Sunday, March 28, 2010

Excuse me, are you in line?

Having stood in various line-ups for many years I am all too aware of the all the bad behaviour that can occur in line-ups. The most common bad behaviour is the person who lets his friends in line or saves places for large numbers of people. There is of course a special place in hell reserved for the person who stands in line in the grocery store or Costco while his accomplice shops for the two of them.

I have noticed a new form of anti-social queuing (or should I call it non queuing).

I noticed this several years ago at our hospital. We have a kiosk which "proudly" serves Starbucks coffee rather than the week old swill available in the cafeteria. Consequently there are long line ups there all day. One day around 10 am I went to get a coffee. There were about 20 people in a long line that extended well out into the wide corridor. About 3 metres back of the that line, standing in a circle were 6 people who were having a conversation about something. I got into the back of the line, when one of them tapped me on the shoulder and said, "Excuse me we're in line". I meekly got in behind their circle. What I should have said was,"Why the hell don't you get in line then, preferably in single file"

Unfortunately this behaviour seems to have become quite widespread, where people seem to think that the proximity or the belief that they are in line, means they are in line. It is getting to the point the when I go to the convenience store, or coffee shop I will encounter somebody standing well behind the queue, sometimes facing the counter, sometimes not, but I know that if I stand at what should be the back of the line, I am going to get the shoulder tap or the glare. Sometimes these people will actually force people who have to stand in line behind them to stand outside or in the doorway. Another variation is the person who stands beside the line; is he in line, is he waiting for somebody in line; is he keeping somebody company. I can't tell.

I am not saying that everybody should be lined up pelvis to buttock. I have my personal space which I try to guard too (at the same time judging by how much I seem to get jostled now there seems to be less respect for personal space). I just wish that people would stand the hell in line. Is that too much?

Friday, March 19, 2010

Have they been isolated from their brains.

I had earlier blogged about the shear stupidity our infection control people exhibit when dealing with patients unfortunate enough to have acquired a drug resistant bacteria (usually acquired in hospital in spite of all the stupid precautions taken).

Case point 1.

One of the urologists was talking about how one of his regular bladder tumour patients has a drug resistant bacteria. This means that when he brings in this unfortunate individual from home to the hospital (where he probably was infected) he has to do him last on the list and usually hoo-haa goes on. The reason this came out is because our urologist had to reschedule the patient two weeks early.

The reason:

The patient wants to fly to Mexico for vacation.


When the patient comes for surgery, he will have to wear a yellow isolation gown, a mask and hat. We will clear the room of all non-essential items and if I want anything during the case I have to ask for it to passed through the door. The same will be done in the recovery room and in the Day Surgery unit. Every area he stops in will have to undergo a thorough cleaning.


He is going to be packed in a plane with about 100 other people in close proximity with the air recirculated.

Case in point 2

I got a call about an inpatient with back pain. The back surgeon had seen him and decided he needed an epidural steroid injection, something I do for a living. I figured the most effective way to get him done would be to just bring him down to the Pain Clinic.

He arrives in a yellow isolation gown, hat and mask. Procedure aborted; we don't want to have to do the major clean up infection control demands after these events. I said I would go up and see him on the ward. I don't really like doing epidurals on the ward but this is a special case.

Later that day I go to see him on the ward. First I find out where his room is. I am expecting to see the familiar pile of yellow isolation gown, gloves and masks along with the infection precaution signs on the door. Nothing there. He is in fact in a four bed room. There is however a pile of yellow gowns outside his bed.

Bewildered I go back to the nursing desk. "Why is Mr. X on isolation precautions?" I ask. He has a UTI says the nurse and until his cultures are clear he has to be isolated. "Is there any risk of transmission to staff or patients?" I ask. "Only if he pees on them" smirked the nurse.

After talking with him and examining him I decided to do the epidural on my next pain clinic.

A couple of days later we phone the unit to have him brought down for his epidural. About 10 minutes later, the unit phones us back. "Do we know he's on isolation?" asks the ward. "Yes we do" we answer.

Nobody likes hospital acquired infections especially drug resistant ones, however one wonders whether all this paranoia does anything other than to keep an army of infection control nurses who work bankers hours at the top of the pay scale busy.

Saturday, March 13, 2010

Sorry I'm Too Drunk to Come In

I have never actually been too drunk to come in, but I did have to say this once.

When I interned I had a surgery elective. There are a lot of interesting things I could have done but for some reason I decided to orthopedics in the Big Teaching Hospital (BTH). I was going in general practice, I really felt I should do some ortho. I didn't do an elective as a student intern because I figured I would get to do more and learn more as a fully fledged MD. How could I be so stupid.

Now maybe I had had a sheltered life or maybe my expectations were too high but up until that point in my life, I had never been treated like a piece of shit, that way I was treated during the four week rotation. Unfortunately that was to be exceeded later in my internship.

During our rotation we did call 1 in 3. This was not unusual in the early 1980s. In fact one in three was considered by many to be ideal balance between education or sheer torture. 1 in 2 is too much (plus you miss half the good cases), 1 in 4 means you miss out on on call experience whatever that is. One feature of 1 in 3 call is it makes weekends a theoretical concept. You are either on call Friday night, all day Saturday or all day Sunday.

Sunday is of course the worst day to be on call because that means you are on call the following Saturday, a seven consecutive day stretch. But, you could say, "At least you have Friday night and all day Saturday".

Ortho (and many of the surgical services) had a way of dealing with this. Mandatory Saturday morning educational rounds. Each Saturday from 8-12 we would have to attend the residents' educational rounds, 4 mind numbing hours of internal fixation systems and joint prostheses. OK but you still have Saturday afternoon? Think again, since you well there, you were expected to round on all the patients on your service and do all the scut work that piled up on ortho. If you were lucky, you might get out by 2 pm. (They also expected you to come in Sunday for the elective admissions which included drawing all the bloods and doing the ECGs).

So it came on the third weekend of the rotation that I was on call on Sunday. In the scheme of things this meant I was on call Thursday. Normally ortho was moderately quiet, lots of IV restarts on confused LOLs, sorting out medical problems etc but you could usually get a few hours sleep. That Thursday night was an exception with a major trauma followed by one of our patients having a respiratory arrest. Then of course one of the staff on our service wanted to round (ortho staff only rounded once a week!) which took us until 6 pm.

I walked home, ordered pizza opened a beer and I was asleep by 9 pm. Now I still really believe that I honestly forgot to set my alarm for 0700 which would have allowed me to get to the hospital in time for rounds and that I didn't intentionally not set it but it was 10 am when I woke up. I felt a little guilty but since I had probably already missed the best part of internal fixation systems and since I remembered that another intern had not showed up the last week, I got up putzed around, had coffee, read the paper; the things normal people do on Saturday mornings.

I can't remember why I was still home at 3 pm or why I answered my phone. It was the hospital and the student intern on call was on the line. He told me that the intern on call had phoned in sick, that they were really busy and could I come in.

At that time I could have said any of the following:

1. I'm sorry you have the wrong number.
2. I'm on call tomorrow and there is no way I am working two nights in a row.
3. There is nothing in my contract that says I have to cover sick calls.
4. Instead of delegating the call to you, why doesn't one of the residents call me and we can talk about what I get in return.

None of these seemed right at the time, I had to think hard about why I couldn't come in. It came to me in a flash.

"Well", I said, "I'd love to come in but I've been drinking since noon." "Oh," said the student intern, "I'm not sure what the rule is about that". "Well I know what the rule is," I said, " and I am sorry but I can't come in." Opening up my first bottle of beer with my spare hand.

I felt a little guilty about this, but as time goes on I feel less and less guilty.

Friday, March 12, 2010

There is Superstition

I went to a medical staff meeting last night. It had been a while since I had gone to one and having attended one I realised why.

One item on the agenda which caught my eye was the hospital's reiteration of its policy towards cell phones. Based on document which it did not supply the hospital reiterated that while cell phones are welcome in certain areas of the hospital (mostly areas where administrators go with their hospital-supplied blackberries), use of them in most patient care areas including the ICUs remains verbotten.

It pained me to see the Hospital's chief executive officer (or whatever title they are using this month) stand up to explain this policy. She seems to be an intelligent lady, probably has an MBA and yet she has to stand up and repeat what is one of the biggest urban legends around: Cell phones can interfere with or reprogram delicate medical equipment.

Another way of looking at things is: You paid six figures for a ventilator, five figures for a monitor or 4 figures for an infusion pump and my little cell phone is capable of playing havoc with them. Maybe your purchasing department should have exercised a little due diligence when they were selecting which make and model to buy. It is interesting that the initial point of contact for buying medical equipment is usually a trade show at a medical conference. Who attends trade shows? Sales reps who are attached to their cell phone and doctors who are likewise attached. Think of the amount of radio interference going on.

It seems that whereas three hundred years ago intelligent people had lots of superstitions that seemed so irrefutable then, we still have superstitions that likewise seem irrefutable. Cell phones and medical equipment are one.

Other examples.


Nobody denies that washing your hands before and after touching a patient is a good idea especially before you make a large hole in his skin. Washing the skin before you make the large hole is probably also a good idea. Not wearing the clothes you put on at home is probably not a bad idea especially the tie you have had for the past 20 years and have never once washed. Not wearing the OR greens you slept in makes sense too. Wearing a hat to keep something from dropping off your scalp probably isn't a bad idea either. Cleaning the instruments makes some sense. Gloves of course protect you from the patient.

Beyond that just about everything else we do in the OR in the name of reducing infection is simply ritual and superstition.

The Case Room

The case room is a hot bed of superstition. Much of this centres around labour epidurals. Many nurses and obstetricians believe the epidurals slow labour. This of course doesn't stop them from requesting them early when they themselves are in labour. Fetal monitoring is of course about as scientific as sacrificing a chicken and reading the entrails.

Wednesday, March 10, 2010

Abortion and Hypocracy

I almost thought this article was real until I read it more closely. Being on the sarcasmist site I should have known better.

You see I knew a doctor like that.

The last job I had before deciding to punt general practice generates a lot of stories that are funnier than they were then. I have posted a couple.

I worked in practice with two other doctors. One was a young charlatan, the other was an older very religious doctor who had done missionary work for about 20 years before settling in this town. He was very active in the local Pentacostal church and by extension in the Pro-Life movement. This meant we had pictures of aborted babies in our waiting room and if I wanted to refer a patient for an abortion, it meant I had to do it secretively, usually making the phone calls from my home. I needn't have bothered apparently.

One of the GPs from the other clinic who also did anaesthesia told me an interesting story about my partner. Our hospital didn't do abortions but we also didn't send our surgical specimens for pathology. My partner it turned out had done lots of D+Cs for "menstrual irregularity". This meant he did a lot of young women. One day my GP anaesthesia colleague looked at slate, talked to a few of the patients figured out what was going on and confronted my partner.

Now at that time abortions were legal in Canada but were regulated. Abortions could only be done in an accredited hospital and they had to be approved by a committee of doctors. This made access to abortion anywhere from a rubber stamp to only in extreme cases depending on the make-up of the medical staff and the hospital administration. Our hospital which was non accredited did not have an abortion committee. (Actually the administrator told me he had intentionally not gone thru the accreditation route precisely so the whole issue of abortion wouldn't raise its ugly head).

Now of course when confronted my partner responded in his usually self righteous bullying fashion which I later came to experience but the other doctor stood firm and pointed that aside from the medical implications, my partner was actually breaking the law.

And from then on women with "menstrual irregularity" had to go to the next town over.

Tuesday, March 9, 2010

You can't deal with supply without dealing with demand

Many years ago I sat on our hospital's utilization committee. That was in the days when in return for your hospital privileges, you were expected to serve on hospital committees on your own time. I was assigned the utilization committee by my chair. Apparently I was just supposed to show up and sit there.

The first meeting I attended, we discussed physiotherapy. There was a six month wait to get physio at the hospital. This was not due to money but more due to a nation-wide shortage of physios. Physios you see are smart. In order to ensure 100% employment and lots of business for those in private practice they restrict university positions and make it difficult for immigrants through their licensing bodies.

Nobody seemed to have a good solution to this so I awoke from my torpor. "What is the point of even getting physio for an acute injury if you have to wait six months," I asked. "There is no point," said the rheumatologist who was leading the discussion. The wheels were now turning in my head. "What percentage of current referrals to physiotherapy are inappropriate?", I asked. The rheumatologist admitted that a significant number of referrals were not appropriate but that was not the point, they needed more physios. "Wouldn't be better to educate doctors on what is an appropriate referral so that the physios we have can see appropriate referrals earlier," I asked, "rather than trying recruit non existent physios?" At this point one of the GPs on the committee informed me that as an anaesthetists I had no right to be commenting on this. I guess I was just supposed to sit there on my own time and eat bad hospital food.

This event which happened years ago came to mind last night when I attended a meeting on wait lists which went well into the evening. As I mentioned in a previous post, our government has decided it is not as poor as it thought it was and is prepared to spend money to bring down wait lists. Therefore a huge meeting was convened with a representative from each surgical subspecialty, multiple administrators and the anaesthetic site leaders from each hospital. We were invited as there is a shortage of anaesthetists now and it was hoped that by the shear pressure of all the high power in room, that we would be able to create anaesthesiologists out of thin air.

Every surgical specialty of course believed that their patients suffered the most by waiting and that their cases should get priority. The most amusing was the head of ENT who gave a moving presentation on how we should be getting their backlog of septoplasties done. Nobody laughed out loud, they were too embarassed for him.

Nobody including me asked the question of could we not reduce the wait lists by looking who is being put on the wait lists for various types of surgery, are they appropriate for surgery, are there alternative treatments that might help them or do they even need to be helped.

Surgeons are only a little bit sociopathic and I don't believe that they would put inappropriate or unnecessary surgery on their wait list solely to puff up the wait list however we have a saying in the pain field, "when you're a hammer, everything looks like a nail". Imagine the poor surgeon faced with a patient who is clearly distressed with his symptoms who has nothing to offer the patient except the knife. Is it easier to say, "I really have nothing to offer you" or is it easier to book him, hope that the patient changes his mind, or gets better before surgery or that your surgery just possibly helps or at least doesn't make him worse.

Much was made of waits for cancer surgery. I certainly would be distressed at having to wait 4 months for cancer surgery, however the physician in me knows that really most (not all) cancers are slow growing, and that there could already be a nest of malignant cells sitting in my liver, bones or brain that will finish me off no matter how early the surgery is and how clean the margins are. A very eloquent presentation was made by the urology rep about prostate cancers. Urinary retention is not pleasant but can be dealt with quickly with a TURP. As it has been observed, more men die with prostate cancer than of prostate cancer. This is something all the surgeons in the room knew but nobody had to balls (appropriately) to say.

Monday, March 8, 2010

I can't really think of a tasteful title for this post

Anesthoboist has posted this, which is about a number of things including pelvic exams.

There has recently in Canadian newspapers been a flurry of stories and denials. This is based on the "discovery" that medical students and junior housestaff perform pelvic examinations on anaesthetized patients who haven't consented for this. There have of course been denials from many Professors of O and G who have all stated that they would never and have never allowed medical students to examine patients under anaesthesia without their consent.


I went to Medical School at one university, interned at another, did my residency at a third and now work affiliated with a fourth and unless all of these four programs are an anomaly, women across Canada are still being violated in the name of medical education. I witness it just about every time I do the gynie list.

Now for those going into gynaecology, family practice, urology and possibly general surgery, the ability to do a pelvic exam is a necessity. Actually with "advances" such as ultrasound, being able to pick up an ovarian mass, fibroid or enlarged uterus is less important and I have never understood why it even matters whether the uterus is anteverted or anteflexed. It is of course important to be able to do a Pap smear (which students don't do in the OR) and an endocervical swab for STDs (also not taught in the OR).

When I was in medical school we learned pelvic exams on volunteer women. These were from what was called the "Women's Health Collective" who had a mission of teaching a largely male class to at least do pelvic exams in a way that would be quick and painless. Remember at that time half of us were going to be general practitioners. It was a good if somewhat uncomfortable experience but we learned stuff like doing a "neutral touch" first, draping and warming the speculum. Some of the women were apparently on social assistance so it was disconcerting to see the instructor pay them in cash at the end the session so they wouldn't lose their benefits. At that time about 20% of the population didn't have medical coverage so some of them got their care at the hospital gynie clinic where they got seen for free by residents and medical students. Actually that resource was drying up (figuratively not literally) by the time I was a student.

And of course we examined women under anaesthesia. You didn't scrub on a hysterectomy without being asked (told) to do it. We were even encouraged to go to the abortion list so that we would learn to "appreciate" the uterus in early pregnancy. (Just so I don't get shot through my window; I didn't actually do any abortions).

Men were not spared although prostates didn't get nearly the attention that the uterus got. I have been forced to do a lot of disgusting things in the name of education and of medical care but this story still stands out.

We started our clinical exposure in the second term of second year. We started out with a course of physical examination skills. As we were told no examination is complete without a rectal.

At that time Vancouver General still had some of the huge open multi-bed wards you see in old movies. One such ward was the male urology ward which was known as the "Penis Palace". Apparently men with urological problems don't need any privacy. Our medical school had undergone a rapid expansion in numbers to fill what was felt to be a shortage of doctors (when we graduated and actually tried to practise, they told us that no there were actually too many doctors but I digress). Unfortunately teaching resources hadn't kept up with the increased numbers of students so what were supposed to small clinical teaching groups had become bigger. There were 9 of us in that group that day.

We were being taken around by a urology resident who quite clearly would rather be doing anything but teaching medical students (something I now understand). An elderly man had been admitted with urinary retention. Examination of his prostate had revealed the classical prostatic nodule. Conveniently he was an alcoholic which meant that he was in a state of delirium by the time all 9 of us arrived. This hopefully made it easier on him when all 9 of us one after the other stuck their fingers up his bum and wiggled it around trying to appreciate the prostatic nodule we were told was there.

All in the name of education.

Wednesday, March 3, 2010


I am told my English great-grandfather was fairly well off; upper middle class or lower upper class I'm not sure which. None of this passed down to me which is why I still have to get up at 0600 to go to work. My grandfather got caught boinking one of the maids so Great Grandpa forced him to join the army where he served in Afghanistan, and South Africa before going to South America where he worked as a mercenary before escaping after his side lost; ending up in Vancouver where he re-enlisted at the outset of the First World War. He was wounded early in the war and ended up blind. The British Army with typical military logic shipped him back to Canada where he enlisted rather than England where he was from. The maid dutifully came out to Canada and married him and she was my grandmother.

So why am I boring you with my family history?

There was a phenomena in Canada in the late 19th and early 20th century called the "remittance men". These were male children of wealthy English families who had misbehaved and so were sent out to the colonies so as to not embarrass their families anymore. They were sent a remittance, hence the name. Some of them bought farms and orchards where they lived the life of country squires, many of them reverted to form and became cads,layabouts and ne'erdowells.

Okay why am I boring you with Canadian history? Mainly because the British tradition of dumping their misfits in the colonies has gone on.

Many years ago I was talking with another anaesthesia colleague and we were talking about how to improve medicine in Canada. Without any prompting we both agreed that the best thing that could happen to medicine in Canada would be to ship every Brit doctor home to wherever they came from.

Just who do I mean by Brits?

English of course. Scotsmen although I can't remember a Scottish doctor I didn't like. The Irish may think they are distinct from the other island but they too are from the BRITish isles.

Then we go to the Commonwealth. Australians are easily the most arrogant and obnoxious Brits, no one will miss them. I can only think of one New Zealand doctor who I rather like but we can't make exceptions.

South Africans even those named Botha and Terblanche are Brits through and through.

Doctors from other countries in the Commonwealth who have themselves suffered from BRITs are welcome to stay.

The British system of medical training is a much longer more apprentice-like system than the Canadian system and it takes much longer to get to the top unlike Canada where there is more of plateau reached soon after finishing training. The point is that in most of these systems once you do reach the top you are on the gravy train in a way unimagined by Canadian doctors. The National Health in Britain may be horrible (I wouldn't know I've never worked in it), however most specialists in Britain merely use it to supplement their lucrative private practice.

What we get in Canada then are those who have fallen off the slope to the peak or who don't want to climb it and come to Canada for it's kinder, gentler and more polite way of treating junior specialists. Now if I had failed in my own society and was now being given a second chance in what is a pretty decent country I would be so grateful, kissing ass and trying like crazy to fit in.

So what does the typical BRIT do? He (she) acts like a total arrogant asshole who believes that he has come here to make our lives so much better and that we should be happy to have him around. The worst is that most Canadians in health care actually believe that and give them the deference that they crave. That plus the remarks about how much worse the schools are here, how much worse health care is here, how much worse the beer is here (actually that is true) etc. And of course the plummy accents that nobody in England except the Royal Family have. I have yet to meet a British doctor with a working class accent although I'm sure lots of them get into medical school now (I met quite a few when I visited England in medical school). Irish doctors of course become more blarney the farther they get from the Emerald Isles and Aussies get more "strine".

I have traveled a bit in England, Wales and Scotland as well as Australia. I found the people there great. Take them out of their own country and they act like barbarians, well bred ones of course. Actually that describes more or less the last 2 centuries of world history.

Now I was raised in Victoria which is the last bastion of the British Empire on Enid Blyton, Winnie the Pooh, Rudyard Kipling, roast beef and Yorkshire pudding and tea every afternoon after school, so I am a bit of an Anglophile but as you can see I find them insufferable.

Now I actually like quite a few BRIT doctors and I am sorry to have to write this blog. It is the 75% of them that give the other 25% a bad name.