Thursday, January 15, 2009

Those Uppity Students!

The chairman of my department got a phone call from the hospital medical director a few months ago. "One of your anaesthetists said it was a good thing one of the medical students was going into family medicine because she is stupid", said the medical director, "I am a family doctor and I really resent that." The chairman investigated this of course and on talking to the anaesthesiologist involved a different story emerged.

This anaesethesiologist who is a really nice guy was preceptored with a student intern for a week as is the practice at our hospital. The student wanted to go into family medicine and told him so. One day after she missed several IVs, he said jokingly, "boy it's good thing you are going into family medicine." (As an aside, I did general practice which was what we called family medicine back then and in rural settings, my ability to start an IV saved my butt more than a few times.) She however didn't take this comment well, complained to the appropriate persons and it ended up on our chairman's lap.

I really hate the term politically correct however the only way to describe our chairman is as someone who is not politcally correct.

And so it happened that a few days later he was doing the plastics list. A student was scrubbed in with the plastic surgeon and was being pretty quiet. For some reason he thought this was a good time to tell this story. Which he did in his loud politically incorrect way.

A few days later he gets a phone from the University Chairman of Anaesthesiology at the CofE. It seems that the rather quiet student intern scrubbed during the plastics case was the same student intern with the problem starting IVs. Says the CofE chair, " I have just gotten off the phone with the assistant Dean in charge of equity." The jist of the whole conversation was that he would like an apology to the student from our chair. Our chair basically said, there is no way I am apologizing for this and that fortunately is how things ended.

Tuesday, January 6, 2009

Bad work habits 1

This being the New Year and resolution time, I feel I should confess some bad habits that I have acquired. I have no intent of changing them but talking about them makes me feel good.

I leave the room while patients are asleep.

Not just when I have a resident and we don't have anesthetic assistants or nurse anesthetists in Canada. From time to time I just get up and leave the room!

This is the cardinal sin of anaesthesia. From day one of our residency it is beaten into us, thou shalt not leave the room. Sleeping, staring up at the ceiling, talking to people with your back to the patient are okay. Reading is slightly frowned upon (I will comment on that in the future).

Our medical protective association considers this such an egregious violation of the standard of care that they will settle any case where this happens out of court. The courts have over the years taken a very dim view of this. Even the criminal courts have taken a dim view of this; about 15 years ago an anaesthesiologist who had a patient die while he was out of the room taking a phone call spend 6 months in jail. This by the way didn't prevent him from getting another job and as far as I know he is still working somewhere.

Now I only go out of the room when I have to, I minimize the time I am out of the room and I try to pick "safe" times in the case. I will give you examples of when I leave the room.

1. Bathroom breaks.

When my kids were younger they brought home all kinds of nasty viruses from daycare and school. This usually resulted in my having to sprint to the nearest toilet every once and awhile. I also confess to having a weak bladder. I am sure I should never have been offered a residency in anaesthesia. I compound this by drinking way too much coffee. I used to work in a teaching hospital. Unfortunately residents no longer think letting staff anaesthesiologists pee is educational. Of course many of my bathroom breaks were sudden and unscheduled.

2. Finding equipment and drugs.

Even after 18 years as a staff anaesthesiologist I still don't anticipate very well what I am going to need or the piece of equipment isn't in my cart and I didn't check. I could ask the nurse to go fetch the equipment but I learned at the CofE how useful that is. Usually I know where I can find it and can get it quicker myself.

When I was a resident, I was in my last year and the staff was "letting" me do a AAA by myself. For some reason we did not keep more than 1 litre of fluid in the room at that hospital and while there were bags and bags of crystalloid in the hall, it had been beaten into my that I could not leave the room, so I asked the nurse to get me another litre. She promptly went to the intercom and paged the staff back to the room. When he arrived quickly figuring something had gone wrong, she told him "I am not spending the entire case fetching things for him (pointing at me)"

3. X-rays

OR nurses and X-ray techs believe that anaesthesiologists are immune to the effects of radiation. At least that is why I think they never bring in an X-ray gown for me. Therefore if they are only shooting a few shots I generally step out into the hall. Actually one of my near misses occurred doing just this. I had taken over a case from someone else, it was an ortho case and they were doing X-rays at the end of the case so I wandered out into the hall for a few minutes. When I came back in the room, the heart rate was 20. I never figured out why that happened but I could be in jail right now.

4. Food and coffee

Cases frequently run over lunch. Infection control frowns on eating in the rooms. Actually I quite frequently fervently eat my sandwich in the room. I have on occasion got nurses to bring coffee and a muffin into the room for me (I paid of course).

5. Recovery room

You take the patient into recovery room, he is completely stable, you go out pee, have coffee eat, chat to your next patient put him to sleep and ....that is inevitably when your previous patient starts to circle the drain. The courts have said, "Thou shalt not leave thy patient". My conscience says I should weight the risks and do what is best. Of course if I think my patient in the OR is stable and can be left I will go to recovery. I have done this a few times in a career, fortunately not often.

There was a case quoted where someone left his patient in the OR because his patient in recovery had arrested. While he was in the recovery room, his patient in the OR arrested. He was undoubtedly unlucky or a really bad anaes. The judge no doubt prompted by "expert witnesses" said that what he should have done was bring the patient from the recovery room into the OR. In what universe did they live in?

Anaesthesia is of course the one specialty where the dogma of total dedication to one patient only applies. During my residency, I had to do six months of internal medicine. I remember several times where I was with a sick patient I felt I couldn't leave and was called for a more trivial problem. I usually explained that yes I would be by sometime but that it would not be for a while because I was with a sicker patient. This was usually followed by a phone call from the nursing supervisor ordering me to attend the other case and in one case a letter. (I never somehow figured out how to lie and say, yes I'm on my way).

Anyway it would do the profession good, if we got off our high horse and went from a total prohibition of hallway time to a harm reduction strategy. We could say in what cases it is acceptable to leave a patient, for how long and what type of contingencies we should use (tell the nurse?, tell the surgeon?).

Meanwhile I continue to live on the edge.

Friday, January 2, 2009

Reusing syringes

About 2 months ago, I caught the end of a radio story and heard that hundreds of patients were going to have to be tested for HIV and Hepatitis. I wondered what had happened. Later in the day, I learned that at a hospital north of here, it had been discovered that nurses administering sedation for endoscopy and dental procedures had for years been using the same syringe between multiple patients. Later we learned that this had been routine practice at another hospital in another province. These stories occupied the front pages of newspapers for days and I believe a few people lost their job over it. Our health authority got into the act by issuing a stern warning against the practice.

One of advantages of aging is that one gets to see the evolution of practice and how yesterday's standard operating procedure becomes today's horrified headline.

In 1986 when I started my residency the re-use of syringes by anaesthetists was routine. There were degrees of this. One prominent anaesthesiologist who we called Dr. Bob used the same 4 syringes all day. (His son-in-law who worked in the same department had to go to elaborate lengths hide the syringes he threw away). Other anaesthetists would switch syringes but often put the contents of a multi-dose amp like fentanyl or droperidol into a syringe which they used all day. There were extremists who preached against the re-use of syringes including our department chair who made dire threats against any resident he caught re-using syringes. (This same individual threw away a brand new laryngoscope after using it on the first known HIV patient to come to the OR).

Partially due my fear of the chief, my distaste for Dr. Bob and common sense lead me to decide that I would not re-use syringes. In my first job as a staff anaesthesiologist I quickly noted that by the end of the morning I would run out of syringes and have to be re-supplied. This lead me to believe that I was the only person who didn't re-use syringes. One exuberantly unrepentant anaes. proudly used the same 4 syringes all day. This fellow was also known for never having mixed up a bottle of pentothal. At some point in the day you would spot him out of the corner of your eye refilling his partially empty syringe out of your pentothal bottle. During my brief tenure as quality assurance person for the department I did raise the issue of re-use of syringes. He stated when there was evidence that it was a bad thing he would stop but frankly he found it wasteful to throw away syringes. He had for years blocked the adoption of circle systems by the department which meant we still used Bain circuits with their 5 L / minute flows. Because it was common knowledge that he (and other members) re-used syringes, at the end of every day, every non-virginal multiple dose bottle, no matter how large and expensive had to be thrown out.

One thing nobody commented on in the press was that the danger to the patient's health of having a nurse administer sedation to them was probably much greater than the risk of catching any blood-born disease.

While I don't know why they did it or what they used, I do have some suspicions about what was going down. I suspect that the nurse was using meperidine for sedation and rather than having to go thru the hassle of signing out a dose for each patient, was signing out multiple doses at the beginning of the day and drawing them all up into a single syringe. She also may have been using propofol or even midazolam.

Thursday, January 1, 2009


I won an award last year. I'm not terribly proud of it and it is still sitting on my desk. A society which I helped found and on whose executive I sat gave me its yearly "Outstanding Service" award. I begged them not to; I gave them all kinds of names of more deserving people but they still wanted to give me the award.

The afternoon of the award ceremony I was having lunch with two other doctors and we got into the topic of awards and how stupid they are (actually the other two got into the topic, I just nodded in agreement). I knew at that time I was going to get that award so I just hoped they weren't coming to the dinner that night.

Anyway, I pretended to act surprised and pleased and used the mandatory speech time to thank all the great people I have worked with or used to work with. (I of course didn't mentioned all the assholes I worked with.)

I thought about this because yesterday the New Years list of the Order of Canada recipients came out. This is Canada's answer to knighthoods and peerages which Canadians are no longer eligible for. I have long given up any pretense or hope that I will ever get one of those awards.

The first thing that raised my blood pressure was the announcement that Celine Dion had been elevated to the highest level. This means that Celine Dion already has an order of Canada. This is of course the Celine Dion who lives in the US, and who waited six months to bring her baby back to Canada just to ensure that her baby would be eligible for American citizenship.

The other Order of Canada that set me off was the announcement that one of the local cardiac surgeons (not the one whose legs are now longer) had received the award. It spoke of his leadership and his role in innovations in cardiac surgery.

Innovations? Basically cardiac surgeons work the way they have worked for the past 30+ years. They sew harvested veins onto diseased arteries. Occasionally they take out rotten hearts and sew in new hearts. They take out old valves and put in new valves. But all the advances in cardiac care in the past 20 years have come from the cardiologists. Most of the advance in transplant care have come from improvements in immunosuppression. We shouldn't forget the anaesthesiologists and intensivists without whose participation cardiac surgery would be a much more risky procedure.

A few years ago our provincial medical society in honour of the provinces 100th birthday came out with a list of the 100 physicians of the century. Now the problem with such an ambitious list is that there are probably a maximum of 20 doctors who obviously need to be included. Then you have to fill out the other 80 positions. This inevitably means you include quite a few "Celine Dions" and ignore a lot of hardworking doctors who worked in the trenches.

One of the more egregious "Celine Dions" was a young transplant surgeon at the CofE. One of the many programs of excellence at the centre of excellence is the pancreatic islet cell transplant program. Research into this had been going on for years when this individual arrived on the scene as a transplant fellow. He was English, had an incredibly posh accent and just happened to be the transplant fellow when years of research by other people reached its fruition. He of course became the face of the program and indeed of other organ transplant programs. The fact that his surgical skills were below average and that he was an incredible arrogant and pompous asshole. Becoming a physician of the century only made things worse.

Bitter, not at all. As I mentioned I got an award last year too!

Stupid Allergies Part 2

I wrote a while ago about stupid allergies that we come across in hospital.

I gave as an example the patient who says she is allergic to penicillin because of a yeast infection. I do remember that example from when I was in general practice but after bringing it up it only took a few weeks to see that allergy rear its stupid head again.

A patient comes down to the OR the other afternoon with two ampules of clindamycin taped to her chart. Using my best Sherlock Holmes without even reading the chart I knew she was allergic to Penicillin.

So of course I read the nursing notes (this being an ortho patient and the history therefore totally useless) and under allergies, it goes Penicillin----Yeast infections. Now this was copied out by a nurse after talking to the patient. You would think that the nurse as an educated professional would say, " No deary, you aren't allergic to penicillin and the yeast infection you might get after Ancef is nothing compared to the C. Diff infection you might get after the Clindamycin".