Tuesday, June 22, 2010

A Blog I Wish I Had Blogged

Great Z's blog post on how to be a good anaesthesiologist needs to be read. A touch sexist (if true) but right on the money.

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!