Monday, April 7, 2008

The Needle and the Damage Done

Most people locally consider me to be a needle guy. I have aquired a reputation as somebody who gives everybody who comes into the clinic some type of needle. I think that is unfair. I do a lot of nerve blocks of various types for patients most of whom come in for repeat injections. Most of these people seem to be happy with their treatment (the other ones post on RateMDs). I also do a lot of medication management including narcotics and methadone. Most of these patients once stabilized I see infrequently and some have been transferred back to their GP.

I still however feel guilty everytime I stick a needle in somebody. I attend all these pain meetings and I know I should be sending them to non-existent multidisciplinary programs. In fact I actually now work in a so-called multidisciplinary pain clinic and almost 100% of the internal referrals are to stick a needle in somebody.

I also do acupuncture. I took a long course which involved some training in traditional Chinese medicine but like most people I just stick the needle where it hurts. Quite frankly I consider acupuncture to be an equivalent treatment to trigger points, however when I do acupuncture I am an open minded practitioner of complementary medicine whereas when I do trigger point injections, I am a money grubbing needle guy.

On the weekend past, I attended a course on fluoroscopically guided injections. I have never done a lot of these mainly due to the inability to access fluoro which the radiologists guard jealously here as if they paid for those expensive machines out of their own pocket. I will be getting more access in the future so I decided I better actually get some training.

At the meeting we learned all kinds of different blocks. What disturbed me was the whole time, I was thinking, "How many of these can I do in a day and how much can I bill for them". (When you go to American Meetings, there is usually about half a day devoted to billing, further some interventional textbooks have chapters on billing). More disturbing was that everybody else taking the course was thinking the same thing.

Now I have been treating chronic pain for over 15 years (longer if you include my 3 years of general practice) and I still haven't figured out what causes back or neck pain, nor what is the best way to treat it. My more recent training has not enlightened me on this.

I can only hope the way I treat back and neck pain will be governed by what I think is best for the patient, and not how much I can get paid or how many fluoro slots I have to fill.

Tuesday, April 1, 2008


Yesterday and today I am on call which means covering the case room. Now a universal feature of caserooms since I was a medical student in the last millenium was "The Board".

"The Board" was a then a blackboard, now a whiteboard with every labouring patient's last name, status including dilatation, station, NPO status, epidual and whether they were being induced.

In the interest of privacy now, the patient's last names have been replaced with only the first 3 letters of their name. This caused a problem for me right away when I arrived in the morning. The first three letters of the only patient with an epidural made up a name that is not common. So in I went saying "high Ms. , I'm Dr. BH" and then went out to the desk to find her chart. After I couldn't find her chart I asked, "who has Ms <3 letter word name>'s chart" and after getting blank looks, "who has room 5's chart". One of the nurses handed me a chart with a six letter last name and when I said no I want <3 letter word>'s chart; they looked at my like I was stupid and told me that they were only putting the first 3 letters of the patient's name on "The Board". I never asked how they proposed to deal with patients whose last name only had 2 or 3 letters something increasingly common now (or two patients with similar three letters).

Most medical and surgical wards used to have boards with everybody's names on and what bed they were in. Alternatively the name was on the door so you could at last walk around looking for the patient you had to see. Unfortunately boards have gone by the way and in several hospitals now there are no names on the door either. This forces you to look for the chart (which if it is in the rack is filed by room number) or ask the ward clerk or a nurse.

At the same time we are very concerned about proper identification of patients to prevent the wrong treatment being done to them. Now I think everybody has had the experience of going in to see the wrong patient and realising half way through talking to them that you really should be talking to someone else. When one wants to estabilish a therapeutic relationship with a patient, the least auspicious way to meet them for the first time, has to be to enter the room and go straight for their arm band to see who they are. Yet with names not on the door, or the patients bed, in patients who are deaf, demented or half asleep, that is now the only way of ensuring you are actually talking to the right patient.

At the same time most units allow patient and their visitors to use the phones at the desk. Of course what are usually sprawled all over the desk for everybody to see. Charts of course, so the patient or their visitors can read whatever is in their visual range. (Maybe that's why nobody writes progress notes anymore).

Very few names are unique anyway. If I see a name on a door that is the same as someone I know, I just assume it is someone with the same name. Occasionally much to my surprise it is someone I know. I once ran into the contractor who built my house while on Pain Rounds. The name didn't ring a bell and people surprisingly don't look the same with an ng tube. I was talking to him when he interrupted me and said, "I built your house". I didn't tell him it was a good thing for him that I didn't give him his anaesthetic.

A number of years ago we had a victim of a gang related assault in our trauma unit. The staff were somewhat concerned that someone was going to come in to finish him off so as this was still when there were names on the door, instead of putting his name on the door, they put his hospital number.


I'm a gang member assigned to finish him off and I learn what ward he is on. So I sneak around the ward and there are 19 rooms with a name on, and one with a number on. I wonder which room I should chose.

I grew up in (what was by today's standards) a small house with three brothers (and two parents). My mother always said, "If you don't have anything to hide, you don't need privacy".

So please put my name on the door.