About a month after the unpleasant incident in the ICU, I was on call for the acute pain service.
At the CofE, all patients who are receiving patient controlled analgesia (PCA) have to have the orders written by anaesthesia and are rounded on daily by the acute pain service. In addition, any problems like inadequate analgesia and side effects are also dealt with by the APS, 24 hours a day, 7 days a week. Further the staff anaesthesiologist on the APS, not the resident fields all the calls.
When the service started in the early 1990s the only way PCA could be sold to the surgeons and nurses was to have this arrangement. It was also felt that the additional after hours calls would be an unacceptable burden on the residents so the staff took the calls. This is probably the only service at the CofE where you make a page and a staff physician calls back. The other reason for this arrangement is financial. In order to make it worthwhile financially it is necessary to bill for consults and visits on otherwise uncomplicated PCA cases.
For practical purposes the PCA orders are written by the anaesthesiologist who does the case and rounded on the the APS doctor. ICU cases are different in that PCA orders are normally not written and the patient is often not started on PCA until days after their surgery when they are stable and ready to be extubated. This means that the APS may be called at awkward times to start somebody on PCA. Most of us, would phone in orders rather than making a special visit to the hospital. It is relatively safe, ICU patients are usually still on a ventilator, have full monitoring and one on one nursing.
So it was that one evening after I had left the hospital I got a call from the ICU about a face-off patient, who they wanted to start on PCA. I phoned, identified myself, asked the nurse some questions about the patient and start to give verbal orders. At that point she asked me "are you giving my orders". I am a bit sarcastic and said, "No I have nothing better to do than phone you.....of course I am giving you orders". I gave the orders, she repeated them back to me. She then asked if I had anything to add and I said no and hung up. We rounded on the patient the next morning and there were no problems.
Why do I even remember this case?
Two weeks later I was forwarded a letter of complaint from the nurse. In it she complained that:
1. I failed to identify myself (how did she know who to complain about).
2. I made her answer questions about the patient on the phone.
3. I gave verbal orders on a patient I didn't know anything about.
4. I was sarcastic (guilty)
5. I almost made her cry.
6. When she asked if I had anything else to add, I simply said no. (guilty).
7. That I still had a grudge against ICU because of the incident I had been involved in weeks earlier. (Not true I am always nasty on the phone)
Now when I read the letter, I couldn't even remember the conversation, but by checking the time and date against my day timer, and because the phone call happened while I was waiting for medical appointment I was able to put together the conversation.
I wrote a letter to my chief stating that I felt that what I had done was both common and good medical practice; that I had not intended to threaten or belittle her and that under the circumstances I did not see any need to apologize.
A couple of days I got a phone call from my very "supportive" chief. This gist of the conversation was, "I see your point BH but this is a sexual harassment complaint and you know you can't win those so you better apologize".
Now the ludicrous thing about this was that the nurse also had to apologize to me for saying that I had acted as I had because of an old grudge against the ICU. So even after writing my letter of apology, the apology score was still BH 2 ICU 1.
Now this was the last year I was at the CofE and I had started to look at other hospitals by that time. Curiously I remember that around that time, I had decided that despite everything I figured I would just stay at the CofE. After this event, I told my chief that this was the last straw and I would be leaving. It was less the complaint, than the complete reluctance of him to support me that really pissed me off.
A month later I got an offer from another hospital and I no longer work at the CofE.
Sunday, December 28, 2008
Saturday, December 13, 2008
Allergies
One of the things we do in the OR in the name of patient safety is the "time out". This is not sending the surgeon to sit in the corner for 5 minutes although that would not necessarily be a bad thing. What we do in the timeout is before the surgeon cuts skin, a nurse reads out what the patient has actually signed the consent for, what side we are operating on and what allergies the patient had.
A few weeks ago I put a lady to sleep for a D+C. She had a few allergies which the nurse read out including epinephrine. "Let me guess", said the surgeon," it makes her heart beat fast". "Yes", said I who had actually talked to the patient, "that is what happened to her". And we had a good laugh. And as I told the surgeon, this is not the first epinephrine allergy I have seen in my career.
Of course we all know what probably happened. She went to the dentist and a little local with epi went into a vessel, she got tachycardic and the dentist instead of saying mea culpa, told her she was allergic to epinephrine. And it goes on her chart.
I barely understand immunology, histamine or IgE so I don't really expect patients to understand allergies either. What we in the medical field have failed to explain to patients is the difference between an allergy to a drug which means you must never ever have the drug again and an adverse reaction which means you may not want to have the drug again but can have.
An important distinction with patients "allergic" to local anaesthetics after misadventures in the dental chair, to penicillin because they got a yeast infection, to anaesthetics because they got sick. All these go on the chart however as if they really were allergies.
My personal favourite is the patient who came to the OR which a lactose "allergy" who requested she not be given Ringer's lactate. I tried to explain that while I normally used normal saline, that lactate and lactose had very little in common and that she could if necessary get Ringer's lactate. She was however adamant and probably still tells the story of the stupid anaesthesiologist who wanted to give her Ringer's lactate even though she told him she was allergic to lactose.
We also have the "latex allergy. I don't doubt for a second that some patients have a true anaphylactic reaction to latex. Most of the latex allergies however are patients who got a rash from wearing rubber gloves or as one patient when I asked what happenned with latex told me, "we were just told avoid it as a precaution". When I did this last patient, the surgeon yelled at me because I used a latex penrose drain over his gown in order to start his IV.
As more of our supplies are now latex free (at probably considerable extra cost) this is less of the problem. When I worked at the CofE, latex allergy meant stripping the room of everything that could possibly have ever come into contact with latex. On several occasions the casual mention by the patient that he might be allergic to latex on entering the room resulted in having to discard the entire set-up for a latex free set-up delaying the start of the case by up to an hour.
A few weeks ago I put a lady to sleep for a D+C. She had a few allergies which the nurse read out including epinephrine. "Let me guess", said the surgeon," it makes her heart beat fast". "Yes", said I who had actually talked to the patient, "that is what happened to her". And we had a good laugh. And as I told the surgeon, this is not the first epinephrine allergy I have seen in my career.
Of course we all know what probably happened. She went to the dentist and a little local with epi went into a vessel, she got tachycardic and the dentist instead of saying mea culpa, told her she was allergic to epinephrine. And it goes on her chart.
I barely understand immunology, histamine or IgE so I don't really expect patients to understand allergies either. What we in the medical field have failed to explain to patients is the difference between an allergy to a drug which means you must never ever have the drug again and an adverse reaction which means you may not want to have the drug again but can have.
An important distinction with patients "allergic" to local anaesthetics after misadventures in the dental chair, to penicillin because they got a yeast infection, to anaesthetics because they got sick. All these go on the chart however as if they really were allergies.
My personal favourite is the patient who came to the OR which a lactose "allergy" who requested she not be given Ringer's lactate. I tried to explain that while I normally used normal saline, that lactate and lactose had very little in common and that she could if necessary get Ringer's lactate. She was however adamant and probably still tells the story of the stupid anaesthesiologist who wanted to give her Ringer's lactate even though she told him she was allergic to lactose.
We also have the "latex allergy. I don't doubt for a second that some patients have a true anaphylactic reaction to latex. Most of the latex allergies however are patients who got a rash from wearing rubber gloves or as one patient when I asked what happenned with latex told me, "we were just told avoid it as a precaution". When I did this last patient, the surgeon yelled at me because I used a latex penrose drain over his gown in order to start his IV.
As more of our supplies are now latex free (at probably considerable extra cost) this is less of the problem. When I worked at the CofE, latex allergy meant stripping the room of everything that could possibly have ever come into contact with latex. On several occasions the casual mention by the patient that he might be allergic to latex on entering the room resulted in having to discard the entire set-up for a latex free set-up delaying the start of the case by up to an hour.
Monday, December 1, 2008
My sexual harassment complaint
I have thought for a long time about publishing this account.
If you read my blog, you will probably get the impression, that I don't suffer fools gladly, and that I occasionally and often unintentionally stir up shit.
Now in case I go into politics, I would like to state that anybody who uses their authority including their sexual gender to bully or disadvantage somebody is a complete slime bucket. I am sure most people share this revulsion. It is however this revulsion that makes accusations of sexual harassment so potent.
I am male and a doctor. Most nurses are female ( a significant number of ICU nurses are male though). Doctors who are mostly male are higher on the hospital food chain than nurses (although as a student and resident I fequently questioned this). In the hospital the relationship between doctors and nurses is often one of tension. Part of this is a good thing. If either side automatically deferred to the other, it would be to the detriment of the patient.
Now, when I first started working at the Centre of Excellence, it was pretty obvious that there was some real bad blood between anaesthesia and the ICU nurses. Everywhere I worked there has been some sort of tension; I think ICU nurses resent anaesthetists who aren't intimidated by all the machines and lines in the ICU. The first time I dropped a patient off in the ICU, one of the nurses asked, "Who is the idiot who sutured in this central line?". I told her I was the idiot and waited for the apology which never came. Anyway it seemed for the first few years all we talked about at staff meetings was the steady stream of complaints: ETT not taped in correctly, line tangled, O2 cylinder empty, patient brought into ICU at inconvenient time for them, and, incredibly, an accusation of billing fraud by anaesthesia. After a while it seemed like things got better but I suspect it was just that things that used to piss me off didn't matter any more and I just learned to do things that wouldn't piss them off. Sort of like a bad marriage.
Sorry that this is taking so long to get to the point but I have to give the background.
About a month before the event in question I took a patient back to the ICU after a major head and neck case. We called these face-offs and they usually last at least 16 hours. This one however had been done once before and only took 8 hours so we took the patient back to the ICU around 1600 hours. When you take a freshed trached, ventillated patient back to the ICU, it is a lot more complicated for anaesthesia than just taking a patient back to the RR. While the CofE does at least 3 of these cases a week, it seems like every time I take a patient back to the ICU it is like they have never done it before. I have to ask for a transport monitor, ambu bag and oxygen cylinder. I'm not sure whether my colleagues just take their patients back to the ICU apneic and unmonitorred. I have to usually connect the monitors, zero the art line, make sure the lines aren't tangled or pulled out during the move. I also have to make sure the patient doesn't wake up on the way to the ICU. In short phoning the ICU to tell them we are on the way, is low on my priority list and something I figure someone else can do. Besides at the CofE when a patient goes to the ICU, an orderly actually goes over there to get the bed so that the patient doesn't have to transferred twice. Sort of a warning that we're coming pretty soon.
Now I don't know whether somebody from the OR phoned the ICU that day. It was apparent when we arrived that they weren't ready for us. For example there wasn't a ventillator.
The second clue that they weren't expecting us was the arrival of the charge nurse into the room where I was ventillating the patient by hand while waiting for the RT and ventillator to arrive. She unleashed a string of invective at me which lasted at least 5 minutes. The jist was that I alone of all the people involved in the case should have phoned the unit.
Now I am married and went to medical school, internship and residency in the 1980s so I have had my share of public tongue lashings and maybe I should have just said sorry and slunk out but on this particular day, I felt that a line had been crossed.
After the ventillator arrived. I walked out in the corridor approached the charge nurse, took her to an out of the way part of the ward and told her that her behaviour was entirely innappropriate and that I expected an apology. She refused.
So, I wrote a letter.
About a week later, the unit supervisor phoned me to tell me that she had a investigated the incident, that what I said happened had actually happened, that it was not appropriate, and that the nurse in question would be writing me a letter of apology which I received in due course.
To be continued......
If you read my blog, you will probably get the impression, that I don't suffer fools gladly, and that I occasionally and often unintentionally stir up shit.
Now in case I go into politics, I would like to state that anybody who uses their authority including their sexual gender to bully or disadvantage somebody is a complete slime bucket. I am sure most people share this revulsion. It is however this revulsion that makes accusations of sexual harassment so potent.
I am male and a doctor. Most nurses are female ( a significant number of ICU nurses are male though). Doctors who are mostly male are higher on the hospital food chain than nurses (although as a student and resident I fequently questioned this). In the hospital the relationship between doctors and nurses is often one of tension. Part of this is a good thing. If either side automatically deferred to the other, it would be to the detriment of the patient.
Now, when I first started working at the Centre of Excellence, it was pretty obvious that there was some real bad blood between anaesthesia and the ICU nurses. Everywhere I worked there has been some sort of tension; I think ICU nurses resent anaesthetists who aren't intimidated by all the machines and lines in the ICU. The first time I dropped a patient off in the ICU, one of the nurses asked, "Who is the idiot who sutured in this central line?". I told her I was the idiot and waited for the apology which never came. Anyway it seemed for the first few years all we talked about at staff meetings was the steady stream of complaints: ETT not taped in correctly, line tangled, O2 cylinder empty, patient brought into ICU at inconvenient time for them, and, incredibly, an accusation of billing fraud by anaesthesia. After a while it seemed like things got better but I suspect it was just that things that used to piss me off didn't matter any more and I just learned to do things that wouldn't piss them off. Sort of like a bad marriage.
Sorry that this is taking so long to get to the point but I have to give the background.
About a month before the event in question I took a patient back to the ICU after a major head and neck case. We called these face-offs and they usually last at least 16 hours. This one however had been done once before and only took 8 hours so we took the patient back to the ICU around 1600 hours. When you take a freshed trached, ventillated patient back to the ICU, it is a lot more complicated for anaesthesia than just taking a patient back to the RR. While the CofE does at least 3 of these cases a week, it seems like every time I take a patient back to the ICU it is like they have never done it before. I have to ask for a transport monitor, ambu bag and oxygen cylinder. I'm not sure whether my colleagues just take their patients back to the ICU apneic and unmonitorred. I have to usually connect the monitors, zero the art line, make sure the lines aren't tangled or pulled out during the move. I also have to make sure the patient doesn't wake up on the way to the ICU. In short phoning the ICU to tell them we are on the way, is low on my priority list and something I figure someone else can do. Besides at the CofE when a patient goes to the ICU, an orderly actually goes over there to get the bed so that the patient doesn't have to transferred twice. Sort of a warning that we're coming pretty soon.
Now I don't know whether somebody from the OR phoned the ICU that day. It was apparent when we arrived that they weren't ready for us. For example there wasn't a ventillator.
The second clue that they weren't expecting us was the arrival of the charge nurse into the room where I was ventillating the patient by hand while waiting for the RT and ventillator to arrive. She unleashed a string of invective at me which lasted at least 5 minutes. The jist was that I alone of all the people involved in the case should have phoned the unit.
Now I am married and went to medical school, internship and residency in the 1980s so I have had my share of public tongue lashings and maybe I should have just said sorry and slunk out but on this particular day, I felt that a line had been crossed.
After the ventillator arrived. I walked out in the corridor approached the charge nurse, took her to an out of the way part of the ward and told her that her behaviour was entirely innappropriate and that I expected an apology. She refused.
So, I wrote a letter.
About a week later, the unit supervisor phoned me to tell me that she had a investigated the incident, that what I said happened had actually happened, that it was not appropriate, and that the nurse in question would be writing me a letter of apology which I received in due course.
To be continued......
Monday, November 17, 2008
Akela
I recently posted about my old scout master who probably was a pedophile and why we might not have seen the warning signs. The fact is there was somebody in our scouting community who was even weirder.
I talk about Akela. If you are unfamiliar with cubs; leaders in cubs are given names from Kipling's Jungle Book series. The head honcho is Akela, then it goes down the chain Baloo, Baghera, etc.
Our scout group at the tail end of the baby boom had enough cubs to make up two packs. These were known as A pack and B pack. Today there would be a stigma about being in B pack which is the pack my brothers and I went through. There wasn't then although A pack was clearly superior in every way. It was all attributable to their Akela. (Our pack had an Akela too , actually we had 2 different ones during the time I was a cub).
Akela was a 50ish gentleman, unmarried who lived with his mother. (Sound familiar?). She helped out with his cub pack and was given the title of Raksha. I'm not sure where in the hierarchy comes Raksha. She died sometime while I was still in cubs. Akela was born in England and had been an instructor at the military college but had retired early. I suspect there was some money in his family.
Our area of Victoria was by no means the slums, in fact it was probably the most affluent area of Victoria, however there were clear class differences. "A" pack were definitely a higher class of cub. Many of them had hyphenated names, quite a few of them went to private school, some had faux English accents. My mother when it was time for me to go into cubs for some reason tried to get me into "A" pack. She phoned Akela, who was quite positive until he asked her what school I went to. She told him and he made some lame excuse about why I couldn't be in his pack and I went into "B" pack. Apparently I came from the less right side of the tracks.
One of the ordeals of my cub career was the twice yearly soccer game against "A" pack. For the most part this meant getting thoroughly annihilated. One game we only had 10 players so "A" pack lent us their worst player who scored our only goal. Once we tied them which was a huge moral victory. After I left cubs, our Akela (Bkela?) got sick of being beaten and brought in ringers, kids who could actually play soccer and the beatings ended. They also beat us in softball and in floor hockey.
Overall even when at the time, it appeared that "A" pack was better organized and had a lot more fun than we did in "B" pack. Partially this was because Akela was retired and had time to do stuff, unlike our Akela who was just a parent of one of the cubs and had other commitments like a job. For example during the 3 summers I was in cubs we only had one summer camp because our Akela couldn't get the time off from work.
Which of course brings me to camp. Akela owned a large property about 30 minutes away. We camped there in Scouts and it was a fantastic location. It was wooded and a small river ran through it which was wide enough and deep enough to swim and dive it. Akela had built some tent platforms and a small building and his cub pack went out there a couple of times a year for a camp.
Once a year, "A" pack had a little party and slide show on a Saturday. One year my mother was asked to bake some squares and help out at the party (apparently A pack mothers didn't bake). She asked me if I wanted to come along, so I did, mostly so I could have some of her squares. Therefore I got to watch the slide show.
Aside from the slides documenting their humiliations of "B" pack on the soccer field, there were a number of slides of the camps out at Akela's property. Most of these slides were of the cubs swimming and it was quite apparent that nobody was wearing bathing suits. No they weren't swimming fully clothed, they were naked. Watching this slide show, were all the cubs parents, sisters, and who know how else.
And nobody thought this was unusual.
Now none of these pictures were graphic although you could see lots of pre-adolescent genitalia.
When I went to Scouts I got to know many of these cubs and it was something most people just laughed about. Apparently Akela and his mother strongly believed that swimming naked was in some way character building. Nobody ever said they had been touched inappropriately although it isn't something you bring up. Some people admitted to being embarrassed because girls in their class at school attended the slide show.
A few years later, one of the parents attended the slide show; complained and the skinny dipping stopped.
A few years later, Akela started up another cub pack labelled "C" pack who were children from a disadvantaged area of town. Every afternoon after school he would pick them up in the panel van our group had bought and drive them to and from the scout hall. He was trying to give them the same experience as his upper crust kids were getting. After a year or so, he went and asked the "group committee" would administered our group and raised funds for $10.00 for a party for his "C" pack. They turned him down and he resigned as Akela of "A" pack. I believe he continued on with "C" pack for a while after.
I was actually there the day he resigned. I was in Venturers and somebody had asked me if I could help out with his cub pack so I agreed. I suspected he was a bit of a pervert even then but I had talked to him a few times over the years and had sort of come to like and respect him. I helped out for about 2 months and had a lot of fun. He really liked his kids and he may have been a little tactile but never in the danger zones.
After he resigned, his pack went thru several leaders and probably folded. Things weren't the same.
He later donated his land to the local Scouts.
Again single man, lives with his mother, takes pictures of naked boys. Eccentric, that's all we thought in the 1960s.
I talk about Akela. If you are unfamiliar with cubs; leaders in cubs are given names from Kipling's Jungle Book series. The head honcho is Akela, then it goes down the chain Baloo, Baghera, etc.
Our scout group at the tail end of the baby boom had enough cubs to make up two packs. These were known as A pack and B pack. Today there would be a stigma about being in B pack which is the pack my brothers and I went through. There wasn't then although A pack was clearly superior in every way. It was all attributable to their Akela. (Our pack had an Akela too , actually we had 2 different ones during the time I was a cub).
Akela was a 50ish gentleman, unmarried who lived with his mother. (Sound familiar?). She helped out with his cub pack and was given the title of Raksha. I'm not sure where in the hierarchy comes Raksha. She died sometime while I was still in cubs. Akela was born in England and had been an instructor at the military college but had retired early. I suspect there was some money in his family.
Our area of Victoria was by no means the slums, in fact it was probably the most affluent area of Victoria, however there were clear class differences. "A" pack were definitely a higher class of cub. Many of them had hyphenated names, quite a few of them went to private school, some had faux English accents. My mother when it was time for me to go into cubs for some reason tried to get me into "A" pack. She phoned Akela, who was quite positive until he asked her what school I went to. She told him and he made some lame excuse about why I couldn't be in his pack and I went into "B" pack. Apparently I came from the less right side of the tracks.
One of the ordeals of my cub career was the twice yearly soccer game against "A" pack. For the most part this meant getting thoroughly annihilated. One game we only had 10 players so "A" pack lent us their worst player who scored our only goal. Once we tied them which was a huge moral victory. After I left cubs, our Akela (Bkela?) got sick of being beaten and brought in ringers, kids who could actually play soccer and the beatings ended. They also beat us in softball and in floor hockey.
Overall even when at the time, it appeared that "A" pack was better organized and had a lot more fun than we did in "B" pack. Partially this was because Akela was retired and had time to do stuff, unlike our Akela who was just a parent of one of the cubs and had other commitments like a job. For example during the 3 summers I was in cubs we only had one summer camp because our Akela couldn't get the time off from work.
Which of course brings me to camp. Akela owned a large property about 30 minutes away. We camped there in Scouts and it was a fantastic location. It was wooded and a small river ran through it which was wide enough and deep enough to swim and dive it. Akela had built some tent platforms and a small building and his cub pack went out there a couple of times a year for a camp.
Once a year, "A" pack had a little party and slide show on a Saturday. One year my mother was asked to bake some squares and help out at the party (apparently A pack mothers didn't bake). She asked me if I wanted to come along, so I did, mostly so I could have some of her squares. Therefore I got to watch the slide show.
Aside from the slides documenting their humiliations of "B" pack on the soccer field, there were a number of slides of the camps out at Akela's property. Most of these slides were of the cubs swimming and it was quite apparent that nobody was wearing bathing suits. No they weren't swimming fully clothed, they were naked. Watching this slide show, were all the cubs parents, sisters, and who know how else.
And nobody thought this was unusual.
Now none of these pictures were graphic although you could see lots of pre-adolescent genitalia.
When I went to Scouts I got to know many of these cubs and it was something most people just laughed about. Apparently Akela and his mother strongly believed that swimming naked was in some way character building. Nobody ever said they had been touched inappropriately although it isn't something you bring up. Some people admitted to being embarrassed because girls in their class at school attended the slide show.
A few years later, one of the parents attended the slide show; complained and the skinny dipping stopped.
A few years later, Akela started up another cub pack labelled "C" pack who were children from a disadvantaged area of town. Every afternoon after school he would pick them up in the panel van our group had bought and drive them to and from the scout hall. He was trying to give them the same experience as his upper crust kids were getting. After a year or so, he went and asked the "group committee" would administered our group and raised funds for $10.00 for a party for his "C" pack. They turned him down and he resigned as Akela of "A" pack. I believe he continued on with "C" pack for a while after.
I was actually there the day he resigned. I was in Venturers and somebody had asked me if I could help out with his cub pack so I agreed. I suspected he was a bit of a pervert even then but I had talked to him a few times over the years and had sort of come to like and respect him. I helped out for about 2 months and had a lot of fun. He really liked his kids and he may have been a little tactile but never in the danger zones.
After he resigned, his pack went thru several leaders and probably folded. Things weren't the same.
He later donated his land to the local Scouts.
Again single man, lives with his mother, takes pictures of naked boys. Eccentric, that's all we thought in the 1960s.
Role Models
One of the questions I ask prospective residents when I interview them is, "who are your non-medical role models?" Just to get them talking, nothing at all to do with their potential as an anaesthesiologist.
I have recently asked myself, who were my role models?
I can think of a few, my parents, a few teachers and....
My old scout master.
Scouting was a huge part of my childhood and adolescence. I was in Cubs, Scouts and Venturers from the time I was 8 until I graduated from high school. The most formative years were however from 11-14 when I was in scouts.
Our scout master liked to be called by his first name. In the 1960s having an adult who let non-adults call him anything other than Mr. was unusual. His first name was Dave and I will call him that for the rest of this blog.
Dave was born in England and had moved to Canada with his parents as a young adult. He was still not married and lived with his parents. Dave ran the scout troop. Other adults and few older teenagers helped out from time to time but it was Dave's show.
We had our meetings every Thursday evening. These were incredibly well organized evenings chock full of several interesting activities all planned by Dave. Every Saturday morning he came to the scout hall for those of us who wanted to pass tests or earn badges. Every couple of months we had a hike on a Saturday or Sunday. We also had weekend camps about three times a year and in the summer we had a 9 day camp in the mountains.
Dave was a real hiking and camping enthusiast. He was big into light weight camping where you packed in all your gear. The idea was to be as comfortable as possible while still carrying in almost everything. We often had over 30 people per camp so every camp was a major military operation supervised by Dave.
Periodically we had "wide games" which were huge operations based on variations of "capture the flag" or a treasure hunt. These were also elaborately organized and some of them must have taken days to set up.
Dave's effect on the troop was such that our troop had over 40 scouts at a time when Scout troops all over the area were folding.
Dave also helped out perioidically with the Venturers, was involved in the local hiking club and was involved as a Big Brother.
Dave was soft spoken, when not in scout uniform (which he wore with short pants and knee socks) he was always well dressed. There was a story that he broke up with a rare girlfriend because she wore jeans to his parents house. He drove a Rover. He was an enthusiastic landscape photographer and had an SLR camera which weren't very common in the 1960s (and was the first thing I purchased when I finally had money). If you had a problem, he was always willing to talk things out and could be very philosophical.
As I said he was a huge influence on my life. I wish I could say that this was the start of a life-long commitment to camping, hiking and mountaineering; sadly while I enjoy looking at mountains, I don't really like climbing and I enjoy my bed too much.
I went up to Venturers at 15 (I stayed an extra year in Scouts, I liked it so much). About a year later, Dave who worked for the government was transferred to another town. He got right into the local Scouting movement and the next summer his new troop had a joint summer camp with his old troop.
I last saw him when I was 20. I was coming home for a break from my summer work and was on the ferry home. He was also visiting his parents. We sat together and talked for the whole trip. It was like two old friends talking together. I have never seen him since.
I went to medical school, kicked around in various places in Canada and I was living in Eastern Canada when I heard that he had been charged and pleaded guilty to sexually abusing one of his scouts. He spent some time in prison. I was out of the province so I missed any media coverage and I have lost contact with just about all of my scouting buddies. I have talked it over with my older brothers who preceded my in Scouts. One says there is no way he was guilty; the other says, of course he was guilty. My father believes he pleaded guilty in order to prevent the child who accused him from having to testify and be cross-examined. I have a hard time believing anybody would willingly go to jail as pedophile.
Now looking back, maybe it should have been obvious. We have a quiet soft spoken man who lives with his parents, is heavily involved in Scouting and Big Brothers, doesn't have a girlfriend, and likes to take pictures. Perfect profile of a pedophile? This was the 1960s; there were lots of men like him and they were largely respected in the community. When I was writing this blog, I googled him and all I could find a was an award for distinguished service to scouting in 1969.
All I can say is he never touched me (maybe I was lucky) and I never ever heard anything untoward about him from any of my friends although being diddled by your scoutmaster isn't something teenagers brag about. One time in Venturers we were hiking up in the mountains and we came across him camping with his Little Brother. In 1973 we didn't think that was unusual.
About 5 years ago our scout troop had a reunion. It was on a weekend and while I wasn't working, it would have meant flying there so I didn't go. I just thought it would be a whole lot of people I had nothing in common with anymore trying to make conversation. The whole uneasiness about Dave played a role. One of my brothers attended and said it was a lot of fun and that Dave was there.
About a month later, I got a letter from Dave. He said that he was now retired and living with his wife(!) on one of the Gulf Islands. I meant to write hime back to tell him what a good role model he had been for me but the letter disappeared into a black hole on my desk and I never did write the letter. I lost his address too.
I attended a workshop on hypnosis last spring and we talked about forgiveness. The speaker said it is possible to forgive somebody without condoning what they did. I cannot condone anybody who uses a position of authority to hurt somebody, especially a child. I can forgive him however for what he did to that child and for the doubts he has raised about my whole Scouting experience.
I have recently asked myself, who were my role models?
I can think of a few, my parents, a few teachers and....
My old scout master.
Scouting was a huge part of my childhood and adolescence. I was in Cubs, Scouts and Venturers from the time I was 8 until I graduated from high school. The most formative years were however from 11-14 when I was in scouts.
Our scout master liked to be called by his first name. In the 1960s having an adult who let non-adults call him anything other than Mr. was unusual. His first name was Dave and I will call him that for the rest of this blog.
Dave was born in England and had moved to Canada with his parents as a young adult. He was still not married and lived with his parents. Dave ran the scout troop. Other adults and few older teenagers helped out from time to time but it was Dave's show.
We had our meetings every Thursday evening. These were incredibly well organized evenings chock full of several interesting activities all planned by Dave. Every Saturday morning he came to the scout hall for those of us who wanted to pass tests or earn badges. Every couple of months we had a hike on a Saturday or Sunday. We also had weekend camps about three times a year and in the summer we had a 9 day camp in the mountains.
Dave was a real hiking and camping enthusiast. He was big into light weight camping where you packed in all your gear. The idea was to be as comfortable as possible while still carrying in almost everything. We often had over 30 people per camp so every camp was a major military operation supervised by Dave.
Periodically we had "wide games" which were huge operations based on variations of "capture the flag" or a treasure hunt. These were also elaborately organized and some of them must have taken days to set up.
Dave's effect on the troop was such that our troop had over 40 scouts at a time when Scout troops all over the area were folding.
Dave also helped out perioidically with the Venturers, was involved in the local hiking club and was involved as a Big Brother.
Dave was soft spoken, when not in scout uniform (which he wore with short pants and knee socks) he was always well dressed. There was a story that he broke up with a rare girlfriend because she wore jeans to his parents house. He drove a Rover. He was an enthusiastic landscape photographer and had an SLR camera which weren't very common in the 1960s (and was the first thing I purchased when I finally had money). If you had a problem, he was always willing to talk things out and could be very philosophical.
As I said he was a huge influence on my life. I wish I could say that this was the start of a life-long commitment to camping, hiking and mountaineering; sadly while I enjoy looking at mountains, I don't really like climbing and I enjoy my bed too much.
I went up to Venturers at 15 (I stayed an extra year in Scouts, I liked it so much). About a year later, Dave who worked for the government was transferred to another town. He got right into the local Scouting movement and the next summer his new troop had a joint summer camp with his old troop.
I last saw him when I was 20. I was coming home for a break from my summer work and was on the ferry home. He was also visiting his parents. We sat together and talked for the whole trip. It was like two old friends talking together. I have never seen him since.
I went to medical school, kicked around in various places in Canada and I was living in Eastern Canada when I heard that he had been charged and pleaded guilty to sexually abusing one of his scouts. He spent some time in prison. I was out of the province so I missed any media coverage and I have lost contact with just about all of my scouting buddies. I have talked it over with my older brothers who preceded my in Scouts. One says there is no way he was guilty; the other says, of course he was guilty. My father believes he pleaded guilty in order to prevent the child who accused him from having to testify and be cross-examined. I have a hard time believing anybody would willingly go to jail as pedophile.
Now looking back, maybe it should have been obvious. We have a quiet soft spoken man who lives with his parents, is heavily involved in Scouting and Big Brothers, doesn't have a girlfriend, and likes to take pictures. Perfect profile of a pedophile? This was the 1960s; there were lots of men like him and they were largely respected in the community. When I was writing this blog, I googled him and all I could find a was an award for distinguished service to scouting in 1969.
All I can say is he never touched me (maybe I was lucky) and I never ever heard anything untoward about him from any of my friends although being diddled by your scoutmaster isn't something teenagers brag about. One time in Venturers we were hiking up in the mountains and we came across him camping with his Little Brother. In 1973 we didn't think that was unusual.
About 5 years ago our scout troop had a reunion. It was on a weekend and while I wasn't working, it would have meant flying there so I didn't go. I just thought it would be a whole lot of people I had nothing in common with anymore trying to make conversation. The whole uneasiness about Dave played a role. One of my brothers attended and said it was a lot of fun and that Dave was there.
About a month later, I got a letter from Dave. He said that he was now retired and living with his wife(!) on one of the Gulf Islands. I meant to write hime back to tell him what a good role model he had been for me but the letter disappeared into a black hole on my desk and I never did write the letter. I lost his address too.
I attended a workshop on hypnosis last spring and we talked about forgiveness. The speaker said it is possible to forgive somebody without condoning what they did. I cannot condone anybody who uses a position of authority to hurt somebody, especially a child. I can forgive him however for what he did to that child and for the doubts he has raised about my whole Scouting experience.
Sunday, November 16, 2008
I Was a Medical Criminal Part III
Just a note that after venting on my blog, I did what someone described as the closest thing an Englishman will do to rebelling, I wrote a letter. I wrote a letter to the chief of staff for the region.
A few days later, his executive assistant phoned me and wasn't really helpful BUT a month later I actually got a signed letter from the Chief of Staff himself, appologizing for the whole incident.
So I am no longer an medical records criminal.
A few days later, his executive assistant phoned me and wasn't really helpful BUT a month later I actually got a signed letter from the Chief of Staff himself, appologizing for the whole incident.
So I am no longer an medical records criminal.
Saturday, November 15, 2008
Am I a Luddite
Technology was supposed to make life simpler for us. In some ways it has. I would never want to go back to submitting my billing on paper; paying my dues on-line is easier and of course if I wasn't writing this stupid blog, I would actually feel obliged to do some work.
A couple of new technological hurdles are making me wonder however.
At a recent staff meeting, a member raised a concern about our new anaesthetic machines. Apparently in our case room we have the newest generation Drager machine. It is in the case room because for some reason Ob-Gyn "paid" for it. The problem with this machine is that if it is turned off, it takes literally 30 minutes for the software to boot up.
So don't turn it off you say.
Unfortunately for infection control reasons all operating rooms are terminally cleaned once a day which means moving all the equipment into the hall. This means unplugging the anaesthetic machine which unlike my laptop, doesn't have a back-up battery. (My laptop also plays music and surfs the internet unlike my anaesthetic machine.) Therefore unless somebody turns it back on, when you show up at 0300 for the prolapsed cord, the machine will not work. Now there is a process where you can "hot boot", the machine however the manufacturer warns that after 10 hot boots, the software will be damaged.
Our department has exclusively Drager machines in the main OR which also have a boot up process after being unplugged but it is possible be randomly pushing at buttons to bypass this.
Does all this software make anaesthesia safer. No.
Gather round children while Grandpa tells you about anaesthesia in the olden days.
We had machines that were essentially copper pipes with valves. They were driven by the compressed gas from the central supply or from the O2 cylinder. And they were safe. If the compressed O2 failed, the N20 which was held open by the gas pressure also shut off, and a loud whistle sounded. There was a mechanical link which automatically reduced the N2O when the O2 flow was reduced and in addition it was impossible (on most machines) to completely turn the O2 off. You didn't need to plug them in to an electrical socket which meant you could if you were stupid enough or where forced to, move them with the patient to another room using the O2 cylinders. Oh yeah the O2 also drove the ventillator.
Now the greatest advance in patient safety in my lifetime was the invention and adoption of pulse oximetry. Not newer more elaborate machines that need to the plugged in to the wall socket and have finicky software. Not to mention those annoying alarms. Talk about crying wolf.
A year or so ago I went down to Ecuador. While there I went over to another hospital to do a case. In the room we were given I encountered an old Ohio machine. Some people would have fled the room in horror but I had actually used a similar machine, I was able to inspect it quickly, ascertain that it was in working order (and I am not very good with machines) and I knew that with a pulse oximeter, I would be able to give a very safe anaesthetic. Later that evening I recounted my adventure to a slightly younger anaesthetist who recoiled in horror at using a machine that in his words should be in a museum.
The second issue was the new Smart Pumps our hospital now has.
These are computerized infusion pumps designed to prevent medication errors. During the early fall nurses had to attend inservices lasting several hours to learn to use these machines. As anaesthesiologists we alone amongst physicians have to adjust these pumps we tried to get an inservice. I spent a great deal of time with the company explaining why we needed a full inservice (instead of just looking at them between cases which was what they offered). As it turned out I had to miss the inservice so I still in the dark about how to adjust these pumps. Again do these expensive and time consuming pumps improve patient safety.
No.
Will still there be medication errors?
Yes.
This reminds me that my wife who recently recertified as a nurse actually had to learn how to calculate flow rates by counting drips. She asked my about this. I told her it showed just how long it had been since most academic nurses had actually been in a hospital because nobody does that anymore.
A couple of new technological hurdles are making me wonder however.
At a recent staff meeting, a member raised a concern about our new anaesthetic machines. Apparently in our case room we have the newest generation Drager machine. It is in the case room because for some reason Ob-Gyn "paid" for it. The problem with this machine is that if it is turned off, it takes literally 30 minutes for the software to boot up.
So don't turn it off you say.
Unfortunately for infection control reasons all operating rooms are terminally cleaned once a day which means moving all the equipment into the hall. This means unplugging the anaesthetic machine which unlike my laptop, doesn't have a back-up battery. (My laptop also plays music and surfs the internet unlike my anaesthetic machine.) Therefore unless somebody turns it back on, when you show up at 0300 for the prolapsed cord, the machine will not work. Now there is a process where you can "hot boot", the machine however the manufacturer warns that after 10 hot boots, the software will be damaged.
Our department has exclusively Drager machines in the main OR which also have a boot up process after being unplugged but it is possible be randomly pushing at buttons to bypass this.
Does all this software make anaesthesia safer. No.
Gather round children while Grandpa tells you about anaesthesia in the olden days.
We had machines that were essentially copper pipes with valves. They were driven by the compressed gas from the central supply or from the O2 cylinder. And they were safe. If the compressed O2 failed, the N20 which was held open by the gas pressure also shut off, and a loud whistle sounded. There was a mechanical link which automatically reduced the N2O when the O2 flow was reduced and in addition it was impossible (on most machines) to completely turn the O2 off. You didn't need to plug them in to an electrical socket which meant you could if you were stupid enough or where forced to, move them with the patient to another room using the O2 cylinders. Oh yeah the O2 also drove the ventillator.
Now the greatest advance in patient safety in my lifetime was the invention and adoption of pulse oximetry. Not newer more elaborate machines that need to the plugged in to the wall socket and have finicky software. Not to mention those annoying alarms. Talk about crying wolf.
A year or so ago I went down to Ecuador. While there I went over to another hospital to do a case. In the room we were given I encountered an old Ohio machine. Some people would have fled the room in horror but I had actually used a similar machine, I was able to inspect it quickly, ascertain that it was in working order (and I am not very good with machines) and I knew that with a pulse oximeter, I would be able to give a very safe anaesthetic. Later that evening I recounted my adventure to a slightly younger anaesthetist who recoiled in horror at using a machine that in his words should be in a museum.
The second issue was the new Smart Pumps our hospital now has.
These are computerized infusion pumps designed to prevent medication errors. During the early fall nurses had to attend inservices lasting several hours to learn to use these machines. As anaesthesiologists we alone amongst physicians have to adjust these pumps we tried to get an inservice. I spent a great deal of time with the company explaining why we needed a full inservice (instead of just looking at them between cases which was what they offered). As it turned out I had to miss the inservice so I still in the dark about how to adjust these pumps. Again do these expensive and time consuming pumps improve patient safety.
No.
Will still there be medication errors?
Yes.
This reminds me that my wife who recently recertified as a nurse actually had to learn how to calculate flow rates by counting drips. She asked my about this. I told her it showed just how long it had been since most academic nurses had actually been in a hospital because nobody does that anymore.
Transferring your stress
I attended a meeting last weekend. It was a pain meeting but one of the talks was on "stress management in the pain provider". It was a talk I looked forward to when I looked at the program first thing in the morning. The presenter is a physician who works for the medical association's physician help program and in addition writes articles that I have always enjoyed reading.
I was disappointed.
Right from the start, this doctor (who is younger than me) stated that his practice was currently restricted to weekend locum coverage and surgical assists. During the talk he casually mentioned his interesting travels, his winter "retreat" in the New Mexico desert and the fact that he never works on his wife's birthday.
So.......
The solution to stress for all of us is:
Work part-time but also only chose work that you really like when you feel like it.
Take lots of vacation.
Now I work more or less full-time both as an anaesthesiologist and also as a chronic pain doctor. This is by choice, anaesthesia is one of the specialties where part-time work is a viable option. I also take between 6-10 weeks of vacation depending on how things shake out. Sometimes my work is stressful, I can't say for sure whether it is more or less stressful than 25 years ago.
But imagine now if all the doctors decided they were going to work part-time and only do work that suited them. Aside from needing 2-3 times more doctors, what about the patients and work that doesn't suit anybody. Who sees these patients.
Our expert in stress is not alone however. There are becoming more and more doctors who are working part-time, refusing to take patients with chronic diseases, refusing to work evenings or weekends (in fairness our expert apparently only works weekends which are a pain but you do get paid more). This is causing more stress on those of us who are old school and believed that you take the good cases with the bad and that real doctors still work evenings and weekends.
Anyway I hope our expert in stress is able to put his honorarium to good use and maybe he can do fewer weekends or maybe take off his neighbour's birthdays. I hope he is thankful to the taxpayers who subsidized his education so that he can work part-time,to mention the individual who didn't get into medical school so that he could, and the physicians in his community who have picked up his slack.
And I am no further along in managing my stress
I was disappointed.
Right from the start, this doctor (who is younger than me) stated that his practice was currently restricted to weekend locum coverage and surgical assists. During the talk he casually mentioned his interesting travels, his winter "retreat" in the New Mexico desert and the fact that he never works on his wife's birthday.
So.......
The solution to stress for all of us is:
Work part-time but also only chose work that you really like when you feel like it.
Take lots of vacation.
Now I work more or less full-time both as an anaesthesiologist and also as a chronic pain doctor. This is by choice, anaesthesia is one of the specialties where part-time work is a viable option. I also take between 6-10 weeks of vacation depending on how things shake out. Sometimes my work is stressful, I can't say for sure whether it is more or less stressful than 25 years ago.
But imagine now if all the doctors decided they were going to work part-time and only do work that suited them. Aside from needing 2-3 times more doctors, what about the patients and work that doesn't suit anybody. Who sees these patients.
Our expert in stress is not alone however. There are becoming more and more doctors who are working part-time, refusing to take patients with chronic diseases, refusing to work evenings or weekends (in fairness our expert apparently only works weekends which are a pain but you do get paid more). This is causing more stress on those of us who are old school and believed that you take the good cases with the bad and that real doctors still work evenings and weekends.
Anyway I hope our expert in stress is able to put his honorarium to good use and maybe he can do fewer weekends or maybe take off his neighbour's birthdays. I hope he is thankful to the taxpayers who subsidized his education so that he can work part-time,to mention the individual who didn't get into medical school so that he could, and the physicians in his community who have picked up his slack.
And I am no further along in managing my stress
Monday, October 6, 2008
I Was a Medical Records Criminal II
When I wrote the previous post, it brought to mind some other brushes I have had with medical records.
When I first finished my internship I went to do locums at a medium sized city in Atlantic Canada. I worked there for 10 months. Even then I was pretty compulsive about medical records and dictated all my histories and discharge summaries promptly or so I thought.
When I left I phoned up medical records, told them I was leaving town and could they get all my charts together because I wanted to finish them before I left. Like I said I was pretty conscientious then.
I worked in another community for about six months and then left the province for greener pastures. A few months after arriving in greener pastures I got a letter from the medical director stating that I was deficient in completing multiple charts and that they would be reporting me to the Medical Board unless I forthwith reported to their medical records department. I wrote a polite letter back stating that I was now on the other side of the continent, that I had actually tried to complete everything before I left, that they could have tried to contact me while I actually lived only an hour away and that despite everything if they sent me the charts I would be happy to try to complete them.
In time I received a large bundle of charts. Many of these were charts belonging to people who I had done locums for who figured it must have been me who looked after the patient in question (in most cases it wasn't). I also found out that many specialists had a little trick of transferring patients back to their family doc on the day of discharge, thus making the family doc responsible for the discharge summary. I was stung pretty badly there, worse because in most cases I never even knew the patient was in hospital and had usually never met them. I also learned for the first time that the hospital had a policy that when you assisted on a hysterectomy (which I did quite a bit) you had to write a consult agreeing that the procedure was necessary. (Imagine me as a very young GP telling the Gynecologist, "you leave that uterus in!")
Anyway I completed them as best I could and sent them back and I never heard back from the hospital again.
The first hospital I worked for as an anaesthesiologist had a very activist medical record department. We anaes don't do a lot of dictating but we do as it turns out give a lot of verbal orders which eventually have to signed. The hospital had a two week cut-off after which you were off staff and you were supposed to keep up on it which meant visiting medical records to see if you had any charts.
Now at this hospital there was a computer screen at the doctor's entrance and you were supposed to log-in every time you came in the hospital so that switchboard would know you were in the hospital. This was of minor importance when you were on call because you couldn't here overhead pages in the OR or caseroom and if switchboard didn't know you were in the hospital they wouldn't try to look for you. This on one occasion resulted in an orthopod yelling at my wife on the phone because she didn't know where I was and I had forgotten to log in. Anyway after that I always tried to log in.
One evening I was coming in to do some type of "emergency" and tried to log-in only to be told I couldn't log-in because I had been kicked off staff for not signing my verbal orders. For a second I thought, this is great, I'm going home and someone else can do this emergency. But I didn't, I worked on illegally. Actually a couple of days later, I mentioned this to the Chief of Staff who told me, "actually it didn't mean you were really off staff", which of course made me wonder what exactly it did mean and why did they even bother.
Another story someone told me around that time is kind of funny. This doctor was driving thru a rural community and was listening to the local radio station when, leading off the local news was the announcement that a doctor he knew had been suspended from staff at the local hospita. He of course contacted his colleague to find out what had happened and was told, "Oh, I just got behind on my charts, I'm not really off staff".
When I first finished my internship I went to do locums at a medium sized city in Atlantic Canada. I worked there for 10 months. Even then I was pretty compulsive about medical records and dictated all my histories and discharge summaries promptly or so I thought.
When I left I phoned up medical records, told them I was leaving town and could they get all my charts together because I wanted to finish them before I left. Like I said I was pretty conscientious then.
I worked in another community for about six months and then left the province for greener pastures. A few months after arriving in greener pastures I got a letter from the medical director stating that I was deficient in completing multiple charts and that they would be reporting me to the Medical Board unless I forthwith reported to their medical records department. I wrote a polite letter back stating that I was now on the other side of the continent, that I had actually tried to complete everything before I left, that they could have tried to contact me while I actually lived only an hour away and that despite everything if they sent me the charts I would be happy to try to complete them.
In time I received a large bundle of charts. Many of these were charts belonging to people who I had done locums for who figured it must have been me who looked after the patient in question (in most cases it wasn't). I also found out that many specialists had a little trick of transferring patients back to their family doc on the day of discharge, thus making the family doc responsible for the discharge summary. I was stung pretty badly there, worse because in most cases I never even knew the patient was in hospital and had usually never met them. I also learned for the first time that the hospital had a policy that when you assisted on a hysterectomy (which I did quite a bit) you had to write a consult agreeing that the procedure was necessary. (Imagine me as a very young GP telling the Gynecologist, "you leave that uterus in!")
Anyway I completed them as best I could and sent them back and I never heard back from the hospital again.
The first hospital I worked for as an anaesthesiologist had a very activist medical record department. We anaes don't do a lot of dictating but we do as it turns out give a lot of verbal orders which eventually have to signed. The hospital had a two week cut-off after which you were off staff and you were supposed to keep up on it which meant visiting medical records to see if you had any charts.
Now at this hospital there was a computer screen at the doctor's entrance and you were supposed to log-in every time you came in the hospital so that switchboard would know you were in the hospital. This was of minor importance when you were on call because you couldn't here overhead pages in the OR or caseroom and if switchboard didn't know you were in the hospital they wouldn't try to look for you. This on one occasion resulted in an orthopod yelling at my wife on the phone because she didn't know where I was and I had forgotten to log in. Anyway after that I always tried to log in.
One evening I was coming in to do some type of "emergency" and tried to log-in only to be told I couldn't log-in because I had been kicked off staff for not signing my verbal orders. For a second I thought, this is great, I'm going home and someone else can do this emergency. But I didn't, I worked on illegally. Actually a couple of days later, I mentioned this to the Chief of Staff who told me, "actually it didn't mean you were really off staff", which of course made me wonder what exactly it did mean and why did they even bother.
Another story someone told me around that time is kind of funny. This doctor was driving thru a rural community and was listening to the local radio station when, leading off the local news was the announcement that a doctor he knew had been suspended from staff at the local hospita. He of course contacted his colleague to find out what had happened and was told, "Oh, I just got behind on my charts, I'm not really off staff".
Friday, September 12, 2008
I was a Medical Records Criminal I
People go into various specialties for various reasons. Now while almost all the potential residents who I interviewed said they had chosen anaesthesia because of their interest in physiology and pharmacology, I am sure that people my generation who largely came out of general practice what rank one factor at or near the top of their reasons:
NOT HAVING TO DEAL WITH MEDICAL RECORDS!
Sadly I didn't learn and went into chronic pain management which of course means dealing with a lot of medical records and also dictating notes.
As you can guess from a previous post, I like lots of information when I see a patient (most times I would just settle for any information). When I was in general practice or working in the ER one of the things that drove me crazy was having to deal with a recently discharged patient presenting and having no discharge summary (or for that matter any records) to help figure out the usually distressed often comatose patients. Patients have certain expectations. When they present to the hospital where they were recently hospitalized they expect that the doctor will actually be able to read their chart. When of course you don't have the discharge summary and have to rely on the nurse notes and illegible progress notes, it is not their beloved doctor who is the stupid one, it is you.
With that in mind, I have always dictated my notes soon after seeing the patient. This is a practical matter. If you ask me in the evening about a patient I saw in the afternoon, I usually can't remember. And that is before I start drinking!
I work in a regionalized health authority. This has meant working in multiple hospitals. Almost 10 years ago our health authority assimilated a small suburban hospital. To make a long story short, for some reason I ended up doing fluoroscopically guided blocks in their OR. They were easy to deal with unlike the CofE where I then worked. Now when you do something in the OR you become the surgeon which means dictating an operative record. It also means signing that record. Now our health authority has always sent our dictations with "DICTATED BUT NOT READ" where the signature should be. This is a little embarassing when you make a big mistake in your dictation or when you dictate while in a bad mood and say something you really shouldn't have said. Despite that fact that your words are now widely disseminated, you are required to physically sign the report. Most medical records departments have made this easy for me by sending my dictations to me in an envelope to sign so that I don't have to go down to medical records. Anyway nowadays we have electronic signature where you read your masterpiece online, press a button and VOILA it is signed.
For some reason my otherwise flexible and helpful suburban hospital has always required me to actually go to their medical records department and sign their charts. They are for some reason which nobody can explain not part of the E-signature program even though their charts are available on-line just like every other hospital. I normally sign the charts on the days when I am out at the hospital doing procedures, which as it happens hasn't been very frequent lately so I had accumulated about 25 unsigned charts. These dictations as I mentioned had by that time been available on-line and had been mailed to the referring doctors including me.
So about a month ago, I got a phone call from the medical director's office saying that I had been kicked off staff at my little suburban hospital for not signing my charts in a timely fashion. But, because we are all part of the same happy family, this meant that I was also off staff at every hospital in the region which meant that my pain clinics were going to be cancelled. The only escape would be for me to sign my charts by midnight which meant driving 30 minutes each way to the hospital. I resigned myself to spending 60 minutes driving that evening in order to keep my priveleges. As I left the hospital though I got a phone call from the medical director's office stating that there had been a mistake by a new secretary and because I hadn't received a registered letter that I couldn't be kicked off staff but could I complete my charts by the end of the month.
Anyway about a week later, I drove out and spent about 10 minutes signing the charts.
NOT HAVING TO DEAL WITH MEDICAL RECORDS!
Sadly I didn't learn and went into chronic pain management which of course means dealing with a lot of medical records and also dictating notes.
As you can guess from a previous post, I like lots of information when I see a patient (most times I would just settle for any information). When I was in general practice or working in the ER one of the things that drove me crazy was having to deal with a recently discharged patient presenting and having no discharge summary (or for that matter any records) to help figure out the usually distressed often comatose patients. Patients have certain expectations. When they present to the hospital where they were recently hospitalized they expect that the doctor will actually be able to read their chart. When of course you don't have the discharge summary and have to rely on the nurse notes and illegible progress notes, it is not their beloved doctor who is the stupid one, it is you.
With that in mind, I have always dictated my notes soon after seeing the patient. This is a practical matter. If you ask me in the evening about a patient I saw in the afternoon, I usually can't remember. And that is before I start drinking!
I work in a regionalized health authority. This has meant working in multiple hospitals. Almost 10 years ago our health authority assimilated a small suburban hospital. To make a long story short, for some reason I ended up doing fluoroscopically guided blocks in their OR. They were easy to deal with unlike the CofE where I then worked. Now when you do something in the OR you become the surgeon which means dictating an operative record. It also means signing that record. Now our health authority has always sent our dictations with "DICTATED BUT NOT READ" where the signature should be. This is a little embarassing when you make a big mistake in your dictation or when you dictate while in a bad mood and say something you really shouldn't have said. Despite that fact that your words are now widely disseminated, you are required to physically sign the report. Most medical records departments have made this easy for me by sending my dictations to me in an envelope to sign so that I don't have to go down to medical records. Anyway nowadays we have electronic signature where you read your masterpiece online, press a button and VOILA it is signed.
For some reason my otherwise flexible and helpful suburban hospital has always required me to actually go to their medical records department and sign their charts. They are for some reason which nobody can explain not part of the E-signature program even though their charts are available on-line just like every other hospital. I normally sign the charts on the days when I am out at the hospital doing procedures, which as it happens hasn't been very frequent lately so I had accumulated about 25 unsigned charts. These dictations as I mentioned had by that time been available on-line and had been mailed to the referring doctors including me.
So about a month ago, I got a phone call from the medical director's office saying that I had been kicked off staff at my little suburban hospital for not signing my charts in a timely fashion. But, because we are all part of the same happy family, this meant that I was also off staff at every hospital in the region which meant that my pain clinics were going to be cancelled. The only escape would be for me to sign my charts by midnight which meant driving 30 minutes each way to the hospital. I resigned myself to spending 60 minutes driving that evening in order to keep my priveleges. As I left the hospital though I got a phone call from the medical director's office stating that there had been a mistake by a new secretary and because I hadn't received a registered letter that I couldn't be kicked off staff but could I complete my charts by the end of the month.
Anyway about a week later, I drove out and spent about 10 minutes signing the charts.
Tuesday, August 26, 2008
More on the Edmonton Folk Festival
About a year ago I published a blog on the EFF. Someone actually read it and made the comment below which I thought I should publish it in my blog.
"For a bunch of hippies, they act in a remarkably selfish, grasping, up-tight, whinging, unfriendly way.
I've been to many hundreds of outdoor and indoor music events but never one like this. I'm not sure if it's common to be as unfriendly and rude to someone who is merely trying to enjoy the same event as you, and who isn't intruding on your space.
We showed up for the evening acts, having purchased an evening-only ticket (full day tickets aren't available, only tickets for the whole weekend).
On arrival we found that this bunch of grasping people had all laid out 10 to 15 foot wide tarps all over the whole seating area, some only had two or three people or chairs on them. This meant that latecomers or evening-only people like ourselves, were meant to stand way at the back miles from the stage.
I suppose the other option was to go to one of the prescribed 'dancing' areas- who has ever heard of a dancing area at a live show? If you want to dance... dance.
We squeezed ourselves into a gap between two tarps somewhere in the middle of the crowd, and had to put up with dirty looks and comments- heaven forbid we sit too close to someone elses staked out seating area.
I will never go back to this festival or any similar one, I've never seen such an unfriendly un-communal attitude from people at an event like this.
At most rock shows you can sit, stand, and dance wherever the hell you like. If you want to stand and the people around you are dancing, move further back. If you want to sit, find somewhere where you can see. "
Now when we go to an event we want to have as good a view of the stage as possible. There are a number of ways a deciding who gets the best seat. Some venues charge more for better seats, some have lotteries, some are first come first serve. The EFF has a combination of a lottery and first come first serve. Except of course the lottery is fixed.
The second thing we want is in outdoor festivals we want to actually be able to reserve a spot where we can leave our stuff and where we can go for pee without losing our place. (At the Bruce Springsteen concern where I had standing room on the floor, I had to stand in one place for 90 minutes to hang on to my somewhat prime spot; this would not have been justified for a lesser artist) That is why the EFF and other festival allow people to plant tarps or chairs etc. The EFF actually restricts tarp size to 8 feet by 10 feet although I didn't see any volunteers out with a tape measure.
Now over the last few years as my correspondent noted, I have been seeing a lot of
big tarps with very few people on them. For example on Saturday night my wife and I sat next to two large tarps. One was never occupied at any time during the day. The other had two people on it for about two hours during the evening concern after which they left. I don't go in the tarp run anymore and since only my wife and I go, I am usually able to get a decent seat just by looking for small spaces that the tarp runners didn't stake out. I do tend to come early in the day however. On occasion where I have come later and squeezed in most people have been polite so on behalf of the whole EFF community I appologize for the assholes my correspondent sat between.
Now in defence of the EFF, they do ask people to do their best to allow people to the people with evening tickets to squeeze in before every evening concert. They also ask people not to dance except in the dance area at the side of the stage. If you want to dance, your view of the band shouldn't matter. Quite frankly if you allow people to get up and dance, it means that everybody stands up and you have to stand up for the whole concert. They have been much less rigid about this in past years.
Anyway despite everything the EFF is the highlight of my summer and I hope my correspondent comes next year. He should buy a weekend pass though, because it is the workshops that are worth the money.
"For a bunch of hippies, they act in a remarkably selfish, grasping, up-tight, whinging, unfriendly way.
I've been to many hundreds of outdoor and indoor music events but never one like this. I'm not sure if it's common to be as unfriendly and rude to someone who is merely trying to enjoy the same event as you, and who isn't intruding on your space.
We showed up for the evening acts, having purchased an evening-only ticket (full day tickets aren't available, only tickets for the whole weekend).
On arrival we found that this bunch of grasping people had all laid out 10 to 15 foot wide tarps all over the whole seating area, some only had two or three people or chairs on them. This meant that latecomers or evening-only people like ourselves, were meant to stand way at the back miles from the stage.
I suppose the other option was to go to one of the prescribed 'dancing' areas- who has ever heard of a dancing area at a live show? If you want to dance... dance.
We squeezed ourselves into a gap between two tarps somewhere in the middle of the crowd, and had to put up with dirty looks and comments- heaven forbid we sit too close to someone elses staked out seating area.
I will never go back to this festival or any similar one, I've never seen such an unfriendly un-communal attitude from people at an event like this.
At most rock shows you can sit, stand, and dance wherever the hell you like. If you want to stand and the people around you are dancing, move further back. If you want to sit, find somewhere where you can see. "
Now when we go to an event we want to have as good a view of the stage as possible. There are a number of ways a deciding who gets the best seat. Some venues charge more for better seats, some have lotteries, some are first come first serve. The EFF has a combination of a lottery and first come first serve. Except of course the lottery is fixed.
The second thing we want is in outdoor festivals we want to actually be able to reserve a spot where we can leave our stuff and where we can go for pee without losing our place. (At the Bruce Springsteen concern where I had standing room on the floor, I had to stand in one place for 90 minutes to hang on to my somewhat prime spot; this would not have been justified for a lesser artist) That is why the EFF and other festival allow people to plant tarps or chairs etc. The EFF actually restricts tarp size to 8 feet by 10 feet although I didn't see any volunteers out with a tape measure.
Now over the last few years as my correspondent noted, I have been seeing a lot of
big tarps with very few people on them. For example on Saturday night my wife and I sat next to two large tarps. One was never occupied at any time during the day. The other had two people on it for about two hours during the evening concern after which they left. I don't go in the tarp run anymore and since only my wife and I go, I am usually able to get a decent seat just by looking for small spaces that the tarp runners didn't stake out. I do tend to come early in the day however. On occasion where I have come later and squeezed in most people have been polite so on behalf of the whole EFF community I appologize for the assholes my correspondent sat between.
Now in defence of the EFF, they do ask people to do their best to allow people to the people with evening tickets to squeeze in before every evening concert. They also ask people not to dance except in the dance area at the side of the stage. If you want to dance, your view of the band shouldn't matter. Quite frankly if you allow people to get up and dance, it means that everybody stands up and you have to stand up for the whole concert. They have been much less rigid about this in past years.
Anyway despite everything the EFF is the highlight of my summer and I hope my correspondent comes next year. He should buy a weekend pass though, because it is the workshops that are worth the money.
Thursday, July 31, 2008
You have been warned, cease and desist with your medical blogs!
I came home for lunch and my wife was reading my CMAJ and showed me this article. I was a little taken back.
Certainly when one is blogging, if you are going to have fun and have a blog that people might actually read, it is necessary to criticize and make fun of individuals and institutions. That is why I remain semi-anonymous and use nick-names. For example I call the institution where I used to work, "The Centre of Excellence". Just about every university town has a "Centre of Excellence". I trained at one.
The article gives the example of an ER resident who vents his frustrations at patients, staff and life on his blog resulting in disciplinary action. It is of course a hypothetical case. This made me wonder for a second why it seems that emergency doctors have so many blogs but then I realized that next to proctologists ER docs have the most interesting and funny cases.
Now a while back I indulged in some gossip about a local physician. Some people might consider this a breach of patient confidentiality and while somebody did in fact breach doctor-patient confidentiality, it was not me. Trust me, I am usually the last person to hear juicy rumours. Also I have never established any doctor patient relationship with the individual. This is extreme rationalization I know, but when the blog police show up, that will be my defence.
I should mention that over the years I have given anaesthetics to or treated my clinic, famous athletes, politicians and other notables. I never even tell me wife who I did (at least not anymore
Certainly when one is blogging, if you are going to have fun and have a blog that people might actually read, it is necessary to criticize and make fun of individuals and institutions. That is why I remain semi-anonymous and use nick-names. For example I call the institution where I used to work, "The Centre of Excellence". Just about every university town has a "Centre of Excellence". I trained at one.
The article gives the example of an ER resident who vents his frustrations at patients, staff and life on his blog resulting in disciplinary action. It is of course a hypothetical case. This made me wonder for a second why it seems that emergency doctors have so many blogs but then I realized that next to proctologists ER docs have the most interesting and funny cases.
Now a while back I indulged in some gossip about a local physician. Some people might consider this a breach of patient confidentiality and while somebody did in fact breach doctor-patient confidentiality, it was not me. Trust me, I am usually the last person to hear juicy rumours. Also I have never established any doctor patient relationship with the individual. This is extreme rationalization I know, but when the blog police show up, that will be my defence.
I should mention that over the years I have given anaesthetics to or treated my clinic, famous athletes, politicians and other notables. I never even tell me wife who I did (at least not anymore
Not enough information
I am a consultant. This means my job is to help other doctors with their patients. I am a little baffled by why other doctors perceive me as smarter than them in a least a very small way.
As a part-time chronic pain doctor, all my patients come to me by a referral.
Some chronic pain patients are very simple. I can take a history and examine them, come to a diagnosis and suggest or initiate treatment.
Most chronic pain patients are more complex. They have had a lot of procedures, medical trials and investigations. To properly assess this, I need to know what they have tried, for how long and in what dose. For example 100mg of gabapentin is a lot different than 3600 mg of gabapentin.
About a year ago, I saw a patient who had moved to town from another community. He had been getting injections with Botox from another doctor and wanted this continued as it seemed to have been working. He was however very vague about where or how much possibly due to a head injury or PTSD. Unfortunately the consult did not have much more than his name and healthcare number. A lot of times I can figure out what to do without my information. This patient wasn't one of those times.
Anyway I took the initiative to call the other doctor up and either discuss the patient or get the file.
This doctor as it turned out has the receptionist we all hate. She answered the phone, "Dr. X's office can you hold" and before I could reply, I was on hold. I put my phone on speaker and killed time for 10 minutes before I hung up and dialed again. The same thing happened. The third time I was ready and was able to interrupt her. I told her who I was, that I would like to talk to her doctor, that I knew she was busy and that I could give him a number to call at his convenience (GPs can actually bill the healthcare system for such phone calls). She just said, "well we're busy" and put me on hold again.
I therefore gave up trying to talk to this doctor or for that matter his receptionist. I dictated a letter and I asked for a copy of his records on this patient. I had told the patient that when I got the letter I would call him in for treatment.
Months passed. Every once in a while, usually while somebody else had me on hold, I would think about the case.
I came in this morning and found a handwritten note from the patient asking why several months later I had still not treated him. Apparently he had showed up the evening before in very bad humour and hassled the receptionist about why I hadn't seen him.
Any in a few weeks I will try to muddle my way thru a very unhappy patient.
Now in the 15 or so years that I have been seeing patients, this lack of documentation has been a major problem for me. When I worked at of CofE we actually designed a form where we asked for more information and would not book the patient until we had received the information. The thing is, most doctors offices have fax machines now; it is a simple matter to fax the rel event documents. It would take a secretary less than a minute. I know this because I frequently fax stuff myself (I thought it was neat when I learned to use a fax 10 years ago).
Almost worse than the family doctors are specialists who refuse to send you a copy of their consults when the family doctor either hasn't or can't send you a copy. Next to them are the family doctors who copy their entire chart so I have to sift thru the pap smear results to find the MRI report. Hospitals now seem to put their records on micro-film after about two years and actually ask you to come down and look for the records on the little micro-film viewer.
The monthly newsletter our friendly college puts out actually has a letters section. About a year ago, a family doctor actually wrote a letter to complain about the bad specialists who were demanding he send them information so that they could actually do a proper assessment on the patients he sent them. Now I would have thought that this would merit a public written tongue lashing from the registrar but it was in fact just published without comment.
(I should note that I did after I posted this (after I sent off an angry letter to the FP copied to the college) that I got an appologetic letter from the FP along with the info requested.)
As a part-time chronic pain doctor, all my patients come to me by a referral.
Some chronic pain patients are very simple. I can take a history and examine them, come to a diagnosis and suggest or initiate treatment.
Most chronic pain patients are more complex. They have had a lot of procedures, medical trials and investigations. To properly assess this, I need to know what they have tried, for how long and in what dose. For example 100mg of gabapentin is a lot different than 3600 mg of gabapentin.
About a year ago, I saw a patient who had moved to town from another community. He had been getting injections with Botox from another doctor and wanted this continued as it seemed to have been working. He was however very vague about where or how much possibly due to a head injury or PTSD. Unfortunately the consult did not have much more than his name and healthcare number. A lot of times I can figure out what to do without my information. This patient wasn't one of those times.
Anyway I took the initiative to call the other doctor up and either discuss the patient or get the file.
This doctor as it turned out has the receptionist we all hate. She answered the phone, "Dr. X's office can you hold" and before I could reply, I was on hold. I put my phone on speaker and killed time for 10 minutes before I hung up and dialed again. The same thing happened. The third time I was ready and was able to interrupt her. I told her who I was, that I would like to talk to her doctor, that I knew she was busy and that I could give him a number to call at his convenience (GPs can actually bill the healthcare system for such phone calls). She just said, "well we're busy" and put me on hold again.
I therefore gave up trying to talk to this doctor or for that matter his receptionist. I dictated a letter and I asked for a copy of his records on this patient. I had told the patient that when I got the letter I would call him in for treatment.
Months passed. Every once in a while, usually while somebody else had me on hold, I would think about the case.
I came in this morning and found a handwritten note from the patient asking why several months later I had still not treated him. Apparently he had showed up the evening before in very bad humour and hassled the receptionist about why I hadn't seen him.
Any in a few weeks I will try to muddle my way thru a very unhappy patient.
Now in the 15 or so years that I have been seeing patients, this lack of documentation has been a major problem for me. When I worked at of CofE we actually designed a form where we asked for more information and would not book the patient until we had received the information. The thing is, most doctors offices have fax machines now; it is a simple matter to fax the rel event documents. It would take a secretary less than a minute. I know this because I frequently fax stuff myself (I thought it was neat when I learned to use a fax 10 years ago).
Almost worse than the family doctors are specialists who refuse to send you a copy of their consults when the family doctor either hasn't or can't send you a copy. Next to them are the family doctors who copy their entire chart so I have to sift thru the pap smear results to find the MRI report. Hospitals now seem to put their records on micro-film after about two years and actually ask you to come down and look for the records on the little micro-film viewer.
The monthly newsletter our friendly college puts out actually has a letters section. About a year ago, a family doctor actually wrote a letter to complain about the bad specialists who were demanding he send them information so that they could actually do a proper assessment on the patients he sent them. Now I would have thought that this would merit a public written tongue lashing from the registrar but it was in fact just published without comment.
(I should note that I did after I posted this (after I sent off an angry letter to the FP copied to the college) that I got an appologetic letter from the FP along with the info requested.)
Monday, July 14, 2008
Bugs and Drugs
I have spent the last few days doing largely orthopaedic "emergencies". While this is good mindless work, it has entailed administering multiple doses of Ancef.
When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.
While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.
Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"
Anyway you get the impression that I find giving Ancef to be distasteful.
Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.
The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.
Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.
Which brings me to a case I did on the weekend amongst all the ortho cases.
This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.
Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.
All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.
Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.
Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.
On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.
No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)
Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.
When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.
While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.
Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"
Anyway you get the impression that I find giving Ancef to be distasteful.
Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.
The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.
Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.
Which brings me to a case I did on the weekend amongst all the ortho cases.
This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.
Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.
All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.
Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.
Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.
On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.
No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)
Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.
Wednesday, July 2, 2008
Lab Work
I wish I had learned more in medical school.
I did learn, what should have been a very valuable lesson, quite early on during the laboratory medicine part of our pathology course. What I was taught was:
Don't order any investigation where the result (positive or negative) will have no influence on the management of the patient.
With that knowledge in hand out I went into the world.
I learned another thing along the way.
If after talking to and examining the patient, you have not the foggiest what could be wrong, no lab test is going to help you.
Now if you read this blog, you will know that collecting blood for the lab was one of my most favourite parts of internship. Through sheer stupidity I actually used elective time to do orthopaedics thinking I would actually learn something useful. Now on ortho, every admitted patient (and back then there was very little day surgery and no same day admission) whether he was 19 or 90 got a laboratory panel of 24 tests known as the SMAC. This required 5 tubes of blood to be collected. So on my first or second day, I asked the resident, "why do we do so many tests on apparently healthy patients?". He looked me in the eye and said, "Anaesthesia wants them". Naturally all these patients were admitted after 1500 when the lab blood collection went home, which left the blood collection to the interns.
Of course "normal" results are in fact the range that 95% of healthy assymptomatic patients fall into. This means that 5% of otherwise normal patients will have an abnormal result to a test. If you order 24 tests, there is an absolute certainty that at least one will be abnormal. These abnormal tests have to followed up on which of course means more blood work.
Now did "Anaesthesia" really want them. Apparently not as I learned a few years later when I read the guidelines for routine lab work. Here are the current ones:
Now I was able to find these in about 30 seconds because I know where to look for them. If I had googled pre-operative blood work it is little more complicated but by simply looking up the guidelines of your national anaes. society, it should be quite easy. Or you could ask your anaesthesia department.
But why do I even give a shit?
1. I pay taxes
Most healthcare is publicly funded in Canada. A significant amount is publicly funded in the US. I want my tax dollars spend on treating patients not on lab work! As an aside, much of the blood work in my province is done by a private company. Do you thing they have any interest in reducing lab work?
2. Healthcare is a zero sum game
Even in the US, there is a finite amount of money that can be spent on healthcare. That means money spent in one area is money that will not be spent in other areas. Every dollar spent on unnecessary lab work is a dollar that could be spent on something useful like chronic pain.
3. It holds up things.
How often has your day in the OR been disrupted by a cancellation or postponement due to an abnomral lab test that shouldn't have been ordered that has absolutely no bearing on the patient's ability to tolerate surgery. Just the same, you have to cancel the case, or wait while the test is repeated or the necessary follow-up tests are done. Many years ago I saw a patient who had been cancelled a month ago because of an abnormal gamma GT that someone had ordered pre-op. It was elevated so she was cancelled, went for the million dollar work-up which was of course normal and was re-booked. Of course somebody ordered the gamma GT again which was still elevated. Remembering from my time in family practice that this test is a marker for alcohol abuse (or use?) I asked her if perhaps she might have had a glass of wine the night before her testing and lo and behold she said yes. I put her to sleep and she survived despite her abnormal lab test.
4. It delays necessary lab work.
A classic example is the PT/PTT. Nobody would deny the benefit of these tests in following response to anti-coagulant therapy. There are also important in the management of an evolving coagulopathy or in monitoring whether a patient has been off his anti-coagulants long enought to do surgery or stick a needle in. Except...when you order the stat PT/PTT you really need, it is going to be queued up behind all the "baseline" PT/PTTs that have been ordered. Therefore you are going to get back your PT/PTT long after you have already bit the bullet and given the FFP your patient may or may not have needed.
5. Nobody looks at it or does anything about it
Sadly, that is the case. We order all this stuff and it gets filed in the chart and nobody looks at it. This includes abnormal lab work which frequently isn't followed up on. Chest X-rays are the classic which are often ordered pre-op and reported on post-op. As I found out as a resident, actually going to X-ray and looking at the CXR is no help. The one and only time I tried that, the tech at the film library laughed at me. Actually at our hospital, CXRs are available on-line now if I could just find the time to fill out the stupid form, make up a password etc. EKGs of course go off to be reported by the cardiologist which means they sit on someone's desk until look after the surgery.
6. Surgeons actually think lab work is a substitute for a proper history and physical.
The last time I cancelled somebody as medically unfit, the surgeon's whine was, "But I ordered a cardiogram". Further people think that lab work is a static thing, like the fact that the patient's K was normal on admission, means his K is still normal after he's been vomitting for 3 days.
7. Politicians know we order too much lab work and use it as a stick to beat us on the head when we complain about lack of funding in other areas. "The ER is full of patients waiting to be admitted?. That's because you doctors order too many blood tests".
8. It leads to more unnecessary testing and interventions
I have a personal story here. My first born was born at term after an uneventful labour and was normal size for gestation. Despite this somebody decided he needed to have a blood glucose done. It was something like 3.0 which would be low for an adult but normal for a full-term neonate (because of this episode the normal range for neonates of 2.5-3.5 which of course I had to know for my recently completed written exams has stayed in my mind). Of course the lab reported that number as low using the adult range, so the first thing the nurses did was to feed him some glucose and water. This meant when my wife woke up a few hours later with swollen boobs, our son didn't want to feed. It also meant he got an extra heel prick the next day to see if his blood glucose was still "abnormal".
I did learn, what should have been a very valuable lesson, quite early on during the laboratory medicine part of our pathology course. What I was taught was:
Don't order any investigation where the result (positive or negative) will have no influence on the management of the patient.
With that knowledge in hand out I went into the world.
I learned another thing along the way.
If after talking to and examining the patient, you have not the foggiest what could be wrong, no lab test is going to help you.
Now if you read this blog, you will know that collecting blood for the lab was one of my most favourite parts of internship. Through sheer stupidity I actually used elective time to do orthopaedics thinking I would actually learn something useful. Now on ortho, every admitted patient (and back then there was very little day surgery and no same day admission) whether he was 19 or 90 got a laboratory panel of 24 tests known as the SMAC. This required 5 tubes of blood to be collected. So on my first or second day, I asked the resident, "why do we do so many tests on apparently healthy patients?". He looked me in the eye and said, "Anaesthesia wants them". Naturally all these patients were admitted after 1500 when the lab blood collection went home, which left the blood collection to the interns.
Of course "normal" results are in fact the range that 95% of healthy assymptomatic patients fall into. This means that 5% of otherwise normal patients will have an abnormal result to a test. If you order 24 tests, there is an absolute certainty that at least one will be abnormal. These abnormal tests have to followed up on which of course means more blood work.
Now did "Anaesthesia" really want them. Apparently not as I learned a few years later when I read the guidelines for routine lab work. Here are the current ones:
Now I was able to find these in about 30 seconds because I know where to look for them. If I had googled pre-operative blood work it is little more complicated but by simply looking up the guidelines of your national anaes. society, it should be quite easy. Or you could ask your anaesthesia department.
But why do I even give a shit?
1. I pay taxes
Most healthcare is publicly funded in Canada. A significant amount is publicly funded in the US. I want my tax dollars spend on treating patients not on lab work! As an aside, much of the blood work in my province is done by a private company. Do you thing they have any interest in reducing lab work?
2. Healthcare is a zero sum game
Even in the US, there is a finite amount of money that can be spent on healthcare. That means money spent in one area is money that will not be spent in other areas. Every dollar spent on unnecessary lab work is a dollar that could be spent on something useful like chronic pain.
3. It holds up things.
How often has your day in the OR been disrupted by a cancellation or postponement due to an abnomral lab test that shouldn't have been ordered that has absolutely no bearing on the patient's ability to tolerate surgery. Just the same, you have to cancel the case, or wait while the test is repeated or the necessary follow-up tests are done. Many years ago I saw a patient who had been cancelled a month ago because of an abnormal gamma GT that someone had ordered pre-op. It was elevated so she was cancelled, went for the million dollar work-up which was of course normal and was re-booked. Of course somebody ordered the gamma GT again which was still elevated. Remembering from my time in family practice that this test is a marker for alcohol abuse (or use?) I asked her if perhaps she might have had a glass of wine the night before her testing and lo and behold she said yes. I put her to sleep and she survived despite her abnormal lab test.
4. It delays necessary lab work.
A classic example is the PT/PTT. Nobody would deny the benefit of these tests in following response to anti-coagulant therapy. There are also important in the management of an evolving coagulopathy or in monitoring whether a patient has been off his anti-coagulants long enought to do surgery or stick a needle in. Except...when you order the stat PT/PTT you really need, it is going to be queued up behind all the "baseline" PT/PTTs that have been ordered. Therefore you are going to get back your PT/PTT long after you have already bit the bullet and given the FFP your patient may or may not have needed.
5. Nobody looks at it or does anything about it
Sadly, that is the case. We order all this stuff and it gets filed in the chart and nobody looks at it. This includes abnormal lab work which frequently isn't followed up on. Chest X-rays are the classic which are often ordered pre-op and reported on post-op. As I found out as a resident, actually going to X-ray and looking at the CXR is no help. The one and only time I tried that, the tech at the film library laughed at me. Actually at our hospital, CXRs are available on-line now if I could just find the time to fill out the stupid form, make up a password etc. EKGs of course go off to be reported by the cardiologist which means they sit on someone's desk until look after the surgery.
6. Surgeons actually think lab work is a substitute for a proper history and physical.
The last time I cancelled somebody as medically unfit, the surgeon's whine was, "But I ordered a cardiogram". Further people think that lab work is a static thing, like the fact that the patient's K was normal on admission, means his K is still normal after he's been vomitting for 3 days.
7. Politicians know we order too much lab work and use it as a stick to beat us on the head when we complain about lack of funding in other areas. "The ER is full of patients waiting to be admitted?. That's because you doctors order too many blood tests".
8. It leads to more unnecessary testing and interventions
I have a personal story here. My first born was born at term after an uneventful labour and was normal size for gestation. Despite this somebody decided he needed to have a blood glucose done. It was something like 3.0 which would be low for an adult but normal for a full-term neonate (because of this episode the normal range for neonates of 2.5-3.5 which of course I had to know for my recently completed written exams has stayed in my mind). Of course the lab reported that number as low using the adult range, so the first thing the nurses did was to feed him some glucose and water. This meant when my wife woke up a few hours later with swollen boobs, our son didn't want to feed. It also meant he got an extra heel prick the next day to see if his blood glucose was still "abnormal".
Only so much niceness to go around
I was explaining to somebody in the non-medical field about how much abuse we received as students, interns and residents from more senior doctors. (I didn't tell her how much abuse I still get as a senior doctor). She said something like, "But I thought all doctors had to be nice!". So I explained the facts of life to her.
Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.
I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".
Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.
Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.
Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.
I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".
Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.
Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.
Sunday, June 1, 2008
Outed?
Webill contacted me about one of my posts.
She warned me that she had been able to come up with my identity in about 5 minutes from reading the post.
While I do post anonymously, I have never tried to hide things about who I am. I suspect anybody who knew me would be able to figure out who I am in about 5 minutes just by reading the blog and figuring out my nationality, province of residence, city, profession, subspecialty, political views, musical tastes, favourite hockey team etc.
I am not certain whether it is better to post anonymously and be outed or to post using my name or otherwise identifying myself.
Anyway I thank her for pointing this out; I am glad anybody actually reads my blog. I don't like to knit but my mother does (further clues to who I am).
She warned me that she had been able to come up with my identity in about 5 minutes from reading the post.
While I do post anonymously, I have never tried to hide things about who I am. I suspect anybody who knew me would be able to figure out who I am in about 5 minutes just by reading the blog and figuring out my nationality, province of residence, city, profession, subspecialty, political views, musical tastes, favourite hockey team etc.
I am not certain whether it is better to post anonymously and be outed or to post using my name or otherwise identifying myself.
Anyway I thank her for pointing this out; I am glad anybody actually reads my blog. I don't like to knit but my mother does (further clues to who I am).
Wednesday, May 7, 2008
I fought the lab and ... hey I won this time
One of my favourite tasks as an intern was acting as the after hours (and frequently during hours) blood collection service. Right up there with IVs and manual disempactions.
We all remember being called to draw blood from a patient. The patient was either:
1. A little old lady covered in bruises on all four limbs from IV and blood collections.
2. A heavy smoker with no veins.
3. A child on chemo with a severe needle phobia.
So after multiple stabs and tears you would fill the multiple different coloured tubes that the nurse handed you. An hour later you would be paged back to the same patient to draw more blood because:
1. There wasn't enough blood in the tube
2. There was too much blood in the tube
3. You collected blood in the wrong coloured tube (I used to fill one of each colour just in case)
4. The specimen was not properly labelled
5. The sample was "hemolyzed".
Of course it is over 25 years since I was an intern so I should have gotten over it by now. I still of course collect blood from patients under anaesthesia, and very rarely get called to the floor because no-one else can get blood. I also collect blood from nurses who got a needle stick which brings me to my story.
Now for several years I have resolved to wear gloves when starting IVs but this year I actually started doing so. The other day I went to start on IV on my first patient of the day. He was a little difficult and I had to try a second time but I got the second IV in. I am not the neatest person but I do make a point of being responsible for my own sharps. I picked up the two IV needles with me gloved hand and walked back towards my sharps container. That was when I felt a little prick (not the surgeon) and when I took off my glove I could see a little break in the skin.
Oh shit.
The patient had no obvious risk factors and no visible tattoos. Nevertheless I felt that I should draw blood from him and myself. At our hospital we have a needlestick protocol. You get a ziplocked bag with two tubes, one for the patient and one for you. There are two reqs one for the patient and one for you. You put everything in the same bag and it goes off to staff health.
The patient was still under some I drew some blood from a vein and put it into one of the tubes which I labelled with a sticker. I put his sticker on the req. Finding somebody to draw blood from me was harder. The OR nurses didn't want to do it. Recovery room nurses are good at drawing blood but the req had written across it in handwriting "please do not ask recovery room to draw blood". I finally found another anesthetist between cases. I labelled the tube with my name, filled out the req including my name, my date of birth and my healthcare number. Everything, mine and patient's blood went into the ziplock bag and off to staff health. Now as I was labelling my tube, I thought back to those happy times as an intern acting as the afterhours blood collection and recollection service.
Not much to my surprise, I got a call from the staff health nurse about 30 minutes later stating that the lab would not process my sample because it was not labelled properly. I suggested maybe she should call the lab and straighten things out with them as there were only two samples in a zip-locked bag and one was labelled with the patient's label, the other one had my name it. She asked if I was concerned about the patient's risk factors. I asked if she had never heard of universal precautions?
Now I could have just found somebody to draw another sample, but hey it's my blood, my integrity was violated to get the sample, they should process it. So I phoned the lab director who actually had heard about the fuss already. He said he would bring the sample to the OR and I could label it properly. About five minutes later he phoned back saying that the lab tech had told him, there was no way even if it was relabelled that they would process it.
I asked him, "Are you a physician?" He said "yes". I asked "and you have done a pathology residency?" Yes again. So says I. You have over ten years of post high school training and you are letting someone who graduated from a two year technical school telling you what you can do.
One hour later, he brought the tube to the OR and we relabled it.
2
Score: Lab 217 BH 1. But at least I'm on the board.
And by the way the patient was negative.
We all remember being called to draw blood from a patient. The patient was either:
1. A little old lady covered in bruises on all four limbs from IV and blood collections.
2. A heavy smoker with no veins.
3. A child on chemo with a severe needle phobia.
So after multiple stabs and tears you would fill the multiple different coloured tubes that the nurse handed you. An hour later you would be paged back to the same patient to draw more blood because:
1. There wasn't enough blood in the tube
2. There was too much blood in the tube
3. You collected blood in the wrong coloured tube (I used to fill one of each colour just in case)
4. The specimen was not properly labelled
5. The sample was "hemolyzed".
Of course it is over 25 years since I was an intern so I should have gotten over it by now. I still of course collect blood from patients under anaesthesia, and very rarely get called to the floor because no-one else can get blood. I also collect blood from nurses who got a needle stick which brings me to my story.
Now for several years I have resolved to wear gloves when starting IVs but this year I actually started doing so. The other day I went to start on IV on my first patient of the day. He was a little difficult and I had to try a second time but I got the second IV in. I am not the neatest person but I do make a point of being responsible for my own sharps. I picked up the two IV needles with me gloved hand and walked back towards my sharps container. That was when I felt a little prick (not the surgeon) and when I took off my glove I could see a little break in the skin.
Oh shit.
The patient had no obvious risk factors and no visible tattoos. Nevertheless I felt that I should draw blood from him and myself. At our hospital we have a needlestick protocol. You get a ziplocked bag with two tubes, one for the patient and one for you. There are two reqs one for the patient and one for you. You put everything in the same bag and it goes off to staff health.
The patient was still under some I drew some blood from a vein and put it into one of the tubes which I labelled with a sticker. I put his sticker on the req. Finding somebody to draw blood from me was harder. The OR nurses didn't want to do it. Recovery room nurses are good at drawing blood but the req had written across it in handwriting "please do not ask recovery room to draw blood". I finally found another anesthetist between cases. I labelled the tube with my name, filled out the req including my name, my date of birth and my healthcare number. Everything, mine and patient's blood went into the ziplock bag and off to staff health. Now as I was labelling my tube, I thought back to those happy times as an intern acting as the afterhours blood collection and recollection service.
Not much to my surprise, I got a call from the staff health nurse about 30 minutes later stating that the lab would not process my sample because it was not labelled properly. I suggested maybe she should call the lab and straighten things out with them as there were only two samples in a zip-locked bag and one was labelled with the patient's label, the other one had my name it. She asked if I was concerned about the patient's risk factors. I asked if she had never heard of universal precautions?
Now I could have just found somebody to draw another sample, but hey it's my blood, my integrity was violated to get the sample, they should process it. So I phoned the lab director who actually had heard about the fuss already. He said he would bring the sample to the OR and I could label it properly. About five minutes later he phoned back saying that the lab tech had told him, there was no way even if it was relabelled that they would process it.
I asked him, "Are you a physician?" He said "yes". I asked "and you have done a pathology residency?" Yes again. So says I. You have over ten years of post high school training and you are letting someone who graduated from a two year technical school telling you what you can do.
One hour later, he brought the tube to the OR and we relabled it.
2
Score: Lab 217 BH 1. But at least I'm on the board.
And by the way the patient was negative.
Sunday, May 4, 2008
Hating the Habs
For me, after last night I can again enjoy the NHL Playoffs.
I am one of the millions of people across Canada who hate the Montreal Canadiens. I have nothing against Montreal, I love visiting there and Montreal Smoked Meat is one of the foods I live for. I have nothing against French people (Montreal actually has very few French players anymore).
Every year I live in dread of another Stanley Cup for Montreal (which has happened 12 times in my life).
My obsession is deep seated.
I grew up in a Habs household. Except when I was six, my older brother told me I wasn't allowed to hope for Montreal because that would be copying him. In a Habs household, hoping for the Leafs was out so I hoped for Chicago first because they had (and still have) the coolest logo in the NHL. Later when the Bruins started making the playoffs I cheered for the Bruins (and still cheer for them, except when they play Edmonton).
Off course being a Bruins fan, I have a lot to hate Montreal for. I like to think my hatred is justified on a wider basis as a hockey fan.
There are a number of legitimate beefs.
1. The arrogance.
After expansion, the Habs became a lot like Central Red Army. Most of the good players were concentrated on the Habs supported by some very good role players. It is well known how this came to be.
When the NHL expanded in 1967, the play was that every team would only be able to protect 6 players. This would have allowed expansion teams to draft second and third line players, in other words genuine NHLers. At the last minute Sam Pollock the Habs' GM pursuaded the other GMs that more players should be protected. So teams were able to protect 10 players (in addition to protecting another player for each player drafted). This meant the expansion teams were left with a few third line players, some fourth liners (at that time most teams only used three lines) and minor leagers.
Faced with a team with limitted talent, expansion GMs were now faced with trying to build a competitive team which would attract fans in cities like Oakland and St. Louis with limited hockey experience. Fortunately Sam Pollock was able to come to their aid. Sammie was happy to trade them over the hill players and minor leaguers for draft choices in the new amateur draft (Montreal also got to pick the first two players from Quebec as well). Montreal also was happy to trade players to the expansion teams who happily traded them back when Montreal needed them again. Usually a draft choice changed hands as well. Montreal even traded players to enable to teams to finish ahead of teams whose first round pick they had. On one occasion they traded a draft choice to prevent Boston from drafting a goalie (John Davidson).
The result was that Montreal in addition to winning the Stanley Cup almost every year got 4 first round draft choices. Some of these like Guy Lafleur, Steve Shutt adn Bob Gainey blossomed into stars. Worse were the first rounders who couldn't crack the Habs' line-up who ended up in the press box or the minors. This is at the time when there were at least 4 abysmally bad teams who could have used an NHL grade player. This is not to mention, the career damage to players who could have stepped into the NHL but instead spent 2+ years in the minors.
2. Habs fans.
These people are unfortunately the least knowledgeable and most obnoxious fans. I went to a Habs -Oilers game with my cousin who is a nice guy except when you let him dress up in a Habs jersey and take him to a hockey game. He complained bitterly over every call even the offsides.
Of course most people develop their hockey allegience as children when they first watch hockey. Of course for anybody who started watching hockey in the 60s or 70s, the Habs won just about every year. Now how much of a challenge is it to hope for a team that wins most of its games as well as the Stanley Cup.
The only bright side is that Leafs fans are almost as bad.
3. Refereeing
At the start of every Coach's Corner we get to see a very old clip of a much younger Don Cherry standing on the bench facing the crowd with his arms outstretched. The significance of that clip has been forgotten. Not by my however. Cherry was interviewed before Game 5 of the 1979 series with Montreal, tied 2-2 and predicted that the Bruins could not get a fairly officiated game in Montreal. This clip was taken after Boston's 4th minor penalty in the first period. Needless to say Montreal won the game.
We all remember Montreal players skating through centre ice, no player within 10 feet of him when suddenly his legs would go up in the air, the crowd would roar and the referee's arm would go up. Steve Shutt was a master of this.
Pat Burns after he left the Habs for the Leafs, commented after a Leaf's game, that the refereeing wasn't what he was accustomed to in Montreal.
4. Danny Gallivan / Dick Irvin
It was bad enough in the 70s having to watch Montreal just about every Saturday night (of course the option was Toronto or Vancouver) without having to put up with this dynamic duo. Danny's broadcast was more of a group fellating of the the Canadiens organization than a objective broadcast. Add to that Dick's nasal colour commentary and you wished the mute button had been invented. Back when Vancouver would play Montreal in Montreal, most of us turned the volume on our TVs (a primitive mute button) off and put on the Vancouver radio broadcast. When the Oilers and Flames joined the league which meant you hardly ever got Montreal home games on Saturday night, most of us in Western Canada kissed our TVs in relief.
5. Scotty Bowman
Scotty Bowman is a better than average coach. I give him this.
His main genius however is selecting which team to coach rather than any particular knowledge of hockey.
His record:
St. Louis Blues. Finished first in division and played in Stanley Cup Final (record 0-12) in bizzarre set-up where all 6 expansion teams played in the same division.
Montreal Canadiens. 1971-2 Took over team that had just won Stanley Cup. Finished in 3rd place and eliminated in the first round. 1972-3 Won Stanley Cup next year only because Bruins were decimated by defection to WHA. 1973-4 without Ken Dryden finished second, lost in first round. 1974-5 with Ken Dryden lost in second round.
1975-9 with team that had the advantage of having 4 first round picks for the preceding 4-5 years won 4 straight Stanley Cups. (Harry Neale could have won at least 3 with that line-up). Even the Canadiens are so unimpressed with Bowman that they chose Irving Grundman over him to succeed Sam Pollock.
Moves to Buffalo as coach-GM. Takes team that was a guaranteed dynasty to a series of early playoff exits.
Pittsburg. Takes over Stanley Cup champions after Coach Bob Johnson dies and wins one and only one more Stanley Cup.
Detroit. Joins team as coach AFTER team had already been assembled taking advantage of the NHLs ridiculous free agency rules and with a payroll double some teams. Wins a few but surprisingly not that many Stanley Cups.
Bowman's chief talent aside from chosing which team to coach was his mastery of the referees. This included inviting referees to a video session showing the penalties they should have called against Boston in the previous game (imagine any profesional league in the world allowing this) and as coach of Buffalo getting the NHL to suspend Tiger Williams for alledged slashing Bowman even though nobody saw it and it was not shown on any video replays of the game. I also remember his whine after Buffalo tied the game on a powerplay goal (and won in OT) that that the referee had promised him he would not call any penalties in centre ice.
I am one of the millions of people across Canada who hate the Montreal Canadiens. I have nothing against Montreal, I love visiting there and Montreal Smoked Meat is one of the foods I live for. I have nothing against French people (Montreal actually has very few French players anymore).
Every year I live in dread of another Stanley Cup for Montreal (which has happened 12 times in my life).
My obsession is deep seated.
I grew up in a Habs household. Except when I was six, my older brother told me I wasn't allowed to hope for Montreal because that would be copying him. In a Habs household, hoping for the Leafs was out so I hoped for Chicago first because they had (and still have) the coolest logo in the NHL. Later when the Bruins started making the playoffs I cheered for the Bruins (and still cheer for them, except when they play Edmonton).
Off course being a Bruins fan, I have a lot to hate Montreal for. I like to think my hatred is justified on a wider basis as a hockey fan.
There are a number of legitimate beefs.
1. The arrogance.
After expansion, the Habs became a lot like Central Red Army. Most of the good players were concentrated on the Habs supported by some very good role players. It is well known how this came to be.
When the NHL expanded in 1967, the play was that every team would only be able to protect 6 players. This would have allowed expansion teams to draft second and third line players, in other words genuine NHLers. At the last minute Sam Pollock the Habs' GM pursuaded the other GMs that more players should be protected. So teams were able to protect 10 players (in addition to protecting another player for each player drafted). This meant the expansion teams were left with a few third line players, some fourth liners (at that time most teams only used three lines) and minor leagers.
Faced with a team with limitted talent, expansion GMs were now faced with trying to build a competitive team which would attract fans in cities like Oakland and St. Louis with limited hockey experience. Fortunately Sam Pollock was able to come to their aid. Sammie was happy to trade them over the hill players and minor leaguers for draft choices in the new amateur draft (Montreal also got to pick the first two players from Quebec as well). Montreal also was happy to trade players to the expansion teams who happily traded them back when Montreal needed them again. Usually a draft choice changed hands as well. Montreal even traded players to enable to teams to finish ahead of teams whose first round pick they had. On one occasion they traded a draft choice to prevent Boston from drafting a goalie (John Davidson).
The result was that Montreal in addition to winning the Stanley Cup almost every year got 4 first round draft choices. Some of these like Guy Lafleur, Steve Shutt adn Bob Gainey blossomed into stars. Worse were the first rounders who couldn't crack the Habs' line-up who ended up in the press box or the minors. This is at the time when there were at least 4 abysmally bad teams who could have used an NHL grade player. This is not to mention, the career damage to players who could have stepped into the NHL but instead spent 2+ years in the minors.
2. Habs fans.
These people are unfortunately the least knowledgeable and most obnoxious fans. I went to a Habs -Oilers game with my cousin who is a nice guy except when you let him dress up in a Habs jersey and take him to a hockey game. He complained bitterly over every call even the offsides.
Of course most people develop their hockey allegience as children when they first watch hockey. Of course for anybody who started watching hockey in the 60s or 70s, the Habs won just about every year. Now how much of a challenge is it to hope for a team that wins most of its games as well as the Stanley Cup.
The only bright side is that Leafs fans are almost as bad.
3. Refereeing
At the start of every Coach's Corner we get to see a very old clip of a much younger Don Cherry standing on the bench facing the crowd with his arms outstretched. The significance of that clip has been forgotten. Not by my however. Cherry was interviewed before Game 5 of the 1979 series with Montreal, tied 2-2 and predicted that the Bruins could not get a fairly officiated game in Montreal. This clip was taken after Boston's 4th minor penalty in the first period. Needless to say Montreal won the game.
We all remember Montreal players skating through centre ice, no player within 10 feet of him when suddenly his legs would go up in the air, the crowd would roar and the referee's arm would go up. Steve Shutt was a master of this.
Pat Burns after he left the Habs for the Leafs, commented after a Leaf's game, that the refereeing wasn't what he was accustomed to in Montreal.
4. Danny Gallivan / Dick Irvin
It was bad enough in the 70s having to watch Montreal just about every Saturday night (of course the option was Toronto or Vancouver) without having to put up with this dynamic duo. Danny's broadcast was more of a group fellating of the the Canadiens organization than a objective broadcast. Add to that Dick's nasal colour commentary and you wished the mute button had been invented. Back when Vancouver would play Montreal in Montreal, most of us turned the volume on our TVs (a primitive mute button) off and put on the Vancouver radio broadcast. When the Oilers and Flames joined the league which meant you hardly ever got Montreal home games on Saturday night, most of us in Western Canada kissed our TVs in relief.
5. Scotty Bowman
Scotty Bowman is a better than average coach. I give him this.
His main genius however is selecting which team to coach rather than any particular knowledge of hockey.
His record:
St. Louis Blues. Finished first in division and played in Stanley Cup Final (record 0-12) in bizzarre set-up where all 6 expansion teams played in the same division.
Montreal Canadiens. 1971-2 Took over team that had just won Stanley Cup. Finished in 3rd place and eliminated in the first round. 1972-3 Won Stanley Cup next year only because Bruins were decimated by defection to WHA. 1973-4 without Ken Dryden finished second, lost in first round. 1974-5 with Ken Dryden lost in second round.
1975-9 with team that had the advantage of having 4 first round picks for the preceding 4-5 years won 4 straight Stanley Cups. (Harry Neale could have won at least 3 with that line-up). Even the Canadiens are so unimpressed with Bowman that they chose Irving Grundman over him to succeed Sam Pollock.
Moves to Buffalo as coach-GM. Takes team that was a guaranteed dynasty to a series of early playoff exits.
Pittsburg. Takes over Stanley Cup champions after Coach Bob Johnson dies and wins one and only one more Stanley Cup.
Detroit. Joins team as coach AFTER team had already been assembled taking advantage of the NHLs ridiculous free agency rules and with a payroll double some teams. Wins a few but surprisingly not that many Stanley Cups.
Bowman's chief talent aside from chosing which team to coach was his mastery of the referees. This included inviting referees to a video session showing the penalties they should have called against Boston in the previous game (imagine any profesional league in the world allowing this) and as coach of Buffalo getting the NHL to suspend Tiger Williams for alledged slashing Bowman even though nobody saw it and it was not shown on any video replays of the game. I also remember his whine after Buffalo tied the game on a powerplay goal (and won in OT) that that the referee had promised him he would not call any penalties in centre ice.
Monday, April 7, 2008
The Needle and the Damage Done
Most people locally consider me to be a needle guy. I have aquired a reputation as somebody who gives everybody who comes into the clinic some type of needle. I think that is unfair. I do a lot of nerve blocks of various types for patients most of whom come in for repeat injections. Most of these people seem to be happy with their treatment (the other ones post on RateMDs). I also do a lot of medication management including narcotics and methadone. Most of these patients once stabilized I see infrequently and some have been transferred back to their GP.
I still however feel guilty everytime I stick a needle in somebody. I attend all these pain meetings and I know I should be sending them to non-existent multidisciplinary programs. In fact I actually now work in a so-called multidisciplinary pain clinic and almost 100% of the internal referrals are to stick a needle in somebody.
I also do acupuncture. I took a long course which involved some training in traditional Chinese medicine but like most people I just stick the needle where it hurts. Quite frankly I consider acupuncture to be an equivalent treatment to trigger points, however when I do acupuncture I am an open minded practitioner of complementary medicine whereas when I do trigger point injections, I am a money grubbing needle guy.
On the weekend past, I attended a course on fluoroscopically guided injections. I have never done a lot of these mainly due to the inability to access fluoro which the radiologists guard jealously here as if they paid for those expensive machines out of their own pocket. I will be getting more access in the future so I decided I better actually get some training.
At the meeting we learned all kinds of different blocks. What disturbed me was the whole time, I was thinking, "How many of these can I do in a day and how much can I bill for them". (When you go to American Meetings, there is usually about half a day devoted to billing, further some interventional textbooks have chapters on billing). More disturbing was that everybody else taking the course was thinking the same thing.
Now I have been treating chronic pain for over 15 years (longer if you include my 3 years of general practice) and I still haven't figured out what causes back or neck pain, nor what is the best way to treat it. My more recent training has not enlightened me on this.
I can only hope the way I treat back and neck pain will be governed by what I think is best for the patient, and not how much I can get paid or how many fluoro slots I have to fill.
I still however feel guilty everytime I stick a needle in somebody. I attend all these pain meetings and I know I should be sending them to non-existent multidisciplinary programs. In fact I actually now work in a so-called multidisciplinary pain clinic and almost 100% of the internal referrals are to stick a needle in somebody.
I also do acupuncture. I took a long course which involved some training in traditional Chinese medicine but like most people I just stick the needle where it hurts. Quite frankly I consider acupuncture to be an equivalent treatment to trigger points, however when I do acupuncture I am an open minded practitioner of complementary medicine whereas when I do trigger point injections, I am a money grubbing needle guy.
On the weekend past, I attended a course on fluoroscopically guided injections. I have never done a lot of these mainly due to the inability to access fluoro which the radiologists guard jealously here as if they paid for those expensive machines out of their own pocket. I will be getting more access in the future so I decided I better actually get some training.
At the meeting we learned all kinds of different blocks. What disturbed me was the whole time, I was thinking, "How many of these can I do in a day and how much can I bill for them". (When you go to American Meetings, there is usually about half a day devoted to billing, further some interventional textbooks have chapters on billing). More disturbing was that everybody else taking the course was thinking the same thing.
Now I have been treating chronic pain for over 15 years (longer if you include my 3 years of general practice) and I still haven't figured out what causes back or neck pain, nor what is the best way to treat it. My more recent training has not enlightened me on this.
I can only hope the way I treat back and neck pain will be governed by what I think is best for the patient, and not how much I can get paid or how many fluoro slots I have to fill.
Tuesday, April 1, 2008
Privacy
Yesterday and today I am on call which means covering the case room. Now a universal feature of caserooms since I was a medical student in the last millenium was "The Board".
"The Board" was a then a blackboard, now a whiteboard with every labouring patient's last name, status including dilatation, station, NPO status, epidual and whether they were being induced.
In the interest of privacy now, the patient's last names have been replaced with only the first 3 letters of their name. This caused a problem for me right away when I arrived in the morning. The first three letters of the only patient with an epidural made up a name that is not common. So in I went saying "high Ms., I'm Dr. BH" and then went out to the desk to find her chart. After I couldn't find her chart I asked, "who has Ms <3 letter word name>'s chart" and after getting blank looks, "who has room 5's chart". One of the nurses handed me a chart with a six letter last name and when I said no I want <3 letter word>'s chart; they looked at my like I was stupid and told me that they were only putting the first 3 letters of the patient's name on "The Board". I never asked how they proposed to deal with patients whose last name only had 2 or 3 letters something increasingly common now (or two patients with similar three letters).
Most medical and surgical wards used to have boards with everybody's names on and what bed they were in. Alternatively the name was on the door so you could at last walk around looking for the patient you had to see. Unfortunately boards have gone by the way and in several hospitals now there are no names on the door either. This forces you to look for the chart (which if it is in the rack is filed by room number) or ask the ward clerk or a nurse.
At the same time we are very concerned about proper identification of patients to prevent the wrong treatment being done to them. Now I think everybody has had the experience of going in to see the wrong patient and realising half way through talking to them that you really should be talking to someone else. When one wants to estabilish a therapeutic relationship with a patient, the least auspicious way to meet them for the first time, has to be to enter the room and go straight for their arm band to see who they are. Yet with names not on the door, or the patients bed, in patients who are deaf, demented or half asleep, that is now the only way of ensuring you are actually talking to the right patient.
At the same time most units allow patient and their visitors to use the phones at the desk. Of course what are usually sprawled all over the desk for everybody to see. Charts of course, so the patient or their visitors can read whatever is in their visual range. (Maybe that's why nobody writes progress notes anymore).
Very few names are unique anyway. If I see a name on a door that is the same as someone I know, I just assume it is someone with the same name. Occasionally much to my surprise it is someone I know. I once ran into the contractor who built my house while on Pain Rounds. The name didn't ring a bell and people surprisingly don't look the same with an ng tube. I was talking to him when he interrupted me and said, "I built your house". I didn't tell him it was a good thing for him that I didn't give him his anaesthetic.
A number of years ago we had a victim of a gang related assault in our trauma unit. The staff were somewhat concerned that someone was going to come in to finish him off so as this was still when there were names on the door, instead of putting his name on the door, they put his hospital number.
Great...
I'm a gang member assigned to finish him off and I learn what ward he is on. So I sneak around the ward and there are 19 rooms with a name on, and one with a number on. I wonder which room I should chose.
I grew up in (what was by today's standards) a small house with three brothers (and two parents). My mother always said, "If you don't have anything to hide, you don't need privacy".
So please put my name on the door.
"The Board" was a then a blackboard, now a whiteboard with every labouring patient's last name, status including dilatation, station, NPO status, epidual and whether they were being induced.
In the interest of privacy now, the patient's last names have been replaced with only the first 3 letters of their name. This caused a problem for me right away when I arrived in the morning. The first three letters of the only patient with an epidural made up a name that is not common. So in I went saying "high Ms.
Most medical and surgical wards used to have boards with everybody's names on and what bed they were in. Alternatively the name was on the door so you could at last walk around looking for the patient you had to see. Unfortunately boards have gone by the way and in several hospitals now there are no names on the door either. This forces you to look for the chart (which if it is in the rack is filed by room number) or ask the ward clerk or a nurse.
At the same time we are very concerned about proper identification of patients to prevent the wrong treatment being done to them. Now I think everybody has had the experience of going in to see the wrong patient and realising half way through talking to them that you really should be talking to someone else. When one wants to estabilish a therapeutic relationship with a patient, the least auspicious way to meet them for the first time, has to be to enter the room and go straight for their arm band to see who they are. Yet with names not on the door, or the patients bed, in patients who are deaf, demented or half asleep, that is now the only way of ensuring you are actually talking to the right patient.
At the same time most units allow patient and their visitors to use the phones at the desk. Of course what are usually sprawled all over the desk for everybody to see. Charts of course, so the patient or their visitors can read whatever is in their visual range. (Maybe that's why nobody writes progress notes anymore).
Very few names are unique anyway. If I see a name on a door that is the same as someone I know, I just assume it is someone with the same name. Occasionally much to my surprise it is someone I know. I once ran into the contractor who built my house while on Pain Rounds. The name didn't ring a bell and people surprisingly don't look the same with an ng tube. I was talking to him when he interrupted me and said, "I built your house". I didn't tell him it was a good thing for him that I didn't give him his anaesthetic.
A number of years ago we had a victim of a gang related assault in our trauma unit. The staff were somewhat concerned that someone was going to come in to finish him off so as this was still when there were names on the door, instead of putting his name on the door, they put his hospital number.
Great...
I'm a gang member assigned to finish him off and I learn what ward he is on. So I sneak around the ward and there are 19 rooms with a name on, and one with a number on. I wonder which room I should chose.
I grew up in (what was by today's standards) a small house with three brothers (and two parents). My mother always said, "If you don't have anything to hide, you don't need privacy".
So please put my name on the door.
Monday, March 31, 2008
Information I really shouldn't be posting on my blog (but that is too juicy not to)
When I worked at the CoE there was a surgeon whose ego was the inverse of his height. Now he was not a modest guy so you can guess he was quite short. He compensated for this by wearing ridiculous cowboy boots with heel lifts and I know everybody (even some short people) made jokes about his height mostly behind his back. Now I am reasonably tall but I have come to realise that outside the NBA, NFL and CFL this is largely a world suited for short people so I couldn't really see what the "big deal" was.
Despite this surgeon's lack of physical attributes he had quite a successful life. (The operative word is had as I will explain below).
He became a successful surgeon, helped pioneer a few new procedures, was well respected in the community (if not by his colleagues), and was a successful political fund raiser for the ruling party. He was incredibly wealthy, had a huge house, and drove what he described as (after one of the nurses' daughters rear-ended him) the most expensive car in the province.
All was not rosy in his life. About 10 years ago he ran away from a long marriage to a woman who had put him through medical school, bore his children, etc to marry a sales rep. This didn't seem to affect his standing in the community, in fact even before he remarried he was in the social pages accompanied by his new wife-to-be. At his second wedding, his adult children from the first wedding picketed the ceremony and he had them arrested.
Now about 3 years ago I heard that he was going to take the whole summer off to have surgery. He was at that time of the age where people get prostate or colon cancer or require joint replacements so I didn't think much of it. That was around the time I left the CofE.
We were talking one day about him in the OR at my new place and somebody said that the reason he had taken the summer off was to have his legs lengthened in New York. The procedure had not been done. Just the fact that he had even considered such a procedure caused much amusement, although this would not have been out of character for him.
A couple a weeks ago someone came out and told everybody that he had actually gone ahead with the leg lengthening in the US. This is by the way called the Ilazarov procedure and is usually used for leg length discrepancy or occasionally for children of short stature. While this procedure is done on adults (particularily in adults who can afford it), there is generally a cut off at age 50 simply because you stop healing well, forming bone and rehabing well at that age. Being 50 myself, that is a little depressing. Apparently in the US, being able to afford a procedure can take years off your life (in both senses unfortunatley).
To make a long story short, he did terribly. His recovery was complicated by pulmonary emboli requiring an ICU stay, he has an infection, non-union and 60 year old nerves not liking being stretched, has developed causalgia which to my (and his?)relief is being treated by one of my colleagues and not by me.
Personally I blame myself. I should have never made all those short jokes.
But seriously....after the snickering about the shear audaciousness of a mature successful man undergoing mutilating surgery for a slight increase in his height, I really had to feel genuinely sorry for him. Not sorry for the predictable complications but sorry that he felt that his life was not perfect enough that he had to improve himself.
Another issue that came up is the issue of confidentiality. Yesterday in the surgery lounge this was the topic of conversation all day with people hearing the story and getting on the phone to someone they knew with, "did you hear about...".
Technically as a hospital patient, his condition should only have been known to his caregivers. While perhaps because of his actions over the years he has done more than most people to make his personal life less private, in his time of personal crisis, even if this came from a totally irrational decision on his part, he is entitled to privacy.
Still we all love gossip and this is a juicy story.
Friday, March 28, 2008
Stethoscopes
In the election we had last month, a local emergency physician ran and won for the ruling Conservative party. Now I have no issue with a physician running for a party that has eviscerated health care in the province; nor do I have any issue with the fact that physicians who go into politics are innevitably an embarassment to the profession; nor even with the fact that if a physician gets into a position of power they are never a friend to the profession.
What I have an issue that his campaign photo was a head and shoulder shot of him wearing an OR green top with his stethoscope hung over the back of his neck. This large photo is, as far as I know, still adorning a bus shelter I drive past too often. It is saying look at me, I am a doctor, I am cool, I save lives.
The old image of a doctor is of course a stethoscope dangling from the neck like a neck tie (which doctors innevitably wore in those days). I often wonder how often they snagged their stethoscope on something.
When I first started going to into hospitals as a medical student, nurses slung their stethoscopes around their necks which most doctors carried their stethoscopes in the pocket of their coats. (Surgeons never carried a stethoscope why would they?)
Gradually people started slinging their stethoscope over the back of their necks. Even I did. We thought it looked cool. Except you still snagged it on things plus the rubber irritated your neck (some people had cloth sleeves made for that purpose). In fact after a while with everybody doing it, it was no longer cool so I stopped as did most people and my stethoscope went back into my pocket. Somewhere along the way, I lost it or it was stolen. I now borrow stethscopes when I need one and I rely on the ETCO2 for tube placement (I still make medical students and residents listen!)
The image of a doctor used to be, a clean white coat, shirt, tie and nice pants. (These doctors were by the way always male). There seems lately to be a trend where doctors are photographed wearing OR greens and with a stethoscope or further props. The stethscope is after all only one of many tools a physician uses. Why didn't he have his picture taken using an otoscope, or a rectal glove?
Anyway why should it matter whether he is a doctor as to whether he will be a good member of the legislature. And certainly there are better ways to advertise your professional qualifications than to have your photo taken wearing your stethoscope.
Monday, March 24, 2008
Whiplash
I spend half my time doing chronic pain management. This has meant spending more time associating with lawyers than anyone should have to. Most of this is related to motor vehicle accidents. I don't really mind doing it; for my patients I feel that I can help them by making their medico-legal reports as timely, balanced and accurate as possible. I have a smaller number of medico-legal referrals. These are very interesting to do and the best thing is that I get to make lots of recommendations knowing there is absolutely no way I will ever have to follow-up on them.
Automobile insurance premiums have increased dramatically this millenium. This for the most part due to the insurance industry's poor investment track record and also because they can. I don't really want to discuss this much in this post. A couple of years ago in order to reduce costs, the Alberta government legislated a $4000 cap on "pain and suffering" which was supposed to reduce premiums. A judge recently ruled this cap unconstitutional so we are waiting to see what our newly re-elected government does.
A few observations on whiplash:
1. Nobody actually knows what causes it.
There have been all kinds of studies and some people say it is due to damage to cervical facets, some people say it is due to muscle damage and of course some people say it doesn't exist.
People don't die immediately from whiplash; autopsy findings on people who die in MVAs are not reliable because the forces are entirely different. I did see a case report on an autopsy of someone who committed suicide shortly after an MVA but that is a single case.
There are no really good models to reproduce whiplash. Animals are no good, there are no animals who are the same size as humans and walk upright. I have seen studies with human volunteers but these are carefully controlled studies and of course there are limits on what you can do to a volunteer. There are studies done with cadavers but we all know that even a freshly dead person feels very different from a live person.
Imaging is not very useful. There is never any bony damage, soft tissues show up poorly on even the most sophisticated types of imaging. Imaging of muscle will show structural but not functional abnormalities.
Bogduk "proved" by doing diagnostic blocks that it is damage to the facets that causes whiplash, however only 30% of his subjects passed his rigorous blinded blocks which makes you wonder what caused the pain in the other 70% of his patients with neck pain.
Now you would think that with such a large public health problem, especially one that has such an impact on the bottom line of the insurance industry that we would like to figure out why people get this condition. Unfortunately the only way to do this is to do a huge cohort study where you can look at as many people as possible with whiplash and follow them thru their course, doing a standardized workup and standardized treatment. This unfortunately requires the cooperation and involvement of the insurance industry which immediately taints the whole process plus most people's lawyers will advise them not to participate. This is exactly what happened to a colleague of mine when she tried to do such a study.
2. Getting rear-ended is not physiological.
Human beings are slow moving. This is probably what forced us to become intelligent in the first place. A sprinter who runs 100m in 10 seconds is running at 36 km per hour. This is of course the fastest speed a highly trained human can run under perfect conditions and only for a short period of time. Most of us move slower. This means that the collisions that we have experienced and survived over our evolution have been a signficantly lower speed than even the slowest car. Actually probably the fastest collision speed humans experienced would have been falling from a height which beyond a certain height is bone breaking if not fatal.
While sitting in your car, you are somewhat protected from the moron who runs into you, your body is still going to have to absorb a lot of the impact. In a sense you are being exposed to an impact that humans have only had to absorb and walk away from over the last 100 years.
In North America we typically don't investigate rear end collisions unless there is significant damage to the car. In Australia they apparently investigate all collisions and a researcher by looking at the crash records found that on the average, the speed of rear-enders with pain was 15 kph higher than rear-ender without pain.
Now add to that, the fact that there is a good chance that the vehicle that hits you is likely to be a SUV, which is much heavier than the cars we drove in the 60s, plus because they are higher the impact point is going to be higher.
3. What about seat belts?
No doubt seat belts prevent deaths in head on collisions and there is absolutely no way I would ever advocate not wearing one. Having said that, there is a theory that seat belts in particularly shoulder belts may actually increase the incidence of whiplash (maybe we should release them when stopped at traffic lights.)
4. Headrests
Most people don't have their headrest at the right height, further taller people cannot get their headrest high enough. But the only way apparently a headrest can help you is if you are leaning back against it at the point of impact. Who does that at intersections. You are looking to the side at traffic, waiting for the light to change, fixing your make-up etc.
5. The legal/insurance complex
Everybody is insured or supposed to be. In a rear end collision the rear-ender not the rear-endee is always in the wrong correct? Apparently not.
Say for example I am rear ended. I just need some analgesics and I have to take some time off work to attend physio. So after everything is said and done, I ask my rear-ender's insurance company to reimburse me for my trouble and lost income. To do this, I have to hire a lawyer who will deal with the insurance company's lawyer and eventually years later if I don't just say shag the whole thing, I might get some money.
The above is a simple claim. Suppose I can't work and/or require more treatment.
This is where the lawyers start to really earn the big bucks. Joining them shamefully are certain physicians of which I occasionally am one. All the treating physicians will be asked to submit a report for which they will be reimbursed handsomely. My medical association says I can charge $400 per hour for such reports, some people charge more.
Then we bring in the IME. This stands for Independant Medical Exam. This is of course not independent, and barely medical. Most IMEs are done by elderly physicians as a way of financing a comfortable retirement. A few younger physicians have gotten into the game in a big way. Now if your retirement or your medical practice depended on the insurance industry (who pay for most of these IMEs) whose side do you think you are going to take, especially when you have a diagnosis as nebulous as whiplash (remember as above we don't even know what causes it). Many patients get several IMEs which judging by the volume of paper generated are costing well over $10K eacg. The Plaintiff's lawyers will also order at least one IME to rebut the other IMEs. I do about one of these a year which with the amount of paper I have to review means that I frequently end up charging more than $10K which the lawyers pay quite happily.
Another thing that really amazes me is the slowness of the process. Occasionally I get behind and let things slide but I rarely get any angry phone calls or letters asking why the hell haven't I finished yet.
Meanwhile, the poor patient is often not working and trying to scrape through why he awaits his eventual settlement. It is not unusual for these things to drag out 7 years.
These cases rarely go to trial. They are almost always eventually settled and the patient gets something. The lawyers in negotiating the settlement will always make sure their costs are covered.
Now as I mentioned, because the driver who caused the accident is always at fault, he will have been paying higher premiums for several years by that time.
Another factor of the endless exams that the patient must go through is describing the accident over and over again. Just about every IME I read has a detailed description of the accident. One thing we have learned about post-traumatic stress syndrome over the years is that the worst thing to do is to describe the event over and over again. Talking is okay in a therapeutic setting with a therapist who knows what he is doing, but the IME is not a therapeutic setting.
6. Most of the these are not simple taps from behind at an intersection.While we talk about "whiplash" most of the patients I deal with in the pain clinic where in much more complex collisions. If they were stuck from behind, they were usually struck at higher speeds and by a vehicle much heavier than those. In fact most of the more severely injured patients I see were T-boned or in head on collisions. Therefore there is almost always an element of PTSD. PTSD is by the way not a sign of weakness but is a consequence of the accident.
7. There is no green cure
That is one of the most pervasive myths in the medico-legal field. Patients do not get better after their settlement. Firstly most of them don't get a settlement. They either give up or they lose due to the "IME's". The rare patient who gets a settlement doesn't get better. Trust me, I have followed some patients from shortly after their accident until years after their settlement.
8. These people are not faking their symptoms to get some money
Many of these people are not working. In only a small percentage of cases is anybody getting any benefits until they get their settlement. Some have lost their houses. Quite a few of these people are on welfare. When they are getting benefits, it is quite often long term disability from work rather than anything related to their accident. Quite a few are on CPP disability. Now anybody who is going to put their life on hold for the 7 years it takes to get a settlement is suffering from some severe psychopathology (of course that's what people say about them anyway).
I have over the years heard about whiplash scams. The operative word is heard just like I've heard about alligators in the sewers. I'm sure it does happen. In fact one of my wife's cousins disconnected her brake lights so that she would get rear-ended. I have heard about incidents where a car was rear-ended and suddenly 5 "passengers" jumped into the car. I have heard of places in such cars being sold. But that is just that, I have only heard; I have never seen any verification. This is, by the way, insurance fraud which our judicial system takes a very dim view of.
Another resource the insurance industry uses is the private detective videotape. I had been following a patient with a whiplash associated injury for about 2 years when I got a copy of an IME which referred to a videotape which proved that she has faking her symptoms. My first impulse was anger, that this patient had pulled the wool over my eyes. In fact what happened that one of the private dicks would let the air out of her car tires and they would then videotape her trying to change her tires. This happened so often she finally joined the automobile association. On the eve of her trial, I actually got to see the videotape. It basically showed her struggling to change her tire with one hand for about half and hour,after which she got out an air compressor, inflated her tire and drove to a garage. Nothing in the video conflicted what she had said about her symptoms. Yet I met another doctor who had been involved in her treatment who, based on what she had been told about the video, now thought she had been faking all along. The other tactic is the edited videotape. One patient I saw was under surveilance for 8 hours out of which 20 minutes of tape were produced. Hardly a representation of his ability to function.
Now I did see a videotape of a patient where after viewing the tape, I told her lawyer that based on what I saw, I would be uncomfortable testifying on her behalf. The video was by the way taken in a very sneaky fashion and it was apparent that they may have tampered with her car as well.
And by the way what do we tell patients in pain management programs? We tell them to live as normal a life as possible, to do everything they possibly can. We do this knowing that somebody might be watching them. (WCB are also great videotapers in this province as well).
9. The adversarial system feeds this whole thing.
For various reasons, auto insurance is mandatory. You could look at this as medicare for the car. Suppose in the 1960s the government instead of bringing in medicare had just made health insurance mandatory. Say if you are having crushing chest pain and your doctor says you have angina. Instead of having your CABG right away, you have to go to a whole bunch of IMEs by your insurer, you get videotaped out walking; "proving" you don't have angina. 7 years later your estate might actually get the funding for your CABG. Kind of what Michael Moore described in Sicko.
Why not replace this system with a no fault system. The current rabble of IME hired guns would be replaced with true Independent Medical Examiners, certified by the Provincial Licensing Bodies instead of the weekend courses they currently take.
That would for the most part cut out the lawyers and about 2/3 of the IMEs currently done. The private dicks could go back to staking out cheap motel rooms or whatever they do.
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