First Do No Harm

There was recently an article published in a leading newspaper, referring to opioids, entitled "First Do No Harm".  I have discussed is this in the past and may again in the future, however the use of this adage struck me. 

I first heard this adage way back in medical school referring to anaesthesia and the fact that anaesthesia contradicts this principle.

In fact when the urologist discovers after the patient is asleep that the patient passed the stone already or the orthopod after the patient is asleep realizes that maybe he should have examined the patient or at least looked at the X-ray  and all the patient needs is a cast, I reassure them.  "Anaesthesia is good for you", I tell them.  I hope this makes them feel better but  most surgeons have no conscience anyway.

The fact is in medicine that we are constantly exposing patients to harm in the hope that we will make them better.   We are in effect betting the ill effects of a treatment versus the likelihood of helping the patient.

The House of God had it down with rule XIII:

THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

This of course isn't always in the patient's best interest either although is probably in their best interest more often than we think.

For example how often do you hear an doctor justify a procedure or test by saying, "I didn't no what else to do" or "Well I had to do something".  I have been guilty of this back when I was in general practice, in the pain clinic and quite often in anaesthesia when things are going south, how often do we try something random which we know probably won't work.  

Here's some questions to ask yourself.

1.  Based on your assessment is the patient going to die within the next few hours without treatment?

2.  Do you have any idea of what is going on and will either the test you order help make the diagnosis or does the procedure or treatment at least have a reasonable chance of stabilizing things.  

But speaking of aphorisms, what about the Hypocratic Oath.  A patient advocate asked me about this oath a few months ago in connection with an op-ed he was going to write.  

"First", I explained to him, "Many doctors, including me, have never taken the Hypocratic Oath."  Some schools have an elaborate oath taking ceremony.  My school didn't.  Am I a worse doctor for that?  "Secondly, " I went on, "there are multiple versions circulating including a modern version."  

"Thirdly", I pointed out, "Many of the things proscribed in the Hypocratic Oath are actually part of medicine, like cutting for stone, administering noxious substances (chemotherapy, anaesthetics) and abortion (controversial but still part of medicine). ". 

The Hypocratic Oath also has things like treating your teacher(s) for free.  We have socialized medicine in Canada and I work in a city where I didn't train, but that doesn't mean I would be interested in treating pro bono the 100 or so physicians who taught me.

About 20 years ago, I bought a handsomely bound of the "Aphorisms of Hypocrates" which now sits in my bookcase along with some of the other handsomely bound historical books from the same series.  And I read the Aphorisms.  I can tell you that if you practised in the Hypocratic fashion, it is a question of who would get you first, the licensing body or the lawyers.  I often wonder why we place such importance on the thoughts of somebody who practised over 2000 years ago.  I do like reading the history of medicine if only because seeing how wrong prominent physicians were in the past, puts into the context the modern practice of medicine. 

I think we need to spend less time worrying about doing no harm and more time stopping using outdated and irrelevant aphorisms.

Things that make my work worthwhile

My wife just read my last blog post.  "You sound like a crabby old man" she said.  Well for a number of years I worked with a lot of crabby old men (and a few crabby old women); sadly or not many of them have retired and there is a niche that needs filling because just as mosquitos and wasps are important parts of the ecosystem, COM just might be an essential part of the OR ecosystem.

About 2 years before I left of CoE, things were at a low point and morale was horrible in our department.  While the causes were at least to me pretty obvious, the solution was to hire a consultant to find out what was wrong.  I am not sure whether our department or the hospital paid for it.  Anyway those of us who wanted to meet with him were allowed a one on one meeting which I enthusiastically signed up for.  As most people who are earning $400 an hour are, he was quite pleasant.  So for about 30 minutes I detailed everything I thought was a problem with the operating room, the surgical service and the anaesthetic department.  At the end of this rant, he asked me, "why do you still work here?".   I thought about it and said something to the effect that I had been there for 10 years, I knew the place, I liked most of my co-workers and that I really hoped that things would get better.  I didn't say that I wasn't really sure I could get a job anywhere else, that the case mix at the CoE was so different from other sites that I wasn't sure that I could handle a different case mix and that I realized that the grass was not necessarily greener elsewhere.  A report which I never saw was duly produced, some minor cosmetic changes were temporarily introduced, things continued to get worse and I decided that maybe in fact I could handle the case mix at another place and that the grass was greener elsewhere.  

The one thing I remember about coming out of the meeting with him, was how good I felt having let it all out to somebody besides my poor wife.

But there are all lot of things about my work that make it all worthwhile.  Not in order of importance by the way.  

1.  The sight of my hospital in my rear view mirror at the end of the day.  (Okay it gets better.)

2. Being part of a team.  Sometimes we don't feel like it but we are part of a team and we can't function without each other.  That doesn't mean we always get along or have to get along but it is great to work towards a common purpose every day.  It is great when for example we get a heavy urology list and we all work through it together, finishing on time or when we all work together on a really sick or dying patient.  

3.  OR nurses.  I have worked with these men and women for 30 years now counting my residency.  I still find it incredible the way they can handle multiple surgical instruments, and complex electronics flawlessly, anticipating the surgeons' next moves.  On call I find it amazing that the same team of nurses can flawlessly go from a complex Ortho case, to a general surgery case and then to a urology case all with radically different equipment and requirements.   Or if I ask for a piece of equipment I maybe use once every 3 years, they can usually find it.

4. The jokes.  OR humour is probably the funniest and most inappropriate humour around which is why I can't give any examples.

5.  Patient contact.  We don't get much of it in anaesthesia but we get more than we are given credit for.  I really like talking to patients pre-op going over their history and explaining things.  I know I am sometimes brief and perfunctory.  I even like the stupid patients or the ones who clearly aren't paying attention to me.

6.  Hitting the sweet spot.  The time when every thing goes right, when you ask the patient to open his eyes as the dressing goes on and he does; and he seems comfortable and not nauseated.  Or when you get the spinal first pass.  Doesn't happen every case or it wouldn't be special.  

7.  My co-workers.  I already mentioned the OR nurses.  I get to work with a great group of anaesthetic colleagues and while the only time we get to work together is when the shit is hitting the fan, I really appreciate the support and cameradery we have.  Sure the surgeons really piss me off sometimes but I  do know that some of the stunts they pull are done with the patient's best interest in mind.  I should also mention all the other nurses, techs, clerks and orderlies I work with most of whom are great to work with. 

8.  Recovery.  Should have mentioned these nurses earlier.  Doesn't get the glamour of places like ICU, but the way these nurses can anticipate problems, pick up problems early and move quickly when the shit hits the fan is positively amazing.  They have saved my ass so many times.

9.  Being an anaesthesiologist.  Within a month of my residency starting, I knew this is what I was born to do.

10.  My lifestyle.  OK the surest way not to get an anaesthesia residency is to mention that we have a good lifestyle.  But we do.  No start up expenses, low overhead, fixed start to the day, when you are finished for the day you are finished for the day.  Easy to work part-time.  Sure there are specialties that have a nicer lifestyle but we have the satisfaction of doing a good job while we are at work.

Things that really bug me

Some of the people at work complement me on my relaxed laid back demeanour.  I would rather they complemented me on how intelligent and handsome I am but I have to take whatever complements I get.   Under that calm exterior lies a smouldering pit of resentment.  

Let me air my grievances.

1.  Electric beds.  Not electric OR beds, but I will get to those.  I am talking about the electric beds from the ward.  It does make sense to reduce the number of times patients are transferred and so some patients go to and/or from the OR on these beds.  Except, these beds are never at the same height as the OR bed which means plugging them into an electric outlet.  Of course they come with ridiculously   short power cords (short enough not to reach the wall but not short enough to not trip over) which means finding an extension cord so that they can be plugged in.  Did I tell you most of the beds in our hospital now have two plugs both of which have to be plugged in, so now two extension cords.  Aside from the fact that we really don't need two more things to trip on in the OR there is a potential electrical hazard here.  When I was a resident we had to learn about electrical safety and it seems that by law most devices in the OR are elaborately grounded to prevent shock to the patient and staff.  And apparently if you use an extension cord, this exposes the patient to micro or macro shock.    (Like I said, I learned about electrical safety, I didn't say I understood it.).  Oh and the new beds come with a piercing alarm which goes off if the bed is unlocked while plugged in, like for example when you are pushing it towards the OR table so you can move the patient.   

A lot of this could be fixed if the beds came with batteries which our OR beds do and which the hospital beds in the hospital in Ecuador where I sometimes work do (the floor nurses would still forget to charge it) or if they allowed the option of manually raising and lowering them without plugging in the bed.

Electric OR beds I for the most part like.  I miss strengthening my legs pumping up the table.  I don't miss wrecking my back bending over to crank the handle.  The only problem I have is with the surgical princesses who insist on moving the bed up and down side to side every 5 minutes.  Cuts into my phone call, Internet and of yeah monitoring the patient time.

2.  IV poles with more than 4 legs.  Space is limited in the OR.  OR tables are rectangular as are beds and stretchers. This means that the right angle of the IV pole with 4 legs fits in nicely against these objects saving space during cases or when you are taking the patient to recovery room or ICU.  Life was good the universe was in balance.  25 years ago the first 5 legged IV poles appeared.  Now they seem to have taken over.

Sadly this picture is typical.  Look at them:  three  5 legged poles (and in the background a lonely 4 legged pole)

Proponents of these claim they are less likely to tip over.  As we all know, if you load enough infusion pumps, blood warmers etc onto on of these, they can and will tip over especially if you add a urology size bag of fluid or two.   They will tip over most likely because some clumsy oaf like me trips on the legs.  And suggesting that adding legs makes them more stable shows a lack of knowledge of geometry because as I learned in Grade 7, three points define a plane which is why for centuries milk maids use three legged stools because they don't tip over.  Not to mention tripods.

3.  Infusion pumps.  Okay I use infusions all the time and would hate to go back to the situation like when I was in medical school where nurses counted drips to figure out how fast the infusion was going.  (My wife when she re-certified for nursing had to learn about drip counts; "nobody does that anymore," I told her.). I certainly don't object to having some medications run thru infusion pumps and I can see that in fragile patients and children, making sure they don't get too much fluid is important.

What really bugs me is the 20 year old with the fractured ankle who comes down with his IV running through an infusion pump.

And do they have to be so freaking complicated.  This is the 21st century.  I am a PC guy but when I got my i phone, I had it figured out and running within minutes.  Why do we now have to have hour long inservices on these pumps before we can use them.  Do people not realize that this is inherently dangerous?  Nowadays when an ICU patient comes down with 10 of these running, I usually try to ignore them, occasionally starting my own IV line.  This would be fine except the ICU nurses always set the VTBI (volume to be infused) to a low number so it will run out during the OR and the alarm(s) will go off forcing me to deal with it.  I think they do it intentionally.  

And can they trust people?   Why is everything locked up.  We got new PCEA pumps for OB recently.  We actually got to play with them at rounds before they went into service and liked  them (not that it would have made any difference if we hated them, they were already bought).  So a couple of weeks ago I decided I would use it on a patient, the pump was now inside a plexiglass locked case which not only made it difficult to read the screen but required a key which the nurses took 10 minutes to find.  Plus in addition to a key to lock the case, there was a second different key on the pump which the nurses also had to find.  

Do they actually think malicious relatives are going to turn up granny's infusion?

4.  This:

If you are concerned about your diet, just don't eat the doughnut or the muffin.  Don't just eat the top of the muffin or cut out half or, as somebody  in the above pictures did,  2/3 of the frigging doughnut.  Because despite all the lectures and posters on hand hygiene,  I know where your hands have been and  the type of person who would do this to a muffin or doughnut is the type of person who doesn't wash his hands, so you think I or anybody are going to eat the fraction of pastry you left behind?

4.  People who drink but don't make coffee.  You know the scenario.  You drop your patient off in recovery, see your next patient and in the remaining 5 minutes before they call you, head to the OR lounge for a coffee to warm you up and keep you awake for the next case.  Except there is no coffee left.  You look around the lounge and just about everybody has full cup so...one of them took the last coffee and didn't bother making another batch.  You could (and probably will) make another batch but you know this is going to be the time when your room turns over quickly.  Making coffee is not difficult.  Most of you went to medical school.  It doesn't take that long.  If you drink the last drop of coffee making another fzcking batch.  OK?

This by the way also applies to the first person in the lounge in the morning.  If you drink coffee, make the first pot.  Don't just sit there and when I arrive ( and I am never first) say morosely, "there's no coffee."

This applies to medical students, residents and sales reps who drink our coffee.

5.  Arm boards.  You would think by now they would have designed an arm board that attaches and detaches easily from the OR table?

6.  Residents, medical students.  Okay I was both a medical student and resident at one time, but I was much smarter, cooler, and hardworking.  Plus less klutzy.  This applies mostly to surgical staff.  I figure by now I have spent a year of my life watching students and residents painfully close incisions.  This applies to anaesthesia as well although our residents are way better and now the only medical students we see are thinking of applying to anaesthesia so actually know something.  Actually we at our place see residents so infrequently that largely I would just rather do my room by myself thank you very much.

Fellows are by the way just as bad and quite a few fellows clearly decided to do the extra year of training because they forgot to learn how to operate during the previous 5 years.  For some of them no amount of training is going to ever make them into surgeons.  

7.  The constant gaming of the "emergency list".   I know we can't just restrict our after hours work to life and limb threatening cases but when you can predict your on call workload based on what surgeons are on call things have gone too far.  Maybe things haven't changed , maybe I am getting older and crabbier.  Most of my 5 years as dept. head, I spent fielding phone calls:  from the anaesthesiologist on call complaining about what the surgeon(s) had booked; from the surgeon demanding that I call in a third anaesthesiologist to do the "emergency" case he had booked 4 days ago that had now been bumped by a real emergency.