More on the CoE

I published several months ago a long diatribe about why I left the CoE.

Anyway several people either left or reduced their committment after me, which left the department which in addition to their total inability to recruit anybody left them severely short of staff. This lead to them actually having to cancel ORs because there weren't enought anaesthesiologists. Now cancelling lists is not a new thing at the CoE. They cancel them all the time because of lack of nursing, because the surgeon was up all night transplanting, because there are no beds, because the single horrendoma booked in a room was cancelled etc etc. This is done frequently with very little angst. Of course when you find out a 0600 you aren't going to work, this hits you in the pocket book. (This is assuming there actually have the courtesy to call you at home which is unusual, they normally wait until you show up or better still make you wait for 2 hours before they decide they can't do anything.) It was when I found I was actually happy when I found my list was cancelled that I realized that maybe I should leave.

But when they have to cancel cases because of no anaesthesia it suddenly becomes a crisis.

So they brought in two academic anaesthesiologists to do yet another external review. I have no idea of what this two charged but I'm sure it was worth their while. They produced a long report. The first half of the report where they went over all the problems at the CoE could have been written by me, except the my spelling and grammar would have been better. The second half where they proposed solutions was completely out of touch with reality. The bottom line was that instead of seeing how they could make the CoE a more attractive place to work at, they focused on how they could make the other places in the city less attractive.
The other interesting thing was that they came all the way out to Edmonton and didn't bother speaking with any of the anaesthesiologists who actually left who might have some insight into the situation.

Of course they could have just stayed home and read my blog. I wouldn't have charged them.

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).

Anonimity

It is nice to know that somebody actually reads my blog as I got an email last month regarding my posts regarding RateMds.com. The emailer expressed some disbelief that an anaesthesiologist would even be rated on such a site as nobody really knows who their anaes is.

That is quite correct and in fact the posts of RateMds relate to my work in the chronic pain field.

Anaesthesiologists are two-faced about the anonomity that comes with the profession. On the one hand, the lack of sustained patient contact is a significant factor in drawing many of us to the specialty. At the same time we resent the lack of recognition we get for the miracles we daily perform in the OR, we get really upset when nurses on the floor announce "anaesthesia is here" rather than Dr. BH is here, when we read about the latest surgical miracle in the hospital which mentions every member of the team except the anaesthesiologist etc etc we get really pissed off.

When I was a GP in small towns, you were very visible and people got to know you after a while. You were occasionally stopped on the street and asked for advice. On the other hand, you couldn't throw temper tantrums about bad service and you had to be very careful about drinking in public.

I always remember how in one small town, I treated a small child for what I felt on examination was a URTI, so I prescribed the usual nostrums. The child did not get better as most URTIs don't in the short term so the mother took the child to another doctor who informed her ( as doctors unfortunately do), "this is is the worst case of pneumonia I've ever seen and this antibiotic will cure it". So the child was sent home on antibiotics and got better as most URTIs eventually do. I will not even discount the possibility that the URTI may have developed into pneumonia.

At any rate, I obviously never learned of this developement until a couple of days later I was eating lunch with my wife in a somewhat cozy restaurant and heard the entire story from the next table complete with a description of how stupid the new doctor was. The lady then got up, saw me and turned beet red.

When I went into anaesthesia somebody told me that it was a good idea to make post-operative rounds on your patients. I actually tried that. One day I located all the patients I had done the day before which involved phoning admitting to find their locations and tried to visit them. This was in addition to the number of pre-operative visits I had to do in those days before same day surgery. I went into each patient's room introduced myself as Dr. BH who had put them to sleep the day before and "how are things going". And I got a lot of blank "who the hell are you" stares. Needless to say I have never made post-op rounds since.

Anyway our licensing body a few years ago decided that we needed our competency and other issues examined. Therefore presumable at great expense (using our dues) a program of assessing our fitness as physicians was initiated. So about two-three years ago I received in the mail a number of surveys about my abilities and personality as a physician. I was supposed to name 10 other physicians to evaluate me as well as 10 non-physicians. I must say I had a little trouble finding 10 surgeons who weren't pissed off at me but I did find 10 names. The 10 non-physicians (nurses) was a little more difficult but I found 10 names.

What was really difficult was that I was given 30 questionnaires that I was supposed to give to patients. I had about a month to do this. Now at the time I was working at the centre of excellence and typically did about one long case a day usually on a patient having some type of horrendoplasty. I thought to my self, these patients are not about to be able to complete a questionnaire about my bedside manner plus I don't do thirty cases in a month. Now at that time I worked 1-2 days a month at a community hospital doing day surgery. So I phoned up the survey company and explained my dilemma. After some negotiation, I was given extra time and over 2 months I was able to get rid of the 30 questionnaires.

Not a single one was returned!

As one of my non-physicians I named on the orderlies that I had befriended. One day, he pulled me out of the hall and said "Hey are you in trouble, I just got this questionnaire about you". I assured him I wasn't in trouble yet.

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.

More on Folk Festivals

Despite the corruption at the Edmonton Folk Festival that I wrote about, I actually like them. I usually attend the Canmore Folk Festival followed by the Edmonton Folk Festival the following weekend. I do have a few suggestions for performers and organizers.

Performers:

We came to see you because of the type of music we have heard you play over the years. If you are a Celtic performer, we want to hear you play Celtic music. We really aren't interested in your excursions into hip-hop or modern jazz. I know playing the same music over and over again for years can be boring but Mick Jagger seems to have done okay playing "Satisfaction". I am kind of bored doing the same thing everyday but it pays the bills and enables me to afford to go to folk festivals.

Also most of us really don't want to sing along. Please don't try to get us to. At the Canmore Folk Festival one of the acts tried for about 5 minutes to get the crowd to sing "The Lion Sleeps Tonight". The same applies to standing up, waving our arms etc.

When at workshops don't be a prima donna with the sound. I always remember how Taj Mahal came to a workshop and just plugged in his guitar and went on. It seems the lesser known or talented an artist is, the more time they spend getting their sound just perfect.

Organizers:

I don't mind you making rules but if you do please enforce them. If for example you tell people not to line up before 0700 and they do; please do some thing about it.

At the same time some of your volunteers take the fact that they are volunteers as an excuse to act like Nazis. Folk festivals are not possible without volunteers, they also won't go far without paying customers.

Remember many of your customers do not have a very good view of the stage. Keep this in mind when you book someone where dancing is an important part of their act.

Things that piss me off: drive thru's

I probably drink too much coffee and lately seem to prefer to buy coffee rather than make it myself. I also have developed a taste for lattes even though I used to sneer at people who made me wait for my ordinary coffee while the barista prepared their latte. (I suppose being Bleeding Heart after all it was innevitable that I develop a taste for latte's)

Patience is not one of my strong suits.

It bugs the hell out of me when I park my car and walk into Starbucks, Second Cup or Tim's and have to stand and be ignorred while the staff services a long line of drive-thru cars. Tim Hortons even has posted time standards for the drive thru which are a hell of a lot shorter than the time it takes me to get served.

What are two of our biggest problems: global warming and obesity. So we let people sit in their SUV's idling for several minutes while they pick up their triple-triple and a donut. Meanwhile I am trying to do my small part for the environment and myself by parking my car or even walking to the coffee place and I have to wait.

Coffee places: be warned. I have had enough. Close your drive thru's or I will do something drastic. Like make my own coffee.

Corruption at the Edmonton Folk Festival

It is hard to think of an institution more pure than the Edmonton Folk Festival. An institution verging at times as holier than thou. Run by volunteers, with real plates to reduce garbage, healthy ethnic foods, thousands of people co-existing peacefully for 4 days with no cops on site.

A couple of years ago I decided to go in the tarp run. This is an EFF tradition. For those readers who don't know Edmonton, the Folk Festival is held on what in Edmonton passes as a ski hill. The stage is at the bottom. People place tarps to hold their places. This is on a first come first served basis. If you come early you are in the first row, if you come later you are much higher up the hill, it seems about a mile away and several thousand feet above the stage. This is not a problem as the music is amplified and there are video screens half way up but going up and down the hill several times a day can be quite tiring.

In years past people lined up overnight to get a good spot. When the gates opened there would be a mad dash from the two entrances to grab a good spot of land. This was even more interesting as one of the gates is at the top of the hill. This culminated a few years ago in somebody running over a festival volunteer and breaking her leg. Because of this and because I think the neighbours really didn't like people sleeping overnight in their neighbour hood, the festival instituted a raffle system.

Now for the Saturday and Sunday shows, you line up at 7 am and are admitted to the compound where you are given a "colour" with a number. Each colour is a group and the number is where you line up in the group. The colours have funny names like "Red red wine" and "Mellow Yellow" (I'm not sure whether they have a "whiter shade of pale"; they should.) At about 8 am, the colours are called out randomly and if your colour is called first, your group gets to walk to the front of the stage and place your tarp (Actually you put your stuff in line in another holding pen and come back after 0900 to start the "tarp run".)

So a couple of years ago I woke up around 0630 and decided, why not go in the tarp run today? So I rode my bike down to the site. The festival asks you not to line up before 7 am so I was careful to time my arrival for 7:01. That was pretty stupid because the line-up was already about 100 metres long by that time (and like most Canadian line-ups it was growing from the centre as people let their friends join them in the line-up!). I did get into the compound however (only 300 people get in at each entrance). The volunteer at the gate looked me over and selected a coloured tag from the sheaf of tags she was carrying. The compound was an area sectioned off by a portable fence like you see around construction sites. It was cage like and about 300 people were penned up like cattle inside this area. This was compound by the fact that many people were carrying seats, and supplies for the festival. In Edmonton in August you have to have clothes for 3 seasons plus rain gear.

At 8:00 I was expecting the colours to be drawn out of a drum. However the head volunteer opened an envelope with a printed sheet of the order of colours. Hmmm I thought, I wonder how many people know which colours are going to be drawn early and are they involved in passing out the colours.

Now I soon realized that people will find a way to make any fair system unfair. You would think that for each tarp, one person would show up. It doesn't work that way. Typically 8 people would show up for each tarp and get 8 different colours, almost ensuring that at least one would be drawn early. 1 person I found out, gets 25 friends to show up and get 25 colours. (I don't have 25 friends, let alone 25 who would show up before 7 am on a weekend). This is a minor annoyance however. It does mean that less than 300 people get to participate in the tarp run because 8-25 people show up and only one of them actually gets in line.

The next year I noticed that the same two people got in the first group both days. These were not people who came in large groups. Hmmm I says, I wonder if one of their friends is a volunteer who knew what colour was going to be called first.

Anyway I didn't go in the tarp run this year. But I was talking to a friend who goes in every year who told me that yes in fact the volunteers know exactly which colours are going to be drawn first, and they give them to their friends or to people who smile at them the right way (I have trouble smiling until well after 9 am). The festival is such a sacred institution that like the Catholic Church in old times, no one wants to expose this. (Until now).

It just shows that even pure events like the Edmonton Folk Festival can be corrupted and what lengths people will go to make a fair process unfair. The other observation I have made about tarps, is that the closer to the stage they are, the less likely they are to be occupied during any of the main stage acts. I will be sleeping in and climbing the hill just like old times.

An Open Letter to Surgeons

It seems in the Medical Blogosphere, every specialty is writing open letters to every other specialty. Maybe some anaesthesiologist has already written one. I haven't looked. Here is mine.

Dear Surgeons:

I actually like most of you guys. At least I like you a whole lot better than most internists. Maybe because we work so much together there are a few things that piss me off.

1. Punctuality. Maybe I am a bit anal about being on time. I frequently arrive at parties at the acutal time the invitation says. However when the case is booked to start at 0730, I try to show up at least 15 minutes early, the nurses show up at least 30 minutes early, all so we can have the patient ready for you. But you consistently show up at 0745. Now if we start 15 minutes late, we rarely ever make up the time which means that we leave 15 minutes late. That is assuming we get to do the last case which is often cancelled if we are running late which hits me in the pocketbook, not to notice having to witness an ugly scene between you and nursing.

When confronted on this, your excuse consistently is, "but it's only 15 minutes". Next time you fly somewhere show up 15 minutes late and see if you get to board the plane.

Maybe 15 minutes isn't much, however when I finish 15 minutes later than I should have, that might mean I don't get to eat supper with my family, I miss my children's soccer game completely or I miss the meeting I scheduled at the end of the day.

And by the way. I cannot start the case until we know you are in the hospital. That is because you could be operating at another hospital, in court, or have died in your sleep. I am aware of all three scenarios happening. Quite often the patient wants to talk to you, frequently the consent has not been signed.

And having started the day, try to arrive on time for each subsquent case. If you can't because you are dealing with something in emergency or on the floors, why not call and tell me. If I know I have an extra 15-30 minutes, I can actually do something with the time.

2. Residents. Those surgeons who don't work in teaching hospitals can skip ahead here. Most doctors my age were junior house staff on a surgical service years ago and we know how hard surgery residents used to work and how completely soul destroying and uneducational it was. The current group of surgery residents are quite right to refuse to put in that amount of work. However... most of that work still has to get done. That means if the residents won't do it, you had better find someone else to do it; the nurses, yourself I don't care. The standard of care on most surgical services is disgraceful. By the way, you might want to ask your colleagues at non-teaching hospitals how they manage to provide pretty good care without residents.

Further while it is important to train the residents, the middle of the night or late in the day when you are already behind are not good times to teach. When I am letting a resident do something I make sure they try to do it as efficiently as possible, I come in extra early and I help them as much as possible so that they can do the procedure or get the case started faster.

3. "I really don't want to do this case but the family is insisting on it" God man, how many years did you train so you could be intimidated by Mrs. Jones' high school dropout grandson. To put it another way, I have as much training as you and do you ever respect my opinion? And isn't it funny how these discussions only occur after hours, never during your elective slate? Grow some balls, sit down with the family tell them how operating on granny will at best slow her demise, may likely hasten demise but will not prevent her demise.

4. Yes we don't work after we've been on call. Sometimes now we don't even work the day before night call. This is not because of some weakness but because we have learned that it is dangerous to work without sufficient rest.

Like the alcoholic who thinks he is witty and sexually attrative when he is drinking, you believe you can provide competent care without much sleep. We have watched you for years. Trust us, you can't and you don't.

5. We do emergency cases in the order determined by whatever protocol the hospital has decided for prioritizing cases. Surgeons presumably had some input into the process. If you feel your case is more urgent than the one ahead of yours, don't whine to us. Call your "colleague" and ask him if you can go ahead.

6. Oh and while we are on call or even in the course of our elective lists, we may have to go the ER, the ICU or the ward to intubate somebody. We may also have to do a labour epidural. This may delay you. We do these because we are physicians.

7. Try telling the truth for a change. Instead of saying you have to do Mrs. Smith right away because she has perforated, why not say,"I know Mrs. Smith can wait but the family is driving me crazy." We may still not do your case when you want it, but won't you fell better about yourself. Be truthful about the patient's medical condition, and how long you are going to take.

8. I don't know about the medical training of people recently but anybody who trained in my era had pretty good grounding in history and physical examination skills. Put those skills to use. Not just in the areas related to where you are operating. Currently when I read a chart, I get my best information from the nurses notes which is kind of disgraceful. Also you might consider writing the odd progress note. Like, say every day. Just so we have some idea about what happened to Mrs. Smith in the 5 days since she was admitted and why she is having surgery today.

9. If you have a problem with the way I work or the way a particulary case went down, talk to me first. In private, not yelling in front of the nurses. Before you write a letter or talk to my chief. Definitely befor you talk to the family. Aside from being courtesty, I may just be able to explain why I do something or what happened in that case. And please no sneaky progress notes that I will never read but that are in the chart forever.

10. No amount of lab work is a substitute for a legible history and physical documented on the chart. The more lab work you order, the more likely something is going to be abnormal which will lead to more testing and possibly the cancellation of your case. Also when you really need something stat like a PT INR, the lab can't do it promptly because it's queued up behind all the routine "baseline" PT INRs you and your colleagues ordered. There are specific guidelines for pre-operative lab work. Look them up and use them. Don't forget, some tests have a shelf life. Electrolytes done on admission don't mean much 2 days later in a patient who has been vomitting or hasn't peed.

11. Your responsibility for the patient doesn't end when you book the patient. Many patients need ongoing monitoring and rescuscitation in the few hours before they are booked and when they get to the OR. Don't tell me after the blood pressure crashes on induction "Oh he might be a little dry". That should have been taken care of before he got to the OR.

12. Yes we do get paid by the hour. Years ago somebody decided that was the best way to pay anaesthesia. It turns out they anticipated laparoscopic surgery. The downside of this is of course of income is limited by how many hours of work you and the hospital will provide us. Essentially we work when you want to work. That's the cross we have to bear. We do not however slow down cases to increase our income or to fill up an underbooked day. I must say, I am bemused and occasionally disgusted by how much time some of my colleagues take to get a case underway, but I actually have life and when I see the chance to finish early, I go for it.

13. No matter what your overhead really is (and it is much less than you always say it is), you make several times more money than the nurses. Please don't whine about how overpaid or lazy they are. Also please don't flaunt your lifestyle in front of the nurses or me. I know you work hard and have a lot of training. So do I. Also if you drive a Porsche, why the hell are you aways late in the morning?

14. I'm all for new technology but nights and weekends aren't the best time to try out the new orthopaedic hardware. Instead of franticly calling the rep and yelling at the nurses, do things the way it has been safely and effectively done for years or postpone the case. Also watching the rep walk you thru a case doesn't engender a lot of confidence in your abilities or judgement.

15. When I am on call, I have to miss things. Please don't use family or personal business to try and get your case done at a time of your chosing. Call up one of your colleagues and get him to do the case for you. I realise some of you are on call more often than me (some of you are also on call less).

16. When you "outsource" your easy cases to the private surgical suite or the community hospital please don't come and boast about how efficient it it there (especially when you show up at 0745 to start your 0730) case. It takes a lot longer to set up a radical neck than it does to set up a myringotomy. Secondly don't be surprised if we are a little surly when you bring your complications back to our hospital. Thirdly it is really good that you help mop the floors in your private suite. Why don't you ask the cleaning staff here if they want some help.

17. Before whining "it's on my card" make sure it actually is on your card. Also if a piece of equipment is so important why don't you, during the changeover that you complain about, make sure it is actually on the tray. We have nurses and techs who are supposed to provide equipment for us like laryngoscopes but we still actually check before the case that we have one that works.

Wow I didn't realize I had some much spleen (the metaphorical kind, not the organ that is bleeding under your retractor) to vent. I really like you guys and I know not all of you do any or all of the above transgressions. It's the 90% of you that give the other 10% a bad name.

See you tommorow (at or before 0730).

Bleeding Heart.

I got sued part 2

Actually maybe things didn't go that well. As the case wore on, she required more oxygen to keep her saturation up. In retrospect, the rotten food I should have sucked up was probably getting past my et cuff.

So I decided to keep her intubated, get a chest X-ray and call ICU.

I took her out to recovery and put her on a ventillator there and called ICU who sent their fellow over right away. As it turned out her oxygenation got worse in the next few minutes and her CXR was gross.

To make a long story short, she spent several months in the ICU, a few more in hospital but was actually discharged with no new deficits. Not that spending a few months in ICU is necesartily a good thing.

I had a somewhat unpleasant meeting with my chief, (who you may recall was the individual who was able to see the patient in a relaxed un-hurried fashion in the preassessment clinic and failed to document the patient's achalasia) and called the Canadian Medical Protective Association.

Several months later the patient's father called me up and asked to meet with me regarding what had happened to his daughter. I called up the local lawyer on my case who advised me to only meet with a lawyer present. I phoned the father back and told him, this. His response was, "Is this how you doctors handle things?" I often think if I had just met with him I might have avoided legal action (or least shifted blame onto the surgeon and my chief). A few weeks later he called me up and asked if he could photocopy the chart. As patient charts are legally the property of the patient, I told him to go ahead. Unfortunately the hospital refused to let him photocopy the chart which lead to me receiving a letter from his lawyer. Strike two.

Time passed. In my province at that time you had only one year to file a lawsuit. As eleven months rolled by, I began to feel good about myself again. At eleven months and two weeks I got served! Along with the surgeon, and the hospital. Curiously my chief managed to escape.

About 2 years later I had what is called an examination for discovery. This is a process in civil suits where you sit down and the other lawyer questions you. Your lawyer is present, but does not ask questions; he may interupt to clarify and he may by hand or eye signals caution you on answering a question. The plaintiff is usually present, although there is no requirment that she be there.

This of course involves taking a day off work although in anaesthesia one can do this by working around the call schedule. The other side of course cancelled the first session on short notice and we had to reschedule.

Now as I have said, there were mitigating factors; the bottom line is that I screwed up. I could have and should have dug deeper asked more questions of the surgeon and patient. I should have got the chart back from the surgery resident. I should have cancelled the case after the induction. I should have checked for a suction. Blah, blah, blah. I should have done all these not so I wouldn't get sued, but rather to prevent a patient would was told she was coming for a simple short stay surgery that would solve her problems forever from spending months in the ICU, a fate I would wish on no-one (even my chief).

The other lawyer of course missed all this in his two hour interogation. The examination ended with the curious question, "Did you give her chlorine" to which I answered no.

Now there were a few other problems. As I mentioned the patient was deaf-mute. She also had a variety of pre-existing neurological problems which of course nobody bother documenting pre-operatively. Also in the ICU as they began to wean her off her sedatives, she developed twitching, which the neurologist said was due to "anoxic brain damage". Although the patient required high concentrations of oxygen and other ventillatory support she was never even hypoxic, let alone anoxic.

Eventually the case was settled out of court for a low six figure amount.

The only consolation when something bad happens to one of your patients, is that you learn something that will help future patients, and the institution may make changes that may prevent future events. I have done achalasia patients since uneventfully and I now know what a "Heller's Myotomy" is. I can even google it now:

http://www.gpnotebook.co.uk/cache/2087387177.htm

Years later I was talking to the scrub nurse in that case and I learned why I had a student nurse helping me. At that time, in the Centre of Excellent, each service had its own head nurse in the OR. Some of the head nurses actually helped out. The head nurse in this case usually didn't. On that particular day because they were behind and were busy setting up for this laparoscopic procedure, they asked the head nurse if she could help me get the case started. Her response was to send the student nurse in to "help" me. I gather that when her bosses in the OR asked her why she didn't help me, she said it was because she didn't like me. At that time I had worked at the CofE for 3 months and had never worked in her room so I must have managed to piss her off in the first couple of hours that day. She retired a couple of months later. This says something about the institutional culture at the Centre of Excellence. Normally when you give an excuse like "I didn't help him because I don't like him", the usual response would be "I don't care whether or not you like him...your job is to help him". As it was one of the items discussed with my chief at the unpleasant meeting I mentioned above was the fact that according to my chief after 3 months all the nurses hated me. Well I certainly wasn't too impressed with the nurses around that time.

I Got Sued Part 1

A few weeks ago while channel surfing I came across the movie "The Verdict" with Paul Newman. I first saw this movie in 1984.

The movie is about a lawsuit against an anaesthesiologist.

The "facts" in the movie are that the plaintiff came into hospital to have her baby and was "given the wrong anaesthetic". Essentially the patient had eaten just before she came into hospital to have a baby and was given a general anaesthetic with a mask during which she vomitted, aspirated, had a cardiac arrest was rescuscitated but was left in what we call a vegitative state.

The movie doesn't say what type of operation she had.

Assuming she had a caesarian section, there was no right or wrong anaesthetic in 1983 or now. The standard of care for a caesarian section under general since the 1960s would have been to intubate the patient. A mask anaesthetic would have definitely been the wrong anaesthetic. Pregnant patients are assumed to have a full stomach regardless of how long they have fasted and stomachs empty much more slowly in pregancy.

Now up until the 1960s or later, it was fashionable to give women heavy sedation approaching or exceeding general anaesthetic for labour and this is what may have happened. Judging from the clothing and hairstyles however, the movie is set in the early 80s/late 70s.

I am constantly amazed that producers are prepared to spend millions on a film without asking a specialist in the field, "Is this a plausible scenario?"

This however is not about reality in the film industry, it is about my brush with the medico-legal system.

Actually it was 14 years ago and I believe it was settled at least 10 years ago. I was reading Dr. Sid Schwab's blog and he talked about how he got sued years ago so I thought I should relate my experience.

Firstly I fully admit that while there were extenuating circumstances which I will detail, there were actions that had I followed them, the whole mess would not have happened. The bottom line is I have always accepted full responsibility for what happened.

It happened a few months after I joined the staff at the centre of excellence. I have been in practice for just over 2 years at the time. Statistically anaesthetists are at their most dangerous in their first 3 years of practice. (Some people think that more experienced anaesthetists are just better covering up their mistakes.)

Anyway as I have mentioned in a previous post, I had already by then realized that I did not fit in at the centre of excellence and that I would probably never fit in.

When I was a resident and in my first years of practice, when a patient needed to stay in hospital after their surgery, they were admitted the night before and they were seen the night before by the anaesthetist assigned to the room. This meant up to an extra hour of (unpaid) work after your list had finished not to mention the Sunday night visits. This was we all belived the cross anaesthetists had to bear. Now it was around that time, the hospitals in the name of saving money decided that patients could be admitted on the day of surgery. This meant that they were seen in advance of their surgery at a Pre-operative Assessment Clinic (PAC) by one anaesthetist who was assigned there that day. That lucky person would see all the patients, review the lab work and fill out the anaesthetic form. Hopefully if there was a potential problem, that would be relayed to whoever was supposed to do the case. At that time a copy of the anaesthetic form would be faxed to the office the day before so you had some idea of what you were doing.

Anyway, the day before I looked at the slate and saw that one of my cases was a "Laparoscopic Heller's Myotomy". Even with a medical degree, five years of medical training and over two years clinical practice, I had no idea what that was. Nor did anybody in the office. I suppose I could have gotten a surgical textbook and looked it up (I did several months later and even some surgical texts didn't use that term). Or I could have phoned the surgeon's office and talked to him. But I didn't. I figured I could talk to the patient the next day, read the chart and I would be able to figure out what I could or couldn't do. (Nowadays I would just Google Heller's Myotomy but back then Al Gore had only just invented the internet).

Complicating matters was that the surgeon was probably the most clumsy incompetent surgeon at the CofE. There are many clumsy and incompetent surgeons and many of them know their limitations and stick to hernias, lumps and bumps. Then there are those who don't know their limitations. This surgeon, widely known for his incidental splectomies was one of the later group. Worse still, he had jumped onto the laparoscopic bandwagon well in advance of many of his colleagues.

Anyway on arrival in the room, I asked the nurses if they had any idea what our second case was. They too had no idea. So we asked the surgeon when he came in. He mumbled something like, "just like a laparoscopic cholie, no problem". Our first case was a breast biopsy which unfortunately needed a frozen section which took much longer than planned, so we were already running late. All this time I was thinking no problem, I'll talk to the patient and read the chart and I can do this next case.

On dumping my first patient in the recovery room, I went out to the receiving area but my second patient wasn't there yet. Quite often I will see the patient in the operating room but I distinctly remember telling the nurse in receiving, " call me when the patient gets there". Then I went to have coffee.

The next call I got was from the room telling me that the patient was in the room. No problem, I can read the chart and talk to the patient there. Except.....

Because patients don't come in the night before, the surgery residents also don't get a chance to read the chart and the surgery resident had taken the chart somewhere to read it. And...

The patient was deaf-mute and no family member had accompanied her.

No problem. One of my colleagues must have been able to talk to the relatives, read the chart in the PAC. So I got the anaesthetic record (which hadn't been faxed over the day before). She had been seen by the chairman of the department, an eminent academic anaesthetist. To be honest there wasn't much on the chart just a couple of meds, no allegies and a note that the patient was deaf-mute. Nothing to get the spidey senses tingling. Now I have learned since and probably knew then that the more eminent an academic anaesthetist is, the less competent they are. But I figured, okay we're dealing with something like a laparoscopic cholie in deaf-mute but otherwise health person.

So we set up to induce anaesthesia. I had a student with me that day, somebody I had worked with for a couple of days. This was a smaller room and we had the two monitor towers on each side of the bed so there was only room for one person at the head of the bed. Since my student was going to intubate,that was him. When we start anaesthesia, there is supposed to be a nurse whose only responsibility for those few minutes is to help us. There was a female nurse-looking person standing at the side of the bed where the nurse usually stands.

So I inject the drugs and after waiting a few seconds, my student goes to intubate. First thing he says is "I think we need suction". So I ask him to get away from the head of the bed because there is not room for two of us because of the monitors and I take a look and her entire mouth is full of some gross whitish material. That was when I discovered that my lovely assistant was a student nurse who had never helped start a case and that she had not got a suction ready. (The nurses get the suction ready for each case, but I admit it is my responsibility to check for its presence).

At this point, the surgery resident wandered into the room with the chart, looked into her brimming oro-pharynx and said, "Isn't achalasia gross?"

ACHALSIA!!!!!!!

Achalasia is a condition where the muscles in the esophagus that are supposed to propel food down towards your stomach don't work. This results in solid food accumulating in your esophagus where it basically decomposes leaving you with a massively dilated esophagous full of rotten food. This patient I learned later had a particularily bad case to the point where she had to sleep sitting up or else all this rotten food would go down her lungs.

Usually patients like this are admitted to hospital several days in advance and all the rotten food is sucked out and they kept on a liquid diet.

Now when you screw up like this, no matter how extenuating the circumstances are, when you should be thinking, "how can I help this poor person?", your first thoughts are, "boy am I in shit!"

So I pushed the student aside waiting for the real nurse to set up a suction, sucked out the oro-pharnynx and intubated. Fortunately the patient's oxygen saturation remained okay and she was not broncho-spastic. I called for a broncho-scope and looked down into her lungs. There was a little bit of "staining" in the parts of the lung I could get to with the bronchoscope which I tried to suction out as best I could.

At that point I should have cancelled the case. The patient had aspirated she was stable but she could get worse during the case and once we started, it might be difficult to stop. I didn't do that though. I felt so bad that my telepathic powers had failed to pick up what the patient had and what the surgeon planned to do that I felt I had to make things up by continuing on with the case. This is very irrational but that is how you think when things like this happen.

At the very least, I should have suctioned out the 2 or so litres of rotten food in her esophagous to keep it out of her lungs. (An endotracheal tube is only partial protectiona against aspiration.)

After that, the case went pretty good.

Bad haircuts

Having lived through the 60s, 70s and 80s I have seen more than my share of bad haircuts. There is one hairstyle that has become popular that is wearing thin (literally).

The shaved head.

Now I know that many balding men are now shaving their heads instead of a comb-over and yes we appreciate that. However it is possible to be balding and still look distinguished without combing over or shaving the entire thing off.

The problem is that what was once a novelty has now become almost boring. While some men look like Bruce Willis with their heads shaved, the unfortunate thing is that most of them look like Dr. Evil.

Oh and by the way nothing looks worse like somebody with a shaved head who had a laceration sutured in the past. I sutured up looks of scalp lacerations during my years as a family doc. Scalp lacerations are always chalenging because they bleed a lot and the hair gets in the way. Fortunately we all thought, no one will ever see the scar we leave. However due to the whim of the fashion gods, all these hideous scars that we thought no one would ever see, are now coming into view.

Please stop, grow your hair back. We promise not to make any more bald jokes.

What Made You Think I Wanted Mayonnaise on My Sandwich?

I was a fussy eater as a child. I will admit that. Mealtimes were a real stressor for me and my family especially when we travelled or ate out. Over the years I have introduced a large number foods, that I hated or wouldn't eat as a child into my diet.

The exceptions however are mayonnaise and its co-offender mustard.

These two condiments are ubiquitously added to sandwiches and other foods without any consideration as to whether people would actually like them on their food. If you go to a self serve lunch counter or a 7-11 and pick up a sandwich, it will most certainly have mayo and may also have mustard. When I am at a meeting and someone brings in sandwiches, if I am really hungry I will have to choke down a sandwich slathered in mayo or mustard.

Why those two. There must be 100s of condiments we could routinely add to our food. Heinz alone has 57 sauces. Go to a supermarket or specialty store and look at what's available in the sauces category and there may be 100s of distinct sauces to flavour your sandwich. Why has our society chosen those two sauces. Better still, why does our society insist on putting any sauce on a sandwich when it is so much easier to allow people to actually make a choice.

Problems With Patients

I am very sensitive about my interactions with patients since that godawful RateMDs.com came up. So I try to please everybody but sometimes you are stretched thin.

For example.

I saw a young lady in the pain clinic several years ago. We tried various therapies but eventually she ended up on oral narcotics and went back to her GP who took over prescribing. Several months ago she phone me stating that her GP had retired (true) and that she was waiting for an appointment to see a new GP (this is called a meet and great appointment). She asked if I would fax in a prescription for her. Remembering her and liking her, I was happy to do so. A few months later she phoned stating that she had missed her appointment with this GP and now would have to wait a few more months and you know what... So I faxed in another prescription. There was a third request stating she only needed a few pills until next week.

Finally last week she called with a convuluted story about seeing the long awaited GP followed by referral to someone else and involving missing an appointment of course. She couldn't remember the name of her new GP so I couldn't phone to verify this story. I told her that I had already faxed 3 prescriptions and that I was unwilling to fax another without seeing her. I told her if she could find the name of her new GP I would phone the GP on her behalf. She never phoned back.

A few months ago I saw a new patient with fibromyalgia. She came accompanied by another lady and the two of them sang my praises. This should have tipped me off. She was on a lot of non-narcotic medications and after some discussion I agreed to prescribe a short acting narcotic to tide her over. I gave her 100 pills and asked her to come back in 4 weeks. Just short of the 4 weeks I got a faxed request from the pharmacy for another 100 pills. Guess what...she no-showed for her next appointment. So in about 4 weeks I got another request for 100 pills with a note from the pharmacist saying she had missed her appointment because of an MVA, I refused to refill the prescription without seeing her again. She no-showed for her next appointment and presumably she and her friend are no longer singing my praises. I can only hope she doesn't have internet access.

My Time is More Valuable Than Yours

A few nights ago I was on call.

We had the usual collection of urgent cases, nothing really that couldn't wait for a few hours or even a few days. One of the surgeons had two cases. They were less urgent than the other cases we had so would normally be done after the more urgent cases.

Now this surgeon who is a nice guy, started asking if he could go before the other cases stating that he had to be home by a certain time because his wife was going out of town for a few days and he had to be home to look after the kids (and presumably have sex with his wife before she left).

Now the bottom line here is: he is on call. I am also on call and I have personal things in my life that I have to miss when I am on call. So when I need to do something in the personal area, I ask one of my colleagues to cover for me. Occasionally somebody is able to do that. Some surgeons are in very small groups or do procedures that only they know how to do. Now this surgeon has a large number of other surgeons in his group who could have covered for him and it was a very basic procedure. But instead of calling up one of his colleagues he instead makes the nurses and me feel guilty.

This isn't an isolated case, surgeons are always pulling this stunt to get their cases done.

The bottom line is we all have to take call some more than others. We all have a personal life (some more than others) which our work affects. But when you pull a stunt like this, you are saying, my time and my life is more important than yours.

It's been a long time since I wrote

I noticed that the last post before the one I just posted referred to my distaste with the shootout which means that the entire playoffs passed without my commenting on them.

My comments.

1. Without any team that I cared strongly about, the playoffs passed relatively quickly not like last year when I watched just about every Oiler's game.

2. The Canucks lost because they had too many Europeans. Same with Ottawa.

3. While it is somewhat off-putting to see Chris Pronger's name on the Stanley Cup, Todd Bertuzzi's would have been more of a travesty.

4. Mike Comrie has excelled on Ottawa being something he couldn't accept that he was on Edmonton, a third line player (entitled to a third line player's salary)

5. The Canuck's loss in the playoffs only justifies what I have said for years, that the Sedin twins are the most overrated players in the league.

Tim Horton's Iced Mocha

Now I realize that Tim Horton's is a business and that if I don't like things there, I can go somewhere else; however face it Tim's has promoted itself as a national icon, the government issues currency thru it (remember the poppy quarters), and our current governing party used restaurants suspiciously like Tim's in it electoral ads etc. Besides I have a long relationship with Tim Horton's going back to my internship in Halifax where I discovered this strange chain named after a 1960s era Leaf player which didn't then exist in BC where I came from. Later I used to stock up on coffee and a donut in Truro on the way to my girlfriend's to gird myself for the amorous adventures that would shortly follow. I know where the nearest Tim's is to every hockey arena in Edmonton, and the location of every Tim's between Edmonton and Vancouver. So I think I have a stake in Tim Horton's.

But something is pissing me off.

It's the Ice Mochas. Tims brought these in a few years ago. I've had a few, they taste okay. The problem is the machines never work. So when you pop into Tims for a quick coffee on your way to or from somewhere, you are sure to be delayed by the person in front of you ordering multiple Iced Mochas. This not only ties up the person making the iced mocha but also the other employees who have to come over and try to make the stupid machine work.

Tim Hortons was built on doing two things well. Making a decent cup of coffee and baking donuts. Their success (thankfully) was not based on iced mochas.

And basically what is an iced mocha. To the best I can see it is a hybrid between a milkshake and a slurpee. Many places do either of these well. Leave it to those places Tim and let those of us who want their coffee, to get it quickly and efficiently.

The Shootout

This is something I have been meaning to write about for some time, however today's hockey results have brought things to a head.

Firstly I am not a Leaf's fan. I would rather they got in the playoffs than the Habs who I hate, however it is not a big disappointment that the Islanders and not the Leafs got into the playoffs. In fact it is probably better for all of us, as it will assure that every game of the Ottawa series is televised nationally (because you know the geniuses who schedule the playoff games would have had Toronto and Ottawa playing the same night).

However the Islanders who blew a 2 goal lead in the last 4 minutes, got to the playoffs by virtue of winning in a shootout. Now I know that over the 82 game season everybody wins or loses by shootouts and that fact that it happens in the 82 game with a playoff position on the line, shouldn't be used for or against shootouts.

However....

What a crappy way to break a tie.

Firstly during the regular season do you really need to break a tie? Soccer which is the world's most popular game doesn't. (They do unfortunately use a shootout in playoff games and two World Cups have been decided by penalty shots.) College football allows ties, NFL and CFL football allow ties after an overtime period. Basketball and baseball have overtime but play until somebody wins.

So if you need to break a tie why, not play until somebody wins. That is of course what happens in the NHL playoff which occasionally results in 2-3 periods of overtime which is clearly impractical in the regular season.

There is a simpler solution which most Canadian NHL players are already familiar with because it is used to break ties in minor hockey. The NHL already uses a version of it in that they start 4 on 4.

My solution, start 4 on 4 and play until the first stoppage in play after 2 minutes. Then each team takes off one player and plays 3 on 3 for 2+ minutes and so on. They can either keep on taking players off or just play 3 on 3 until somebody scores. Some of the most exciting minor hockey games I saw went down to one on one. Imagine Crosby and Ovechkin one on one. A lot more interesting than watching them taking penalty shots?

The whole problem with the shootout is that it brings the whole game down 4 players, the shooters and the goalie. Now hockey is unfair in that the best team often doesn't win, however usually when a badly outplayed team ekes out a tie after 60 minutes it is usually because of the play of their goalie and of their star players who are able to score against the flow of play. So, who do you now let decide the game?

The other problem I have is that the team who wins in a shootout gets 2 points, same as a team that wins 8-0. Stupid. They should make it 3 points for a win, 2 for an OT/SO win an one for an OT/SO loss. (I know, I saw an analysis in the Globe and Mail where such a system really wouldn't make much difference to the standings but fair is fair).

But say the supporters of the SO, "the fans love the shootout". I suppose the fans who buy the 2 for $9.99 tickets the American teams use to fill their stadiums do. Probably the people who attend the odd game with their company's season tickets do. I doubt the individual fan who shells out $3-5K per season for a season ticket likes the shootout. And if "the fans love the shootout" why not use it in the playoffs? I could actually do with not coming to work bleary eyed from April to June.

How I Almost Got the Strap

I was a pretty good student. I got good marks, behaved well etc.

In Grade five though I almost got the strap. I have gone over this incident in my head for the succeeding 39 years and now wish to come clean.

When I was in school we had corporal punishment which meant being hit on the hand with a modified leather strap a number of times depending on the severity of your offense or your record. "The Strap" was administered out of sight in the Principal's office or occasionally in the hall or the cloakroom by your teacher. Usually 1-2 children got "The Strap" every year which increased the mystique behind it.

I never got "The Strap" which I will explain later but I suspect it hurt a lot less than the spankings most of us got from our parents. It was the mystique behind "The Strap" which was sufficient to keep most of us in order.

Now I say I was well behaved but this may not have been the case in Grade 5. We had that year, a very old teacher who had always taught Grade 1 and 2 but this year was given a split Grade 5 and 6 class. Not only that, but she was given the worst Grade 6s in the school. So things got a little out of control in our class shall we say, and I probably took advantage of that. Nothing serious, more talking out of turn, that sort of stuff.

On the day in question, two or more of the Grade 6 boys had got a piece of pipe-cleaner from an art project and had rolled it into a small compact stick that they were throwing back and forth around the class. Every once in a while the teacher at the blackboard would catch it out of the corner of her eye and wheel around. It got quite annoying actually.

Just after lunch, the projectile landed on my desk. I had two conflicting emotions. I was fed up at this thing being thrown around the class, but at the same time now that it was on my desk, I was scared that I was going to be blamed. Logically I should have closed my hand around it, stood up walked to the garbage and deposited it. Instead I did something really stupid. I threw the projectile in the general direction of the garbage can which was next to the teacher's desk, which was where she was sitting at that time. Instead of landing in the garbage can, it landed on the teachers desk.

The result that I, along with two Grade 6 boys, was marched to the principal's office. The principal however was sick that day and the secretary who normally would have summoned the vice-principal (who gave the strap much harder than the principal) to the office was not at her desk. Our teacher said, fine we'll come back after school.

I remember coming back to my desk and shaking uncontrollably. I don't think I learned a thing that afternoon.

After school the three of us stayed at our desks, waiting to be taken to the office. A few people in the class hung around to watch us make the walk. The teacher came to us and said, "Are you ready to go?", I said yes. She said "Do you want to go" I said no. She said that if we promised to behave for the rest of the year we would not get "The Strap".

I left the school feeling freer than I have ever felt before or after.

The Ride of Your Night

In several places around the city there is a billboard advertisng a cowboy nightclub. This has a picture of a cowboy-hatted woman wearing a denim miniskirt and halter top and suggests if you visit said club, you will get the ride of your night with this or similar women.

The sad reality:

1. Women like that rarely go to bars that you go to.
2. If they do;
a) they are not interested talking to you or dancing with you. They are most definitely not interested in having sex with you.
b) they most likely are accompanied by a muscle bound boy-friend who, if you are lucky, will only beat you up if you look at her the wrong way.

I just thought I should straighten this out.

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.

My Diary

It seems funny that I am exposing my thoughts on the internet. Maybe not my innermost thoughts but still my thoughts albeit under a pseudonym.

It reminds me of the diaries I kept as a child as a teenager.

I got one of those diaries for Christmas when I was ten. I think I may have asked for it. I think I wrote in it for a few weeks. My parents had the views that if you had nothing to hide you didn't need privacy which meant everybody in the family was allowed to read it, which they did. One of my brothers even wrote in corrections if his version of events was different from mine. I think that was why I stopped writing in the diary. We also had to keep a diary as a project in Grade VI and my mother kept it and presented it to me on the occasion of my 25 high school anniversary.

In Grade X, I was thinking that a lot of really interesting if trivial things happened every day and I would forget them if I didn't write them down. I also decided I should write everything down which of course included things I really didn't want me parents or brothers to read.

I kept the diary in an ordinary school notebook and hid it in plain sight in my room figuring no one would look in one of my school notebooks. This actually worked and nobody read it until in Grade XI, my little brother discovered the book and read it.

Now nothing about my high school life was controversial except that I had the hots for a certain girl which I wrote about extensively in the diary. Needless to say my little brother bugged my continuously about this.

Anyway I ended up destroying two notebooks of my diary and never kept a diary again. Until now; sort of.

Is it time to regulate real estate?

One of the more prescient things I have done financially was to buy a house, a vacation property and more recently some rental properties. Consequently much of my net worth is now real estate.

Real estate prices are now thru the roof and expected to rise. It has gotten to the point where even in situations where both of a couple work, they cannot afford a house.

Of course banks are being very understanding, offering low interest rates and low or no down payment.

While my house is now worth the high six figures, this is fine except that I have to find a place to live. If my wife and I wish to downsize to a condo or move somewhere where Real Estate isn't ski high we might realize a modest tax-free profit. On the other hand, I lie awake at night thinking about how much capital gains tax I will have to pay on my vacation house.

What is more concerning is the amount of debt that is tied up in these highly valued homes. These homes are only worth something if you can find somebody who can pay what you want and I can see a time where people are just going to accept the fact that they will be renters for the rest of their lives. This is going to result in a glut of houses with an innevitable crash in prices. Those of us who have fully paid off their mortgages won't suffer too much except the loss of money we never really had. I worry about those with high mortgages who now owe more than their house can be sold for and the ripple effect on the economy. One thing is certain, it won't be the banks that suffer.

It seems that the real estate explosion is certainly being sustained by two factors; people who speculate or flip houses and the real estate industry who benefit from house transactions.

I read somewhere that back in the 70s when house prices rose in Ontario to the unprecedented high of $50K, the "socialist" government of Bill Davis put the brakes on this. It was quite simple, they put a wind-fall profit tax on flipping houses. If you sold your house in the first year, you paid 90% of the profit, 80% in the second year etc. This would put a brake on flipping properties which is a major factor driving price upwards.

Secondly Real Estate commissions have to be capped. The commission is essentially a built-in inflationary factor. Just to break even if you sell your house, you have to charge what you paid plus the commission which is usually now greater than 10K. When you think about it does the realtor really earn 10+K. Not on your life. Selling houses is easy now with listings on the Internet. Our last lot was found on the net, we bought it and the agent collected a commission basically for answering the phone. Our lawyer did more work and only got about $1000. Imagine somebody making more than a lawyer!

Why not cap commissions at $1000 or some sensible figure.

I should also mention, the Realtor does not necessarily have your best interests in mind when you sell your house. According the book Freakonomics, Realtors who sold their own house consistently sold them for more than their clients' equivalent houses.

Little Things That Piss Me Off 2

I went skiing last weekend.

Have you ever noticed that people wait for their friends in the line-up. This means you have to either step around them with your skis on or ask them if they actually intend to board the chair.

WAIT FOR YOUR FRIENDS OUTSIDE THE ROPE!!!!

Cell phones in ears

Do people who wear those cell phones in their ears know how utterly stupid they look?. Or do they just feel so important that they can't risk missing a call by having to fumble to get their cell phone off their belt or out of their pocket.

Rate MDs.com

I heard about this new site where patients could rate their docs. I practise chronic pain medicine so I was a little curious about how people saw me.

Not surprisingly somebody had already rated me and she was not happy. There was however only one post and so I am hoping somebody else who is happy with me will actually post although I am not holding my breath and I haven't sunk as low as asking people to please post so my rating will go up (not that it hasn't crossed my mind).

I have pissed off a lot of people in the last few years and I would like to appologize.

1. Sorry I wouldn't prescribe any more narcotics for you after your third positive drug screen. I really didn't care that you were using crystal meth and coke, I was curious how you were paying for them.

2. Sorry I wasn't that interested in hearing how great your insert alternate health provider here is and how stupid every other doctor was. I just knew that you were going to add me to that list within a few months.

3. Sorry I didn't know what drugs you were on when you didn't bring a list and your doctor didn't send one with his referral. I should have known what that green pill was and besides doctors are part of a collective consciousness.

4. Sorry if I wasn't sympathetic on the phone when you called in the middle of a busy clinic after missing your last two appointments.

5. Sorry I didn't spend a lot of time with you after I squeezed you in at the request of your GP in front of a year's worth of patients.

6. Sorry that WCB doesn't jump to my commands. Maybe you should clue into the fact that you really don't need a doctor, you need a lawyer.

7. Sorry your condition was not diagnosed or treated by the seven doctors who saw you before me. Now can you try to get on with you life and let me make some suggestions that might actually help you.

8. Sorry that you quit school to work on the oil rigs and now your days of six figures are over due to your back injury.

I'm sure I will think of some more things to appologize for. After all I AM CANADIAN.

Little things people do that piss me off 1

1. At intermission last Friday we stood in line for drinks for most of the intermission. When they announced 5 minutes to go, we were one person from the front. The person in front of us then pulled out his Interac card to pay for his drink. When people are waiting behind you pay cash!!!!!

2. Many restaurants buy a copy of the newspaper for their patrons to read with their breakfast. Why do some people, instead of just taking one section, insist on taking the whole paper to their table so nobody else in the restaurant can read it.

Coat checks and Valet Parking

I normally try to remember that most people in the service industry make what less than I do, work harder and generally have a worse life, so I try to be nice to them no matter how much they are pissing me off.

When you give your coat or your car to someone to look after and money changes hands there is a contract formed.

Last Friday I went to a musical and checked my wifes and my coats along with a plastic bag containing our winter shoes (we follow the local custom of changing into our indoor shoes at the door). I told them to hang the bag up on the hanger with the coats and they gave us two tags.

At the end of the show, I stood in line and handed in my two tags and they gave me my wife's coat and our bag of shoes. I told them I had another coat coming and they said no you only have 2 tokens. I told them they only gave me two tokens and that I could point out my coat to them. They said I would have to wait until everybody else had picked up their coats which I did and they gave me my coat. Now I was a little irrated as it was late and I still had a half hour walk home and I may have showed it. The coat check person looked at me like I was a total asshole. I'm sorry I gave you my coat and you lost it.

A couple of months ago I parked in valet parking at the airport. This is a little indulgence I give myself. When I come back from somewhere, the last thing I want after waiting an hour for my baggage is to walk thru the parking lot or wait for the shuttle. Besides usually I can write it off or somebody else is paying.

Anyway, I get back and head to the desk and ask for my car which is supposed to be parked outside as I gave them my flight number and time when I dropped it off. The lady stares blankly at me and starts to shuffle paper, and tells me they have no record of my car. More staff gather and I hear ,"I think somebody already picked it up". I think of shit, somebody has stolen my car. After about 10 minutes of watching the staff shuffle paper and whisper, I notice somebody driving my car up to the valet parking. So I say, "Look here is my car".

As I felt that they hadn't really fulfilled the valet part of the contract, I picked up my keys and left without paying. I later phoned the head of parking at the airport who agreed with me and I didn't have to pay for parking.

Bad Karma

I was thinking this morning about some of the people who had done me wrong in the past and all the bad things that happened to them. I like to think it was as the result of the bad karma.

My Grade XI locker partner used to steal my lunch. He didn't steal my sandwiches or fruit, just the cookie. At first I thought my mom had just stopped putting them in because I was too fat. Then one day she asked how I liked the sweet she put in. We figured out it was him. Stapling the bag shut solved the problem. Years later he was swept off a fishing boat and lost at sea.

Dr. A. was an doctor whose clinic I joined. He was very friendly when they were trying to recruit me. After a brief honeymoon period he and his other partner treated me like shit for six months after which we parted company somewhat acrimoniously. He died of a heart attack 6 months later.

Dr. K. interned with me. We did obstetrics at the same hospital for the same two months. At this hospital you were preceptored with two gynies for the two months (one each 4 weeks). She got the two good preceptors, I got the two bad preceptors. I would have thought that this was bad luck but it turned out that she had learned before the rotation who she was getting, who were the two I eventually got and arranged to have the preceptors switched. I never would have known this if she hadn't told me. She was struck down with a pulmonary embolus about 7 years ago.

There are probably some examples I don't know about yet.

Like I say don't mess with me.