Saturday, February 27, 2010

Why I May Have Developed Issues with Meaniors

I made a post a while back about meaniors. Some people may think I am a little insensitive about seniors.

I grew up in Victoria like I said. It was not that great a place to be a child.

For example.

I used to go to the Safeway with my mother when she bought groceries. Safeway at that time had an automatic door. The door going out of the store had a device where you stepped on it and the door opened. Only the out door had this. No motion sensors and only the outdoor.

We thought that this was the neatest thing and I used to hang out by the door while my mother paid for her groceries.

One day I was hanging out by the door when a herd (posse) of meaniors approached the door. One of the ladies was in an electric wheelchair. Electric wheelchairs were huge bulky devices then. As I watched they proceeded to try and get her and her electric wheelchair in through the out door. The outdoor only opened to the outside.

I was standing there when one of the meaniors demanded, "Help us young man". Meaniors always called you "young man". I tried to tell them that they were going in the wrong door and if they backed up, I would hold open the in door which was not automatic for them. The lead meanior didn't listen to me she just said, "Oh he's no help he's stupid". My mother finished up paying for her groceries around that time and we left through the out door at the other end of Safeway.

I never found out whether they go into Safeway. I hope they didn't.

Thursday, February 25, 2010

Anesthesia Manpower

When I finished my residency 20 years ago and was sitting my oral exams, I was talking with the 4 other people being grilled at the same time as me and I was the only one who had a job after his residency. Times have changed and now we have a shortage of anaesthesiologists in Canada.

A couple of weeks our oil-rich government decided they were actually not as poor as they thought they were and announced that in order to reduce the wait lists for total joints, and cataracts they were going to have a blitz of surgery, involving opening closed operating rooms for a short period of time to do this. The time line was of course very short.

This is not an issue at our hospital because we don't have any closed OR's but 2 of the larger hospitals are running under capacity and have physical space. I was at a meeting where this was discussed. The site chief of one of the larger hospitals stated that there was no way he could get 2 more bodies for the couple of week blitz but that he would post the opportunity and see if part-timers and people on holiday were interested in working. He also pointed out that he had had to turn down qualified applicants to his department because the hospital had closed operating rooms.

I was therefore amused last week to read in our local paper an article on the proposed surgical blitz. The article pointed out that there was a hitch in performing the proposed surgeries because of a shortage of anaesthesiologists which it attributed to the fact that 2 are currently doing a mission in Ecuador (true).

This reminds me of an event early in my career during my first run as an administrator. I was at a meeting where a senior administrator announced that for budgetary reasons it would be necessary to close a room for the month of March. At that time we were already down one person which meant that nobody could take vacation without getting a locum. Therefore innocently I opened my big mouth and said that there wouldn't be a problem because people wanted to take vacation in March and closing a room just meant we wouldn't have to look for a locum.

To what shouldn't have been a surprise, I read in the local paper the next day, that the hospital would have to shut down an OR in March because of a shortage of anaesthesiologists. I should have written a letter explaining what actually happened except that I suspect I would have been the target of some reprisal plus the hospital actually at that time had a gag order on doctors.

Anesthetic manpower is of course a complex issue which seems to be beyond the understanding of most physicians. Anaesthesiologists are completely dependent on what work the hospital can give them. In the past 20 years people have found creative ways of making work for themselves like acute pain services,pain clinics, private surgical suites, sedation etc but the bulk of our work is still hospital based. I found it amazing when I worked at my first hospital how during my brief tenure as chief I was constantly under pressure to hire another anaesthesiologist at the same time as the hospital clearly didn't have the funding to run the rooms it had, let alone an extra room.

As I said to the chief of staff during one of the numerous meetings I had to attend during that time, "It's not like we can just hang up our shingle and start practising". He still didn't seem to get it.

There are a few other interesting angles to the surgical blitz. The areas targeted were total joints, cataracts and MRIs. Total joints currently have an average wait time of 6 months which may sound like a lot, however if you consider that most patients are referred earlier so they are less disabled and in less pain plus the fact that total joint surgery is a major life altering event (especially when it goes wrong) that people may actually need some time to reflect on whether they actually want the operation. Judging from some of the medical wrecks coming through the OR now for total joints I sometime wonder whether they have any wait list or whether they are just bringing in patients off the streets. Cataract wait lists are currently measured in weeks. I am not sure what the case is for MRIs except the patients I see in the Pain Clinic seem to be getting theirs quite quickly.

There are a lot of things in the healthcare system that are underfunded like chronic pain management, we have patients in stretchers in the ER waiting for hospital beds, chronic patients in acute beds waiting for chronic beds, and patients with no family doctor. Therefore I am wondering why the geniuses who run the healthcare system decided to focus on 3 particular surgeries (cardiac surgery was also addressed) and one diagnostic procedure. Is it any coincidence that 4 of the most highly paid specialties are getting their needs addressed. Oh BH, you are getting way too cynical.

In the announcement was also the fact that most of the extra total joints in the province will be done at a private hospital in Calgary for $12,000 a pop. The spokesman commented that he realized that that was a lot more than a total joint costs in the public system but that there were intangible costs in the public system that made the costs relatively equal. He didn't outline what the intangible costs were; treating the complications from the private hospital at the public hospital? paying 6 figure severance packages to recently dismissed political appointees.

I used to disgusted.....

Monday, February 22, 2010


The mall where my sometime office has many doctors offices in it. As mostly seniors go to doctors, this means there are quite a few seniors hanging around the mall. There is a pharmacy in the mall where I occasionally go to buy shaving cream and stuff like that. Because 4/5 customers in the pharmacy are seniors, paying for your stuff tends to be a drawn out process by the time you wait behind 3-4 seniors all of whom are buying lottery tickets as well (and counting out the change from their change purses).

I do try to be respectful of the elderly.

That was why when I found myself in a foot race with an elderly lady with a walker for an open checkout, instead of going into my finishing kick and beating her cleanly to the front of the line, I slowed down and let her go ahead. Age before beauty I thought.

Not again.

This lady came to the cash register and proceeded to send the clerk around the store to individually pick up the 4-5 items she wanted to buy. This was while I waited impatiently behind her.

Fred Eaglesmith who is one of the greatest singer/songwriters around was going thru one of his long monologues last summer and was talking about his recent trip to Vancouver Island. Vancouver Island according to Fred is populated entirely by hippies and mean seniors. Say Fred, "I call them meaniors".

One thing that amazes me as I get older is how seniors today who are only 15 or so years older than me act just like the seniors I grew up with 40 years ago. You would think they would have learned something and resolved "I am not going to behave like that when I am old" but they haven't. Same clothes, same attitude, same sense of entitlement.

When I think about it, the meanior of my childhood had actually been through something. Many of them had been affected by the First and later Second World Wars. All of them had lived through the depression. Maybe they had the right to be crabby. Maybe not. Our current group of meaniors has never been thru any war, has lived in great economic times with good jobs, bought low and sold high, had universal healthcare and indexed pensions. They haven't done anything to earn the respect to which they believe they are entitled to.

I grew up in Victoria, which had lots of nicknames, including God's Waiting Room. There were to say the least a lot of old people there. We didn't call them seniors then, we called them little old ladies and little old men. No question though they were mean when you were a little kid. I grew up with a real hatred for anyone with gray or white hair. This had not dissipated at all by the time I started medical school. I mean like who told me I was going to have to treat old people? This of course proved to be somewhat of a hindrance during my orthopedic and internal medicine rotations. It certainly didn't help me when I was in general practice (although I came to hate drunks worse).

In anaesthesia I have come to enjoy doing older patients if only because as everybody knows it is impossible to kill a 90 year old. In the pain clinic I have come to dread them. The main reason is my frustration at not being able to do much for them, having to fight with the multiple other specialists involved in their care and of course dealing with the families.

As I tell my wife, I will be eligible for the senior's discount in some places in 3 years and I intend to make full use of it. I already forget to turn off the blinker, (I tell everybody now that I'm over 50 I don't have to) and I am obsessed with my bowels. I find myself getting to be a bit of a crabby old fart already; read my postings on medical students and resident, not to mention how much better everything was in the olden days.

Wednesday, February 17, 2010

Why Euthanizing Your Dog is Not Like Flushing Your Goldfish Down the Toilet.

Or why country and western songs are starting to make sense.

I euthanized my dog this afternoon. She was 15+ and was lame first in one and then another hind leg. For her last week on earth, she mostly slept by the door getting up painfully a couple of times a day to do her business outside. She was still with it, although appearing a little blank at times.

My wife had to go to work and clearly didn't want to do the deed so since she took the last dog for the big sleep, I agreed to do it.

Our dog was our second dog of the same breed. Our first dog had to be put down at 12.5 years so once that milestone passed we knew the day was coming.

We never had dogs growing up. My wife's family raised and trained dogs. I in fact used to be afraid of dogs. I did come to like all three of the dogs we have had (we still have one). I get frustrated with taking them for walks in bad weather, cleaning up poop and their insistence on getting up the same time regardless of the day of the week.

Every dog I suppose has good qualities but this dog was really a great dog. We bought her shortly after the death of our first dog. She was five then, she had been a show dog but was unable to breed so her owners were happy to get rid of her. She was an incredibly friendly dog, who fit right in to our family. She loved people, especially young children, she loved other dogs, she even loved cats. She was a vocal dog who loved to howl. When we first got her she was so well trained that she would only eat kibble. We had gotten into the bad habit of feeding our dog table scraps. A week spent with one of our friends cured her of this and she became an incredible mooch although never a counter surfer. She loved apples and I could never eat an apple without giving her a piece.

She was such a good dog we thought if we got a puppy she would teach the puppy all her good qualities. It didn't work.

When I took her to the vet and we both agreed that she had to be euthanized, I cried like a baby. I felt terrible, I am after all a doctor, I am used to patients dying. The vet gave her a "premed" injection of some type of phenothiazine. For ten minutes I sat on the floor petting her. Finally the vet put a butterfly in a vein and injected a lethal dose of pentobarb. She stopped breathing almost immediately, felt cold to touch and after a minute the vet listened to her chest with a stethoscope and said she was dead. She told me I could stay as long as I wanted. I thought of the last line in "A Farewell to Arms" and left right away.

Stopping to pay the bill of course.

Tuesday, February 16, 2010

The Judge

During my residency I spent 6 consecutive months at a downtown Catholic Hospital. The first three months were anaesthesia which was a fantastic experience. The second three months were on the internal medicine service which was an ordeal of one in three call which I am still proud of surviving but bitter about having to do. One patient who stands out from those six months was The Judge.

Every time we encounter a member of the legal profession our collective assholes all go into spasm. This is really not necessary. Lawyers are for the most part well educated people who actually understand tort law, realize how much frivolous litigation will cost them and how little chance they have of succeeding. The upshot is that lawyers tend to actually get worse care; they get over investigated which generates further investigations and procedures; their care seesaws between overly conservative and overly aggressive. I suspect that about 50% of anaes. would for example not put an epidural in a lawyer for fear of a lawsuit, whereas we would all like one ourselves.

Judges in Canada are all appointed either by the federal or provincial governments. This is usually but not always done after consulting the legal community. Some judges are eminent lawyers or legal scholars, some are involuntarily retired politicians and some are appointed in recognition of their service to the ruling party. For all its flaws the system more or less works.

There is a feeding chain of judges going from Supreme Court judges down to family court judges and justices of the peace (who often aren't even lawyers). Often when a judge is in hospital we refer to them as "The Hanging Judge" although Canada to its credit hasn't strung anybody up since 1962.

I don't know what type of judge The Judge was or what his qualifications were for his bench.

The judge presented to the thoracic surgeon at our downtown Catholic Hospital (DCH) with lung cancer. Sadly this was unresectable even for our thoracic surgeon who was known for his heroic procedures. When told of his grim prognosis, The Judge told the surgeon he wanted no aggressive treatment. This would have been nice, if the surgeon had actually written a note in the chart, however when The Judge went into respiratory failure about a week after his diagnosis, the internist on call had him intubated and put on a ventilator.

Did I mention that two of The Judge's sons were lawyers?

This lead to 4 months of sheer misery for the The Judge. He was in and out of ICU, trached and had multiple line insertions (usually with no sedation or local anaesthetic). I myself inserted several lines in him. I remember during lucid intervals he would have a most malevolent look, the type of look he would have reserved for when he was sentencing someone to death (if he could do that in Canada). At one point during a brief period out of the ICU on the ward, he told one of the interns that he had been going through hell.

Being a judge, there were always jokes about him being a judge. I remember once when he had gotten off the ventilator and was sitting in a chair in ICU, one of the internists remarked that all he needed was his robes. One of the nurses told me she was rolling him, thinking him our of it and called him "judgey poo" at which point he opened his eyes.

Despite everything he was gradually not surprisingly dying of cancer. Eventually he developed brain mets. Despite everything no DNR order was ever written (or as far as I know requested). I wasn't on his service and only covered him at night so I have no idea about what discussions went on with his family.

I was on call the night he died. He was by this point in the CCU, the ICU being full. The CCU nurses called me quite concerned because they felt he was going to die soon, there was no DNR order but they did not feel comfortable running a code. I told them, when he arrests, don't call a code, page me, I will call the code off and say we did everything we did. This is in fact what we did about 2 hours later.

One of the interns told me later that he had overheard a conversation between The Judge's two lawyer children to the extent that, "He was a bastard to us and look how we have made him suffer." I didn't actually hear the conversation, I hope it actually didn't occur although it does make for a good story.

I must check out my personal directive.

A story I am reminded of

I was perusing Great Z's blog when I found this story which reminded me of something similar that happened at the C of E which unfortunately didn't go as well for the patient.

A patient with a previous esophagectomy and pull-thru presented for a CABG. Unbeknownst to the cardiac surgeon who never asked (or probably even talked to the patient or read his chart beyond the cardiac cath report), the pull thru had for some reason been done anterior rather than posterior to the mediastinum.

When they sawed thru the sternum, they also sawed thru the piece of colon that was now acting as the esophagus. Oops. A general surgeon was called to fix things and I don't think the gentleman got his CABG that day.

The surgery resident who looked up at the lateral CXR up on the viewbox which showed something in the anterior mediastinum which didn't belong there, said, "I guess we should have looked at that first!"

Monday, February 15, 2010

Just When Did Valentines Day Become an Adult Event?

When I was four, we had for some reason a mailbag lying around the house. On Valentines day 1962, my Mom "helped" me write Valentines to all the kids on our street and she then put them one at a time into the mailbag and I hand delivered them. This being the baby boom there were lots of kids. I had so much fun I even delivered them to the kids I didn't like. Many years later my mother ran into one of the mothers on our street who still remembered me and the mailbag delivering my Valentines.

In elementary school, you either gave out Valentines to the whole class or curiously to all the people of the same sex in your class. No boys liked girls then, we all knew that we would eventually marry one although we couldn't figure out why? It was of course embarrassing to get a Valentine from a girl and these usually ended up in the wastepaper basket so my older brothers wouldn't read them.

We certainly didn't have Valentines in junior high or high school. The schools some years had Valentines dances.

Likewise in University there often was a Valentines dance some time around Valentines day but except for the decor, it differed little from social functions where we (always) got drunk and (seldom) met girls.

In second year medical the men in our class actually prepared a Valentines slide show for the women in our class. The central theme was various members of our class posing naked with a large red Valentine covering their members. The Valentine read "Have we got a heart on for you!". (I wasn't one of the models. At the party where the pictures we taken I had already passed out.) I suspect today such a slide show would earn the perpetrators a visit to the Dean's office and maybe even a few weeks of sensitivity training.

Time went on, I actually met someone at a drunken social function, got married, had kids, a career etc. Somewhere along the line, I missed something and Valentines Day became an adult occasion. (I suspect a holiday with vaguely Christian roots, celebrating the difference in the sexes is now verboten in the schools.) In fact I have recently seen signs in stores proclaiming Valentine's Week!

I read this interesting article in the Globe last week

The Valentine's Dinner has of course become a duty for most adults. These now have to booked months in advance. As the article points out most couples (except for the guy getting the blow job) don't really seem to be having a good time. I guess the point is that if there is very little romance in your relationship, what makes you think that a dinner with a bunch of other couples once a year is going to fix things?

One does have to feel sorry for the chocolate, greeting card and lingerie manufacturers for whom this is one of the biggest sales days but is it time we gave this special event back to the children. Assuming they even want it.

Sunday, February 14, 2010

Wonder Boy

I hate to use this blog to air grievances but where else would I?

I got to work with a number of "interesting" people during my time at the C of E.

A number of years ago we had a new resident. He had come to medicine via a roundabout way obtaining degrees in Engineering and a PhD along the way. He was very interested in research which of course warmed the chairman's heart. I will call him Wonder Boy. If you read regional anaesthesia journals you should be able to figure out who he is.

One day I was working with him early in his R2 year. At that time I was interested in spinal cord stimulation and was doing trials of this with the neurosurgeons putting in the permanent leads. Wonder Boy asked me if I knew any practical way of stimulating the epidural space with a a goal of knowing where the epidural catheter is.

Knowing where the epidural catheter is seems to be of some importance. We have all been there. You do a case under epidural, after injecting 20 cc and then 10 more, there seems to be no block. You either have to switch to a GA or do a spinal and hope that the lake of local anaesthetic that might be in the epidural space doesn't leak thru your spinal hole. Or the patient with the post-op epidural where you are getting calls from the ward because it's not working; is it because it's not epidural or are there other reasons.

Now as I told Wonder Boy, the leads I used for epidural stimulation cost about $1000 which made them impractical. I then had a revelation.

During my residency one of our neurosurgeons for a certain procedure liked to have a central line placed in the atrium. When you actually want your CVP in the atrium, this is quite difficult so we used an atrial EKG. We put a attached a hollow metal lead to our CVP catheter, filled that catheter with saline which conduct electricity et voila when we got the humongous P wave we were in the atrium..

I told Wonder Boy this. I told him he should be able to introduce current to the epidural space thru a column of saline in the epidural catheter. I also pointed out that the equipment for this probably existed. Wonder Boy was not impressed. He said that what I had suggested simply would not work.

About a month later, Wonder Boy showed me his prototype which was a wire soldered to the metal coiling of a Arrow catheter. I wished him well.

I went to the resident's research day that year and WB presented his research. He actually had 3 presentations but he talked about his method of epidural stimulation. Or he sort of talked about it. He in fact didn't talk about it at all because as he told the audience he was patenting it and had been advised not to talk about it. Some of us rolled our eyes. He then went on to praise the two staff members who had helped him with his research neither named BH.

Fast forward to the 1998 ASRA Meeting in Seattle which I attended. Somebody told me the WB was presenting his research and I should be in audience for moral support. And so it was that I was in the audience while WB introduced to the world his method of epidural stimulation. Which was....attach a hollow metal lead to your epidural catheter, fill the catheter with saline and stimulate it. Which was of course what I had suggested several months ago. The method had by that time been patented and WB had modestly named it after himself.

Now quite frankly, I am better at suggesting things for other people to try than I am on trying them myself and I have to applaud him for all the time he spent trying out my idea on animals and humans even though he did most of it instead of the clinical work for which he was actually being paid.

Like all great researchers WB was able to create a research niche for himself by publishing multiple variations of trials with his epidural stimulation method. He has branched out to other things, is in demand at meetings and has co-authored a book. He is now on staff at the C of E (after taking two tries each to pass his written and oral exams).

Meanwhile I am just a bitter anaesthesiologist with a blog.

Saturday, February 13, 2010

A Most Inept Robbery Attempt

I have visited Ecuador for the last 4 years on a medical mission. I know Ecuador like most places is dangerous. When I travel there, I carry all my cash and documents in a money belt, I keep my back pack zipped up and I am constantly whipping my head around looking to see who is around me. I don't go out at night except in large groups and I stick to the "tourist" areas. This is not say that Ecuadorians are inherently dishonest or violent. Most of the people I have met are friendly and helpful and not a few times a local has warned me about potential danger.

While our group flies into and out of Quito, I have never really spent much time there. We typically arrive late at night, go a hotel near the airport and spend the next day visiting the fabulous Otovolo market and buying cheap but hight quality leather purses and jackets at Cotacachi before flying to Cuenca the next day. Going we stay at the same airport hotel before leaving early in the morning.

For this reason, I was looking forward to having a day to explore Quito after coming back from the Galapagos which I visited with my wife.

The driver from the tour company who drove us to our hotel suggested that we should definitely visit the old town which is a Unesco World Heritage site. He said that we could walk to the old town from our hotel which would be a one hour walk but a very pleasant walk, he said. I was skeptical but before we took off the next day, we asked the concierge the same thing. He said that yes, it was a nice walk, and very safe as long as we got back before 6 pm.

I always try to blend in when traveling but face it, 6'5" light skinned people blend in poorly in places like Quito. Therefore my wife and I set up dressed as Tommy Tourist. Small backpacks, zippered pants, and of course my Tilley hat to keep off the Equatorial sun. Naturally I carried a map which I checked frequently and our Lonely Planet guide was handy.

The first part of the trip was very pleasant. There was a large park we had to cross. People were out exercising and there were police on horseback patrolling. We turned onto Avenue Rio Amazonia which is Quito's main drag. This was a busy street but for the most part the sidewalks were in good condition and lots of people were out walking. Along the way we stopped at a money machine to pick up money to pay the airport tax the next day and also for the shopping we hoped to do at the market. We even stopped for a coffee con leche and visited a travel agent to ask about potential trips for our next visit. We eventually arrived at the Hilton Hotel where we had stayed prior to going to the Galapagos.

At that point we had to decide how to get to our destination. On the map there was a large square labelled Zona Historica which we assumed was the old town. Most of the attractions were well in the middle of this zone in a southwestery direction. There was no clear route marked. No problem I thought we will walk into the Zona Historica and zig zag until we reach the attractions in the centre.

The buildings were clearly of an older vintage but the stores in the buildings were for the most part, run down stores. Nevertheless there were lots of people out, it was daylight and I felt quite safe.

About 20 minutes into our exploration, I felt something wet on my back. I first thought was that my water bottle had leaked (except I wasn't carrying a water bottle), but when I put my hand back on my shirt, and smelt it, I smelt salad dressing. My wife took a look and said, "O god, a bird has shit on you, we have to wash this off". I haven't ever tasted bird shit but I still thought it was salad dressing. My wife now noticed she has some on her.

Shortly 3 "good Samaritans" appeared with bottles of water offering to wash us off. Like I said, I have travelled in Ecuador for 4 seasons and while I had let my guard down I suspected something wasn't quite right. My wife kept saying we have to wash this off, I said we should keep on walking and wash this off later. One of the good Samaritans tried to grab my backpack which also had salad dressing on it so he could wash it off. I of course kept hold of it. All the time I was saying no, no, no to their offers while watching to make sure none of them went for my money belt or my wallet which was fortunately in a zippered pocket. Eventually two of the good Samaritans left while one more persistent persuaded us to go to a fast food "pollo" restaurant to wash off in the bathroom. I finally gave him a dollar to get lost. I probably didn't have to as a restaurant employee who seemed to know this individual all too well quickly escorted him our of the restaurant. He also came back to ask if we were okay.

My wife who hasn't travelled much in South America was a little shaken up by this but I was able to persuade her to keep on walking and we eventually arrived at the Gothic Basilica into which we took sanctuary. It was cool and mostly empty. This didn't stop someone from accosting us and offering us a brief tour of the basilica for which he insisted we pay him not one dollar but two dollars "for the church". He offered to give us a tour of the old town stating it was dangerous for us to walk there. That was when I figured that he was probably also in cahoots with the other good Samaritans.

We eventually got to the central plaza. By this time my wife just wanted to go back to the hotel. We took some pictures, had a very nice lunch and took a taxi home to safety and comfort of our hotel where we watched English movies with Spanish subtitles. We never got to do any shopping at the market.

As I said just about every Ecuadorian I have met has been honest and hard working. When we North American visitors have so much while they have so little, some people might say a little dip into one's money belt is justified. I still have a hard time with robbery be it by good samaritans, contractors or the like.