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.


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.



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.