Friday, April 24, 2009

Observe and Report

I feel sorry for most security guards. They don't get paid well, they have to wear funny uniforms and people shit on them. Plus they are never going to be police officers.

On the other hand, they for the most part work indoors, there is no lifting, they get to make people's lives less pleasant and they get to wear a uniform. The pay is not great but no-one is lining up to employ the typical security guard type.

Which brings me to my latest brush with hospital security.

We have hospital ID cards which we are supposed to wear all the time. These cards also enable us to get into the doctor's parking lot. At night we need them to get into the hospital thru the ER.

I have never gotten into the habit of wearing a hospital ID. I like to leave mine in my car so that I will be able to get into the parking lot when I need to. But then I usually walk or bike to work which means that my hospital ID is sitting in my car at home or wherever my wife has gone with my car. When I have to go to the hospital after hours, it is because I am on call and I always drive. This is how I have lived my life for several years.

For various reasons my hospital ID left its safe home in my car ; my wife using my car to drive to work, having to get into the hospital afterhours etc, etc. The result was that my hospital ID disappeared.

That is why a couple of weeks ago I had to head over to the parking office to pick up a new ID. The parking office is normally run by a nice English lady who is a huge Who fan judging by the photos on her bulletin board. She wasn't there that day but 2 security guards were. Now one of course could have been on his break and just wanted to keep the other one company but I did wonder why there needed to be two there. I explained that I needed a new ID. The alpha guard told me it would be $10.00. Just to jerk his chain, I pointed out that that I had just finished paying $800 to park for the year (remember I walk or ride most of the time but I need to park when I am on call). He said that the ID wasn't for parking (I guess that's why I had to go to the parking office to get it). Needing to establish his alpha male status in the room, he lectured me on why I hadn't reported my hospital ID missing immediately on noticing it was missing so they could deactivate it. Sure like all kinds on wrongdoers are just waiting to use my hospital ID to get into the hospital.

Anyway he made a new ID (using the picture taken over 10 years ago) and asked for $10. I whipped out my Visa and he tried to run it through the machine and of course couldn't get the machine to work. Major loss of face! I had about $100 in cash in my wallet but after the little lecture I wasn't about to let him off the hook and said, "I guess this pass is on the house" and left to room with my new pass.

Now while I do feel sorry for the individual security guard with his low pay and ill-fitting uniform I have a fair bit of contempt for the whole security apparatus in the hospital. The past twenty years have seen major shrinkage in hospital personnel and we are trying to do more with fewer bodies. The one exception is security whose numbers in most hospitals have exploded. But does this make us more safe? Despite all these individuals in uniform hospitals are more and more closed off. Rooms are locked that weren't locked before. To get into the emergency from INSIDE the hospital requires ID. Over a year ago I posted about a stalker that got into the OR . The thing was; the CofE had a lot of security around, sociopaths know how to circumvent security.

I remember years ago when you had a confused patient, a "special" nurse was brought in to keep the patient company. Often the family paid extra for this or it was covered thru their extended medical. Frequently the nurse was provided because that was the right thing to do. This of course was expensive; one on one nursing usually getting paid overtime. Nowadays a security guard sits with the patient. The first time I saw this I was astounded. Now this is cost effective. Someone who is barely getting minimum wage vs nurse getting overtime. Imagine however grandpas first glimpse of lucidity is the sight of someone wearing a uniform. The securitization of medicine has gone further. In Kamloops BC a confused patient was actually tasered.

Sunday, April 19, 2009

Are we getting stupider?

Two recent cases have lead me to believe that the medical profession as a whole is getting stupider rather than smarter.

I got a phone call from an acquaintance a few months ago asking if I could intervene with X-ray. I explained to him that I had absolutely no clout with X-ray but asked him what the problem was to see if I could help in some other way.

His father-in-law as part of a check up had a PSA done which was elevated. He was referred to a urologist who sent him for an ultrasound guided biopsy. This unfortunately could not be done for 3 months and his father-in-law was very upset about being eaten away by cancer while he waited.

I told him, don't worry.... PSA is a very non-specific test, prostatic cancer is slow growing and I am sure your urologist did a rectal exam so if there is cancer it is very small if he couldn't feel it.

Turns out his urologist didn't do a rectal exam!!!!. This is not some elderly urologist eking out a living to pay off his first wife or his bad investments. This is the program director of our urology residency program.

One of the few things I remember from medical school is urologists imploring us to stick our fingers up people's bums. "The worlds greatest cancer detector" they would call their index finger. "You don't put your finger in it, you put your foot in it".

Anyway I advised my friend to ask X-ray to phone his father-in-law in the event of a cancellation which they did and the biopsy was negative.

The second case was related to me by two colleagues who were equally disgusted.

These lucky individuals work in a private dental suite. (Taking wisdom teeth out of healthy people pays a whole lot more than doing ?necessary surgery on sick people.) One day the dentist wasn't feeling well; he was nauseated and had pain in the right lower quadrant. One of my colleagues examined him and told him he might have appendicitis and told him to go to the ER.

After waiting in the ER he was seen by an ER doctor who may or may not have examined him before trying to do an ultrasound of the abdomen. Unfortunately the dentist was in two much pain to be able to press down on the ultrasound probe so they weren't able to do the exam. (I believe this is a sign of peritonitis but then again I am only an anaesthesiologist). So the unfortunate dentist was send back to the waiting room to get a CT. Only after the CT was positive was surgery consulted and he was relieved of his appendix. Surgery was not consulted until after the CT.

Now I am not much of a Luddite and I appreciate the use of diagnostic tests but the bottom line is that as physicians we talk to patients and examine them and then order the relevant tests. The means sticking your finger up peoples bums (and that is one major reason I went into anaesthesiology). It also means that when you have a diagnosis like appendicitis which was first described in the nineteenth century, has a classic presentation and has been diagnosed fairly reliably by surgeons using only history, physical exam and a white blood count for years, why would you subject a patient to two unnecessary exams and delay his treatment when the presentation is so obvious that an anaesthesiologist for god's sake was able to make the diagnosis?

We all complain about ER overcrowding, and waits for diagnostic testing but how much of this is now because we as a profession have become so stupid and helpless?

As an aside, I used to belong to a discussion group on pain and chemical dependency. Some of the doctors on the group were being hassled by the DEA or licencing bodies which I think is unfortunate. One doctor actually complained that he had been criminally charged after a DEA agent came to his office "wearing a wire". I had to jump in and I asked why he didn't ask the agent to take off his shirt and examine him. The doctor replied, "why would I examine someone with a perfectly good MRI?" and several other people jumped to his defence.