Privacy

Yesterday and today I am on call which means covering the case room. Now a universal feature of caserooms since I was a medical student in the last millenium was "The Board".

"The Board" was a then a blackboard, now a whiteboard with every labouring patient's last name, status including dilatation, station, NPO status, epidual and whether they were being induced.

In the interest of privacy now, the patient's last names have been replaced with only the first 3 letters of their name. This caused a problem for me right away when I arrived in the morning. The first three letters of the only patient with an epidural made up a name that is not common. So in I went saying "high Ms. , I'm Dr. BH" and then went out to the desk to find her chart. After I couldn't find her chart I asked, "who has Ms <3 letter word name>'s chart" and after getting blank looks, "who has room 5's chart". One of the nurses handed me a chart with a six letter last name and when I said no I want <3 letter word>'s chart; they looked at my like I was stupid and told me that they were only putting the first 3 letters of the patient's name on "The Board". I never asked how they proposed to deal with patients whose last name only had 2 or 3 letters something increasingly common now (or two patients with similar three letters).

Most medical and surgical wards used to have boards with everybody's names on and what bed they were in. Alternatively the name was on the door so you could at last walk around looking for the patient you had to see. Unfortunately boards have gone by the way and in several hospitals now there are no names on the door either. This forces you to look for the chart (which if it is in the rack is filed by room number) or ask the ward clerk or a nurse.

At the same time we are very concerned about proper identification of patients to prevent the wrong treatment being done to them. Now I think everybody has had the experience of going in to see the wrong patient and realising half way through talking to them that you really should be talking to someone else. When one wants to estabilish a therapeutic relationship with a patient, the least auspicious way to meet them for the first time, has to be to enter the room and go straight for their arm band to see who they are. Yet with names not on the door, or the patients bed, in patients who are deaf, demented or half asleep, that is now the only way of ensuring you are actually talking to the right patient.

At the same time most units allow patient and their visitors to use the phones at the desk. Of course what are usually sprawled all over the desk for everybody to see. Charts of course, so the patient or their visitors can read whatever is in their visual range. (Maybe that's why nobody writes progress notes anymore).

Very few names are unique anyway. If I see a name on a door that is the same as someone I know, I just assume it is someone with the same name. Occasionally much to my surprise it is someone I know. I once ran into the contractor who built my house while on Pain Rounds. The name didn't ring a bell and people surprisingly don't look the same with an ng tube. I was talking to him when he interrupted me and said, "I built your house". I didn't tell him it was a good thing for him that I didn't give him his anaesthetic.

A number of years ago we had a victim of a gang related assault in our trauma unit. The staff were somewhat concerned that someone was going to come in to finish him off so as this was still when there were names on the door, instead of putting his name on the door, they put his hospital number.

Great...

I'm a gang member assigned to finish him off and I learn what ward he is on. So I sneak around the ward and there are 19 rooms with a name on, and one with a number on. I wonder which room I should chose.

I grew up in (what was by today's standards) a small house with three brothers (and two parents). My mother always said, "If you don't have anything to hide, you don't need privacy".

So please put my name on the door.

Stethoscopes

In the election we had last month, a local emergency physician ran and won for the ruling Conservative party. Now I have no issue with a physician running for a party that has eviscerated health care in the province; nor do I have any issue with the fact that physicians who go into politics are innevitably an embarassment to the profession; nor even with the fact that if a physician gets into a position of power they are never a friend to the profession.

What I have an issue that his campaign photo was a head and shoulder shot of him wearing an OR green top with his stethoscope hung over the back of his neck. This large photo is, as far as I know, still adorning a bus shelter I drive past too often. It is saying look at me, I am a doctor, I am cool, I save lives.

The old image of a doctor is of course a stethoscope dangling from the neck like a neck tie (which doctors innevitably wore in those days). I often wonder how often they snagged their stethoscope on something.
When I first started going to into hospitals as a medical student, nurses slung their stethoscopes around their necks which most doctors carried their stethoscopes in the pocket of their coats. (Surgeons never carried a stethoscope why would they?)

Gradually people started slinging their stethoscope over the back of their necks. Even I did. We thought it looked cool. Except you still snagged it on things plus the rubber irritated your neck (some people had cloth sleeves made for that purpose). In fact after a while with everybody doing it, it was no longer cool so I stopped as did most people and my stethoscope went back into my pocket. Somewhere along the way, I lost it or it was stolen. I now borrow stethscopes when I need one and I rely on the ETCO2 for tube placement (I still make medical students and residents listen!)

The image of a doctor used to be, a clean white coat, shirt, tie and nice pants. (These doctors were by the way always male). There seems lately to be a trend where doctors are photographed wearing OR greens and with a stethoscope or further props. The stethscope is after all only one of many tools a physician uses. Why didn't he have his picture taken using an otoscope, or a rectal glove?

Anyway why should it matter whether he is a doctor as to whether he will be a good member of the legislature. And certainly there are better ways to advertise your professional qualifications than to have your photo taken wearing your stethoscope.

More Shame

A couple of weeks ago a patient came into get her medication refilled. This is a patient who had a stroke a couple of years ago and while she more or less recovered, she was left with a thalamic stroke and post-stroke pain. This is among the worst pain patients can suffer with and usually responds poorly to anything.

She was already on OxyContin when I saw her. After trialing a few things, I trialed her on methadone. When I trial patients on methadone, I always ask the family doc to agree to get a methadone licence to follow the patient indefinitely. I do this so that my clinic doesn't fill up with methadone patients and I can actually see new patients. Her family doctor agreed.

On this visit, the patient brought a letter from her old family doctor which basically said that he was changing the way he was practising and that she would have to find a new doctor. She was actually able to find a new doctor, who surprise, surprise, told her he would look after her other medical issues but would not prescribe OxyContin (which means he will never prescribe methadone I suspect).

Like the title of this blog says, I use to be disgusted, now I try to be amused so I took this in stride as the new face of medicine and I suppose I have married another patient.

Today in the newspaper, presumable in response to complaints there was an article on this doctor with a testimonial from the head of the college of family physicians praising him for modifying his practice and discharging 500 patients at "random".

Like I say, I used to be disgusted.

Residency Interviews

In Canada, most residencies are at least 5 years and while it is possibe to switch programs, this is by no means a given. This means that the both the specialty and the site where you do it have major implications on your life.

We have a national match in Canada. Residency programs rank their applicants, applicants rank their residencies; the computer spits out a match. To ensure that they get at least a job next year, students are advised to apply to as many programs as possible including at least 2 different specialties (one resident blurted out that he was applying to urology so anaesthesia was his fall back). Each residency however still interviews its own applicants and while some specialties have centralized the process so that students can travel to one city to interview to all their desired programs; most including anaesthesia don't. The one concession is that most programs have coordinated their interview dates so that students can make a single road trip for all the interviews at least within a single region. You can imagine the expense of travelling to 14 programs which I think is the average number applied to. This is after 6-8 years of university and medical school.

Which leads to to what I did today which was to interview 14 prospective residents. Now given my antipathy for the CoE where the residency program is based, one wonders why I would even bother to volunteer for this but the fact is they asked nicely; I actually like the program director and her secretary; they sounded desperate and I thought it would be classy thing to do.

Now I only got back into town the day before and had to spend the evening before, on the web reading over the information of my 14 interviewees which are published on the web. The first thing I realized was that I was about to interview 14 individuals whose shit not only did not stink but had never stunk.

The problem is that most residents seem to be well coached into writing a really good personal letter and with work processing it is really easy to personalize a leter to each program you are applying for. People get letters of reference from staff they have had a good experience with; staff are of course reluctant to spoil a student's career by giving them any less than a pristine letter of reference. Further because programs vary so much in Canada, looks at their marks is of no help.

Therefore the half hour the applicant spends with me becomes important.

In the interview we ask the applicant a lot of general questions (I had a lot of fun asking them what their favourite medical TV show was). We look at how they answer these questions, their body posture, general demeanor etc. We are not allowed to ask them where else they are applying, are they married or do they plan to have children.

Problem is, none of these have any bearing on the applicants ability to be trained as an anaesthesiologist or any other specialty for that matter.

At the end of the day, all 14 applicants, I interviewed I could live with as residents. Some I really liked, some I liked less. I assigned them scores between 7 and 10/10 we talked them over with the program director. She will have the huge job of ranking them based on my "objective" score and by reading their documents. Later this year the computer will spit out what they will be doing for the next five years which will have a major bearing on the rest of their lives.

And I have participated in this whole exercise and quite frankly I'm not sure what I accomplished.

Is it time to bring back hospital nursing schools?

The convergence of a number of circumstances in my life has lead me to ponder this.

1. We have a severe nursing shortage which is leading to cancellations of cases in the OR which is of course affecting my income. (This would be nice if my income was reduced by just working less; however a significant proportion of the lost time is time sitting around seeing if they will be able to do your case.) The reason is that years ago when it was decided that healthcare was too expensive and that the work of a RN could be done by cheaper workers, many nurses were laid of, retired, took up other jobs etc. Of course after reading about layoffs of nurses there was very little incentive for young people to go into nursing and secondly because we were lead to believe that RNs were unnecessary, nursing programs were reduced. Now in order to train the number of nurses necessary to run the system at it's present capacity, we are told that it will be necessary to have more academic nurses which means that we will actually have less nurses involved in patient care before we have more.

2. My wife is retraining as a nurse after being out for about 10 years. (Any nurse who reads this, no matter how bad nursing seems or how good life as a housewife looks, DO NOT let your registration lapse; work the minimum necessary to keep it; read on). This has involved over a year of home learning with periodic exams mostly covering irrellevent information, some of it incorrect (the parts dealing with anesthesia, which I know a little about, for example). Now she is in the middle of a one month unpaid practicum after which I am lead to believe if she pays her fees she will be a RN again.

3. My son is taking engineering at University. One popular option at his and other Universities is the co-op program where they get work experience and earn a little cash while pursuing their degrees.

NOW....

Historically most professions learned their craft on the job by apprenticeships or other forms of servitude. This includes doctors, lawyers, accountants and nurses. Around the turn of the century (20th that is) doctors, lawyers and accountants began to go to universities although there was still some form of servitude involved.

While there were university nursing programs early in the 20th century, most nurses were trained in hospital schools. In addition to lectures, they worked on the wards and were considered an important part of the staffing of the hospitals involved. They lived in nurse's residences, got free room and board and were paid a small stipend. Gradually these hospital schools were closed and the only route to becoming a nurse was thru universities, community colleges and technical schools. (When I joined the CofE, there was still a hospital school attached which graduated its last class the year I started). Many nurses I work with now are graduates of these hospital schools and speak fondly of their experiences, both learning and social

Now many nurses would argue that nursing is a profession as dignified as medicine, law, accounting and others that now require degrees and I have no arguement with that.

However as mentioned above, many university professional schools now offer co-op programs which are surprisingly like the old apprenticeship programs that these professions evolved away from. So why not start some type of co-op program for nursing where after some basic training they can hit the wards, and help out while getting some valuable experience. They would receive some type of stipend for their time. They could be affiliated with universities of professional schools. After getting their RN, they could have the option of obtaining a BSN either by attending university full or part-time.

I think that besides being an immediate partial solution to the nursing crisis, this would enhance the practical experience of the graduate nurse.

Picking Cherries

It is alwasy gratifying to know that somebody is reading your blog. Somebody actually posted a response to my posting,

http://theblogofbleedingheart.blogspot.com/2007/11/there-but-for-grace-of-god-went-i.html

They asked me whether I went into medicine to look after healthy people. Actually I went into medicine because my parents thought I should be a professional and engineering, law, education, nursing and pharmacy didn't appeal to me. I really had no idea that I would ever be asked to look after healthy people and I sure had no idea how sick people could actually get and how totally soul destroying looking after them could be. Having said that, at least sick people you can actually do something and occasionally despite everything you do, they actually get better. Unlike healthy people who can only get worse.

It was in fact healthy people that lead me to flee general practice. Give me somebody with crushing chest pain and I knew what to do; asthma/COPD ditto. "Weak and dizzy" however I had no idea to treat except for admitting them to hospital and ordering every test in the book which bought you at best a week's peace.

Likewise in anaesthesiology sick patients are in many ways easier to treat. When I used to work at the CoE about every night I was on call we would do some poor soul from the ICU, often a liver transplant gone bad,usually for a laparotomy and washout. One night, surveying the individual on the table, connected up to about 20 infusion pumps, tubes sticking out of everywhere, I commented to the resident, "The one good thing about these cases, is that nothing you can do can make them worse". We also had a large dialyis unit at the CoE which was a steady source of business for our OR. I used to say,"If the nephrologist hasn't killed them yet, nothing I can do can". This didn't stop me from reading the obits for about two weeks after I did the vascular access list.

Some people actually enjoy doing big cases on sick (or soon to be sick) patients. I used to enjoy this too until I thought of all the hassle of doing these cases versus what the innevitable result was. During my residency I remember an eccentric vascular surgeon coming into ICU and surveying the ruptured aneurysm whose "life" he had saved and stating, "I give you a miracle, you give me a vegetable". On recollection, too many of the people on whose behalf I busted my butt ended up maybe not a vegetables but sometimes I wondered if I hadn't been such a skilled anaesthesiologist and had let them die, things might have been better for everyone.

I have however always regarded myself as a professional and team player and am prepared to accept what the surgeons, nephrologists and ICU throw at me. Do I enjoy it? Well there have been certain aspects of parenthood I haven't really enjoyed (0700 hockey practices, Christmas concerts) but overall you can't really have the good without the bad.

As I mentioned above, I was really naive about what I would be getting into by going into medicine. I seem to have had this vision of a culture where we all helped and supported each other, shared the difficult cases, as well as the easy cases. Every job, I had, I just thought okay, that isn't the way in just community or this department but the next one will be different. As I said I was very naive.

One of many things that disgusts me about medicine in this century is the tendency for certain doctors to cherry-pick the good cases, which means more difficult cases for the rest of us. In Canada, the president of our national medical society, is a surgeon who owns a private surgical suite. This suite does elective cases on healthy patients, it has no inpatient beds, it doesn't do sick patients, it doesn't do emergencies. This and other individuals then take this clinic and rub the rest of our noses in it stating if only we allowed patients to pay for their surgery, everything would be okay. The fact is that by outsourcing the easy cases to the private sector, the public system now deprived of those cases and with the responsibility to deal with however else comes in the door (including the complications from the private suites) is even more innefficient.

I'm not sure whether this post satisfies the commenter on my other post.

Stay out of my other life!

I do get some long term patient contact in the Pain Clinic and so patients do get to know me in my clothes.

About a week ago I was at a play and a woman walked by who I thought I recognized. After about a minute I figured out she was a patient I see about every 6 weeks for trigger point injections. Anyway I kept my head down because I really didn't want to have to talk to her.

I try to keep my professional and personal lives separate, and I do not ever wish to invite patients into my personal life. There are exceptions, occasionally I get asked to see somebody I know socially, more frequent someone comes in who it turns out I know socially, either the patient or a relative.

A number of years ago I went to a school band concert and a lady came up to me and said, "Hi Dr. BH". After a couple of seconds, I realized it was a lady I had been doing trigger points on for a couple of years. She proceeded to introduce me as the doctor who was helping her with her pain. I said something like, "Oh hi" and kept on walking. I know this was rude however like I say I kept my professional and personal lives separate and you're only allowed to be in one of my lives. I was going to explain this at her next appointment but however I never saw her again, I suspect because she thought I was a rude arrogant doctor.

So a couple of months ago a patient told me he was going to a music festival that I was also going to and I told him that I like to keep my lives separate and that if he tried to talk to me, I would just say hi and walk away. And he accepted that and as it was, I never ran into him anyway.

There but for the grace of god went I

In yesterdays paper on the front page was a story about how a court had recently given a $900,000 settlement against a general practitioner who had "missed a heart attack".

According to the paper, the patient, a 45 year old smoker, arrived in the ER at a small country hospital clutching his chest, sweaty etc. He was, curiously, not however complaining of chest pain. The EKG was normal. The paper didn't say what blood work was done, or for that matter what bloodwork would have been available on a STAT basis in that hospital at that time of the day.

The GP examined the patient, asked the appropriate questions and admitted the patient to hospital overnight, asking the nurses to observe for any chest pain. The patient had no further chest pain overnight; however in the am, the cardiogram showed that sometime between admission to hospital and the morning, the patient had had an infarct which was now too late for thrombolyis, assuming it was available at that hospital.

The court presumbably acting on the testimony of experts found that this was negligent and assessed damages of $900K to the patient who is now a cardiac cripple. (Of course I would suspect in a smoker who has ischemic heart disease in the 40s it is merely a question of when he becomes a cardiac cripple, nothwithstanding the fact that the odd patient stops smoking, modifies his lifestyle and runs marathons.)


Here's where I started thinking there but for the grace of god....

I was in general practice for 3 years and did a great deal of call during that time. It was not unusual for patients to present with chest pain and a normal EKG. Depending on where you worked you could or could not get cardiac enzymes on a STAT basis. So if we were really suspicious we did what this poor GP did, we admitted them to hospital, asked the nurses to watch for chest pain, get a EKG if they had chest pain and we got an EKG in the morning. Now EKGs were usually sent out to be read by a cardiologist which meant that when you missed something, if you were lucky the cardiologist phoned you; usually you got a dictated report a week later. I know I sent at least one patient home with what proved to be an inferior MI, another patient had been transferred to a different hospital by the time I got the report.

Part of my anaesthetic training involved 6 months of internal medicine during which time I was on call for cardiology consults in the ER. I know for a fact that on at least one occasion the cardiologist and I sent a patient home with what proved to be a MI. There may have been other cases that we never found out about. On another occasion, we did just what the GP did; admitted the patient to the CCU for observation, did a EKG in the morning which showed a completed infarct that it was too late to do anything about. (Worse for me,this was the father of a staff anaesthesiologist who I really liked.)

Further, EKGs are notoriously hard to read. Inferior MIs can be missed easily, in addition anterior MIs frequently present with what we can "poor R wave progression" which unless you have an old EKG to compare it with you may miss. I remember as a resident standing in the ER with a very competent internist trying to figure out whether the EKG we were looking at showed poor R-wave progression in which case we needed to give a thrombolytic which is not an innocuous therapy. Fortunately we decided that was what he had, we gave the thrombolytic, he did well and cardiac cath did show a critical lesion.

Of course the other factor in this case was that the GP in question had been on call by himself for the previous 3 weeks and according to the paper, working from 0800 to 2100 (not including the innevitable night visits and phone calls).

Operating on no sleep

We in anaesthesia do not work after being on call. This has always been a topic of derision among our surgical colleagues.

I was having supper with the former OR director at my former hospital a few months ago. The OR director is the poor sucker who is responsible for the smooth running of the operating room. This poor individual tried to do his best for over a year frustrated by the OR administration who wouldn't take his advice and his own Department who wouldn't back him up so he quit and went back to just being an ordinary anaesthesiologist and we went without an OR director for over a year until we found someone stupid or optimistic enought to do the job.

Anyway my former hospital does a lot of transplants. For various reasons most of these occur at night. There are reasons for this. You have some poor soul in ICU who is beyond hope. At morning rounds the decision is made to abandon life support and think about organ donation. By the time all the necessary tests have been done to establish brain death and all the relative have had their last visit, most of the day has passed and we are in to evening which is when the "harvest" starts. This means that the liver, heart and lung transplants don't start until close to or after midnight.

This of course means that if we can potentially have 1 heart transplant, 2 lungs and a liver all going on at the same time. That means that 4 sub-specialist anaes are working all night. These services are not staffed so that the anaes. is off post-call, however most individuals have no interest in working the next day. Therefore however is the OR coordinator is supposed to find 4 anaes to fill in the next day. Although there are a number of part-timers who can be called on, this can be a problem. After such nights there is usually a massive shuffling of lists which is annoying to those POAs in the department.

Surgeons however, like the alcoholic who believes he is witty and sexually attractive when drunk, still believe they can operate competently on no sleep.

My colleague was faced with this problem one morning of trying to find anaes. to work. He looked at the list and saw that one of the cardiac surgeons scheduled to work that day was also one of the individuals who worked all night. He spoke with the individual, a paediatric cardiac surgeon, who assured him that he intended to do his elective list, even though he had worked all night. So my colleague shuffled rooms and cajoled people and the surgeon was able to do his list.

The surgeon's elective case which was a paediatric patient and a re-do died on the table. My colleague still wonders whether he should have just cancelled the list.

The Stalker

I heard this story second hand when I worked at the CofE and have heard at least 2 versions but something like this actually happened.

Several years ago a young man approached one of the cardiac surgeons, telling him that he was a student at one of technical colleges and could he watch some cardiac surgery. The surgeon was of course only too happy to have somebody witness his genius and so the young man was welcomed into the OR to watch cardiac surgery. After he had been there for a couple of weeks people got used to him being around and he started to drift into other rooms to watch other types of surgery. At that time and even after it nobody was required to wear ID in the OR or anywhere in hospital for that matter. The odd memo came out about wearing ID but nobody ever paid attention.

One day he showed up in a non-cardiac room and introduced himself to the anaesthetist and watched the surgery on a female patient including the insertion of the foley catheter at the beginning. (Female patients are positioned for foley catheter insertion in a Penthouse pose) At the end of the case he walked back to the recovery room with the anaesthetist. Shortly after arrival in the RR the patient opened her eyes, saw the young man and started screaming uncontrollably.

Turns out he had been stalking her, had learned she was having surgery and had weaseled his way into OR where in addition to watching surgery enabled him to view the daily OR slate with patient names on it.

I can only speculate how much the CofE paid out on this case.

Rate MDs.com 2

Okay now I'm getting mad.

Two days ago on CBC there was a feature on this site. My wife saw it and went and checked my profile. Since I last looked there was another post which was even worse than the last one. It stated that I was uncommunicative and didn't listen (i.e I didn't talk and didn't listen, I guess we just sat and stared at each other for 30 minutes).

Anyway I was talking with my colleagues today and they asked if I had looked at the site. I told them I was on it and about the negative comments. They were very sympathetic and promised to log-on and write more positive comments.

I looked at the site after lunch to see if they had done so. There was now a third post stating that I had made someone wait for three hours while I talked and joked with a friend after which I cancelled their appointment and my receptionist booked them one a year away.

Now.... I may be moody, I have difficulty forming an empathetic bond with a small minority of patients, I am frequently in a hurry but...

In 13 years I have never made anybody wait 3 hours. On occasion when somebody came on the wrong day, they may have had to wait until I finished what I was up to but I can't remember an instances. Part of the reason I rush is so that I don't make people wait. Secondly I have never sent a patient away who had an appointment. Now on occasion when a patient walked in without an appointment and I was really busy or had to leave right after I may have told them to come back but never one year later. I am usually pretty good about seeing patients who come on the wrong day, come without an appointment or even patients who just walk in off the street. One of the major criticisms of my colleagues where I used to work was that I was too nice to the patients (I tried to help them instead of telling them to get off their asses and go back to work).

I have contacted the site and hopefully this post will be removed.

Why I left the Centre of Excellence

15 months ago I left the large teaching hospital I will call the "Centre of Excellence" to practise at a smaller community hospital. I had worked at the CofE for 14 years. People often ask me why I left. There was no single reason; it was a series of small reasons. Taken individually they seem petty, as a whole they are a powerful reason.

1. I never fit in there.

When I was a resident I worked at a hospital that was similar to the CofE. I vowed I would never ever work in such a hospital. After my residency I worked at a community hospital in New Brunswick. Problem was, my wife and I are both from BC and I began to pine for BC or least Western Canada. In addition the New Brunwick government was in financial straits in the early 90s and was cutting money from health care like crazy. This not only affected my income but actually increased the number of hours I had to work for less pay. Now at that time, they was a glut of my specialty in Canada so when I got an offer to work at the CofE, I forgot about how much I hated that type of hospital and jumped at it. Within a month I knew I had made a major mistake but I had already spent a lot of money and time moving and besides there weren't a lot of jobs in Canada. In addition when I moved, I told my wife this would be our last move ever.

2. Personality Cults

I am an anaesthesiologist. I realize that patients don't come to the hospital for anaesthesia, they come for surgery. However I soon realized that at the CofE there were actually "personality cults" approaching worship of most of the surgeons. The problem was many nurses worked exclusively in one single sub-specialty while you rotated between rooms. This actually hurts rather than improves care as nurse tend to overlook flaws in the surgeons while focusing on your flaws real or imagined. For example a few years ago a surgeon left his resident to do a mediastinoscopy undersupervised. When the resident biopsied the pulmonary artery (actually he didn't but with the amount of bleeding that was what we thought) the surgeon could not be found. After several anxious moments another thoracic surgeon came from his office. It turned out the surgeon had actually left the hospital. I felt this had to be reported and when we discussed it at the next staff meeting several others had had the same thing happen with this surgeon so it was reported to the medical director and the surgeon was hauled on the carpet for a "corrective interview". Naturally I didn't work in that room again for about six months. I was expecting a frosty reception my first time back but to my surprise (maybe not) it was the nurses and not the surgeon who were frosty. I should mention that this surgeon is now on a forced leave of abscence.

There have of course been less egregious episodes. Like the nurse hissing, "I'm helping the surgeon!" when I asked for help with the severely burned patient.

3. Face-offs
This isn't about hockey. Our hospital does a lot of major head and neck surgery. We call those face-off because they take the patient's face off for cancer and reconstruct. These cases last about 16 hours. They don't require a lot of work once the case starts and always go to ICU post-op so they are not terribly intellectually stimulating.

The problem is that during those 16 hours, you have to eat and pee. This requires you to ask for another anaesthetist to come into your room to take over the case briefly. Most anaesthetists will do this for one another as a courtesy. The CofE has residents as well so they can often take over the case. Recently residents no longer regard helping another colleague to be educational so that route has been closed. There also seemed to be a lack of respect within the department so people would not automatically ask if you needed a break. This meant that around 1400 you were basically phoning around begging for a break so you could pee. We discussed this at multiple staff meetings without any resolution.

Long cases like this are not new. In the "old days" you would do about one a month. At the CoE they do 3 a week. This is in addition to the odd long Plastics or Neurosurgery case. The major head and neck cases used to be thought of as a cross you had to bear in order to do the lucrative ENT short cases. In our city however all the lucrative cases are done at another hospital. Go figure.

Usually one of the on call people takes over the case around 1600. There had been a tendency to assign the second call to that room which meant the lucky second call person gets to do the whole sixteen hours. Of course this means one of the on call people is now finishing an elective case from the day during the evening instead of doing emergency cases.

Add to that the personality cult among the nurses in that room.

4. Major cases
When I came to the CofE we actually did minor cases. Then the regional health authority decided that the CofE should be a pure "tertiary referral centre" and all the minor cases were moved to other hospitals. This means most of the cases are 3-5 hours long with the usual problems peeing and eating. It also means that cases often run into the evening without warning and the second call can't take over your case because he is in the face-off (see above). In addition many of the cases are in patients with a bad prognosis which is bad for morale.

Somebody has to do these cases (well actually some of them would be better off not being done). It just shouldn't be the same people all the time.

Also as people started to leave and it became hard to recruit staff, the chairman recruited a number of staff with questionable skills and qualifications. So guess who gets to do the few low intensity cases we have because they can't be trusted with sick patients?

5. Lack of help

I would think I am at the top of the scale of self-sufficiency for doctors. I can do most things without much assistance. There are a number of things that require an extra pair of hands. Also sometimes somebody has to go and fetch equipment or drugs solely because you can't leave the patient. Oftentime equipment is stored in a location where only somebody else knows how to find it (sometimes I think they do this intentionally).

When I interviewed for the job at the CofE they raved about their anaesthetic techs. I was actually looking forward to having somebody to help me. Unfortunately the techs work mostly in the cardiac rooms and are of very little help in other rooms. I found them very unhelpful.

Because we have techs however, most of the nurses were reluctant to help out. Many of them when I asked for help would go to the intercom and page a tech who never came. Sometimes a tech would come, open the door a crack push in the piece of equipment you needed and leave. Sometimes they would actually come in the room, look around and leave.

As low intensity surgery was moved out of our hospital, the need for the techs became greater, however the level of service did not improve, if anything it got worse.

Over the years I learned how to function without much help. When the hospital started renovating the OR, everything was moved and moved again which meant I couldn't find anything.

In contrast when I did locums or when I worked at other hospitals in the city I was amazed at the level of assistance I could get.

For the last couple of years, if I had to do a major case the next day I would lie awake at night worrying about how I would get throught the case with no help. One thing that always bothered me was that there were certain types of cases we did a lot of like for example liver resections but every time I did such a case, I would have to come in first thing in the morning and ask individually for every piece of equipment I would need to safely do the case.

This was brought up multiple times at staff meetings, and the chairman's (he only works in the cardiac room) was "we get excellent service from our techs".

My "Colleagues"
The CofE has a lot of anaesthesiologists whose shit doesn't stink. I noticed this from about the first month. I would sit in the lounge and hear people talking about the horrendoma they had done and how it was only thru their skill that the patient pulled thru.

I felt very inferior until I realized that I was doing the same cases as them and that my patients were pulling thru if only because no matter how incompetent you or surgeon are, it is very hard to kill somebody.

There were and still are a lot of people there I like. Over the years quite a few people came in who I didn't really like, some of the people I liked left and so on. I used to come to department social functions early on. I stopped going after a while, if somebody asked me, I said," its bad enough having to work with you". After a while, I realized that I wasn't joking.

When I started thinking about working at the community hospital, I thought about the anaes. who already worked there and realized how much more I liked them (and till like them after a year).

Lack of Respect
There are two types of respect.

The first type of respect is a type you have to earn. I know that I have to earn that respect and I don't take that as a given.

The second type of respect is the basic respect that everybody is entitled to regardless of their station. I like to think I try to treat everybody with respect. Maybe I haven't always done that but I always try now.

That second type of respect was totally lacking at the CofE. And for that matter forget about trying to earn the first type of respect.

It was only after working at other hospitals that I learned that I was actually an important member of the team whose input was important.

The declining standard of care

"Back when I was a resident" teaching hospitals functioned on the backs of residents, interns and medical students who worked their buns off. Staff physicians and surgeons did very little patient care and the nursing staffs tended to be more helpless than in a community hospital. It was soul-destroying work and I am glad that residents don't work as hard as they used to.

Except.... if they don't do the work, somebody has to do it. That means that the staff surgeons have to start earning their generous fees and that the nurses have to learn that the solution to every problem is not to page someone (because that someone is not going to answer that page anymore).

Unfortunately the slack is not being picked up. Problems are being missed, patients are coming to the OR on an emergent basis for problems that could have been picked up earlier and dealt with electively or not at all, patients are coming to the OR inadequately investigated or inadequately rescusitated. Charting is attrocious especially on the medical side. I find it disgraceful that I have to rely on the nurses' notes to find out what is going on and even then these are frequently less than adequate.

This happens to a lesser extent at our community hospital but in general the surgeons seem more vigilant and insist on a higher quality of care from their residents.

Disorder in the Operating Room

When I first came we had a clinical director who directed the flow of cases in the operating room Things worked out quite well. Then the health authority decided we didn't need one.

Now we have a clerk at the desk who manages the flow of cases. When a surgeon wants to book an emergency that involves disrupting a room, instead of talking to a physician or even a nurse who might be able to tell when he is lying, the clerk simply gets on the phone and disrupts whatever room she feels like. If you are involved in one of these so-called E1 emergencies, you of course have no idea of what you are getting into because of course the surgeon does not talk to you.

Unbelievably this was raised at staff meetings and nobody thought it was important although a few months after I left, they actually did change the system and now you have to talk to an anaesthetist to book your case.

We also have transplants. I have a lot of problems with transplants but then again I am just one needle stick away from needing a liver transplant so I will shut up. The problem is they typically harvest the donor starting in the evening which means that the heart, liver and lung transplants start after midnight so that come 0700 we have 2-4 anaesthetists who are not available to do their scheduled list. Instead of trying to deal with the problem (do the harvests earlier in the day so that the transplants are in the evening or do the harvests at night and the transplants first thing in the day), we came up with a solution where we have to take turns being the person who has to find 2-4 individuals to work the next at 2300 hours. So after working all day, you get to spend about an hour at 11 pm finding somebody to work the next day.

The transplants also screw up the OR slate incredibly the next day plus on weekends trauma cases get backed up.

There are actually some good people there

I don't mean to be entirely negative. There are a lot of really good people there who are disgusted by what has happened to their hospital and continue to labour on because of loyalty.