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.

Saturday, August 30, 2014

Reefer Madness part two

Medical marijuana has its boosters and detractors.  I have rarely seen a topic in medicine so polarized.

The following points have been raised by one side or the other.

From the medical establishment.

There is no evidence of the efficacy of medical marijuana

Actually there is considerable evidence of the efficicacy of cannabinoids in both pain and spasm both in human and animal studies.  Cannabinoids have in fact been thoroughly studied, possibly more than many classes of drugs.  The mechanism of action is quite well understood.  There has only been one study comparing smoked marijuana with placebo but this is a reflection of the difficulty of studying a drug which is illegal in most of the world.  This study was by the way positive in favour of smoked marijuana.  

The percived lack of evidence is more of a sad reflection on the academic pain community and the pharmaceutical industry who have had 13 years to test marijuana for pain but have with a few exceptions sat around twiddling their thumbs or pontificating.

Further if we look critically at the evidence for many conventional treatments they too are quite weak.  Even the best treatments for pain have a NNT of 3 or higher which simplistically means that they don't work in over 2/3 of patients.  Then we have to look at the large number of drugs that are used off label for which no studies have been done, the drugs that are used in pediatric patients and the drugs that are used in the frail elderly; neither children or frail elderly get included in clinical trials.  And of course we have to look at the treatments which have never been tested because, well, we've always done it that way.

The potency of medical marijuana is variable and unpredictable.

This would almost be a valid argument if conventional drugs had pharmacokinetics and dynamics which were constant from person to person.  But we all know that isn't true.  If we for example give 10 mg of morphine IV to a group of similar 70 kg individuals we know that we can expect a variety of responses.  Some people will get sleepy, some nauseated, some itchy.  Some will get good analgesia, some will get no analgesia.  This applies to most drugs which is why when things are critical we measure blood levels as we do with antibiotics, digoxin and many anticonvulsants.  Further as we all know and practise in anaesthesia, we titrate to effect.  

This also assumes that bioavailable is constant for the same drug.  We also know this isn't true, there are huge differences in bioavailability between generic and brand name drugs.  This is of course a major problem with drugs like Coumadin and Digoxin.  

The current requirement to obtain drug from a registered supplier also means that patients can get marijuana of known potency.  Not that I like to praise any policy derived by our Canadian Tea Party.

Smoking is harmful

Hard to argue with this one.  Except.

As every anaesthesiologist knows one of the best ways to deliver drugs is through the lungs.  A lot more drugs would probably be administered by this route if a reliable delivery system could be devised.    Smoking while harmful does deliver vapour to the lungs.

It is also possible to purchase a vapourizer to vapourize the marijuana.  This may or may not be safer than smoking.

Patients who smoke marijuana for pain typically smoke way less than do recreational users.  Many patients will only take one or two puffs and typically less than 2 grams a day are necessary.  Interestingly enough our government allows patients to have up to 5 grams a day.

It is possible to take marijuana by the oral route as well.  Because of the reduced bioavailability higher doses are necessary which can be a problem with a drug which is controlled tightly and now fairly expensive.  There is an interesting book, "Cooking with Cannabis" available for free download on the internet.

We have many good treatments for pain, marijuana should not be necessary

Except we don't.  Most of the drugs we have either don't work or are not tolerated in large proportions of patients (this also applies by the way to marijuana).  Some like opioids are extremely controversial.  Multi-disciplinary pain clinics have long wait lists, are expensive and quite frankly really aren't that efficacious.  (At a seminar I gave to a group of pain physicians years ago, I asked if anybody had ever seen somebody benefit from a rehab program.  Only one person had.)  Interventional treatments are great for the interventionalist's bank account but are of limited benefit for patients.  

Further marijuana or any treatment should not be a stand alone treatment but should ideally be a part of an inter-disciplinary approach to pain involving many modalites, focused on the patient.  I also believe in the Easter Bunny.

Marijuana can cause psychosis.

This is based on a retrospective observational study looking at the developement of schizophrenia in teenagers using marijuana.  Funny how observational studies are okay when they justify somebody's agenda.  The saying correlation does not imply causation applies here, and it is quite likely that teenagers with the early symptoms of schizophrenia might be tempted to try marijuana, easily available in most high schools to relieve these symptoms.  Notwithstanding this, I will not authorize it for teenagers (easy for me because I only see adults).  

Conventional drugs are not innocuous either.  NSAIDs cause GI bleeding and renal failure with prolonged use.  Acetaminophen cause liver and kidney disease.  Anti-depressants cause weight gain.  Opioids cause endocrine abnormalities and have been shown to produce loss of grey matter.  I could go on.  

Cannabinoids may be effective but we should wait until more research is done and until the pharmaceutical industry comes up with a pharmaceutical product.

Again, how much more research do we need?  Marijuana has been sort of legal in Canada for medical uses since 2001 and have we seen any new products?  (Oh I forgot, we don't do pharmaceutical research in Canada.)    The only recent cannabis derived product to come out is Sativex which was developed in Britain.  Some pharmaceuticals may have something in the pipe as it were.   While most of Big Pharma is inherently evil, most of use would welcome the opportunity to be able to prescribe something made by Pfizer or Eli Lilly.

Doctors are being forced......

No they are not.  If they chose to write a prescription, they can if they don't they can refuse, just like they can refuse any service which is not life or limb threatening.  This applies by the way to other requests that may be made by patients.  It is the failure of physicians to act as responsible gatekeepers which helps to maintain the ongoing crisis in healthcare.

And from the advocates of medical marijuana:

Marijuana is a natural medicine.

Actually the marijuana smoked today bears very little resemblance to that smoked 100 or even 30 years ago.  Todays marijuana is the product of breeding and cloning to maximize the amount of THC.  It is for the most part grown hydroponically using who knows how many chemicals.  If you want to consider that natural, go ahead.

Marijuana was widely used as a medicine prior to being made illegal.

Not really a great endorsement.  Strychnine, arsenic and mercury were also widely used as medicines.  Marijuana based preparations were used in the 19th and early 20th century.  They didn't persist largely because they didn't work that well.  Further they were not used in Western medicine prior to their introduction from India in the mid 19th century. 

Marijuana is a wonder drug, a panacea

When I used to give talks on chronic pain management, the first thing I would tell the audience is that there are no panaceas.  This applies to marijuana.

In closing

We don't have a lot of good treatments for chronic pain and most of us in the business welcome any addition to our tool box.  Most of us don't like the way medical marijuana came about, by a court decision, we would rather the government had shown some leadership there.  We are stuck with a bad process and those of us who have chosen to authorize or prescribe are trying to do what is best for our patients.  

It would certainly be refreshing to get a dialogue free of hyperbole because this is not going away.

Reefer madness part 1

Early on in my career trying to treat people with chronic pain, people would tell me that the only thing that worked for their pain was smoked marijuana.  Of course people told me lots of other things that were the only thing that worked for their pain including alcohol, cocaine, injectable Demerol and 30 percocet a day.  I of course told them sorry I couldn't comply with their request.  Marijuana was illegal but as I told patients, if you believe it helps your pain, do it discretely.

Marijuana is still illegal in Canada.  The law is enforced with a certain lack of vigour and consistancy across the country.  Despite this Canada spends between $500 million and $1 billion dollars a year, arresting, proscuting and punishing people for possession of marijuana.

In 2001, courts in Canada decided that it was unconstitional to bar patients from using marijuana for their pain and the government of Canada was forced to design a process by which patients could receive medical marijuana.  This initially involved the signatures of 2 specialists and allowed the patient to grow his own supply, designate a supplier or buy from the government.  

One day in 2001 I got a phone call from the Public Relations department of the hospital.  "Would you like to be interviewed by the CBC?", they asked.  "You cannot however mention the hospital".  The interview was as I should have suspected on medical marijuana.  The regulations had at that time not been finalized, I had never actually prescribed marijuana to any patient and my only knowledge was what I had read or seen at meetings but I figured any publicity is good publicity and so I was interviewed live on the afternoon radio show at 1700 hours.  End of story?

Not really.  On Monday my wife phoned me at work,  "Your interview is on the CBC national radio news".  I was subsequently interviewed by both local papers and got to have my second 15 minutes of fame.  

Keep in mind that I still had not prescribed marijuana to any patient.

I soon started getting phone calls from patients desperate to get the authorization forms filled out yesterday.  I explained that they would need to have a referral from another doctor and that I had a wait list.  After about a year, I started noticing a certain type of new patient showing up.  These were usually men, men with pony-tails under leather ball caps.  They usually had some vague pain complaint, had not really tried anything else for their pain except marijuana which I could usually smell on them.  I patiently explained, that the regulations as I understood them only allowed medical marijuana after other treatments had been trialled and failed and offered to start these treatments.  That was usually the last I saw of them.  

At that time I practised at the Centre of Excellence in a an academic pain clinic with 3 other doctors.  Shortly after the new regulations came into effect, The Professor at a staff meeting sternly forbode us to sign any authorizations.  I felt that this was curious as he professed to be all about research and this was virgin research territory plus the publicity for the clinic but I kept my mouth shut lest I be verbally castrated which was (and still is) how he dealt with differences in opinion.

For the next year or so, I politely explained to all patients, legitimate or not that I could not fill out the authorization.  That was until a patient I had seen years ago came to see me.  He had what we called failed back syndrome after back surgery with quite severe pain and spasms.  He had been using marijuana which he grew in his house which had lead to his arrest.  He had not really had any treatments since the epidurals I had tried years earlier and so I explained that we actually had lots of great treatments now and that he should try them.  Not surprisingly the first two gave him severe side effects and no relief which sadly is true of most of the wonder drugs in chronic pain.  At that point, I just said shag it and signed the damn forms.  

At that time I had an out in that I worked in another clinic so I just directed the patients to that clinic away from the scrutiny of The Professor.  And I continued there in a small way.  I started doing talks on cannabinoids for Valeant which markets nabilone (Cesamet) in Canada.  I was very cautious with patients, I treated them like any other consult, I listened to their story, examined them and if there were treatments they hadn't tried, I suggested that they try them.  Wherever possible I tried to get them to try nabilone a cannabinoid which is available by prescription and covered under our provincial drug paln or Sativex which is not reimbursed.

A few doctors saw business opportunities in medical marijuana and set up clinics specifically for the authorization of medical marijuana.  Most of these clinics charged $400 for completion of the paperwork, some even allowed you to be interviewed by Skype.

Patients came in a variety of presentations.  Many were sketchy but had a legitimate problem, quite a few were straight-laced folks with intractable pain who had tried somebody's marijuana out of desperation and some were just plain crazy.

In the interim, the Canadian Tea Pary came into office and the idea of people smoking marijuana recreationally or otherwise gave them dyspepsia.  Their hands were tied however by the court decision and so they had to keep the program.  They did however find a way to modify it in a way to make medical marijuana less available as well as reward well connected businessmen.  Effective last April, patients can no longer grow their own or designate a supplier but must buy from a Government registered supplier of which there are about 10.  Doctors rather than fill out the paperwork, must now write a "prescription" which the patient can they send to one of the companies who will then courier the week.  This has upset many long term medical marijuana users who previously grew their supply but now have to spend money with one of the suppliers.  The suppliers are for the most part slick operators with nice glossy brochures, they now sponsor pain meetings and I met my first detail man the week before last.

The change in regulations also sparked responses from both the medical societies and regulatory bodies.  From a physician point of view, the new regulations are actually better.  The "prescription" which I now write is a lot shorter and less complicated than the form I used to have to fill out.  Further just as doctors chose in the past whether or not to fill out an authorization, doctors can now chose whether or not to "prescribe" medical marijuana.  This didn't stop our College (Medical Board) from publishing regulations and demanding that doctors register with them; something they hadn't done between 2001 and 2014.  The Canadian Medical Association or at least the miniscule fraction of the profession that attends its annual meeting condemned the smoking of any plant material.

As someone who has been in the Medical Marijuana trenches for over a decade opinions are extreme on both sides and I wish to comment on and maybe refute some of the myths in my next post.

Friday, August 22, 2014

Dangerous medications or how I saved the 5 cc fentanyl

Hospitals, as we know, are dangerous places and most of us know of ways that we at least think would make things safer.  The problem is that most of these would involve spending money or would interfere with somebody's agenda.  So instead our hospital like most hospital focuses instead on creating solutions for things that aren't really problems.  This is not unique to hospitals, governments do this as well.

A significant source of badness in hospitals is when somebody injects the wrong drug.  This can range from innocuous to catastrophic. Another variation is when a more potent concentration of a drug or electrolyte is injected by somebody thinking they are injecting the lower concentration (often unaware that the higher concentration exists).

I went to a meeting a few months ago.  We were discussing what were called high alert medications and opioids were on the table which is why I attended.  There were a number of highly placed nursing administrators and a few pharmacists present and like most people who actually don't have to work for a living they were very pleasant and friendly; maybe a little surprised that a doctor showed up (if only because they had scheduled the meeting in the middle of the day, just for that purpose).  Specifically the 50 mg per ml morphine, the 10 mg per ml hydromorphone and incongruously the 5 cc fentanyl ampoule were on the chopping block.  Somebody high up in administration for various reasons wanted these medications gone except in various situations.

The first two are pretty much no brainers.  Obviously injection of 50 mg of morphine or 10 cc of hydromorphone could be catastrophic.  On the other hand many cancer patients are getting injectable narcotics by clysis requiring these highly concentrated solutions.  So either restrict them to palliative care units or keep them in pharmacy until they are needed.  Nice idea except that cancer patients also show up on medical or surgical wards and they are often admitted after hours when the hospital pharmacist is tucked into his bed.  We weighed this for most of an hour and I'm not sure what we actually decided.  The high concentration morphine and hydromorphone typically come in large bottles while regular strength comes in single dose ampoules which should alert all but the most brain dead nurse or physician.  Logically suggesting that people actually read the labels before they draw up medications makes sense but we all know about human factors analysis and not giving people a change to screw up.  I suggested why not put some harmless dye in the high potency narcotics like we do with 4% lidocaine.  Nobody thought that was a good idea although in about two years somebody will take credit for it.

We then went to the 5 cc fentanyl.  I don't use fentanyl much but some people do and like most doctors I don't like being told that a medication that has been used for at least 30 years can't be used anymore. Fentanyl is almost exclusively given by anaesthesiologists in the OR, by emergency room nurses or doctors and by ICU nurses usually to intubated or at least closely monitored patients.   First they kept on called this a high potency formulation.  Calmly and politely I explained that, no,  the 5 cc fentanyl has the same concentration as the 2 cc fentanyl.   I can see that giving 250 mcg of fentanyl when you only wanted 100 mcg could cause a problem for the patient, but unless you are someone who believes that the correct dose of any drug is one ampoule, this is unlikely to happen.  I then explained that we frequently use more than 100 mcg of fentanyl to induce anaesthesia and that while we could break open multiple ampoules of 100 mcg, this could lead to drug errors, injury to staff and problems with counts.  They then asked me what safeguards I proposed so that we could use the 5 cc fentanyl.

What I should have said was:  we go to medical school and then do 5 years of post graduate training, and we understand the pharmacology of fentanyl.  Further we are of moderate intelligence and can tell the difference between a 5 cc ampoule and a 2 cc ampoule.  I really should have said this but atypically for me I didn't take this obvious set-up.  Instead I mumbled the obvious that these patients were always monitored, that they was always an anaesthesiologist present and that the patients were usually intubated and ventilated shortly after the fentanyl was given.  

This went over well and the pharmacist filled out the appropriate exemption form.  I left the room thinking I had saved the 5 cc fentanyl.

About a week later, I came home late in the evening and did something I should have learned never to do.  I checked my email.  There was a form from our "quality" department which stated that our request for the exemption for the 5 cc fentanyl had been rejected because they did not have sufficient details about how we actually administered the fentanyl.  It has signed by the Head Stasi of Quality, (HSQ)  a lady I know all too well.

I had a fit.  I tossed and turned all night.  

What really pissed me off was that HSQ who signed the rejection had spent half a day in the OR with me because she wanted to see how we handled medications in the OR.

So first thing in the morning I wrote a letter.  I reminded the HSQ that she had spent a morning in the OR with me and had she not notice that I, not the nurses, the surgeon or porters,  injected all the medications.  I pointed out a lot of other stuff too.  I was maybe a little rude and condescending but in a controlled and logical fashion.  I then actually sat on the letter for about 3 hours, read it again decided everything was perfectly true and widely broadcast it by email.  

About an hour later I got a call from the head of Pharmacy who was apologetic.  Half and hour later, the Chief of Staff, a surgeon called me. "Why didn't you go through me, " he asked, "Don't you think I could have helped you?"  "Actually, " I said, "no I don't think you could have helped me."

Anyway we still have the 5 cc fentanyl.  And the HSQ was moved off the narcotic file so I at least temporarily no longer have to deal with her. 

We have now  turned to other "high alert" medications.

First came hypertonic saline.  About 10 years ago at other hospital a patient died of hyponatremia after a prolonged TURP.  It probably would not have made a difference but because it was the evening, there was nobody in pharmacy to get any hypertonic saline.  Consequently all OR's that do TURPs have hypertonic saline in their Pyxis.  How quickly people forget.  Our safety Stasi wanted to make hypertonic saline a patient specific medications meaning we would have to have to write an order and call pharmacy if we wanted hypertonic saline.  This required multiple exemption forms (one for the OR  and one for recovery room) to be filled out.  I realize all the bad things that can happen if you inject hypertonic saline by mistake, which is why I don't want it in my cart but keeping it in the Pyxis makes sense.  Anyway I filled out the form explaining that hyponatremia was a severe condition, the treatment of which was time sensitive, that we know what we are doing (I didn't actually say that) etc, etc.

They have also moved on the Magnesium Sulphate 5 g per 10 cc.  Some of my colleagues and I like to give 2-5 g and Mg to patients in the OR.  We believe it is analgesic and there is some evidence to this.  It is also a good anti-hypertensive and anti-arrhythmic.  Further I use it in the Pain Clinic on a completely non-evidence based basis.   Pharmacy who cite over-work whenever you ask to them to do something were proposing to put Magnesium into 100 cc mini-bags.  Another exemption form to be filled out.

Calcium Chloride/Gluconate had also been deemed dangerous.  Calcium disappeared from ACLS years ago although it is still on the crash cart.  We do use in in massive transfusion which I had to remind them we usually can't predict plus it is a pretty good inotrope in a pinch.  (It will also reverse the hypotension you get with  Magnesium if you inject it by mistake)  Pharmacy's solution was to draw up Calcium into syringes which would be stored in Pyxis. It is of course as easy to inject a pre-filled syringe (possibly easier) by mistake as it is to draw up a drug from a bottle and inject it and I could have pointed this out but they were on a mission and I can live with this one.

The euthanasia size bottles of Potassium Chloride disappeared years ago, now we have 10 MEq of KCl in 100 cc.

While I was writing this, I was reminded of something which happened about 10 years ago.  In an emergency room to the south of us, a nurse gave a patient 10 mg of hydromorphone instead of 10 mg of morphine leading to the patient's death on the way home from hospital.  When you think of it, this involved drawing up 5 cc instead of 1 cc, except that there is a 2 mg per ml morphine so one can sort of see the confusion.  (I am wondering if some well meaning administrator figured that the 10 mg morphine was dangerous and replaced it with 2 mg)  Our medical protective association, whom I (mostly my government actually) pay thousands of dollars a year to, came out with an atypically idiotic statement that hydromorphone was a dangerous drug.  Another physician and I had to write them a letter stating that hydromorphone doesn't kill patients, people kill patients (or something to that effect).