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.

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.

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.

Death on the table

We recently had a death in the OR. Actually the patient died in the ICU afterwards but it was essentially a "table-death". This was a laparoscopic gall bladder in an octagenarian. She had an uneventful OR and then arrested in the recovery room. I didn't do the case but responded to the alarm, stayed for while until I figured there was enough help, so went on my way. Anyway she had a complex but no pulse which lead me to think she might be bleeding. After some rescuscitation they took her back to the OR where there was bleeding in the retroperioneum around the pancreas that nobody had noticed. She as I mentioned later died in the ICU.

This reminded me of a few things.

The first thing that came to mind was something that happened to a staff anaesthetist where I trained. This individual was not a very good anaesthetist. He however felt that he was the best anaesthetist around. This is a bad combination. He wasn't really fun to work with as a resident. (Aside from being a pompous twit, he had a nasty habit of poking you in the shoulder to make his point; nowadays laying hands on a resident would land you in the Dean' office.)The event in question however happened about 2 years after I finished. By that time I gather there had been a few other episodes.

He was doing a laparoscopic cholie around the time that surgeons started doing laparoscopic cholies and those of us who worked in that era remember what a dark time that was(3 hours of farting around followed by an open cholie). I gather during the case, the blood pressure continued to fall and fall. He asked the surgeon if there were any problems and of course the surgeon said no so on they went until the patient died.

My former "mentor" was told soon after that it was time he retired. This was before the autopsy showed a belly full of blood which the surgeon had failed to notice. Unfortunately my mentor had to keep retired while the surgeon is to my knowledge still working and hopefully learned something that day.

I have unfortunately over the years had a few deaths in the OR and few people that expired shortly after. Most of these have been predictable, ruptured aneurysms of both types, traumas and of course the ICU cases sent to the OR to be euthanized (this patient is going down the tubes and we can't think of anything to do so lets operate on him). Self flagellation comes naturally to anaesthesia and we always wonder if there was anything we could have done differently and looking back over the years, I don't think there was except maybe I could have run away.

The wierdest thing about a table death is that you usually have to start another case right after. Either you are on call or this case bumped into your elective list or it was in the middle of your elective list. So after an hour or so to clean up the mess and do the paper work, back in the saddle. Strange.

Several years ago, we had a province wide committee on peri-operative deaths and it was an interesting exercise. Essentially if a patient died within two weeks of surgery you had to come down to medical records, review the chart and fill out a form. Many of these were of course patients you knew died or you thought were going to die but you got the odd patient who just happened to die a few days post-op for no apparent reason. As I say it was interesting (and easier than reading the obits and looking for names you recognize.) This initiative stopped during our time of health care reform and downsizing in the mid 1990s when the province and hospital admins got worried that death might be attributed to their restructuring efforts.

More Shame

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

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

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

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

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

Like I say, I used to be disgusted.

Why I Went Into Anaesthesiology

As I mentioned, I interviewed new prospective residents about a month ago.

I didn't ask people why they wanted to be an anaesthesiologist (instead I asked them why they thought it might be a bad idea to go into anaesthesiology). The stock answer to why they wanted to become an anaesthesiologist seemed to be something about being interested in the physiology and pharmacology involved with anaesthesiology.

That wasn't why I went into anaesthesiology.

One day during my clinical clerkship, I was "assisting" on an open cholie. "Assisting" involved retracting the right costal area with the infamous Deever retractor (eager beaver with the deever). This of course meant you couldn't see anything which was afterall the justification for you actually being in the OR. In addition because you couldn't see anything you couldn't see whether you were actually helping, which meant you were constantly being nagged about this with the volume and sharpness of the nagging going up as the case went on and your arms got tired. Plus in those days, it was actually acceptable to hit students which meant the odd rap across the knuckles with a needle driver.

Anyway I was in the midst of one these ordeals when I looked over the drapes. There was the anaesthesiologist sitting in his chair with his feet up, doing his crossword.

And I said right then, "that's got to be a good job!".

Yet another reason to be ashamed to be a doctor

A number of years ago, a lady came to me with a diagnosis of fibromyalgia. She was in significant pain, was on long term disability and had tried all the usual nostrums for fibromyalgia.

After some discussion I put her on a small dose of methadone. Because methadone blocks NMDA receptors, the theory is that it might be a good medication to try in fibromyalgia.

Now I have not been able to duplicate this success with many other patients but she did fabulously. Her pain decreased, she slept better, she was more functional. She had at that time been off work for many years so going back to work was not really in the cards and her disability insurer didn't seem too unhappy with that.

Over the year or so I followed her, she increased her medication slightly but stabilized on less than 10 mg per day. Her family doc who did palliative care and had a methadone licence then took over her care again.

About a year ago I got a new referral to see her. The letter said that her family doc, had retired and that her new doc didn't have a methadone licence.

Methadone licences to treat pain are relatively easy to get in our province; in addition it is possible to get a licence to treat only one patient. I phoned her doctor and told him I would send a letter supporting his application for a patient specific licence. He said he really didn't want to do that.

Several months later I actually saw the patient again.

She told me that since her old family doc had retired, she had been making the rounds of family docs who were taking new patients. All of them flatly refused to see her after learning she was on methadone even though it was clearly for pain and not for addiction. The last guy, the one who referred her to me said he would be happy to look after her medical concerns but would not prescribe methadone or any narcotic for her.

While certainly prescribing narcotics is controversial and little bit of a hassle, here we have a patient who is on a stable dose of medication that is clearly benefiting her and yet we have a series of doctors who refuse not only to look after her pain but refuse to even take her on as a patient.

I can think of a few medical conditions that are a lot more of a hassle to deal with than a patient on a stable dose of narcotics. Insulin dependent diabetes and anticoagulation come to mind. I wonder how many doctors turn down those patients. (Sadly I suspect quite a few).

As I said in my referral letter, "this is a sad reflection on the medical community".

Excuse me, aren't you on call?

A couple of days ago, a patient of mine in the pain clinic had a seizure. This was after an epidural steroid injection. I didn't use any local except for skin infiltration. Like many epidural steroid injections he was olders. In addition he was a diabetic and a smoker.

After I checked my own pulse and reassured myself that I hadn't done anything wrong (unless you believe epidural steroids are inherently wrong), I thought what the hell is wrong here. So the differential included:

1. A sycopal epidode because of pain followed by a seizure secondary to cerebral hypoxia.
1a. In a diabetic smoker a sycopal event associated with cardiac ischemia.
2. Seizure secondary to a cerebral mass lesion exacerbated by increased ICP during epidural injection.
3. Electrolyte abnormality
4. Hypoglycemia
5. Others that I haven't thought of.

Although the seizure only lasted about 15 seconds and he wasn't very post-ictal afterwards I felt that he probably warranted further investigation and probably some observation. So I paged internal medicine on call.

The internist answered my page right away and I told him the clinical scenario. His response was, "well I don't know when I'm going to have time to see him". He told me to order some blood work and if everything was normal to send the patient home with no follow-up.

I was somewhat astounded. This wasn't a newer physician but one of the older more "respected" members of the medical staff.

I have some empathy for internal medicine. I spent 3 months on a general internal medicine service as a resident. They tend to be a dumping ground for every type of medical problem without a lucrative procedure attached; for those people who don't have much wrong with them except that they can't be sent home etc. They make a lot less than their procedurally inclined colleagues. Fine that is a problem that is at least 20 years old. I shouldn't be put out because you haven't figured out how to deal with this.

It strikes me that general internal medicine like family practice before them is in the process of getting out of the hospital and in general in looking after sick patients at all. I am told that most of them now only round 3 times a week on their inpatients which of course means that their patients don't get discharged as quickly which has meant medical patients spilling over onto surgical beds. Instead as family practice focuses more on looking after patients who really don't have anything wrong with them, internal medicine is sliding into the niche of looking after patients who only have a little bit wrong with them but are getting paid consultant rates for doing so.

Take the traditional pre-operative medicine consult. This was a cash cow for internists in the past with every consult ending with, "Fit for surgery, avoid hypoxia and hypotension." Now less than 10% of those consults were actually necessary or useful but now we very often can't even get those 10%.

I brought this up with the chief of my department who suggested reporting this to the licensing body. I am mulling it over but I really can't bring myself to rat out another doctor for only following what has become a trend in medicine.

So I put it on my blob