Saturday, May 16, 2015

Good doctor, bad cop


When I was on the Big Pharma speaker gravy train, I used to give a lot of talks on prescribing opioids for chronic pain.  In one talk I remember saying that you had to be at the same time Rex Morgan and Sipowicz from NYPD Blue.  In retrospect I don't think I influenced a lot of doctors; most of them, I now realize, were there for the free meal or for the CME points.

While no one can agree on how or whether to treat chronic pain and the prescription of opioids is controversial there are certain facts or beliefs I still hold.  One is that a certain percentage of patients have pain that no amount of exercise, lifestyle changes, or chat therapy is going to help.  The second is that a certain percentage of patients do well on oral opioids.  The third is of course that some patients are in both groups.  

Oral opioids of course come with a price.  A certain percentage between 6 and 15% will become addicted to them.  Addiction is different from just using opioids, it is different from developing a tolerance to them and it is different from developing a withdrawal syndrome if you stop taking them.  This confusion always clouds any discussion of opioid addiction both in the medical and lay community.  The other issue is that a certain percentage of oral opioids leak out into the community where people buy and sell them for non-pain related issues.

The problem of course is that no matter how carefully I assess a patient, no matter how many addiction screens I administer, I can't predict with certainty whether a patient will become addicted to his medication or whether I am being duped and he intends to sell his OxyContin.  

To combat this, smarter people than me came up with the process of universal precautions.  The cornersone of the universal precautions is the urine drug screen.


 According to the gurus of universal precautions, everybody should get a urine screen on initiation of treatment and regularily.  This includes both the little old lady with a compression fracture and the oil field worker with the bad back.  Once you start administering UDTs however, you shift over from Rex Morgan to Sipowicz. 

Firstly no matter how nicely you explain it, asking someone to pee in a bottle before you prescribe them a medication starts your relationship off on a rather strained note.  A significant number of these UDTs are negative which means you have done them for no good reason.  The next issue is how you deal with the positive results.  

Probably the worst thing that can happen is that the medication you are prescribing is not even in the UDT which means the patient is not taking the medication and presumably selling it.  Some narcotics don't show up in generic UDTs, in our centre hydromorphone doesn't.  Most psychopaths are smart enough to at least take some of the drug they are getting from you and selling, so that doesn't happen very much.   Our lab tests for methadone metabolite, presumably some people just added the liquid methadone they weren't taking to their urine sample.  

What happens more frequently is that another substance shows up in the sample.  Marijuana is quite common.  Quite a few of the patients I see freely admit to smoking marijuana either recreationally or for pain reasons.  I used to smoke marijuana, all my friends in university used to.  Most of us just raise our eyebrows at this and go on.  Cocaine and amphetamine are a bigger concern and generally when these show up, it is time for a serious talk or to discharge them from your practice.  This is what I did recently when I discovered a patient of mine had had 3 recent positive tests while under the care of another doctor.  

Is it perhaps time to look at cocaine use as a marker for addiction.  Taking out the crack and meth heads, a lot of people who we call respectable use cocaine occasionally or regularily.  As has been observed, if it was not for the apetite for cocaine in the affluent class, it would not be worth importing.  Patients and physicians who treat these patients, have told me that cocaine use is part of the culture in the construction and oil field industries.  (Cocaine because it is cleared rapidly has become preferred to marijuana  in those industries that get job related UDTs)  I met someone a few years ago who told me he had brokered a cocaine sale between a friend of his and two anaesthesiologists who he didn't name but who worked (and still may be working)   at the hospital I was working at.  

The rationale of course for booting somebody over a positive test for cocaine is the assumption that they are selling their prescription in order to obtain cocaine.  There are of course other explainations.  Some of these people are working, something we who treat them are very proud of, and can afford many illicit substances.  Some have spouses or friends who are happy to share.  Some regretably use their meagre disability or social assistance income to buy their drug of choice (just as they do with cigarettes or alcohol).

Most of us in the medical profession have won the lottery in life.  With a few exceptions, we grew up in nice neighbourhoods, attended college and medical school unaware of how the majority of the population live or what their values are.   It shocked me to find out how some people lived their lives and I still impose my middle class WASP values on the patients I see.

Take double doctoring, a sure fire warning sign of drug abuse.  Turns out the doctor-patient relationship may mean something to doctors but it has never meant anything to patients.  In the small towns where I practised as an unhappy general practititoner most patients were happy to see just about every doctor in town.  Not just to get narcotics or sedatives.  They shopped around for second opinions, for antibiotics and for convenience.  In this time where so many patients have no family doctor and where doctors screen their patients and limit their practices, it is hard to think of a time when there was a glut of primary care docs and I remember angry fights between doctors over who the patient belonged to.  This still goes on.  When I review medicolegal charts it is not unusual for patients to be seeing doctors in two different practices over the same period of time.

A common scenario I see is where a patient's family doctor retires or moves away and they can't find anybody to either take them on as a patient or prescribe their meds.  There is a 1+ year wait list for the pain clinic so what they do in the interrim, they buy their drugs.  Why would you not buy something that has worked for you in the past, if you can't get it legally?  Or they borrow from somebody.  But who hasn't taken someone else's medication.  One time in medical school when I had a migraine, a well meaning classmate gave me some of her Fiorinal.  I didn't know what it was (it didn't work either) and I was a little horrified when later I found out what I had taken.  I used to see patients who were taking the antibiotics that had been prescribed for a family member and not finished.  I used to lecture them on this.  Then I was talking to a colleague, "Oh, I tell them to save the leftovers in case they get sick," he said.  What's a bigger societal problem, addiction or antibiotic resistance?   Think really hard about this.

And why do we treat some addictions differently from others.  Smoking for example is a risk factor for low back pain and for CRPS both of which I see in the pain clinic.  So why am I telling patients I won't treat them if they use cocaine which probably isn't hurting them but will treat them if they continue to smoke which actually is hurting them.  Obesity which could be said to be form of food addiction is a huge cause of chronic pain.  Even exercise is an addiction in some patients, some of who come to pain clinic but I see a lot more in the OR getting arthroscopies for their sore knees.  Even alcoholics tend to get a pass, unless they come in falling down drunk.

Like most things in medicine there are no easy answers to any of the questions and I guess as long as I continue to treat chronic pain I will have to continue on in my dual role.

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.