Thursday, July 30, 2015

My new religion

I was in the pain clinic a couple of days ago hearing a patient tell me how his doctor wouldn't order a certain treatment because it was against the doctor's religion.  Already doctors are refusing to provide such services as birth control or referral for abortion citing religious reasons.  Some refuse to treat unwed mothers, some homosexuals.  

Since my parents let me stop going to church and Sunday school when I was 13, religion has not been a part of my life.  I have attended the odd wedding, funeral baptism or midnight mass but I suspect I have spent more time in churches as a tourist than as a participant.

But now that I realize I can actually refuse to do things I don't enjoy doing based on my beliefs, I think I just got religion.


I am not going to observe isolation precautions.

God obviously loves antibiotic resistant bacteria because he makes so many of them.  So who am I to stop them from being fruitful and multiplying.  My righteous brothers and sisters on the wards are already helping this by allowing patients on isolation to go outside to smoke and visit the cafeteria.  Plus I think wearing yellow gowns is specifically proscribed in Deuteronomy or maybe Leviticus.

I am not going to do patients with no coverage (yes we have them in Canada),

I think the passage about render unto Caesar covers this.  I mean, how can I tithe if I don't get paid.  And for what you or  your Canadian relatives paid for you to fly to Canada for pro bono surgery, I am sure there is a little left over for my modest fee.  Plus if you came to Canada to ski or ride in the rodeo and didn't buy adequate travel insurance maybe you don't deserve to have your broken leg fixed.  And I really don't care if the surgeon also didn't get paid, because I expect in about half the cases he actually is getting paid.  Therefore if you want my services you better visit the money changers at the ATM in the hospital lobby to get some money to make the  appropriate offering.  Some people might get a warm fuzzy feeling from providing services for free to people but my righteous life gives me all the warm fuzziness I need.

Working on the Sabbath is out.

I haven't got this Sabbath thing down yet.  Is it Saturday or it is Sunday?   Never mind.  I won't work on either.  Nor on Statutory holidays or should I call them feast days.  Hmmm better think this one out....we get paid more to work on those days.  OK I will work those days, except when I am tired, hungover, something good is on TV, I don't like the surgeon or the slowest nurses are working.

No more emergency sections for breeches.

I'm not talking about the breech vaginal delivery gone wrong; I'm talking about the "stat" section for a persistant breech because they have either started labour or their membranes are ruptured.  Funny how these stat sections never happen during office hours.  If God wants you to come out butt first, you should come out butt first.  Besides if untrained birth attendants in the developing world can do a breech delivery, an Obstetrician with five years training should be able to.  

Because I am a righteous family guy, I get to go home when I want to and take vacation when I want to.

My kids are grown up but still it is the principle.

Obese patients violate my beliefs.

I am sure there must be something in the Bible about this.  We are blessed with a nice premium for patients with BMI over 35 so I will keep on doing those but the 45s and higher where you actually earn the premium are out. 

I am not going to fill out narcotic tracking forms.

Narcotics are one of God's gifts to mankind.  Besides as a righteous man of God, I would never misuse narcotics (and if you really to see what I may have given the patient, you can consult the holy anaesthetic record). 

No more futile surgery.

What can I say.  Who am I to try to interfere with God's will.

If you want me to come to a meeting before work you better provide breakfast and that breakfast better include bacon.

In my religion bacon is a sacrament, and if you expect me to get up half an hour early for a meeting to decide something you could have settled by email or phone call you better feed me.

I intend to live my life outside of work righteously as well.  For example some extreme religions do not allow their adherents to sit next to a woman on a plane.  Okay, it is an abomination for my legs to touch the seat in front of me.  Therefore the airline in the interest of religious freedom must allow me to have a bulkhead, exit or business class seat.  For no extra charge of course.  Also my religion prohibits me from sitting next to young children, people with body odour problems, people drunker than me or obnoxious people.  

I am sure in time I will find more ways in which society can ensure my life goes in as righteous a fashion as possible.  Stay tuned and God bless you all, except those of you who piss me off.

Friday, July 3, 2015

Reflections on a quarter century

25 years ago today or maybe it was yesterday I gave my first anaesthetic as a specialist.  I remember it was an oral surgery list.  I also remember my first patient was a Pediatric patient and I remember thinking how it was a good thing I hadn't looked carefully at the list the night before because I might not have slept well knowing I was doing a kid first.  Fortunately that child and the two other patients I did that day did well.

The child I would have induced with Halothane before starting an IV, giving a muscle relaxant (probably vecuronium) and intubating after which I would have maintained him with N2O, oxygen and halothane.
The two adults I would have used Alfentanyl, thiopental to induce and either succinylcholine or vecuronium to intimate.  I would have maintained with nitrous and oxygen and either isoflurane or enflurane.  Because the surgeon may have wanted induced hypotension, I may have used curare as my muscle relaxant.  Morphine would have been given for analgesia and I probably gave droperidol as an antiemetic.  Interesting how many of the drugs I used then are either no longer available or have fallen out of favour.

My machine would have been a Boyle machine.  No electronics, no software, driven by compressed gas and just as safe or safer than the $100K behemoth I use today.  To switch fron the bag to the ventilator, you manually disconnected the bag and connected the ventilator hose, remembering to close the APL valve.
The anesthetic circuit was the Bain circuit, with its necessary high gas flows which meant you went thru at least 1 bottle of isoflurane a day.  The circle circuit which had fallen out of fashion was just coming back into fashion.  Circuits were changed every case but there was no filtering.

Monitoring was with EKG, NIBP, pulse oximetry, and  ETCO2.  The latter two had only recently been mandated as standard.  There was no expired gas monitors.  Most of us figured that by dialling in a certain percent, we got a certain end tidal gas concentration.  Pulse oximetry had not been mandated in recovery yet.  Our recovery had one or two pulse oximeters which they put on whoever they figured needed it the most.

A significant number of patients were admitted the night before surgery which meant seeing them the night before after your list  and coming in Sunday evening.  At our hospital then, the person on call saw all the pre-ops which meant 10-20 patients on Sunday evening on top of doing emergency cases and I remember rounding at 2300 some nights. (When people complain about the pre  assessment clinic I remind them of this, but so few people remember having to do this that it doesn't work any more.)

Cholecystectomies, appendectomies, and hernias were still done open.  The laparoscopic cholie appeared early in my career ( initially three hours of farting around followed by an open cholie), the others later.
Over time things changed.  Propofol was introduced early on.  At first pharmacy refused to supply, then rationed it; I got into the habit of mixing it with Pentothal, I called this mixture President's Choice propofol.
Muscle relaxants came and went, rocuronium came and stayed, less so cisatracurium and pipicuronium. Curare disappeared soon after I started.  Pancuronium hung on until recently.  Atracurium and vecuronium, introduced while I was a resident are gone.

Sevoflurane and desflurane appeared in the mid to late 1990s.  I still don't think they are much better than halothane and isoflurane which have also disappeared from use.  So has enflurane.

The laryngeal mask airway was introduced early in my career.  Who remembers mask anaesthesia?  That was how we did short cases like D+C s and cystoscopies, holding the mask with one hand, and writing up the chart with the other.  Some of our older colleagues even did longer cases and had elaborate set ups with the black mask strap and tongue depressors to free up their hands.  (Periodically a resident comes across the mask holder and asks me what it was for).  The LMA has mostly supplanted the ETT in many of the cases I used to intubate although I am still a lot more conservative that some.

When I started well over half of Caesarian Sections were done under general.  Now GA is reserved for special exceptions and dire emergencies.  Some commentators are now saying we don't do enough GAs. Unfortunately in my time the section rate has increased from 15-20% to 30%.

My malpractice premiums were $9000 (14,600 in 2015 dollars) that first year.  I currently paid $8600.  I would like to think that this is because we are all better anaesthesiologists but I credit the pulse oximeter for most of this.

One constant in my career has been the drive to cut costs.  For the past 25 years, the mantra has been that health care costs are spiralling out of control.  With that logic they should now be consuming 200-300% of the total provincial budget or GDP however you want to express it.

One major change in anaesthesia and in medicine in general has been the increase in obesity.  On my fellowship oral exam, I remember being given a case of a morbidly obese lady presenting for a D+C.  I see at least one such lady every time I do the Gyne list.

Two things I thought were inevitable when I started have not come to pass.  Today as I have for the past 25 years, I charted on a paper chart.  Lots of places have an EMR; in my chronic pain practices I use an EMR at some but not all sites, but if you offer me good odds that I will not be exclusively charting electronically before I retire I will take them.  Secondly I am still billing exclusively fee for service.  I gave this 5 years maybe, when I started.  I will take the same odds that I will be billing fee for service until I retire.

Since my first day I have moved cities once and lived in 3 very different neighbourhoods in my current city.  I have fathered a second child, and watched 2 boys grow up.  I have gone thru 4 dogs.  I became an accidental chronic pain specialist.  After working unhappily at the C of E I now enjoy my life at my medium size Catholic Hospital.  I have gone into and survived administration.

When my wife learned I was blogging on this, she asked if I was nostalgic or whether I was happy with the way things had changed.

I am nostalgia for the way I felt during the first few weeks in practice when everything was a novelty, and you realized that after 4 years of training, you had made the right decision and you were competent at it.  You never get that feeling back.  I feel nostalgic for some of the people I first worked with who helped me out.  I also feel nostalgic for the little town in Atlantic Canada where I first worked for 2 years before I went to the Centre of Excellence.  I don't know how many times in the first few months, I wanted to call them and ask for my job back.  All in all I still think that the move was for the better.

Have things gotten better?

I do like the short acting drugs we have now although they are not always a short acting as we would like them to be and sometimes because we don't respect them we get into trouble.  Like the recent article in Anesthesiology suggesting that a significant number of patients still get discharged incompletely reversed from their intermediate muscle relaxant.  Pancuronium and curare we knew lasted a long time, so we used them sparingly.  If the surgeon complained about bucking while he was closing, we didn't give another dose.  It may be a good thing that patients are more awake post-op, however I wonder how whether the recovery room nurses appreciate the awake, anxious, painful patients we now drop off as opposed to the sleepy ones we used to.  No matter what anaesthetic you use, discharge is driven by things like policy, availability of porters and when the patient's ride shows up on time.  When I recently had a colonoscopy with sedation, I liked being able to walk out 15 minutes after the end of the procedure (I told my wife, "I've driven in worse shape then this.")

The greatest advance in anaesthesia is the pulse oximeter.  The ETCO2 is also a useful monitor and one I am glad to have.

With the medical system in constant crisis, I often wonder whether we are worse off.  I sometimes think that we are like the frog in the pot of water that is slowly being heated, and don't realize that we are being boiled alive because it is so gradual.

I like history and one of the advantages of growing old is to look back on how things have changed (and how things have not changed) ; how dogma becomes heresy and how heresy becomes dogma.

Looking forward to the next 25 years.