Saturday, February 28, 2015

Childhood Illnesses, a memoir

One of my oldest memories is the Christmas of 1959.

Christmas, 1959, was the Christmas I had measles.  I still remember seeing pictures of me at Christmas in my pyjamas with a blanket wrapped around me which was, then and now, all you could really do for measles.  I didn't suffer any ill effects and it wasn't until 20 years later in Medical School that I learned about all the bad things that could have happened to me.

As an aside, I have actually seen cases of measles in Canada.  One year, an entire cohort of children got vaccinated with a bum batch of vaccine which meant about 5 years later we had teenagers all the same age presenting with fevers and rashes and I finally got to see Koplik's spots.  All of the cases I saw were mild suggesting there was partial immunity.

By that time vaccination existed for polio, diphtheria and tetanus all very nasty diseases.  We were not that far removed from the polio epidemics of the early and mid 1950s.  We were constantly reminded of it by the kids in wheelchairs and the kids with leg braces some of whom attended school with us.  

Diphtheria is of course a really nasty disease, thankfully as a physician primarily working in the developed world, I have never seen a case.  I do remember reading in Kipling's autobiographical
"Stalky and Co." how the headmaster saved a child with diphtheria's life by doing some sort of 19th century intubation or tracheostomy.  Not sure whether this was based on a real incident or just something Kipling thought up.  Tetanus I have seen, usually in older adults some ending up on ventillators some not, at least one dying from it.

I remember going for my vaccinations as a toddler.  My mother would take me to the public health unit where a nurse would paint a rabbit on my arm with mercurochrome and stab the rabbit with a needle.  It still hurt although the ice cream cone afterwards almost made  it worthwhile.  Later, I get the Sabin vaccine which came on a sugar cube.

Vaccinations took place in the schools in Grades 5 and 10.  I believe it was possible to get a note from your parents exempting you but I don't think anybody did.  Why would they?  As I mentioned, we still had reminders of the polio epidemics all around us plus a lot of our parents had had a sibling, friend or classmate die of an infectious disease.

Along with vaccinations for diphtheria tetanus and polio, we were vaccinated for smallpox.  I was re-vaccinated for smallpox just before medical school in 1978, making me one of the last people vaccinated for it.

Vaccines for measles, mumps, rubella didn't exist when I was a child so I got to have them all along with chickenpox.

I got mumps at 3 or 4 which I remember as not all that bad, again treated by wearing pyjamas during the day.  I do remember my older brothers who got it the same time as I did were a little sicker.  Mumps has a lot of adverse consequences although more in adults.

Pertussis or whooping cough I got at age 6.  I don't know if I even missed school.  I did have to miss the swimming pool part of a friend's birthday party but not the dinner and ice cream after.

Chickenpox came at age 7, keeping my out of school for a few days (although this time I didn't have to wear pyjamas) and postponing my father's home made haircuts which I hated.  Chickenpox as I found it in medical school is highly contagious, one of my classmates who had never had it spent less than a minute in the door of the room of a child with chickenpox contracted it which means he wasn't allowed on the wards until the infectious disease department deemed him fit to do so.

Rubella I didn't get until age 17.  It was again a mild disease, fever and myalgias and I stayed away from school for a week or so.  Rubella of course can cause congenital malformations and I could potentially have infected somebody something I still wonder about.  Rubella was still fairly common when I was in medical school.

While living in university residence in 1976, I came down with a very severe flu, which years later I figure was probably the H1N1 strain, then called swine flu.  I missed a couple of days of classes and basically crawled to classes for another few days.  I have not ever been so sick.  I never sought medical attention, some people with the same thing who did, were promptly hospitalized.  

If it appears I am making light of all the vaccine-preventable diseases I had as a child, I am not.  I was shocked when in medical school I learned what could have happened to me as a child.  I often wonder how my mother who had been a nurse and who knew of the awful consequences of these diseases kept calm with sometimes 3 children sick with something.  As I have pointed out, this was still in the early antibiotic and vaccine era and many adults then had had somebody close to them die from an infectious disease so there may have been a fatalism that helped them get through. That same experience of premature death was why the parents of my generation embraced vaccines so enthusiastically.

We of course did a lot of things in the 1960s which we would never do now, like not wearing seatbelts and I like to think that as a society we have evolved. I continue to be disappointed.

Saturday, February 21, 2015

I got profiled

I have been reading for some time now about the profiling of blacks and other visible minorities some just a hassle and some tragic.  I often think, how can the police be so stupid?   Then I thought about what happened to me 30 years ago and how it made me feel.  Now I didn't get arrested, didn't get frisked and suffered no consequences (one of us did which I will explain below).

The summer before I started medical school I was working for the forest service in Wells BC.  Nice little town, you should visit there; I haven't been back, for no specific reason.  There were 4 of us working up there and by accumulating overtime hours, which as casual staff we were supposed to take as time off, we were able put together a 4 day weekend, so we headed down to the coast where we were all from.

We left around 3 in the afternoon on a Thursday four of us in a beater car,and stopped for Chinese food in 100 Mile House.  I had a beer with supper, I can't remember if the driver did; it wouldn't have been more than one.  We kept on heading south passing Cache Creek on to the Fraser Canyon.

It was on the appropriately named Jackass Mountain that it happened.

As we proceeded on, going at or slightly above the speed limit, there was an RCMP cruiser parked along the side of the road.  As we passed it, somebody, maybe me turned his head to look back at it.  "Don't look back," said the driver, somewhat annoyed.  We all knew you never looked back at police cars because it invited suspicion.

Now we were all university or technical school students.  I became a doctor; I have lost touch with the other three, I am sure they all went on to become productive members of society.  We were just a little nerdy.  Our hair wasn't short but it wasn't that long.  And we were all white.

Within a minute of the look back, the cruiser was on our tail with the lights on.  We pulled over to the side and the driver got out his license and registration. As the cop walked over and stuck his head in the driver's side window I still remember what he said.

"You guys look suspicious, why do you look suspicious?"

He made us all give him our names.  I knew that legally I didn't have to do that but it was getting late and we just wanted to get down to the coast.  He asked a few questions about what we were doing and finally we were on our way.

At that time the Fraser Canyon highway went through rather than around every little town which of course meant slowing down from 80 km to 50 km, which most drivers didn't bother with.  So about 30 minutes later cruising through Boston Bar going with the traffic flow, our car , of all the cars going the same speed, got pulled over for speeding.  We figured the cop on Jackass Mountain had radioed ahead.

Because it was our driver's second speeding ticket that year, it cost him his safe drivers discount on his insurance, worth about $150 which he was a little pissed off about.  The other three of us suffered no consequences other than getting home a little later than planned.

I have thought often about that incident,  now almost 37 years ago, and how I felt and I can only feel sorry for those people for whom this is a weekly or daily occurrence.

Tuesday, November 11, 2014

Hey I wore a poppy this year.

I think it was last year that I blogged about why I wasn't going to wear a poppy.  I did wear one this year.  This was partly under duress but mostly because of some reading and some deep thinking over the year.

The duress part.  The adult band I just joined played a "Lest we Forget" concert last Saturday and we were told to put a poppy on our suits.  40 or so years of band-geekdom have led me to blindly accept the commands of my conductor and I wore a poppy on the left lapel of my suit, which I learned is the correct way to wear it with suit.

However I put a poppy on my winter coat today when I went out.

During the last year or so I have read a couple of books about WWI and have thought about my two grandfathers who fought in that war.

For Christmas last year I got Margaret MacMillan's excellent book, "The War That Ended Peace."  All senior politicians in the world should be locked in a room and not let out until they have read this book (they may need to make a comic book version for Republicans and Canadian Conservatives).  As I read it, the central thesis of the book is that none of the great powers in Europe really wanted to go to war but they were all convinced that the other countries did and so gradually and inevitably everybody went to war.  The WWII is really just the end-game of WWI, the Cold War was the end game of WWII and all the little and bigger wars since then are really just the end game of the Cold War.

Just recently I read "Into the Silence" by Wade Davis.  This book is about the first 3 Everest expeditions culminating in the disappearance (and death) of Mallory.  About a quarter of the book however describes the first world war which had a marked effect on the mountaineers almost all of whom were veterans that war.  This is one of most vivid descriptions of the horrors of the first world war.  Events like patrolling no man's land and stepping on rotting corpses or of horribly maimed and unidentifiable dead being thrown into mass graves with orderly crosses being placed on top to give the illusion that the soldiers were buried intact in individual graves.  He also talks about the British Commander General Haig who lived the war in a French chateau miles away from the Front, which he never visited.

I grew up in the 1960s when there were still a lot of WWI veterans alive and when practically everybody's father had served in WWII.  I read a lot of war literature in that time and the impression I got of conditions for soldiers in WWI is a lot different from what we read in Davis' book or in many of the excellent books about WWI which are now being published.

The impression most of us, as children got of WWI was that it was a pleasant war with smiling soldiers who sang, "It's a long way to Tipperary" and met French girls.  The trenches were pleasant safe places and if conditions were a little rough, they were not that much rougher than your last Scout camp.  If a lot of people were killed, came back missed parts of their body or with minds that didn't function like they did before, that was a side issue.

I have been thinking a lot lately of the two grandfathers I never knew.  Both my grandfathers survived but didn't survive WWI.  One grandfather was in the first chlorine gas attack of of WWI.  He was later blinded when a grenade blew up in his face.  He returned to Canada later moved back to England, was trained as a masseuse, got involved with British Fascist party and died of respiratory disease in the 1930s.

My other grandfather was wounded at Vimy Ridge.  He too had been gassed earlier in the war.  He married an English nurse and moved back to Nelson where he had lived before the war, surviving on his army pension.  Like my other grandfather he suffered from chronic respiratory disease having been gassed, contracted TB and died along with his wife in the 1930s.

My parents never talked much about their fathers.  I never even saw photographs of them until I was an adult.  My mother had her father's medal ribbons (her brothers had the actual medals) which I took to show and tell once a year.  I do remember once when my brothers and I were talking about WWI, my mother saying, "if it wasn't for that war my parents would both be alive."

I still think about what lead my grandfathers to enlist.  One grandfather had already been in the British army serving in South Africa and Afghanistan.  It is a little unclear how he ended up in Vancouver where he enlisted but it is quite likely that he was at loose ends and maybe welcomed a return to the military.  My other grandfather was a miner, so I am not sure what lead him to enlist.  I suspect that compared to mining in the early 20th century, a military life seemed pretty pleasant; steady salary, 3 square meals and a warm place to sleep.  Plus you were joining the British Army which had a pretty good record of success since the American Revolution.  People talk about King and Country, however I wonder how patriotic Canadians in that era were.  There was of course peer pressure and of course a sense of adventure.

The other thing I have been thinking about is how disconnected we are now from the military.  Unlike WWI and WWII which were fought by teachers, farmers, clerks and miners who returned to their jobs after the war, the army now predominantly composed of career soldiers who enlist as teenagers.  We now see where the army is a family profession with sons and daughters serving because their father served.  (There is true, a reserve army as well.)  This leads to the army being disconnected from the community.  This makes it all the easier for politicians to order them into danger and unfortunately makes all of care a little less because we really have no connection with them.

I often think of how the 20th century would have unfolded without WWI.  I get the impression the world or at least Europe might look a lot the same as it does now.  I also get the impression things just might have been a lot better.  No Hitler, no Stalin for example but who knows what other monsters might have arisen.

I remember in the early 1990s when the Cold War ended looking forward to a peaceful 21st century where all the resources devoted to killing people could be turned towards the betterment of our planet and our species.  How horribly wrong I was.

So when I wore my poppy today, I wore it for the poor soldiers like my grandfathers who endured horrible conditions in a stupid war, for the relatives who lost or got back damaged loved ones, and for the civilians in the war zones whose lives were turned upside down.

And the poppy-wearing -war -mongering- politicians and generals can go fuck themselves.

Wednesday, October 1, 2014

Guess what, I now work in a client service area.


I have been sparring with our administration over accreditation and "high alert" medications something about which I have blogged about and will again in the future.  Apropos to that I was able to obtain a copy of the accreditation standards that our administration is using as a club to beat us with.

Right away, I came across the term "Client Service Area" which refers to the operating room where I work sometimes but also presumable refers to the wards in the hospital and the clinics and most likely also to the Tim Horton's outlet in the cafeteria.

Like the title of this blog says....I used to be disgusted.....


Saturday, September 13, 2014

Okay I Finally Have to Say This, I Hate People Who Bring Carry OnLuggage on Planes



Disclaimer.  I ocasionally do not check luggage.  I do this in two circumstances.  If I have a very short trip overnight or back and forth the same day, I bring a small bag with a single change of clothes, toothbrush and shaving stuff.  I put this in a backpack or duffel bag which can be squished into the overhead or under my seat (not just to be considerate but because that is what I am probably going to have to do.).  The second is when I am on a medical mission and all my checked luggage is medical supplies so I have several days worth of clothes jammed into a carry on bag.

I have known this for years but it only became crystalized yesterday after hearing the young man one row back of me complain the entire flight because they had made him check his bag because there was no room in the overhead.  We were sitting at the back of the plane so he would have gotten to board first had he not been goofing around and yes it pisses me off when people in the front put bags above my seat but hey, as he told everybody in ear range, he had a four hour stop-over in Vancouver plenty of time to collect his baggage.

For about the past ten years now just about every flight I have been on has taken off late because of problems stowing everybody's carry on.  At the end of the flight it takes forever to deplane because of the reverse, people taking their steamer trunk out of the overhead where it has become wedged or trying to get to the back of the plane against the traffic flow to collect the steamer truck they stowed above somebody else's seat.  I remember being in the Toronto airport around midnight waiting for my baggage after a flight which left an hour late because of having to stow hand baggage and thinking, "those assholes who made the flight late are already in bed".

I have obviously spent a lot of time analyzing this and I can't help but observe that most mid-large size planes actually have enough overhead space to allow every person on the flight to stow one piece of carry on luggage.  If there is not enough room, it is because multiple people have stowed more than one bag especially because I only use the overhead compartment in situations like the first paragraph, this means they have ignorred all the warnings and signs about hand luggage and that the airline staff have ignorred this.  This is probably because the airline staff would rather deal with one obnoxious passenger than multiple but my obnoxious friend above has a point, why is everybody else's luggage more important than his?

You can of course or some will blame the airlines for charging extra for the second (or first)  bag and for not having enough baggage handlers.   I have never understood why the airlines now conscious about fuel costs have not figured out that a piece of luggage weighs the same whether it is stored in the belly of the plane or in the overhead compartment.  Actually I have figured it out, it is a naked cash grab.  (The United Airlines flight I took back from Ecuador last year realized that the flight was full and there was going to be carry-on rage and kindly offered to check a second bag for free something I took advantage of as this is one of the two situations when I bring a carry on bag).  Slow delivery of your baggage to the carousel is another issue but I expect airlines are using the excuse that everybody carries their luggage on anyway so they can get away with fewer baggage handlers.

And of course we have people who insist on carrying on way more hand baggage than they are allowed and get away with it like the obnoxious sociopath in Live Strong apparel who sat next to me on a flight from Kigali to Nairobi.  He and his buddy had apparently paid (bribed) the gate agent to allow them to carry on all their expensive video equipment.  He then tried to stiff the gate agent who came on the plane and wouldn't let us take off until the fee (bribe) was paid.  We were of course already 2 hours late.  While he was doing this he made everybody take their carry on out of the overhead compartments so he could put his stuff in and what he couldn't fit he stashed behind the seat in front of him spilling over into my leg room.  Another loser on a flight from Washington to Chicago who was in business class with us was actually allowed to carry on a duffel bag almost as big as what we in Canada call a hockey bag.

Another thing that galls me is people who don't check luggage when going on vacation.  Sure I can see if you are going on a short trip, that you can get away with a small amount of clothing and sundries, but I am been amazed on travelling to vacation destinations to have passengers on board who have managed to stuff 1-2 weeks of clothes into a carry on bag.  Or it could be that they couldn't fit all their stuff into their 50 lb of checked luggage.  Either way anti-social.

I went cycling in France with a corporate lawyer from Washington who told me he wanted as his epitaph, "Never checked luggage".  He also insisted on sprinting off every morning and riding a couple of km ahead of the group, stressing out the guide, smoking cigars before dinner and only drinking the duty free scotch he had bought over from the US until one hotel in Normandy told him he was not allowed to bring his own liquor onto their terrace.

Sunday, September 7, 2014

If you aren't willing to put yourself in the line of fire, shut the fzck up.

There has been a lot of concern expressed in the media and by our politicians about the situations in the Ukraine and in the Middle East and talk of sending troops including those from Canada.

I am pretty disgusted about what is happening in either locale although there are two sides to every story and we are pretty consistently only hearing one side.  I also don't want to engage in a history lesson, although if people studied the history of those areas, they might think twice about sending in troops.

Actually if our politicians had studied the history of those regions at any time over the last 75 or so years ago we might not even be where we are now.

However:

If you feel really strongly about military action in the Ukraine or the middle East and are under 40 years of age (according to the website there is no upper age limit), you should enlist in the army so you can go over there and fight.

Or if you are over 40, you should strongly encourage/force your children to enlist, they can join at 17 with your permission.

Otherwise:

SHUT THE FZCK UP!

Just had to get that off my chest.

Friday, September 5, 2014

Reefer Madness: Hopefully But Probably Not the Last Word


It took at little time but Anonymous has replied to my screed on medical marijuana.  Part of the reason I blogged on this was to initiate reasonable debate on this issue.  In addition in the interests of brevity I did not include a lot of information or arguments.

I have commented on his comments:

 Cannabinoid studies should not be confused with medical marijuana (smoking the whole leaf). How many medications do we smoke? Think about it; If the lungs were the best method then why not nebulize like albuterol.
Not sure whether the lungs are the best method to administer drugs but as I pointed out, since 1846 we have administered general anaesthetics through patients lungs.  I also pointed out that there were objections to smoking including lung damage and risk of fire.  Vapourizers are available, (they are expensive) and I have read that e-cigarettes are being used to smoke marijuana.  Aside from the being safer from the fire point of view, it is questionable whether vapourizing marijuana is any less harmful to the lungs.Further as I pointed out, many patients use extremely small amounts of marijuana.
Also, why include all the other non-useful components of the leaf...we don't do that with opium poppy or any other drug for that matter.
We actually still use opium.   Just about every patient at our site who gets a cystoscopy procedure gets an O and B suppository.  Further opium has been used within my career.  Pantopan which is an extract of opium with the "tar" removed was widely used up until at least the late 1990s.  For all I know it still may be used.  It was the opioid of choice in the burn unit in Vancouver when I was a medical student and on the orthopedic service in Halifax when I was an intern.  It was considered to be superior to morphine or meperidine for bone pain and to have a euphoric effect.  It was still used as a pre-med when I was a resident including by our ultra-paranoid professor.  Some anaesthesiologists, mostly Brits, used it instead of morphine intraoperatively. 

There are reasons why combinations of similar drugs might work better than a single pure drug like perhaps working at different sub-types of receptors or affecting metabolism.  For example in Europe you can get a combination of Morphine and Oxycodone in a single pill. 

In the case of marijuana it appears that a second cannabinoid cannibidiol (CBD) may be synergistic with THC both in analagesic effect and also in reducing side effects.  This is why Sativex has a 1:1 mixture of THC and CDB and why most of the commercially available forms of medical marijuana now specify their THC:CBD ratio.  Now if we have evidence that a second cannabinoid promotes the action of THC, could it be possible that 3rd or 4th cannabinoids might also have a role?
Further, oral cannabinoids exist as treatment (e.g. Marinol).
Marinol is no longer available in Canada.  The manufacturer withdrew it because of low sales.  It was very expensive ($20 per pill) and was not covered under any drug plan.  Nabilone (Cesamet) on the other hand while expensive is covered on our province's drug plan.  I prescribe nabilone widely for a variety of pains. It is a useful drug to try in small amounts in cannabis naive patients.  Some patients who have gotten relief with medical marijuana do get good relief of their symptoms with nabilone.  Many however find that nabilone is not as effective as marijuana or that they get worse side effects.  It has actually been suggested that nabilone may antagonize the effects of medical marijuana by acting as a competitive blocker.

Marijuana does work well orally however because of the bio-availability larger quantities are required, which is a problem with something that was illegal and is now expensive.  It is possible to improve the bio-availability in many ways, including buying this book, or one of the many other ones now available.  You used to be able to download a book on PDF but I guess nothing is free now.  One of my patients practically has a chemistry lab in his kitchen.

Sativex a mixture of THC and CBD from a cloned plant is available in a buccal spray in Canada.  It is unfortunately expensive and not covered under any drug plan, therefore it never caught on although I think it is still a promising product.

So, if you want to promote the use of cannabinoids than more power to you. But you should focus on the pharmacologic properties and appropriate delivery of the drug, like we do with every other drug.
I think I covered this in my previous two posts but apparently not.

Most of us in the pain business would rather we had a pharmaceutical grade cannabis product that we could prescribe to patients either in oral form or as a spray (okay we do have Sativex).  As I mentioned in my previous posts it reflects poorly on the academic pain community and the pharmaceutical industry that with longer than 13 years to work on this we do not have a plethora of products.  In fact with the exception of one evangelical person, nobody in Canada has really done any clinical research on this.  A major factor is of course that it is practically impossible to do any research in cannabinoids in the US which is unfortunately where most of the new drug research for Canada is done.

13 years ago others and I could have stuck our heads up our asses and ignored this issue, like so many people did, but we tried to work with patients to try to get them the best treatment with the limited resources we have.