues who get stuck with complications of gynae or urological surgery.  Talking about podiatrists to one of our orthopods is a sure fire way to generate a long rant.

We anaesthesiologists of course get to tag along on these little misadventures because they almost always end up in the OR, usually after hours, occasionally bumping the enjoyable list you thought you had, often in ICU with 20 infusion pumps going or with MRSA, VRE, XYZ etc.  I remember early in my career noting that I had worked until 0400 all on complications of surgery done at other sites.

And we all love to hear of the patient with the post-spinal headache in the ER, who had her baby at another hospital or who had a misadventure with a lumbar puncture.

My chronic pain side is not immune.  I get to struggle with the patients put on megadoses of narcotics by other people, those on big doses of benzos and of course the sloughs from my colleagues who have exhausted their repertoire of lucrative blocks and now want me to manage their patient medically.

Complications are a consequence of medicine and modern medicine is really just a bet that the benefits of the procedure or treatment outweigh the adverse effects, transient or permanent.  This is a bet patients frequently lose.   Sometimes the adverse effects are something we can deal with ourselves, sometimes in the best interest of the patient, some else is better able to deal with it.  It would be nice if there was some mutual respect and communication.