Thursday, August 27, 2009

Love Boat

I posted a couple of weeks ago about a doctor who went off on holidays leaving her patient high and dry, and in narcotic withdrawal.

I wrote a letter to the doctor as a courtesy explaining what had happened and why I had written a prescription for her patient.

She wrote back explaining that she works a lot as cruise ship doctor and can't get a locum (or persuade the doctors she is in partnership with) to cover her practice. She also said she took this patient on as a "favour".


Somebody else didn't get into medical school and the taxpayers paid for 80% of the cost of educating you so you can work on the love boat and see patients as a favour into between cruises.

Like the title of this blog says:

I used to be disgusted......

Wednesday, August 19, 2009

Time to Bite Your Tongue

I saw a patient in consult regarding her back pain a few months ago.

She was accompanied by her husband and actually when I saw the husband, my heart sank at the prospect that he might be my consult. He was morbidly obese with no neck and breathed very loudly. Sleep apnea until proven otherwise, I thought and I suspect his wife has not slept thru the night in the last 10 years.

Her family doc gave me some background. She had previous back surgery and complained mostly of low back pain with no leg pain. This was reasonably well-controlled with a modest dose of morphine and the family doc only wanted to see if I thought some type of block might help her. He also mentioned she looked after 8 children, 7 of hers fathered by her current husband and 1 of her husband's by a previous relationship.

I talked to her and examined her. She really didn't have a lot a findings and talking to her I got the sense that her pain was pretty well-controlled and nothing I could do was going to help her. So I gave her my "you're doing really well, nothing I can add to your treatment is likely to improve where you are' spiel.

At this point the husband awoke from his torpor. "Damn it", he said, "Don't you know she has to look after 8 children?"

Now what I should have said at this point was:

"So Mr. Doesn't-believe-in-birth-control? Why don't you get off your butt and help your wife out around the home?"

But I am such a wimp in matters like this.

Sunday, August 16, 2009

Stupid Allergies Part 3

I should mention that a stupid allergy almost killed a patient under my care.

I had only been at the CofE for less than a month then. The CofE was in the process of developing sub-specialization. This included pediatrics. The problem of course was that most surgeons were not sub-specialists but did both adults and kids. The other issue was what type of training was necessary to be a pediatric sub-specialist (and not a single member of the group at the time had any post-fellowship training in pediatrics). I had done pediatrics in my last job, and was interested in joining the group but was sort of on some type of double secret probation.

Anyway, because of a liver transplant, that day's list was thrown into chaos and instead of the nice general surgery list I was supposed to have, I was sent into the pediatric ortho room. I was to do a 14 kg child with Rett's syndrome (which I understand is like cerebral palsy but is not really CP) for spinal instrumentation. (Every orthopod knows that straightening the back will raise your IQ).

I went out to the receiving area and talked to the father who was quite nice and very concerned about his daughter if not terribly realistic about her prognosis. As we were wheeling the patient down to the OR with the surgeon, he mentioned that he thought that his daughter "might" be allergic to cephalosporins.

I had a very junior resident with me that day. We induced the patient, and I placed an art-line and a central line (I was pretty proud of getting these in). I was a little nervous but I had done some pediatric backs as a resident. We turned the patient prone, started the surgery. I sent the resident off for coffee, he came back we talked for while and about 2 hours into the case I decided that things were running smoothly enough that I could go for coffee and a pee.

Seconds after a left the room the orthopod asked the resident if he could give 500 mg of Vancomycin to our 14 kg child with the undocumented cephalosporin allergy. My resident gave this over 10 minutes which he thought was quite safe and so it was 10 minutes later that I was paged stat back to the room.

When I arrived, the blood pressure was 20/-. I interogated the surgeon and resident about what had happened since I left the room and after what seemed a long time, they fessed up to the Vancomycin. 200 mcg of epinephrine solved that problem and we went on our merry way.

The CofE had quite an active Quality Improvement program at the time and this and other aspects of the case came to their attention with the result that a couple of months later, I got a copy of an unsigned letter accusing me of administering an overdose of Vancomycin among other sins. I fired off a reply stating that as per the note on the chart which I had written at the time, the drug and dose were chosen by the surgeon and administered by my resident under his direction.

Anaphylactic reactions to Cephalosporins even in patients who are "allergic" are fairly rare, anaphylactoid reactions to Vancomycin are quite common. The whole issue of allergy should perhaps have been straightened out long before the patient came to the OR; Clindamycin while also a fairly nasty drug should possibly have been the next choice.

I should have learned something about the culture of blame that existed and still exists at the CofE.

Needless to say, I was never invited to be part of the pediatric group.

Paging Etiquette

I have intermittently worn a pager since since 1981 and finally somebody has put down what I have been thinking all these years.

I will print it out.

Rules for Paging Properly:

1) If you are going to be allowed to page me incessantly, then you should be required to wear a pager so I can return the favor.

2) If you page me, please wait 5-10 minutes for a response before paging back. Heaven forbid I be answering another page, seeing to an emergency, walking in a hallway without a phone, or sitting on the john. I am very conscientious about returning pages and really try hard not to make you wait, but sometimes it's unavoidable.

3) Please attempt to coordinate your pages. Having 2 different nurses page me about the same patient within 30 seconds of each other (indeed, I received page #2 while I was on the phone with nurse #1) is a little annoying. Especially when said patient isn't actually dying of a heart attack or writhing in severe pain, but "just wanted to talk to the doctor."

4) I know mistakes happen, but please attempt to look through the medications before paging me to say Ms. so-and-so needs a sleeping pill. If I stop what I'm doing and pull up the chart only to find Ambien in their list of meds, it's a little irritating.

5) Blood pressure of 135/anything does not excite me and I do not need to be paged for this, unless it was 220/190 5 minutes ago (in which case, why are they on a psych floor?).

6) The primary team arrives around 8 am M-F. I do not need to be paged at 7:20 (while I'm trying to check out and leave) for 2-day long sore throats or potassium of 3.2 drawn 4 days ago. I appreciate your incentive and that you are trying to help care for your patient, but it can wait.

7) When possible, please page me to an extension you'll be easily reached at. If you page me and I call you right back, only to reach someone who puts me on hold "while I find out who paged you", I get a little irritated, especially when this happens frequently.

8) Perhaps most importantly, when I call you back, please introduce yourself and state the patient's name clearly (perhaps even spell it) before rushing into the story of how the patient has an urgent foot rash. I have some hearing problems--not your fault--and I will have to interrupt your story to ask you to repeat the name, spell it, and wait while I access that patient's chart in the computer before you get going again. Also, if you have a non-American accent, it is going to be difficult for me to understand you over the phone, especially if you speak rapidly.

9) On my end, I promise to keep trying to answer pages promptly, identifying myself clearly when I call back, being really nice (or at least non-snarky) when I answer, and trying to educate the people paging me about appropriate paging. (Hey, I said "trying", didn't I? Stop looking at me, swan!) I know I fail at this frequently, but I really do try, I swear. I don't like paging people only to get yelled at, so I don't want to be the person yelling.

We are now in what I call the "Cult of Availability". With pagers and cell phones so freely available and widely used, there is now a tendency for people to call somebody instead of trying to solve the problems themselves using the resources available.

My mother was a nurse until she got married in 1951 and had to quit (that was the rule then no married nurses!). Back then doctors had only a single land-line rotary dial phone in their house or office. I highly doubt most doctors sat by their phones waiting to be called. They had a life outside of medicine plus some of them did housecalls. I asked my mother once, what did they do when they couldn't find the doctor. She said she didn't remember. She probably didn't remember because it was never an issue. The nurses back then probably were able to think independently and did what they could to solve the problem with the resources they had.

Like the blogger above, I try to answer my pages quickly and I don't know how many times I have answered the page, to be told, "it's okay we've solved the problem." The question I always want to ask is "why the hell didn't you try to solve the problem before you interrupted my supper/TV viewing/sex?" But of course I have learned from sad experience never to say what I am thinking on the phone.

Intimidation Based Learning

There have only been two occasions when I have wanted to give up medicine for good. The second was when I was in general practice and I went as far as getting a law school application but went into anaesthesia instead.

The first was during my internship.

I don't like internal medicine. I should elaborate. I enjoy the clinical problems, and much of the patient care aspect. I don't like the constantly having to justify why you did even the most minor thing to a staff person who was home asleep when you did it, I don't like the hours, I don't like the scut work and I don't like the placement problems. Therefore I really wasn't looking forward to my 8 week internal medicine rotation during my internship which to make matter worse took place in December- January (i.e. over Christmas).

At least I thought I had the foresight to pick a non-academic hospital to work in. In the internal match, I chose and got Camp Hill Hospital which was an old former veterans hospital in Halifax.

Camp Hill didn't have an emergency room. This should have been a godsend and indeed was during my surgery rotation at the same hospital. In medicine however we accepted emergency admissions from the large teaching hospital about a kilometer away. In theory there were 4 medicine services at the LTH and our hospital was the 5th which meant that we took every 5th emergency admission. It wasn't exactly like that however. The patients had to be stable enough to transfer by ambulance. This meant that we usually got elderly failure to thrive patients who became placement problems, and alcohol related problems. There was a tendency of the ER docs and the internal medicine residents at the LTH to lie bald-facedly about the condition of the patients they sent over.

We had a 4 bed ICU which was covered by the interns. This was a glorified CCU mostly made up of patients on medicine who had deteriorated after their admission, disasters from the surgical service and the odd patient from the LTH who was stable but needed to be monitored. We had three teaching wards which acted as services with two staff physicians on each ward, each of whom had their own house staff. When you were on call as an intern, you covered your own ward, were second call for the wards covered by medical students and you covered the ICU. The rule was, if you were the unfortunate who admitted the patient to ICU, you covered that patient for the duration of his ICU stay or life whichever was shorter. We also had residents. These unfortunately were either junior medical residents with a few months more training than us or second year family practice residents. At that time, you could go into general practice after your internship; we called the two year family practice residency "the internship for slow learners". Therefore having a second year "slow learner" as your back-up was not terribly reassuring.

Our little ICU was covered by two staff physicians. Each covered for a month. On weekends and holidays, a single physician covered all the ICUs in the city and went from hospital to hospital rounding. The first physician was Dr. Kookie . He may or may not have gone to medical school somewhere in the third world but had obtained a fellow-ship in Internal Medicine something I have since learned is not correlated with intelligence or good judgment. He also practised as gastroenterologist at our hospital. The second was Dale the Hut. Later in my internship, "The Return of the Jedi" came out and as I watched the movie, I had the odd feeling of deja vu on seeing Jabba the Hut. I later realized he reminded me of this doctor. Dale the Hut was fat and smoked stinky cigars back when you could smoke in hospitals. He had a really bad comb-over. He practised as a cardiologist although as I later learned, he only had a fellowship in internal medicine. He also had an untreated strabismus so it was difficult to know whether or not he was looking at you. (He may have had a grudge against doctors because his strabismus was missed and not treated which he took out on trainees). He was extremely dogmatic on just about everything.

The fact was as I learned later when as a resident I had to look after ICU patients, neither Dr. Kookie or Dale the Hut knew anything about looking after ICU patients. I suspect they were either covering ICU because they needed the extra money or because Camp Hill couldn't find anybody else. Unfortunately as I have learned, when you are uncomfortable with something, a good strategy is to make everybody feel uncomfortable too.

So if you were unfortunate to end up in our little ICU. You were looked after by an intern, backed up by a junior resident, with Dr. Kookie or Dale the Hut (who were idiots) as your staff physician. After hours the nurses would page you for problems. Occasionally they would go over your head and page the resident instead. If you didn't know what to do, you could phone Dr. Kookie or Dale the Hut and get yelled at on the phone, or you could do what you thought was best and get yelled at at rounds the next day.

The low point of every day was ICU rounds which started at 1100 to allow us to get our ward work done and to ensure that we would have no appetite for lunch. We would all sit at the desk with Drs. K or Hut and the intern responsible for the patient would present the case. This you learned had to be a detailed and organized present no matter how long the patient had been in hospital. If there had been changes over night, the on call intern had to describe what happened. I tend to be a bottom line person: this is what he has; this is why I think he has this; this is what I did and this is why I did it. That didn't cut it.

Dr. Kookie was merely clownishly incompetent and indecisive; once you accepted that you could survive rounds. With Dale the Hut, ICU rounds was a hour long ordeal of squirming in your seat, in pool of sweat under his strabismic gaze. One the big problems was that occasionally changes were made by the medicine resident who usually didn't attend rounds, or on weekends by the covering ICU staff who usually knew what he was doing and Dale the Hut inevitably disagreed with what somebody else had done but you now had to justify as if you have ordered the test or treatment.

This is a long digression to how I almost gave up medicine.

As the 8 week rotation went Christmas, we were given 4 days off out of the 8 days over Christmas and New Years. I worked 1 in 2 over Christmas and then had 4 days off. The last night I worked I was lucky enough to admit a patient to ICU. She was a 90+ year old lady who was still relatively with it. She had presented to the LTH ER with left arm pain and got a cardiogram which showed she was in complete heart block. The rest of her cardiac work-up was normal and she was transferred to our hospital for monitoring. I admitted her and went home the next morning. I thought she would only be in ICU for a few days; I couldn't imagine anybody putting a pacemaker in an otherwise assymptomatic 90 year old.

One of my coping mechanisms is that I usually completely forget about what I have done at work as soon as or before I get home. When I returned on January 2, I had completely forgotten that lady. I got in a little late and spent the morning catching up on what had happened to the ward patients while I was away. At 1055, the ICU nurses phoned me to ask me if I realized that I still had a patient in ICU, that I was going to have to present to Dale the Hut in 5 minutes?

Dropping everything I did, I ran (or walked fast, I never run) over to ICU. During the Christmas break, the ICUs were covered by city wide ICU staffmen, a different one every day. Somewhere along the line someone had decided to put a temporary pacemaker in the my LOL. The temporary pacemaker was giving her PVCs and someone else had started her on lidocaine. There was a paucity of progress notes explaining the rationale for any of this. She was booked for a permanent pacer later that day.

When my turn on the hot seat came up, I presented the case in my disorganized fashion. Dale the Hut was not impressed. When I said she had a temporary pacer, his response was "Why?". I mumbled something about how I didn't personally think she had needed one either but that I was not working that day. He also didn't like the lidocaine. I gave the same response. This precipitated a lecture on just because I had been away for 4 days didn't absolve me of responsibility for the patient's care.

I was on call that night. Our patient went over to another hospital to have the permanent pacer put in. (Even though Dale the Hut hated the pacemaker, he was not about to kibosh it). Someone at the other hospital stopped the lidocaine infusion, a permanent pacer was put in and the temporary pacer was left in to be removed the next day. When she came back to our hospital, she was not on lidocaine, I elected not to re-start it and she had no PVCs during the night.

1100 came and it was my turn on the hot seat. I presented the case in slightly more organized fashion at which point the Hut asked me why the lidocaine was stopped. I said it had been stopped at the other hospital. Why wasn't it restarted, asked the Hut. I said she wasn't having PVCs anymore so I didn't restart it. "Why was she having PVCs in the first place" asked the Hut. Because of the temporary pacer, I replied. "And is the temporary pacer still in?" asked the Hut.

I had been up for most of the preceding 28 hours and I was losing this interrogation badly. I decided to punt and I shrugged in a "yes I should have done that but no harm no foul" manner. This precipitated the worst temper tantrum I have witnessed in 30 years as a student/intern/resident/staff. "Get that smirk off your face", yelled the Hut. Because of his strabismus my first impulse was that he was yelling at one of the other interns who was taking too much pleasure in my discomfort. "And stop shrugging" That was when I realized he was yelling at me. He went on to yell about how we were the worst, stupidest, laziest, most incompetent interns ever, that the standard of care over the past few weeks had been terrible and this had to change.

At that time just to confirm his point, one of the four patients in the ICU arrested. After failing to resuscitate that patient and finishing rounds, he stormed out taking the two residents with him for a little talk.

As I said, I don't like internal medicine, but I am a professional and I do take pride in my work and am my own worst critic and looking back over 25 years to the incident I don't think there was anything wrong with MY management of this patient. Later that afternoon, the two residents called all the interns for a meeting in which they told us that basically Dr. McMahon is very dogmatic (true), he has a bad temper (true) but he is a good clinician (false) and you can learn a lot from him (false). I suggested that maybe if we actually got some formal teaching on looking after ICU patients we might actually be able to look after them in more praise-worthy way but neither resident thought that was practical. I thought but didn't say that maybe the Hut should be told that we are all actually fairly intelligent and hard-working interns who don't deserve to be yelled at.

I got home at 7 o'clock that night (after admitting another ICU patient because it was "my turn"), opened several bottles of beer and ordered pizza. I was so depressed, I had spent my first Xmas away from home, it was a drizzly grey Halifax winter etc etc. I seriously wondered if I really was even a marginally competent doctor, and whether I would be able to survive the remaining 4 weeks of internal medicine not mention my internship. But I got up the next day, went into work, survived internal medicine and sailed thru my intership. I never saw my evaluation for internal medicine; I assume it wasn't too hot.

Nowadays, there wouldn't be any question. I would have headed straight for the Dean's office and Dale the Hut would have been off for anger management courses.

For a few years, every time we got a Dal grad, I asked them about Dale the Hut but nobody seemed to remember him so I assume shortly after I left, his clinical teaching career ended. Pity.

Friday, August 14, 2009

Summertime Blues

I got a phone call the other week that I was expecting having gotten several every summer just about every year.

I practise chronic pain management part-time. In addition to sticking needles into people, I also prescribe medications. These include opioid medications. After a number of years, I realized that a significant number of my appointments were people whose only purpose was to get a refill of their opioid prescription. Don't get me wrong, in carefully selected patients (which of course describes all mine), opioids are the most appropriate way to manage chronic pain and most of those patients were doing well on the opioids. I was concerned that because I was using up valuable clinic time simply to see someone, ask them how they were doing and write them a prescription for what was often the same dose of the same drug they had been on for years, I was unable to see as many new patients and was not able to spend as much time with more complicated patients.

I therefore did the logical thing. I made up a form letter for their family doctor, explaining that their patient was on a stable dose of medication and that in order to free up pain clinic time I was asking that the the FP take over the prescribing. In almost every case the FP did.

Now however between June and September I can expect to get at least one phone call or visit from a patient asking for a prescription because their FP has gone on vacation (often for more than a couple of weeks) and either has no one covering his practice, has a locum who will not prescribe opioids, or has partners who will not prescribe opioids. As I have told some of these patients, these requests put me in a bit of a bind because I have no way of knowing whether the story they are telling me is true although I suspect it is.

The most recent lady is a lady from the north of the province where family docs last about a week. She was already on a fairly hefty dose of opioids when I first saw her in consult and because I accepted that she would probably have trouble getting the doctor of the week to prescribe for her, I wrote prescriptions for her for three years. Despite trials of other drugs she is more or less what I was on when I first saw her. There were problems because of the distance, and she missed some appointments especially in the winter and I had to fax in prescriptions which I find to be a hassle. (Narcotic prescriptions which are triplicate in our province cannot be phoned in).

Earlier this year she triumphantly told her that she had found a doctor in one of the larger towns about an hour away from her small town who had agreed to take over her care including writing the prescriptions. I breathed a sigh of relief.


About two weeks ago I got about 4 messages on my voice mail followed by 2 or 3 direct calls to my cell phone, the number which she had somehow obtained. Seems her family doc had taken 4 weeks off and neither of her partners who either see the patient or write a prescription for the patient. The patient was now our of medications, going thru withdrawal and was unable to go to work (did I mention she was working full time?). I wasn't too please with the whole affair, I told her that doctors were obliged to cover their practices, and anyway didn't she realize that doctors also took summer vacations and shouldn't she have anticipated this? I did phone the FP's office to verify that she was indeed on vacation and to ask if one of the other docs could write a prescription for her. The receptionist told me that the other docs were only covering "Warfarin and lab results" and that anyway it was well known that this particular patient was double doctoring. I phone our College and got a copy of the narcotic profile which verified that the patient had in the last two years only got prescriptions from her new family doctor and from me. After this I faxed in a new prescription which I suspect I will be doing a few more times until either she dies or I retire.

This isn't the most egregious case. I once co-managed a patient with one of the FPs. The FP prescribed OxyContin and I did trigger point injections. This patient again was doing fine, working full-time etc. Until the FP decided to take the summer off to go to Europe with his wife. He is a good FP and got a locum. Our patient showed up for an appointment to get a refill of his OxyContin. The locum recoiled in horror, called up a psychiatrist who arranged for an emergency psychiatric admission. He was detoxed and discharged on diazepam, in my opinion a far more addictive medication. Nobody bothered calling me although my progress notes were all over his FP chart. I only learned of this when he showed up in August for his trigger point injections. I sent off a hopefully not too-tactfully worded letter to the doctors involved.

I have a methadone licence. When I first got it, I was the only doctor in the clinic who had one. In 1999 I took three weeks off and while my colleagues covered my practice, neither could write a methadone rx. Because of this, I and the unit clerk spent the two months prior my departure, trying to ensure that every patient on methadone would not run out while I was gone. We managed to cover every patient but one. And she complained to the College. And I got a phone call from the deputy registrar and an aural hand-slap. But that of course was 10 years ago.

Humiliation Based Learning

I still remember the day I learned I had been accepted into medical school and intense feeling of euphoria because I knew that I was essentially set for life. Once in medical school it is extremely hard not to graduate, once graduated after going thru some type of post-graduate training (for which you are paid) you are assured of being employed earning a comfortable and possibly lavish income for the rest of your working life. (Actually I was unemployed for weeks at a time as a family doc and in the early 1990s a number of anaesthesiologists I knew didn't have jobs).

For that privilege you have to put up with a few things, including student loans, long hours, hospital food and of course proving that you are actually learning something.

A general surgeon at our hospital preceptors medical students which means he takes them for several weeks, during which time they come to his office, his clinics, round on his patients and come to the OR with him. This is a heck of lot nicer than my surgical clerkship which largely consisted of dealing with problems on the ward and holding retractors. He is to be accurate not the only surgeon in our city who preceptors students.

He recently read the evaluation on his rotation by one of the students he had preceptored for a few weeks. This was a negative evaluation and the student accused him of "humiliation based learning". Seems our surgeon actually expected his students to read up on what they were seeing or going to see, to answer questions and if they didn't know something to read up on it. He would ask them questions during the day including in the operating room and the clinics where there were people like me and the nurses to listen. I heard him many a time and he was never disrespectful although he would remind the student that they had already talked about this.

This was of course how I and most of my generation of doctors learned things. We went around the wards with a clinician who would ask us questions in front of our peers and whoever else happened to be in earshot. If you didn't want to publicly humiliated, you learned to read up on your material. If the clinician knew that you were generally up on your stuff, he or she was a lot easier on you when you didn't know something. As you got higher up the food chain with more responsibility for patient care, the questions could become more pointed and the response to not knowing was often a reflection on your competency. There is no doubt some clinicians were bullies and targeted the weaker students/interns/residents.

Worse were the clinicians who played the "what am I thinking?" game. This involved a vague open ended question to which any answer you could give was not what the clinician was looking for. We had a number of clinicians like this in medical school. Sessions with them could be miserable.

Humiliating anybody is wrong. However we learned that if you knew the answer, if you at least appeared like you had read around the topic, if you had a reputation for usually knowing the answer or sometimes if you just said, "I don't know" instead of bull-shitting your could usually avoid the humiliation. The pendulum seems now to have swung too far.

When I was a resident, there was still the mantra, that a resident must be prepared to present on any topic at any time. We actually believed that and the first year of your residency was a terrifying game of catch up. The upside of this was that the last year of your residency when you had exams was less of a terrifying game of catch up. Due the CofE being on academic probation our little hospital is seeing more residents especially juniors and I am sometimes amazed (although less so now) but how little they have read, how they don't read journals at all and how a simple question like "tell me the anaesthetic implications of diabetes" (this is usually asked while we are doing a diabetic patient) sends them into a panic.

One of our gynaecologists informed me that they were told they shouldn't ask residents questions where the resident doesn't know the answer!

One likes to think that things like OSCEs, written exams and FITERs will weed out the unsuitables,knowledgeables and incompetents , however another doctor told me she is never going to fail a medical student again after having to take an unpaid day off work to attend the (successful) appeal. As a future consumer of the healthcare system, I am more than a little worried.