Tuesday, December 28, 2010

My Big Screen TV is Sucking Out My Brain

When we renovated our 40 year old house, we added a Man Room above our garage. This is nominally my home office. It was supposed to be place where I would read, reflect and practise my saxophone. Except I went out and bought a Big Screen TV. Now instead of improving myself, I am watching Seinfeld and The Office re-runs.

A few years ago I got hooked on a group of my favourite series; ER, The West Wing, NYPD Blue etc. One day I had the revelation that these shows had taken over my life and that I was actually scheduling things around them (including taping the shows if I wasn't going to be around). I also realized that I wasn't reading and as I had just recently started playing saxophone, I wasn't practising. In a rare moment of self control I resolved to not watch TV anymore except of course for hockey and football games. This I mostly kept until the BSTV came into my life.

My relationship with TV has been on and off. We got our first TV in 1961 or 62. It was a large black and white set which my parents actually bought used. We had an large antenna on our roof which in Victoria enabled us to get all 3 American Networks plus some Canadian channels. My parents actually exercised some restraint on what we watched. We watched very little during the day and my parents tended to only watch the CBC news and public affairs programs. And Hockey Night in Canada of course. This is at least what I remember.

Cable came to Victoria in 1965. Every other house on the street got cable. We didn't. Worse my principled parents took down the antenna so as to not be the only house on the street with one on their roof. We instead got rabbit ears. It was a dark time in my life. We could only get three channels. Consequently I missed most of TV during the 1960s; I am horrible at Trivial Pursuit Baby Boomer Edition.

We did finally get cable around 1970. Our TV was still black and white. One day my father came home from visiting a friend incredulous that on his friend's TV you could actually see the puck roll. We got a new TV. I believe it too was black and white but we did soon get a colour TV.

Even in the dark days without cable our TV had a place of honour in the living room. My parents set the agenda as to what we could watch which for the most part was whatever was on the CBC.

My wife and I when we got married both agreed to limit our TV exposure and as soon as we got a house, our TV went down into what we called our family room. Our living room became a sanctum where we entertained company or sometimes read when we didn't want to watch TV.

When we initially got our first vacation dacha, we decided there would be no TV, we would read and play board games. We soon broke down and bought a TV which we watched rented movies on plus whatever we could get on rabbit ears. A couple of years ago I finally got cable. I rationalized that people wouldn't come over to our house on Saturdays because they wanted to watch hockey. Plus I got internet.

Meanwhile at home, only having one TV lead to no shortage of conflicts especially at playoff time. When our children were younger, we watched slightly risque movies on my laptop in our bedroom so as not to corrupt our children (actually watching sex scenes with your adult children is kind of creepy too). Therefore I like to think that getting the second TV has increased the harmony in our household. Now I can watch TV sports, the History Channel, and of course Seinfeld reruns without any guilt or conflict. Except of course at the growing pile of books which I seem to buy faster than I can read them.

And my brain is slowly being sucked out.

Saturday, December 25, 2010

Merry Christmas

I love Christmas. I am not sure whether it is the presents, the time off or the knowledge that once again the days are going to get longer (even if we are still possibly looking at 4 more months of wintry weather).

I am off once again this Christmas. I have been fortunate most of my professional life in working in large departments with people who preferred to work Christmas in exchange for other parts of the season off, not to mention those with ex-wives and large mortgages who have to work.

The hospital where I now work, is only open for emergencies throughout the Christmas slow down which this year is from December 23 through January 3. Therefore we only have to provide 2 people every day and as we had more people available then were slots for them to work, I won the lottery (not necessarily the one I would like to win) and am enjoying an extended time off work.

One of the more interesting things about Christmas that fascinates me is how we are more or less shut down the health care system for almost 2 weeks and no one seems to suffer. Of course people still have heart attacks, trauma, appendicitis and babies but we seem to handle it all very well on a skeleton staff. I say this of course as someone who hardly ever works at Christmas but it seems true. We don't do much scheduled surgery over Christmas and sadly a lot of our work comes from complications of scheduled surgery.

Of course while at work just before Christmas I did find this article from the National Post which seems to contradict everything I just said. I could try to explain.

Merry Christmas and barring my own injury or illness, you won't be catching me near a hospital.

Saturday, December 18, 2010

Some Heavy Reflections

As I posted earlier, I am now what we now call site leader which among other things means I get to referee disputes between the surgeons and us.

Around midnight I was roused from my mid-winter's nap by a phone call from the anaesthesiologist on call closely followed by the surgeon on call. It seemed my surgical friend wanted to do emergency surgery on a 600 pounder. There were a number of problems with this most important was that there was no ICU bed available. (My buddies in ICU are of course in no hurry to take on a patient who may be on a ventilator for weeks.) The other issue was that he did all his other emergencies before taking on this patient instead of doing it early in the evening when people are fresh and there is more help. In the surgeon's defense this was the classic internal medicine Friday afternoon dump whereby they sit on a patient with a clearly surgical problem until the weekend looms. The second call anaesthesiologist was pleading off citing having worked since 0700 and medical issues, leaving the night call person to deal with this horrendoplasty by herself. I figured that now that my sleep was totally disrupted and that the beers I had drank earlier in the evening had worn off, that the simplest solution was to come in myself and help. Plus there was the thrill of the chase; I have never done a patient that big.

I am not going into the details of the case but as we walked from the room where we had gone to see just what we were in for, I remarked to her, "I hope I never let myself go like that."

I thought about what I had discussed with one of the nurses earlier in the day. I was looking at the pile of Christmas candy that grateful patients had brought into the Pain Clinic (and the clinic before it) and I had remarked that with so much hunger in the world, why do we allow so much of our caloric production to be devoted to food that is so unhealthy and so largely unwanted. I realize world hunger is much more complicated than me simply giving up my Ferraro-Rochers but what a concept.

While trying to salvage my Saturday plans that had been turned on their heads by my late night/early morning adventure, I was thinking about the whole issue of obesity. I realize that obesity is again a relative thing; that by arbitrarily assigning a BMI to it we may over-estimate it; that moderately obese patients may actually live longer... etc, etc. The thing is that most of us agree that someone with say a BMI over 50 is probably obese and we are seeing more and more of these. It clearly is becoming a public health issue with its comorbidities of diabetes, sleep apnea and the like all of which we on the front lines have to deal with.

When well meaning politicians or public health people actually talk about doing something about obesity like for example limiting people's choices in the types and amounts of food available, there are howls of protest from the right wing press and their libertarian sometime fellow travelers. Nanny state is one term usually bandied about.

On the other hand, if we look at medicine prior to the first half of the 20th century, infectious diseases were the prime cause of death. Even before Pasteur and Koch public leaders recognized that certain measures could prevent the transmission of illness including things like clean water, clean food and on occasion quarantining people. We also developed things like mass vaccination before we even knew about bacteria virus, and immumoglobulins. All of these were in some way an infringement on individual freedoms such as they existed then. They were however for the most part effective.

So why for example do we tolerate a situation where a pack of Twinkies costs less than the equivalent amount of calories in fresh vegetables. I occasionally talk to patients in the Pain Clinic about eating healthy and the usual response is that they can't afford to. Why do we allow our fast food to become supersized? Remember when you could buy an 8 oz Coke or a 12 oz Coke? Remember when buying a soft drink was something you did once a week as treat?. Our hospital has given over half its cafeteria space to a Tim Horton's outlet. Tim Hortons sells mostly donuts but they do actually sell some healthy food. Our hospital's Tim Horton's however only sells donuts (and coffee). On any morning if I am standing in line about 1/3 of the people in line in front of me are wearing hospital gowns.

By way of disclosure, I have been fat all my life. I currently weigh over 50 lbs more than I did in University. I love food. I love a lot of food that is probably not that good for me. I love beer. Periodically my weight balloons and as my clothes get tight my appetite goes down. I have often wondered at what point does one actually lose his self respect and just start to enjoy the pleasure of food.
Perhaps my distaste for the super obese is similar to that of the alcoholic by the reformed alcoholic. I was looking around the room as we got the case underway and about one third of those in the room were less than svelte but I expect they all shared my distaste.

I hope I never end up like that.

Thursday, December 9, 2010

An Open Letter to Don Cherry

Dear Don,

I know you read my blog just like I never miss Coaches Corner. I have bought many of your Rock Em Sock Em Videos and both your books (I don't think I'll be getting your latest this Xmas) Unfortunately you have crossed the line and I not sure whether I will be able to watch you anymore.

Now you and I are the biggest Bruins fans in Canada. You came to the Bruins as coach following the Bruins' loss in the Stanley Cup finals. I wasn't initially too happy with you as coach, we all remember what happened that first season. I was even more sceptical when you traded Esposito. To the Rangers of all teams. But you started to get results, there were the two Stanley Cup appearances, and of course the heart-breaking game 7 overtime loss to Montreal. By the way I like the way you have always taken the fall for Don Marcotte. And of course we loved the way the Bruins played during those seasons, a true team that played hockey the way it was supposed to be played. And a team that has continued to play that way for 31 years after you left them.

I was delighted when you started appearing on Hockey Night in Canada which was at that time the lamest broadcast around. Finally somebody who would tell it like it is, criticize people and wasn't afraid of stepping on toes. Every hockey broadcaster in Canada owes you a debt of gratitude. I like the fact that unlike many ex-NHLers, you chose to come back to Canada. You could have stayed in the US, you married an American after all. I love your support for Canadian teams, including the way you stuck up for our World Junior Team. I also loved your support for our Women's hockey team right from the start.

Lately however you have betrayed your lunch pail roots. That was what we loved about you and Bruins their lunch pail work ethic, how hard they worked for everything. You have instead become a shill for the right wing elite. That's right the right wing elite. There is no left wing elite, Don. Your new conservative friends have always been in power, they have been the elite.

Part of your hagiography Don is your working class father. Well Don, I suspect your working class father was able to afford a house, maybe a car and was able to pay for your hockey equipment so that you could make a career of hockey. And you were probably able to have a pretty nice lifestyle on just one parents' salary. How many working class people can say that nowadays? That's right Don, working class lunch pail guys made a living income back then because they had things like unions and even some "liberal elite" politicians who gave a shzt about them.

Your conservative friends, Don have over the past 25 years conducted a war on the lunch pail guys. They have transferred much of the tax load onto them, allowed industries that employed them to close or leave the country and lately caused the economy to crash. Wages of the lunch pail guys have not kept up with the cost of living. And all those poor dead soldiers who bring you to tears every few weeks? Sent off to Afghanistan to prop up a corrupt government that oppresses women, Christians and ethnic minorities.

What really pisses me off Don, is your latest statements about cyclists. I ride a bike Don. I ride to work, I ride for pleasure, I ride for exercise. Lots of us Bruins fans do. But your new friends don't like cyclists or for that matter lunch pail guys who take the bus to work instead of driving. Now Don, I ride my bike for pleasure but when I go to work early every morning, I pass lots of lunch pail guys riding their bikes to construction sites and factories. They aren't riding for fun Don, they are riding because they had to decide between a car and a place to sleep at night. All they and I want Don, is to feel safe when we go out for a ride.

And those "left wing elites" Don? These are the guys who actually care about those lunch pail guys. Not like your new friend Rob Ford. I don't think they make a lunch pail big enough for him. Rob Ford isn't a lunch pail guy. He inherited his business and all his money. I suspect that after the Leafs are out of the playoffs he cheers for the Habs (maybe even before the Leafs are out). He even pulled a few dirty tricks, that even Scotty Bowman would have been ashamed to try, in order to get elected.

O yes Don. What do you do for a living? You work for the CBC. All of your new friends know that the CBC is a hotbed of the liberal elite. You make a pretty good living from those liberal elites, high 6 figures I heard. Not bad for a 12 minute broadcast.

So Don, why don't you stick to being a buffoonish caricature of yourself between the first and second intermissions and stay the hell out of politics. Because Don, at the hockey rink, left and right wings are positions you play, not positions you hold.

Sunday, December 5, 2010

And by the way I didn't used to play basketball

I am 6'5" (196 cm).

I was always the tallest kid in the class from kindergarten until Junior High. This meant I always got to sit at the back of the class, a habit I still have.

Nonetheless, I was and still am, incredibly uncoordinated and no matter what your size, games like basketball do require some degree of skill. Further most of my growth spurt occurred between Grade 10 and 11 by which time it was really too late to learn how to play basketball. I do remember my Grade 11 PE teacher /basketball coach looking interestedly at me at the beginning of the term. His interest lasted about 5 minutes.

Ice hockey and football, sports where my size would have been an advantage, I never really played.

Essentially all my size gets me is a lot of trouble finding clothes to fit (thank god for the LL Bean catalogue and I hope the Canadian $ stays near par) and a lot of knocks on the head.

What really gets me is how people have nothing better to say to me when we meet but, "Boy are you tall, did you play basketball?" This is not just outside the hospital but frequently in work situations. Now I am physician, a medical specialist, department head, and I have a lot of outside interests. So why is it that people feel necessary to start any discussion by discussing my height.

Other people have distinguishing physical features too. Imagine me starting a conversation, "Wow are those ever big, what are you a 38D?" This would no doubt earn me a trip to the medical director's office and a few weekends spent at sensitivity camp.

Actually I didn't really want to look at your junk

The male body is not really that attractive even for those inclined that way. Some men have faces which can be described as handsome, some men have taken care of their bodies in a way that I can respect. And then there are the other 95% of men.

Even in the most handsome well toned male, the genitalia cannot be described as visually pleasing. It is interesting that the male genitalia have not been subject to the same evolutionary pressures that have driven the breasts and buttocks in women.

Why am I writing this?

About a month ago I joined the local YMCA. This is by my count the seventh time I have joined a gym. Most of them I lasted for at least a year and I always had a good excuse for stopping going. There are of course certain visual insults one has to accept on joining any gym. These include the gym rats, the muscle-bound meatheads, and people wearing outfits they should never be wearing in public or committing crimes against spandex. And what I am going to write about below.

While the Y is an egalitarian organization, this particular Y offers an enhanced membership. This includes an adults only change room with a hot tub, TV, newspapers and a towel service. This costs $200 extra per year. I naturally went for that. No more children's birthday parties in the change room and no more awkwardness changing next to female children brought into men's change room by their dad. Not to mention not having to dry myself with the moldy towel I found in my gym bag.

Anyway I registered paid my fee and the nice lady at reception suggested I check out the members plus change room. I walk in there and what do I see but a rather large naked man sitting on the imitation leather armchairs in the room reading the paper. And air drying in contact with that imitation leather is what popular vernacular is now calling his junk.

I am maybe a little self conscious of my body, and I realize that a certain amount of nudity is necessary in a change room; while changing from street to exercise clothes, walking to and from the shower and of course in the shower. Towels are of course provided although the small towels we get are rarely enough on their own to cover up anything. Aside from that if you want to hang out with all the boys at the Y, you should be either in your workout clothes or your street clothes. Even draping yourself in multiple towel is better.

I would like to think that individual sunning his junk on the imitation leather chair was just an eccentric. Wrong. Just about every time I go there someone is baring it all. Some of them at least have the courtesy to at least sit on a towel.

Myself, after I shower, and soak in the hot tub, I am getting my clothes on post-haste and leaving with my eyes averted.

Monday, October 25, 2010

I Never Knew I Was A Victim

Our national newspaper has over the last week documented the indignities we males suffered and still suffered in the school system

I hope what I am going to say will be taken in the spirit that I have intended it.

As a male who "survived" quite nicely our educational system and as the father of two male children now attending university, I am glad that after 45 years this scandal has been unearthed (sarcasm).

I remember well elementary school. All the girls who showed up to class immaculately dressed while we boys wore whatever we found on the floor; who brought flowers for the teacher; their neat handwriting; their better artwork; how they could sit through 5 hours of class; they were smarter; often bigger; better coordinated (remember skipping in the playground, no boy could have mastered that). They never got sent to the principal's office, never got THE STRAP. Our teachers were all women until at least Grade 6; usually older unmarried women. It was a dark time to be a man.

All of us boys hated girls then. We knew we would eventually marry one but we really weren't sure why.

At the same time at least in the 1960s our mother was at home; our father worked, he was usually gone before we had breakfast, he showed up around supper. He controlled the household, he was the breadwinner. How were we going to go from our state of oppression in elementary school to our eventual destiny?

Somehow between elementary and high school gradually the tables turned. By Grade 12 boys were clearly in charge. Sure some girls got to be student council president but that was only because we let them.

Really not much had changed a generation later. My son actually had a male teacher for Grade 1 but it was clear that elementary school was not a friendly place for boys. I remember going to a play put on by my son's school and being amazed that even the male roles in the play were played by girls with boys playing only secondary roles. But just like when I went to school by high school the tables had turned and boys were at least equal.

The series of articles bemoans the lack of males in university. Actually females outnumbering males is not a new thing; it was the case prior to the second world war, even when I attended university the number were roughly equal. More interesting was the section on McMaster University where 75% of the class were female with the result that affirmative action for males had to be instituted. McMaster is by the way an interesting case, a medical school which from its inception committed to accepting students from a variety of backgrounds with less emphasis on academics with the result that females have for most of McMaster's time been the majority.

My medical school class was 3/8 female the highest percentage and absolute number in the history of our medical school. Once we got over the whole sexual tension of the whole thing (or realized that most of us had absolutely no chance with these intelligent hardworking women, many of whom had boyfriends) we were able to accept them as colleagues and friends and I think they really gave a positive tone to our medical school class. The class behind us which split evenly 50:50 generated 10 couples (as opposed to one from our class).

With our class and with the one a year later, there was much muttering about affirmative action for females. This was in my opinion rubbish. Most of the women who entered medical school in the that time entered with marks as good and usually better than the men, not to mention other intangibles such as personality, life skills etc. What should have been more of an issue was the affirmative action for children of doctors which was the case for not a few people in my class.

Likewise much has been made of how women doctors work less than do male doctors which may be true although many of the new generation of male doctors who want to work less hard than our generation. On the other hand I have trained with a number of female residents, interns or staff whose work ethic put mine to shame.

The bottom line is that while the education system may be a system that gives females an advantage, that advantage is solely limited to within that system and that both sexes are going to go out into a world that is still tilted towards men. It is probably a good thing that boys have to labour against sexism in the education system. Whatever doesn't kill you makes you stronger, besides how else would boys learn to write neatly, behave in public, read, and learn about music all skills that the female centric system forces on boys.

Saturday, October 23, 2010

Nickel and Diming

I read this on Great Z's post and as almost always I agree with his sentiment if not his solutions.

I have always taken my role as a gate-keeper into health care very seriously and so I try with limitations to give the patient not only the best but the most cost effective care. In the scheme of things anesthesiology are not big contributors to hospital costs but ever since I started practice we have had to look at every little cost.

As I mentioned, one of the advantages of getter older is the perspective one gets over practices over the years.

When I started I did my first rotation in pediatric anaesthesiology (the result of this is that to this day, I know the dose in mg/kg of every drug). One of the anesthetists, an older British fellow used what was called the Liverpool technique. This involved 70% N2O, curare, and morphine. No volatile! It was a marvelous anaesthetic from a practitioner point of view; you reversed the muscle relaxant, turned on 100% O2 and the child woke up (or was never asleep?). They all received 0.2 mg per kg of morphine so they were comfortable as well. There was never any hypotension and as the children woke up promptly, laryngospasm was infrequent. What was more significant was the cost. Each case must have cost less than $1 in drugs. The other anaesthetists at the hospital used a similar technique with small doses of halothane.

When I went to the adult hospital for my first adult rotation, the anaesthetist (after admonishing me for trying to figure out the dose of pentothal in mg/kg) chided me for turning on Isoflurane. "You really like the expensive stuff", he said, turning off the Isoflurane and turning on the Enflurane. We of course used Bain circuits with their 5 L flows then.

So it went during my residency. The first time I used vecuronium on a case, the staffman warned me that the patient would sit up during the case. I told him I planned to also put the patient to sleep.

It was the introduction of propofol when we first became aware of costs. I was on staff then at a larger community hospital. Our first attempt at using it was rebuffed by pharmacy, however by sending our bad cop anaesthetist to the next P&T committee, we were able to obtain a rationed supply. Each anaesthetist was rationed to 6 200 mg vials a week. This resulted in a lot of after hours borrowing from other people's carts (we had our own carts there, something I wish I had where I am now) and of course diluting with pentothal to create what I called "President's Choice" propofol. It also lead to the widespread practice of "saving" propofol in syringes or in the original vial until we found out how easily propofol could be contaminated.

Propofol is of course unquestionably better than pentothal for short cases; less so for long cases. It has of course eclipsed pentothal which is actually temporarily unavailable in Canada. Propofol does allow for earlier discharge from recovery room and day surgery however the clinical significance of this is questionable because discharge times are more affected by factors like hospital policy, availability of porters and whether the patients ride home has showed up. In addition savings from shorter stays are only realized if the shorter stay is accompanied by staff reductions.

When I joined the CofE, they were in the midst of a massive cost cutting exercise. The administrative strategy du jour was to give each department a budget which they had to keep within. Therefore our department was responsible not only for our drug and disposable costs but also for the cost of our techs. This was an interesting exercise where we learned that for years our techs had manipulated their shifts to maximize the amount of overtime they got, something that should have been easy to fix but which we never really got a handle on. Drug costs were another matter. Pharmacy was able to give us a monthly figure of how much we spent on drugs which we divided by the number of cases to come up with a cost per case. This was quite rough as cases at the CofE went anywhere from 30 minutes to 30 hours. Our average cost per case varied from $15 to $20 per case. This was something we all strived to reduce although that is the cost of a single suture or 2-3 doses of Ancef.

We subsequently went through decade and a half of very little control in anaesthetic costs during which Sevoflurane, Desflurane, Rocuronium, and Remifentanyl where introduced. Much of the research on Sevoflurane and Desflurane was done during my residency which is when (unlike today's residents) I actually read journals. It was pretty clear to me and to other residents that Desflurane and Sevoflurane were going to be huge busts. Desflurane for example requires a special heated pressurized vaporizer, which Sevoflurane breaks down to toxic metabolites. All this for a recovery time which is statistically but not clinically significantly better than Isoflurane. Despite this, when I go into my room today, I will have the choice of Sevoflurane or Desflurane because we only have room for two vaporizer on our machine and it was too expensive to keep Isoflurane vaporizers which nobody was using around. Des and Sevo are really triumphs of marketing over science. Remifentanyl on the other hand is a huge advance although I remember poo-pooing it. "What is the use of a short acting narcotic," I used to say.

But getting back to Great Z's discussion about how everybody else gets expensive drugs and we don't. This has also been my observation and of course I remember the fights as I outlined above we had to just be able to try out new drugs. This also applies to some anaesthesia drugs and products which other specialties get before us. I remember, as a resident, when midazolam came out, anaesthesia requested it and were denied; then gastroenterology requested it and got it, therefore we also got. The same thing happened with EMLA cream which pediatrics got after anaesthesia was turned down (we soon found out that EMLA is worse than useless). At the CofE, our emergency physicians got rocuronium before anaesthesia did (aside from the spectre of half trained ER docs burning their airway bridges with a non-depolarizer; what an insult to anaesthesia!).

We haven't (yet) come to point of not having propofol, we have as a mentioned temporarily and I suspect permanently lost pentothal. I could certainly see that anaesthesia could be at risk. Even in a country the size of Canada, a corporate bean counter could look at the potential profits to be made by making propofol versus what can be made using the third generation version of Lipitor and decide that maybe they won't make propofol anymore.

Perhaps however the answer is not to demand our own expensive third generation drugs but to ask why we are using what are for the most part unproven and in many cases harmful drugs in place of the old standbys. Take hypertension for example. The Canadian guidelines from 1999 which they have not seen fit to revise state:

1. Initial therapy should be monotherapy with a thiazide
diuretic, preferably at a low dose, a β-adrenergic antagonist
or an angiotensin-converting-enzyme (ACE) inhibitor
(grade A). If the response is inadequate or there
are adverse effects, substitute another drug from the initial
drug therapy group (grade D).
2. Combination therapy, either with a thiazide diuretic
and a β-adrenergic antagonist or with a thiazide diuretic
and an ACE inhibitor, should be used if there is
only a partial response to monotherapy (grade A).
3. If blood pressure is still not controlled, or there are
adverse effects, try other classes of antihypertensive
drugs (calcium-channel blockers, angiotensin II receptor
antagonists, α-adrenergic antagonists or centrally
acting agents) either as monotherapy or in
combination (grade D). Consider possible reasons
for a poor response to therapy, such as noncompliance,
secondary causes of hypertension or interactions
between prescribed treatment and diet or other
drugs (grade D).

So when was the last time you saw a patient on a hydrochlorthiazide for hypertension? Or a beta blocker except when there is some ischemic heart disease. They are usually on about 3 different drugs that you have never heard of (but will soon learn about when you read in the newspaper how that drug has been pulled from the market because it is killing people). Psychiatry is the same. Everybody is on a cocktail of "atypical antipsychotics" all of which have side effects of weight gain. Like we need more obese patients. This has rubbed on onto family practice where these drugs are being prescribed for things like insomnia and anxiety.

Enough of this rant. Like the title says, I used to be disgusted now I try to be amused. It is getting harder.

Monday, October 18, 2010

The Most Arrogant Thing I Have Ever Heard A Surgeon Say

I should have posted on this a long time ago. This happened in the last millennium at the C of E.

Naturally being a Centre of Excellence, the Centre of Excellence has doctors from all over the world come there to become excellent. In the late 1990s we had a surgeon from a third world middle eastern country spend a year or so to learn to do liver transplants. Now there are a lot of people who would think that most third world countries should maybe focus on things like public health, vaccinations and non-excellent things but they are not thinking excellently. As the fully qualified surgeon working as a fellow, he was given some latitude in working and was mostly working unsupervised on the memorable day.

I came in to find that as usual my list was all messed up and my first scheduled case couldn't start until the early afternoon, however in consolation, I was allowed to pick up an emergency case from our ICU. This was a liver transplant patient who had had his abdomen packed due to oozing at the end of the case. It was now time to remove the packs. I was not a liver transplant anaesthesiologist but now that he had a sort of a functioning liver I was deemed competent to anaesthetize this patient. He was still ventilated, lines in, plug and play.

After removing a number of packs our now more excellent surgeon announced he was closing. "Not so quickly", said the circulating nurse who had the count sheet from the original operation. "There is still one more pack in." "No there isn't" said our surgeon. Fine said the nurse we'll X-ray. Our surgeon left the room leaving his residents to close which they did in time. X-ray was summoned and a flat plate showed surprise, surprise, the missing sponge. Our surgeon was summoned back.

There are a number of appropriate responses to this scenario; most of them involving some expression of regret or remorse. None of these were forthcoming. Was did come was the surgeon angrily accusing the nurse of not being more forceful in insisting that he look for the sponge. I rolled my eyes; I do after all get paid by the hour.

The last time I worked with this surgeon was during the evening and I witnessed him being walked through a laparoscopic cholie by a junior resident. I decided this wasn't really appropriate and complained and he shortly returned home where I suppose he is doing liver transplants and laparoscopic cholies and might even listen to the nurses occasionally.

Saturday, October 9, 2010

Tipping Point

I recently finished a guided bike tour of the Czech republic which was easily the best holiday of my life. At the end of every guided trip however comes what I find to be unpleasant. How much to tip the guides?

There are a variety of formulas, some people do so much a day, some people do a percentage of how much the trip cost (which is what we ultimately did). Many tour companies are happy to help you out by "suggesting" how much you should tip. Then there is the question of currency; local currency (if the guide is not from the country where you are now), Canadian dollars, US dollars, Euros. This followed by the trip to the bank machine to get the requisite money.

This is not to say that our guides were not fantastic. I fortunately have never had a bad guide. They do work hard and long during the trip but hey they are guiding not working in some dead end job. On this trip however one of the other members decided that one guide should get much more than the other which I didn't really think was fair; one guide clearly appeared to do more but she was the lead guide and that was her role and we didn't really know how much the other guide did behind the scenes. I pointed this out to the lady who was collecting the money but she was adamant that the two guides shouldn't get the same so under her watchful eyes we actually took back some of the money for the second guide. I really had a hard time looking our guide in the eyes for the rest of the trip.

Of course while we did all put our tips into a single envelope I have no idea how much everybody put in. Guided bicycle trips like the one I recently went on are quite expensive and while I can afford these trips now, I wonder however about some people who save up and budget for these trips and find out at the end of the week that they are expected to pony up what usually amounts to hundreds of extra dollars for what they thought they had already paid for. (At the end of a kayak trip once not only where we supposed to tip the guides but the tip was to be presented at a dinner where we also picked up the guides' tab; I don't mind doing this on my own but hate being told I have to do it!)

I make a good income and I am very sympathetic to people who make less than me. I tip 20% usually even when the service is bad. Occasionally when the service is bad I have been tempted to withold the tip but in the interval between the bad service and the presentation of the bill I always soften and consider whether the bad service was really the fault of the server or whether it was beyond his control. (My father usually tells the server when the service or food has been bad and has received numerous free meals in his life.)

But here is an interesting concept. Why not end the charade of tipping and actually pay people a decent wage? I am not naive enough to expect that if we had 15-20% added to our restaurant bills that this would necessarily result in a wage increase for servers. In Europe and Australia however where tipping is less common, waiters and bartenders are actually valued employees who are paid a good wage. This is unlike Canada and US and this shows in the service we sometimes get. As an aside, I remember as an intern 6 of us went out to dinner at ski resort. The service was not very good, the waitress was surly and at least two people didn't get the meal they ordered (she argued about that two). Nonetheless we are put in cash which included a 10% tip and handed it to the person who agreed to settle the bill for us. For some reason (he said it was an error) he only left enough to cover the tab. The waitress actually chased us our of the restaurant to ask why we hadn't left a tip. Oh yeah we said, a mistake and handed her the extra money.

There is the question of who gets tipped. My server I suspect gets about the same wage as the guy who washes the floor in the OR. Why does one get tipped and not the other. I could give more examples.

One of our guides (ironically the one I reluctantly stiffed) who guided us on another trip works as a server in the off season and we actually had a long discussion about tipping on this trip and she had some interesting experiences in that field to relate. She told me for example that in some restaurants the servers are expected to pay 6% of the bill as the share to the cooks and dishwashers whether or not they get a tip and that she has often wondered how much of this money actually gets back to the workers.

Now as a physician, I never get tips or expect one. I do get chocolates and liquor at Christmas from patients. There was once a Greek lady who I treated who would bring to every treatment a bottle of Ouzo and $200 in cash. I kept the Ouzo and would walk the $200 over to the hospital foundation office. (They told me that they sent her a charitable receipt and she sent it back). She stopped coming after a while by which time my wife and I had acquired a taste for Ouzo which I now have to buy myself.

Monday, September 20, 2010

Funeral for a Friend

Sitting alone in my favourite cafe, just finished my cinnamon bun, sipping on my latte. Nice Sunday morning, a little cool but sunny. I rode my bike over to my favourite cafe. Nothing really in the free community paper and somebody is hogging the local paper so I get out my I-phone and check my messages. Not really expecting much on Sunday. I notice a message from one of my old medical school classmates and the subject is another medical school classmate. Oh shzt I am thinking as I open the message. Sure enough, Dave my old friend from medical school is dead.

Everybody in my medical school class is now safely over 50, so it is not surprising that people are going to drop off. You just never thought that it would be somebody you knew and liked really well.

I didn't really know many people in my medical school class from my undergraduate years. A few people I recognized from labs or smaller classes, nobody I was really that close to. I hardly even knew anybody who had ever been to medical school. It was a complete mystery to me. I had this impression going in that I was looking at 4 very hard and boring years.

I was assigned to the same group as Dave in anatomy. Him, me and two others on a cadaver. I remember pulling off the case cover, peering at the unnatural brown skin, the face covered with a mask still. We had a scalpel and a dissection manual. The other two people looked a little green. "Should I go first or should you?" said Dave. I can't remember which of us actually made the first cut but one of us did and that was how our group got started in anatomy. I remember thinking how serious and mature a guy Dave was.

I am not a really good judge of human nature.

Dave turned out to be the most irreverent guy I have ever met. He had a warped sense of humour that complemented my warped sense of humour. He loved puns, the sicker the better. We spent the 6 months of dissection mostly bent over in stitches at some joke that he had usually made. We did tasteless pranks like dropping fat into people's lab coat pockets as they passed our table. Anybody who visited our table to look at our dissection, was in for an insult. Our anatomy professor cautioned our class about elbowing people away from our dissection; we said we just gave verbal elbows.

In those days Dave was politcally left wing like me. He did disrespect environmentalists whom he called granolas and since I was an environmentalist he called me a granola. He also called me a bleeding heart liberal which years later I called myself in online forums and in my blog.

One of the best attributes of a friend is someone who will tell you when you are being stupid. In that respect Dave was the best of friends to me. Dave didn't suffer fools gladly, there were classmates Dave didn't like very much; he was always very coldly polite to them. In fact if Dave wasn't rude to you it meant he didn't like you.

In between 2nd and 3rd year medical school Dave and I did rural doctor electives in adjacent towns. We got horrendously drunk together two nights in a row at the Kimberly Beer Festival and after our electives ended we visited a friend of Dave's at Invermere after which we travelled in a convoy my VW Rabbit chasing his Datson pickup to his home town where I stayed at his house for a couple of days before returning to Vancouver.

Dave was a good friend to a lot of people which I realized when I read the tributes to him after he died and spoke to the classmates who went to his memorial service. Everybody had a story about some road trip or something else that they had done with Dave. Even now when I think of some stupid pun or joke or intentional mispronounciation of a word; quite often I heard it first from Dave 25+ years ago.

I saw Dave less in our clinical clerkship year and we interned in different cities. I was surprised to hear that Dave was going into Urology. We had often talked over coffee about surgeons and how unscientifc most of what they did was. He finished his residency and went to practise in his hometown which he really loved and which was unfortunately where he died.

Dave came to my wedding but after that I only saw him every five years at our class reunion and he missed the last two due to illness or death in his family. Periodically he would phone me up out of the blue. The last time was on provincial election day to remind me to vote Conservative. Dave had become more conservative and bitter about politics since starting in practice. He had also become a gun collector and was adamantly against the gun registry (it is ironic that he died thinking the gun registry had been abolished in Canada only to have it resurrected weeks after his death). None of this stopped him from discussing his points of view in a civil fashion.

A couple of weekends ago I was driving down for his memorial service and my wife who was keeping me company and who I met after medical school asked me if I could tell her some stories about Dave. I kept on for about an hour with story after story. Some of them I hadn't thought about for years. The tears were rolling down my eyes, I couldn't figure out whether I was laughing or crying. After about every story, my wife said, "If you get asked to speak at the memorial you are not telling that one."

After the service the 6 of my classmates who came up, sat down for a few beers. Dave would have wanted it we all said. Actually we don't know what Dave would have wanted and I am sure he would have had some pointed words for us all.

Friday, September 10, 2010

What Do Fundamentalist Christians and Fundamentalist Muslims Have Against Each Other?

1. They are against womens rights.
2. They are against birth control or abortion.
3. They both like guns.
4. They seem to like to die for their religion (or preferably send other people to die for their religion).
5. They are politically conservative.
6. They both like to kill other people.
7. They don't like Jews.
8. They like the death penalty.

I really can't figure it out.

Monday, September 6, 2010

Dropping my son off University

I dropped my youngest son off at University yesterday. Unfortunately my oldest son has so far ignorred all my hints and is attending University in town and living at home.

I was trying to visualize my first day at University. Then I realized it was almost 35 years to the date. Holy shzt how did I get that old? Mine was a little different. I loaded all my stuff in my backpack and took the bus over to Vancouver and then another bus to UBC from where I walked to the residence. My parent brought over my stereo and record collection (remember records?) a week or so later.

Moving in a day is a much more choreographed event now than 35 years ago. There is a way bigger parental presence. Parental presence 35 years involved dropping off your kids at residence or in the case of my parents driving me to the bus depot. Now the day is built around the parents with an afternoon of "classes" for those interested. I suppose we are paying for the whole affair.

My wife was tearful even though this son has been living away from home for the last four months albeit in our dacha. My son even appeared nervous. I reassured him.

"I spent 7 years in University", I told him, "They were the best 7 years of my life. It goes downhill after that." And I meant it.

I hope that inspired him.

Insert foot here

Men and women have different fat profiles. Men develope a beer belly like Randy on Trailer Park boys; women tend to store their fat all over their body. This difference usually helps us tell whether a woman is pregant or is merely fat.

I was at a meeting recently when I ran into a clinician who had trained with me a couple of years ago, who I had met at meetings since and had always enjoyed a good long talk. It had been a couple of years since I met her and the first thing I noted was the protruding belly. "Oh", I thought, "She is pregnant." So as we re-introduced ourselves, I made the usual banal joke I make whenever I meet someone who is pregnant. "Gained a little weight, have we?", I joked. "Actually, I have," she said. It was apparently a side effect of the meds that she was on. There was an uncomfortable silence, I exchanged a few pleasantries and made an excuse to get the hell out of there.

This is not the first time I have done this. When I was doing locums, I did it a couple of times which is probably one reason I wasn't a very good or popular GP. One time I was seeing a lady who I had never seen before. Her chart had a pre-natal chart on it, which if I had actually looked closer was 2 years old. I went into the office and there she was lying on the bed with her protruding belly. So I went into prenatal mode, only to find out she was actually in for a cold or something. This happened at least one other time but I don't remember the details.

Live and learn. Remove foot.

Thursday, August 26, 2010

SI you- nit

This is a sick joke my physics profs made when they wanted to introduce us to System Internationale Units. These professors were extremely entertaining and funny individuals which is really the only way to teach a pretty boring subject.

I have a pet peeve. It is the way people write dates, more the various ways people write dates.

Today for example is August 26, 2010. This can be written as 26.08.2010; 08/26/2010;26/aug/2010. I could go on, the permutations are endless. This is a concern for me because I write dates several times a day, and occasionally have to fill in patient birth dates on forms.

That is why 20 years ago, I decided that I would follow the SI convention of writing dates as YYYY.MM.DD or YY.MM.DD (we are far enough into the century now). This may not be best or most logical solution but they did make a decision and I have chosen to follow it.

While I realize that the US decided not to use the metric system, Canada and most of the world did and I can't understand why we are unable to figure out a consistent way of writing dates. Every time I fill out a form now, I have to look at how they want the date configured. Worse is when you are copying from one form with the date in one format to a form with the date in another format.

Come on people even in the US we are not dosing in grains and minims anymore.

SI You Nits!

Sunday, August 22, 2010


Emergency docs probably next to proctologists, have the best stories to tell which is why some many of them seem to have blogs.

I blogged some time ago against the routine use of antibiotics in surgery.

Here is an interesting article from White Coat's Call Room.

One of the 200 or so things that I hated about general practice that drove me into specialty training was the constant demand for antibiotics from patients (and the knowledge of that if you didn't prescribe them, one of your colleagues was going to and make you look stupid).

A long time ago, I was at a meeting at our licensing body regarding our triplicate narcotic program. This program is, as I found out, actually quite expensive and probably does very little to prevent drug diversion. The question was, what drugs should be on it? I suggested antibiotics. I was surprised how many people agreed with me.

Thursday, August 19, 2010

Euphemisms, Politics and the English Language

This is a good article,

A while ago I blogged about the tendency to substitute customer or client for patient and how it is subtly affecting medical practice. This article comments on our tendency to substitute less loaded words for loaded words such as substituting "unhealthy weight" for obese. Substituting "hearing impaired" for deaf and "visually impaired" for blind are other examples. It also points out that there is a drift with euphemisms gradually acquiring a loaded meaning. I am just waiting for the guy in front of me at the football game to call the ref visually impaired.

A few years ago I saw a patient with low back pain and dictated a consult in which I referred to her as mildly obese. Her family doctor showed her my consult and she arrived in ill humour at the next visit. "What do you mean I'm obese," she asked,"and how do you define obesity" I told her the I defined obesity as anyone fatter than me. This defused things, she is still seeing me and has lost a significant amount of weight (unlike me).

I still remember 1st year university English. This was a disaster for me. Although I was trying to get into medical school, my chosen career was to be a writer and medicine was just how I was going to support myself until I got published. I loved reading and thought I was going to do well in English. Unfortunately while I love reading, I really can't give a shzt about whether Robert Frost was contemplating suicide in "Stopping in woods...", whether Ophelia and Hamlet were lovers or what was "the theme of language" in Camus' "The Plague". I struggled through with a 66% which was my lowest mark until medical school.

One important thing I did learn in English 100 was the lessons in George Orwell's "Politics and the English Language" which was in our essay book. It still should be mandatory reading for anybody in any position of power or authority.

Orwell of course wrote 1984 and Animal Farm which some commentators have taken as his dismissal of socialism and communism, something the life long member of the British Socialist Party and anybody who has read any of his other books would disagree with.

Orwell's thesis if I remember it, was that people hide their unclear thinking behind overblown language. He also mentioned how politicians misuse the English language for their own malicious ends. "Shot while escaping" was a post WW2 example he gave. We have in the succeeding 50+ years come up with many by own our political and business elite. Laid off becomes downsizing which becomes right-sizing; torturing becomes extraordinary rendition. I could go on.

Healthcare has become a living example of Orwell's thesis. Patients have become clients who have become customers. Doctors, nurses, physios all noble professions with much to offer are lumped in as Healthcare professionals. We all talk about stakeholders, I don't even know what stakeholders used to be. Now that I attend more and more meetings, I find myself slipping into this bizarre newspeak. I have to sometimes step outside and slap myself in the head.

Orwell had a number of rules.

(i) Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.

(ii) Never us a long word where a short one will do.

(iii) If it is possible to cut a word out, always cut it out.

(iv) Never use the passive where you can use the active.

(v) Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.

(vi) Break any of these rules sooner than say anything outright barbarous.

The interesting thing is that reading Orwell's essay written over 60 years ago, one gets the sense that it could have been written last week. We have learned nothing. It is interesting that many of todays leaders in politics, business and administration are contemporaries of mine who probably studied "Politics and the English language" in 1st year English. It was in the Norton Anthology afterall.

Thursday, August 5, 2010

Dang Kids Get Off My Lawn

Maybe I am getting old.

Firstly I should say, I support the legalization of most drugs and certainly that legalization would probably stop what I am about to complain about.

3 years ago we moved to a quiet street closer to where I work. The most attractive feature of our new house is the green space across the street from us. From our front window we look onto a grass field, trees in the background and behind that a drop down to the river. We are a touch possessive of our green space even though it belongs to the city.

A snake seems to have invaded our paradise.

For the last couple of months, a couple of times a week around midnight we are awakened by voices in the park across the street. Frequently there is a car parked in front of our house with the motor running most of the time. We hear loud conversations, young men shouting "yeehaw", girls giggling.

It took me a while to figure this out, but it became quite clear. Someone is selling drugs in the park across from our house. Either they hang out there possibly in the woods above the river or our street has been chosen for the transaction being out of the way with little traffic.

After the most recent disturbance, I decided that maybe the police should know about this. Not that I oppose young adults buying drugs. Just not in front of my house.

Police as we know love to enforce drug laws. They are quite happy to attribute just about every crime to drugs. I figured they would jump at the opportunity to bust someone. Actually I just hoped that they would drive a police car down our street around midnight for a couple of nights in a row and get the people to move their business somewhere else.

So the next morning after my most recent interrupted sleep, I phoned the cops. It took me a while. I tried to phone my "community" police station which seems to be nowhere near our community and was directed to the Crime Stoppers snitch line. Obviously I had no one to snitch on so I tried a different number and actually got to talk to a cop. I gave him my address, explained the situation and asked if he could help.

What I got was a bunch of excuses about how busy they are most nights and how it would be totally impractical to patrol our neighbourhood. He did say that if I went to my local police station and filed a complaint in person, I might be able to talk to a sergeant. I said,"How about I contact my city councilor", which is what I did.

Of course like most things, there have been no more late night interruptions since I complained. I suspect that the local drug dealer has figured out that eventually someone would complain to the police who would actually patrol the area.

What has he been smoking?

Tuesday, August 3, 2010

The Cross and the Border

Entering the United States is a huge hassle. This is even worse when one is simply in transit through the US. This makes going to and coming back from my yearly mission to Ecuador more of an ordeal than it should.

I have never quite understood the antipathy US Border guards have towards Canadians. OK we are one of two countries to win a war against the US (North Vietnam is the other) and we did burn Washington to the ground in that war but hey we are reaching the 200th anniversary of that. Further why are customs agents in such a bad mood. They get to wear uniforms, work indoors, do no lifting, have a pension plan and occasionally get to arrest bad guys.

Coming back to Canada via the US means either going thru Miami or through the ominously named George Bush International Airport in Houston. This last trip we arrived in Houston to the large Customs room to find a huge line-up for those non US Citizens of us. No problem, this time I had convinced our travel agent that we would need a long connecting time in Houston and we had 6 hours to get through this hurdle. After about an hour or so we were directed into a short line of about 10 people. We had obviously gotten into the wrong line. The lines around us were moving relatively quickly. I looked up at the counter and saw the crabiest most prototypical US Customs agent waiting for us.

Our mission is a Christian mission. A few years ago a minister who comes with us suggested we wear crosses and so we bought a large number of small wooden crosses with us which we wore and gave to patients, relatives etc. I roomed with this minister the first year so got into the habit of wearing the cross. I figure if it makes people feel good why fight it. This is why I was wearing a wooden cross under my shirt on this day in George Bush International Airport.

As I approached Mr Hardass I flipped the wooden cross out from under my shirt. Mr. Hardass grabbed my wife's and my passports. After a while he looked up, and saw the cross. "What were you doing in Ecuador," he asked. "A medical mission", I replied, fingering my cross. Mr. Hardass smiled, "Have a nice trip home sir".

Monday, August 2, 2010

Patients, Clients and Customers

I have been having a lot of problems with the private pain clinic I work with.

These have been going on since I joined them, but have come to a head recently. Part of this has been to do with one of the "Customer Service Representatives" who worked mostly for me, quitting. I am assured that her departure was purely personal and not related to work but I suspect the fact that it was clear that increasing she was doing everybody else's work as well as her own had something to do with it.

Problems have included frequent no-shows, huge gaps in my schedule with no effort to fill them, coming work to find out that they have forgotten to book patients, finding out that they have booked patients when you clearly told them months ago you weren't going to be there, not cleaning the rooms in between patients and the most recent egregious folly where a patient I had been lead to believe had no showed had been sitting out in the waiting room for over 2 hours, necessitating a return to the clinic over lunch to apologize profusely to him, and try to assess him in the remaining 45 minutes before my next scheduled patient. Wbat was more amazing was the first thing I was asked was whether I just wanted to reschedule the "client"?

There are a number of reasons why the front desk at our little clinic are so bad including the fact that our clinic pays them less than any other doctors office pays and substantially less than an equivalent unionized position in the hospital. (Keep in mind when I say unionized, that our province is not the Socialist Worker's Paradise.) The main reason I have come to a conclusion is that:

1. Instead of being called receptionists they are called "Customer Service Representatives".
2. Instead of patients our clinic has customers or clients. Increasingly we talk about customers.

The first I can deal with simply. A receptionist is someone who receives. This implies the establishment of a relationship with some responsibility on the behalf of the receptionist. Customer Service Representative brings to mind what you get nowadays when you deal with the phone company. Yeah not a pretty picture is it?

Client/customer vs. patient is an interesting lesson in semantics. To break it down, a client is someone who seeks a service from a provider. Providers of course want to provide the easiest and less expensive service for the greatest price. This is human nature and capitalism. Partially (very partially) is the right of the customer to take his services elsewhere. Even this is limited. 25 years ago, you dealt with a single phone company, single cable company etc. Even with the somewhat artificial competition in those areas, there are still de facto monopolies with very little competition.

A patient on the other hand is someone who seeks help from a provider. This is usually a service that the patient believes will have a positive aspect on his health. While the provider naturally like the provider in the provider-client picture wants to provide as little service for as much money, there is an ethical framework applied here. For example if we believe a service is not in a patient's best interest, we don't offer it often to the displeasure of the patient. Imagine on the other hand, the cable company telling somebody he doesn't really need HD. Further while we would all like to get paid as much as possible for as little work as possible, in the doctor patient relationship, we actually try to help the patient regardless of ability to pay and given the choice of therapies, we actually chose what we think is best for the patient not what will pay us the most money.

When I started in Medicine, there was a move afoot to change patients to clients. This fortunately never took root in the medical community although it did to an extent in the paramedical community. Client is an interesting word because while it implies a slightly more equal interraction than does patient, it still implies some degree of responsibility and professionalism by the provider.

Consequently what used to be called patients or clients are now referred to as customers or consumers. The semantics of this are clear. While as with patients and clients, a business relationship is established, customers lose most of the rights that patients or clients have. Sort of like the cable company example above. This is why the people involved in the planning and delivery of health care services increasingly talk about customers and consumers rather than patient or clients.

Now I know I am being naive and the ideal doctor patient relationship doesn't always happen in medicine, but it is still the ideal. We do these things partially out of a sense of ethics drummed into us by role models during our training but also due to outside pressures like licensing bodies, hospital QA committees and of course our friends the personal injury lawyers. This is opposed to the provider customer relationship which is reduced to a business transaction.

But you can see that when we go from receptionists dealing with patients to "Customer Service Reps" dealing with customers and you can see that it is inevitable that this old school physician is going to get a little pissed off.

Monday, July 26, 2010

Riding With No Cause

I rode 100 km on my bike yesterday. This is my 4th metric century, the second this year. I am no longer scared but still respectful of the distance.

A few months ago when I did century #3 (actually 120 km which is limit of my envelope) I posted this on Facebook. A number of people replied to ask what cause I was riding for.

As with yesterday's century, I spent 4-5 hours out in the sun and wind for my overall health and for companionship of 1000 or so riders (most of whom passed me).

We have in our province a couple of long bike rides in support of a particular cause. We have the MS Bike Tour which is 160 km over 2 days in support of MS and we have the Ride to Conquer Cancer which is also a two day event. I have thought of going in both of them but have never been able to due to conference, call or family. To ride in the MS Bike Tour you have to raise $250 in donations; the Ride to Conquer Cancer is more ambitious,the ante is $5000 which means you get a lot of emails from friends and acquaintances looking for sponsorship.

Both trips are well supported with lots of good food etc for the riders

Treating and supporting people with MS and Cancer are worthy goals and I would certainly never begrudge them the money. However, I sometimes wonder why in the 21st century in one of the richest countries in the world, in the richest province in that richest country and with "socialized" medicine, why should we be asking people to ride a longish distance other than for their personal edification.

While having my post ride lunch yesterday, I was listening to a lady at our table talking about her recent experience in the RTCC. As I often do I drifted off into a fantasy others and I should have more frequently.

"What" I thought, "if instead of having people fund raising to provide things that society should really be providing anyway, we had fund raisers for things that society really could do without"

"Like, for example, the military. Want to send troops to Afghanistan? Have we got a bike tour for you. 50 Billion for fighter jets we don't need? Some Air Force general is going to have to run across the country. New uniforms? Have a bake sale."

Taking it further.

"Want a seat in the Senate? (for those Americans our senate is appointed much like the British House of Lords except for the lack of funny titles.) Whoever raises the most money for a worthy charity gets the seat. (and no writing a cheque on your personal account, you actually got to lean on people to donate)"

I don't ride very fast but I can dream.

Friday, July 9, 2010

News Flash

Just out.

And in related news, the Pope is Catholic and bears still shit in the woods.

Tuesday, July 6, 2010

Follow up to choice in Health Care

I got this comment from Z-MD on my last blog which due to some glitch I couldn't publish so I am putting it here.

Your brothel story perfectly illustrates the lack of capitalism and competition in American health care. People with means will gravitate toward the more expensive product, even if the outcome is the same. Unfortunately many Americans who can't afford it still demand the expensive treatment. With government funding and insurance companies obscuring the true cost of treatments, people want nothing but the best ie/costliest care since they are not paying the full cost. If Medicare was subsidizing brothel visits (isn't sex one of life's necessities?) every old geezer would be down at the Chicken Ranch to get his $10 worth instead of paying $2 out of pocket. And if somebody's getting their $10 worth of subsidized nookie instead of paying $2, then everybody will want it, quickly bankrupting the system which is where we are today.

The point I think I made was that there is no difference between the $10 fzck and the $2 fzck and maybe the problem is not that we have "poor" people demanding $10 fzcks but rather that we offer them at all. I could give examples and maybe will some other time.

Monday, July 5, 2010

Choice in Healthcare?

Great Z has posted again.

Now I admire his blog although it is quite clear that politically we are a little ways apart. I both agreed and disagreed with aspects of his blog.

His story about the choices in his local car wash reminded me of a movie I saw a long time ago (Lady in Red). In this movie a young woman was starting out in a brothel and was told that there were three prices for her product, $2, $5 and $10. "What is the difference?" she asked the madam. "There is no difference", replied the madam.

Health care is however more of a black and white thing. It is either done right or it is done wrong. Actually it is various shades of gray but what makes it less black or less white is more intangible. Those of us in the know all know who our first choice of surgeon or anaesthesiologist would be for any given procedure. We would never think of paying more for them, we just request them. We don't ask for a $2000, $5000 or $10000 gall bladder because we know there shouldn't be any difference.

I have always maintained that if you had three doctors each charging $20, $40 or $60 for a visit, each doctor would be equally busy and that the social strata in each office would be quite similar.

When ondansatron came out 20 or so years ago, it seemed to be clearly a better anti-nauseant than what was available (I am less sure of that now). Unfortunately because of its $20 per dose cost, our pharmacy restricted it. I remember thinking, "I would happily pay $20 in order not to puking out my guts". This is in fact what we did; if a patient came in really concerned about nausea and we saw him in sufficient time, we wrote him a prescription for oral ondansatron, he picked it up and took it pre-operatively. Likewise propofol; I would have happily paid the extra $7.50 in order to be more awake and less nauseated.

Length of stay is another issue, if a patient wants to stay an extra night in hospital and can afford to, why not charge him the extra $1000. The problem here comes, because rich people are notoriously cheap and because frequently patients do have to stay longer than normal, there would be all kinds of disputes over whether the extra night was necessary or not.

Our province and other provinces allow people to pay for MRI examinations. If you have a sore back and want to know what is wrong when your stupid doctor is just telling you to exercise and lose weight why not? This is fine except that radiologists especially when they know the patient has paid out of pocket will never report an MRI as normal. They will find something to report, and the patient will take the MRI to his doctor, and the subsequent follow-up tests, consultations etc will fall on the public sector.

Our hospitals are funded by the government through byzantine and ever changing funding formulas. To raise extra funds, hospitals in Canada depend on revenue from the cafeteria, parking and private room charges. Even then the government insists upon dipping its beak. One of our obstetric hospitals has had for many years theme rooms for post-partum moms for extra cash. Of course because obstetrics is so unpredictable, these rooms are frequently not available plus we discharge normal deliveries so early anyway. The newest of our hospitals was built with no room more than 2 beds. Therefore by definition if you are admitted to that hospital you will get a semi-private. If you keep your mouth shut you will not be charged extra for this semi-private room. If however you don't realize this and ask for a semi-private room on admission, you or your extended health will be billed for this. When I heard this I could not believe the utter sleaziness of the whole arrangement.

Now columnists in the right wing and sadly in a few of the mainstream newspapers are calling for competition in health care as a means of improving quality while decreasing costs. Even our provincial government is once again in the process of getting hospitals to compete with each other. I attended a day long strategic planning session more or less on that.

It would be nice if hospitals actually competed on things like, our infection rate is better, our preventive programs are better, our rehab is better, our costs are lower etc. We all know that that is not going to happen; where hospitals are going to compete is, our theme rooms are nicer, our foyer has better art work etc. We also no that hospitals are going to compete to see who can do the most simple procedures on the healthiest patients, leaving those sicker more complicated for some other hospital. It is already happening.

I did have my car detailed a few years ago and was offered gold, silver or bronze packages. Being Canadian I chose bronze and asked what was included. After hearing all of what was included just in the bronze package, I wondered what more could be included in the silver or gold packages. I had some ideas that were slightly obscene but we really shouldn't go there.

Friday, July 2, 2010

Cardiac Anaesthesia

I suspect if you get a bunch of non-cardiac anaesthesiologists together in a room after a while the discussion will inevitably get around to cardiac anaesthesia, especially if you include enough people who work or have worked in one of these centres. That includes most of us since we all had to do a rotation during our residencies.

Most of us who worked in a centre with cardiac surgery as I did at the centre of excellence, have realized what cardiac surgery is: a resource sucking monster staffed by the most incredibly arrogant individuals (including some anaesthesiologists unfortunately).

I refer to adult cardiac surgery of course. I have only the most respect for those pediatric cardiac surgeons (even more for the anaesthesiologists) who have to figure out those complex lesions. Even those ones who work when they shouldn't. I also don't doubt the necessity of a significant amount of cardiac surgery; while I don't smoke, drink plenty of dark beer and red wine, try to exercise, chose my parents well etc, I have consumed a lot of bacon and fried bread in my time which could come back to haunt me in the future.

Firstly cardiac surgery is pretty easy. You basically sew a piece of vein onto an artery 4-5 times during a procedure. I probably can't do that but I suspect in the course of a 6 year residency I might be able to. Valvular surgery, true might be a little more difficult. Cardiac anaesthesia is even easier. I trained in a centre which didn't have a separate cardiac surgery call schedule, which meant when you were on call you might have to do an "emergency" by-pass. This kept me awake for my first few nights on call. I should have slept. Back in the 1980s we used to describe a simple standard anaesthetic as "Big Syringe (pentothal)- Little Syringe (sux). When I got to do my first Saturday "emergency" CABG, the staff man gave me a Really Big Syringe (60 cc of fentanyl) which we followed up with a Little Syringe (10 mg of pancuronium) and we proceeded happily along. The art line and Swan Ganz catheter are basic skills for any anaesthesiologist and of course we now know that Swan's were actually not very useful and probably harmful.

I actually found it amusing when I actually rotated thru a 3 month cardiac anaesthesia rotation that I would go up and see the patient, look at the cardiac cath report which I would then have to relay to the next day's staff at home on the phone. I would have to recite the location of all the lesions, the wall motion abnormalities and the EF. I could have saved my breath. Regardless of how bad the anatomy and physiology, the induction the next morning consisted of the Really Big Syringe and the Little Syringe. Maybe things have changed? Naw.

A few years before I joined the centre of excellence, an academically inclined anaesthesiologist joined the department. He was one of those fellows who had done his training in multiple programs in multiple countries. This had however resulted in him never having done a cardiac case at all in his residency (apparently not compulsory then). Because at that time (and now) at the CofE, not belonging to a sub-specialty group meant a career of second classness and because of his impeccable academic credentials, he was allowed to join the cardiac group. On his first day on the job, he induced the patient using the "cardiac anaesthetic", inserted the requisite monitors and kept the patient asleep and stable until it was time to come of bypass.

Hmmmm how do we get somebody off bypass?

He went to one of the perfusionists who told him how to get a patient off bypass and went on to a glorious career as a prominent cardiac anaesthesiologist of excellence. (As a junior resident, I asked one of the senior residents how you got somebody off bypass and he said something about walking counter clockwise around the room shaking a bottle of nitroglycerin in one hand and a bottle of dopamine in the other.) That reminds me of course that where I trained we were not allowed to use inotropes to get the patient of bypass. The cardiac surgeons apparently considered the concept of their patient requiring inotropes to be an insult to their skill. This did introduce some degree of art (and occasionally deception) into getting a patient off bypass. I was amazed when I went to the CofE that the cardiac anaesthesiologists were not only allowed to use inotropes but did so with gusto. Where's the sport in that?

Cardiac anaesthesiology off course means working with cardiac surgeons who are with a few exceptions the most arrogant assholes ever to call themselves doctor. Not very smart either. They are also noted for their bad temper. I am not certain whether I have blogged about a cardiac surgeon known as F-tach for his repetitive use of Anglo-Saxon words. It actually took two anger management courses to fix him although one wonders whether any non cardiac surgeon would have been tolerated so long.

A surgery resident I trained with was home one evening when his phone rang. It was the hospital switchboard who connected him to the ward, where his staff man was apparently sitting. His staffman, ordered him to immediately come in and fill out a disability form for one of the patients. Nothing like, "can you do this tomorrow?" or "Since I'm here why don't I just fill out the stupid form?"

The hospital where I trained was a smaller centre where cardiac surgery was only done 3 days a week. This of course left lots of leeway for the "emergency" CABG. Most of these took place on Saturdays in order to take advantage of the weekend premium. Occasionally they were booked on Tuesdays or Thursdays. I remember one day our senior alpha male cardiac surgeon announced during his booked list of Monday that he really had a patient he had to do on Tuesday. To justify fzcking up the OR schedule, he described how unstable the patient was and how he had been afraid he would have to do him on the weekend (so why didn't he bump his elective case on Monday?). Anyway the plan was that the unfortunate patient would be transferred from the hospital where he was languishing in the CCU to our hospital where he would be directly admitted to the ICU and have a balloon pump inserted to off-load the heart. I happened to be on call that night and as well my wife was working in ICU. The resident on cardiac asked me if I could see the patient pre-op. We were of course expecting an ambulance transfer which was why we were surprised, when around 1900 there was a knock on the door of the ICU and the patient was standing outside, having walked over from the admitting department CARRYING HIS SUITCASE, after coming over by taxi. Nevertheless, the IABP was inserted, that the "emergency" CABG went ahead the next day.

I can't help but mention that this particular surgeon carried on an affair with one of the anaesthesiolgist/intensivists for 3 of 4 years of my residency. When they broke up, it made for some interesting dynamics in the OR and ICU.

I could go on and maybe I should, but the bottom line is that most of us really resent the sucking of OR resources into the cardiac room. This happens both during the day and also during the night. There is also the assumption that the flow in OR can be disrupted to accommodate their "emergencies" or conveniences. Nobody ever calls them on this.

There is also the issue that a considerable amount of resources are going to treat a condition which can largely be prevented or treated by much simpler measures. Back when I worked at the CofE, our department chairman made a rare appearance in the coffee room. He described an interesting dilemma. Under the bizarre funding formula in our province, our cardiac surgery team would have to do 300 heart surgeries in the next few months. In order to do this, the CofE was prepared to authorize overtime, etc anything to get those cases done and avoid whatever penalties the province would be imposing. The problem was that because of things like health lifestyles, angioplasties, statins etc. there were only 200 patients actually waiting for surgery (the CofE is capable of doing 40 cases a week). I never found out whether they met their quota. In the odd glance at the OR slate, I did notice a lot of single vessel bypasses and that the average age of patients seemed to be higher. Just a coincidence though.

At that time the CofE was erecting a temple to cardiac surgery next door. This after several glitches is finally opened. As the opening approached it became apparent that because of things like healthier lifestyles,etc that the whole centre was way too much supply for any demand and there was talk of doing non-cardiac surgery in some of the redundant ORs.

I have gone onto greener pastures at my nice community hospital of course.

Monday, June 14, 2010

How Much Longer Are Your Going To Be?

I realized how much this question bothers me the other night while on call.

I can usually estimate how long it is going to take me to do most things. It is trying to estimate how long the surgeon is going to be that gets on my nerves. Like as if I can actually control that. I would love to be able to control surgical times, I fantasize about implanted chips or scrotal clamps that give shocks or tighen up if the surgeon is working slowly.

The other night it was the Case Room calling just after surgical incision (and just after I had told the second call to go home) to find out how long we would be as they had a C-Section they "needed" to do. They were of course very vague about how urgently they "needed" to do the C-Section. For all I knew and for all they were prepared to tell me it could have been a prolapsed cord or just someone who wanted their child born that day for astrological reasons (don't laugh, we have done at least one C/S for those reasons).

It is not just the Case Room. Other surgeons frequently phone into the room asking to speak to me to find out how long their colleague is going to be.

I could ask the surgeon. If it is shortly after incision, they will answer that they don't know until they actually see what is involved. Or they will give me an estimated time which I will then have to decide whether to multiply by 2 or 3 times based on their past performance. Some surgeons are a little sociopathic and actually slow down or let the resident do the case when they know, they are going to get bumped.

More often as the evening witching hour approaches it is just another surgeon trying to decide whether the case which was urgent a few hours ago can now wait until tomorrow.

I should know better; I was a little rude to our Case Room. I told them I could no more predict how long the surgeon would take, then they could predict who would need a labour epidural and when.

Saturday, June 12, 2010

The Needle and the Damage Done?

One of the most onerous tasks lately as department head (or site leader as we say in newspeak) has been the implementation of what our leaders call "Safety Engineered Devices". These are essentially needles that cap or blunt themselves automatically to prevent needle-stick injuries.

As an anaesthesiologist I should be in favour of these devices. After all for a living I for the most part stick sharp things into people, take them out and dispose of them. As such I am at high risk for needle-stick injury. In fact I blogged about my last needle-stick. Early on in my career I read a depressing article where someone calculated a 1 in 3 chance of an anaesthesiologist being infected with HIV during his career. This gloomy article was based on 3 needle-sticks a year and assumed a population incidence of HIV that we have fortunately never reached in North America. Wearing gloves does not of course prevent needle-sticks, it may in fact increase the risk.

Our most recently foray into safety actually originated with our Ministry of Labour which in our province is in charge of Occupational Health and Safety not the Ministry of Health. Legislation was passed and we are now approaching the July 1 deadline. This has meant multiple emails, multiple meetings and I cannot pass anyone in my department in the hall without getting an earful.

Why do we hate these so much? Most of these devices were introduced 3-5 years ago. The hypodermic needles in order to have their built in blunting or capping devices are incredibly bulky. This is not much of the problem with the larger needles that we use to draw up drugs (although we hate them too). The smaller needles that we use for infiltration or occasionally nerve blocks are cumbersome to use, and the extra bulk often makes it difficult to see the needle tip, something most of us like to see as we are sticking it into somebody. Fortunately with some needles it is possible to break of the capping device which I do, although I was informed last week, I can be fined for doing so.

Worse are the intravenous needles. These either come with a spring loaded blunting device which shoots up the needle hopefully after (but frequently during) the intracath insertion. The other variety has a spring loaded device that withdraws the needle back into the hub like a reverse switchblade.

3 years ago we were given the first variety. Even accounting for a learning curve, they were terrible. The needles were blunt, the catheter did not slide easily, they were bulky and the flashback chamber was small. Within days because of complaints the old IVs appeared in the OR but the nurses on the floors were forced to use them which meant that patients came down to OR with bandages all over their arms from failed attempts.

With the deadline looming however, a better safety IV appeared, the BD Insyte with its retractable needle. While they are a little bulky, they seem to be something I at least can live with especially as we already use the old BD Insytes and are used to them. We are assured we can use them, I suspect they may suddenly disappear in a year or so and we will be left with a less user friendly needle.

Fortunately, as there is no "safety engineered device" available, epidural, spinal and nerve block needles are for now exempted. Interestingly enough acupuncture needles are not. It is possible to apply for an exemption which I did last week for all our "dangerous" sharps and we are assured that these exemptions will be granted although only for six to 12 months at a time which should help the pulp and paper industry.

It is only a matter of time before the companies that make both types of devices realize that there is no point in manufacturing a cheaper device when they can with the government's blessing sell a much more expensive device.

More ludicrous has been the search for a safety engineered scalpel. With 3 weeks to go to the deadline, no such satisfactory device, has been found and as far as I can see they aren't even trialing one. I was going to suggest that they just use box-cutters.

One issue nobody has raised so far is the cost of all this. I learned this last week at a meeting. The SED hypodermic needles currently cost 26 cents a unit versus 2 cents a unit for the old device. I suspect the gradient for the intravenouses is even higher. These may be only a matter of a few cents however think how many needles get used every year. For example in our late (and I am told futile) H1N1 vaccination blitz SED needles were exclusively used. So say in our province one million people were vaccinated, the means that $260,000 rather than $20,000 was spent on needles alone. At the meeting I was informed that while we are trying to cut healthcare costs in other areas, when it comes to SED's money is no object.

I like to protect myself and don't really like the needle-stick experience I seem to get every couple of years with its paperwork and blood drawing. Worse I would hate to have a nurse or other colleague stabbed by one of my needles. I wish that this whole initiative was driven by a concern by worker safety but I think it is being driven by an occupational health and safety industry that is farther and farther removed from the realities of the workplace.

Sunday, June 6, 2010

Work relationships.

This is an interesting article which puts a different perspective on this story.

For the rest of the world who don't get news from Canada, a brigadier general from Canada was recently relieved of his command in Afghanistan after admitting to having sex with a subordinate officer. When you are a brigadier general I suppose you are limited to having sex with Lt. Generals, Major Generals and of course plan old Generals. The fact that he was married to a different woman adds to this. He was at 42 the youngest general in the army and could have had a promising career ahead. On the other hand he was also court martialed for accidentally shooting himself around the same time which says something about what it takes to advance in the Canadian Forces.

I am quite happy to have one less Canadian soldier in Afghanistan.

Leah McLaren points out however that without workplace romances, many of us would be celibate and many would have never got married.

I have been married for 25+ years to a nurse. Most of my close friends from medical school are married to nurses. I met my wife in a social setting, however it was a medical party. I have never gone out with any nurse that I met at work. I would like to say that this is because I deeply respect nurses as fellow healthcare workers but that would be bullshit. It was not for lack of trying, but I was held back by a number of factors.

1. I am usually inept around women.
2. The idea of working with someone for 4 or more weeks after being turned down has never appealed to me.
3. Most nurses hate me within a few hours of working with me.
4. I am too frigging busy at work and I suspect most nurses are too. If I have nothing to do, the last thing I want to do is hang around the ward hoping to make time. If I am not on call, I would rather be home, if on call I would rather be sleeping or watching TV.

I have often heard doctors describing their on call sexual exploits. Again I wonder when they found the time (or the woman). I can remember two occasions when it might have highly theoretically been a possibility for me. Both times my beeper started smoking for the next 3-4 hours effectively losing any highly theoretical opportunity for on-call sex.

The other interesting subject is whether a doctor who "dates" a nurse is making use of her subordinate role to him. I would suspect most residents and quite a few staff physicians would argue that at least in teaching hospitals it is the reverse. Doctors are completely subordinate to nurses!