I used to be disgusted, now I try to be amused

Coaching in Medicine

2011-12-13T11:10:00.003-07:00

http://blog.openmedicine.ca/node/323

This is an interesting idea for CME or CPD or whatever they call it nowadays. Why not spring training every year for everybody. Go over some new things in medicine, practise up on skills that are rusty.

The idea of coaching is interesting too. When a player is having trouble at the plate, he asks a coach (an ex-player) for help or the coach approaches him. Why don't we have a similar model in medicine?

Eventually some academic will have this idea which he will promote as if it is a new concept even though baseball has been doing it for a century now.

Some rob you with the six gun, some rob you with the electronic statement

2011-12-11T11:50:00.007-07:00

I hate to use this blog to vent my personal problems. No actually that's why I have a blog.

Many years ago after using pay as you go plans, I decided to get a dedicated cell phone with a number and all the gadgets. At that time there were 3 cell phone providers in Canada. As it was more or less six of one and half a dozen of the other (actually 3 of 1 and a quarter dozen..) I ended up with Bell. Up until now Bell has not been bad to me, they have not been particularly good to me either. Periodically Bell calls me and tells me that my contract has been extended. They never ask me if I want it extended and I never argue.

I also signed up for e billing. I hate filing phone statements and as they were automatically debiting my card and am going to lose any fight over the statement anyway (as I found out) so why use it. I had to chose a user name. The usual user names, my first initial and last name or vice versa weren't available so I chose another user name which I of course forgot.

About a year and a half ago I got an i phone. As I was still under contract with Bell, I picked it up at the Bell kiosk in the mall and got a new data plan which enabled me to surf the Internet with my phone. Of course they tell you that you get X number of free bytes of downloads but neither I nor the salesman actually know what that amounts to in the real world. I of course knew that the monthly cost they quoted was nowhere near what I was going to have to pay. When a cell phone company tells you your service is going to cost $X, it is about the same as the surgeon telling you he is only going to take an hour.

By September of 2010 I was so attached to my i phone that when I went to Europe I wanted to be able to use it. I phoned Bell on the #611 number explained that I was going to Europe and wanted to be able to use my phone and download data and the nice lady at the call centre sold me a package. Because my visit overlapped my billing period she said I would have to pay for two months which is a bit of a rip off but hey Bell are not the only people who do things like that. Off I went to Europe where I was able to use Google maps, phone home, receive texts and even almost got a call from the one patient who has managed to get my cell number (I recognized the number and didn't answer). When I went to Africa in June, I spent a couple of days in Belgium and just to check I tried to use my i Phone and got no service.

I continued to see these bills for Bell on my credit card statement and they were a little high but not excessively high so I just figured I must be downloading too much. I kept saying that I should really look at my statement but I had forgotten which of the alternate user names I used and the only way to find out was to log on to Bell's site which of course required my user name. I suppose I could have just called #611 but I really didn't feel like spending time on hold when I have more important things to do like blog, go on Facebook and watch Big Bang Theory re-runs.

Just last week, I tried to log on again and much to my surprise Bell had upgraded their website so that it was actually possible to find out what my user name and password were. I still didn't get around to checking until today. That was when I found out that I had been charged $60 a month for the past 14 months for service in Europe that I wasn't using (I promptly cancelled it on line). I promptly phoned #611 and after a surprisingly short wait (at 0900 on Sunday morning) I talked to a customer service rep who informed me that she could refund the past three months but that was all. She pointed out that I should have checked my statements, I pointed out that I had not asked for more than 2 months service and that if I had planned to relocate to Europe, I would have bought a cell phone there for considerably less than what it costs in Canada. I of course got nowhere. I told her that while I was under contract until 2012 or 2013, I would definitely not forget this and I would be using a different cell company assuming they haven't all amalgamated by then. She seemed unconcerned. Obviously not a shareholder.

So okay, I should have checked my statements. I might even have picked up on it earlier. But that logic is like saying, it was okay for me to burglarize your house because you didn't lock the door. Or say Bell through some glitch forgot to bill me for the past three months, do you think I would have gotten away with saying, "Sorry you should have checked your statements?"

I can of course afford this. My cell phone is paid for by my PC and so it is tax deductible. $700 isn't that much in the scheme of things. But $700 here , $700 there and you're talking real money.

Bell Canada's most recent profit was $2.1 Billion. I wonder how much of that profit was generated by people like me who didn't realize they were paying for services they hadn't asked for and weren't using.

The Golden Rules

2011-12-04T19:36:00.003-07:00

I found this blog post on facebook.

It made me think. When was the last time you saw a doctor getting heroic chemotherapy or having a "metastasectomy" or a tumour debulking. Or for that matter saw a doctor on a ventilator. Or having a redo CABG. Or attended a Code on a severely demented doctor with no DNR order.

My son took biomedical ethics course. No.... he is not in medical school, doctors don't take ethics courses but we did actually have some discussions about ethics. I have a little problem with ethics as it tends to be jargon focused but I thought about this and sad basically ethics comes back to the the Golden Rule: Treat others as you would treat yourself.

So the question is: why are we treating patients in a fashion that we would never ask for either for ourselves or our families?

Just asking.

We Beat Libya Big Whoop Part 2

2011-12-03T12:30:00.002-07:00

Once again it is nice to know that somebody actually reads my blog and Paul Turnbull responded rather quickly to my last post.

His reply is much too important to deal with in the comments section.

He commented in italics and I have responded in bold:

While it's fine to oppose operations like this you could at least try to be accurate. The Canadian air force in Libya definitely did fire shots. By the end of August they had been involved in a disproportionate number of the air strikes (over 700) and the Navy had been involved in at least two battles with Libyan ships. I believe it was the first time since the Korean war Canadian warships actually fought.

Yes you are right, I checked on the internet and found a National Post article which confirms your comment. Like most Canadians I rarely read the National Post (and never buy it). The National Post which is the official paper on the Canadian Tea Party essentially prints government press releases.

So while our Air Force did fly over 700 missions, it is not like they were having dog fights with Messerschmidts or MIGs.

And please remember.... it was Libya. We beat Libya.

And while Canada's mission in Afghanistan was not an unmitigated success Canadian troops definitely did not get their butts kicked. They held the most dangerous province of Afghanistan for over five years.

If you support Canadian troops at least acknowledge what they have accomplished.

If you call living in a fortified camp and going out in heavily armed convoys holding the most dangerous province in Afghanistan, you are welcome to your opinion.

Canada only joins a list of countries who have failed to conquer Afghanistan including Britain, the USSR and most recently the US who are also getting their butts kicked.

And I support our Canadian troops. It is their leaders I am a little disgusted with.

Personally I'm ambivalent about our participation in the Libyan intervention as I agree with you that things might not have been this bad if the west hadn't cozied up to Gaddafi for the last few years. On the other hand I also see it as the U.N. doing what it was actually designed to do: provide a mechanism for nations to deal with state's like Libya.

When we start invading every dictatorship whether or not they have oil and whether or not they treat our corporations nicely I will support this type of action.

We Beat Libya, Big Whoop

2011-11-28T19:55:00.008-07:00

I just got back from the Grey Cup which is Canada's Football Championship, the equivalent of the Super Bowl. If we numbered it in Roman Numerals it would have XCIX. There I witnessed more falling down drunkenness and random vomiting than I have since University. I also saw an okay football game.

Even though I am a pacifist I have nothing against the men and women in our military. They have to deal with a moronic command structure dating back to the 1700s, have to do all kinds of ridiculous things in the name of discipline and, when our Prime Minister feels insecure about the size of his penis , have to go to places where other people try to kill them. There has recently become more of a presence of the military at sporting events in Canada. We were never as bad as the US in this respect but are rapidly catching up.

At the recent Grey Cup we were treated to a huge Canadian flag and about 50 members of various branches of the military in their dress uniforms down on the field. There were also two generals and the Minister of Defense (who of course personally leads our troops into battle ;Q). As I mentioned I support our troops especially when they are in Canada and so I thought nothing of it. That was until I learned the reason for this expensive display of testosterone.

Apparently our military recently defeated Libya. Yes we beat Libya! After our NATO allies destroyed the antiaircraft guns and most of their air force defected, our "Royal" Canadian Air Force burned a lot of jet fuel over Libya, and didn't fire a shot. Meanwhile our Navy ships bobbed around in the Mediterranean in support of our planes. I am not sure what our "Royal" army did but I am sure they played a huge role. I have never been so proud to be a Canadian. We are getting our butts kicked in Afghanistan but we beat the crap out of Libya.

I am not a big fan of Gaddafi and I am certainly glad to see him gone. I wonder how long he would have lasted if we hadn't been so willing to do business with him all these years. I hope the Libyan people end up with a liberal democracy in the Western model. I also hope that the Easter Bunny will come this year.

The Hood

2011-11-20T19:20:00.004-07:00

Someone was murdered across the street from the house I used to live in recently. I know this because the lady who bought the house from me wrote a letter to the local paper bemoaning what had happened to the neighbourhood.

In 1997 we bought an old shack in the neighbourhood, knocked it down and built a Victorian style house in what we believed was the style of the neighbourhood. This area of the city was one of the older parts of the city. At the time we moved in, it was a mixture of Victorian style houses from the early 20th century, 1960s and 70s style houses and older houses that the workers who used to live in the area, when it was more working class lived in. When we moved in, people were renovating the old Victorian houses, knocking down the older run-down shacks and even renovating the 1960s houses. The main thoroughfare 3 blocks to the south had been transformed to a vibrant street with older brick buildings, lots of small stores, restaurants, coffee shops, student bars, bookstores, and an art-house theatre. There was a farmer's market on Saturdays. To the east of us lay a wooded ravine with walking and cycling trails. Moreover I could walk to work from our new house. The neighbourhood school was a few blocks away. It was on paper the perfect place for a Bleeding Heart Liberal to live and raise his family. At election time orange NDP signs festooned the streets.

10 years later we moved away to another neighbourhood. There are a lot of reasons but the main reason was that the neighbourhood had evolved in a way that we had not anticipated.

One of the reasons was what we in our neighbourhood called "The Avenue". This was the street with the bookstores etc that we loved to visit before we lived 3 blocks away. The problem was that as the area became more popular, the rents went up which forced out the smaller independent stores. In their place came bars, lots of bars. Not the nice artsy bars that were there when we moved in. Bars that played loud dance music, and where people apparently felt they had to carry knives. Garbage from the party the night before was strewn all over the streets in the morning, and often not cleaned up at all. The area began to be referred to as an "entertainment district" oblivious to the people who actually lived in the area for whom it was part of their neighbourhood. When our hockey team made its playoff run, the local media actually encouraged people to come down to "The Avenue" to celebrate victories (and defeats) which meant a near riot a couple of times a week not to mention the honking of horns at all hours of the night.

Secondly two of the local churches set up homeless shelters in their basement. Now there had always been homeless in our neighbourhood. Many of them slept in the nearby ravine. They had been a somewhat sad part but something you could live with. With the homeless shelters opening a different class of homeless showed up. A harder more aggressive homeless who got in your face and wouldn't take no for an answer. As many of the bars simply put their empties out in the alley rather than recycling them, you had created a gold mine for the bottle pickers and this spilled over onto our neighbourhood. Soon you had people going through your garbage looking for empties, even if you didn't have empties they often dumped out your garbage some they could use your plastic bag. There began to be way more homeless camps in our ravine. (Keep in mind that we were in the midst of a huge economic boom then). These people had to shit and pee somewhere.

Complaints to the police went nowhere plus a lot of my fellow BHLs didn't trust the police. The police grudgingly agreed to have 4 officers on foot patrol along "The Avenue". They of course never patrolled the surrounding neighbourhoods. Our community league had meetings with the police but all the police wanted to talk about was crystal meth which according the police was the root of all evil in our neighbourhood. They also had the police helicopter hover our our house between 10 and 11 every evening as a general deterrent to crime. It became apparent to me that the police has decided to bottle up all the noise and crime into a "combat zone" in our hood so as not bother the residents and businesses of more politically connected neighbourhoods.

Eventually we moved away. It was the peak of the real estate boom and our house sold in a flash. It was tough for me because I really loved the hood and I felt like I was abandoning it. We are much happier now even though we still have drug deals across from our house. Now when I visit "The Avenue" it seems like a dirtier, unfriendlier place than I remember. Maybe I am just older. There is now a Dairy Queen where one of the coffee shops used to be.

There is a lesson here which if I ever have a second career as an urban planner I will pay attention to. That is how easy it is to ruin what should be the showcase neighbourhood and shopping district of your city through lack of proper zoning, allowing rents to run rampant, lack of policing and of course encouraging riff-raff to hang out. I often wonder how much extra property taxes the city collected from people like me who knocked down shacks and put up nice houses at zero infrastructure cost to the city.

Cold OR s

2011-11-20T16:12:00.002-07:00

Once again I am poaching one of Great Z's posts.

When patients arrive in the room and remark how cold the room is, the nurse will inevitably reply, "But our hearts are warm."

Canadian surgeons like their American colleagues, like the room cold. Some anaesthesiologists try to fight back. This has lead to at least one surgeon storming out of the room stating they would cancel the rest of their list unless the room temperature was turned down. Some orthopods claim the bone cement won't set properly. I used to turn the temperature up at the end of the case while the resident was closing, stating that the patient was cold and I needed to warm him up. My real motive was to make the resident uncomfortable that he would actually work faster and win the race against the fibroblasts. I once made a resident almost faint, something that I am immensely proud of.

During the summer our hospital runs the air conditioning on full blast. I once asked the resident how much fossil fuel was being burned to make everybody uncomfortable. Once when the recovery room nurses noted how cold my patient was, I asked them to take my temperature, which they did with their ear thermometer. My temperature was 35. I am sure it has been colder. One of the rooms at the C of E had a vent which blew cold air full-blast over the chair of anaesthesia. They liked to do long cases at night in this room, so you could be both cold and tired.

Our ortho surgeons are not just content to make everybody else uncomfortable. They have made the hospital spring for water cooled vests for long cases and elaborate helmets with fans for total joints. Meanwhile I have asked for a desk light for my anaesthetic table so I can read the ampoules when they turn off the room lights and am always told it is too expensive.

Meanwhile Bair Huggers proliferate around the ORs; our patients even get them pre-operatively now. This is wasted because mainly nurses will not allow you to turn on the Bair Hugger until the patient is draped believing that the Bair will blow germs all around the sterile field (I turn it on anyway). Nobody ever asks if there might be a cheaper way to keep patients warm. Surgeons and nurses don't make it easy by insisting on huge operative fields. Every time I get asked to move one of my EKG chest leads so they can prep the chest for an abdominal procedure, I ask them if they are going to take the gall bladder out thru the sternum.

Of course people go too far in the other direction. Our charge nurse in plastics made keeping patients warm her mission which meant that our burn patients had an array of warming blankets, fluid warmers and radiant heaters. Periodically burn patients would come to the OR febrile so I would turn off everything, she would come back from one of her many breaks, turn everything back on and so it went. Pointing out the patient's temperature was of no help.

To do nothing is sometimes the best medicine.

2011-11-17T10:22:00.002-07:00

Sometimes I read an article which says what I am thinking much more eloquently than I ever could.

I was talking to retired geriatrician today who told me that a significant amount of his work when he practised was undoing the work of other doctors.

Picard in his article refers to the 13th law of The House of God:

“The delivery of good medical care is to do as much nothing as possible.”

It is sometimes hard to believe that "The House of God" was written in 1974. Add in the "advances" that have occurred since then and it could have been written last week. Just about every medical student read it when I was going through medical school. My generation are now the senior doctors. Did we learn nothing?

Say it ain't so Joe

2011-11-16T14:13:00.003-07:00

Ever since I read his biography as a teenager, I have admired Joe Paterno. That is until about a week ago when like just about everybody outside apparently most Penn State students and alumni I became completely disgusted.

This blog has an interesting spin on it.

Last evening as my mind wandered off during a "leadership" retreat, I tried to figure out why the hell Paterno or the graduate assistant, who witnessed the rape, didn't go to the police. Then I thought about my experiences in "quality assurance" in the hospital both before and after joining administration.

I along with every doctor in my hospital are restrained by a gag order against publicly commenting on anything. I am not sure whether that includes calling the police, however if I was a junior doctor with a career ahead of me, I might just want to go through what I was told were the appropriate channels. Had a gone through the appropriate channels I know exactly what would have happened. Faster than I could blink, the risk management people would have been all over the case.

"Is that really what you saw?",

"What is this going to do for the hospital's reputation"

"Can we get sued for a wrongful accusation?"

"Let's investigate more"

"Don't go to the police until we tell you."

I suspect this is exactly what went on at Penn State years ago.

On the other hand Paterno could just be a senile old bastard who put his friendship with a pervert ahead of protecting children.

I'm sort of leaning that way.

Getting Stiffed!

2011-11-14T10:35:00.009-07:00

Most doctors outside of Soviet Canuckistan (as an American commentator called us) assume that doctors in Canada are salaried employees of the state. While it would be nice to have paid holidays and a pension plan, this fortunately or unfortunately is not the case. We do get over 90% of our income from the government either through the provincial health plan or through Workers Compensation, however we do this in a fee for service fashion. This means that we have to eat what we kill and as anaesthesiologists we are dependent on what the surgeon brings to the OR for our living. Depending on your outlook this either gives you the best or the worst of the public and private systems. We are fortunate in only having to deal with a small number of payers.

All Canadians citizens and landed immigrants are theoretically eligible for health care in Canada. I emphasize the word theoretically. It is first of all necessary to register. This is not automatic, when you are born you are registered with your parents, when you turn 18 or when you finish university it is necessary to re-register. Nobody tells people that and so some people don't bother. Some people apparently believe Medicare violates their religious or other freedoms and intentionally refuse to register. I get a list of their numbers about once a year. Some provinces also charge premiums. Our province did until 3 years ago, as an election promise, premiums were removed. Every province that charged premiums also had premium assistance for low income patients including the working poor. Some people of course proudly refused to apply for premium assistance, considering it to be a form of welfare. They weren't too proud of course to stiff the doctor. Some people intentionally didn't pay their premiums knowing that they were unlikely to use the healthcare system, if it was minor the fee would be less than their premiums and if it was major the province would allow them to "back pay" their premiums. One of these people wrote me a nasty letter after I billed $47.00 for seeing her daughter for an earache at 0600. And no, there wasn't a cheque in the letter.

Things have improved but at one time up to 20% of patients in the provinces that charged premiums did not have medical coverage. When we did have premiums, they were often paid by employers. If the patient changed jobs or his company went out of business or if they "forgot" to pay their premiums, they weren't covered anymore and you didn't get paid. One lady I saw in the Pain Clinic was supposed to have her ex-husband pay her premiums as part of the divorce settlement. When I advised her that her last billing had "bounced" she burst into tears. Not very therapeutic.

Some people also move around a lot. During the oil boom we had many people from other provinces presenting to the OR. Most have them had lived in our province for a year or more but still had their original province's healthcare number. Surprisingly I got paid for most of these. Because all Canadians are supposed to get healthcare, the federal government has agreed to cover those people for whom no province will cover. This is a bureaucratic process but may be worthwhile if you have a particularly long case.

It is actually visitors to our country who are the most likely to stiff you. Most people are smart enough to buy travel insurance. Travel insurance however, typically has a ceiling which, if hospitalization or ICU is involved is quickly reached, with the hospital getting all the money before there is any consideration of paying you. I did a fellow from New Zealand years ago who came to Canada to ride in the rodeo. He had an insurance policy which had a $200 per day limit. I did send a bill to the Canadian address he provided and it came back "return to sender". Insurance companies also require you to send the bill to the patient who is supposed to pay you and send the bill to them for reimbursement. Most patients don't bother. There are exceptions of course. One very wealthy American that we did an emergency subdural on, not only paid but phoned me to make sure I had gotten the cheque.

In the scheme of things, we are well paid and at the end of the year, the couple of hundred bucks someone didn't pay you doesn't really affect your income that much. The problem is that many of these cases were emergency cases where you either got out of bed, as for the American hunter who shot himself in the foot requiring an emergency debridement at 0400 or stayed late as in the case of the kick-boxer from Switzerland who had the 5 hour ORIF of his mandible (I stayed late because most surgeons take only a hour to do these; this surgeon let the resident do the case and then had to re-do himself). I have heard some anaesthesiologists advise guests to Canada requiring surgery, "The fee is ____, there is a cash machine in the lobby." I have never had the cojones to do this.

What has often bothered me about getting stiffed is not the lost income; I do lots of things for free. I just wish sometimes people would just tell me that they can't or won't pay; I could then decide whether or not to do the case and if I did do the case I could get the moral feel-goodness that you just can't put a price on.

Prestige My Ass

2011-11-03T14:20:00.003-06:00

Because I flew a lot in 2009, late in the year I got a letter from Air Canada that I was now a Prestige frequent flyer. I don't fly a lot, I fly more than most people and I get frequent flyer points with my credit card. I do like flying business because of my size, the meal is a little better as is the wine. I also like the first class lounge for long connections or when I arrive early. When I fly on points if I have enough I try to get business, if I am flying away to whore for Big Pharma I usually try to get a business class ticket out of them. (After flying to Toronto in the middle seat between two people my size, I vowed never to fly to Toronto on "business" without a business class ticket. Now when I get invited to a meeting, I demand business class, they almost always agree. Maybe that's why I hardly get invited anymore.)
I don't pay for business class however. I would have to drink a lot of wine to justify the price differential between economy and business. When I am paying for it myself, I fly economy, get an aisle seat, if possible a bulkhead or exit seat (you can pay a little extra to get one now) and I suck it up. They often don't feed you in economy, therefore I eat before the flight, I bring a sandwich or trail mix. If I want a drink, I pay for it.
I was therefore really excited to learn that I had joined the ranks of the privileged frequent flyers. I had visions of stop-overs in the Maple Leaf Lounge, using the special check in and boarding lines and of course the upgrades to business class.
Then I read the small print.
Prestige is the bottom tier. Elite and Super Elite are way ahead of you. A Prestige class membership and $6 will get you a small plastic bottle of wine on most Air Canada flights. In other words all you really get is a dark grey piece of plastic. You do get 4 "free" upgrades. In order to be eligible for these upgrades you need to buy the most expensive economy class ticket which costs twice as much as the least expensive. This is the flexible ticket which allows you to cancel or reschedule (which is preferred by business travellors who may have to reschedule and whose companies won't shell out for business class). Buying that ticket isn't enough. You then only get an upgrade if there is room in business (which is logical). Therefore you have to bet against your more expensive ticket that you might get upgraded. I actually did this en route to a meeting where my travel was being reimbursed. I got upgraded going out but not going back. And of course I felt bad for stiffing the conference with a more expensive ticket.
You also don't get to use the shorter check in lines, or get to board at your leisure. You do get 4 passes to the Maple Leaf lounge which is better than a kick in the teeth I guess (I used two and lost the other two).
I don't mind not getting something. I do hate thinking I am getting something and then having it pulled away.

A good if somewhat late post on 911

2011-10-31T14:37:00.002-06:00

Rafe Mair posted this.

Rafe Mair was a cabinet minister in the 1970s and 1980s under the right wing coalition government that existed then in BC. He was then a radio hot line host.

His conversion to Progressivism is an inspiration to all.

Supplements, a personal history

2011-10-31T08:58:00.013-06:00

I found this interesting article on Nation of Change

I have for one reason or another taken some type of supplement for most of my life.

As a child my mother would not think of letting us go to bed without taking what she called an oil pill which I believe was cod liver oil and a Vitamin C tablet. I continued to take Vitamin C into adulthood in only because the chewable ones tasted good. I don't think they prevented colds, I seemed to get more colds and longer colds than most. I never quite figured that out. In university my room-mate who was doing his PhD in biochemistry convinced me to take Vitamin B complex as well which I did for a few years. In medical school they told me that all vitamins did was create expensive (but nutritious healthy) urine. I stopped taking Vitamins.

In the mid 1990s I for some reason developed PVCs. After a panicked trip to the ER, sleeping overnight in a stretcher, a stress test and echo it was decided that I had what were "benign PVCs". I stopped coffee for 6 months and still had PVCs so I started coffee again. A medline search on benign PVCs lead me to believe that salmon oil might be effective so I started that and have taken that ever since. I also started to take Vitamin E and aspirin. Somewhere along the line I learned that Vitamin E actually increased rather than decreased cardiac mortality so I stopped. I also ran out of aspirin and just never got around to getting any more. My heart continued to merrily beat on irregularly for several years until one day the PVCs disappeared (I lost about 25 lbs on South Beach around that time, most of which I have put back on). I still take fish oil.

Cold FX was the next supplement. This extract of ginseng was actually developed at our university. Despite its being endorsed by Don Cherry, I was sceptical until a study came out showing taken prophylactically it did reduced the frequency and length of colds. I take 2 a day now and rarely get colds. There are of course other factors, I have probably had every possible strain of rhinovirus and am immune, and I wash my hands a lot more nowadays at work.

After I gave a talk to family medicine rounds, one of the family docs approached me and asked if I had ever prescribed Vitamin D for my patients. I said not, but right away went onto Medline and sure enough there was something there, especially at our northern latitude. I now measure Vitamin D in my chronic pain patients (it is universally low!) and take 6000 units a day myself. This seems to have solved my seasonal affective disorder. The jury is still out on Vitamin D and chronic pain but I figure if someone's level is low it makes sense to treat it. I of course have never measured my level either before or after treatment.

Oh yes my SAD which I self diagnosed about 10 years ago. Going to work in the dark, coming home in the dark and working all day in a windowless room didn't help that at all. I bought a SAD light, the problem with is however you have to get up 30 minutes earlier to sit with the light. I also brought one of the blue SAD lights for when I spent the day in a windowless room. Somebody stole that light, I hope they are feeling better. As I mentioned Vitamin D and changing work environments helped the most.

About 3 years ago I developed tinnitus. I attribute this to sitting in front of the trumpets in band, although I am sure the high pitch of the cautery and suction in the OR have something to do with this. When I was a GP patients occasionally presented with tinnitus; I usually dismissed them as complainers, wasting my time. I had no idea tinnitus could have such an effect on your life. I got custom fit ear-plugs for band practice which I couldn't use because they distorted the sound so much (my conductor told me most musicians just use the cheap foam ones). I still use them for rock concerts, hockey games and plane flights. I tried Vitamin B6 which I had always recommended to patients. I had heard it caused "flushing". Flushing poorly describes the total body burning I got after I took my first and only dose. Ginkgo was also ineffective if better tolerated. Finally I read about CoEnzyme Q 10 and picked up some. My tinnitus seems to have been reduced although it could just have gotten better on its own, plus I no longer sit in front of the trumpets.

I suffer from gout for which I tried various supplements none of which worked. Conventional medicine wasn't that effective until I got an internist I know to prescribe colchicine, which I fortunately tolerate and which kills gout in about a day. I could stop drinking beer and red wine but I like beer and red wine.

The result is that this morning I took:

6 capsules of Salmon oil
2 capsules of Cold FX
6000 units of Vitamin D
500 mg of Vitamin C
150 mg of Co Enzyme Q
81 mg ASA

I chewed the Vitamin C, the rest I threw in my mouth and washed them down with a large glass of water. I followed this with my favourite supplement: coffee.

I know that the evidence for most of this is weak but there is evidence and for some of them there is as much evidence as there is for conventional treatments. The difference is we don't see detail men out buying lunch for Vitamin D and CoEnzyme Q. And I know that periodically evidence will come out that these supplements don't work or may even be harmful, just as they have been for countless conventional medicines since I became a physician. I mentioned above the Vitamin E may in fact be harmful. We recently learned that multivits may be harmful. Next time I have a few hours I will discuss all the conventional medicines we now know to be harmful or useless.

I also know that most supplements are not manufactured by mom and pop operations on their solar powered organic farm but are in fact made by big corporations, often by Big Pharma. Shoppers Drug Mart (which owns or is owned by a tobacco company) makes its own house brand of supplements as do the other large chains. There is huge money to be made in supplements largely unfettered by the regulatory scrutiny prescription medications have to undergo.

I can't really say that the handful of supplements I swallow every morning are helping me. Maybe if I just ate better and exercised more I could accomplish the same thing. Some of my complaints like the PVCs and the tinnitus have gotten better; on the other hand no supplements helped with the gout and some supplements didn't work for the tinnitus either. I spend a significant amount of money every month for which I don't get reimbursed by my drug plan. Expensive placebos. Who knows? I learned long ago if the patient believes something is working, you should encourage him to take it (provided it isn't harmful).

Some Days I Long For the Boyle Machines

2011-10-23T17:17:00.004-06:00

I mentioned some time ago that our department in a moment of stupidity bought two Drager Primus machines to be used in Obstetrics. That was until we discovered that if somebody turned them off, there was a 30 minute boot-up. Not very useful for obstetrics. Therefore they were exiled to our Day Surgery OR where they will never ever see and emergency. Last year the hospital tried to force us to buy 8 more of these machines but we were able to block that.

About a month or so ago the Drager rep made a visit to our site to install a software update. It went for the most part un-noticed until about two weeks ago, of our anaesthesiologists pushed the wrong button. The Drager Primus has a number of "soft keys" with which you select the various modes of ventilation, spontaneous, volume controlled, pressure controlled etc. To the right of the buttons was a unlabelled button. Most people know better than to push unlabelled buttons, no good can come from that. This was the case. Immediately the gas flow ceased and patient could not be ventilated, nor could he by pushing any of the labelled soft keys restore things back to where things had been. Fortunately it was not in the middle of night, he didn't panic, he got an ambu bag and hand ventilated the patient while switching him to TIVA. The machine was taken out of the room and one of the older machines brought in.

After much investigation, we figured out that the following happened. The Drager Primus comes with the option of using a Mapleson D, E, F or Bain circuit which we never use and therefore when the machine was installed the connection was "tied off" and the software was adjusted so that the option of using the Bain circuit could not come up. When the software update was installed this disabling of the Bain option ended and when my colleague pushed to unlabeled button, the machine went into Bain mode, discovered that the Bain lines were "tied off" and basically shut down the machine.

Our biomed people reprogrammed the machine to disable the Bain option again and the machine worked okay. About a week or so later Drager got around to sending someone to fix the machine.

This all makes me long even more for the Boyle machine. Simple, powered by compressed gas from the central supply or from the cylinders if the central supply failed. No need to plug in. Everything mechanical with ingenious inventions like the interlink and the fail-safe valve. No software. Ready to use as soon as you were. And with a pulse oximeter on your patient, just as safe (actually safer if you have Drager Primus).

A Visit to Our Orthopedic Surgery Centre

2011-10-20T10:12:00.005-06:00

Our orthopods have done a marvelous job of marketing the total joint arthroplasty as the be all and end all of orthopedic care. While all kinds of surgical procedures and for that matter medical treatments and diagnostic procedures have wait lists in Canada they have managed to convince governments that their procedures merited special attention. I am not crapping on the total joints, if I need one, I sure hope I get one in a timely fashion and as an anaesthesiologist I love what is for the most part good mindless work. I just am curious about the attention paid to something which is really only a part of the care for osteoarthritis.

This post was inspired by my visit to the new Orthopedic Surgery Centre which is separate from the adjacent Big Downtown Hospital (BDH) but tethered to it by a walkway. The idea was that all our region's total joints would be done Monday thru Friday, uninterrupted by emergencies, no infectious patients to spread their germs and no internal medicine patients spilling over onto surgical beds. Our hospital has so far managed to hang on to its share of total joints and so I decided to see what the competition was.

I arranged to be met in the spacious foyer at 0800. As usual I arrived early. You would have no idea you are in a hospital, there are laminate floors and oddly retro furniture to sit in. (The other reason you don't think you are in a hospital is that there are no smokers clustered around the door holding their IV poles. )

Upstairs to the ORs where the head nurse took me there was spacious receiving area and recovery room as a single large space. The OR's were large and had modern equipment. Because it was designed by surgeons, there were no induction or block rooms, so the surgeons won't have worry about pesky block happy anaesthesiologists slowing their room. There are 4 rooms with only 3 open .

Upstairs there were more laminate floors and the rooms which I got to look at from the door way were large and had comfortable furniture for the visitors. I can't help but wonder what that laminate flooring is going to look like after a year of stretchers, walkers and general foot traffic.

Of course ASA 3 and 4 patients and the revision horrendomas will still be done in the main hospital to which the OSC is tethered. I can't think of the last total joint I saw who wasn't ASA 3 but maybe that's because they are all being done elsewhere. Another example of cream-skimming but at least in the case the cream is staying in the public system. Also because they never bothered to ask urology, when the nurses can't catheterize the patient, they have to cancel the case.

The preassessment process is done on another site as are the follow-ups which makes no sense if you are going to build a completely new building but of course you have to remember it was designed by and for surgeons.

One thing I have learned by working in chronic pain and by having older parents is that total joints are great except when you are either too young to have one yet or too old and sick (although ortho keeps on pushing the envelope on old and sick). There is a tendency to just throw one's arms up in the air when you just can't fix things by sawing out bad bone and gluing in metal and plastic. Also with so much attention paid to two procedures, other less sexy orthopedic procedures are sure to languish.

The other thing I have learned as operating time for total joints has increased in the time I have practised is that as more time is freed up, the indications creep. I mentioned older and sicker patients above. At our site we do a lot of patients whose mobility is as restricted by their COPD or CHF as it is be their arthritic joint. At the other end of the spectrum we see people who really don't seem to that bothered by their arthritic hip. We are doing younger and younger patients now, which means the innevitable revision.

As a taxpayer, I can't help but wonder if we needed a new building to accomplish this improvement in total joint arthroplasty care. One of the three rooms at the new hospital does total joints that were formerly done at another hospital which means a room is now empty at that hospital. The other two come from the BDH which essentially means the closure of two rooms there. I suspect some administrator is already looking at the total joints done at our hospital and soon we may have some vacant OR time. I am only the Site Leader for anaesthesia, no need to let me in on this.

But what happens if other specialties demand their own separate hospital. Cardiac surgery already has their own. Why not a hospital for laparoscopic cholies, one for hernias etc the list could go on. Are we going to see the general hospital become a thing of the past, or a just a dumping ground for stuff that can't be safely outsourced to a fancy new building?

Why I Support the Occupiers

2011-10-19T13:14:00.008-06:00

Other than the loss of much of my retirement income, the current financial crisis has not really hurt me much. I work in the healthcare sector, people keep on getting sick, having surgery and ending up in chronic pain. Our province is buffered from economic reality by virtue of sitting on top of large amounts of oil and gas. Moreover Canada's banks didn't collapse if only because successive governments ignored the advice of business sector and didn't deregulate our banks. (It will take at least a few years before the Canadian Tea Party which currently governs us figures people have forgotten and moves to deregulate everything that moves.)

Yet I am behind the thousands of people who are occupying Wall Street, Bay Street and central business cores across the developed world.

Much of this is because I am proudly a Bleeding Heart liberal who never backed away from a chance to challenge the MAN even if I have become part of the MAN. While this is a good time to be rich in North America and I believe I could now be called rich, it is hard to ignore what is happening to our fellow men. It is also hard to ignore the war on the middle class that has gone on for the past 25 years. It is hard to not be disgusted at the super-rich. How much money do you actually need?

But more it is just a feeling that Wall Street, the Stock Market and the whole financial services sector just need a good spanking and those of us who should have done this about 10 years ago and certainly should have in the last three years have just stood by kind of like the soccer mom at the playground repeating to her spoiled child, "Oh that is so inappropriate." when what the kid needs is good swat.

I have had a long relationship with the "Stock Market". As someone who is self employed I don't have a pension plan. Doctors could have negotiated a really good one years ago but our leadership said there wasn't any need because we could do better with the Stock Market. It is therefore necessary to put away money. You can only put so much in a registered retirement savings plan which our financial advisers tell us nowhere near enough to retire on so it is necessary to have other savings. Having read "The Wealthy Barber", I began to pay myself first and put away 10% of my earnings. In its wisdom our government taxes capital gains and dividends at a lower rate than interest so it is necessary to invest in the stock market usually through a mutual fund. There are a lot of doctors who eschew investment funds and are happy to regale you with their investment secrets, however most of them are in their 70s and still working.

The first thing I noticed was that although my mutual fund claimed to be earning 10+% per year, the money fund wasn't growing anything like that. I never really asked any questions because you don't question the stock market. Next we have the Dot.com stock market crash, followed a couple years later by the Enron stock market crash, and after a few years of "stability" and growth this latest market meltdown.

I used to be disgusted by all this but now I am merely amused (hey what a great name for a blog). I have long ago given up retiring at 55; 65 is a fantasy and I am cautiously optimistic about 75. Not that I am complaining, I like my job. There is of course the resentment that I did everything right and still haven't come out much ahead. Sheep-like, every month by direct deposit so much goes into my RRSP, so much goes into my mutual fund. Every six months or so I meet with the frat boy who manages my portfolio and we rearrange the deck chairs. I could of course put it into interest bearing funds and earn 2% which sounds low until you look at the negative return on your mutual fund statement. Besides I am actually not allowed by law to put my corporate investment accounts into interest bearing funds.

What has always fascinated me is the mystique behind the Stock Market which really is just the sale of small pieces of large and not so large companies. The share price is based on the companies assets and their earnings or potential earnings. Theoretically if you hold a number of companies over time, the average value of the companies will only grow as much as the economy grows. Shares of companies fluctuate for sometimes a good reason and sometimes no apparent reason. Money can be made by betting on these fluctuations. I have always been amused by the stock market responding to current events positively or negatively even when the event in question could really have no conceivable effect on the value of companies. It was like the stock market was a living person who sat in a room stating "we are /are not amused". This was followed by the slavish devotion of governments trying to keep the stock market happy.

More sinister was the way companies could increase their stock value by hurting people. Close a plant for example and your value goes up. I always thought the purpose of a company was to make things. Even more sinister is the way people are able to make money by betting against the share values. What conceivable use can this have in our economy.

The results is that I have figured out that the stock market is essentially a glorified Ponzi scheme and a form of legalized gambling. It depends on suckers like me sending in my monthly withdrawals in the hope that I can retire some day while the insiders get insanely wealthy. Which they do whether or not the markets actually go up or down.

In the run up to all this latest madness we of course had the Real Estate bubble which hasn't quite broken in Canada. This meant that my former house appreciated at least 2.5 times what it cost me to build it in 1998. That would be great if I could move somewhere with lower housing costs. Usually places that have lower housing costs have lower costs because nobody wants to live there. Of course if my wife and I have the good taste to die before we sell the house, my kids are in for an unearned windfall. What concerns me however is the fact that a house or even a condo is quite possibly out of reach for my children. Joking about them living in our basement at age 40 doesn't seem so funny any more. And who really made all the money in this housing bubble? The banks and the realtors of course.

But what infuriates me was that the government actually had the opportunity to come out of this ahead. Imagine if they, instead of bailing out the banks, had actually taken over the failing ones. A government owned bank imagine, what we could do with that. Our province which is not quite North Korea (except for only having one political party) has had its own government owned bank since the 1920s. It takes money deposited in the province and for the most part loans it out within the province. Quite a few of these loans are shady ones to friends of the government. The auto companies likewise. The government could have bought every share of GM for a fraction of what it cost to bail them out. Wow imagine a government owned car company that made cars people actually wanted to buy. Safe cars that got good gas mileage.

Some people have said that instead of occupying places people should get involved in the political system. Good idea except consider that our Canadian Tea Party got a majority government which is the closest thing you can get to an absolute dictatorship with only 40% of the vote. They are currently merrily dismantling programs that took most of the 20th century to achieve. All the opposition can do is talk, the government with it's majority in the house will pass the legislation and they know that keeping their 40% base happy will guarantee re-election. No wonder fewer and fewer people vote. Every four years I make a trip to the polls to vote against my Conservative candidate. It doesn't matter, she gets 60% of the vote.

A lot of conservative pundits are downplaying the protest. "After all things are not as bad as the Great Depression," they say. My parents grew up in the depression as did a lot of their friends and I used to hear, growing up, a lot of nostalgia for the Depression years. But frankly is that the best they can do; sure things are bad now but things were a lot worse in the Great Depression. Like haven't we learned anything in the succeeding 70+ years about how we really don't want to go thru that again?

Or the other objection: things are a lot worse in the third world economically and politically. Again, isn't it better to do something about the way things are spiraling down before we become part of the third world. Isn't it better to complain about the erosion of our democracy while we still have one?

And sure some of the protesters are the people we see at every protest, some of them are vegetable rights people and some of them are not very clean, have piercings and funny haircuts. I suspect (I haven't gone down to my local occupation) that there are a lot of people who are fed up with the way society is going and frustrated with the inability to effect any change through political channels. And you have to admire how peaceful and well-behaved everything has been.

I am a student of history and have read about a lot of popular movements. Many were crushed, some fizzled out, some were co-opted and some went horribly wrong. I am pessimistic but at the same time optimistic that this surely is the start of good things to come.

Yet another thing I learned while on the toilet

2011-10-15T15:11:00.004-06:00

Whilst in my "office" this afternoon I picked up a copy of the Bathroom Reader and opened it at random. There was a page of quotations from Mark Twain. One caught my eye.

"Every time you stop a school, you must open a jail."

Sounds like our politicians should spend more time reading in the bathroom.

Follow up on the environment in Healthcare

2011-10-12T18:36:00.003-06:00

I found this site (courtesy of Steve Duckett of all people)

Apparently I am not the only one concerned about the environmental footprint of healthcare.

Out out damned spot

2011-10-06T13:37:00.005-06:00

I have a confession. I used to read Science Fiction. Not the pulpy stuff but quality writers like Arthur C. Clarke and Ray Bradbury. I especially like Bradbury who doesn't always write science fiction. It is one of his non-SF pieces that I just thought about.

The story is about somebody who after a disagreement with a friend or acquaintance murders said individual. He prudently decides that he must remove all evidence that he was in the house and starts wiping every surface he may have touched. He of course keeps on remembering places he may have touched and so has to wipe these off and so on and so on. The result is of course that he never leaves the house and is still there the next morning when the police come to arrest him. The last thing he does as he is lead out handcuffed, is to wipe off the door-knob.

This unfortunately reminds me of the hand-washing campaign at our hospital.

Hospital acquired infections are not nice and anti-biotic resistent ones are even worse. Anything we can do to prevent these is a motherhood issue and hand-washing is a pretty simple and cheap solution. Our zone went through an audit of hand-washing several months ago and our hospital did not do well with of course doctors leading the way. This sounds really bad until at an executive meeting I learned (for the first time) the rules that we are supposed to follow.

It is not enough to wash your hands after seeing a patient, you must also wash your hands before you see the next patient even if all you do is walk from one bed to next without even picking your nose. Even if you have no intention of touching the patient you must wash before and after. If you wear gloves, you must wash before putting on the gloves and after "doffing" the gloves. (It is so nice to see an archaic verb like doffing come back into use.) Miss a single step and you are non-compliant. Because of this a lot of well meaning docs failed the test.

Because you now have to wash your hands twice for each encounter, visualize this. If I see 24 patients in the pain clinic and see them an average of two times each visit, that is 96 hand washes in 7 hours (13.71 hand washes per hour). I could do this more because hand sanitizer bottles are conveniently placed by every door in the hospital and being slightly obsessive compulsive I actually stop and wash my hands.

To help with our compliance, bottles of hand sanitizer are appearing on walls all over the hospital. Many of these are empty which is a good thing because people are washing their hands but a bad thing because you have to look for another one to wash your hands before the hand washing Stasi see you. Our receiving area on the other hand doesn't have room to put a hand sani dispenser at every cubicle, a single dispenser has to do for 7 cubicles. (They had to take them out of the emergency department of our inner city hospital because people were drinking the alcohol gel).

Hand sanitizer doesn't work for C. diff of course and we don't know who has this but we are going to just forget about this for a while.

Private doctors offices which is where most of the doctor patient interractions occur are of course exempt from this well intentioned madness and in some offices like the one I am working in today, you actually have to go way out of your way to wash your hands. I recently saw a patient at a private office and referred her to my hospital pain clinic where the nurses somehow discovered to their horror that she was MRSA positive and wisked her off to the isolation room where she was placed in the magic yellow gown.

Stethoscopes are another issue. Wiping your stethoscope with hand sanitizer which I do apparently doesn't work and it is necessary to use another anti-septic. Unfortuately this anti-septic eats plastic so they have not yet made any recommendation about what you do with your stethoscope. Fortunately most doctors have forgotten what exactly a stethoscope actually is so we don't have to worry in that respect.

Thinking of all the times you forgot to wash your hands,all the times other people forgot to wash your hands and the surfaces all of you touch has made me feel like Bradbury's character. Who for example knows what germs are on this keyboard I am typing this on. We can eliminate a lot of germ transmission but even the best intentioned most OC person is going to slip up.

Packaging

2011-09-26T10:48:00.009-06:00

I lost the little adapter that enables me to plug in my I phone directly to a wall outlet. As I knew I was going to be in the hospital all night and would probably need to charge my phone, I headed off to the mega mall to get a new adapter which I found no problem.

Here is the charger above. Not a great photo and I should have put a ruler or something next to it but most of you can figure out how big it is.

Here above is the charger before I took it out of it packaging and below is the packaging which I recycled.

This kind of reminds me of a clip from Curb Your Enthusiasm.

I handled this in a more mature fashion than Larry did but why does everything we buy now have to come in a hard to remove plastic case which is often 2-3 times bigger than what we bought. The worse case was the USB stick I bought at Costco that came encased in a plastic cases that was 30 cm long and 20 cm wide. I suppose that one reason for packaging a small item in a large package is to prevent shop-lifting. There are other approaches like for example hiring more staff.

Just Friday I was looking at the large garbage can in the Pain Clinic. I typically fill this to the rim by the end of a clinic. I trained using reusable epidural trays and I never want to go back to that (on the other hand the reused needles were so blunt it was impossible to get a wet tap) but do we really need all this packaging. I have a number of patients with intrathecal pumps who come in every 1-2 months for a refill. The kit we used to fill the pump comes in a box 20 by 20 cm. This holds a 22 gauge needle, a filter, a 60 cc syringe and a narrow bore tubing I use to empty the pump and refill it. It also comes with an instruction manual in multiple languages that is the size of a small paperback novel. All the packaging and literature goes straight to the garbage.

Another anaesthesiologist told me how in their hospital the German company that makes pedicle screws used in back surgery had been bought by an American company with the result that the size of the packaging actually tripled in size. Germany many years ago forced companies to reduce the size of their packaging. Just about all our surgical equipment comes in elaborate plastic cases. Some of them are quite useful. You see them around the OR used to store things. Nurses bring them home sometimes; I have brought home the odd piece of OR plastic. Most of them go straight to the garbage from where they are trucked to the incinerator. No recycler will touch them, they could have some nasty bug on them. Which reminds me, when I came to the CofE they had an incinerator in the building that burned all their medical waste. Drapes, syringes, needles all went into the same bag, somebody took them downstairs and they were burned, heating the building in the winter we were lead to believe. That was of course too good to be true and now by government edict all medical waste has to be separated and trucked 200 km south to a waste disposable facility owned by some well connected people.

A Ugandan doctor who visited our OR years ago was appalled at how much we threw out. In Ecuador we bagged our garbage to be disposed of by the hospital but realized that the local OR nurses went through it looking for things they could re-use. We started separating our garbage to help them out.

In my first job a senior staff member religiously scoured the garbage for things he could re-use. Periodically an award in his name was issued for a particularily creative re-use of what would otherwise be medical waste. For example tubing used in opthamology was re-used as ETCO2 tubing. (I wonder how many prions were transferred).

There was an article in the recent Medical Post which I am ashamed to admit I read ( it was in the lounge and I was bored okay?) This outlined the large amount of waste particularily with orthopedic cases and the environmental cost. We are big offenders in anaesthesia and maybe we should be taking the lead in this.

Adventures in Automobile Service Land

2011-09-19T12:29:00.002-06:00

I recently leased a car which I am overall happy with.

Except:

At the beginning of last month the radio died. This was the stock radio which is standard on that make of car and it has a CD player also standard. Car stereos are no big deal anymore. I figured it was a loose connection and so I (my wife actually) phoned the dealer to make an appointment to get it fixed. The service department asked us ,"Did we know that we are due for scheduled service at 8000 km". We didn't actually because the service manual says 15000 but that's okay, I like my car to work properly and I feel sorry for the poor car dealers who make a lot of money servicing the cars they sell in this recession, even if they were partially responsible for it.

On the appointed day, a Friday, I dropped my car off at 0700. I phoned just before noon in the delusion that I might be able to pick it up at lunch and of course it wasn't ready. Around 1500, the service guy phoned and told me that my radio definitely didn't work but that they were going to have to order a new radio and would I mind coming in next week. I asked them why they just didn't take a radio out of one of the new cars on the lot and he explained they weren't allowed to do that. He did it in a patronizing way that made me feel like I was stupid for even suggesting that as a possibility. They should have the radio by Monday and I could bring my car in.

Problem.

I am going on vacation taking that car; now not only do I not have a radio but I have to make another trip to the dealer.

I phone the Monday after my vacation and get referred to the parts guy who says my radio still isn't in. He also lets slip that they actually didn't order one on the Friday the car was in the dealer but waited until the following Monday. I get pissed off, ask to speak to the general manager and actually get to talk to the comptroller who on hearing my story is apologetic and offers to facilitate things.

Tuesday afternoon I get a message that my radio is in. I ask if I can bring the car in after work. They agree reluctantly and I drive to the dealer. I bring a book because I know I am going to have to wait. After about an hour or so, a flustered employee comes out to tell me that the radio they received also doesn't work but they took a radio out of a new car on the lot and I am free to go.

OK so why didn't you just do that 10 days ago?

While I am waiting, a receptionist comes out to tell a man in the waiting room that they dropped his car off the lift and it is damaged but don't worry they will get the damage fixed and pay for a rental car. I hear him phone his boss to tell him he is going to be late for work. I feel a little sheepish getting so worked up about my radio.

On the other hand maybe the dealers pay actors to sit in the waiting room with sad stories so you feel bad about complaining about the lousy service. I wouldn't put it past them.

Overpaid Porters

2011-09-17T16:09:00.005-06:00

Cataract surgery when I was in medical school was a 2 hour surgery under general anaesthetic with a 7 day recovery in hospital. Anyone who operates on eyes of course deserves to be well paid and ophthalmologists were even in those days. This blog by the is not a complaint about ophthalmology although I could probably rant about that for a while.

Cataract surgery is now a 15 minute procedure done under topical anaesthetic. The ophthalmologist still gets the same fee in inflation adjusted dollars which I promised above not to complain about.

When I arrived in my current city, cataracts were done under retro or peribulbar block with the anaesthesiologist providing the block. We had a nice deal in those days where the anaesthesiologist got a minimum of one third of the surgeon's fee which is a nice chunk of change for a day's work. That's why they were known as retro-dollar blocks. I never learned to do them where I trained and as I tell anybody who asks, "there are some places even I won't stick a needle.". Fortunately we were in a revenue sharing group and there was no reason for me to learn to do them. Times changed, some cataracts were farmed out to private clinics and the rest of them centralized in another hospital. Because a small group of individuals were in the process of cornering the market on cataracts, the province's anaesthesiologists actually voluntarily reduced the fee and the extra money went to other areas.

The joke among ophthalmologists in that era was that while they were capable of doing the blocks themselves, if the anaesthesiologist wasn't present, who was going to push the stretchers in and out of the OR?

Several years later I did a locum in a hospital in another province that still did cataracts. The fee schedule in that province was such that you couldn't make large amounts of money so I actually got to do the list. This list was entirely under topical. The ophthalmologist explained how to do the topical. For 8 hours I put in various eye drops and lidocaine jelly into seniors' eyes and pushed them in and out of the OR. It was a pleasant day, I felt like a bit of slut getting paid to do it and I joked with the nurses that I was just an overpaid porter.

Somewhat apropos as our department recently started doing endoscopy sedations. We started this gradually and just this month made the leap to full-time coverage of endoscopy. Sedating endocopies is an interesting process with the older patients, intensely stimulating parts of the procedure followed by less stimulating times, the high turnovers and the shared airways.

One of the gastroenterologists typifies the old joke about the definition of a colonoscope (a long black tube with an asshole at each end). This fellow has enthusiastically been using propofol for the past few years. He claims have done this uneventfully for years although the first thing I noticed when I first work in endo was how good the nurses were at bagging patients. He did agree to having us sedate his patients. This goodwill lasted about one session after which he "fired" our department, sending off a poison pen letter accusing us of all kinds of unsafe practices. One of his parting shots called us "just overpaid porters". What was worse for me, was the loud and vocal opposition from a small number of department members who believed that sedating a patient was an abuse of their considerable skills. Our GI friend didn't help much here.

The problem of course with anaesthesia is that we make it look so easy. This leads to things like GI, ER and sundry other specialists merrily sedating patients everywhere in the hospital. Drugs like propofol which have a large margin of safety are even more dangerous if only for the false sense of security they give the doctors. One thing I have learned over the years is that a good general anaesthetic is better than a bad sedation. We now have some short acting options which enable us to more safely sedate patients. The "more safely" is as I mentioned as safer or easier also means less respected or less feared. As site chief for anaesthesiology I feel I am responsible for all anaesthetics given in the hospital including those given by non-anes.

There is as I am becoming aware, a turf war in the US between endoscopists who believe they can safely sedate patients while looking up their bum and anaesthesiologists who say they can't. There is a little self-interest in both. In a private system it is cheaper for the patient or the insurer not to have an anaesthesiologist. At the same time endoscopy sedation offers employment for anaesthesiologists and generally a pleasant decently paid day. Our health region recently wanted to trial a servo system that would enable endoscopists to 'safely' sedate patients. They wanted anaesthesiologist to participate in the trials which we politely declined. There are of course studies both pro and con which largely depend on the bias of the person who ordered the study.

As we get better sedatives there are a lot of cases we currently do under general which could be done with local and sedation. Turf is an issue here. The operating room is "our house". If say, a surgeon wants to do some or all of his cases under local, this can be a loss of income. We can stay in the room "monitoring" and portering the patient or we can cool our heels at home or in the lounge. In eastern Canada where I first worked and trained, local cases were almost exclusively done in a local room where surgeons worked while nurses gave sedation. Occasionally we got a stat call to the local room but it usually worked out okay.

I like to think that by sedating patients I can achieve a perfect balance between comfort and safety. One of my mentors as a resident used to lecture me and the difference between being a professional and a technician. When one tries to get the best possible outcome for the patient you are being a professional. If you just show up and squirt in a little propofol, you are being a technician. I hope I am being that I am not just another overpaid porter.

My 9/11 post

2011-09-11T17:08:00.002-06:00

After 911 we had the opportunity to show the Muslim world how Christians can turn the other cheek (not that 2000 years of history have shown the Christians have ever done that).

911 was the day that as a Canadian I felt solidarity with Americans. On that day we were all Americans.

So what the hell went wrong?

Cyclist kills pedestrian / Man bites Dog

2011-09-11T11:28:00.006-06:00

A couple of days I confessed in my blog that I occasionally ride on the sidewalks. This prompted a lecture in comment soon after. I always glad people read my blog.

Almost around the same time I read this in the Globe and Mail. An editorial no less. I obviously missed the original story.

I must of course offer my condolences to the family and friends of the unfortunate gentleman.

While I do ride on the sidewalks, I am always aware of the fact that pedestrians have the right of the way, which is why I generally ride as slowly as it is possible while staying upright and if there are lots of pedestrians I either get off my bike and walk or I brave the traffic. I would never think of riding fast enough on a sidewalk to kill anyone, I can barely ride that fast anyway.

But what the Globe failed to mention was how many pedestrians are killed by cars every year and how many cyclists are killed every year by cars. I was able to find it on the internet in about 10 seconds. In 2009, it was 307 pedestrians and 41 cyclists. Multiply this by 10 to get the American numbers. These certainly didn't warrant an editorial, if there were articles, they were buried on the back pages. Not all the drivers are charged and if they do get charged they often plead to something lesser and get a wrist slap months later. There was no hand-wringing about how this is a tragedy and how can we prevent this.

Interestingly enough I did get yelled at once for not riding on a sidewalk. Our city actually permits riding on sidewalks in certain locations where traffic is heavy. So it was that one Sunday afternoon I was riding along one of these routes. The trail/sidewalk was crowded with people jogging or walking so I decided to ride on the road which was not that busy. Within seconds a pick-up truck (of course) pulled up alongside me, slowed down and the driver rolled down his window to yell at me for not riding on the sidewalk.

I saw this video on Facebook recently. Here it is on You-Tube

That's all I'm saying.

Bike Rage

2011-09-08T10:07:00.010-06:00

One of my staff was riding his bike to work the other day on the road as is his right. He was passing a shopping centre when a car turned left in front of him with the result that he broke her windshield with his head and sustained some soft tissue injuries. Fortunately he had a helmet on and didn't break anything. To my surprise when I phoned him, ostensibly to see if he was okay but in reality to see whether he would be able to work, he expressed remorse that he had broken the lady's windshield. He also told me that she had been looking into the sun and couldn't see him (as a general rule I don't drive when I can't see where I'm going which has so far kept me out of any serious accidents.)

I used to ride my bike down the same street to get to work before I moved. I still ride down it occasionally. I told him that I always rode that particular stretch of road on the sidewalk. He told me he never rides on the sidewalk.

I am not a serious bike rider but I do enjoy riding to work whenever I can. Typically when I drive to work, I arrive at work feeling tired and yet stressed out. When I ride or walk to work I arrive feeling wide awake and almost euphoric (maybe because I survived another bike commute?). While our city does have some bike paths and some designated bike routes, for the most part riding anywhere within city limits is a combination of service roads, side streets, riding cautiously in traffic and unfortunately riding on the side walk. I also ride across crosswalks sometimes. I know that under the motor vehicle act, I am equal to a car and am not supposed to ride on sidewalks. On the other hand, I am not protected by one ton of steel and I really don't want to end up on somebody's windshield or under their front tire and the fact is we have some pretty bad drivers. Besides nobody walks on the sidewalk anymore.

Currently we have some great paved bike paths in our city. Unfortunately most of them end abruptly forcing you to rejoin the road. Our city does have an ambitious plan for bike paths all over the city. Ambitious, as in expensive which means that it will never get done.

Worse than the bad drivers are the drivers who have a hate on for cyclists. A couple of years ago I was riding on a side street designated as a bike route. This runs parallel to a major street which is quite busy and so many drivers use it as a short cut (me included). I was riding along minding my own business when I hear, "Get off the road you asshole.". Just then a car passed me and in case I missed it, he repeated it. He drove on ahead but had to stop at a stop sign, where I caught up to him. I knocked on his window. "Do you want to step out of your car and call me an asshole?", I asked him. I am not an aggressive person but I felt empowered. Besides I could see he was a senior (meanior) citizen half my size and I figured I could probably kick his butt. He looked terrified quickly locked his door. Through the glass he started yelling at me about what was I doing riding down the middle of road (I wasn't). I gave his door a kick, not hard enough to dent it but hard enough to make an impact. He quickly turned left and sped away.

That is probably the worst episode I have been involved with. I have of course been yelled at many times, sometimes for riding across crosswalks or doing rolling stops which I know are wrong but hey it is only my life I am endangering. Many times the driver's rage has been existential. As I told my wife after a pick-up driver honked at her, "you have to remember his drive to work (in the city) in his big pick-up is probably the best part of the day in his pathetic life and you ruined it by forcing him to slow down."

This is not an isolated attitude. Our local tabloid paper actually printed a letter from someone declaring open season on cyclists who ride on the road.

One of the prominent members of the local riding community who my son knows, is much more aggressive. Any driver who misbehaves is chased down. While cars can drive faster than bikes, they too have to stop at lights and he can generally catch them although it may take several blocks. I can imagine the shock and surprise of the motorist on being accosted by an rather large angry cyclist. This is may be a little extreme.

Even pedestrians with whom we should feel solidarity are selfish when we have to co-exist on the shared trails. I have a bell on one of my bikes; I haven't gotten around to getting one for my other bike but I yell loudly, "on your left" as I approach them. Despite this I get a number of snarky looks and remarks as I pass; quite a few refuse to yield. One fellow on hearing our bell actually lurched across the trail in an attempt to block us. As we passed he yelled , "you know I have the right of way!". About 75% of walkers and runners now are listening to their I-Pod, you could have an airhorn and they wouldn't hear you. (MEC sells a bike air horn but my wife won't let me buy one). Dog walkers still haven't learned that if your dog hasn't figured out that it needs to stay out of the way of bikes or worse if it is aggressive toward bikes, there is a device called a leash which the dog should be wearing even though you might be in an off-leash area. Toddlers are a challenge too. Some people find it quite cute watching them zig-zag across the path. I used to too when I had toddlers. They make me very nervous when I am on my bike trying to get past them. Not that I advocate leashes.

This was a victory for those of us who have been bullied by malicious drivers. The driver in this case, an emergency physician had a habit of braking suddenly in front of cyclists. They had complained to the police in the past without avail but with this happened, charges were laid, the doctor was in true American Justice fashion perp-walked from the ER and eventually jailed.

Stop Complaining, You Got to Play in the NHL

2011-09-05T08:03:00.006-06:00

Recently a number of currentand former goons and tough guys have died from suicide, drug overdose or other causes. This is of course tragic for the players, their families and their friends. This has resulted in a lot of soul searching regarding the role of players whose main role in the game is to fight. It has also resulted in a lot of whining from current and former goons about the stress of the role they had to play.

I have never liked fighting in hockey. I remember the exact time when I decided that. It was during the 5th game of the 1972 Bruins Rangers Stanley Cup Final. This game was a classic which the Rangers won 2-1. At one point a fight broke out, I don't remember betweeen who but I do remember thinking that this was interrupting what was a classic game and how stupid it was.

Many years later when I had seasons tickets I remember a game between Edmonton and St. Louis. Midway through the second period, George Laraque came out for Oilers and Tony Twist for St. Louis. They lined up next to each other. The crowd started cheering, the morons with seats behind the glass started pounding on the glass and of course Twist and Laraque dropped the gloves and had a fight. Both got 5 minutes and the game went on. I remember thinking, "What did that just accomplish". I don't think Laraque and Twist had been on the ice together that game so they had no reason to be angry with each other.

The NHL has always had its' fighers. John Ferguson, Dave Schultz, Wayne Cashman, Gordie Howe, Eddie Shack, and later Bob Probert. The difference between these fighters and the current group of goons is that these guys actually played regular shifts. Gordie Howe of course was the leading career goal scorer for years, most of these guys scored 20 goals a season Bob Probert scored 40 goals one season. (Probert is one of the recent deaths, however he had substance abuse issues as a player and died of a heart attack which may or may not have been related to his fighting history.) Philadelphia, the Broad Street Bullies won two Stanley Cups but these had more to do with the goaltending of Bernie Parent than the intimidation factor.

Sometime in the late 70s some teams started keeping a goon on their bench. This player would play a few minutes a game usually to start a fight with the other team's goon or one of their tougher players. This was in the place of a player who could actually play the game, which meant that many marginally talented players spent their career in the pressbox or the American Hockey League so that a team could keep a goon on the bench.

I am not going to go into the pros and cons of fighting. What bothers me is the current series of sob stories in the media by current or former goons about how difficult it was to fight, how they dreaded games etc. One goon lamented that he was paid the minimum $500,000 a year on which he claimed to pay 50% in taxes (he needs to get a better accountant).

OK guys.

I grew up wanting to play in the NHL. My two sons wanted to play in the NHL. Every Canadian playing organized hockey wants to play in the NHL. Only 1 in 10000 kids in organized hockey every makes the NHL. You got to play in the NHL. Moreover you got to play at the expense at some other player with way more talent than you. You got paid more than the Prime Minister. You certain made or are making more than you would be if you weren't playing hockey. So shut the fzck up. Or you can quit or maybe even learn to skate and see if you can make it on your ability to play hockey.

Hours of work

2011-09-03T09:31:00.004-06:00

"The problem with one in two call is that you miss half the interesting cases."

Anon
This article caught my eye.

To summarize, an arbitrator in Quebec has ruled that the 24+ hours shifts some residents still have to work are unfair and have to stop. This ruling of course only applies to Quebec but will no doubt reverberate across Canada. There is no question that long hours and lack of sleep affect performance and judgement. We all know that, we just haven't figured out how to deal with it.

This debate has been seriously brewing for at least 10 years. In our program junior housestaff are allowed to go home after 1200 when they have been on call. Peer pressure usually prevents them from doing this. The innevitability of reduced work hours for trainees has been extensively discussed in academic forums and the conclusion has been that in order to allow residents to work shorter shifts it would be necessary to add 1-2 years onto their 5 year residency.

Anaesthesia on the other hand has allowed residents to go home post-call since before I started training. Some programs now even have 12 hours shifts. Anaesthesiology trainees do 3 years of anaesthesia during their 5 year residency getting their post call days off. They also do 6 months of ICU which also allows them to go home after call. Assuming anaesthesia trainees when they are working work as hard as other residents (judging from the condition of the patients coming to the OR they work way harder than surgery residents), this means that anaesthesia residents get about 20% less clinical exposure during their residency than do surgery or medical residents. That is one whole year.

Consider this however:

If your life depended on the skills of either a newly qualified surgeon, a newly qualified internist or a newly qualified anaesthesiologist who would you pick?

Any anaesthesiologist would of course pick the anaesthesiologist. I suspect however a significant amount of surgeons and internists would also pick the anaesthesiologist. It is quality of training not quantity of training that matters.

When I was a resident I got involved with what was called the Interns and Residents Association and what I called the Residents Union. We negotiated things like salaries and work conditions with the hospitals and the government. Late in my residency our contract was up for renewal. We realized that because of the economy we were not going to get any more money so we decided to negotiate terms of work. At that time we were required to come in for 4 hours on Saturday morning so getting rid of that was a no-brainer. We then moved on to call frequency. At the time we were restricted to maximum of 10 days in 30 (1 in 3) call. We decided to go to maximum of 1 in 4 call. Most services at that time actually did less call than that, the surgical and some internal medicine services being the exception. I sat on the University's Residency Training Committee and attended a meeting where that proposal was discussed. At that meeting there were dire predictions of the collapse of patient care and loss of training opportunities from the staff physicians there. There were also a few threats. The Head of Orthopedics said and I quote, "Any resident who won't do 1 in 3 doesn't get to pick up the knife." We eventually backed down and only got rid of the Saturday mornings.

It was as they said however a fait accompli and now residents only do 1 in 4 call, the collapse of the medical training system has not yet happened.

We do learn a lot of medicine at the bedside. We also have to deal with emergencies some of which happen after normal working hours. Unfortunately forcing trainees to deal with patient care when they are tired is not educational, it teaches them a lot of shortcuts to deal with the problem now in a way that you can get back to bed or watching TV. A lot of advice I got from kindly residents as a student intern dealt with just that, how to defer or patch up the problem until someone else can take care of it. It also makes patients the enemy for destroying your sleep and your sanity. It took me a few years to get over that.

Another issue often raised is the issue of hand-over and continuity of care. It is felt that if residents work shorter shifts patients will suffer as information is not passed on. Nobody has ever commented on what happens now in the evenings when residents go home, leaving everything to the on call resident or on weekends when only the on call staff show up. In most services there is no sign out. When I did general internal medicine for 3 soul destroying months, I recognized quite early that around 1900, I would start getting pages about patients on other services with fairly significant and complex medical problems; patients I knew nothing about. I also learned that if I phoned the attending physician I would get yelled at. Therefore I approached the head of medicine and suggested that around 1600 the housestaff have a signover rounds where these complex patients could be discussed. This was of course rejected as the 30 or so minutes required would take the housestaff away from more important work.

Fortunately nurses who actually do sign over patients between shifts knew something about the patient, something which probably saved my, and more importantly the patient's butt, more times than I can think of.

In retrospect a big part of the opposition to sign over was the whole concept that you shouldn't leave a complex patient which meant you were often expected to stay well into the evening if you had somebody in trouble, rather than signing the patient over to the physician who was eventually going to have to look after your patient anyway because sooner or later you were going to go home and the patient was not going to suddenly get better. Of course the person you were signing over to would have worked as long as you had already that day, probably a little bit harder and wouldn't it have been nice to be able to sign over to someone who was just coming in relatively fresh. What a concept.

Jack Layton

2011-08-24T15:57:00.013-06:00

I seem to get all my bad news in coffee shops lately. I was having breakfast at a coffee shop last Monday when my wife texted me to tell me that Jack Layton had died.

I have supported the NDP all my life. In my income bracket, the Conservatives would be far better for me; I am a corporation, lowering taxes is what they are all about. ( I might even create some jobs with the extra money, that's what corporations do with their money from tax cuts ;Q.) I periodically get involved, mostly I just donate and show up to futilely cast a vote (my Cons member routinely gets 60%)

The past 20 year have not been good to the NDP. They were reduced to a small rump in the House of Commons, and have lost some of the provincial governments that they had. Most of Canada's is now governed by governments more right wing than we would have ever thought possible 20 years ago. Federal and provincial governments in the past 20 years have rolled back many progressive changes that took most of the 20th century to accomplish.

The NDP has always picked polite, well meaning, non-charismatic intellectuals as their leaders. They have run nice polite campaigns while the other two parties kicked sand in their face. They have won lots of moral but very few actual victories.

Jack Layton was different. He was a politician. Yes, a politician. Someone who fought back, who played by the same rules as the other parties. Some people didn't like that. After all the NDP is supposed to been polite and principled. (These were usually the same people who said in the past that they couldn't vote NDP because they didn't have a strong leader). And sure he made claims we knew weren't possible. Like for example he talked about hiring new family doctors. Like, where was he expecting to find them (in the medicentres and cosmetic clinics?). But he brought back a new respect for politicians and what they could accomplish. Many people support all or a large part of the progressive agenda. It's just that the salesmen and women have not been very good at it. Until Jack Layton.

But he made politics interesting and the last five years have been an exciting time for progressives. I remember the coalition a few years ago, when it looked like for the first time Canada was actually going to overthrow a government. Too bad Iggy screwed that one up. But Jack got him back when he skewered him about his attendence in the House of Commons in the debate. And in that debate it was fascinating watching Harper looking at Jack with a mixture of hatred and fear. And of the excitement of the Orange Wave this year and the possibility on the last weekend with the Liberal vote collapsing that Jack and the NDP just might win. And on election night the sight of him on stage waving his cane in the air.

But what I like about Jack was that he always seemed to be having fun. Like the picture, how many times have you seen a politician hoisting a beer (too bad about the Habs sweater). Other politicians go through their photo ops but they don't look like they are having any fun.

But one thing that nobody ever points out is that Jack with his popularity as a municipal politician and his pedigree (which unfortunately seems to be important in Canadian politics) could have run for the Liberals in the 1990s, been given a safe seat, a Cabinet position and we just might now be having a state funeral for a sitting Prime Minister, not the Leader of the Opposition. Who would have blamed him, so many other progressive politicians have sold out (run for the Liberal party). Instead he threw his lot in with a party that had been reduced to 11 members and took three tries just to win a seat. That is committment to principle.

I did meet Jack once at barbecue put on by the party. My wife told me I should go and talk to him so I did but overwhelmed by his aura I was tongue tied and didn't get much beyond introducing myself and saying how nice it was to finally meet him. He was polite and smiled. I wish we (I) could have talked more.

From the grave Jack sent this letter to Canadians which he composed two days before his death. What impressed my wife and I was his advice to Canadians on how we can all try to be better. What an inspiration.

My wife and I attended a candle-light service for him last night. A few thousand people came out and we had speaches from politicians. As we left a choir sang the Canadian version of "This Land is Your Land" . We used to sing this song in elementary school. It is too bad many of my generation never thought about what it means.

Jack said:

"Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world."

Joe Hill said, "Don't mourn, organize". Maybe I should get off my ass.

The Genocide Museum

2011-08-24T14:20:00.008-06:00

My wife and I visited the Genocide Museum in Kigali which I blogged about in my alternate blogoverse. Here is my posting below and I will comment further underneath it.

I am a keen student of history. I wish more of our world leaders studied history. On the other hand I like to live in the now and try to move forward while learning from what has gone on in the past.

We had a free day in Kigali today so we decided to visit the Kigali Genocide Museum. Many people had suggested that this would be a must see in Kigali so we went. I really didn't know what to expect.

We found the museum on the map. Because safe taxis don't come to our neighbourhood we decided to walk to central Kigali where we could get into a decent taxi and get there that way. We stopped at the Cafe Bourbon for a latte and chocolate croissant by which time we actually felt energetic and decided to walk the rest of the way. Like most things in Kigali there is no straight line between two points and while it looked like we were half way there already, what the map didn't show was that we were at the top of one large hill and to get to the museum we would have to descend to the bottom of the hill and then walk up half way up the next hill. This is complicated by the lousy map we have and the lack of street signs in Kigali. The guide did say that we could see it across the valley.

Eventually we arrived at the museum. What impressed me the most was the number of Rwandans in their best clothes heading up or coming down the hill from the Museum/Memorial to pay their respects to their dead relatives.

The Museum itself is surrounded by a number of themed gardens related to life before, during and after the genocide. After passing through these gardens you then visit the mass graves. The remains of 300,000 people mostly from Kigali are entombed there. The graves are covered with flowers left by relatives. At the end of the garden is the Wall of Remembrance which is about 50 metres long. They are trying to put of the names of all the dead, however they have only managed to fill two panels and there is a lot of wall to be filled.

After this we went into the Museum. This contains a history of Rwanda before during and after the colonial period. It then explains in great detail the events of the Genocide. This is underscored by filmed interviews of survivors and historic news footage. There is a room of pictures of the dead, and a room full of some of the skulls and bones. Many of the skulls have bullet holes or machete marks. There is another room devoted to the children who were murdered.

The second part of the Museum is devoted to other genocides including the Armenians, the Herraro of Namibia by the Germans (which I never knew of), the Holocaust, Cambodia and the Balkans.

The goal of the museum is to maintain awareness of genocide in the hope that this will never happen in the future. I always thought that by now we would have found a way of resolving disputes that doesn't involve killing people. I continue to be disappointed.

We walked the long climb home somewhat somberly. The streets we walked through were humming with activity and it seems that the Rwandans are at least trying to live in the now.

This article in the Globe last weekend rekindled my memory.

As you can read, there is a dispute threatening this new Museum over whose rights were the most abused or who got genocided the hardest.

Now having your friends, relatives or ancestors shot, macheteed, gassed or starved is not pleasant at all, no matter how many or how long ago. I suspect if we go far enough back in our family tree we will come across an ancestor whose rights were egregiously abused (in my case you might have to go back to the Norman Conquest!). More likely you are going to find an ancestor who participated enthusiastically in taking away someone else's human rights. The fact is as a student of history and unfortunately an observer of current events, I can't believe how badly we treat and treated our fellow human beings.

The Rwandan genocide occurred 17 years ago. Some of the participants are in jail. To distinguish them from other prisoners they wear pink pajamas, Some of them worked in the hospital doing chores. They looked somewhat old and not at all evil or dangerous. From all accounts I have read a lot of people participated in it either actively or passively. Not all of these people are in jail or exile, which means if you have a group of Rwandans over 30 there is a good chance that you are in the presence of someone who may have hacked someone up with a machete or been the crowd egging them on. It would be hard to imagine a group of people being whipped up into such a state of irrational rage, except that it has happened quite a few times in other so called civilized societies in recent memory. I try to put things in perspective by imagining how I might respond if something similar happened in Canada (and don't think it couldn't). Would I shelter those people being persecuted at risk to myself or my family; would I, if asked to participate, join in knowing that failure to participate might endanger me; would I even enthusiastically participate? I hope it would be the first but I don't know.

I kept thinking of the episode on Fawlty Towers where a group of Germans comes to Basil's hotel and he keeps on telling everyone "Don't mention the war!". On Monday after our visit, a Rwandan asked me what I had done on the weekend and I mentioned that I had gone to the Genocide Memorial. I then felt that I had put my foot in my mouth but he didn't react and I went on to talk about what I did for the rest of the weekend. The first time we really discussed it was with Jean our driver, who it turns out lost both his parents in the genocide. He went to a refugee camp in Burundi where his sister and he were adopted by a Burundian couple. He is currently suing to try to get back his parents' house in Kigali. Another time at dinner with one of the anaesthesiologists we asked him about the genocide. He put his head down, started to cry and told us that he was a genocide survivor and that 500 members of his extended family had been killed. I still don't know whether it was something we should bring up or whether is best left to brought up by a Rwandan.

Aside from the Kigali Museum, there are smaller genocide memorials all over the country. Every year, the genocide is commemorated with no just one day but 100 days of commemoration, equalling the 100 days of genocide. It is almost like the country itself has become a monument to the memory of the genocide. Rwanda however is so much more than its ugly past and I keep on wondering whether it is time to live in the present.

As an aside while swimming at the Serena Hotel my wife and I met Linda Melvern who has written extensively on the genocide and I am reading one of her books right now, trying to just make sense of what happened.

I read somewhere that the buildings at Auchwicz are now falling apart and there is a debate as to whether to restore them or not. I like history but sometime it is better to let evil just crumble into the ground.

Why Internists Should Never Be Intensivists.

2011-08-21T17:28:00.007-06:00

I had a really interesting phone conversation with one of our internist/intensivists this morning.

My morning on call started out with an abdominal washout from ICU. This unfortunate lady had her anastomosis break down a few days ago.

Much to me surprise unlike most abdominal wash-outs from ICU she arrived extubated and "breathing" O2 through nasal prongs.....with a SaO2 of 81%, She frankly looked like shzt. Rapid sequence induction with ketamine and her sats perked up with the endotracheal tube back where it belonged. The plan had been to try to hook her back up and close everything however even our most cowboy surgeon looked a things and said no way. Anyway 2 hours or so of digging around the abdomen, creating a colostomy and closing the wound ensued. As he got into her abdomen, I noticed I needed 100% O2 and some PEEP to keep her sats up. So my plan was to send her back ICU ventilated. That actually was my plan from the start of the case.

As we were in the home stretch one of the nurses called me over to the phone.

"Why aren't you going to send her back to the ward?" a voice asked.
"Who am I talking to?", I asked.
"Dr. Yankovic (not his real name, but the resemblance is striking)," came the reply.

Dr. Y is our head of critical care, a pulmonologist who was practising ICU when I showed up in town.

"Let me see, " I said, "She came down with a sat of 81%"
"So she needs some oxygen" snapped Yanko.
"She was on oxygen", I said,
"Which you would have known if you actually made rounds before 0900, " I thought. "Further," I said,"the surgeon wasn't able to hook her back up, he is closing the abdomen but it is quite tight, and I don't think she will tolerate early extubation."

"Fine," said Dr. Y, "I guess I will have to finish your job for you" Click.

Now I might expect this from some young whipper-snapper intensivist who hasn't seen a surgical patient since medical school but this is someone older than me who is head of his department. I might even expect something like this if ICU was full and this lady didn't have a bed. More and more ICU has come to expect us to run our recovery room as a step-down where patients can be ventilated for a few hours which usually runs into a few days. One of my colleagues who never complains had a similar conversation with one of Yanko's colleagues, also an internist, which ended with the exclamation, "well, if you can't look after her, I guess we will have to take her!"

ICUs historically were run by anaesthesiologists who understood surgery and actually knew something about medicine. That was until internists realized there was good money to be made in ICU, as opposed to internal medicine. Now a significant number of intensivists have an internal medicine background.

The bottom line Dr. Yankovich: I'm not asking you to finish my job, I'm asking you to do yours and I shouldn't have to ask. And by the way, get a haircut.

Rwanda, A Stranger in a Strange Land

2011-08-19T10:32:00.019-06:00

I returned from Africa at the beginning of June, having spent 4 weeks in Rwanda and a week safari in Kenya. I have already posted on my experience with the teaching aspect which was not that positive although I am getting over that and also re-posted some pieces from my travel blog. I have not really posted on my total experience over there which to say the least interesting and eye opening. People who I continue to meet for the first time since coming back always ask me in passing how was my trip? It is really hard to express what I did and felt in a short conversation.

I volunteered 2 years in advance of the mission. I thought that would give me lots of time to get my life in order. In the interim there were a few changes like becoming site leader and I never did (or ever will?)get my life in order. As the trip approached I began to experience near panic attacks; Africa is a huge mystery to me. Rwanda with its still recent violent past was another issue and even though people assured me it was (and is) the safest country in Africa I was a little scared. And then of course there is the packing and trying to make sure you don't forget anything because you know you will not be able to buy it there (again not true, you can buy just about anything at the Nakumat in Kigali).

Inevitably the time came. My wife drove me to the airport with a huge duffel bag of everything I thought I would need for 5 weeks in Africa. I first went to Halifax for a Global Horizons course. Halifax was of course where I interned and where I met my wife, it still remains a city I enjoy visiting and with a lot of pleasant (and less pleasant) memories. After 4 days in Halifax, it was off to Toronto where my wife rejoined me, to fly to Brussels. We spent 2 days in Brussels, one of which we mostly slept but did so some sightseeing, drank some beer and had some good and bad meals. It was also a last chance to buy some of the stuff we realized we had forgotten.

Our European mini-vacation had to come to an end however and early in the morning we went by taxi to the airport to fly to Kigali. After taking a very long time to get through security we got to our gate where we met "my" resident who had flown overnight from Canada.

When I am flying somewhere I have never been before I often look around at the passengers and wonder what their story's are, why are they on this flight etc. The flight was a mixture of people who were obvious Africans although whether they were returning or visiting was hard to tell and quite a few whities. It was a comfortable flight in a large not fully booked plane which gave my wife and I lots of room to stretch out and even try to nap. We alternately napped, and read with interruptions for airline food and drinks. The map on the screen in front of us showed our steady progress, over Europe across the Mediterranean, skirting Libya and down over Egypt and the Sudan. The eight hour flight passed almost too quickly and we were soon descending into Kigali. It was pitch black by the that time but we could see lights below. The Kigali airport lies on a ridge and the landing was so smooth that seeing the lights still below us, I thought for a moment we were still descending. We exited the plane into the African darkness, which seemed darker than I had ever experienced. There was a strong smell of wood-smoke in the air. We walked along the tarmac to the terminal which was newer and nicer than I expected. To our surprise we sailed through immigration and were soon waiting for our bags. Outside the baggage area we could see people waiting for us and we knew someone would be meeting us but weren't sure who.

Exiting baggage we with some relief saw a sign with our names on it and met the resident Damascene, who had come to pick us up with a hospital driver. I had been advised to change money at the airport. $100 US gave me a huge wad of Rwandan francs.

One of the first things I remember once we left the airport was the large number of people out walking along both sides of the sidewalks in the darkness of the mid-evening. Traffic was light and moved quickly. We drove along the sides of hills looking down at lights below until we passed onto what we would come to be familiar with, the Nyamirambo Road which lead to our apartment. The apartment was a three story building on a dirt road, a block off the main drag. It was walled off with spikes on the top of the wall. Our driver honked, and the gate opened and we entered a courtyard. Our apartment was one floor up and we hauled up our bags. We were relieved to see that while sparsely furnished, our apartment was at least clean and comfortable.

Damascene suggested that we would need some food for the next day, so he drove us back to the "Simba" supermarket. I was still in a little shock, we had dropped into this strange country and now I have figure out what I am going to eat for the next few days and I have no idea what things are supposed to cost or what a sensitive Western stomach can handle. We ended up buying some milk, coffee, juice and pastries to eat for breakfast the next day. Oh yeah and of course beer. While we were in Simba's, people were watching the Champion's League final on a TV in the snack bar. I went in to watch feeling very conspicuous. One of the men watching pulled up a chair so that I could watch.

We came home unpacked a bit and watched the rest of the soccer game on our only TV channel, drinking the beer we had bought. We went to bed around 2200. It was very noisy outside our room and still quite hot. We slept under a mosquito net for the first time in our lives. While I waited for the Zopiclone to kick in so I could sleep, I remember almost trembling in fear of the unexpected over the next four weeks.

I awoke with the sun around 0530 went back to sleep and it was after 0800 when I finally got up. Our apartment had a balcony and I was able to go outside and see what we had not been able to see the night before. We were at the intersection of two dirt roads with the Nyamirambo road a block away. Surrounding us were a mixture of concrete one story buildings with corrugated tin roofs often with rocks on top to presumably keep them on, and some nice houses walled off from the street. It was Sunday and people were walking to church. To the west rose Mt. Kigali, the east the land dropped off into a valley and you could see large villas on the slopes across the valley. It was already getting hot.

After coffee and the pastries we had bought the night before we decided it was time to venture out. We had only the Bradt guide with its small maps but I figured we could probably find the hospital which we needed to find the next day and the tourist office. Armed with this we ventured out and turned right down the Nyamirambo road which I was lead to believe would lead us to the hospital and the central town.

Rwanda is known as the land of Mille Collines which means one thousand hills and Kigali is spread over many hills. This means that most of the roads tend to follow the contours of the landscape so a flat two dimensional map can be extremely misleading and two points which appear to be close together can be separated by a deep valley. In general it is not possible get between any two points in Kigali by travelling in a straight line. Because the roads curve it is very easy to lose your orientation. This is further exacerabated by the lack of street signs.

Public transport in Rwanda consists of Mutatus, garishly decorated minibuses crammed with passengers that travel predetermined routes and let people off wherever and motorcycle taxis which are cheap if you want to put your life at risk. There are car taxis which can be easily found in the tourist areas, less easily where we were living. These generally charge Westerners 5000 Rwf (about $9) no matter how short the trip.

We wanted to walk and so we set off down the Nyamirambo road. It was crowded with people walking in both directions. We stuck out like sore thumbs, our white skin and large hats shielding us from the sun. People were neither friendly or unfriendly. There was a large concrete drainage ditch along the side of the road that you had to be careful not to step into. Mutatus and motorcycle taxis raced along the road honking their horns. Alongside the road below road level were small shops and about every 50 metres was a small bar usually painted blue advertising Primus beer or another brand. The road sloped downwards at first until we reached the bottom of the hill where it proceeded upwards towards what we hoped would be the central town. We passed a large Mosque (Muslims in Rwanda, who knew?) and kept on going following the road which began to swing around the side of the hill which dropped off into a deep valley with houses all along the steep hillside. After some twists and turns we actually stumbled on the hospital but we were now hopelessly turned around and disoriented, our map had become more or less useless. More aimless wandering lead us to the Simba supermarket which we recognized from the night before. We stopped in the snack bar where we had watched soccer the night before and had a latte and a sausage roll on the terrace.

Pouring over our guidebook, we were now able to figure out where we were and found the Tourist Office and of course the Mille Collines Hotel, better known as the Hotel Rwanda from the movie. We also found the Union Trade Centre with the large Nakumat and the Bourbon Cafe which we patronized a lot. We also found the Serena Hotel where for $200 US you can use their pool and more importantly their showers for a month.

Mission accomplished we retraced our steps back the Nyamirambo road. It was now scorchingly hot and we had a long hill to climb back to our apartment. About a block from our abode, we decided to venture into one of the Blue painted bars for some rehydration. Inside we sat at resin chairs and a table like you might find on a patio and a waitress took our orders in my very bad French. Three large beers appeared which we drank gratefully before returning to our apartment.

One thing that had become apparent on our walk, was that while there were lots of bars in our neighbourhood, there was nothing we would recognize as a restaurant. This became more acute later that evening when we got hungry and decided to find somewhere to eat. Most of the restaurants in our guidebook were around the centre of town where we had been earlier that day. On our map was a restaurant called the Green Corner which a previous volunteer said they had heard was okay. It looked like it was an easy walk from our apartment. Therefore we ventured out into the night and turned left on the Nyamirambo road. According to our map we should have been able to reach the Green Corner by travelling due west but due west would have involved unlit dirt roads so we took the long way eventually arriving there with some relief.

The Green Corner was an outdoor bar and restaurant with some covered tables. A lady met us and I asked to see the menu in my bad French. There was no menu said the lady, we have chicken or fish. I made an executive decision that fish was safer and about an hour and several beers later some barbecued Tilapia arrived. It was one of the best meals we had. Just before the fish arrived a man came over with a kettle of warm water and some soap so we could wash our hands. As we learned, we were supposed to eat with our hands although when we asked for forks, they brought some. At the end of the meal the man with the kettle and the soap came over again.

We retraced our steps through the busy and crowded streets back to our apartment. We had survived our first day in Rwanda.

Cart Wars

2011-08-15T18:19:00.005-06:00

While not as sexy as the anaesthetic machine, the pulse oximeter or any of the other toys we get to use, the humble anaesthetic cart is an essential player on the anaesthetic team. Basically the cart is where you store your drugs, syringes, needles, ETTs, LMAs etc etc. The surface is where you keep your induction drugs and your emergency drugs. You draw up your medication on the work surface and write your chart up there. Every couple of months, we get some patient with a superbug shows up in the OR, out goes our cart, replaced by what equipment and drugs we anticipate we might need, piled onto a Mayo stand or the machine top and we wish we had been more appreciative of our Friend the anaesthetic cart.

Boy do I need to get a life.

This is all prompted by our recent attempt to get new carts which has stirred up some memories and reminded me again of how and why healthcare is so expensive.

Our hospital is going through accreditation. This is my first as site leader although I have lived through many. Accreditation usually results in a rush of questionable "improvements" which if they were so important should have been done gradually over the last 3 years instead of being rushed into place in the last three weeks.

The carts in our OR are probably the best I have worked with. That is because they were actually custom made in the last millennium. They are a trifle large but have lots of storage space, are well organized and have a large work surface. Unfortunately they don't meet accreditation standards apparently. The problem is that we store our non-controlled drugs out in the open instead of in a drawer. (Our carts actually don't have drawers). Labour and delivery picked up on this first and modified (without asking us) our carts to put little trays in which the drugs could be stored out of sight and mind. Of course everybody on principle hated this if only because Labour and delivery did it and after about fifteen minutes of fruitless discussion at our staff meeting, in the most brilliant move of my administrative career I assigned the biggest loudmouth to design a better cart.

Fortunately someone had already done that. Our friends in the other large city in our province had in an exhausting process, which produced an article in the CJA, had come up with the optimum drug configuration in the cart. Down south went the loudmouth accompanied by two administrators to look at the wonder carts.

Consequently we decided to try out the anaesthetic carts designed by the wise men from the south. First we had to obtain a cart to try out. Our head anaesthetic tech who apparently can do this just picked one she liked in a catalogue and bought one directly from the company for about $2400. Our purchasing department however found out about this and lambasted her. "You should go thru us," they chided, "we can get you a better deal." This they did by going thru a medical supplies company instead of contacting the supplier directly. Cost: $4000.

The new cart arrived early this summer. One of the advantages of the cart is that the top drawer can be locked to keep your drugs safe. It unfortunately has an auto-lock function which means someone immediately auto-locked the keys inside the drawer. Nobody owned up and after a few phone calls, the company sent out a new set of keys and the new cart was back in action. Nobody likes it but I figure if everybody is equally unhappy, it must have something going for it.

The next problem is that the hospital doesn't have any money in its budget for the $44,000 it will cost to get the 11 more carts we need (how about out of the $800,000 I saved by turning down the anaesthetic machines we didn't need or want). And accreditation is coming up in October which means the administration which means me has to figure something out.

I lamented this morning in the coffee room that we could buy an automotive cart at Sears or Costco which would work just fine as an anaesthetic cart. The problem is that there is no way the hospital will spend $500 when it could (not)spend $4000. An OR supervisor at a small hospital near us did just that. She was sick of complaints about the old anaesthetic carts and the lack of money in the budget to buy a "real" cart. So she got her pick-up truck, headed down to Sears, picked up two carts for her two ORs, loaded them in the box of her truck, brought them to the OR, submitted the bill, got reimbursed and her hospital has new "anaesthetic" carts.

I am so jealous.

Counting Numbers

2011-08-10T10:16:00.006-06:00

I couldn't sleep last night so instead of counting sheep, I counted all the numbers by which I am counted.

Firstly my social insurance number which I got when I was 16. The card is long since gone but I still remember the number. You got asked for it a lot back then, banks, universities etc. If you wrote a cheque they often wanted your SIN. In the 1970s the military used it as a service number(I had some friends in the military so I knew that), some provinces used it as your health care number and some universities (not mine) used it as your student number. People soon started objecting to having to give out their SIN and now the number is treated with strict reverence. I have often wondered what malicious information some hacker living in his parents basement could get by knowing my SIN that he couldn't just get by for example reading this blog or my facebook page.

Next was my student number. For 7 years I had to write this on applications, exams, essays, cheques at the bookstore etc. Consequently the number is burned in my brain. I actually had to give it out recently for some alumni thing and was amazed I could still rattle it off. The university of course also wanted your SIN so that they could send you your tax receipts.

When I became a doctor I was deluged with numbers. Firstly I have my provincial college number that I have to write on prescriptions now so I have it memorized although I recently got a rubber stamp to guard against early Alzheimer's. Very importantly I have a billing number which is 9 digits although as every doctor's number ends in 08 and there is a check number only 6 of them are used. I also have two business arrangement numbers both 9 digits. I also have a WCB billing number which is my old medicare billing number which is 5 digits and a letter. In addition every professional association I belong to gives me a number which I need to know to access their websites etc and the Medical Protective Association won't even answer the phone unless I have it handy. I also have my LMCC number and every province I ever worked in gave me a number.

A few years ago I read a news article in a medical journal where every doctor in Canada was going to be assigned a unique number. What a great idea, I thought. Unfortunately I read on and found out that this number was to be in addition to, not in place of all the other numbers. As an aside the registrar of the New Brunswick Medical Council wrote a very folksy apology for having to assign numbers in New Brunswick when they computerized.

Just about every patient I see has a healthcare number as do I. Our province has a 9 digit number although every number ends in 0 or 1 and there is a check digit for only 7 of numbers are being used. When I moved here the number was 11 digits but they managed to shed two of them. Every province has a different number. BC has 10 digits although every number begins with 9. Ontario likewise has 10 digits. Manitoba manages to get along with 6 digits. Newfoundland with its 500,000 population has 12 digits. Their number is unique as it can be generated by the patient's date of birth. Every military patient has a number which you usually have to chase down in order to get paid. WCB patients usually have at least one claim number and they also want the health care number and the SIN.

Our healthcare numbers are called ULIs which means Universal (or Unique I can't remember) Lifetime Indentifier. Just because a patient has a ULI, doesn't mean they have healthcare. To find out whether they do you can call a phone number.

When you check into hospital you are assigned a hospital number which is different from your ULI number. Just to things more complicated each hospital has a different numbering system. Because with regionalization, most patients will have visited more than one hospital patients will have several different hospital numbers. Private clinics of course have their own chart numbers.

To log on the province's shamefully inadequate EMR from outside the hospital I have to use a series of six numbers preceded by another 4 digit number specific to me. If I actually get through which is not a sure thing, I have to then enter my user name and another password (see below).

I also have 3 credit cards whose numbers I give out a lot on the Internet hopefully known only to me, the hacker living in his parent's basement and the guy who probably skimmed my cards yesterday. When I used to order a lot of pizza I actually had my credit card number memorized. I have two bank cards with incredibly long numbers which I have to type in, to log onto the online banking.

I have a number of phone numbers most of which I can't remember but fortunately I have them stored on my I-phone. For some reason I can still remember my parent's first phone number which was changed in 1972 to another when Victoria started running out of phone numbers for the 38 exchange. I also for some reason know my mother in law's old phone number but not her current one. Most other phone numbers I have had, I forget. I have had the same residential phone number for 19 years now. That is over one third of life. I also have a cell phone number and a voicemail number which I recently got.

Oh yes passport numbers. I wrote mine down so many times during my last trip to Africa where you couldn't check into a hotel without giving it that I finally memorized it. I have since forgotten it.

We are not even going to talk about the number of user names and passwords which many other people have vented on. These are at least easier to remember except that every site has different rules for user names and passwords and I have yet to find a combination that works for every site. Plus some of them make you change your password every few months. If you steal my I-phone you will get a reasonably up to date list of my user names and passwords.

All these numbers and I still didn't get to sleep last night.

Another aphorism

2011-08-08T14:59:00.002-06:00

Just after my last post, I realized that there is another important aphorism that would improve medical care.

"Just because you can do something, doesn't mean you should."

Move over Hippocrates.

Getting Away With It.

2011-08-07T09:10:00.002-06:00

I often hear older surgeons rhapsodizing about their chief who apparently taught them everything they currently know. I can't really understand this because just about every academic chief of surgery I have known has been an idiot and I have worked in 4 different programs.

The only thing I learned from my chief was how to survive long periods of time without bathroom breaks or food.

And this:

My chief said:

The goal of anaesthesia is NOT to see what you can get away with.

What a great principle. Why not apply it to medicine. Post it on every ward and operating room

The goal of medicine (or surgery) is NOT to see what you can get away with.

Okay now I am really disgusted

2011-08-07T08:48:00.003-06:00

Whilst grocery shopping yesterday, I was just turning the corner to go up the next aisle when the five letters spelling bacon caught my eye. Unfortunately the suffix "aisse" was attached to it.

Bacon is to men what chocolate is to women. It is a sacrament. Bacon belongs to breakfasts, hamburgers and sandwiches. Combining it with the evil despoiler of good sandwiches and salads is sacrilege.

Enough said.

You can die!, I can break your teeth!

2011-07-28T12:57:00.005-06:00

One of my colleagues advises every patient of this. He has a thick Czech accent so you have to be there.

Dental damage is of course an inherent risk of anaesthesia. I have never broken or chipped teeth but I have at least 10 years to go so I know it is going to happen. I am however becoming aware of how frequently (by which I mean a couple of times a year) it happens because as department head I seem to find out about it. Our hospital has a very active disclosure policy and usually on the discovery of any complications, the patient is inundated by risk management people. The result of this is often that the patient starts to see dollar signs. This usually leads to a claim against the hospital once the patient goes to his dentist. I am beginning to believe that when a dentist hears that teeth were damaged during surgery, they too see dollar signs.

I shouldn't comment on events so recent but the following case is so silly and so outrageous that I just have to post it because in 2-3 years I will have hopefully forgotten about it.

I got an email from our patient concerns office copied to the medical director. The story is:

A patient had surgery at our hospital. Some time postoperatively he had a cardiac arrest. A code was called and someone attempted to intubate. In our hospital, that would usually be an RT. The intubation was difficult, anaesthesia was called and fortunately they weren't tied up with some ortho "emergency" and intubated the patient with some difficulty using a Bougie.

The patient survived and woke up in ICU. Most people would be relieved and thankful but however the patient also woke up with..... a broken tooth. Which they want someone to pay to fix.

As I told patient relations, I couldn't see from the chart they gave me who chipped the tooth, I suspect it was the RT. As I told them our medical protective association fights most dental damage claims no matter how small just on principle but if in fact the RT was the culprit, the hospital might be liable. I also mentioned I thought that any judge would probably award a tiny amount of damages for having one's teeth broken while one's life was being saved. Maybe I underestimate our judiciary.

This reminds me of another case on which the statute of blogging limitations has expired.

A patient presented for some type of day surgery procedure requiring intubation. She had veneers which the anaesthesiologist noted and checked off on the record that she had warned the patient (maybe not in a Czech accent). Surgery was uneventful, the recovery room nurses did not notice any dental damage. Someone between recovery and day ward, her veneer fell off. Worse still, it ended up in her stomach (better than her lung anyway). Naturally her dentist wanted 5 figures to fix it. Not happy with her prospects in the civil law system she went to a higher court.

The Global Troubleshooter.

So it was then that I got a phone call from the medical director asking if I would go on TV and discuss this case. "Are you fzcking crazy?" I was thinking but there was a temporary disconnect between my brain and mouth and anyway I like being on TV. First of course I had to meet with the risk management people to discuss what I should say and what I shouldn't say. I actually took at media relations course once and I learned that it is important to stick to the message. My message was going to be "dental damage is an inherent risk of anaesthesia no matter how competently performed, discuss this with your anaesthesiologist".

For authenticity they wanted to shoot the segment in an operating room, so we chose our block room which has a machine. I put on my greens, my favourite OR cap and got a selection of laryngoscopes, airways and suctions to demonstrate all the ways your teeth could be broken. I thought the interview went well, I stayed on message and I thought I had done an educational service to the community. The risk management lady who sat off camera the whole time agreed.

I never asked when they were airing it and I don't watch the 6:00 news (especially Global) so I only learned about it a couple of days later when people told me they had seen me on TV. (America's Most Wanted? I asked). Fortunately Global archives their broadcasts on their website so I was able to see my performance.

It was not pretty.

They had taken the patient's side. The show started out showing the outside of the hospital from a curious oblique with the voice over, "they broke her teeth during surgery and now they don't want to pay". My interview was heavily edited and I was usually cut off mid sentence so everything was out of context. They at least acknowleged that it wasn't me who broke her teeth.

I should learn but I suspect I would probably make the same mistake again.

Big Pharma

2011-07-25T12:49:00.006-06:00

I was having lunch with the local Pfizer rep when he told me an interesting story. His company makes a drug for Alzheimer's. A doctor had contacted him to help with a presentation she was giving. His company had developed an assessment tool for dementia and she wanted him to attend to show the attendees how to use it. The problem was that the talk was sponsored by our University's CME department which has recently taken a hard line on pharmaceutical sponsorship. In fact the doctors attending were actually paying out of their pocket (or their corporation's pocket) to attend.

The rep realized that he might not be welcome and so he phoned the CME department to ask if they minded. As expected he got a sanctimonious lecture on the evils of pharmaceutical sponsorship and was of course told he could not attend. Fine, he said, where should I drop off copies of the assessment tool? Our office is in the << insert corporate robber baron >> building, said the CME person.

So.....

It is okay to sell naming rights to your university buildings to the highest bidder; it is not okay to accept money or any other help from Big Pharma.

I of course sold my soul years ago. In the last millennium I think. I have always given CME talks. I never really cared how much I got paid for them or how much income I was losing by not doing something else. In the 1990s I was evangelical about chronic pain. I can't remember the first Pharma talk I gave or who I gave it for. All I know is that pretty soon I was doing a lot of talks for various companies. And making pretty good money for it.

I have to say however I was never told what to say or to promote any particular product. I had a generic talk I mostly gave where I reviewed all the treatments for chronic pain. I did use slide kits provided by the companies because they often had good pictures that I could use. If I didn't agree with something on the slide, I either modified it or didn't use the slide. I inserted my own slides, I mixed and matched various slide kits. I also searched Google for really funny pictures. I had a good time preparing the talks and a lot of fun presenting them. I had visions of getting on the national speaker tour but I never got beyond the local dinner circuit.

I should mention that I was never told what I should prescribe either. I did a ton of talks for Purdue even though at that time I mostly prescribed methadone because of the tertiary care nature of my practice. Pregabalin as I tell the Pfizer rep is a nice drug but unfortunately it is isn't covered by most drug plans so there is no point prescribing a drug that they can't afford. Besides gabapentin is just as good (I don' tell them that). Likewise CR tramadol which three companies released at the same time in Canada setting off a marketing frenzy to the benefit of the local restaurants. Duloxetine the same. When it gets covered I will prescribe it. Very few of my patients can afford it. This doesn't stop me from giving talks on it. I have read the research I know they are good drugs at least based on what has been published.

At the same time I started to get involved with the national pain society and got to meet many of the heavy hitters in chronic pain management. And with a few exceptions they were all on the Big Pharma lecture circuit for multiple companies.

Along the way I have gotten to go to some interesting venues courtesy of Big Pharma. These include Vienna, Sydney Australia, and Glasgow for IASP meetings; Cancun, Stockholm, Bermuda, New York, Phoenix, San Diego, Memphis and who knows how many trips to Banff, Toronto, Montreal and Vancouver. Some of these trips I even got paid for in addition to the free trip. I like to think I did some networking, most of the "friends" I have in the chronic pain world I met at these meetings. The trip to Stockholm which was sponsored by Pfizer was an excellent scientific meeting and only mentioned pregabalin once.

Gradually over time Big Pharma developed a code of conduct and the rules changed. They started to get accreditation for their talks for example. What accreditation meant was you had to stick to script. If you didn't like a slide, you could delete it but you could not modify it. You could not add your own slides and no funny pictures. I have done a few of these and they are absolutely unrewarding and I get the sense that the audience is as bored as I am. A real paradox. Without University accreditation I don't have to follow the script and can say what I want. With University accreditation I have to stick to the script which more or less makes me a shill for whatever product I am supposed to talk about.

Between the new rules, the economy and mergers of Pharma companies, I am doing less and less of these. I don't really miss it that much although I wouldn't mind the extra money.

Obviously a bleeding heart liberal like me should be no friend of Big Pharma. If fact most of what they do disgusts me. The problem is that without Big Pharma support most CME would either not exist or be horrendously expensive. I recently went to two meetings that had no pharma sponsorship and they both cost over $2000. I realized early on that the small number of chronic pain consultants in our area and I could not treat everybody and that the primary care docs had to be educated on this. The problem was that nobody really wanted to pay for this so when Big Pharma came calling I jumped on the bandwagon. The opportunity to get to talk to the family docs who sent patients to the pain clinic was the impetus, the money and the nice suppers were secondary. I later was the treasurer of our national pain society and I can tell you that without Big Pharma funding, there would be no meetings and probably no society.

Those of us involved in CME do a delicate dance with Big Pharma. We want to teach other docs about chronic pain. They want to sell drugs. We actually prescribe most of those drugs anyway and we actually want family docs to prescribe those drugs when the indications are appropriate. We actually want them to do a whole lot more and those supper meetings actually give us a pulpit from which to preach our gospel. At least that is what I like to think. But of course I have lost most of my soul.

I volunteered in Africa and all I got was this lingering feeling of disillusionment.

2011-07-16T08:41:00.002-06:00

It has now been 14 days since I returned from Africa where I spent 4 weeks teaching in Rwanda and 1 week recovering on Safari in Kenya.

Firstly it was probably the greatest holiday of my life, I saw rain forests, savanna, chimps, gorillas, lions, more types of antelopes than I ever thought possible, giraffes, zebras and hippos. I also got to stay in some fantastic hotels (and some not so fantastic). I also lived in Kigali in an apartment, so had a chance to live amongst the Rwandans. We bought food in the local markets, ate in a local restaurant, walked everywhere and drank the local beer in the local bars. On that alone the trip was a success.

Why do I feel so disillusioned and somewhat unworthy?

Some background.

At the end of the genocide, there was only one certified anaesthesiologist left in Rwanda. That doesn't mean that patients having surgery in Rwanda were biting bullets; anaesthesia was presumably performed by nurses, technicians, surgeons and doctors with little or no anaesthetic training. A call for help went out to which Canadian (and some American) anaesthesiologists responded. The problem with training specialist anaesthesiologists in Rwanda and other developing countries is that it was necessary to send them overseas to Belgium or France to get the specialty training. Of course once they got their overseas specialist credentials, very few of them really wanted to come back to a country where they would have to work harder for much less money. It was decided that the country needed to develop a local training program to meet the needs of the country which would produced well trained consultants but consultants whose certification had no value in France, Belgium or other desirable places. To help with this goal, a Canadian anaesthesiologist +/- a resident would go down to Rwanda each month to teach formally and in the operating room. In addition each Rwandan trainee would get 6 months of training in Canada.

Now I am not one of those people who did all kinds of overseas volunteer work or electives in third world countries in medical school. While early on in my career I flirted with working overseas, life and children intervened. 5 years ago out of the blue, I got invited to accompany a mission to Ecuador to do total joints and it was like I rediscovered medicine again. I went 4 more times and am going again next January.

Much has been written pro and con about the benefits of international aid and most of what I have read is strongly coloured by the political bias of the writer unfortunately. After one trip to Africa, I don't claim to be an expert on the continent nor do I have any solutions to its problems (stopping selling them weapons would be a good start?). I have always been a believer that it is better to teach a man to fish than to give him a fish and so this Rwandan mission appealed to me for that reason. I had also met with people who had been there and at the last CAS Meeting I attended an exceptionally enthusiastic presentation on the program. I was a little nervous but I thought that I was stepping into a well-oiled machine that was producing results.

Just prior to the meeting I attended the Global Outreach Course which I have previously blogged about. I was really impressed with the mantra of doing the best you can with the resources that you have and looked forward to learning about that.

What I actually found:

Currently there are two larger teaching hospitals in Rwanda, CHUK in Kigali and CHUB in Butare (where the medical school is). Surgery is also done in about 30 district hospitals and in a private hospital in Kigali which I will discuss below. Anaesthesia is for the most part provided by anaesthesia technicians. These are well trained with good airway management skills and are also able to do spinals. For the most part they work unsupervised. There are specialist anaesthesiologists, 2 at CHUK and 4 at CHUB. There is a residency training program with junior residents at CHUB and senior residents at CHUK. The idea is supposed to be that the more difficult cases will be done in part by the physicians while the techs do everything else. This model of technicians supervised by consultants is one that should work well and is roughly similar to the situation with CRNAs in parts of the US. I never actually found out who does the anaesthetics in the district hospitals, I suspect it is mostly techs.

I observed a number of problems almost immediately.

1. Lack of professionalism. The two staff anaesthesiologists at CHUK never attended morning report or arrived late. One of them only showed up in the OR twice during the days I was at CHUK, his side-kick was not much better. The residents were only marginally better, they were almost always late for morning report and for the OR. Some days no physician showed up to the OR at all. This but me in a bad position, my rules of engagement was that I was there to supervise residents and not to give anaesthetics. Frequently on ethical grounds I was forced to give the anaesthetic when the techs found the case difficult (they had fairly good judgement in this respect). This meant I did a number of neonatal cases. (They really are just small adults). More often I just ended up standing around waiting for a resident to show up.

When the residents did show up, they mostly just stood around and watched the techs do the case. Despite 4 weeks of nagging there was never any effect to set up the room, draw up emergency drugs or actually make any plan beyond fentanyl thio sux which seemed to be the only induction sequence the residents knew (with the occasional substitution of ketamine for thio). The technical skills of the senior residents were well below what I would expect from a junior resident in Canada because they never did anything.

This was a problem that seemed limited to CHUK. CHUB in Butare ran much like a teaching hospital in Canada with the 4 staff anaesthesiologist and residents working as a team with the technicians.

2. Equipment. I trained on Boyle machines and I am not overly anal about monitoring (except for SaO2). I wasn't expecting to see the equipment we expect in a Canadian OR. CHUK actually had newer machines and monitors. I suspect they were donated. These were supplemented by Glostavent machines. The problem was of course that most of the monitors didn't have working cables so that often there were 3 different monitors in a room in order to get SaO2, EKG and BP and techs were constantly shuffling monitors and cables between rooms. The machines while new were connected to disposable tubing that was been reused and was heavily patched. Most rooms had nothing resembling an anaesthetic cart, before every case there was a flurry of bringing in equipment and drugs. When I sharply asked a resident why he hadn't got a laryngoscope ready, I was told that there were only 3 working handles in the OR and that a handle would arrive just in time. In obstetrics one suction was shared between the two rooms; a second non-working suction was parked against the wall, nobody had bothered sending it out to be fixed. I never saw an oxygen cylinder on any machine which is a concern because I had been warned that the central oxygen supply had failed in the past.

Now I accept that a developing country like Rwanda may not have the resources that Canada has, however most of the above deficiencies are not that expensive. What was lacking was leadership from the consultant anaesthesiologists who unfortunately rarely showed in the operating room.

3. Dysfunctional OR. It has been my observation that dysfunctional ORs make for bad teaching environments. The OR at CHUK is one of the few ORs in the world that actually needs more rather than less administration.

4. Techs vs. Physicians. As I mentioned the techs for the most part did a very good job. Which made we wonder, what exactly is the plan for anaesthesia in the country. Clearly there is not going to be a physician-only model in the near future or ever which makes me wonder if we really need to be training as many anaesthesiologists as we were training.

5. Training doctors to work overseas. One of the reason that there were only 2 physicians at CHUK was that 3 people were doing subspecialty training overseas. I was told that one of them had no intention of returning and it was doubtful whether the other 2 would. Great I thought. We are giving their training program the Canadian Seal of Approval so that they can get jobs in Belgium.

6. Lack of QI process. Early on we noticed that we were getting a huge number of obstetrical horrendomas. For example I knew of at least 4 Caesarian hysterectomies during the 4 weeks I was there. One of the anaes. was shocked when I told him I had only even done one. We had a number of cases of obstetrical sepsis and/or hemorrhage transferred in. When we raised the issue of why are we not discussing these cases to find out why they are happening and can we prevent future occurrences, this was met with blank stares.

I was asked to make a report at the end of my mission. I waited for over week because I thought I might be more positive however I mostly sent in a report outlining what I have discussed above. Quite quickly the two people in charge of the program emailed me back, to explain that they too had encountered the same problems, that they had raised them with local people and had gotten nowhere. It was suggested that we needed to just keep on plugging.

The question is then, aside from a nice partially subsidized, otherwise tax deductible African vacation, what the hell are we doing taking 4 weeks away from our practices and our family. And of course the answer is: a nice partially subsidized, otherwise tax deductible African vacation which nobody wants to jeopardize. That and of course the warm fuzzy feeling of having volunteered in a developing country.

By the end of the month, I was basically showing up for morning report, going to the OR to see if there was a resident who actually wanted to taught and then bugging out to the comfort of the pool at the Serena Hotel where for $200 you can buy a month's membership. It was only after I left that I had the revelation that probably every doctor before me had done just that, gone to the pool, gone sightseeing or golfed (one of the doctors from Canada raved about the Kigali golf course to me).

As we left the country to fly to Kenya, I had never felt so worthless in my life. I felt that I had accomplished nothing in the 4 weeks; that this must have been due to some character flaw as so many doctors have apparently found the mission professionally rewarding. Then of course the above revelation occurred and I felt a little better.

But I probably will return. Africa has this kind of hold on you.

The Curse of the Digital Camera

2011-07-10T16:46:00.002-06:00

I was in Africa (Rwanda and Kenya) for 5 weeks which was a great experience and we really got to do a lot of sightseeing. I know that people are soon going to ask me to see all the photos I took. Therein lies the rub.

We took hundreds of digital photos in Africa with two cameras. Obviously I really don't want to subject anybody to such a slide show although lots of people have no qualms about doing this. At the same time it is hard to decide except for the obvious out of focus shots which ones to discard. And of course with a digital camera it is really easy to just keep shooting. And of course no photo no matter how good really replaces the experience of being there. At the same time if you delete the photo you feel like you have deleted part of your experience.

When I started out taking pictures of course, we used film which was a lot more expensive, plus it came in rolls of maximum 36 exposure. You would come back from holiday, take your rolls of filmm to the drug store and a week or so later you would get your pictures, some of which were good some weren't. If you threw away or lost a print, you had the negatives.

Sometimes I think we take pictures as a substitute for the experience and as a consequence lose some of the experience.

A few years ago I visited Ularu (Ayers Rock) and its sidekick rock, Katajuta. We were taken to Katajuta to watch the sunset one night. It was a really magical experience, we were out in the desert, there were no clouds and as the sun set further and further the rock appeared with each passing moment to be a different shade of red. This we dutifly photographed. When I looked at the photos on my computer a few weeks later, I had about 20 photos of Katajuta all the same identical shade of red. And I haven't had the heart to delete any of them.

Likewise on this trip we spent about 20 minutes less than 5 metres from a pride of lions with 5 cubs. Being that close to a group of animals that could kill you in under a minute and watching them go about their business, playing, sleeping and nursing is one of the enduring images I have of Africa. And of course we have about 30 photos of the that special time.

But I know that on Tuesday people will be expecting to see my pictures, so enough blogging and more editing.

A visit to the cousins (Summer re-run)

2011-07-09T15:27:00.000-06:00

Last Wednesday afternoon we left Kigali to go to Butare to teach the junior residents there. Kigali seemed hot, dusty, crowded and noisy and we were happy to get out the city for a while. Our driver Jean arrived promptly at 1400 and we piled into the car, Brady, Mary and I along with Brady's Dad Mike who had “dropped” in the night before. We left Kigali to the west travelling along a valley and sound ascended into the hills surrounding Kigali. When they call Rwanda the county of a thousand hills, they are perhaps understating things. There seem to be a lot more than one thousand. We went literally over hill and dale. The hills were terraced with crops, the valley bottoms heavily cultivated. Every 15 minutes or so we went through a small town, not even slowing down much. Everywhere along the road, we saw people walking, women carrying loads on their head and school children returning home in their uniforms. The vistas as we drove along the sides of the hills were incredible. We tried some drive by photos and we couldn't stop for a photo op. After 2 hours we entered Butare and checked into the Hotel Credo.

After freshening up, we decided to go out to what was described as the best restaurant in Butare by our guidebook. Guidebook....FAIL. I will probably post on this separately.

We were sleep deprived from the heat in Kigali and our noisy neighbours and in the cool quiet of Butare we slept like logs. Until.....at 0500 the sound of what was for 0500 beautiful singing. It turns out there is a Mosque about 500 metres away complete with loudspeakers to call the faithful to prayer. In case the faithful missed it, it was repeated at 0515. We got up, ate breakfast on the terrace; a bean soup which was quite good, a plate of fruit and toast plus coffee. Just after 0745 Dr. Theo arrived to pick and Brady and me to go to the hospital.

CHUB was a refreshing change from CHUK. We changed in Dr. Theo's office before going to the OR where we were met by Isaac and Adolphe two of the junior residents who greeted us dressed in clean white OR scrubs. We had a great day working with them, they were enthusiastic, asked a lot of questions and were open to suggestions. After our list finished I had the usual Rwandan buffet lunch with Adolphe before heading home. We all dined that night at the Hotel Ibis along with it seemed just about every other ex-patriot in Butare. I ate the special grilled rabbit. It really does taste like chicken.

After another sound sleep until 0500, we had breakfast and Brady and I walked to the hospital. Friday is a short day in Butare with only emergencies scheduled. Dr. Theo met us and asked us whether we wanted to attend their Friday morning case presentations or do the three emergencies. We decided on the case presentations. We all sat around in the store room. Dr. Theo quietly asked that we start the meeting with a prayer and everyone (except Brady and I) joined in, in a beautiful hymn followed by a short prayer. We certainly don't start our meetings in Canada that way although sometimes we could use a little prayer.

Butare lies in the southern part of the country as does the Nyumgwe National Forest, one of the must sees in Rwanda. Unfortunately tourism is not that well developed in Rwanda. We got very little information from the tourist office in Kigali and our Bradt travel guide wasn't that much help either. We had originally thought of just staying in Butare and commuting to the park on Saturday and Sunday until we learned the park is actually 3 hours from Butare. They looked so close on the map. We therefore booked rooms at the Gisakura guest house. We still figured that we could get there on the bus which Bradt said was possible. At the last minute we decided to ask our driver Jean how much he would charge to drive us there Friday and pick us up on Sunday and he quoted a very reasonable rate.

Therefore at 1300 on Friday we set out west from Butare. We first when up a broad valley which was heavily cultivated with some fish farms as well. We soon however got into hilly country. The hills were terraced with farming often up to the top of the hill. Some of the hills stuck out like sugar loafs circled with terracing. Again we passed people on the road and small towns. As we got farther west we started to see tea planted on the slopes. After an hour or so we reached Nyungwe National Park. The road very quickly got very rough even by Edmonton standards. Our driver tried as best he could to steer around the larger tank traps often going onto what shoulder there was or into the other lane. We were surrounded by hills covered by jungle with deep valleys off the side of the road. We could see the dense canopy. At one point we saw our first group of monkeys at the side of road, necessitating a photo stop.

Unfortunately at that time our driver noticed he was leaking brake fluid from his rear brakes. We check the fluid levels and he seemed to have sufficient fluids plus hey the front brakes work and we were out in the middle of nowhere so we pushed on.

After some time we passed the Gisakura Tea Plantation which is on the western side of the park and which was close to where we were supposed to stay. We saw no sign for our guest house and we figured that our driver knew where he was going so we pushed on for another 30 minutes. At that point our driver stopped to phone someone and it was at that point we realized he didn't know where he was going either. We consulted the guidebook, turned around and headed back. At every village our driver stopped to ask directions. As a man I could feel his pain. Eventually we arrived at the Gisakura Guest House.

Some travel guides have not been kind to the Gisakura Guest House and I was expecting some spartan and not particularly clean accommodation. I was surprised. The guest house is a series of brick buildings, surrounded by nicely manicured grounds with the jungle just past the fence. The staff welcomed as and showed us our rooms which were clean and comfortable. You do of course have to share a bathroom. We had an excellent buffet dinner with the small number of guests later that night.

National Parks in Rwanda are different from National Parks in Canada. Firstly as we found out, you really need a driver to get around. Uwinka were many of the good trails are is 20 km from where the hotels are. To see the chimps is a 30+ minute drive. Fortunately we ran into our driver Jean who had decided not to drive back and were able to negotiate his services for Saturday and Sunday.

We all decided we would like to see the chimps. This involved phoning a ranger to book the trip and it was already 1800 and the rangers had gone home from the Gisakura Ranger Station. Fortunately a guard was still there who knew the phone number and we called a ranger. We then had to each come with $90 US, give it to Jean who took it to the ranger who would sleep overnight at the Gisakura Ranger station. Oh by the way, we are leaving at 0430.

We went right to bed after dinner. Our alarm was set for 0400 but we woke around 0345 and got into the clothes we had put out the night before. The guesthouse had given us the key to kitchen and had put out small bananas, bread and most importantly coffee for us to eat. 0430 came and we met Ranger Robert in the pitch black night. We piled into the car and headed west down the bumpy road. In time we turned onto a dirt road that was strangely smoother than the “paved” road. In the headlights we frequently came across people out walking in the predawn. We passed small villages as we went up and up the winding road. The sun began to come up. We passed a large group of people out running in the dawn. Finally our truck pulled over. We got out. Another ranger and 4 trackers were awaiting us. They all wore green uniforms with their pants tucked into their gumboots. Below us we could hear the “cousins” whooping it up.

Ranger Robert handed us each a walking stick. We figured this was a nice touch for the tourist. We headed down a steep trail cut into the side of the hill. There was a wooden handrail which probably wouldn't have taken my weight. “The vegetation will stop me, “ I thought but I wasn't really confident. We walked mostly downhill with the occasion uphill. Periodically Ranger Robert would talk on the radio to the trackers. Eventually we stopped. The cousins were not coming to us, we were going to have to go to them. We backtracked and suddenly left the trail onto a narrower “trail”. Vegetation was dense and I had to crawl under obstacles. The camera I had at the ready for my chimp shot went into the backpack as did my hat. We were perched on the edge of a steep hill. The soil was very loamy and it was hard to get a foot hold. It was that when I realized what the walking sticks were for. After about 20 minutes of hard slogging we stopped. “Chimps” somebody whispered. High above over 20 metres in a tree we saw an adult male perched on a branch in a perfect pose. Too bad the camera was in my backpack. We saw a total of 5 chimps including 2 babies up in that tree. Around us we could hear the whoops of the tribe who we had disturbed.

The pack moved north and we decided to follow them. This involved about an hour of bushwhacking thru the underbrush, clambering up impossibly steep slopes and descending treacherous downhills. We gave up eventually but has some more bushwhacking to go to get back to the trail after which we could walk back to our truck where Jean was waiting for us.

Then came the decision of how much to tip. We huddled briefly and decided that 10,000 Rwf between the four of us would be appropriate and gave this to Ranger Robert. He looked a little displeased so we came up with another 10,000. I remember how one of his men had possibly saved my life when I started to fall backwards and came up with another 5000.

It was now 1000. We had been up for 6 hours already. We backtracked along the dirt road passing villages and tea plantations until we got to the main “road”. We passed multiple villages. Finally we stopped in a small village. Jean pointed to the gas gauge. Almost empty. We had agreed to pay for gas. There is of course no Esso station. Ranger Robert yelled out the window and in time someone appeared with a large Jerry can of diesel. There was a negotiation, and the proprietor inserted a hose into the Jerry can with one end inserted into the gas tank. He then blew over the opening of the Jerry can to force gas into the hose which was then syphoned into the gas tank. He had to repeat this several times. Meanwhile the whole village gathered around to watch. Later after Mary asked about corn, we stopped in another small village, Ranger Robert yelled out something and four cobs of roasted corn appeared which somebody paid for. They were delicious.

It was just after 1130 when we arrived back at the Gisakura guesthouse. After a hot shower(!) and a delicious lunch, it was time for a nap. Later Mary and I sat in the gazebo in the midst of a major thunderstorm and reflected on our day and what we were to do the next day.

Pictures to follow once I get a decently fast internet connection.

The Nyamirambo Road (Summer Re-run)

2011-07-09T15:23:00.001-06:00

When I found out the neighbourhood our apartment was in, I got out my guidebook to try and figure out where it was and more importantly where it was relative to the hospital. We are in a neighbourhood called Nyamirambo. Try pronouncing that a few times quickly. On the map there was a long road which leads to the hospital and to central Kigali. The distance looked about 5 km.

Here is what Bradt's guidebook on Rwanda says about our neighbourhood.

"...lively busy district of small streets and colourful little local shops. The atmosphere has a touch of London's Soho about it."

The centrepiece of this road is the Nyamirambo Road. We have now walked this road back and forth between the hospital several times including twice on one day. A map of course cannot convey what a road actually looks like.

The Nyaraminbo Road is a two lane road which carries all the traffic between our neighbourhood and central Kigali. It is hopping with cars, minibus “taxis”, trucks and the ubiquitous motorcycle taxis. On each side of the road are small shops. About every 10 feet there is either a hair “saloon” or a small bar. The are also multiple cell phone shops, tiny grocery stores, clothing stores and who knows what else. There are narrow sidewalks on most but not all of the road. You have to be careful because there is a 1 metre wide ditch alongside some of the sidewalks. There are also 30 cm deep trenches on the western side of the street to allow rain to drain downhill in the rainy season and if you aren't careful you can step into one of those as I have twice already.

The roads going off to the side are dirt roads which we have not explored much but those that we have walked on have their own small shops and bars. These dirt roads are irregular and rutted from the recent rainy season.

Kigali seems to wake up at 0530 and we usually leave to walk to the hospital at 0630. The street is bustling even more at the time with people walking to work and kids walking to school wearing their school uniforms. Quite often to pass people or to yield to people coming in the opposite direction, we have to step off the sidewalk onto the street which means taking your life into your hands as motorcycles, minibuses and cars are whizzing by, often as close to the curb as they can.

For the last two days we have walked home around 1700 which seems to be when school gets out which means that the kids have a very long day. Today I got "swarmed" by a group of school children who all wanted to hold my hand and failing that my arm. In other countries I would start wondering about my wallet. Many of the young children like to high five us or will ask us "how are you doing" in English.

There is a market nearby called (of course) the Nyamirambo Market. While certainly not the Otovalo market, it has a wide selection of local fruits and vegetables and is overall quite clean. You can get clothing made for you there although Mary and my first try didn't work out that well.

Buying beer in a grocery store is a major endeavour. A 750 ml bottle of beer goes for about 600 Rwandan francs ($1). If however you wish to take it out of the store you have to pay a 500 Rwf deposit. That makes 1100 Rwf for your beer. Still less than $2. The first time we did this however the lady sternly warned us over and over about this and only reluctantly let us buy the beer. Now .... the next time your want a beer, you bring the empty back to the store and you can buy another one for 600 Rwf. And so on and so on. The problem is, that the beer you bring back has to be the same as the beer you want to buy so if you buy something you don't like, you are forever doomed to drink the same beer over and over. Plus if you did like we did and let the people who cleaned our house take the empties, you are back where you started. This sounds a little impractical, however there is absolutely no broken glass on the street, and people don't drink in the streets. Plus there is are at least two bars every 50 metres and it costs the same to drink a beer in a bar as it does to buy it in a store (without the deposit).

Sorry I haven't been posting many pictures. Our internet connection is quite slow and I have not figured out yet how to shrink the pictures down to a more uploadable size.

Visiting the in-laws (summer rerun)

2011-07-09T15:20:00.001-06:00

I did some interesting blogging on my travel blog that I would like to share with my other audience.

gorillas

From gorillas

Any visit to Rwanda of course requires a visit to see the Mountain Gorillas. This requires the purchase of a permit at $500 per permit non-refundable. And no they don't take Visa or any other credit card for that matter. The only payment is by bank draft and hope they don't lose it. Buying one once you arrive in Rwanda is risky as a permit may not be available. Therefore to simplify matters we got a local tour company to buy one for us. I did this back in January and had of course completely forgotten what I had booked and really only had a voucher and the local phone number and email for the tour company.

There are at least two ways to travel in developing countries. One method is to use your travel guide, read everything you can about the area, chose a hotel, hope the travel guide writer actually visited this hotel, book the hotel and use local public transport to get to where you are going. Then there is the way we went.

Our day started out in Butare where we were teaching. Butare is two hours away from Kigali where our pick up was and we were supposed to teach all morning. We were finished around 1130 and our favourite (actually our only) driver Jean was ready to leave around 1200. Jean has an interesting approach to driving. Any vehicle in front of him must be passed, no matter how much traffic, how narrow the road or how steep the hill. Also his SUV is right hand drive which meant I was sitting on the left side. After about the 20th time pulling out into traffic, I figured out that some special force must be protecting Jean and stopped worrying.

We arrived in Kigali around 1400 and repacked for our Gorilla trip. Our driver was supposed to come at 1600 but we were ready early and he was able to come early so around 1530 he pulled up in front of our apartment in a huge Toyota Land Cruiser FWD. Surely a little overkill, I thought, for such a well travelled tourist route? We piled in and our driver Shema, explained that the trip was going to take 3 hours. We also learned that he was our personal driver for the weekend. We had had visions of being crammed into a bus with a bunch of other tourists so were very happy.

We left Kigali and headed west and then northwest, climbing a huge winding hill out of Kigali. We were going thru a forest of Eucalyptus and other trees. Soon we reached the top and were driving along a ridge with spectacular vistas on either side of us. We descended another winding hill into a broad valley which we followed for a while before ascending yet another long and winding hill. After about 2 hours we drove through Musanze which is the gateway town to Gorilla trekking. We were heading towards Virunga Lodge. “Do you know anything about the hotel?” Mary asked. “Not the slightest” I replied. We continued onwards and after about 2.5 hours we turned off the main road. Shema pointed towards lights that he but not I could see and said that is your hotel. The road meanwhile got rougher and steeper. It was getting darker but we could see lakes on either side at least 1000 feet down a steep hill. Finally we pulled up to the Lodge.

Staff came out to welcome us and we were directed to two couches to be oriented to the lodge. Virunga Lodge is an Eco-lodge which is entirely off grid and solar powered. After further instructions two staff headed quickly up a moderately steep hill to our cottage carrying our bags. We opened the door to discover what is probably the nicest hotel room we have ever stayed in. There was a huge bed, hardwood floors in the bedroom and a stone floored bathroom that was about the same size as the bedroom. The staff explained that the shower was solar powered as well. It was now about 1840 and we grabbed a quick solar powered shower which was hot enough that we had to add cold water.

From gorillas

No bed bugs here!

Then it was up the hill to the main lodge for dinner at 1900. Dinner it was explained was served family style to allow guests to share their trekking experiences. It was cocktail hour when we arrived and a waiter quickly approached us and took our drink order. There were about 10 other guests seemed to know each other although one or two came over and introduced themselves to us. We were then summoned to the common table in another room. Our co-guests were a collection of fairly wealthy Americans and one Swedish banker. We had ordered our entrees on checking in and they were delicious accompanied by an excellent red wine with which our servers kept our glasses full. After dessert we were asked what time we wanted our wake up call, whether we preferred tea or coffee to be brought to our rooms and what would we like for breakfast.

After a sound sleep we arose at 0500 and sure enough someone was outside our door with a pot of coffee which we drank quickly which getting dressed and packing. At 0530 we were in the dining room where our breakfast arrived quickly accompanied by more coffee. A large packed lunch also appeared still warm.

At 0600 we were down at reception where Shema was waiting. We headed down the hill, in the morning light we could now see the incredible vistas on either side of us. All along the road, people were walking starting their day. Today was the “Naming of the Baby Gorillas” ceremony to be attended by the President as we drove towards the staging area, the road was lined with people. I felt regal as we drove by.

The staging area was a mass of activity. A group of about 10 dancers were dancing traditional dances lead by a small Kwa man. There was also a traditional medicine man and a lady grinding sorghum. All the gorilla trekkers were milling around. We had aspirations of the Susa group, the largest but also most inaccessible group but our driver had judged me as not Susa worthy and we were assigned to a group with an older couple, 3 teenagers and a New Zealander.

We took off again in our Landcruiser and turned off onto a dirt road which rapidly deteriorated into what was more of a creek bed with 20 cm round volcanic stones. The truck ahead of us spun its tires and lurched around and I wondered whether we would have to get out and walk. We soon came the parking area however. We elected to hire porters to carry our packs and with the group set off through potato fields heading gently up the hill. We had to cross a medium size creek and the guides and porters arranged stepping stones for us. After about 15 minutes we crossed a crude stone wall that was the boundary of the park.

One of the trackers carried an submachine gun which our guide explained was to scare off buffaloes and elephants that we might meet and we saw fecal evidence of both. As the brush got denser and the trail narrower I felt like I was in Apocalypse Now what with the machine gunner walking point in front of us. After an hour or so our guide stopped us. We were according to him now 100 metres from the gorilla troop. We had to leave our packs, walking sticks and proceeded on with only cameras. Soon we could see in the distance a gorilla in a tree. I tried to point this out to Mary in front of me but she had already come almost face to face with an almost fully grown gorilla at the side of the trail. As he got up and ambled towards us, our guide shooed him off with a low pitched growl. He passed us and lay on his back shovelling food into his mouth.

From gorillas

We moved on single file and soon we were in the middle of the troop. As our guide had explained to us, we are supposed to stay 7 metres away but gorillas do not know what 7 metres is. The next hour was incredible as we saw all the gorillas in the troop. There was a mother with a small baby who we watched for a long time, two young gorillas fought each other, one scratched his manly bits, the Silverback alpha male casually ambled through the group, and a gorilla high in a tree let out a stream of urine which just missed us. Everywhere you looked there was a gorilla!!! They are such docile, fun loving creatures who happen to be built like “brick shit houses”...After shooting terabytes of pictures it was time to leave.

From gorillas

We left two of the trackers, submachine guns at ready to guard the group. The walk back was anti-climatic and we soon arrived at the parking lot. After paying our porters and tipping our guide we headed off down the bumpy road.

The Bruins

2011-07-03T05:21:00.002-06:00

I have been a Bruins fan since the 1967-68 season. I was rewarded early on with two Stanley Cups in 1970 and 1972. While the Bruins remained a dominant team for the rest of the 1970 and 1980 into the early 1990s (establishing a consecutive playoff appearance record that will never be broken); they became a less dominant team in the 1990s, started missing the playoffs, and finished last overall one season. I moved to Edmonton, started cheering for the Oilers even when they played Boston. I began to accept that I would never see the Bruins win the Stanley Cup in my lifetime. In some ways I was right; I was in Africa during the final series. So it was that the morning after Game 7 against Vancouver I took my computer upstairs in the Credo Hotel in Butare where they have wireless internet and learned that the Bruins had beaten Vancouver in convincing fashion and had won the Stanley Cup. I had to take it all in before going down to wake up my wife (a Habs fan) with a bad rendition of "We Are The Champions"; something I couldn't finish because I started crying, which I knew I would do if the Bruins ever won the Stanley Cup again.

In a sense along with winning the Stanley Cup, this playoff was an exorcism of the Bruins' playoff failures.

The Bruins can't beat Montreal...they did albeit winning Game 7 in overtime.
The Bruins have never won a series after trailing 2-0....they did it twice.
The Bruins' record in Game 7s is abysmal...they won all three Game 7s
The Bruins' record in overtime is abysmal...they won their first 4 OT games and only lost one to Vancouver
The Bruins record in Game 7 OTs is abysmal...they beat Montreal in OT.
Other teams always had the hot goalie...the Bruins had Tim Thomas this year.

And this of course exorcises all the playoff failures; the losses to Montreal in the 1970s and 80s. Getting out-thugged by Philadelphia. Losing twice to Edmonton in the final. Having to trade Ray Bourque to allow him to win the Stanley Cup with another team. Ulf Samuelson sticking his leg out and essentially ending Cam Neely's career. The disappointment of the Joe Thornton era teams. This current version of the team losing Game 7 in OT against Carolina; and blowing a 3-0 series lead against Philie.

More impressive is that the Bruins top offensive player Marc Savard missed the entire playoffs, Milan Lucic only scored three goals, Nathan Horton missed most of the last 5 games of the final, they couldn't buy a goal on the power play and they still won.

People often ask why I cheer for an American team.

When I started following hockey there were only 6 teams, two in Canada. Growing up on the west coast, I had no natural affinity for either Toronto or Montreal. I did however grow up in a Habs household. My older brother however told me I couldn't cheer for Montreal. (I am not sure whether to be grateful or not). Cheering for the Leafs in a Habs household was out the question. Therefore I first hoped for Chicago who had (and still have) the coolest crest and then after I played my only year of minor hockey on "The Bruins" I switched to Boston. You must rememember that in the 1960s either player in the NHL was Canadian. The two dominant stars of the 1960s Gordie Howe and Bobbie Hull played for American teams. Even today with all the Europeans, and Americans in the NHL, the Bruins carried 14 Canadian players, more than Montreal or Vancouver who they faced in the playoffs.

I am writing this after having returned from Africa yesterday, sitting in my Cam Neely replica jersey and I hope I never lose this feeling. Sorry to gloat but I have waited 39 years for this.

International Missions

2011-05-25T08:55:00.005-06:00

I attended the recent Global Outreach course in Halifax, Nova Scotia for the last 4 days. This is a timely course as I will be arriving in Rwanda to teach anaesthetic residents next Saturday. Right now I am sitting in the Halifax airport en route to Toronto where I meet my wife and then off to Belgium for a couple of days before our flight to Kigali.

I planned this trip 2 years ago but it is almost on me now. I have been really nervous about this for the last month.

Attending the course made me feel reassured in someways, scared in some ways and depressed in some ways. There were a lot of people there who had been on missions both like the one I am about to go to in Rwanda, MSF missions, Red Cross missions, large and small missions and a fascinating surgeon/anaesthesiologist couple who had lived in Uganda for most of the past 20 years.

Some reflections:

1. I learned (actually I already knew) that we are not going to make any more than a small change at a local level if that. We are not going to make a big change in the way things are done even though we are trying to teach. We will actually only influence a small number of people.

2. If I save someone or improve just one person's life, my trip will have been a success. We are supposed to teach but there will be a time when I will just have to jump in and do things myself and this may be a good thing.

3. International aid may be making people in less developed countries more dependent however there are a lot of people in developed countries making a very good living off maintaining that dependence.

There, I have really set the bar low for my trip.

By the way in my last post I talked about some of the neat equipment I got to use.

At the top is a drawover vaporizer kit. This is portable and with an open circuit could be used in remote locations (like the X-ray department?) This vaporizer can use Halothane or Isoflurane but they make a Sevo vaporizer. You do have to use an open circuit and it would be better to use spontaneous ventilation. You can attach oxygen or just use air. This kit sells for $5000!

Below is the Glostavent machine. It runs off an oxygen concentrator but can run off ambient air. The machine uses 1/7 of of the tidal volume to power the ventilator (meaning it can run for several hours using a small oxygen cylinder). It uses a drawover vaporizer and an open circuit. It can be used without electricity or compressed gas (granted using air). Cost: $5000!

By the way you cannot use either of these devices in Canada or the US as they are not approved for use. This means that the US Navy which uses these devices has to go to Britain to train on them.

We also had a lecture on Halothane which they talked like it was some old drug. Of course when I was a resident we still used Halothane exclusively in children. And it worked pretty good as I remember. We also had a demonstation on the Boyle machine which they actually used when I was a resident (and for the first 4 years I was on staff). Quite frankly I still long for their simplicity. I felt really old when some people asked how you connected them to a ventilator and I was the only person who knew how.

We also had a fascinating lecture on ether. Except for being explosive and making 20-30 % of people nauseated it sounds like a great agent. You do have to take the bad with the good?

I will be posting more on my other blog. If you contact me I may just give you the URL.

What have you been holding out on us?

2011-05-21T17:48:00.003-06:00

I have been attending the Global Outreach course in Halifax NS prior to my deployment to Rwanda.

What has really impressed me is how easy it is to give a really good anaesthetic for not much money.

Like for example anaesthetic vapourizers that cost $5000 and last forever with very little mantainance or anaesthetic machines that cost under $20,000 (including the cost of those above vaporizers) which will work without compressed gas or electricity.

And of course using standard monitoring which we have to use anyway capable of giving as good an anaesthetic or better as what we can do with the $100K machines we are told we have to buy. Of course they don't come with a sound system either.

Won't be Bloggin' for a while

2011-05-19T11:11:00.002-06:00

Tomorrow I am heading off to eventually end up in Rwanda for 4 weeks to teach with the CAS International Education Fund program before a Kenyan safari.

I will be posting my experiences and pictures on another blog, however as I like to keep my work and life separate, I will also keep my one blog life and my other blog life separate.

I may post a few pictures and posts if I have time.

"See" you in July.

EBL

2011-05-15T20:21:00.003-06:00

I have to start thinking of some original topics instead of responding to Great Zs posts.

I am not sure what the importance of the EBL is anymore. It is so much easier just to get a hemoglobin (which we are now able to get again on the blood gas machine since I kicked respiratory's asses).

We never ask at our hospital anymore. At the Centre of Excellence, they asked after total joints. I started giving it to them right down to the nearest 1 cc which the nurse dutifully would write down. Probably why they hated me there.

After one surgeon low balled his blood letting, I looked at him and said, "There's that much on your gown."

IV s

2011-05-05T12:04:00.003-06:00

I am only getting around to commenting on this old post by Great Z

I honestly thought I was the only anaesthesiologist who was bothered by IV s.

I think I do most things fairly well. Spinals I get first shot most times; epidurals likewise. I can do a wide range of pain clinic procedures quickly and efficiently. Central lines don't usually cause me grief.

But the difficult IV?

I dread them, the patient who comes to OR covered in bandaids from previous attempts, the heavy smoker, the chemo patient, the scared stiff shut down patient and of course the child. Anaesthesiologists, because we do so many, are better at the easy and moderately difficult IV. When it comes to the above patients we are floundering just like everybody else.

My visceral dislike of IV s possibly stems from my internship where I was used as an IV service. This was a little hard on me and the patients as where I did my student internship, the nurses started the IVs so I was learning on the fly as it was. Fortunately early on during a 4 week anaesthetic rotation, one of the anesthesiologist taught me a technique of starting IVs which I use to this day. Early on however I had a patient who had been on IV antibiotics for weeks and had no veins. I asked the resident if she could go on oral antibiotics and he insisted that she needed the IV and suggested I call anaesthesia. I did so and talked to the resident who passed me on to his staffman. "When your staffman comes in and can't start the IV." said the anaesthesiologist, "I will come down and try to start it."

We do have some aces up our sleeves. We know some places where people usually don't look; the palmar surface of the wrist, the medial forearm just below the elbow and of course the feet. I am never shy about using the antecubital vein. I also will use smaller bore gauge needles such as a 22. We have other aces like central lines, IM ketamine and inhalational inductions (which I occasionally do on adults with poor veins). These last two are of course only useful for patients who are going to get a general anyway. Most of us dread the call to the ward for the patient in whom nobody is able to start an IV.

About a year ago, I had a lady for a C/S under spinal. As it turned out she had a mastectomy with an axillary dissection on her right side and of course chemo which screwed up the veins on her left side. I stared at her left arm for a while and couldn't see anything resembling a vein. Using her foot,assuming there were veins there, is of course out as in the event that the OB gets into the pelvic veins, I am going to be transfusing the suction bottle. After thinking, I told the patient that I was going to have to put a central line in her neck. She was quite cooperative and the line went in smoothly under local. I then proceeded with the spinal and she had her baby. At the end of the case I offered to try to put an IV in her foot so that the central line could come out. "Don't bother," said the OB.

For the rest of the day, I got a phone call about every hour from the post-partum ward. "You know we can't have central lines on this ward," the call would go. I would explain that there was no IV access. There was an attempt to transfer her to the General Surgery ward which could take central lines but they weren't comfortable with an obstetric patient. After a while, I told them to sort it out amongst themselves and think about what was good for the patient and not what was in the policy manual. The phone calls stopped and I started waiting for the letters (which never came.)

A couple of years ago I got a call from the pediatric ward. While we have a large Pediatric Centre of Excellence in our city, our hospital for reasons of pride had insisted on keeping a pediatric ward which thankfully they closed about a year ago. "We have a child with bacterial lymphadenitis here," said the nurse,"who needs IV antibiotics and his IV is gone." Okay I don't like being used as an IV service, but I do have some skills in that area, I wasn't that busy, plus in 30 years (including medical school) I had never seen a case of "bacterial lymphadenitis" so I was pretty excited.

I arrived on the pediatric ward to find a happy child playing with his mother. Happy that is until he saw me approaching with the IV tray. Seeing it was going to be struggle, I looked at the child and thought, "he looks awfully healthy to be needing IV antibiotics". So I examined him. Firstly I felt around his neck where the infected lymph nodes were supposed to be and couldn't really feel any. Not even the "shotty" lymph nodes we used to use to justify giving antibiotics to what we knew was a viral infection. I asked what his temperature was and it was normal. I looked in the chart and the white count was normal. I phoned the pediatrician's office. He was not in but I asked his secretary if he could call me back about the patient and left my cell number. He of course never called back.

It was of course quite possible that the child had a dramatic response to the IV antibiotics and the pediatrician just hadn't made rounds yet. It is unfortunately more probably that the child just had a URTI, the pediatrician took pity on the mother, admitted the child and felt he had to have a treatment to justify the admission, something I saw countless times in medical school and internship.

So I empathize with Great Z and all our brother and sister anaesthesiologists who I now know are as stressed out as we are over this issue.

Bin Laden; Random thoughts

2011-05-02T11:27:00.003-06:00

OK....

Bin Laden has been living just outside the capital of Pakistan for who knows how long in a large luxurious fortified compound. Presumably also getting hemodialysis every 2 days.

How much does the US spend on "intelligence"?

Meanwhile we have been taking off our shoes in security, having our shaving cream confiscated and getting to the airport 3 hours early for flights.

Canadian troops have been in Afghanistan for years at a huge financial and worse human cost. We won't even talk about the financial and human cost to the US.

And of course killing Bin Laden is not going to bring back all the people who died in 911 and other related terrorist activities, not to mention the at least 10 fold higher number of innocent people who have died in reprisals in Iraq and Afghanistan. Nor is killing Bin Laden going to end terrorism; by either side.

And with the convenient "burial at sea", conspiracy theorists are going to have a field day.

Life's been good to me so far

2011-04-25T19:06:00.007-06:00

"I can't complain but sometimes I still do,
Life's been good to me so far"
Joe Walsh

I know I whine a lot in this blog. I am really not a negative person. I have a whole lot to be thankful about.

1. I have been married to the same smoking hot wife for over 26 years.
2. I have two great adult children and I actually got one to move out of the house.
3. I belong to the best anaesthetic department in the province and I am the boss.
4. I make a ton of money. Money can't buy happiness but it sure can rent a lot. Sure a lot of doctors make more than I do but who wants to work as hard as they do or do what they do?
5. At 53, I am actually in better shape physically then I was at 43... or 33.
6. I live in a great neighbourhood. Who cares if rich kids buy drugs across the street?
7. I was raised by two educated parents in a middle class neighbourhood. I went to the best high school in the province. My parents instilled the values of a university education but never insisted on what we took. When I phoned my mother to tell her I had been accepted to medicine, she said,"Oh I guess that's what you wanted."
8. I am in a specialty I like. During the first year of my residency , I remember thinking, "this is what I was born to do."
9. I have a great staff in the Pain Clinic.
10. Sure I spent over 13 years at the Centre of Excellence but I had at least 4 chances to escape before I pulled my parachute. Truth is, I must have liked it a little there. I also with very little resources and support established a Pain Clinic there which has evolved into something much bigger. Too bad I don't work there anymore.
11. I won an award.
12. Surgeons actually aren't that bad to work with. I actually like most of them. Even the psychopaths are entertaining, watching all the games they play.
13. I also really admire nurses. Not just because I married one. Sometimes when I am bored I watch surgery and I am just amazed at how the OR nurses anticipate what the surgeon wants and keep track of all that equipment. Floor nurses of course do a great job doing what must be a really shitty job. If you want to get the lowdown on a patient, you ask the nurse.
14. Quite a few administrators are really hard-working individuals who if you divided their salary by the number of hours they worked would be making less per hour than most of their underlings. Much of what they do is affected by how much money they have and by politics; two things they have no control over.

So why don't I blog about that.

Well...

When I started my blog 4 years ago in addition to having stuff to get off my chest, I actually hoped that people would read it. I am by nature a sarcastic person; sarcasm is the lowest form of humour but it is humour. It is also usually negative. I could write about the list of arthroscopies I did where nothing happened but that would be pretty boring so I would rather write about the horrendoplasty I was involved with. Likewise I could write about some of the really great people I have met and worked with over the years but that would also be boring so writing about assholes and sociopaths is much more interesting and sooooo therapeutic.

I will try to more positive.

I can't promise anything though.

Finger pointing; a life of blame.

2011-04-24T09:50:00.007-06:00

My fellow blogger the Anesoboist is becoming more cynical.

This reminds my of several incidents in my professional life. Surgery is of course an inexact science. People do not always get the outcomes that they were promised, many times they are left worse off than before. To cut and saw another human being requires a huge ego and a lot of self confidence. It is therefore difficult to accept that when what you promised the patient didn't turn out that it was simply bad karma or maybe even your fault.

Fortunately it is not possible to do most surgeries without an anesthesiologist so you have a living human being to blame.

It is of course possible to be blamed for a case you were not even involved in. When I was resident, I was sitting minding my own business in a general room. There was a general surgery case going on next door and at the end of the case they were one sponge short. The staff surgeon therefore un-scrubbed and dug into the garbage. After some time he found the missing sponge. It was in the same strata as the central line kit. It was therefore "obvious" that the anesthesiologist had surreptitiously removed a sponge from the sterile table for his central line without telling the nurses. After appropriately venting his spleen in his room, he had some spleen left over, so went into my room where he regaled at length the surgeon with his accusations. I wasn't paying much attention until one of the nurses came over to me and said, "he is really taking anesthesia's name in vain." As I have said I wasn't paying attention and replied,"You should hear what we say behind his back." That was the wrong thing to say apparently. He got right in my face and yelled, "Well it was bloody irresponsible" and stormed out of the room. I actually had to ask exactly what it was he was upset about. It was then that I learned it was possible to be blamed for something that went on in the next room.

The first night on call as a staff anaesthesiologist, there were actually no emergency cases booked at the end of the day so I was able to go home. Around 1830, I got a call from a gynaecologist. "I have a lady with a pelvic mass that I need to remove," said the gynie. "Unfortunately I have an evening office so I can't start until after 2000". "Fine," I said, " But if something else gets booked, it will have to go ahead of your case." Seconds later the phone rang and ortho had booked a case. I went in, the case of course took longer than it should have and because the hospital only had two nurses on evenings there was a long turnover and it was 2300 before we were ready to do the pelvic mass. I was sitting in the lounge waiting for the patient to come into the room when I heard the GP who had come in to assist, on the phone to his wife. "We are running late," he said, "anesthesia bumped our case." I should have confronted him and pointed out that we were starting late because the surgeon hadn't been available earlier but he was a nice guy who became our family doctor and delivered my number two son. I also found out why the gynie had an evening office. It was so he could golf in the afternoon.

About a year later, I found out from the recovery room nurses that Dr. P a surgeon long past his best-before date had been sniffing around recovery room asking about the open cholie we had done two days ago. Apparently the patient had aspiration pneumonia. The patient was obviously still in hospital so I went up to see her. Did I mention she was a lawyer? I was able to read in the chart that she indeed had pneumonia, as did her husband and that her blood culture had grown strep pneumonia. Sounds like a community acquired pneumonia to me, I thought. This hadn't stopped Dr. P's son, an intensivist from writing a consult stating she definitely had aspiration pneumonia. I spoke with the patient who was quite reasonable and accepted the fact that her pneumonia had very little to do with her surgery. I wrote a note in the chart which started, "while it is nice to learn about potential complications of anaesthesia, even by such a back-handed method...." A few days later Dr. P. approached me to sort of apologize. "She is a lawyer," he reminded me; translation it is better that you get sued than that I get sued.

Being blamed for turnovers comes with the game. Early on my career I was working with a plastic surgeon who had a morning list with another surgeon having the afternoon list. The surgeon had an emergency case he wanted to do at the end of his list. He was quite quick and could normally do this. Unfortunately his first case went 30 minutes over, the turnovers were glacial and he just ran out of time. I could see that as the morning went on he was getting more and more pissed. As it happened his wife was working in the room that day. "I wonder who he is going to blame for this," I wondered. I shouldn't have wondered. After dumping his last case in the RR, he pulled me into his office where I received one of the ten worst tongue lashings of my life for delaying his list.

One of my colleagues told me of an interesting story. He was approached many years ago to come to internal medicine grand rounds where they were presenting a case of Halothane hepatitis. He didn't review the chart of the patient they were presenting until the day of rounds. After the case had been presented, the question came to him, "Dr. H, do you think this patient had halothane hepatitis," "No," said my colleague. "Why," came the question. "Because she had a spinal," said Dr.H.

Internal medicine...fail!

(I have always suspected most cases of "Halothane hepatitis" were actually hepatitis C,D,E,F or G which is hardly good grounds to abandon such a safe and inexpensive drug.)

We always joke about "anaesthetic bleeding". Sometimes this isn't a joke. A the CofE. I was doing a cystectomy. On opening it was found that the bladder tumour was invading the pelvic wall. A less excellent surgeon would have said,"she has had a good life" and closed. Not this surgeon and so I had about 6 hours of major blood-letting. Fortunately I knew the surgeon and had "come to play" with a 7 Fr. CVP, large bore peripheral and an art line. None the less she lost about one blood blood volume, developed a coagulopathy and ended up in ICU. I heard from an anaesthesiologist at another hospital where the surgeon also worked that he had been slagging me in the doctor's lounge. Apparently I had caused the coagulopathy by giving too much fluid.

The CofE was of course a culture of blame except you didn't just have to deal with surgery, internal medicine and ICU. Your anesthesia colleagues were always ready to enthusiastically join in, in true Lord of the Flies style should something go wrong.

I could go on. What really concerns me is the number of times I may have been blamed for a bad outcome where I never found out about it.

Part of this is of course our fault. We often see patients in a rushed fashion, we ask them a whole bunch of questions(some they have been asked already, some they haven't but should have been), we dress mostly like the rest of the OR staff, there is very little to distinguish me from one of the porters. We warn them about things like dental damage and other bad things that might happen to them. We never see patients post-op. It is pretty easy to blame somebody like that.

I have often thought it would be interesting to go up to a patient's room when something surgical goes wrong and actually tell the patient what happened. "Did you know that it was the surgical resident who 'accidentally' ruptured your spleen." "By the way how do you like your scar, the student intern closed" "Did you know that your surgeon didn't get any sleep last night?" "This happened to his last total hip by the way".

MAFAT

2011-04-21T14:53:00.006-06:00

MAFAT as any surgeon will tell you very early in your career means Mandatory Anesthetic Fzcking Around Time. They will tell you this with great glee when they should be scrubbing, prepping or actually operating on the patient.

About a year ago when I took over as Department Head or in newspeak Site Leader I had a farewell interview with my predecessor, who is a living legend both in the anesthetic and medical communities. I was expecting some very insightful words to inspire me to reach the heights of notoriety that he had reached, however most of the time he spent telling me to make sure that I never let certain anesthesiologists do certain lists or work with certain surgeons. "They just cannot handle the work", was the way he put it.

I consider myself to be a pretty efficient anesthesiologist. I remember a few years ago an older nurse who had been trained by the nuns telling me that she had been taught by one nun that, "the biggest sin is wasting somebody else's time". I had never really thought about it, but I hate to wait, I hate to have my time wasted why should I waste other people's time. I was fortunate to be mentored in my residency by three role models who just happened to have the same first name as me.

The Samurai warrior was a Japanese Canadian pediatric anaesthesiologist who was always in a hurry but at the same time incredibly compulsive. Very stressful as a junior resident to work with but at the same time in retrospect a great education.

The Bull was an English anesthesiologist, very much less compulsive than the Samurai, but still hard driving wanting to get the cases started and finished as quickly as he could.

Dr. Gadget loved monitors and other toys which he of course applied quickly to the patient. One day one of the nurses remarked, "One day he is going to catch up with himself". I remember as a resident working with him and finishing two CABGs by 1430, a record that will never be broken.

All three of them taught me that you can be fast and still be safe.

In anaesthesia we typically work alone so the only insight I get into the work habits of others is when I work with a resident. Usually when a resident is doing something stupid, I figure that they must have learned this from somebody because no rational person could have figured out how to be so stupid on their own. The first case I did with a resident at the CofE I remember several times having to tell him to "get on with it", an expression I learned from the great Ernie Hew during an elective at Mt. Sinai. The epidural is not going to get done by you staring at the patients back!

One annoying habit that residents have which I can only assume someone is teaching them is what I call the appetizer approach. This is where the resident will give a little of the fentanyl du jour and then ask the patient several times, "are you feeling it yet?". OK this is not a restaurant, I am about to have surgery, I am in a cold room, if I look to one side I can see the weapons being prepared by the nurses, and now some idiot is making me dizzy and nauseous and asking me if I am feeling it. For the love of God, put me to sleep.

Some things like art line, central lines and epidurals take longer; they are going to take a lot longer if you don't think about them until the last minute, don't tell the nurses and the techs you are doing them and to quote again the great Dr. Hew, don't get on with it.

A lot of MAFAT is of course beyond our control. Surgeons especially those in teaching hospitals live in a delusional universe where after they scrub out and leave the room, the wound closes itself, the patient awakes immediately, the room cleans itself, the next patient arrives on time with his consent signed and the IV starts itself. All with no time elapsed. To their dismay the rest of us live in another universe. Long turnovers frustrate me too. When I have to wait 30 minutes between cases, I feel I have to rush and cut corners to make up for everybody else's inefficiencies. I call it "wait and hurry up".

At the same time our fee schedule has devolved into a situation where for the most part we are paid by the hour. This means if I do 5 cases in 8 hours, I get paid the same as if I do 4 cases in 8 hours. Or if I do 5 cases in 8.5 hours because I am less efficient, I actually make a little more. Multiply that 0.5 hours by 250 work days and we are talking about some serious cash. Not that this ever crosses the mind of some of my colleagues. Never.

Periodically administration approaches us about extending the day or working on Saturday to clear up a perceived backlog of cases, total joints are the current cause. I have learned that the best way to shut them up is to suggest that they first look at using the time they have more efficiently. End of discussion.

As I am reminded, patients don't come to hospital for an anaesthetic however we are only part of team. As my band teacher told us over and over again, a band is only as good as its weakest member. I try not to be that person.

Cars

2011-04-18T12:43:00.004-06:00

I am not really a car person. Like all boys I played with Dinky Toys and Hot Wheels but then I grew up.

A few years ago, my wife showed me a picture of a car. "Isn't this beautiful?" she said. I thought for a second. "You are beautiful, music is beautiful, scenery is beautiful; cars are tools. They sometimes get you to where you want to be; that's all." Which more or less summarizes my attitude towards cars.

I obviously work with people who don't share my lack of enthusiasm and I get to park next to all lot of cars which could be called beautiful if I was that way inclined. I have noticed a few things about expensive cars. For the most part they are driven by very hard-working doctors, the kind who don't have a lot of leisure time. So...the best part of their day is driving their expensive car 15 minutes each way in traffic to work. Sounds like somebody really needs to get a life. And of course the faster a doctor's car is theoretically able to go, (assuming they ever got to drive it anywhere else than too and from work,) the more likely they are to be late.

This is all precipitated by the fact that I leased a new car last week. The lease on my Volvo S40 expires at the end of this month. I was given the choice of buying it out or handing back the keys. I decided I really had no attachment to this car and didn't really want to shell out $16K to keep it when for no money down I could get a brand new car. (I guess I do like cars a little bit.)

Every time I start to get a new car, I resolve that this is time I am going to do it right. I am going to test drive lots of different cars, I am going to bargain hard, I am going walk out of the dealership if they don't give me the price I want. I am not going to get any of the options I don't want. I am definitely not going to get the undercoating or the upholstery treatment.

So what did I do.

I test drove 1 car, a diesel VW Jetta. I liked it, I fit in it and they had one in the colour I liked. If you can believe the dealer it gets 60 mpg on the highway(I mostly drive it 5 minutes to work, when I don't walk or bike). I showed it to my wife and we decided to lease it.

So we start to haggle on the base price. I am figuring we'll lop off $2K right off the get go. The dealer of course points out that diesels get sold quickly and they can't bargain much. I wimp out and start with a $1K off and we settle at $500. What I should have done since I was really in no hurry was to threaten to go to another dealer, in another city if necessary. I am such a wimp and anyway if you are leasing we are really talking about less per month than I spend on lattes.

Now off to the finance manager for lease. I always find this the bad cop to the good cop of the sales man. First I have to ask a whole lot of personal questions about my credit history etc. Taking all this information, he goes off for a few minutes and comes back with a print out of my bank balances, and all my credit card balances. Talk about big brother is watching. This is all complicated by my split personality as a personal corporation in addition to a person.

The finance manager's job is not just limited to assessing your credit-worthiness. His real job is to sell you the paint and upholstery treatment. This adds another $1K onto the price and is now pushing the monthly lease payment up to $100 more than I thought I was going to pay assuming I had also negotiated with more balls. Should I waiver, he of course reminds me that this is a lease and there will be dire consequences in 4 years, if having turned this down, I have a paint chip or a stain. (Dealers of course used to sell you the undercoating which has sort of become a joke; I remember years ago solemnly signing a long and detailed waiver after I declined the undercoating.)

With this information, I then had to arrange insurance coverage by phone so that I could pick up the car (after of course the paint and uphostery treatment had been applied). The insurance guy of course tries to sell me all kinds of extra riders and doodads. I try to explain that all I want is exactly the same coverage as the car I am giving up. I am of course calling from the OR, in the time that I have been on hold and listening to all the options, things have changed, alarms are going off and the surgeon wants the table raised or lowered.

On pick up day I of course made the mistake of going after work and before supper. Before getting the keys I have to make another visit to the finance manager's office to sign the lease agreement. This is of course not the sole purpose of this visit. The finance manager has more to sell me. Would I like to purchase a service plan against door dings and uphostery tears. For $20 extra a month, if such an event occurs, somebody will come to my house and fix it. "Can I think about it?" This offer is only available at the time or purchase. He again reminds my that this is a lease with dire consequences. He gives the example of a cigarette burn. I point out that I don't smoke. By this time it is 1900 hours, I started work 12 hours ago, lunch was at 1100. All I want to do is drive my new car home (we are having a late winter/early spring snowfall so I don't even get to take it for a longer spin), have supper and drink a beer.

Repeat in 4 years.

Terms of reference, terms of schmeference !

2011-04-10T10:57:00.004-06:00

After years of waiting, dexmedetomidine is now available in Canada. I have been in the business long enough to know that there are no panaceas and the best thing since sliced bread is still sliced bread, however we felt dexmedetomidine might be useful in the MRI suite where we anaesthetize obese claustrophobic patients and for other uses. Consequently we placed a request into our pharmacy committee for the addition of dex.

Anaesthetic drugs which cost $40 are low priority in comparison with other more important drugs like the latest cancer drug which will increase life expectancy by one month in 10% of patients, so I wasn't expecting much. A couple of days ago, I got this from our new P and T committee.

Here is an update on the status of your request:

“Dexmedetomidine for Procedural Sedation” was on the agenda for the late March provincial P&T meeting.
Because the March meeting was the first time the group had met, more than half of the five hour meeting was spent reviewing the Committee’s structure and Terms of Reference.
Consequently, the committee ran out of time to discuss a few of the agenda items and “Dexmedetomidine for Procedural Sedation” was one of those items.
“Dexmedetomidine for Procedural Sedation” will remain on the agenda for discussion at the next meeting.
The plans are that the committee will meet every two months initially.

That is right. This committee spent 2.5 hours reviewing its structure and terms of reference. About 2 years ago all the health regions in the province were amalgamated into one single region. Up until recently we didn't even have a P and T committee which was the reason given for not approving drugs. Now we have one and it has finally met and spent one half of its meeting time looking at its navel. P and T committees aren't a new thing, every region had one, before that every hospital had one. It is pretty certain that every member of the new super-committee had been on a P and T committee.

What is the name of this blog again?

This gave me an unpleasant flashback to the last millennium and the first reorganization of health care I was involved in. At that time our newly formed region decided they were going to develop and region-wide chronic pain program. The timing was auspicious; there were people actually interested in doing this and with downsizing and closing of hospital beds there was actually ample physical space in which to have one. Moreover somebody had actually spent two years under the previous administration drawing up a plan complete with a budget that we could actually have rolled out within a few months.

Instead of just doing this, we did the logical thing and formed a committee. Once a week from 1600 to 1800 we would meet to discuss how we were going to deliver chronic pain management to the community. But first we had to develop a mission statement. This took 2 or 3 meetings. Then we had to define what exactly chronic pain was. This took 2 or more meetings (I'm not making this up). We had two all day retreats on weekends during which the stakeholders were consulted and more meetings. After a while I figured that the fix was in and stopped going. I was right of course. While we were busily filling flip charts, the entrepreneurial physiatrist who was chairing the committee had been negotiating directly with the government and guess who got all the money? 15 years later I more or less do things the way I did 15 years ago. I should get over this but I won't.

To Tired to Work?

2011-04-03T10:47:00.003-06:00

I just realized that this May I will be celebrating an anniversary; 30 years of night call. Not an auspicious one but one deserving of reflection.

Nobody in my family was in medicine, so I had no idea of what the lifestyle of a doctor was. I figured it would be like on MASH where Hawkeye and Trapper John sipped Martini's in the swamp in between tormenting Frank Burns and boinking the nurses. Or maybe like Doc Adams who spent most of his time arguing with Festus in between digging bullets out of the Marshall. I at least figured that I would only be seeing really sick people who needed urgent attention. Why else would you work after hours?

I was moonlighting in emergency during my residency and was suturing up a rare treat, an unobnoxious drunk around around 1 am. "You must be pretty smart to be a doctor," said the drunk. "If I am so smart," I replied, "what the hell am I doing here at one in the morning on a Saturday." Even back then I had it figured out but I am apparently no smarter.

I am pretty certain that anaesthesiology is the only specialty that works harder on call than they did 25 years ago when C/S rates were under 20%, labour epidurals were uncommon and fractures were actually treated with closed reductions.

This has become an issue lately because of complaints by my colleagues related to on call especially on weekends. Our department like many around the city has developed what is at face a very civilized call system. Nobody is on first call for 24 hours. We have a Day Call who works from 0700 to 1600 after which he becomes second call until 0700 the next morning. Night call starts at 1600 and goes until 0700 the next morning. Night call usually follows Day Call which means that after being on Day Call you don't work.

This system works well on weekdays, it is weekends when it is beginning to break down. The problem is that if you are Day Call on Friday or Saturday; you effectively become second call for the next 24 hours after which you become first call. This should not be a problem as second call should normally only be coming in for life and limb threatening emergencies when first call is tied up. Think again, our OR is staffed to run two rooms until 1100 on weekdays and from 0800 to 1600 on weekends. On top of that we have a not that busy Caseroom which we also have to cover. Increasingly surgeons and administrators are asking (demanding) that we run two rooms on evenings and weekends. This means that it is possible to work until 2300 on Friday, be called in at 0900 on Saturday and then work until 0700 Sunday. It is unusual to work all night, however the Case Room can make for a lot of interrupted sleep.

We could of course fix this by having a second call on weekends that is separate from Night Call. The problem with this is that we are a relatively small department and to bring in a second call would result in call every 1 in 3.75 weekends during the year and 1 in 2.75 during the summer (somebody else calculated that not me). Most people are prepared to just grin and bear it. Many weekends are not that busy. Adding a second call in addition to increasing our weekend call load would dilute our income from on call.

Switching to shifts is an interesting option and one that emergency docs have been doing for years. As one staffman explained to me during my residency however, the reason we work 24 hours or longer on call is so that we get more weekends off. As most of our work is done during the weekdays, shift work is something that would be harder to schedule for anaesthesiology without a lot more redundant manpower.

But what about if we only did cases that actually need to be done? Imagine being on call and only doing appendectomies, compound fractures, and caesarian sections. You would still be on call as often but would be earning a lot less under the fee for service system. Occasionally I get a day or an evening on call where there is nothing booked, and the Case Room is completely quiet. Those times are almost as bad as working. There you are tethered to being within a 20 minute radius from the hospital, if you and your wife go out you have to take 2 cars. Start doing something and the phone is sure to ring. So you sit around watching mindless TV or reading; later on you go to bed for a fitfull sleep worrying that you are going to sleep through the phone. It was a lot worse before cell phones; I can remember going out with a pocketful of change for the pay phone in case my beeper went off. So the answer is that most of us want to work but not a lot.

On call work is very surgeon dependent. One man's emergency is another man's put it off until Monday. Kidney stones are a case in point. Some surgeons like to operate on all of them before something happens (like the patient passes it). Others are happy to send them home with some analgesia. Our hospital actually has a stone room on Fridays to allow urologists to do their urgent stones during the day. This still doesn't stop a small sub-group of urologists from booking stones on weekends. (As an aside in my first job, one of the urologists before he went home on Friday would in his illegible scrawl, book "John Smith" and "Bob Jones" for ureteroscopies on Saturday morning. His rationale was that two patients were sure to present during the evening or night and he wanted to go first. He died in his sleep a year or so after I left, which may or may not be karma.) Many surgeons believe that if they are going to be on call they want to work. Many years ago an orthopedic surgeon was caught telling patients on his wait list for arthroscopy to go to the ER with "locked knees". Much less egregious abuses of on call operating time still occur. The chief of surgeon recently confirmed what I had always believed. As he said, if we (which means if I) am not busy and I have a patient with a gall bladder who is not coping well at home I will call them in. There are also surgeons who figure that if they have to do one case, they may as well do two. The less urgent case is always booked first, so that you have to do the more urgent case regardless of how late it is or what else is booked. I could go on with examples.

Surgeons it is true also take call and often take call more often that do anaesthesiologists. Surgeons do have much more control over their workload however, there are very few surgical cases that have to done right away. If they are feeling tired, they can and do put cases off until the next day. Surgeons also have several layers of buffers between them and the patient; nurses, hospitalists, interns and residents. They are therefore only seeing the tip of the iceberg of their on call work. The problem is of course that while we have multiple surgical subspecialties, we only have one (or two) anaesthesiologists. These means that after the orthopedic surgeon decides around 8 pm that he has had enough and puts off the rest of his huge trauma list until the next day, we are still stuck with whatever appys, D+Cs and the real emergencies that come through the door. I am now starting to accept what I should have always known. I am just not as sharp after 8 hours of working. I start to cut corners, I do stuff I know I shouldn't do. Sometimes looking back at a specific case all I can think is, "what was I thinking?" This is not limited to anaesthesia. I have blogged in the past about operating on no sleep. Having recently had the "pleasure" of some long ortho trauma lists on Saturday I have noticed that as the day goes on the work get sloppier. Locking the IM nail that was easy at 0900 seems to take a lot more time at 2000. I remember watching a really tired Ob-Gyn trying to do an ectopic laparoscopically late at night and it was not pretty.

A couple of years ago at a meeting, I ran into some anaesthesiologists around my age who I worked with in my first job before in a long moment of insanity I moved to the C of E. The discussion topic we arrived at was the techniques we use to stay awake during cases late in the evening and at night. One person had an interesting technique. She would sit in the chair of anaesthesia and lean on the machine so that if she fell asleep she would not fall off her chair. There are other techniques of course: playing your music loud if the other people in the room will allow it, turning up the volume on the monitor, setting alarms to go off all the time, talking to the nurses. I remember late at night trying to stay awake during a really boring head and neck case. One of the nurses finally took pity on me and brought in some Readers Digests. "Read these," she said, "that will keep you awake." I started bringing in books and magazines. I once read most of an entire novel during an all night case.

Some cases of course are easier to stay awake during that others. Ruptured aneursyms, major traumas come to mind. Adrenaline and the need to actually do something during the case keep you awake. Sometimes the effect of having done 12 hours of mind numbing orthopedics, makes you less fresh.

Compounding matters is that I no longer recover well from those all nighters. I have never been able to sleep well on call. The odd time when from shear exhaustion I do sleep, I am groggy almost drunk when I am awakened. I am crabby when I am tired. I say things I shouldn't say. I have gotten in trouble for this in the past. I did one in three call for most of my internship and for 6 months in my residency. I have no idea how I survived. I would quit Medicine if I knew I had to do it again.

If you get a group of anaesthesiologists together long enough, the conversation will inevitably come down to call and the whining will start. This is my whine.

Why Do Coffins Have Galvanized Nails?

2011-03-31T20:36:00.010-06:00

1. So oncologists won't pry them open to try to give chemotherapy
2. So nephrologists won't pry them open to try to dialyze them
3. So orthopods won't pry them open to try to fix their hip.

Choose one or all of the above.

I only read the National Post when somebody leaves it around and I am really bored, however this is quite interesting in a depressing way of course.

This of course reminded me of where I trained. We had an oncologist who liked to give his last dose of chemo in the morgue. This combined with the lack of balls of our intensivists meant that on occasion half the ICU were patients with terminal cancer. Our local nephrologists weren't much better.

I had to do 6 soul-destroying, spirit-breaking months of internal medicine during which I had to deal with quite a few of these dilemmas. At that time the older people I was seeing tended to have had large numbers of children. I observed a truism: the children who still lived in the area and had cared for their parents tended to be quite reasonable about extraordinary measures; the children who had moved away were usually very unreasonable and wanted everything done. I am trying to think of an exception to this but I can't. There were as in this case, more malevolent motives

My son is studying bio-medical ethics which for some reason doctors don't have to study. I told him my simple ethics test: "Don't do anything to a patient you wouldn't do to yourself or to a member of your family." A little simplistic, however I have applied it retrospectively to most of the ethical situations I have found myself in over the last 29 (!) years and it seems to more or less work for most of them. (Abortion is an exception; I believe in abortion, some doctors don't) Many times of course what I would do if it were me is not necessarily what the patient wants or more frequently what the family wants but I think if I or preferably somebody else actually sat down and gave the hard facts, I think a lot of people would come around.

The thing is, judging from my coffee room conversations with other doctors, most of them don't want aggressive measures should they have some horrible terminal disease or for that matter some horrible injury that leaves them with a diminished quality of life. Granted I don't drink coffee with a lot of oncologists or nephrologists. With these beliefs however we submit our patients to weeks to months of what must be living hell in the belief that that is what they want. As I mentioned a long time ago one of my least favourite things to hear a surgeon say is, "I don't want to do this case but the family is insisting on it."

Part of my job now as Site Leader is to sit on a QA committee with the Chief of Surgery and some high powered nursing administrators. Some time ago we had a unfortunate (maybe not) 95 year old drop dead in our recovery room after his IM nailing. He had a DNR order which the anaesthesiologist quite correctly respected. Cases like these are always interesting because by hospital policy DNRs are suspended when a patient comes to the OR. The correct response here would then have been to pound on his chest for some time. Nobody was critical of how the case went down, the reason I presented the case was to ask the question of whether it was even appropriate to try to fix his hip and if so could it have been done in a simpler fashion than the gamma nail, which is the method du jour of fixing hips now, especially as his demise was probably due to a marrow embolus from the IM nail.

We seem to get into a few dilemmas like this in our like OR as we do a steady number of IM nails for pathologic fractured femurs. These have a significant incidence of tumor embolism which is almost always universally fatal. This has lead to complaints against members of our department for both over-rescuscitating and under-rescuscitating depending on the attitude and the grief of the surviving relatives. A lot of this could be avoided by having the orthopod actually talk to the family but hey, these are orthopods.

Aside from the ethical issues involved here the article points out that there are financial issues in play as well with a significant amount of health care dollars going into the last six months of care. Of course we all know what happened when they tried to talk about this in the US. Death panels anyone. Sounds like a plan.

It is Indeed a Special Moment the First Time Your Son Injures Somebody

2011-03-20T19:39:00.003-06:00

All the commentary about head shots and concussions in sports have brought back repressed memories from my years as a hockey dad.

Now men like to hit each other or fight. You only have to watch young children playing to appreciate this. This is also apparent in other species where it is not necessarily limited to males. Consequently we have sports like hockey football and boxing. This is not a North American phenomena, we also have rugby and hurling.

I only played one year of organized hockey. My parents gave all kinds of reasons including, the early ice times and the fact that I was not very good. This is despite the fact that in 1977 when I would have been eligible to play in the NHL, all the teams were drafting big guys who couldn't skate and at 6'5" I would have been the tallest player in the NHL (you can check on this if you want). I should get over this but I won't. This trauma is why when my oldest son announced at age 7, that he desperately wanted to play hockey I did nothing to stand in his way.

Of course having 2 boys, you can't just put one in hockey without putting the other in hockey and so little brother had to go in as well.

Little brother had a different personality from big brother, he was one of those cute kids who skates around in circles oblivious to the puck. This was fine at the Tom Thumb level where he had kids who would actually play the game for him but as he reached novice where he was put on a team with kids of similar ability, it became painful.

Hockey in our province is non contact until age 11 at which time body checking is permitted. I wish we could say that we were mortified but actually we were quite proud that this was an area of the game in which number 2 son excelled. Body checking gave him a role on the team, his interest peaked, he actually started scoring goals and playing at the outdoor rink. And of course he injured players. Many players I learned don't watch Don Cherry and don't appreciated that you don't cruise across the blue line with your head down. Thanks to Don Cherry our son realized that players would do this and many of his worst hits came on those players. Now my son was not a dirty player, many of his hits were to the head which was legal then but they were with his shoulder not with his elbow. He got a penalty every couple of games unusual unrelated to hitting. In his second and final year of contact hockey he was badly mis-tiered at the beginning of the season which meant he played with and against a number of players in their first year of contact hockey.

The carnage every week was incredible. I remember seeing a player skate out of the corner, head down and my son laying him out; I saw the legs buckle, the player slump the ice and the other team's trainer sprinting across the ice. Meanwhile number 2 son was getting high fives at the bench and I had never been so proud of him. At the end of season party one of parents came up to my son and said, "Thank you for protecting my son".

Body checking is an integral part of hockey just as tackling is an integral part of football or rugby. Most 11 year old kids in minor hockey want to body check.

Sadly my son also suffered a number of concussions in minor hockey. Some of these were inflicted by his own team in practice as some players wanted to see how tough he was. A few were in games, at least one skiing.

My number two son is in University now and doing well. He no longer lowers his shoulder into people's heads. He just skis and bikes off cliffs.

At the Centre of a Scandal

2011-03-11T19:33:00.003-07:00

Rarely does one find oneself actually having worked in what is shaping up to be a major political scandal.

Thoracic surgery at the C of E was a poor cousin to cardiac. This was unfortunate for them as they shared beds and operating time and guess who won out there.

About 5 years into my tenure at the C of E a new thoracic surgeon was recruited. Now at the C of E at that time there was only room for one thoracic surgeon which as you can see could potentially cause some problems.

The fellow they recruited was a local boy who trained at another centre and had done some training over in Britain. He was technically not a bad surgeon, he was a little whiny, he liked to operate at night etc. Despite some interpersonal problem I had with him early on, we actually got along, and I actually enjoyed working with him. After a few years, he started to complain about things like not being able to recruit other thoracic surgeons due to lack of OR time (which meant he had to be on call every night), and his beds being filled by cardiac surgery patients meaning that he often had cases canceled due to no beds. He also couldn't get beds in the cardiothoracic ICU, the hospital wouldn't open a step down unit which was all most of his patients needed. He also complained about being on call every night because the hospital couldn't or wouldn't recruit another thoracic surgeon. Briefly a city wide call schedule was instituted but the other surgeons in the city soon tired of working at the C of E at night.

Suddenly he was gone. The story which I only heard today was that one day he arrived to find the locks on his office changed and the chief of surgery and two security guards waiting. He was escorted from the building.

In his place was a wise man from the East, a thoracic surgeon recruited from Toronto. He seemed to be a nice guy a first, he was fast, and didn't always want the lung down. Soon it became apparent there were problems with him. His judgment seemed a little questionable; we started seeing his patients on ventilators in recovery; he insisted on operating on patients we wanted to cancel, he left residents in the room and couldn't be located when the shzt hit the fan. At the same time suddenly we got a step down unit, there never seemed to be cancellations of thoracic cases and two more thoracic surgeons were recruited.

Rumours then started flying about how this wise man had been recruited to evaluate the whiny one's practice and being told, " Oh by the way how would you like to work here?"

Things rapidly went south, the two other thoracic surgeons moved to other hospitals mainly because they didn't like working with the wise man from the east. I left the C of E. I think that the prospect of working with the wise man was a major factor in my leaving. About a year after I left, I got a memo stating that the wise man was taking a leave of absence. He has never returned from this.

Why am I digging up more dirt on the C of E.

This fellow a physician member of our legislature has been making accusations of cover ups of cancer deaths on the wait lists and pay-offs to physicians. My first impulse was that even our health authority and government aren't that malicious. Then I thought about the whiny one. And today this appears on the front page of my local paper .

The whiny one of course sued and according to scuttlebutt around the OR today got between 8 and 12 MILLION dollars in an out of court settlement. No wonder he is smiling.

And here I was at the centre of it all. Sad to think of how many nurses 12 million could have paid for.

Unmasked Sort Of

2011-03-06T07:53:00.002-07:00

I started this blog in a moment of boredom on New Year's eve 2006. I was on call, my family were at the dacha, there were no cases on and the case room was quiet. I sat at home. There is never anything good on TV on New Years eve so I started fooling around on my computer and that was when I started this blog.

I never thought it would amount to much but I kept on writing. Gradually people started commenting, I saw other blogs were linking to mine and I kept on writing. Some of posts I have written, I am really proud of; a lot are petty or stupid.

Throughout that I never told me wife. Until yesterday. I had always intended to tell her but as the months went on and I still hadn't told her, it got harder. While I write anonymously, I have given out so many hints that anybody who reads the blog can figure out who is writing it pretty easily if they know me. I was worried she might actually stumble on it that way. Anyway I told her on the way to dinner yesterday and after dinner she read most of my posts some of which I explained to her. She reacted pretty well on the whole. I never had told her about the problems I had during my internship, nor about my sexual harassment complaint. We of course went through my lawsuit and my bad marriage with the C of E together.

This blog was sort of like a perverse diary where you hide it from your family but the entire Web is able to read it. Not anymore.

By the way as she is probably going to read this: She is an amazing woman who has been a constant source of support through all the shit I have been through and all the shit I have put my family through.

Ending My Silence on the King's Speech

2011-03-04T15:10:00.008-07:00

There are a lot of good movies out lately and so when my wife announced on date night that she wanted to see the King's Speech I was a little hesitant but I went and thoroughly enjoyed it.

I stutter. Many fellow stutterers have writen about this, much more eloquently than I can.

This, as I remember started in Grade I. I probably started before that but with the reading out loud, you have to do in Grade I it became apparent. My Grade I teacher alertly picked this up and I was started on speech therapy that year which lasted until Grade 5. Once a week an old English lady, Miss Crickmay would appear at the door of our classroom and another student and I would go for our weekly speech therapy sessions. This mostly consisted of reading from our readers and being told not to talk loudly and read slowly. The sessions stopped after Grade 5. I believe I had broken her spirit.

I went thru a lot of teasing throughout school. I remember in Grade 1 we would have the morning and afternoon role calls. As the teacher called out our names we would have to say, "Good morning Mrs. Murphy" or "Good afternoon, Mrs. Murphy". That instead of just saying "here" or "present". I could easily say "good afternoon"; "good morning" was a daily ordeal. In Grade 2 I was actually placed in the dummy reading group until the teacher realized that I could read better than anybody in the class. I went to the same school from Grades 1-7; as I got along, the other students knew that I stuttered, the teasing stopped; some other students came to my defense if somebody imitated me or laughed.

Junior high was another matter. Only half our school when to that Junior High and there were three other feeder schools. A whole new group of students to whom I was going to have get to know. My solution was to clam up. I only spoke when spoken to and stuck with my small group of friends. I believe that as a result of this I missed a lot of socialization during adolescence. I still have a hard time making conversation, people find me aloof. I really wanted to learn French in junior high so I took an enhanced course. Part of the reason may have been that I felt I could be more fluent in another language. As I found out I stutter in French although not as badly as in English probably because I have to speak slower and think more in French. Nonetheless, French class became an ordeal.

When I was in high school there was a televised quiz show for high schools called Reach for the Top. I am especially good at trivia, so much to everybody's, but not my, surprise I made the team in Grade 11. I have only recently thought of how stressful this must have been for my parents. Their stuttering son on TV at 7:30 in the evening, broadcast province-wide. Fortunately for some reason I usually don't stutter under pressure and the one word and short phrase answers required for these shows never bothered me.

Notwithstanding Miss Crickmay's efforts I did come to a truce with my stutter but it is an uneasy and frequently violated truce. Soft S's and C's are difficult as are H's and W's. For example scissors is a word I have a hard time saying (I actually bought my own as an intern so I wouldn't have to ask the nurses). Worse are the times when I just self destruct, the words stop flowing, I grimace, my tongue protrudes from my mouth. These come without warning; I can be in the middle of a conversation and without warning the attack will come. I do a lot of speaking now, I have learned that after about half an hour this may happen. I have learned to have a glass of water handy more to use as a prop while I wait to reset. I like King George and Winston Churchill try to avoid words I know I cannot say. This is frequently awkward, in medicine with its most precise terminology it is often impossible to avoid certain words. Like King George, I don't stutter when angry and I can swear. I like to sing in private. I went thru my fellowship oral exam completely fluently, I have no idea how or why.

Alcohol of course makes it worse. I hold my liquor rather well except when it comes to speaking when I frequently appear way drunker than I am. Coffee is another villain. I try to avoid coffee when I have to give a talk. I stutter more when I am tired. There is an obsessive component to it, certain situations make me stutter more.

Public speaking is another source of stress in my life. I dreaded the presentations we had to give in medical school; presenting a case in a small group was never a problem (except that I tend to be very to the point which a lot of people don't like). When I was a resident we had to present a lot more. I suddenly found that I enjoyed it. I loved researching a topic and breaking it down to a way that an audience could understand. I was also able to structure it in a way that I could actually present it effectively. I now do a lot of talks for the medical school and mostly for Big Pharma. For the most part I am able to get through them. Early on I remember giving a talk for the dental class on head and neck pain and all of a sudden self destructing, limping to a finish. I was never invited back. Nonetheless I have spoken at two national meetings as an invited speaker, something I am still very proud of.

I now attend a lot of meetings. Depending on how I am feeling, I may or may not participate in the discussion. Sometimes this has been to my detriment, I often actually have something useful to say. I frequently now send letters or emails after the meeting; I just thought of this I say, although I probably thought about it during the meeting. I often think about how if I had spoken up at staff meetings when I was at the Centre of Excellence, that I might have changed the way things went. Nah.

A few years ago I resolved to kill the beast once and for all and attended weekly sessions at ISTAR. I found them helpful but at the end I got the impression that I was as good as I was ever going to get and that there were people worse than me. Still I highly recommend them to anybody. By the way they are always looking for donations.

Interractions with patients are interesting. People will think I chose anaesthesiology as a specialty where I would not have to talk to people. Everybody knows, don't they, anaesthesiologists never talk to patients. As such my choice of chronic pain is questionable. I was never a good family doctor; my stutter might have contributed to it. It may have made me appear less sure of what I was telling patients. It made me more direct and to the point which some people like, most don't. In certain practices I worked in, the doctor's practice was to call the patient in from the waiting room. Certain names of course I have trouble saying. At work, sometime asking for stuff is difficult; I am known as someone who is fairly self sufficient, I would rather just get something myself. When this happened my ever supportive chairman suggested that I had not more thoroughly interogated the surgeon or asked for help because of my stutter. I don't think so but what if?

I realize this is a handicap but that I am more fortunate than people who are blind, deaf or have a mobility problem, many of who have overcome their problems to go on to great things. On the other hand it is handicap not always accepted by society. I remember being always being told to speak slowly and other hints. I was told that I could stop stuttering as if I really wanted to just keep on doing it. As a teenager I remember thanking my father for something and being told, "you can thank me by stopping stuttering."

Stuttering of course runs in the family. The gene has apparently even been localized. My father stutters although he mostly overcame it, my younger brother (but not my other brothers) stutters. I have a cousin I have never met who stutters. Painfully for me, my son also stutters although after a year long ordeal of speech therapy he controls it much better than do I.

I thank the writers and producers of the King's Speech for bringing out the problem I share with so many other people. I suspect however this fascination will only last a few years and we will continue to go on as before. Meanwhile I have my blog.

When no doctor is better.

2011-02-18T21:43:00.011-07:00

This story popped up recently. A similar story pops up a couple of times a year in Canada. Sometimes it is a radiologist, it could be a surgeon, even an anaesthesiologist. CT scans came into being while I was in medical school which is a really long time ago so if a radiologist hasn't been trained in reading what has become a pretty basic test, one has to wonder when did he train and the real question which the story doesn't answer is where did he train?

On the other hand except when a CT scan is done for trauma or a suspected intracranial bleed, interpretation is pretty much something that needs to done in days not in minutes. Urgent CTs are usually read by surgeons or ER docs anyway. Remember, a CT scan is a computer generated interpretation of multiple X-ray beams which means the image we seen on the screen or in the old days printed on a film, is really a series of 1 s and 0 s which means that it can nowadays easily be sent electronically in real time to be read by somebody who knows what he is doing. This is already being done and we of course hear of X-rays being outsourced to other countries.

Surgery and anaesthesiology of course can't yet be reduced to 1 s and 0 s which means that both of us have to be on site to do our jobs. This is causing problems in rural Canada and I suspect in the rural US.

Canada and the US are gradually becoming exclusively urbanized countries. In our province which is felt to the redneck heartland of Canada, 2/3 of the population actually live in the two largest cities. Rural populations are shrinking or not expanding; our neighbouring mostly rural province has the same population as it had in 1920. No one is denying the importance of the rural areas in producing our food, our lumber,drilling for oil and mining our minerals; clearly people need to live in there and clearly people want to live there. Increasing the rural population is devoted only to those activities with the rural population seeking services in the cites. Many people in fact involved in activities like mining and oil live temporarily in those communities while their families now live in the cities. Whereas people in rural areas used to buy their clothes at the local Saan, their hardware at the local hardware store and their groceries at the local grocery store, they now drive 1-2 hours to shop at Winners, Home Depot and Costco.

When I was in medical school, smaller hospitals still did a lot of surgery. The surgeons were usually individuals who had done a lot of surgery either in a formal residency training program or as medical missionaries. They did general practice as well and could do hernias, gall bladders, Caesarian sections and some orthopedics. A few of the these surgeons were Brits who had gotten sick of waiting for a consultant to die so they could have his position and they were very well trained. More recently we have South African surgeons fleeing their country for greener pastures who are largely good surgeons as well. (There was the embarrassment of the South African orthopedic surgeon practising in rural Saskatchewan who was wanted by the Truth and Reconciliation Commission to explain his actions while working with the army; something about death squads.)

Times are changing. Surgical training is increasing becoming pyramidal with senior residents doing a lot of surgery and junior residents doing almost none. The days when a doctor who was interested in doing a little surgery could sign up for one or two years and expect to get experience are over. I suspect the situation in other countries in the British Commonwealth where a lot of Canadians went to get surgical training is the same. At the same time job prospects for Brits are better with the government having created more consultancies. Further, graduates of Canadian training programs are reluctant to move to rural communities where they can be guaranteed to be on call all the time and may have to supplement their income by being family docs (something which under our licensing policies isn't even possible anymore).

Anaesthesia in rural areas is provided by what is a uniquely Canadian job, the GP-Anesthetist (GPA). These are family docs who have done an extra year of anaesthesia training. Our program trains these individuals, they are for the most part excellent well motivated docs. (Many of them in fact chose to do the entire residency). In the community these docs typically will do one or more morning lists with their offices in the afternoon. They also take call for anesthesia in their hospitals.

Back in the 1990s when jobs for specialists were lacking we noticed that quite a few suburban hospitals around our city were being staffed by these GPA s, some in fact were working full-time in anaesthesia. Many of us felt that these ORs should be staffed by specialists and the result was that another of the hospitals in our city refused to train GPA s. This precipitated the usual shzt storm and we were able to reinstate the program with the stipulation that the trainees had to be sponsored by a community suitably distant from our city with a "commitment" to work there. These commitments and $1.65 will get you a coffee and there still are a number of GPA s encroaching on our city (largely because specialists don't want to work and take call in those suburban hospitals).

When working with a GPA trainee I try to emphasize what should be the key point in their training. Not what they can do but rather what they can't do and more importantly what they can do but shouldn't do. For example a certain surgical procedure may be well within the skill set of both a surgeon and an anaesthesiologist but the hospital may not be able to care for the patient post-operatively. Worse the anaesthetist may be able to give a good anaesthetic but the surgeon may not be able to do the surgery competently or worst still the surgeon can do the surgery but the anaesthesiologist cannot do the patient. An interesting case took place many years ago in a rural hospital with an itinerant surgeon from the city. The surgeon wanted to do a hernia repair in a neonate. The GPA quite correctly said that he could not do the case. The surgeon who is a bit of a bully offered him a compromise. "I will start the IV and intubate the patient for you," said the gracious surgeon. You know where this is going. The surgeon could start the IV but couldn't intubate or bag the patient. There was a lot of fuss and apparently the child did okay and had an uneventful surgery weeks later in the city hospital to which he should have been referred in the first place.

The justification for keeping operating rooms open in these small centres is often so that locals can get their surgery close to home. Frequently now much of their surgical volume comes from itinerant surgeons from the city who are looking for OR time and compliant anaesthesiologists who won't trouble them with concerns about the patient's medical problems, ICU beds or regional blocks. The patients are as likely to have come from the city as they are to be locals. Full-time surgeons have as I mentioned above largely fled these smaller hospitals. A few specialists have actually been allowed by smaller hospitals to develop boutique practices where they practice their specialty in the hospital but do not do trauma or take call.

The problem is as has become very clear is that as surgical volume drops complications go up. In fact the administrator of our hospital at a meeting was quite clear about this when she said at a meeting I was at that if you have surgery at a hospital with fewer than 50 beds, you are putting yourself in harm's way. She said this in a closed meeting. No public official would ever say that in public.

People in small towns while happy to drive to the city to do their shopping are attached to their little hospitals. Reducing any service, let alone close them is political suicide. In many small communities the hospital is the town's largest employer. Closing these hospitals is not the answer, they need their emergency rooms, they need to be able to stabilize patients for transport,they need to be able to take patients for short admission and be able to act as convalescent care areas where people can recover from surgery or serious medical problems close to home. It is hard to think of an surgical problem that is not amenable to stabilization and transfer to a more advanced surgery centre.

Obstetrics is of course the justification for most small hospitals keeping their surgery units. This would be a good justification except that currently many of them are transferring in their patients to deliver in the city as family docs flee obstetrics or refuse to be on call 24/7 meaning that our hospital gets a significant number of transfers because nobody in town is doing obstetrics that (usually) weekend. Further it is getting harder to find someone trained in general surgery who is capable of doing a caesarian section. The days of surgery (or obstetrics) residents doing off-service rotations are over.

But getting back to the problem of the less than competent radiologist; we also have the problem of the less than competent surgeon who is hired to staff a rural hospital. I have actually spent whole evenings on call where every case we did was a complication of surgery done at rural hospitals by surgeons with questionable training.

We also have the problem of the less than competent anaesthesiologist. A few years ago we had an apparently specialty trained anaesthesiologist from another country who married a Canadian teacher who lived in our city. She asked to do a self-funded (meaning unpaid) residency which our chairman approved. I soon noticed she was showing up in my room to work with me quite a bit. She was very pleasant to talk with but in my mind was functioning at a very junior resident level and had some very bad habits. After a while she asked me if I would do a letter of reference for her. I assumed that she was applying for a Canadian residency which we had discussed. It was with some shock that about a month later I received a letter from a hospital an hour away asking for a letter of reference for a staff position. As I said, I like her but I felt I could not recommend her; I talked with the residency program director, who disavowed any responsibility for her saying it was the chairman who had arranged her "residency". I therefore wrote a letter stating that I felt that she was not capable of independent practice to Canadian community standards. She still got the job.

The point of all of this is that sometimes it is better not to have a doctor at all and deal with that problem than to have a doctor who is incompetent. This is not limited to specialists, an incompetent family doctor can hurt rather than help a community. The resources needed to keep these small operating rooms operating could be more efficiently used opening more rooms in larger centres. Residents of rural areas want access to health care which is understandable; what they fail to realize is that by keeping access to less than competent care they are preventing themselves and unfortunately others from accessing competent care.

Into the Maw of the Insurance Industry

2011-02-03T02:17:00.005-07:00

I have been fortunate not to have been involved in any motor vehicle accidents of significance. I have had lots of car stereos stolen back when car stereos were stolen but have for the past 10 or so years, just paid my premiums.

Unfortunately this summer while at work and fortunately not doing anything, I got a call from my wife who had been T-boned at a stop light. I dropped everything and raced over there forgetting of course my wallet which had the automobile association card to find our beloved Volvo station wagon severely dented on the driver's side, airbags deployed. A few feet away was the Porsche Cayenne which had T-boned her.

The first thing the driver of the Porsche had said to my wife was," You ran the red light." (not something , like are you okay?) He was quickly corrected by the lady who had been in the next lane to him who informed him that the light had still been red in his direction when he decided to accelerate into the side of our car. On my arrival to the accident scene, I knocked on his window and asked for his insurance info and he told me to go away. All in all not a pleasant encounter.

But nobody was hurt, it was not our fault and we have insurance. Everything should be okay?

We got the address of a body shop recommended by the Volvo dealer and had the car towed there. I drove back to work, my wife got a ride home with the police (after they charged the other driver).

I am less patient and perhaps have unrealistic ideas of how long it should take to fix things but as a month passed I began to wonder why our car wasn't ready. Don't worry said my wife, these things take time. Six weeks passed and our car wasn't ready. We had rented a Kia Rio to get around town plus we had our third car so we weren't greatly inconvenienced? September came and we went off on a vacation to Europe fully expecting to have our car back when we returned. It was now getting close to 3 months.

A couple of days into our European vacation, we came back to our hotel to find a text message from our son. Our other Volvo (S-40) which was parked on the street due to work on our sidewalks which had made our driveway inaccessible had been spray painted and the window had been smashed along with every other car on our street. We sighed, told him to secure it as best he could, remove all the valuables and we would take care of it when we got back. No worry, we have insurance.

Arriving back a week or so later, my wife drove our spray painted car to the body shop where our other car was hopefully fixed and ready to come home. It was then that the body shop told us that it would be two weeks before our first car would be ready and that the reason for this was that the insurance company was questioning every single repair. Because Volvo parts are expensive and have to come from Sweden, body shops don't like ordering them if they aren't going to get paid for them. That meant that after the insurance company approved the repair, there was a one week wait for the part and this happened more than once. The adjudicator on our case was apparently a notorious hardass hated throughout the body shop community.

I decided that it was time to have a little talk with our insurance company. This required multiple minutes on hold, redials after being disconnected, explaining my case over and over again etc. Finally I left a message with our adjuster, saying if I didn't get a reply within an hour, I would be changing insurance companies. 55 minutes later I got a call back, "You seem to be upset about something", she said. Meanwhile I learned that our second car was being adjudicated by the some adjudicator. I asked the company if they minded assigning someone else which they eventually did.

We still had one car in the body shop. This car only had some spray paint on it, smashed windows and a dent in the door. After about two weeks I phoned the body shop to ask why it wasn't ready. "We are still waiting for the insurance company to approve the repairs", was the answer. Adjudicator #2 on his initial assessment missed a whole bunch of stuff that also had to be fixed. Back on the phone to our adjuster whose phone number I had now memorized. "I don't know what you are so upset about, " she said, "90% of the time we miss something the first time we check out a car."

We now have both cars back. I looked at changing insurance companies but decided that it was too much of a hassle plus as our insurance is a group rate through the medical association, we would probably pay more although, I wonder whether paying more might have been worth it.

Eventually we got back both our cars.

As an aside the kids who vandalized our car got caught. It turned out they were 15 year olds from the adjacent (richer than our) neighbourhood. About a month after the vandalization, I got a knock on my door one Saturday evening. There was a plain clothes policeman on our porch. "I have a letter of apology from one of the kids," he said, and produced a type-written unsigned letter. I read it briefly. We apologize a lot in Canada so I have heard or read a lot of apologies and this one covered all the bases. I asked my friendly policeman if the apology came with the $500 deductable I was going to have to pay, and if maybe I could also get an apology from the parents who didn't know what their kids were doing a 3 in the morning and also how could kids vandalize 100 cars without the police being aware of it? He didn't really have a good answer for any of that. I didn't ask him, but wondered whether if it had been a 15 year old from a worse neighbourhood, a plainclothes officer would have hand-delivered an apology?

Downregulation of Stat

2011-01-10T11:11:00.005-07:00

The most overused word in medicine has to be "stat". This is supposed to mean "right away because harm will come to the patient if something isn't done" but has come to mean "I do don't really know if this has to be done right away but it would be much more convenient for me if it was done right away" or "I don't really think this has to done right away but I know if I want to get the results in a timely fashion, I have to order it stat".

I have been thinking a lot about this lately because of problems I have been having with my friends over in the respiratory technology division. Lately arterial blood gas machines have evolved so that they now give results such as hemoglobins, electrolytes, calciums and blood glucose in addition to pHs etc. This has been extremely helpful for those of us in anaesthesiology and ICU who occasionally actually need the results. For example when a patient is bleeding, a 30 minute old hemoglobin is of little use. Likewise your TURP who looks funny in the recovery room after his 2 hour TURP, you would feel a lot better starting your next case or going home knowing what his sodium is, not to mention getting the phone call from the lab 45 minutes after your patient with the double figure sodium had his seizure is pretty useless. The problem is of course when you order a stat Hb because your patient is bleeding, it gets queued behind all the other stat Hbs which were ordered for other reasons (baseline, patient seemed off etc). Don't get me started on trying to get a stat PT, PTT. Phoning the lab to explain that your test really is STAT is a useless exercise.

Unfortunately our friends in the ER have cottoned on to this. Lab work in the ER is as I remember a huge hassle when you are trying to juggle multiple patients and the lab values are important in your decision tree (and to going home when your shift is over). Consequently my friends in the ER also started using the blood gas machine to get what they considered to be stat blood work. Rather than do an arterial stick however they (as do we) were sending these as venous blood gases.

This has predictably caused more work for the respiratory techs who have to run these blood gases. Blood gas machines aren't that difficult to use. In my residency we ran our own gases as did the ICU nurses. Part of this is a turf issue with the RTs not wishing to lose control of the blood gas machine but at the same time not really wanting to work to hard. Our respiratory departments solution to this workload however was to unilaterally announce that they would no longer run venous blood gases from the OR (not however from the ER). This is not a problem during the day when our techs can do the gases but in the evenings and on weekends we cannot get our "stat" blood work. This has lead to me having to make a number of increasingly pointed phone calls, letters and emails to various people.

I am not a big fan of blood work anyway as I have blogged. Even when I have an art line, I do ABGs infrequently. I have a pulse oximeter and except when it is really important to control the CO2, I use the ET CO2. Hemoglobins are different matter. With routine "preventative" transfusions being quite correctly out of fashion we now allow our patients to flirt with hemoglobins of 7 or 8. This is a delicate balance requiring frequent and most importantly timely hemoglobins. When I know the patient is going to bleed, I usually have an art line. I of course cannot anticipate when the bowel resection or joint revision is going to go south and for those I usually draw blood from whatever vein is available so I can see where I am. The other day when one of our backs started bleeding profusely, mindful of the ongoing problem with venous blood gases I drew some blood and sent it stat to the lab. After 30 or so minutes we phoned the lab for the results and were told it would be another 20 minutes (and another 30 minutes for the stat PT, PTT we had sent at the same time). I think next time I am just going to fight with RT.

Of course stat is egregiously misused in the surgical setting especially by our obstetrical colleagues. Every non booked C/S is of course stat. These range from prolapsed cords to patient wishing to have her baby today for astrological reasons (we have done at least one such stat C/S). Attempts to ask the person who phones you just how urgent this case is (i.e. do I need to call in the second call) usually gets a rude response.

The OR has of course been burned by this in the past and classifies cases by urgency. Our hospital uses E1,E2, E6 and E24, the number refers to within how many hours the case should be done. This system is susceptible to gaming as well. I find it amazing that appendectomies are only E1 or E2 after 1600 on weekdays and on weekends of course. I have of course never figured out whether an E24 becomes an E1 after 23 hours. The surgeon would say so, unless of course he is already operating or has a office ( or is baby sitting).

Where I used to work all the surgeons also booked their booked cases as urgent rather than elective. As a surgeon explained to me, if he booked his cases elective they would be continuously bumped by his and everybody else's urgent cases. The cardiac surgeons where I trained booked all their CABGs as urgent, which also helped to inflate their wait list number so that they could point out that the wait time for an "elective" CABG was 9 months. Problem was that they never did any elective CABGs, they were all emergencies (and usually done within 2 months of symptoms onset).

Part of the whole system is our unwillingness to triage patients; to say what truely has to be done right away, what can wait a little while and what can be done whenever (or never). Individually we may be willing to do this but we don't trust our colleagues to do the same and as we all use (and pee in?) the same pool of resources we try to get the best for ourselves and our patients.

I am however getting tired of all of this and am awaiting a resolution. STAT of course.

Another reason why Healthcare Costs are Soaring

2011-01-10T07:52:00.004-07:00

Our department is trialling new machines this month. Our old machines are still functional but according to the manufacturer will not be serviceable in three years time.

Just before Christmas, I learned that we would be getting 8 new machines. As department head I was a little confused because no one had approached me about these machines. Worse I was told that we would have no choice about what machine it was and that we would not be able to trial the machine. The reason I was given was that money was now available for the purchase of these machines and it had to be spent now or it would be lost forever.

Worse still was that the machines that had been chosen for us were the Draeger Primus machine. Our department bought two of these a couple of years ago for use in Obstetrics. Unfortunately as I blogged about, these machines if unplugged have a 30 minute boot up which of course makes them unsuitable for obstetrics (or for anaesthesia in general for that matter). In addition they have a tiny work surface, do not have the modes of ventilation some of us have come to love and of course they have Draeger's annoying wolf-crying alarms.

About a year ago my predecessor was faced with a similar demand. Get new monitors or the money disappears. He replaced our perfectly good monitors with new monitors from Philips which have been disastrous.

I wasn't too happy about being rail-roaded into buying machines that I certainly didn't want and the rest of my department didn't want so after a few few phone calls my reasoning was thus: when if three years we actually do need new machines, what are they going to do? shut down the OR?. Of course not, the money will come from somewhere. I also got the strong impression that we were being railroaded into taking machines that somebody else had already rejected.

So I phoned up the lady who is in charge of purchasing these machines. She is as it happens a nurse who was in charge of the neurosurgical ORs at the Centre of Excellence when I worked there. I told her that we did not want the machines, that we realized that we were going to "lose" the money; that we did not care and that we would let the chips fall where they may. She just said, "I hope you know what what you're doing BH". I said I did.

One hour later I got a phone call from the same person, asking if I would be willing to trial a different machine.

BH 1 Administration 0.

Seriously though, in twenty years I have seen so much perfectly good equipment thrown out because the capital budget had to used up. Some new equipment has been an improvement over what we had before, quite a lot of new equipment has been a huge step backwards.

As an aside, it now difficult to find a machine that is not completely electronic, which of course makes them susceptible to software and hardware problems and of course a software glitch could easily disable an entire department's computers. This usually requires a tech from the company to come in from out of town. I long for the old mechanical machines with their simplicity and easy serviceability. I challenge anybody to prove that our newer machines are anymore safe than the old mechanical machines people of my vintage trained on.

My Big Screen TV is Sucking Out My Brain

2010-12-28T15:26:00.004-07:00

When we renovated our 40 year old house, we added a Man Room above our garage. This is nominally my home office. It was supposed to be place where I would read, reflect and practise my saxophone. Except I went out and bought a Big Screen TV. Now instead of improving myself, I am watching Seinfeld and The Office re-runs.

A few years ago I got hooked on a group of my favourite series; ER, The West Wing, NYPD Blue etc. One day I had the revelation that these shows had taken over my life and that I was actually scheduling things around them (including taping the shows if I wasn't going to be around). I also realized that I wasn't reading and as I had just recently started playing saxophone, I wasn't practising. In a rare moment of self control I resolved to not watch TV anymore except of course for hockey and football games. This I mostly kept until the BSTV came into my life.

My relationship with TV has been on and off. We got our first TV in 1961 or 62. It was a large black and white set which my parents actually bought used. We had an large antenna on our roof which in Victoria enabled us to get all 3 American Networks plus some Canadian channels. My parents actually exercised some restraint on what we watched. We watched very little during the day and my parents tended to only watch the CBC news and public affairs programs. And Hockey Night in Canada of course. This is at least what I remember.

Cable came to Victoria in 1965. Every other house on the street got cable. We didn't. Worse my principled parents took down the antenna so as to not be the only house on the street with one on their roof. We instead got rabbit ears. It was a dark time in my life. We could only get three channels. Consequently I missed most of TV during the 1960s; I am horrible at Trivial Pursuit Baby Boomer Edition.

We did finally get cable around 1970. Our TV was still black and white. One day my father came home from visiting a friend incredulous that on his friend's TV you could actually see the puck roll. We got a new TV. I believe it too was black and white but we did soon get a colour TV.

Even in the dark days without cable our TV had a place of honour in the living room. My parents set the agenda as to what we could watch which for the most part was whatever was on the CBC.

My wife and I when we got married both agreed to limit our TV exposure and as soon as we got a house, our TV went down into what we called our family room. Our living room became a sanctum where we entertained company or sometimes read when we didn't want to watch TV.

When we initially got our first vacation dacha, we decided there would be no TV, we would read and play board games. We soon broke down and bought a TV which we watched rented movies on plus whatever we could get on rabbit ears. A couple of years ago I finally got cable. I rationalized that people wouldn't come over to our house on Saturdays because they wanted to watch hockey. Plus I got internet.

Meanwhile at home, only having one TV lead to no shortage of conflicts especially at playoff time. When our children were younger, we watched slightly risque movies on my laptop in our bedroom so as not to corrupt our children (actually watching sex scenes with your adult children is kind of creepy too). Therefore I like to think that getting the second TV has increased the harmony in our household. Now I can watch TV sports, the History Channel, and of course Seinfeld reruns without any guilt or conflict. Except of course at the growing pile of books which I seem to buy faster than I can read them.

And my brain is slowly being sucked out.

Merry Christmas

2010-12-25T15:42:00.003-07:00

I love Christmas. I am not sure whether it is the presents, the time off or the knowledge that once again the days are going to get longer (even if we are still possibly looking at 4 more months of wintry weather).

I am off once again this Christmas. I have been fortunate most of my professional life in working in large departments with people who preferred to work Christmas in exchange for other parts of the season off, not to mention those with ex-wives and large mortgages who have to work.

The hospital where I now work, is only open for emergencies throughout the Christmas slow down which this year is from December 23 through January 3. Therefore we only have to provide 2 people every day and as we had more people available then were slots for them to work, I won the lottery (not necessarily the one I would like to win) and am enjoying an extended time off work.

One of the more interesting things about Christmas that fascinates me is how we are more or less shut down the health care system for almost 2 weeks and no one seems to suffer. Of course people still have heart attacks, trauma, appendicitis and babies but we seem to handle it all very well on a skeleton staff. I say this of course as someone who hardly ever works at Christmas but it seems true. We don't do much scheduled surgery over Christmas and sadly a lot of our work comes from complications of scheduled surgery.

Of course while at work just before Christmas I did find this article from the National Post which seems to contradict everything I just said. I could try to explain.

Merry Christmas and barring my own injury or illness, you won't be catching me near a hospital.

Some Heavy Reflections

2010-12-18T18:44:00.004-07:00

As I posted earlier, I am now what we now call site leader which among other things means I get to referee disputes between the surgeons and us.

Around midnight I was roused from my mid-winter's nap by a phone call from the anaesthesiologist on call closely followed by the surgeon on call. It seemed my surgical friend wanted to do emergency surgery on a 600 pounder. There were a number of problems with this most important was that there was no ICU bed available. (My buddies in ICU are of course in no hurry to take on a patient who may be on a ventilator for weeks.) The other issue was that he did all his other emergencies before taking on this patient instead of doing it early in the evening when people are fresh and there is more help. In the surgeon's defense this was the classic internal medicine Friday afternoon dump whereby they sit on a patient with a clearly surgical problem until the weekend looms. The second call anaesthesiologist was pleading off citing having worked since 0700 and medical issues, leaving the night call person to deal with this horrendoplasty by herself. I figured that now that my sleep was totally disrupted and that the beers I had drank earlier in the evening had worn off, that the simplest solution was to come in myself and help. Plus there was the thrill of the chase; I have never done a patient that big.

I am not going into the details of the case but as we walked from the room where we had gone to see just what we were in for, I remarked to her, "I hope I never let myself go like that."

I thought about what I had discussed with one of the nurses earlier in the day. I was looking at the pile of Christmas candy that grateful patients had brought into the Pain Clinic (and the clinic before it) and I had remarked that with so much hunger in the world, why do we allow so much of our caloric production to be devoted to food that is so unhealthy and so largely unwanted. I realize world hunger is much more complicated than me simply giving up my Ferraro-Rochers but what a concept.

While trying to salvage my Saturday plans that had been turned on their heads by my late night/early morning adventure, I was thinking about the whole issue of obesity. I realize that obesity is again a relative thing; that by arbitrarily assigning a BMI to it we may over-estimate it; that moderately obese patients may actually live longer... etc, etc. The thing is that most of us agree that someone with say a BMI over 50 is probably obese and we are seeing more and more of these. It clearly is becoming a public health issue with its comorbidities of diabetes, sleep apnea and the like all of which we on the front lines have to deal with.

When well meaning politicians or public health people actually talk about doing something about obesity like for example limiting people's choices in the types and amounts of food available, there are howls of protest from the right wing press and their libertarian sometime fellow travelers. Nanny state is one term usually bandied about.

On the other hand, if we look at medicine prior to the first half of the 20th century, infectious diseases were the prime cause of death. Even before Pasteur and Koch public leaders recognized that certain measures could prevent the transmission of illness including things like clean water, clean food and on occasion quarantining people. We also developed things like mass vaccination before we even knew about bacteria virus, and immumoglobulins. All of these were in some way an infringement on individual freedoms such as they existed then. They were however for the most part effective.

So why for example do we tolerate a situation where a pack of Twinkies costs less than the equivalent amount of calories in fresh vegetables. I occasionally talk to patients in the Pain Clinic about eating healthy and the usual response is that they can't afford to. Why do we allow our fast food to become supersized? Remember when you could buy an 8 oz Coke or a 12 oz Coke? Remember when buying a soft drink was something you did once a week as treat?. Our hospital has given over half its cafeteria space to a Tim Horton's outlet. Tim Hortons sells mostly donuts but they do actually sell some healthy food. Our hospital's Tim Horton's however only sells donuts (and coffee). On any morning if I am standing in line about 1/3 of the people in line in front of me are wearing hospital gowns.

By way of disclosure, I have been fat all my life. I currently weigh over 50 lbs more than I did in University. I love food. I love a lot of food that is probably not that good for me. I love beer. Periodically my weight balloons and as my clothes get tight my appetite goes down. I have often wondered at what point does one actually lose his self respect and just start to enjoy the pleasure of food.
Perhaps my distaste for the super obese is similar to that of the alcoholic by the reformed alcoholic. I was looking around the room as we got the case underway and about one third of those in the room were less than svelte but I expect they all shared my distaste.

I hope I never end up like that.

An Open Letter to Don Cherry

2010-12-09T18:22:00.006-07:00

Dear Don,

I know you read my blog just like I never miss Coaches Corner. I have bought many of your Rock Em Sock Em Videos and both your books (I don't think I'll be getting your latest this Xmas) Unfortunately you have crossed the line and I not sure whether I will be able to watch you anymore.

Now you and I are the biggest Bruins fans in Canada. You came to the Bruins as coach following the Bruins' loss in the Stanley Cup finals. I wasn't initially too happy with you as coach, we all remember what happened that first season. I was even more sceptical when you traded Esposito. To the Rangers of all teams. But you started to get results, there were the two Stanley Cup appearances, and of course the heart-breaking game 7 overtime loss to Montreal. By the way I like the way you have always taken the fall for Don Marcotte. And of course we loved the way the Bruins played during those seasons, a true team that played hockey the way it was supposed to be played. And a team that has continued to play that way for 31 years after you left them.

I was delighted when you started appearing on Hockey Night in Canada which was at that time the lamest broadcast around. Finally somebody who would tell it like it is, criticize people and wasn't afraid of stepping on toes. Every hockey broadcaster in Canada owes you a debt of gratitude. I like the fact that unlike many ex-NHLers, you chose to come back to Canada. You could have stayed in the US, you married an American after all. I love your support for Canadian teams, including the way you stuck up for our World Junior Team. I also loved your support for our Women's hockey team right from the start.

Lately however you have betrayed your lunch pail roots. That was what we loved about you and Bruins their lunch pail work ethic, how hard they worked for everything. You have instead become a shill for the right wing elite. That's right the right wing elite. There is no left wing elite, Don. Your new conservative friends have always been in power, they have been the elite.

Part of your hagiography Don is your working class father. Well Don, I suspect your working class father was able to afford a house, maybe a car and was able to pay for your hockey equipment so that you could make a career of hockey. And you were probably able to have a pretty nice lifestyle on just one parents' salary. How many working class people can say that nowadays? That's right Don, working class lunch pail guys made a living income back then because they had things like unions and even some "liberal elite" politicians who gave a shzt about them.

Your conservative friends, Don have over the past 25 years conducted a war on the lunch pail guys. They have transferred much of the tax load onto them, allowed industries that employed them to close or leave the country and lately caused the economy to crash. Wages of the lunch pail guys have not kept up with the cost of living. And all those poor dead soldiers who bring you to tears every few weeks? Sent off to Afghanistan to prop up a corrupt government that oppresses women, Christians and ethnic minorities.

What really pisses me off Don, is your latest statements about cyclists. I ride a bike Don. I ride to work, I ride for pleasure, I ride for exercise. Lots of us Bruins fans do. But your new friends don't like cyclists or for that matter lunch pail guys who take the bus to work instead of driving. Now Don, I ride my bike for pleasure but when I go to work early every morning, I pass lots of lunch pail guys riding their bikes to construction sites and factories. They aren't riding for fun Don, they are riding because they had to decide between a car and a place to sleep at night. All they and I want Don, is to feel safe when we go out for a ride.

And those "left wing elites" Don? These are the guys who actually care about those lunch pail guys. Not like your new friend Rob Ford. I don't think they make a lunch pail big enough for him. Rob Ford isn't a lunch pail guy. He inherited his business and all his money. I suspect that after the Leafs are out of the playoffs he cheers for the Habs (maybe even before the Leafs are out). He even pulled a few dirty tricks, that even Scotty Bowman would have been ashamed to try, in order to get elected.

O yes Don. What do you do for a living? You work for the CBC. All of your new friends know that the CBC is a hotbed of the liberal elite. You make a pretty good living from those liberal elites, high 6 figures I heard. Not bad for a 12 minute broadcast.

So Don, why don't you stick to being a buffoonish caricature of yourself between the first and second intermissions and stay the hell out of politics. Because Don, at the hockey rink, left and right wings are positions you play, not positions you hold.

And by the way I didn't used to play basketball

2010-12-05T15:07:00.002-07:00

I am 6'5" (196 cm).

I was always the tallest kid in the class from kindergarten until Junior High. This meant I always got to sit at the back of the class, a habit I still have.

Nonetheless, I was and still am, incredibly uncoordinated and no matter what your size, games like basketball do require some degree of skill. Further most of my growth spurt occurred between Grade 10 and 11 by which time it was really too late to learn how to play basketball. I do remember my Grade 11 PE teacher /basketball coach looking interestedly at me at the beginning of the term. His interest lasted about 5 minutes.

Ice hockey and football, sports where my size would have been an advantage, I never really played.

Essentially all my size gets me is a lot of trouble finding clothes to fit (thank god for the LL Bean catalogue and I hope the Canadian $ stays near par) and a lot of knocks on the head.

What really gets me is how people have nothing better to say to me when we meet but, "Boy are you tall, did you play basketball?" This is not just outside the hospital but frequently in work situations. Now I am physician, a medical specialist, department head, and I have a lot of outside interests. So why is it that people feel necessary to start any discussion by discussing my height.

Other people have distinguishing physical features too. Imagine me starting a conversation, "Wow are those ever big, what are you a 38D?" This would no doubt earn me a trip to the medical director's office and a few weekends spent at sensitivity camp.

Actually I didn't really want to look at your junk

2010-12-05T14:34:00.005-07:00

The male body is not really that attractive even for those inclined that way. Some men have faces which can be described as handsome, some men have taken care of their bodies in a way that I can respect. And then there are the other 95% of men.

Even in the most handsome well toned male, the genitalia cannot be described as visually pleasing. It is interesting that the male genitalia have not been subject to the same evolutionary pressures that have driven the breasts and buttocks in women.

Why am I writing this?

About a month ago I joined the local YMCA. This is by my count the seventh time I have joined a gym. Most of them I lasted for at least a year and I always had a good excuse for stopping going. There are of course certain visual insults one has to accept on joining any gym. These include the gym rats, the muscle-bound meatheads, and people wearing outfits they should never be wearing in public or committing crimes against spandex. And what I am going to write about below.

While the Y is an egalitarian organization, this particular Y offers an enhanced membership. This includes an adults only change room with a hot tub, TV, newspapers and a towel service. This costs $200 extra per year. I naturally went for that. No more children's birthday parties in the change room and no more awkwardness changing next to female children brought into men's change room by their dad. Not to mention not having to dry myself with the moldy towel I found in my gym bag.

Anyway I registered paid my fee and the nice lady at reception suggested I check out the members plus change room. I walk in there and what do I see but a rather large naked man sitting on the imitation leather armchairs in the room reading the paper. And air drying in contact with that imitation leather is what popular vernacular is now calling his junk.

I am maybe a little self conscious of my body, and I realize that a certain amount of nudity is necessary in a change room; while changing from street to exercise clothes, walking to and from the shower and of course in the shower. Towels are of course provided although the small towels we get are rarely enough on their own to cover up anything. Aside from that if you want to hang out with all the boys at the Y, you should be either in your workout clothes or your street clothes. Even draping yourself in multiple towel is better.

I would like to think that individual sunning his junk on the imitation leather chair was just an eccentric. Wrong. Just about every time I go there someone is baring it all. Some of them at least have the courtesy to at least sit on a towel.

Myself, after I shower, and soak in the hot tub, I am getting my clothes on post-haste and leaving with my eyes averted.

The Working Class Can Kiss My Ass, I've Got the Foreman's Job At Last

2010-11-14T19:39:00.002-07:00

About 6 months ago I became Department Chairman at my community hospital or as they now call it Site Leader.

This is actually my second kick at leadership. The first was briefly 18 years ago at another hospital. Things have changed.

People ask me why I applied for the job. I can't really say, ambition maybe, a desire to make things run smoother (how naive I was), a feeling it was my turn? Whatever my life has changed.

1. People who never gave me the time of day now speak to me. Occasionally with respect. This includes both surgeons and nurses.
2. I get a lot more emails, most of which have many attachments. I naively waited a few months hoping the hospital was going to give me a smart phone. They didn't and I went out and got an I-phone. Of course I at first didn't know which attachments were and were not important so I had to read them all. Now I don't read any of them until somebody asks me whether I have read them yet.
3. An invisible line has formed between me and the rest of my department. I have in essence crossed over to the dark side. Most of the site leaders meetings I have to attend are at the same time as Dept. rounds so I have to miss those. Worse I now look at things differently; more from the perspective of what is good for the OR and for the hospital. I used to say, "what is good for anaesthesia, is good for the OR". I am not sure about that all the time now. I used to believe that anaesthetic manpower should be the limiting factor in how many cases we could do; I now realize that when we are short staffed, I am going to be getting heat from administration. Worse I find myself disgusted at times by the behaviour of my colleagues.
4. I now realize how difficult it actually is to change things.
5. I attend a lot more meetings. Many of these are in the am before work, some are after work, occasionally I have to get out of work to attend meetings. Initially many of these meetings were not really important for me to attend; I had no way of telling so I went to all of them. I don't do that anymore. It is funny how no matter how trivial the question; instead of trying to just exchange emails or talking in the halls, a meeting has to be called with all the "stakeholders".
6. I am now the principal. I have to mete out discipline. This has been difficult so far but as they piss me off more and more I am having an easier time of it all.

I Never Knew I Was A Victim

2010-10-25T18:47:00.005-06:00

Our national newspaper has over the last week documented the indignities we males suffered and still suffered in the school system

I hope what I am going to say will be taken in the spirit that I have intended it.

As a male who "survived" quite nicely our educational system and as the father of two male children now attending university, I am glad that after 45 years this scandal has been unearthed (sarcasm).

I remember well elementary school. All the girls who showed up to class immaculately dressed while we boys wore whatever we found on the floor; who brought flowers for the teacher; their neat handwriting; their better artwork; how they could sit through 5 hours of class; they were smarter; often bigger; better coordinated (remember skipping in the playground, no boy could have mastered that). They never got sent to the principal's office, never got THE STRAP. Our teachers were all women until at least Grade 6; usually older unmarried women. It was a dark time to be a man.

All of us boys hated girls then. We knew we would eventually marry one but we really weren't sure why.

At the same time at least in the 1960s our mother was at home; our father worked, he was usually gone before we had breakfast, he showed up around supper. He controlled the household, he was the breadwinner. How were we going to go from our state of oppression in elementary school to our eventual destiny?

Somehow between elementary and high school gradually the tables turned. By Grade 12 boys were clearly in charge. Sure some girls got to be student council president but that was only because we let them.

Really not much had changed a generation later. My son actually had a male teacher for Grade 1 but it was clear that elementary school was not a friendly place for boys. I remember going to a play put on by my son's school and being amazed that even the male roles in the play were played by girls with boys playing only secondary roles. But just like when I went to school by high school the tables had turned and boys were at least equal.

The series of articles bemoans the lack of males in university. Actually females outnumbering males is not a new thing; it was the case prior to the second world war, even when I attended university the number were roughly equal. More interesting was the section on McMaster University where 75% of the class were female with the result that affirmative action for males had to be instituted. McMaster is by the way an interesting case, a medical school which from its inception committed to accepting students from a variety of backgrounds with less emphasis on academics with the result that females have for most of McMaster's time been the majority.

My medical school class was 3/8 female the highest percentage and absolute number in the history of our medical school. Once we got over the whole sexual tension of the whole thing (or realized that most of us had absolutely no chance with these intelligent hardworking women, many of whom had boyfriends) we were able to accept them as colleagues and friends and I think they really gave a positive tone to our medical school class. The class behind us which split evenly 50:50 generated 10 couples (as opposed to one from our class).

With our class and with the one a year later, there was much muttering about affirmative action for females. This was in my opinion rubbish. Most of the women who entered medical school in the that time entered with marks as good and usually better than the men, not to mention other intangibles such as personality, life skills etc. What should have been more of an issue was the affirmative action for children of doctors which was the case for not a few people in my class.

Likewise much has been made of how women doctors work less than do male doctors which may be true although many of the new generation of male doctors who want to work less hard than our generation. On the other hand I have trained with a number of female residents, interns or staff whose work ethic put mine to shame.

The bottom line is that while the education system may be a system that gives females an advantage, that advantage is solely limited to within that system and that both sexes are going to go out into a world that is still tilted towards men. It is probably a good thing that boys have to labour against sexism in the education system. Whatever doesn't kill you makes you stronger, besides how else would boys learn to write neatly, behave in public, read, and learn about music all skills that the female centric system forces on boys.

Nickel and Diming

2010-10-23T12:33:00.006-06:00

I read this on Great Z's post and as almost always I agree with his sentiment if not his solutions.

I have always taken my role as a gate-keeper into health care very seriously and so I try with limitations to give the patient not only the best but the most cost effective care. In the scheme of things anesthesiology are not big contributors to hospital costs but ever since I started practice we have had to look at every little cost.

As I mentioned, one of the advantages of getter older is the perspective one gets over practices over the years.

When I started I did my first rotation in pediatric anaesthesiology (the result of this is that to this day, I know the dose in mg/kg of every drug). One of the anesthetists, an older British fellow used what was called the Liverpool technique. This involved 70% N2O, curare, and morphine. No volatile! It was a marvelous anaesthetic from a practitioner point of view; you reversed the muscle relaxant, turned on 100% O2 and the child woke up (or was never asleep?). They all received 0.2 mg per kg of morphine so they were comfortable as well. There was never any hypotension and as the children woke up promptly, laryngospasm was infrequent. What was more significant was the cost. Each case must have cost less than $1 in drugs. The other anaesthetists at the hospital used a similar technique with small doses of halothane.

When I went to the adult hospital for my first adult rotation, the anaesthetist (after admonishing me for trying to figure out the dose of pentothal in mg/kg) chided me for turning on Isoflurane. "You really like the expensive stuff", he said, turning off the Isoflurane and turning on the Enflurane. We of course used Bain circuits with their 5 L flows then.

So it went during my residency. The first time I used vecuronium on a case, the staffman warned me that the patient would sit up during the case. I told him I planned to also put the patient to sleep.

It was the introduction of propofol when we first became aware of costs. I was on staff then at a larger community hospital. Our first attempt at using it was rebuffed by pharmacy, however by sending our bad cop anaesthetist to the next P&T committee, we were able to obtain a rationed supply. Each anaesthetist was rationed to 6 200 mg vials a week. This resulted in a lot of after hours borrowing from other people's carts (we had our own carts there, something I wish I had where I am now) and of course diluting with pentothal to create what I called "President's Choice" propofol. It also lead to the widespread practice of "saving" propofol in syringes or in the original vial until we found out how easily propofol could be contaminated.

Propofol is of course unquestionably better than pentothal for short cases; less so for long cases. It has of course eclipsed pentothal which is actually temporarily unavailable in Canada. Propofol does allow for earlier discharge from recovery room and day surgery however the clinical significance of this is questionable because discharge times are more affected by factors like hospital policy, availability of porters and whether the patients ride home has showed up. In addition savings from shorter stays are only realized if the shorter stay is accompanied by staff reductions.

When I joined the CofE, they were in the midst of a massive cost cutting exercise. The administrative strategy du jour was to give each department a budget which they had to keep within. Therefore our department was responsible not only for our drug and disposable costs but also for the cost of our techs. This was an interesting exercise where we learned that for years our techs had manipulated their shifts to maximize the amount of overtime they got, something that should have been easy to fix but which we never really got a handle on. Drug costs were another matter. Pharmacy was able to give us a monthly figure of how much we spent on drugs which we divided by the number of cases to come up with a cost per case. This was quite rough as cases at the CofE went anywhere from 30 minutes to 30 hours. Our average cost per case varied from $15 to $20 per case. This was something we all strived to reduce although that is the cost of a single suture or 2-3 doses of Ancef.

We subsequently went through decade and a half of very little control in anaesthetic costs during which Sevoflurane, Desflurane, Rocuronium, and Remifentanyl where introduced. Much of the research on Sevoflurane and Desflurane was done during my residency which is when (unlike today's residents) I actually read journals. It was pretty clear to me and to other residents that Desflurane and Sevoflurane were going to be huge busts. Desflurane for example requires a special heated pressurized vaporizer, which Sevoflurane breaks down to toxic metabolites. All this for a recovery time which is statistically but not clinically significantly better than Isoflurane. Despite this, when I go into my room today, I will have the choice of Sevoflurane or Desflurane because we only have room for two vaporizer on our machine and it was too expensive to keep Isoflurane vaporizers which nobody was using around. Des and Sevo are really triumphs of marketing over science. Remifentanyl on the other hand is a huge advance although I remember poo-pooing it. "What is the use of a short acting narcotic," I used to say.

But getting back to Great Z's discussion about how everybody else gets expensive drugs and we don't. This has also been my observation and of course I remember the fights as I outlined above we had to just be able to try out new drugs. This also applies to some anaesthesia drugs and products which other specialties get before us. I remember, as a resident, when midazolam came out, anaesthesia requested it and were denied; then gastroenterology requested it and got it, therefore we also got. The same thing happened with EMLA cream which pediatrics got after anaesthesia was turned down (we soon found out that EMLA is worse than useless). At the CofE, our emergency physicians got rocuronium before anaesthesia did (aside from the spectre of half trained ER docs burning their airway bridges with a non-depolarizer; what an insult to anaesthesia!).

We haven't (yet) come to point of not having propofol, we have as a mentioned temporarily and I suspect permanently lost pentothal. I could certainly see that anaesthesia could be at risk. Even in a country the size of Canada, a corporate bean counter could look at the potential profits to be made by making propofol versus what can be made using the third generation version of Lipitor and decide that maybe they won't make propofol anymore.

Perhaps however the answer is not to demand our own expensive third generation drugs but to ask why we are using what are for the most part unproven and in many cases harmful drugs in place of the old standbys. Take hypertension for example. The Canadian guidelines from 1999 which they have not seen fit to revise state:

1. Initial therapy should be monotherapy with a thiazide
diuretic, preferably at a low dose, a β-adrenergic antagonist
or an angiotensin-converting-enzyme (ACE) inhibitor
(grade A). If the response is inadequate or there
are adverse effects, substitute another drug from the initial
drug therapy group (grade D).
2. Combination therapy, either with a thiazide diuretic
and a β-adrenergic antagonist or with a thiazide diuretic
and an ACE inhibitor, should be used if there is
only a partial response to monotherapy (grade A).
3. If blood pressure is still not controlled, or there are
adverse effects, try other classes of antihypertensive
drugs (calcium-channel blockers, angiotensin II receptor
antagonists, α-adrenergic antagonists or centrally
acting agents) either as monotherapy or in
combination (grade D). Consider possible reasons
for a poor response to therapy, such as noncompliance,
secondary causes of hypertension or interactions
between prescribed treatment and diet or other
drugs (grade D).

So when was the last time you saw a patient on a hydrochlorthiazide for hypertension? Or a beta blocker except when there is some ischemic heart disease. They are usually on about 3 different drugs that you have never heard of (but will soon learn about when you read in the newspaper how that drug has been pulled from the market because it is killing people). Psychiatry is the same. Everybody is on a cocktail of "atypical antipsychotics" all of which have side effects of weight gain. Like we need more obese patients. This has rubbed on onto family practice where these drugs are being prescribed for things like insomnia and anxiety.

Enough of this rant. Like the title says, I used to be disgusted now I try to be amused. It is getting harder.

The Most Arrogant Thing I Have Ever Heard A Surgeon Say

2010-10-18T14:02:00.003-06:00

I should have posted on this a long time ago. This happened in the last millennium at the C of E.

Naturally being a Centre of Excellence, the Centre of Excellence has doctors from all over the world come there to become excellent. In the late 1990s we had a surgeon from a third world middle eastern country spend a year or so to learn to do liver transplants. Now there are a lot of people who would think that most third world countries should maybe focus on things like public health, vaccinations and non-excellent things but they are not thinking excellently. As the fully qualified surgeon working as a fellow, he was given some latitude in working and was mostly working unsupervised on the memorable day.

I came in to find that as usual my list was all messed up and my first scheduled case couldn't start until the early afternoon, however in consolation, I was allowed to pick up an emergency case from our ICU. This was a liver transplant patient who had had his abdomen packed due to oozing at the end of the case. It was now time to remove the packs. I was not a liver transplant anaesthesiologist but now that he had a sort of a functioning liver I was deemed competent to anaesthetize this patient. He was still ventilated, lines in, plug and play.

After removing a number of packs our now more excellent surgeon announced he was closing. "Not so quickly", said the circulating nurse who had the count sheet from the original operation. "There is still one more pack in." "No there isn't" said our surgeon. Fine said the nurse we'll X-ray. Our surgeon left the room leaving his residents to close which they did in time. X-ray was summoned and a flat plate showed surprise, surprise, the missing sponge. Our surgeon was summoned back.

There are a number of appropriate responses to this scenario; most of them involving some expression of regret or remorse. None of these were forthcoming. Was did come was the surgeon angrily accusing the nurse of not being more forceful in insisting that he look for the sponge. I rolled my eyes; I do after all get paid by the hour.

The last time I worked with this surgeon was during the evening and I witnessed him being walked through a laparoscopic cholie by a junior resident. I decided this wasn't really appropriate and complained and he shortly returned home where I suppose he is doing liver transplants and laparoscopic cholies and might even listen to the nurses occasionally.

Tipping Point

2010-10-09T13:51:00.003-06:00

I recently finished a guided bike tour of the Czech republic which was easily the best holiday of my life. At the end of every guided trip however comes what I find to be unpleasant. How much to tip the guides?

There are a variety of formulas, some people do so much a day, some people do a percentage of how much the trip cost (which is what we ultimately did). Many tour companies are happy to help you out by "suggesting" how much you should tip. Then there is the question of currency; local currency (if the guide is not from the country where you are now), Canadian dollars, US dollars, Euros. This followed by the trip to the bank machine to get the requisite money.

This is not to say that our guides were not fantastic. I fortunately have never had a bad guide. They do work hard and long during the trip but hey they are guiding not working in some dead end job. On this trip however one of the other members decided that one guide should get much more than the other which I didn't really think was fair; one guide clearly appeared to do more but she was the lead guide and that was her role and we didn't really know how much the other guide did behind the scenes. I pointed this out to the lady who was collecting the money but she was adamant that the two guides shouldn't get the same so under her watchful eyes we actually took back some of the money for the second guide. I really had a hard time looking our guide in the eyes for the rest of the trip.

Of course while we did all put our tips into a single envelope I have no idea how much everybody put in. Guided bicycle trips like the one I recently went on are quite expensive and while I can afford these trips now, I wonder however about some people who save up and budget for these trips and find out at the end of the week that they are expected to pony up what usually amounts to hundreds of extra dollars for what they thought they had already paid for. (At the end of a kayak trip once not only where we supposed to tip the guides but the tip was to be presented at a dinner where we also picked up the guides' tab; I don't mind doing this on my own but hate being told I have to do it!)

I make a good income and I am very sympathetic to people who make less than me. I tip 20% usually even when the service is bad. Occasionally when the service is bad I have been tempted to withold the tip but in the interval between the bad service and the presentation of the bill I always soften and consider whether the bad service was really the fault of the server or whether it was beyond his control. (My father usually tells the server when the service or food has been bad and has received numerous free meals in his life.)

But here is an interesting concept. Why not end the charade of tipping and actually pay people a decent wage? I am not naive enough to expect that if we had 15-20% added to our restaurant bills that this would necessarily result in a wage increase for servers. In Europe and Australia however where tipping is less common, waiters and bartenders are actually valued employees who are paid a good wage. This is unlike Canada and US and this shows in the service we sometimes get. As an aside, I remember as an intern 6 of us went out to dinner at ski resort. The service was not very good, the waitress was surly and at least two people didn't get the meal they ordered (she argued about that two). Nonetheless we are put in cash which included a 10% tip and handed it to the person who agreed to settle the bill for us. For some reason (he said it was an error) he only left enough to cover the tab. The waitress actually chased us our of the restaurant to ask why we hadn't left a tip. Oh yeah we said, a mistake and handed her the extra money.

There is the question of who gets tipped. My server I suspect gets about the same wage as the guy who washes the floor in the OR. Why does one get tipped and not the other. I could give more examples.

One of our guides (ironically the one I reluctantly stiffed) who guided us on another trip works as a server in the off season and we actually had a long discussion about tipping on this trip and she had some interesting experiences in that field to relate. She told me for example that in some restaurants the servers are expected to pay 6% of the bill as the share to the cooks and dishwashers whether or not they get a tip and that she has often wondered how much of this money actually gets back to the workers.

Now as a physician, I never get tips or expect one. I do get chocolates and liquor at Christmas from patients. There was once a Greek lady who I treated who would bring to every treatment a bottle of Ouzo and $200 in cash. I kept the Ouzo and would walk the $200 over to the hospital foundation office. (They told me that they sent her a charitable receipt and she sent it back). She stopped coming after a while by which time my wife and I had acquired a taste for Ouzo which I now have to buy myself.

Funeral for a Friend

2010-09-20T15:51:00.004-06:00

Sitting alone in my favourite cafe, just finished my cinnamon bun, sipping on my latte. Nice Sunday morning, a little cool but sunny. I rode my bike over to my favourite cafe. Nothing really in the free community paper and somebody is hogging the local paper so I get out my I-phone and check my messages. Not really expecting much on Sunday. I notice a message from one of my old medical school classmates and the subject is another medical school classmate. Oh shzt I am thinking as I open the message. Sure enough, Dave my old friend from medical school is dead.

Everybody in my medical school class is now safely over 50, so it is not surprising that people are going to drop off. You just never thought that it would be somebody you knew and liked really well.

I didn't really know many people in my medical school class from my undergraduate years. A few people I recognized from labs or smaller classes, nobody I was really that close to. I hardly even knew anybody who had ever been to medical school. It was a complete mystery to me. I had this impression going in that I was looking at 4 very hard and boring years.

I was assigned to the same group as Dave in anatomy. Him, me and two others on a cadaver. I remember pulling off the case cover, peering at the unnatural brown skin, the face covered with a mask still. We had a scalpel and a dissection manual. The other two people looked a little green. "Should I go first or should you?" said Dave. I can't remember which of us actually made the first cut but one of us did and that was how our group got started in anatomy. I remember thinking how serious and mature a guy Dave was.

I am not a really good judge of human nature.

Dave turned out to be the most irreverent guy I have ever met. He had a warped sense of humour that complemented my warped sense of humour. He loved puns, the sicker the better. We spent the 6 months of dissection mostly bent over in stitches at some joke that he had usually made. We did tasteless pranks like dropping fat into people's lab coat pockets as they passed our table. Anybody who visited our table to look at our dissection, was in for an insult. Our anatomy professor cautioned our class about elbowing people away from our dissection; we said we just gave verbal elbows.

In those days Dave was politcally left wing like me. He did disrespect environmentalists whom he called granolas and since I was an environmentalist he called me a granola. He also called me a bleeding heart liberal which years later I called myself in online forums and in my blog.

One of the best attributes of a friend is someone who will tell you when you are being stupid. In that respect Dave was the best of friends to me. Dave didn't suffer fools gladly, there were classmates Dave didn't like very much; he was always very coldly polite to them. In fact if Dave wasn't rude to you it meant he didn't like you.

In between 2nd and 3rd year medical school Dave and I did rural doctor electives in adjacent towns. We got horrendously drunk together two nights in a row at the Kimberly Beer Festival and after our electives ended we visited a friend of Dave's at Invermere after which we travelled in a convoy my VW Rabbit chasing his Datson pickup to his home town where I stayed at his house for a couple of days before returning to Vancouver.

Dave was a good friend to a lot of people which I realized when I read the tributes to him after he died and spoke to the classmates who went to his memorial service. Everybody had a story about some road trip or something else that they had done with Dave. Even now when I think of some stupid pun or joke or intentional mispronounciation of a word; quite often I heard it first from Dave 25+ years ago.

I saw Dave less in our clinical clerkship year and we interned in different cities. I was surprised to hear that Dave was going into Urology. We had often talked over coffee about surgeons and how unscientifc most of what they did was. He finished his residency and went to practise in his hometown which he really loved and which was unfortunately where he died.

Dave came to my wedding but after that I only saw him every five years at our class reunion and he missed the last two due to illness or death in his family. Periodically he would phone me up out of the blue. The last time was on provincial election day to remind me to vote Conservative. Dave had become more conservative and bitter about politics since starting in practice. He had also become a gun collector and was adamantly against the gun registry (it is ironic that he died thinking the gun registry had been abolished in Canada only to have it resurrected weeks after his death). None of this stopped him from discussing his points of view in a civil fashion.

A couple of weekends ago I was driving down for his memorial service and my wife who was keeping me company and who I met after medical school asked me if I could tell her some stories about Dave. I kept on for about an hour with story after story. Some of them I hadn't thought about for years. The tears were rolling down my eyes, I couldn't figure out whether I was laughing or crying. After about every story, my wife said, "If you get asked to speak at the memorial you are not telling that one."

After the service the 6 of my classmates who came up, sat down for a few beers. Dave would have wanted it we all said. Actually we don't know what Dave would have wanted and I am sure he would have had some pointed words for us all.

What Do Fundamentalist Christians and Fundamentalist Muslims Have Against Each Other?

2010-09-10T15:49:00.005-06:00

1. They are against womens rights.
2. They are against birth control or abortion.
3. They both like guns.
4. They seem to like to die for their religion (or preferably send other people to die for their religion).
5. They are politically conservative.
6. They both like to kill other people.
7. They don't like Jews.
8. They like the death penalty.

I really can't figure it out.

Dropping my son off University

2010-09-06T12:17:00.002-06:00

I dropped my youngest son off at University yesterday. Unfortunately my oldest son has so far ignorred all my hints and is attending University in town and living at home.

I was trying to visualize my first day at University. Then I realized it was almost 35 years to the date. Holy shzt how did I get that old? Mine was a little different. I loaded all my stuff in my backpack and took the bus over to Vancouver and then another bus to UBC from where I walked to the residence. My parent brought over my stereo and record collection (remember records?) a week or so later.

Moving in a day is a much more choreographed event now than 35 years ago. There is a way bigger parental presence. Parental presence 35 years involved dropping off your kids at residence or in the case of my parents driving me to the bus depot. Now the day is built around the parents with an afternoon of "classes" for those interested. I suppose we are paying for the whole affair.

My wife was tearful even though this son has been living away from home for the last four months albeit in our dacha. My son even appeared nervous. I reassured him.

"I spent 7 years in University", I told him, "They were the best 7 years of my life. It goes downhill after that." And I meant it.

I hope that inspired him.

Insert foot here

2010-09-06T11:42:00.005-06:00

Men and women have different fat profiles. Men develope a beer belly like Randy on Trailer Park boys; women tend to store their fat all over their body. This difference usually helps us tell whether a woman is pregant or is merely fat.

I was at a meeting recently when I ran into a clinician who had trained with me a couple of years ago, who I had met at meetings since and had always enjoyed a good long talk. It had been a couple of years since I met her and the first thing I noted was the protruding belly. "Oh", I thought, "She is pregnant." So as we re-introduced ourselves, I made the usual banal joke I make whenever I meet someone who is pregnant. "Gained a little weight, have we?", I joked. "Actually, I have," she said. It was apparently a side effect of the meds that she was on. There was an uncomfortable silence, I exchanged a few pleasantries and made an excuse to get the hell out of there.

This is not the first time I have done this. When I was doing locums, I did it a couple of times which is probably one reason I wasn't a very good or popular GP. One time I was seeing a lady who I had never seen before. Her chart had a pre-natal chart on it, which if I had actually looked closer was 2 years old. I went into the office and there she was lying on the bed with her protruding belly. So I went into prenatal mode, only to find out she was actually in for a cold or something. This happened at least one other time but I don't remember the details.

Live and learn. Remove foot.

SI you- nit

2010-08-26T10:54:00.003-06:00

This is a sick joke my physics profs made when they wanted to introduce us to System Internationale Units. These professors were extremely entertaining and funny individuals which is really the only way to teach a pretty boring subject.

I have a pet peeve. It is the way people write dates, more the various ways people write dates.

Today for example is August 26, 2010. This can be written as 26.08.2010; 08/26/2010;26/aug/2010. I could go on, the permutations are endless. This is a concern for me because I write dates several times a day, and occasionally have to fill in patient birth dates on forms.

That is why 20 years ago, I decided that I would follow the SI convention of writing dates as YYYY.MM.DD or YY.MM.DD (we are far enough into the century now). This may not be best or most logical solution but they did make a decision and I have chosen to follow it.

While I realize that the US decided not to use the metric system, Canada and most of the world did and I can't understand why we are unable to figure out a consistent way of writing dates. Every time I fill out a form now, I have to look at how they want the date configured. Worse is when you are copying from one form with the date in one format to a form with the date in another format.

Come on people even in the US we are not dosing in grains and minims anymore.

SI You Nits!

Superbugs

2010-08-22T19:02:00.005-06:00

Emergency docs probably next to proctologists, have the best stories to tell which is why some many of them seem to have blogs.

I blogged some time ago against the routine use of antibiotics in surgery.

Here is an interesting article from White Coat's Call Room.

One of the 200 or so things that I hated about general practice that drove me into specialty training was the constant demand for antibiotics from patients (and the knowledge of that if you didn't prescribe them, one of your colleagues was going to and make you look stupid).

A long time ago, I was at a meeting at our licensing body regarding our triplicate narcotic program. This program is, as I found out, actually quite expensive and probably does very little to prevent drug diversion. The question was, what drugs should be on it? I suggested antibiotics. I was surprised how many people agreed with me.

Euphemisms, Politics and the English Language

2010-08-19T17:30:00.005-06:00

This is a good article,

A while ago I blogged about the tendency to substitute customer or client for patient and how it is subtly affecting medical practice. This article comments on our tendency to substitute less loaded words for loaded words such as substituting "unhealthy weight" for obese. Substituting "hearing impaired" for deaf and "visually impaired" for blind are other examples. It also points out that there is a drift with euphemisms gradually acquiring a loaded meaning. I am just waiting for the guy in front of me at the football game to call the ref visually impaired.

A few years ago I saw a patient with low back pain and dictated a consult in which I referred to her as mildly obese. Her family doctor showed her my consult and she arrived in ill humour at the next visit. "What do you mean I'm obese," she asked,"and how do you define obesity" I told her the I defined obesity as anyone fatter than me. This defused things, she is still seeing me and has lost a significant amount of weight (unlike me).

I still remember 1st year university English. This was a disaster for me. Although I was trying to get into medical school, my chosen career was to be a writer and medicine was just how I was going to support myself until I got published. I loved reading and thought I was going to do well in English. Unfortunately while I love reading, I really can't give a shzt about whether Robert Frost was contemplating suicide in "Stopping in woods...", whether Ophelia and Hamlet were lovers or what was "the theme of language" in Camus' "The Plague". I struggled through with a 66% which was my lowest mark until medical school.

One important thing I did learn in English 100 was the lessons in George Orwell's "Politics and the English Language" which was in our essay book. It still should be mandatory reading for anybody in any position of power or authority.

Orwell of course wrote 1984 and Animal Farm which some commentators have taken as his dismissal of socialism and communism, something the life long member of the British Socialist Party and anybody who has read any of his other books would disagree with.

Orwell's thesis if I remember it, was that people hide their unclear thinking behind overblown language. He also mentioned how politicians misuse the English language for their own malicious ends. "Shot while escaping" was a post WW2 example he gave. We have in the succeeding 50+ years come up with many by own our political and business elite. Laid off becomes downsizing which becomes right-sizing; torturing becomes extraordinary rendition. I could go on.

Healthcare has become a living example of Orwell's thesis. Patients have become clients who have become customers. Doctors, nurses, physios all noble professions with much to offer are lumped in as Healthcare professionals. We all talk about stakeholders, I don't even know what stakeholders used to be. Now that I attend more and more meetings, I find myself slipping into this bizarre newspeak. I have to sometimes step outside and slap myself in the head.

Orwell had a number of rules.

(i) Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.

(ii) Never us a long word where a short one will do.

(iii) If it is possible to cut a word out, always cut it out.

(iv) Never use the passive where you can use the active.

(v) Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.

(vi) Break any of these rules sooner than say anything outright barbarous.

The interesting thing is that reading Orwell's essay written over 60 years ago, one gets the sense that it could have been written last week. We have learned nothing. It is interesting that many of todays leaders in politics, business and administration are contemporaries of mine who probably studied "Politics and the English language" in 1st year English. It was in the Norton Anthology afterall.

Dang Kids Get Off My Lawn

2010-08-05T10:54:00.004-06:00

Maybe I am getting old.

Firstly I should say, I support the legalization of most drugs and certainly that legalization would probably stop what I am about to complain about.

3 years ago we moved to a quiet street closer to where I work. The most attractive feature of our new house is the green space across the street from us. From our front window we look onto a grass field, trees in the background and behind that a drop down to the river. We are a touch possessive of our green space even though it belongs to the city.

A snake seems to have invaded our paradise.

For the last couple of months, a couple of times a week around midnight we are awakened by voices in the park across the street. Frequently there is a car parked in front of our house with the motor running most of the time. We hear loud conversations, young men shouting "yeehaw", girls giggling.

It took me a while to figure this out, but it became quite clear. Someone is selling drugs in the park across from our house. Either they hang out there possibly in the woods above the river or our street has been chosen for the transaction being out of the way with little traffic.

After the most recent disturbance, I decided that maybe the police should know about this. Not that I oppose young adults buying drugs. Just not in front of my house.

Police as we know love to enforce drug laws. They are quite happy to attribute just about every crime to drugs. I figured they would jump at the opportunity to bust someone. Actually I just hoped that they would drive a police car down our street around midnight for a couple of nights in a row and get the people to move their business somewhere else.

So the next morning after my most recent interrupted sleep, I phoned the cops. It took me a while. I tried to phone my "community" police station which seems to be nowhere near our community and was directed to the Crime Stoppers snitch line. Obviously I had no one to snitch on so I tried a different number and actually got to talk to a cop. I gave him my address, explained the situation and asked if he could help.

What I got was a bunch of excuses about how busy they are most nights and how it would be totally impractical to patrol our neighbourhood. He did say that if I went to my local police station and filed a complaint in person, I might be able to talk to a sergeant. I said,"How about I contact my city councilor", which is what I did.

Of course like most things, there have been no more late night interruptions since I complained. I suspect that the local drug dealer has figured out that eventually someone would complain to the police who would actually patrol the area.

What has he been smoking?