Monday, April 29, 2019

The Board

I trained as a medial student and intern in 3 different labour suites, caserooms whatever you
The unifying feature of caserooms was the The Board.

While The Board slightly varied between sites, there were constants.  The patient’s name, attending physician, Gravida and Parity, gestation and dilatation.  There was usually room for other info such as pre-eclampsia or VBAC.  It was such a valuable source of information for seeing what was going on and predicting workload.  The Board when I was junior was a blackboard with chalk.  Lately it is a whiteboard.  Such a low tech but effective way of communications.

At Vancouver General Hospital which did OB in the early 1980s, the medical students had to keep The Board up to date, which meant constantly having to bother the nurses about what the dilatation was (they didn’t tell you when they did vag exams, because you might want to do it yourself, which after all was one of the reasons you did an OB rotation) lest you get yelled at by  the crabby soon-to-be-former OB resident.  

When I came to my current medium size Catholic hospital 13 years ago the board had become more streamlined than what I remembered.  Dilatation and gestation were not charted, but it at least had the patients name, attending physician, gravida and para.  They also wrote a big E next to the patient if there was an epidural.  Very useful for anaesthesia when you came in on call.  

Something as effective and elegantly simple as the board was bound to come to an end of course.

Several years ago, I was called for an epidural and looking on the board saw that her last name was 3 letters long.  I went into the room but noticed she had a different name more than 3 letters long.  Back to the desk I went.  No I was told the 3 letters are the first three letters of her name which for privacy purposes we are now only allowed to use.  I rolled my eyes and did the epidural.  Of course as I commented many people nowadays have 2-3 letter last names, plus it is highly likely that you will have 2 people in labour at the same time who share the first three letters of their last name (McDonald/McDowell. Chan/Chang).  Other people whose opinion counted more than mine must have weighed in because they started putting on the full name again.  

About two years ago I got called for an epidural.  At our site they never tell us the patient’s name only the room #.  “Room 5 wants an epidural” they tell me.  I walked past The Board and noticed that the patient had the same last name as one of the obstetricians.  Of course when I walked into the room the patient had another name.  It turns out that for privacy now they were now only posting the name of the doctor on The Board.  Twice as it turns out under patient and under physician.  

The day before yesterday I walked onto the ward and The Board had shrunk to about 1/3 of its size.  “Why is The Board smaller?”, I asked.  “Its an accreditation standard, “ I was told.  I am not sure why it should matter at all to the accreditors but apparently it does.  The Board is now literally tiny.   Whereas you used to be able to stand back of the nursing station and read it, you now have to go right up to it.

This presumably is in the name of privacy.  My mother always told me if you had nothing to hide, you didn’t need any privacy.  I wonder how many patients really cared about their names being flashed up on The Board.  People after all pay to put birth announcements in the newspaper.  Labours are live-Tweeted, Facebooked and Instagrammed.  Plus I am sure in the past if people wanted the anonymity, they were accommodated with a pseudonym.  And if you’ve figured out that your husband’s mistress is in labour at this hospital you can probably find out which room she is labouring in.

At the same time, we actually have made labour a group activity.  It is not unusual to have multiple family members in the room, or hanging around the hallways (usually talking outside the call room) while the mother is in labour.   I frequently have to ask for all but one of them to leave when I do the epidural.  (As department head, I had to deal with a complaint about one of my colleagues doing just that).  My father on the other, even if he had wanted to, was not allowed to see any of the births of his 4 children, which may explain why I grew up so messed up.  

And there is the issue of depersonalization.  I seem to remember during my OB rotations that I actually knew the patient’s name.  Now most patients are referred to by their room number.  I even find myself writing the room number on the patient label I collect for billing so I can tell them apart.

Of course in the 21st century we could have replaced The Board with something electronic that might even be an improvement but I’m not holding my breath on that

Why I stopped subscribing to my local newspater.

The Edmonton Journa didn’t publish my letter but I have a blog:

My wife and I cancelled our subscription to the Edmonton Journal.

Since moving to Edmonton in 1992, we have subscribed to your paper.  I remember it as an excellent paper with balanced coverage of local, national and international news and issues.  The large Saturday and Sunday editions were a true joy to read,  taking several hours.

Over the last few years, the quality of the paper has declined, there is no longer a Sunday edition and the size of the paper has decreased to the point where the flyers deposited in our mailbox along with the paper are often  larger in size.  In addition the national and international news and opinion section has been outsourced to the National Post.  

Worse was the behaviour of the Journal during the election and in the run up to the election.  On at least two occasions the UCP was allowed to buy full page ads on the front page of the journal giving the impression that this was news not advertising.   During the election various PACs were allowed to buy full page ads in the news section of the paper.  In addition the Journal endorsed the UCP which is really not surprising although disappointing.

I realize that papers depend on ad revenue to survive and am not naive enough to expect that advertisers and owners of newspapers will always agree with me.  I realize that their coverage of news of their editorial opinions will always subtly reflect the bias of the owners and advertisers.  I have always enjoyed reading the other point of view if only to mentally rebut it (and occasionally agree with it).  The Journal in the past has always presented a diversity of opinions and tried to present both sides of the story.  It is clear however that the promotion of a single agenda is now being blatantly pushed not only in editorial content but also in the way that news is being presented.  This is reflected in the Journal ignoring certain stories and by presenting opinion as news.

For the past few years, I have noticed that the Globe and Mail’s coverage of Alberta and Edmonton issues is more thorough and balanced than that of the Journal.  The Journal has now become a newspaper which features the worst aspects of the Edmonton Sun and National Post. Quite frankly most days, now I find myself going straight to the comic section which is actually still quite good.

I have read newspapers since shortly after learning to read.  As I mentioned above, I still find the Globe and Mail to be a high quality source of information and entertainment.  Recently while visiting Victoria, I read the Times-Colonist and was thoroughly impressed with quality of the journalism.

Newspapers have been observed to be under siege with competition from the internet and other platforms.  I have always preferred to read a paper and I suspect that a significant number of people do not read newspapers any more not because of the internet but because the content in newspapers has become so awful.  

Tuesday, April 9, 2019

Sometimes you write a really good letter but don’t send it.

About a year ago I applied for a licence in my neighbouring province (where I was born, went to school and worked for a while).  This was an interesting experience  which I should blog about some time.  The caper was in addition to having to get a criminal records check, having to be fingerprinted.  This was because apparently a sex offender has the same birthday as I do.  

I quixotically phoned the agency, knowing that it wouldn’t change anything but I needed to yell at someone on the phone.  They were very polite; it was like I wan’t the first person and I went down to my local police station and good fingerprinted.  Interestingly enough, so many people need to get fingerprinted now that our police force has a free standing office which does nothing but fingerprint people.  

And I wrote this letter. 

“Thank you for your letter and for the time your two employees took trying to explain it on the phone.  It is nice to know that I am not suspected of being a sex offender.

For your information, I was born in British Columbia, grew up, attended medical school there and practised medicine there.  I have practised in Edmonton since 1992 and have been at my current hospital since 1996.  I have lived in my current house for over 10 years.  I have paid both federal and provincial income taxes as well as property taxes.  I have a drivers licence.  I recently renewed my passport for 10 years. (I provided a notarized copy to the CPSBC).   I have a Nexus card.  It is my understanding that every year I have had criminal records check through the CPSA.  I also had one when I got a visa to go to Rwanda to volunteer teach.   I show up in Google searches of my name.  It is not like I have hiding for the past 40 or so years.

I accept however the possibility that during this time, I may have lived a double life involving nefarious activities under another name leading to my acquiring a criminal record.  It is also possible that I continued to work and raise a family while incarcerated.  An alternative explanation might be that I used my time while incarcerated to learn how to construct a time machine which I used on release to travel back in time and create a new identity.

Seriously I think that people who exploit the vulnerable especially those who abuse children are the lowest form of humanity and if by getting fingerprinted, I could prevent one such incident of abuse, I would happily get fingerprinted every day.  The truth is that this policy is not about protecting the vulnerable; it is a make work project for the public safety industry and a cash cow for the RCMP and local police forces.  Even the nice lady who spoke with me on the phone acknowledged that this policy has resulted in a huge increase in the number of staff needed to maintain it and one wonders how many nurses or police officers could be employed with the money necessary to employ these people.  The other and more concerning issue is that policies like this are primarily designed to give the appearance of doing something about the problem rather than actually doing anything about it.

It further needs to be noted that saying, “we’re only enforcing policy” is a somewhat empty excuse when you are the ones who made the policy.  It also sounds very much like “we are only following orders”, an excuse that was deemed invalid around 1945.”

Monday, January 7, 2019

Do I feel guilty about getting drunk the day my father died.

While I'm not  necessarily proud of going on the wine tour on my father's last day on this earth, I am not ashamed also.

Would I have been ashamed if in an alternate universe, he had not broken his hip but rather had had a huge myocardial infarction or stroke on that day while I was out wine touring. 

As I said, it still bothers me that he died alone but I got to see him the week he died and spent a lot of time with him during his last two years alive.  I would rather remember him as he was when he was younger because the last two years weren't really that great for him or for us for that matter.

While anaesthesia doesn't get involved in end of life very often, I did do general practice for 3 years and also anaesthesiologists get to do 6 months of internal medicine so I saw my share of death watches where the entire family assembles around the bed of a dying parent or grandparent in various stages of awareness and pain.  Overall, I didn't get the impression that anyone, patient or family got any comfort from the practice.

Friday, January 4, 2019

Thoughts on my father's death.

My father died last June 2.  He was 94 and it shouldn't have been unexpected.   As I was to find out, it was still difficult.

I go on a few medical and teaching missions nowadays.  In 2011, I went with CASIEF to Rwanda for 4 weeks (a total of 6 weeks away between pre and post-cations).  My parents were pretty old by then, so I believe  I told them, if something happened while they were away, I was not coming home.  Therefore every time I visited and left my parents it was like I was saying goodbye forever.

Between placing my parents in various levels of care over the past 2 years I have been visiting about every month, which is more than I saw them when I was attending university in Vancouver, a ferry ride away.

Anyway I was on my way to the Canadian Pain Society meeting in Montreal.  On arriving in Montreal, I turned on my phone and my brother had texted me to tell me that my father had fallen and broken his hip.  We were still in the airport.  "Do you want to fly back?" asked my wife.  No, I said, it won't make any difference.  He will have surgery in the next couple of days which he may or may not survive and whether I am there or not will not make any difference.  And besides I had said my goodbyes.  I kind of had the sense that this was it.  He was going to die within a couple of weeks or it would be the start of an inevitable downward decline.

After some consideration, I decided that after returning to Edmonton, the Friday, I would fly to Victoria on Saturday to visit Saturday and Sunday.  I had a busy next week planned.  A medicolegal in Calgary on Monday, Pain Clinic in Grande Prairie Tuesday and Wednesday , a medicolegal in Vancouver. Thursday and one in Kelowna on Friday.  Now I could have cancelled all this but really it really wouldn't have made any difference would it?  I phoned the ward regularly during the week I was in Montreal.

So I flew out to Victoria Saturday am, rented a car and went straight to the hospital.  My father had had surgery by then.  I never ever learned whether he had a hip pinning or a hemi-arthroplasty or whether it was a GA or spinal.  He was in a private room and was pretty delirious.  He did recognize me.  It was very interesting because in between bouts of delerium he actually made sense and was talking about politics which he loved doing.  He had a bundle of newspapers which he clutched tightly, not letting the nurses take from him.  I also went and visited my mother.   She kept on asking where he was and I kept on telling her he had broken his hip.

I visited again on Sunday.  The nurses said he had had a bad night and he was lying in bed but recognized me.  I spent a little time with him and then drove back to the nursing home to see my mother. I asked the staff at the nursing home if it would be okay to bring her over.   I had mixed feelings about this.   She was already not terribly able to walk even modest distances and I would have to park and walk over to the hospital with her.   The other thing that worried me was what I would do if she refused to leave my father's bedside.   Nevertheless, I took her, we walked slowly over to the hospital and up to my dad's room.  By this time the nurses had hoisted him into a chair and he was in a deep sleep.  We say there for almost half an hour, my mother and I.  At one point my father opened his eyes but didn't seem to recognize us and went back to sleep.  After half an hour, my mother said, "that's not my husband is it?" and we left, stopping for coffee and a snack at the coffee shop in the lobby.

I returned my mother to the nursing home and spend a little time before leaving.  I had a flight in the late afternoon and so had lots of time.  I could have visited my father again but I thought what difference really would it have made.  I figured he had survived the first few days of injury and surgery, the delirium would resolve and he would be eventually starting a long (and most likely futile) rehab program.

I later flew to Calgary, then to Grande Prairie, to Vancouver where my wife met me and then to Kelowna where I had a medicolegal Friday.  My son lives in Kelowna and we had planned to spend Saturday in Kelowna and leave in the evening.  My son works Saturday so we couldn't visit with him that day but took him and his girlfriend out to dinner Friday.

My wife suggested we do a wine tour Saturday and we found a taxi driver who did private tours and who would take us to the airport afterwards.  We were just on the way to our first winery when my brother phoned me.  My father was apparently now septic from at UTI with decreased blood pressure.  He gave me the pager number of the hospitalist.  I paged her and she phoned back right away.  By that time we were outside of our first winery.  She confirmed what my brother told me, I confirmed his resuscitation status and suggested that if he didn't respond to modest amounts of fluids not to do anything.

We went into my first winery.  "I hope you don't think," I said to my wife,"I am being callous by tasting wine when my father is most likely dying."  She didn't think so.

Wine tours are really just an excuse for getting drunk during the day and we did that quite happily and I am may have even forgotten about my father.  At one point our driver suggested we visit a craft brewery which we did.  Outside the tasting room, my phone went off.  It was the hospitalist.  My father's blood pressure was now worse, falling to as little as 40 systolic.  I told her that I understood and that he would probably die.  I then phoned my brother and told him, I didn't think my father would live out the day.  I am not usually good by the way at predicting deaths.

For some reason I decided to taste a flight of beers and I ordered them and took them out to table outside.  Then it hit me, my father was going to die.  I started crying.  People were looking at me.  I got myself together and then tasted my craft beer.  Why waste it. 

We finished our tour and went to the airport.  We flew to Calgary.  At the Calgary airport while waiting for my plane to Edmonton, I phoned the unit.  The nurse said my father was hanging in there.

Sometime while I was in the air between Edmonton and Calgary my father died.  My brother left a message on my phone which was on airplane mode.

It doesn't bother me that my father died.  He was 94 and had never adapted to nursing home life or my mother's dementia.  He had a great life including 33 years of retirement on a comfortable pension.  It does bother me that he died alone although I don't know that it would have made any difference or whether in his last hours he would have even noticed the company.  I don't know what goes on in peoples minds while their body is shutting down; I hope that during the hours he was unconscious before he died, he was having visions of his childhood in Sussex or meeting my mother for the first time.

My father requested that he not have a funeral.  Some people I talked to thought that it was weird and that we should have something but we didn't.  My brother got him cremated which is what he wanted.  I assume he has the ashes.

I went to visit my mother a few weeks later.  The staff had told her that he had died but of course she forgot this after getting quite upset.  She of course kept on asking me where he was.  I told her over and over he was resting.  At one point she said, "What is he resting from?".  "Arguing"  I replied because that is what he loved to do and she actually laughed.  When I went into my mother's room the book "Silk Roads" was on table in her room.   I gave that book to my father the previous Christmas.  He like to read in my mother's room.  I really enjoyed the book.  I hope he got far into it.