Wednesday, November 14, 2007

Picking Cherries

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

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.

Tuesday, November 13, 2007

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.

Wednesday, November 7, 2007

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).

Friday, November 2, 2007


It is nice to know that somebody actually reads my blog as I got an email last month regarding my posts regarding 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.