Sunday, April 20, 2014

Bloody stupid

About 2 or years ago a patient, lets call him Patient A was having surgery at the Big Downtown Hospital (BDH).  For various reasons intraoperatively it was deemed that he needed blood and so the anaesthesiologist drew blood for cross match.  This was put into the appropriate tube and handed to the nurse.  Shortly after, things got better and it was decided that Patient A didn't need blood after all.  The nurse put the tube on a ledge in the operating room.

The next case was Patient B.  Intraoperatively it was decided that Patient B also needed blood.  The nurse (maybe the same one or a different one) saw the tube of blood on the ledge, assumed it had been drawn from Patient B, put Patient B's sticker on it, filled out the appropriate forms and sent the sample to the blood bank.

Fortunately for Patient B when the blood bank ran the blood sample they checked against Patient B's records and discovered that Patient B had not only been typed in the past but that his blood type was different from the sample that was sent to the blood bank which was of course Patient A's blood.

A certain tragedy was averted.

Now there were obviously a few procedural issues about collecting blood samples in the operating room at the BDH that needed to be addressed and certainly the nurse(s) and the anaesthesiologist involved in this case needed to be taken out to the woodshed on this.  Unfortunately we don't take people out to the woodshed anymore when they screw up.  Instead we get bodies like this involved.

Therefore instead of meeting with the individuals involved, presenting this at the local QA committee and developing or reconfirming a policy of properly identifying blood samples drawn in the OR, multiple high paid individuals, mostly removed from clinical practice got to pontificate about this for several weeks and finally arrived at policy, which we we all learned of for the first time when it was announced as a fait accompli.

Henceforth a type and screen done must have a second confirmatory blood sample drawn to check the blood type if the patient has not previous had a blood type. This doesn't just apply to samples drawn in the operating room where this event occurred, but also to samples drawn by the lab, who already have fairly rigourous procedures for identifying patients and labelling samples.  Hematology also announced that rather than routinely collecting this second sample in elective cases that needed it, they would not because they were too busy and that it would anaesthesia's responsibility to collect the second sample (not withstanding the fact that it was anaesthesia drawing a blood sample which caused this problem in the first place).  But don't worry said hematology, if because of time pressure it was not possible to send the second confirmatory sample they would send O negative blood.

This is somewhat moot in that many patients have had a blood type done in the past including every obstetrical patient who has had prenatal care.  Further as the hematologist pointed out to me only a small fraction of patients who get a type and screen actually ever get transfused.  And as he kept repeating, it is not like the patient will not get blood, they will just get O negative blood.

This was not reassuring for me or my colleagues.  Most of us feel that we have enough to do at the beginning of the case without having to check whether the patient has had a previous blood type, draw the blood and fill out the forms.  With newer transfusion guidelines, we let patients bleed down to what were previously considered dangerous hemoglobins which means when we need blood, we need it now.  Most of us consider giving O negative blood a sign of failure, an admission that we were not properly prepared or vigilant enough.  There is also of course the issue of the supply of O negative blood if we are going to be giving it out willy-nilly for purely bureaucratic reasons.  Being O negative myself, I wonder what happens if I get into a car accident driving home from work and there is no O negative blood available because they gave it to other patients.  (The hematologist assured me that as a man it would be perfectly same for me to get O positive blood).

I have never seen an ABO transfusion reaction in my career, nor am I aware of any in any hospital where I worked.  I have however been in multiple situations where blood was needed and was not immediately available for various reasons and it is sickest feeling mainly because even if it wasn't your fault, you always blame yourself, you should have called earlier etc.

Our hospital's hematologist was very good during all this.  This policy was arrived at with minimal if any consultation of front line physicians.  I watched him come to our department meeting and patiently explain the policy which I could pretty much see he didn't agree with but had to implement.  Some of our guys gave him a rough ride.

Things seemed to have calmed down now after months of shouting matches over the phone between members of my department and the blood bank and we are finding a way to work with this policy.  (I seem to spend a significant amount of time as department head figuring out how to do end runs around stupid policies.)  No one seems to be harmed by it (except for patients getting an extra stick) and nobody seems to be benefiting from it.

Monday, March 31, 2014

This is what happens when anaesthesia doesn't control who sets up their machines.

Somebody sent me these photos of ET CO2 tubes gone astray.  OR administrators think that anybody can set up an anaesthetic machine.  Usually this means the nurse who is orienting to the OR, the casual who works once a month or quite often the student nurse gets to attach the circuit to the anaesthetic machine before the case.  

Hmmm what's this little tube with a female Luer lock on the end.  Where does it go?  No problem just find a male  Luer lock to attach it to.  Doesn't really matter where.  Just attach it.

ET CO2 tube connected to anaesthetic mask.

ET CO2 hose connected to Sevo drain.

Sunday, March 16, 2014

We agreed to work stupid hours, they agreed to pay us stupid amounts of money

I recently posted on this.

As it happened I attended a recent meeting of our provincial medical society and this whole issue was front and centre.

At the meeting the deceased father gave a moving but rational presentation on the events following his son's death.  He has tried to put a positive face on his son's death that maybe this can prevent other events or near events.  We learned that his son was an engineer and a pilot in other words an intelligent individual not some yahoo.  Not that that should have made any difference to how he was treated.  We also learned that he did indeed die of a pulmonary embolus.  What he didn't say was what the emergency room doc who saw him the day before did to rule out a DVT.

Their take on the whole mess can be found here.

This generated much discussion.  Much discussion was of course on looking for passive ways of improving communication and what almost nobody wanted to say was that unless we go back to the way we practised 20-30 years ago, we can expect similar events.  One younger doctor did say that the doctors who graduated with him, universally expect to make large amounts of money for as little work as possible.  That was when the President, an old GP came up with the statement in the title, which is essentially the social contract between doctors and society.  His point was that you can't get rid of one stupid without getting rid of the other stupid.  Part of the problem is the fact that 100 or so years ago we did agree to work so hard, which is why we have never set up systems to deal with problems during the day and after hours because there was never any need to because the hard-working doctor was always available.

In face as people started to want to work less stupid hours they were able to do so because other people were still willing to work stupid hours and pick up their slack.  GPs got our of the emergency rooms because other doctors were willing to work there leading in time to the specialty of emergency medicine.  They got out of hospital medicine because specialists were willing to look after their patients for them.  They got out of obstetrics because obstetricians could do normal deliveries for them.  As specialists got sick of working, the hospitalist was invented meaning that really two doctors are now getting paid for what one doctor used to do.   Medicentres enable docs to see large number of patients over a fixed shift with no long term follow-up.  Specialists started to hive off the lucrative and easy parts of their practice, leaving the rest of the work for their not so smart (or more ethical) specialist brethren.

Remuneration is not a problem.  We now have after hours premiums and retainers for being on call that I could only have dreamed of 30 years ago.  

Not to complain but anaesthesia is one of the few specialties that actually works harder now than they did 30 years ago and we haven't figured out how to get hospitalists to do our work for us.  A lot of us feel guilty the odd time we have to let a resident do an after hours case by himself (those of us who have residents).   

The interesting thing about this case is that 30 years ago, not being able to contact his urologist would have been moot.  He would have called the hospital switchboard or visited the emergency and would have been seen by the urology resident or by the rotating intern on the surgical service.  Rotating interns are of course extinct and urology residents now take call from home.  House staff worked really stupid hours for not so stupid money in the old days.  Not saying that that was right and I support to a degree the more relaxed lifestyles residents have today.  Problem is that as residents eased out of the medical workforce, especially the after hours work force, nobody thought who was going to pick up the slack and it certainly wasn't going to be the consultants.

Interesting times and it will be interesting to see how the medical profession in Albertafigures its way out of this problem or whether it is forced to do something by outside forces.  It is again quite possible that we will just weather the storm until the next outrage.

Wednesday, March 12, 2014

Working 9 to 5

This is a very long document however the chronology is summarized on Page 6.

This unfortunate,now deceased, man developed a mass in his testes for which he consulted a physician at a walk in clinic on two separate occasions months apart.  On the second occasion he was referred to a general surgeon.  After 3 months he had not heard from the general surgeon's office but developed back pain for which he consulted the same physician (you know where this is going).

He was sent for a battery of tests which showed something ominous.  An urgent CT of his pelvis was ordered and performed.  When he didn't hear about the results he went back to the walk-in clinic but was told that the doctor who ordered the test no longer practised there and he was given an appointment to see another doctor who at the radiologist's suggestion ordered an ultrasound of the scrotum, making the diagnosis of testicular cancer.

He was referred to a urologist who worked in a multi-urologist practice grandly called an Institue of Urology (this seems to be an affectation of urologists, our city's group also calls itself an institute).  Unfortunately far from being an institute, this institute, like the one in our city is just a bunch of doctors who share office space.  It turns out that the urologist he had been referred to was on a long vacation and nobody was looking at his referrals to see if there might be something urgent like a testicular mass.    This, our patient found out when he phoned the urologist's number and got a recorded message.  Another urologist was located and surgery was performed urgently with follow up scheduled at the local cancer centre.   Two months passed between the presumed diagnosis of testicular cancer and the actualy surgery.

Two days later our patient noticed swelling of his legs.  After not being able to reach his surgeon (or presumably whoever was on call for the Institute) he went to the emergency where the ER doc ignorred the red flags of leg swelling in a post-op patient with cancer and sent him home where he died suddenly the next day.

The report doesn't say what the autopsy found,  My money is on a pulmonary embolus but what do I know?

I can be a little smug about this because I am an anaesthesiologist and we don't have to deal with patient care issues like this.  Trust me, if there was a way to blame anaesthesia for what happened here, we would have been blamed.

This report hit the press a month or so ago and generated some outrage until people forgot about it and started worrying about important things like Justin Bieber and the Olympic Games.  

Like most catastrophes there was a chain of small mistakes resulting in a huge fatal mistake.

1.  The patient went to a walk-in centre.  This may be because he didn't have a family doctor or maybe just because his family doctor wouldn't give him an appointment when it was convenient for him.

2.  Instead of thinking, "hmmm testicular swelling in a young man... rule out testicular cancer", the walk-in doctor referred him to a general surgeon.  Now in the old days, some general surgeons did urological procedures and this is probably still the case in the developing world which is where the walk-in doctor is most likely from.

3.  Presumably instead of having his receptionist call the office to arrange an urgent referral, he just faxed an illegible referral form which the general surgeon's secretary couldn't read and so just put it on the pile with the rest of the illegible referral forms.

4.  After discovering that the man probably had (mostly likely) metastatic cancer, instead of then getting on the phone to a urologist or an oncologist, walk-in doctor #2 faxed in an illegible referral note to the a urologist at the Institute.  Presumably nobody was looking at this fellow's referrals.  On the other hand did they even have a mechanism for triaging really urgent referrals.  Probably not.  And of course trying to get any specialist on the phone is next to near impossible.

5.  Not knowing exactly how he presented to the ER and what degree of leg swelling he had or what investigations the ER docs did, it is hard to comment on what happened there.  At the very worst,the ER doc may have just thought, "OK he is seeing the oncologist tomorrow, he will take care of this."  Because you know, getting a venous doppler, phoning the urologist or starting someone on heparin is a such a drag.

Canada has socialized medicine.  What we really have are hundreds of physicians practising independently, the only commonality being the single payer.  While the government and individual physicians are spending milions on EMRs, these unfortunately do not talk to one another.  It is quite likely that even if the emergency room doctor worked at the same hospitall where the surgery was done, the operative report might not have been available to him on the computer because it hadn't been typed yet.  The urologist's consult would definitely not have been available.

The headline above was that our registrar reminded doctors that medicine is not a 9-5 job which unfortunately may come as a surprise to many doctors.  He also took the time to reminisce about his long ago career as a general surgeon and the excellent coverage he provided.  I actually worked with him 15 years ago, before he bailed for what lead to his  current job, and for a general surgeon he did provide pretty good care to his patients.  He didn't mention however, that he worked in a teaching hospital where his house staff fielded, screened and triaged all his calls for him.  He might have seen into the future how house staff coverage was going be eroding and that might have been why he bailed.
I have been practising for 31 years now and maybe I am looking back at the past with rosy glasses but it seems that we used to communicate better and actually try to serve our patients a little better.  There may be reasons for this.

There is the whole boomer, Gen X and Gen Y thing and how they look at life differently.  I could expound on this but others have done so more eloquently.

More and more there has become more of a divide between primary care docs and specialists.  Primary care docs used to work in hospitals, they largely don't now.  Primary care docs and specialists used to train together at least as junior staff.  Now primary care docs and specialist train in their individual silos with no interraction.  There used to be more respect between the groups.

Finally the licensing bodies have gradually over the years lowered the bar in what is considered standard on communication between doctors and after hours coverage.  While I suspect most people are already in the process of changing this, I can predict pretty safely that if I call most family doctors' and quite a few specialists' phones after hours, I will get a recorded message directing me to call 911 or go to the emergency.  Further many patients that I see in the pain clinic tell me that their doctor has gone on vacation with no replacement.  This used to be only patients from rural areas with small numbers of doctors, increasing I see it in patients from the city.  A couple of summers ago, one of the medical clinics in the town where I have my dacha placed an ad in the local paper announcing they were closing their office for all of July and August.  There was no suggestion where their patients would be going.  Who can blame them, when you live in a resort community what a drag having to work?  Likewise patients have told me that they have shown up at their family doctors office, only to find he has left town permanently.

Further complicating matters is the fragmentation of care.  Patients have slices of their care provided by various specialties and subspecialties.  There is very little communication between them.  They obtain their urgent care from a walk-in clinic where they see a different doctor every time.  It may be fine to parcel out pieces of the patient but conditions overlap and who is in charge when the shit hits the fan?  I am guessing the answer is "not me"

We talked about this at our Medical Advisory Committee meeting last Friday.   A couple of the surgeons stated that their patients had been admitted to hospital with complications of surgery and they had never been notified.  They only found out when the patient showed up for a follow-up visit or didn't show up because they had died.  A pulmonary specialist complained that patients he was following would be admitted to internal medicine and he was not called.   A lady from admin who was there, stated that yes, they had known for years it was a problem and that not calling a doctor who might actually know something about the patient's condition frequently prolonged the patient's hospital stay.  She didn't say why admin had not tried doing something.

Anyway it strikes me that the horse has long left the barn on this and I am interested in how our licensing body is going to play this out.  I am attending the semi-annual representative forum of our provincial medical society this weekend and it should be interesting.

Sunday, February 23, 2014

Good apple, bad apple

I had an interesting experience last week which shows the good and the bad of customer service.

I didn't get a computer until 1991 when I finally could afford one and when I needed one for billing.  At that point I had to make a choice between PC and Apple.  I had had to make a similar choice between Beta and VHS a few years earlier, fortunately choosing correctly.  I asked a few computer savvy docs and it really appeared that Apple was going the way of Beta and so I chose a PC.

Probably thousands of MBA thesi have been written explaining why Apple got their butt kicked by PC in the 1990s and I am not going to enter into that discussion.

This has lead to a succession of PCs including the laptop I am typing this on.  I have over the years spoken with people who use Apple and they are enthusiastic almost evangelical about their computers.  I even briefly considered getting one after getting fed up with Dell but I am a creature of habit.

I even resisted getting an i Pod when they came out.  I got a Creative Zen instead which while not as compact as the i Pod is in my opinion a much more versatile MP3 player.  I did finally get an i Pod about 6 or 7 years.  This iPod has lasted up until now, I keep on waiting for it to die but it won't.  4 years ago I got an i Phone 3 and when it died an i Phone 4 which I currently still have.  Both these interface quite nicely with my PC although I had a little trouble getting my iPod to sync with my current laptop.

I had a little Dell netbook which I used for traveling and to take to work until it became so unreliable that I stopped using it.  I wanted something smaller than a laptop for work and travel so I started looking for a tablet.

A couple of Xmases ago after my wife told me she didn't want an i Pad, I gave her one anyway and fortunately she loved it.  My kids on the other hand tell me that iPads are over-priced and that there are cheaper better tablets available.  This left in a bit of a quandary as to what to get so I asked the Chinese guys in my department and they told me with impeccable logic, that since I already had an iPod, iPhone and my wife had an iPad, it made sense for me to also get an iPad.  Besides I thought, I will be able to share charging cables.  With that in might I proceeded to the Apple Store, bought an iPad air, gave it to my wife who presented it to me for Xmas.

And very nice it was.  Within half an hour of getting it on Xmas day, I had my email set up and my schedule and contact list was synced with my iPhone.  I was able to download versions of all the apps I had on my iPhone.  And I soon loved my iPad as much as one can love an inanimate object.  No love is perfect.  It used a different power cord than my iPhone and my wife's i Pad and as we found out when we visited South America, only an Apple charger will work which meant the travel USB charger I bought didn't work and it was just fortunate that for some reason I threw one of the Apple chargers in my bag.   Also the word processing soft wear is not as good as Word or Open Office and an iPad is more or less useless without Wifi and our hospital is about the only site in the developed world without Wifi.

I started using it all the time, I watched Netflix on it, during the Olympics I streamed the CBC feed onto it.  Next to the iPad my laptop seemed like something from the Stone Age (not far off as it runs Windows 8).

Then one day as I was multitasking while watching TV, I absent mindedly pressed on the screen and I felt a tactile sensation like the sensation one gets on breaking a thin film of ice.  And when I looked down this is what I saw.

No problem.

The iPad is less than 2 months old, it is still under warranty and I have the receipt because the Apple Store emails the receipt to you.  Off to the Apple Store in the mega mall I go.  Arriving at the Apple store I was able to flag down an employee, not always an easy thing, and I explained my situation.  He directed me to a table when 4 other people were sitting or standing and waiting my turn, I explained my situation again.  The employee pushed a laptop in front of me, told me to log in using my Apple ID and when I logged on, told me to make an appointment.  "You mean I came down here just to make an appointment?," I asked.  Grumpily I made an appointment.

The next afternoon I was back at the Apple Store in the mega mall at the appointed time.   I flagged down an employee and was directed to the "Genius Bar" where about 5 other people were sitting.  20 minutes after my appointment time (not complaining I am a doctor after all), a technician came out and looked at my iPad.  The following conversation ensued:

Technician :  "Interesting, I have never seen a crack pattern like this."
Me:  "Must have been a flaw, "
Technician: "Tell you what, since you didn't buy the extended warranty (for $200), I can give you a new one for replacement cost of $300."
Me: "Surely after 2 months it is still under warranty"
Technician:  "The warranty doesn't cover damage from impact"
Me: "From my thumb?"
Technician: "Sorry".
Me: "Can I speak to the manager?"

After 10 minutes somebody about the same age as the technician comes out with a badge saying manager.  I always suspect that when somebody asks to see the manager, somebody just goes into the back room and changes their name tag.

Manager:  "If you had bought the extended warranty, we would have replaced it for free, less a deductible"
Me:  " You mean if I had been stupid (or prescient) enough to spend one third of the price of the iPad on a warranty, I still would have had to pay more money?"
Manager:  "That is correct.  Do you want us to get you a new iPad for $300 plus taxes".
Me:  "I can get a tablet from another company for $300 so why should I pay you for another tablet when I paid you $600 two months ago and now the screen is cracked?"
Manager (almost speechless at my logic):   "That is up to you sir."
Me:  "Well, I also have an iPhone and an iPod and when they die, I will be dealing with a different manufacturer."
Manager:  "That is too bad."

I slunk home thru the mega mall with my damaged iPad.  I was really pissed and at the same time a little sheepish about how I had spoken with the Apple employees.   I doubt they get paid very much and probably a lot of them are over qualified for what they do plus they are only following company policy.  I make a good living, paying $300 for a new iPad is not going to bankrupt me especially as a member of the 1%, my corporation actually owns it and can write it off.

Getting home I went to the Apple site and lo and behold there was a toll free phone number to call, it was one of those annoying voice response phones but after about 2 minutes I actually got to talk to a human with a North American accent who when I explained what had happened, called his manager who asked my to email him the picture I had taken, which I did using my iPhone and he actually phoned me back about 10 minutes later and told me I could have a new iPad.  I suspect this had more to do with my demographic than  any sense of fairness and justice.   "What do I do now, " I said.  "There is a note on your file, " he said, "just go back to any Apple store and they will give you new iPad".  I actually made an appointment online for the next day.

I was a little nervous about this because the only assurance I had was the verbal assurance from someone who said he was a manager but when I arrived at the Apple Store at 1600, next day, I was quickly directed to the back of store where a nice Apple employee gave me a new iPad, helped me set it up and made sure I didn't lose any of the data on my old one before we erased my old one and I walked out of the store happy and relieved. 

Saturday, February 22, 2014

Olympic reflections

The Olympics are almost over for another 4 years, time to reflect.

1.  Isn't hockey better with no fighting?  True, these are elite players and the stakes are high but just the same, no interruptions for fights, scrums etc.  Many of the players playing in the Olympics occasionally drop the gloves so it is not a matter of non fighters being chosen.  Further the general managers who chose these players are the same GMs who argue that it is necessary to have a least one spot on the roster for a player whose only role is to fight.

2.  Bigger ice doesn't necessarily make for a more exciting game or more goals.  Not that it wouldn't be nice to see a bigger rink in the NHL.

3.  These athletes actually compete in the 3 years between Olympics but nobody watches them.  We have 2 all sports networks in Canada.  Half the time when I turn them on, they are showing Poker.  And lets not forget that many of these athletes we fall in love with and take for ours every four years struggle to support themselves and train for the four years in between Olympics.

4.  Olympic medal standings.  Note how these get manipulated.  If you are leading in gold medals you rank the countries in order of golds.  If you are leading in total medals you rank in order of total medals.  Logically it would be 3 points for gold, 2 for silver and one for bronze.  Or why not include top ten performances.  There are no actual official medal standings so why even post them?  This article has an interesting slant on medal counts.

5.  Are all medals equal?  Some sports like downhill skiing and long track speed skating are a single run against the clock.  Some are multiple heats leading to a final.  Some have back door routes.  Some are tournaments with playoffs.  (In hockey you could lose your first 3 preliminary games, still make the the playoffs and almost upset Canada as Latvia almost did)  Some are invidual, some are team.  Some are in sports that only a few countries excel in or even participate in.  Some are in sports that most countries participate in.

6.  Men (and women) in blazers.  Its about the athletes!

7.  Already talked about judged sports.  They have to go even if it costs Canada medals.  On the other hand by diverting the resources expended on "sports" like ice dancing into real winter sports which Canada being a cold snowy country should excel at we actually might start picking up medals.

8.  Really like seeing the Americans lose in hockey.  It just never gets old.  And we are going to hold you to that: