Coaching in Medicine

http://blog.openmedicine.ca/node/323

This is an interesting idea for CME or CPD or whatever they call it nowadays. Why not spring training every year for everybody. Go over some new things in medicine, practise up on skills that are rusty.

The idea of coaching is interesting too. When a player is having trouble at the plate, he asks a coach (an ex-player) for help or the coach approaches him. Why don't we have a similar model in medicine?

Eventually some academic will have this idea which he will promote as if it is a new concept even though baseball has been doing it for a century now.

Some rob you with the six gun, some rob you with the electronic statement

I hate to use this blog to vent my personal problems. No actually that's why I have a blog.

Many years ago after using pay as you go plans, I decided to get a dedicated cell phone with a number and all the gadgets. At that time there were 3 cell phone providers in Canada. As it was more or less six of one and half a dozen of the other (actually 3 of 1 and a quarter dozen..) I ended up with Bell. Up until now Bell has not been bad to me, they have not been particularly good to me either. Periodically Bell calls me and tells me that my contract has been extended. They never ask me if I want it extended and I never argue.

I also signed up for e billing. I hate filing phone statements and as they were automatically debiting my card and am going to lose any fight over the statement anyway (as I found out) so why use it. I had to chose a user name. The usual user names, my first initial and last name or vice versa weren't available so I chose another user name which I of course forgot.

About a year and a half ago I got an i phone. As I was still under contract with Bell, I picked it up at the Bell kiosk in the mall and got a new data plan which enabled me to surf the Internet with my phone. Of course they tell you that you get X number of free bytes of downloads but neither I nor the salesman actually know what that amounts to in the real world. I of course knew that the monthly cost they quoted was nowhere near what I was going to have to pay. When a cell phone company tells you your service is going to cost $X, it is about the same as the surgeon telling you he is only going to take an hour.

By September of 2010 I was so attached to my i phone that when I went to Europe I wanted to be able to use it. I phoned Bell on the #611 number explained that I was going to Europe and wanted to be able to use my phone and download data and the nice lady at the call centre sold me a package. Because my visit overlapped my billing period she said I would have to pay for two months which is a bit of a rip off but hey Bell are not the only people who do things like that. Off I went to Europe where I was able to use Google maps, phone home, receive texts and even almost got a call from the one patient who has managed to get my cell number (I recognized the number and didn't answer). When I went to Africa in June, I spent a couple of days in Belgium and just to check I tried to use my i Phone and got no service.

I continued to see these bills for Bell on my credit card statement and they were a little high but not excessively high so I just figured I must be downloading too much. I kept saying that I should really look at my statement but I had forgotten which of the alternate user names I used and the only way to find out was to log on to Bell's site which of course required my user name. I suppose I could have just called #611 but I really didn't feel like spending time on hold when I have more important things to do like blog, go on Facebook and watch Big Bang Theory re-runs.

Just last week, I tried to log on again and much to my surprise Bell had upgraded their website so that it was actually possible to find out what my user name and password were. I still didn't get around to checking until today. That was when I found out that I had been charged $60 a month for the past 14 months for service in Europe that I wasn't using (I promptly cancelled it on line). I promptly phoned #611 and after a surprisingly short wait (at 0900 on Sunday morning) I talked to a customer service rep who informed me that she could refund the past three months but that was all. She pointed out that I should have checked my statements, I pointed out that I had not asked for more than 2 months service and that if I had planned to relocate to Europe, I would have bought a cell phone there for considerably less than what it costs in Canada. I of course got nowhere. I told her that while I was under contract until 2012 or 2013, I would definitely not forget this and I would be using a different cell company assuming they haven't all amalgamated by then. She seemed unconcerned. Obviously not a shareholder.

So okay, I should have checked my statements. I might even have picked up on it earlier. But that logic is like saying, it was okay for me to burglarize your house because you didn't lock the door. Or say Bell through some glitch forgot to bill me for the past three months, do you think I would have gotten away with saying, "Sorry you should have checked your statements?"

I can of course afford this. My cell phone is paid for by my PC and so it is tax deductible. $700 isn't that much in the scheme of things. But $700 here , $700 there and you're talking real money.

Bell Canada's most recent profit was $2.1 Billion. I wonder how much of that profit was generated by people like me who didn't realize they were paying for services they hadn't asked for and weren't using.

The Golden Rules

I found this blog post on facebook.

It made me think. When was the last time you saw a doctor getting heroic chemotherapy or having a "metastasectomy" or a tumour debulking. Or for that matter saw a doctor on a ventilator. Or having a redo CABG. Or attended a Code on a severely demented doctor with no DNR order.

My son took biomedical ethics course. No.... he is not in medical school, doctors don't take ethics courses but we did actually have some discussions about ethics. I have a little problem with ethics as it tends to be jargon focused but I thought about this and sad basically ethics comes back to the the Golden Rule: Treat others as you would treat yourself.

So the question is: why are we treating patients in a fashion that we would never ask for either for ourselves or our families?

Just asking.

We Beat Libya Big Whoop Part 2

Once again it is nice to know that somebody actually reads my blog and Paul Turnbull responded rather quickly to my last post.

His reply is much too important to deal with in the comments section.

He commented in italics and I have responded in bold:

While it's fine to oppose operations like this you could at least try to be accurate. The Canadian air force in Libya definitely did fire shots. By the end of August they had been involved in a disproportionate number of the air strikes (over 700) and the Navy had been involved in at least two battles with Libyan ships. I believe it was the first time since the Korean war Canadian warships actually fought.

Yes you are right, I checked on the internet and found a National Post article which confirms your comment. Like most Canadians I rarely read the National Post (and never buy it). The National Post which is the official paper on the Canadian Tea Party essentially prints government press releases.

So while our Air Force did fly over 700 missions, it is not like they were having dog fights with Messerschmidts or MIGs.

And please remember.... it was Libya. We beat Libya.

And while Canada's mission in Afghanistan was not an unmitigated success Canadian troops definitely did not get their butts kicked. They held the most dangerous province of Afghanistan for over five years.

If you support Canadian troops at least acknowledge what they have accomplished.

If you call living in a fortified camp and going out in heavily armed convoys holding the most dangerous province in Afghanistan, you are welcome to your opinion.

Canada only joins a list of countries who have failed to conquer Afghanistan including Britain, the USSR and most recently the US who are also getting their butts kicked.

And I support our Canadian troops. It is their leaders I am a little disgusted with.

Personally I'm ambivalent about our participation in the Libyan intervention as I agree with you that things might not have been this bad if the west hadn't cozied up to Gaddafi for the last few years. On the other hand I also see it as the U.N. doing what it was actually designed to do: provide a mechanism for nations to deal with state's like Libya.

When we start invading every dictatorship whether or not they have oil and whether or not they treat our corporations nicely I will support this type of action.

We Beat Libya, Big Whoop

I just got back from the Grey Cup which is Canada's Football Championship, the equivalent of the Super Bowl. If we numbered it in Roman Numerals it would have XCIX. There I witnessed more falling down drunkenness and random vomiting than I have since University. I also saw an okay football game.

Even though I am a pacifist I have nothing against the men and women in our military. They have to deal with a moronic command structure dating back to the 1700s, have to do all kinds of ridiculous things in the name of discipline and, when our Prime Minister feels insecure about the size of his penis , have to go to places where other people try to kill them. There has recently become more of a presence of the military at sporting events in Canada. We were never as bad as the US in this respect but are rapidly catching up.

At the recent Grey Cup we were treated to a huge Canadian flag and about 50 members of various branches of the military in their dress uniforms down on the field. There were also two generals and the Minister of Defense (who of course personally leads our troops into battle ;Q). As I mentioned I support our troops especially when they are in Canada and so I thought nothing of it. That was until I learned the reason for this expensive display of testosterone.

Apparently our military recently defeated Libya. Yes we beat Libya! After our NATO allies destroyed the antiaircraft guns and most of their air force defected, our "Royal" Canadian Air Force burned a lot of jet fuel over Libya, and didn't fire a shot. Meanwhile our Navy ships bobbed around in the Mediterranean in support of our planes. I am not sure what our "Royal" army did but I am sure they played a huge role. I have never been so proud to be a Canadian. We are getting our butts kicked in Afghanistan but we beat the crap out of Libya.

I am not a big fan of Gaddafi and I am certainly glad to see him gone. I wonder how long he would have lasted if we hadn't been so willing to do business with him all these years. I hope the Libyan people end up with a liberal democracy in the Western model. I also hope that the Easter Bunny will come this year.

The Hood

Someone was murdered across the street from the house I used to live in recently. I know this because the lady who bought the house from me wrote a letter to the local paper bemoaning what had happened to the neighbourhood.

In 1997 we bought an old shack in the neighbourhood, knocked it down and built a Victorian style house in what we believed was the style of the neighbourhood. This area of the city was one of the older parts of the city. At the time we moved in, it was a mixture of Victorian style houses from the early 20th century, 1960s and 70s style houses and older houses that the workers who used to live in the area, when it was more working class lived in. When we moved in, people were renovating the old Victorian houses, knocking down the older run-down shacks and even renovating the 1960s houses. The main thoroughfare 3 blocks to the south had been transformed to a vibrant street with older brick buildings, lots of small stores, restaurants, coffee shops, student bars, bookstores, and an art-house theatre. There was a farmer's market on Saturdays. To the east of us lay a wooded ravine with walking and cycling trails. Moreover I could walk to work from our new house. The neighbourhood school was a few blocks away. It was on paper the perfect place for a Bleeding Heart Liberal to live and raise his family. At election time orange NDP signs festooned the streets.

10 years later we moved away to another neighbourhood. There are a lot of reasons but the main reason was that the neighbourhood had evolved in a way that we had not anticipated.

One of the reasons was what we in our neighbourhood called "The Avenue". This was the street with the bookstores etc that we loved to visit before we lived 3 blocks away. The problem was that as the area became more popular, the rents went up which forced out the smaller independent stores. In their place came bars, lots of bars. Not the nice artsy bars that were there when we moved in. Bars that played loud dance music, and where people apparently felt they had to carry knives. Garbage from the party the night before was strewn all over the streets in the morning, and often not cleaned up at all. The area began to be referred to as an "entertainment district" oblivious to the people who actually lived in the area for whom it was part of their neighbourhood. When our hockey team made its playoff run, the local media actually encouraged people to come down to "The Avenue" to celebrate victories (and defeats) which meant a near riot a couple of times a week not to mention the honking of horns at all hours of the night.

Secondly two of the local churches set up homeless shelters in their basement. Now there had always been homeless in our neighbourhood. Many of them slept in the nearby ravine. They had been a somewhat sad part but something you could live with. With the homeless shelters opening a different class of homeless showed up. A harder more aggressive homeless who got in your face and wouldn't take no for an answer. As many of the bars simply put their empties out in the alley rather than recycling them, you had created a gold mine for the bottle pickers and this spilled over onto our neighbourhood. Soon you had people going through your garbage looking for empties, even if you didn't have empties they often dumped out your garbage some they could use your plastic bag. There began to be way more homeless camps in our ravine. (Keep in mind that we were in the midst of a huge economic boom then). These people had to shit and pee somewhere.

Complaints to the police went nowhere plus a lot of my fellow BHLs didn't trust the police. The police grudgingly agreed to have 4 officers on foot patrol along "The Avenue". They of course never patrolled the surrounding neighbourhoods. Our community league had meetings with the police but all the police wanted to talk about was crystal meth which according the police was the root of all evil in our neighbourhood. They also had the police helicopter hover our our house between 10 and 11 every evening as a general deterrent to crime. It became apparent to me that the police has decided to bottle up all the noise and crime into a "combat zone" in our hood so as not bother the residents and businesses of more politically connected neighbourhoods.

Eventually we moved away. It was the peak of the real estate boom and our house sold in a flash. It was tough for me because I really loved the hood and I felt like I was abandoning it. We are much happier now even though we still have drug deals across from our house. Now when I visit "The Avenue" it seems like a dirtier, unfriendlier place than I remember. Maybe I am just older. There is now a Dairy Queen where one of the coffee shops used to be.

There is a lesson here which if I ever have a second career as an urban planner I will pay attention to. That is how easy it is to ruin what should be the showcase neighbourhood and shopping district of your city through lack of proper zoning, allowing rents to run rampant, lack of policing and of course encouraging riff-raff to hang out. I often wonder how much extra property taxes the city collected from people like me who knocked down shacks and put up nice houses at zero infrastructure cost to the city.

Cold OR s

Once again I am poaching one of Great Z's posts.

When patients arrive in the room and remark how cold the room is, the nurse will inevitably reply, "But our hearts are warm."

Canadian surgeons like their American colleagues, like the room cold. Some anaesthesiologists try to fight back. This has lead to at least one surgeon storming out of the room stating they would cancel the rest of their list unless the room temperature was turned down. Some orthopods claim the bone cement won't set properly. I used to turn the temperature up at the end of the case while the resident was closing, stating that the patient was cold and I needed to warm him up. My real motive was to make the resident uncomfortable that he would actually work faster and win the race against the fibroblasts. I once made a resident almost faint, something that I am immensely proud of.

During the summer our hospital runs the air conditioning on full blast. I once asked the resident how much fossil fuel was being burned to make everybody uncomfortable. Once when the recovery room nurses noted how cold my patient was, I asked them to take my temperature, which they did with their ear thermometer. My temperature was 35. I am sure it has been colder. One of the rooms at the C of E had a vent which blew cold air full-blast over the chair of anaesthesia. They liked to do long cases at night in this room, so you could be both cold and tired.

Our ortho surgeons are not just content to make everybody else uncomfortable. They have made the hospital spring for water cooled vests for long cases and elaborate helmets with fans for total joints. Meanwhile I have asked for a desk light for my anaesthetic table so I can read the ampoules when they turn off the room lights and am always told it is too expensive.

Meanwhile Bair Huggers proliferate around the ORs; our patients even get them pre-operatively now. This is wasted because mainly nurses will not allow you to turn on the Bair Hugger until the patient is draped believing that the Bair will blow germs all around the sterile field (I turn it on anyway). Nobody ever asks if there might be a cheaper way to keep patients warm. Surgeons and nurses don't make it easy by insisting on huge operative fields. Every time I get asked to move one of my EKG chest leads so they can prep the chest for an abdominal procedure, I ask them if they are going to take the gall bladder out thru the sternum.

Of course people go too far in the other direction. Our charge nurse in plastics made keeping patients warm her mission which meant that our burn patients had an array of warming blankets, fluid warmers and radiant heaters. Periodically burn patients would come to the OR febrile so I would turn off everything, she would come back from one of her many breaks, turn everything back on and so it went. Pointing out the patient's temperature was of no help.

To do nothing is sometimes the best medicine.

Sometimes I read an article which says what I am thinking much more eloquently than I ever could.

I was talking to retired geriatrician today who told me that a significant amount of his work when he practised was undoing the work of other doctors.

Picard in his article refers to the 13th law of The House of God:

“The delivery of good medical care is to do as much nothing as possible.”

It is sometimes hard to believe that "The House of God" was written in 1974. Add in the "advances" that have occurred since then and it could have been written last week. Just about every medical student read it when I was going through medical school. My generation are now the senior doctors. Did we learn nothing?

Say it ain't so Joe

Ever since I read his biography as a teenager, I have admired Joe Paterno. That is until about a week ago when like just about everybody outside apparently most Penn State students and alumni I became completely disgusted.

This blog has an interesting spin on it.

Last evening as my mind wandered off during a "leadership" retreat, I tried to figure out why the hell Paterno or the graduate assistant, who witnessed the rape, didn't go to the police. Then I thought about my experiences in "quality assurance" in the hospital both before and after joining administration.

I along with every doctor in my hospital are restrained by a gag order against publicly commenting on anything. I am not sure whether that includes calling the police, however if I was a junior doctor with a career ahead of me, I might just want to go through what I was told were the appropriate channels. Had a gone through the appropriate channels I know exactly what would have happened. Faster than I could blink, the risk management people would have been all over the case.

"Is that really what you saw?",

"What is this going to do for the hospital's reputation"

"Can we get sued for a wrongful accusation?"

"Let's investigate more"

"Don't go to the police until we tell you."

I suspect this is exactly what went on at Penn State years ago.

On the other hand Paterno could just be a senile old bastard who put his friendship with a pervert ahead of protecting children.

I'm sort of leaning that way.

Getting Stiffed!

Most doctors outside of Soviet Canuckistan (as an American commentator called us) assume that doctors in Canada are salaried employees of the state. While it would be nice to have paid holidays and a pension plan, this fortunately or unfortunately is not the case. We do get over 90% of our income from the government either through the provincial health plan or through Workers Compensation, however we do this in a fee for service fashion. This means that we have to eat what we kill and as anaesthesiologists we are dependent on what the surgeon brings to the OR for our living. Depending on your outlook this either gives you the best or the worst of the public and private systems. We are fortunate in only having to deal with a small number of payers.

All Canadians citizens and landed immigrants are theoretically eligible for health care in Canada. I emphasize the word theoretically. It is first of all necessary to register. This is not automatic, when you are born you are registered with your parents, when you turn 18 or when you finish university it is necessary to re-register. Nobody tells people that and so some people don't bother. Some people apparently believe Medicare violates their religious or other freedoms and intentionally refuse to register. I get a list of their numbers about once a year. Some provinces also charge premiums. Our province did until 3 years ago, as an election promise, premiums were removed. Every province that charged premiums also had premium assistance for low income patients including the working poor. Some people of course proudly refused to apply for premium assistance, considering it to be a form of welfare. They weren't too proud of course to stiff the doctor. Some people intentionally didn't pay their premiums knowing that they were unlikely to use the healthcare system, if it was minor the fee would be less than their premiums and if it was major the province would allow them to "back pay" their premiums. One of these people wrote me a nasty letter after I billed $47.00 for seeing her daughter for an earache at 0600. And no, there wasn't a cheque in the letter.

Things have improved but at one time up to 20% of patients in the provinces that charged premiums did not have medical coverage. When we did have premiums, they were often paid by employers. If the patient changed jobs or his company went out of business or if they "forgot" to pay their premiums, they weren't covered anymore and you didn't get paid. One lady I saw in the Pain Clinic was supposed to have her ex-husband pay her premiums as part of the divorce settlement. When I advised her that her last billing had "bounced" she burst into tears. Not very therapeutic.

Some people also move around a lot. During the oil boom we had many people from other provinces presenting to the OR. Most have them had lived in our province for a year or more but still had their original province's healthcare number. Surprisingly I got paid for most of these. Because all Canadians are supposed to get healthcare, the federal government has agreed to cover those people for whom no province will cover. This is a bureaucratic process but may be worthwhile if you have a particularly long case.

It is actually visitors to our country who are the most likely to stiff you. Most people are smart enough to buy travel insurance. Travel insurance however, typically has a ceiling which, if hospitalization or ICU is involved is quickly reached, with the hospital getting all the money before there is any consideration of paying you. I did a fellow from New Zealand years ago who came to Canada to ride in the rodeo. He had an insurance policy which had a $200 per day limit. I did send a bill to the Canadian address he provided and it came back "return to sender". Insurance companies also require you to send the bill to the patient who is supposed to pay you and send the bill to them for reimbursement. Most patients don't bother. There are exceptions of course. One very wealthy American that we did an emergency subdural on, not only paid but phoned me to make sure I had gotten the cheque.

In the scheme of things, we are well paid and at the end of the year, the couple of hundred bucks someone didn't pay you doesn't really affect your income that much. The problem is that many of these cases were emergency cases where you either got out of bed, as for the American hunter who shot himself in the foot requiring an emergency debridement at 0400 or stayed late as in the case of the kick-boxer from Switzerland who had the 5 hour ORIF of his mandible (I stayed late because most surgeons take only a hour to do these; this surgeon let the resident do the case and then had to re-do himself). I have heard some anaesthesiologists advise guests to Canada requiring surgery, "The fee is ____, there is a cash machine in the lobby." I have never had the cojones to do this.

What has often bothered me about getting stiffed is not the lost income; I do lots of things for free. I just wish sometimes people would just tell me that they can't or won't pay; I could then decide whether or not to do the case and if I did do the case I could get the moral feel-goodness that you just can't put a price on.

Prestige My Ass

Because I flew a lot in 2009, late in the year I got a letter from Air Canada that I was now a Prestige frequent flyer. I don't fly a lot, I fly more than most people and I get frequent flyer points with my credit card. I do like flying business because of my size, the meal is a little better as is the wine. I also like the first class lounge for long connections or when I arrive early. When I fly on points if I have enough I try to get business, if I am flying away to whore for Big Pharma I usually try to get a business class ticket out of them. (After flying to Toronto in the middle seat between two people my size, I vowed never to fly to Toronto on "business" without a business class ticket. Now when I get invited to a meeting, I demand business class, they almost always agree. Maybe that's why I hardly get invited anymore.)
I don't pay for business class however. I would have to drink a lot of wine to justify the price differential between economy and business. When I am paying for it myself, I fly economy, get an aisle seat, if possible a bulkhead or exit seat (you can pay a little extra to get one now) and I suck it up. They often don't feed you in economy, therefore I eat before the flight, I bring a sandwich or trail mix. If I want a drink, I pay for it.
I was therefore really excited to learn that I had joined the ranks of the privileged frequent flyers. I had visions of stop-overs in the Maple Leaf Lounge, using the special check in and boarding lines and of course the upgrades to business class.
Then I read the small print.
Prestige is the bottom tier. Elite and Super Elite are way ahead of you. A Prestige class membership and $6 will get you a small plastic bottle of wine on most Air Canada flights. In other words all you really get is a dark grey piece of plastic. You do get 4 "free" upgrades. In order to be eligible for these upgrades you need to buy the most expensive economy class ticket which costs twice as much as the least expensive. This is the flexible ticket which allows you to cancel or reschedule (which is preferred by business travellors who may have to reschedule and whose companies won't shell out for business class). Buying that ticket isn't enough. You then only get an upgrade if there is room in business (which is logical). Therefore you have to bet against your more expensive ticket that you might get upgraded. I actually did this en route to a meeting where my travel was being reimbursed. I got upgraded going out but not going back. And of course I felt bad for stiffing the conference with a more expensive ticket.
You also don't get to use the shorter check in lines, or get to board at your leisure. You do get 4 passes to the Maple Leaf lounge which is better than a kick in the teeth I guess (I used two and lost the other two).
I don't mind not getting something. I do hate thinking I am getting something and then having it pulled away.

A good if somewhat late post on 911

Rafe Mair posted this.

Rafe Mair was a cabinet minister in the 1970s and 1980s under the right wing coalition government that existed then in BC. He was then a radio hot line host.

His conversion to Progressivism is an inspiration to all.

Supplements, a personal history

I found this interesting article on Nation of Change

I have for one reason or another taken some type of supplement for most of my life.

As a child my mother would not think of letting us go to bed without taking what she called an oil pill which I believe was cod liver oil and a Vitamin C tablet. I continued to take Vitamin C into adulthood in only because the chewable ones tasted good. I don't think they prevented colds, I seemed to get more colds and longer colds than most. I never quite figured that out. In university my room-mate who was doing his PhD in biochemistry convinced me to take Vitamin B complex as well which I did for a few years. In medical school they told me that all vitamins did was create expensive (but nutritious healthy) urine. I stopped taking Vitamins.

In the mid 1990s I for some reason developed PVCs. After a panicked trip to the ER, sleeping overnight in a stretcher, a stress test and echo it was decided that I had what were "benign PVCs". I stopped coffee for 6 months and still had PVCs so I started coffee again. A medline search on benign PVCs lead me to believe that salmon oil might be effective so I started that and have taken that ever since. I also started to take Vitamin E and aspirin. Somewhere along the line I learned that Vitamin E actually increased rather than decreased cardiac mortality so I stopped. I also ran out of aspirin and just never got around to getting any more. My heart continued to merrily beat on irregularly for several years until one day the PVCs disappeared (I lost about 25 lbs on South Beach around that time, most of which I have put back on). I still take fish oil.

Cold FX was the next supplement. This extract of ginseng was actually developed at our university. Despite its being endorsed by Don Cherry, I was sceptical until a study came out showing taken prophylactically it did reduced the frequency and length of colds. I take 2 a day now and rarely get colds. There are of course other factors, I have probably had every possible strain of rhinovirus and am immune, and I wash my hands a lot more nowadays at work.

After I gave a talk to family medicine rounds, one of the family docs approached me and asked if I had ever prescribed Vitamin D for my patients. I said not, but right away went onto Medline and sure enough there was something there, especially at our northern latitude. I now measure Vitamin D in my chronic pain patients (it is universally low!) and take 6000 units a day myself. This seems to have solved my seasonal affective disorder. The jury is still out on Vitamin D and chronic pain but I figure if someone's level is low it makes sense to treat it. I of course have never measured my level either before or after treatment.

Oh yes my SAD which I self diagnosed about 10 years ago. Going to work in the dark, coming home in the dark and working all day in a windowless room didn't help that at all. I bought a SAD light, the problem with is however you have to get up 30 minutes earlier to sit with the light. I also brought one of the blue SAD lights for when I spent the day in a windowless room. Somebody stole that light, I hope they are feeling better. As I mentioned Vitamin D and changing work environments helped the most.

About 3 years ago I developed tinnitus. I attribute this to sitting in front of the trumpets in band, although I am sure the high pitch of the cautery and suction in the OR have something to do with this. When I was a GP patients occasionally presented with tinnitus; I usually dismissed them as complainers, wasting my time. I had no idea tinnitus could have such an effect on your life. I got custom fit ear-plugs for band practice which I couldn't use because they distorted the sound so much (my conductor told me most musicians just use the cheap foam ones). I still use them for rock concerts, hockey games and plane flights. I tried Vitamin B6 which I had always recommended to patients. I had heard it caused "flushing". Flushing poorly describes the total body burning I got after I took my first and only dose. Ginkgo was also ineffective if better tolerated. Finally I read about CoEnzyme Q 10 and picked up some. My tinnitus seems to have been reduced although it could just have gotten better on its own, plus I no longer sit in front of the trumpets.

I suffer from gout for which I tried various supplements none of which worked. Conventional medicine wasn't that effective until I got an internist I know to prescribe colchicine, which I fortunately tolerate and which kills gout in about a day. I could stop drinking beer and red wine but I like beer and red wine.

The result is that this morning I took:

6 capsules of Salmon oil
2 capsules of Cold FX
6000 units of Vitamin D
500 mg of Vitamin C
150 mg of Co Enzyme Q
81 mg ASA

I chewed the Vitamin C, the rest I threw in my mouth and washed them down with a large glass of water. I followed this with my favourite supplement: coffee.

I know that the evidence for most of this is weak but there is evidence and for some of them there is as much evidence as there is for conventional treatments. The difference is we don't see detail men out buying lunch for Vitamin D and CoEnzyme Q. And I know that periodically evidence will come out that these supplements don't work or may even be harmful, just as they have been for countless conventional medicines since I became a physician. I mentioned above the Vitamin E may in fact be harmful. We recently learned that multivits may be harmful. Next time I have a few hours I will discuss all the conventional medicines we now know to be harmful or useless.

I also know that most supplements are not manufactured by mom and pop operations on their solar powered organic farm but are in fact made by big corporations, often by Big Pharma. Shoppers Drug Mart (which owns or is owned by a tobacco company) makes its own house brand of supplements as do the other large chains. There is huge money to be made in supplements largely unfettered by the regulatory scrutiny prescription medications have to undergo.

I can't really say that the handful of supplements I swallow every morning are helping me. Maybe if I just ate better and exercised more I could accomplish the same thing. Some of my complaints like the PVCs and the tinnitus have gotten better; on the other hand no supplements helped with the gout and some supplements didn't work for the tinnitus either. I spend a significant amount of money every month for which I don't get reimbursed by my drug plan. Expensive placebos. Who knows? I learned long ago if the patient believes something is working, you should encourage him to take it (provided it isn't harmful).

Some Days I Long For the Boyle Machines

I mentioned some time ago that our department in a moment of stupidity bought two Drager Primus machines to be used in Obstetrics. That was until we discovered that if somebody turned them off, there was a 30 minute boot-up. Not very useful for obstetrics. Therefore they were exiled to our Day Surgery OR where they will never ever see and emergency. Last year the hospital tried to force us to buy 8 more of these machines but we were able to block that.

About a month or so ago the Drager rep made a visit to our site to install a software update. It went for the most part un-noticed until about two weeks ago, of our anaesthesiologists pushed the wrong button. The Drager Primus has a number of "soft keys" with which you select the various modes of ventilation, spontaneous, volume controlled, pressure controlled etc. To the right of the buttons was a unlabelled button. Most people know better than to push unlabelled buttons, no good can come from that. This was the case. Immediately the gas flow ceased and patient could not be ventilated, nor could he by pushing any of the labelled soft keys restore things back to where things had been. Fortunately it was not in the middle of night, he didn't panic, he got an ambu bag and hand ventilated the patient while switching him to TIVA. The machine was taken out of the room and one of the older machines brought in.

After much investigation, we figured out that the following happened. The Drager Primus comes with the option of using a Mapleson D, E, F or Bain circuit which we never use and therefore when the machine was installed the connection was "tied off" and the software was adjusted so that the option of using the Bain circuit could not come up. When the software update was installed this disabling of the Bain option ended and when my colleague pushed to unlabeled button, the machine went into Bain mode, discovered that the Bain lines were "tied off" and basically shut down the machine.

Our biomed people reprogrammed the machine to disable the Bain option again and the machine worked okay. About a week or so later Drager got around to sending someone to fix the machine.

This all makes me long even more for the Boyle machine. Simple, powered by compressed gas from the central supply or from the cylinders if the central supply failed. No need to plug in. Everything mechanical with ingenious inventions like the interlink and the fail-safe valve. No software. Ready to use as soon as you were. And with a pulse oximeter on your patient, just as safe (actually safer if you have Drager Primus).

A Visit to Our Orthopedic Surgery Centre

Our orthopods have done a marvelous job of marketing the total joint arthroplasty as the be all and end all of orthopedic care. While all kinds of surgical procedures and for that matter medical treatments and diagnostic procedures have wait lists in Canada they have managed to convince governments that their procedures merited special attention. I am not crapping on the total joints, if I need one, I sure hope I get one in a timely fashion and as an anaesthesiologist I love what is for the most part good mindless work. I just am curious about the attention paid to something which is really only a part of the care for osteoarthritis.

This post was inspired by my visit to the new Orthopedic Surgery Centre which is separate from the adjacent Big Downtown Hospital (BDH) but tethered to it by a walkway. The idea was that all our region's total joints would be done Monday thru Friday, uninterrupted by emergencies, no infectious patients to spread their germs and no internal medicine patients spilling over onto surgical beds. Our hospital has so far managed to hang on to its share of total joints and so I decided to see what the competition was.

I arranged to be met in the spacious foyer at 0800. As usual I arrived early. You would have no idea you are in a hospital, there are laminate floors and oddly retro furniture to sit in. (The other reason you don't think you are in a hospital is that there are no smokers clustered around the door holding their IV poles. )

Upstairs to the ORs where the head nurse took me there was spacious receiving area and recovery room as a single large space. The OR's were large and had modern equipment. Because it was designed by surgeons, there were no induction or block rooms, so the surgeons won't have worry about pesky block happy anaesthesiologists slowing their room. There are 4 rooms with only 3 open .

Upstairs there were more laminate floors and the rooms which I got to look at from the door way were large and had comfortable furniture for the visitors. I can't help but wonder what that laminate flooring is going to look like after a year of stretchers, walkers and general foot traffic.

Of course ASA 3 and 4 patients and the revision horrendomas will still be done in the main hospital to which the OSC is tethered. I can't think of the last total joint I saw who wasn't ASA 3 but maybe that's because they are all being done elsewhere. Another example of cream-skimming but at least in the case the cream is staying in the public system. Also because they never bothered to ask urology, when the nurses can't catheterize the patient, they have to cancel the case.

The preassessment process is done on another site as are the follow-ups which makes no sense if you are going to build a completely new building but of course you have to remember it was designed by and for surgeons.

One thing I have learned by working in chronic pain and by having older parents is that total joints are great except when you are either too young to have one yet or too old and sick (although ortho keeps on pushing the envelope on old and sick). There is a tendency to just throw one's arms up in the air when you just can't fix things by sawing out bad bone and gluing in metal and plastic. Also with so much attention paid to two procedures, other less sexy orthopedic procedures are sure to languish.

The other thing I have learned as operating time for total joints has increased in the time I have practised is that as more time is freed up, the indications creep. I mentioned older and sicker patients above. At our site we do a lot of patients whose mobility is as restricted by their COPD or CHF as it is be their arthritic joint. At the other end of the spectrum we see people who really don't seem to that bothered by their arthritic hip. We are doing younger and younger patients now, which means the innevitable revision.

As a taxpayer, I can't help but wonder if we needed a new building to accomplish this improvement in total joint arthroplasty care. One of the three rooms at the new hospital does total joints that were formerly done at another hospital which means a room is now empty at that hospital. The other two come from the BDH which essentially means the closure of two rooms there. I suspect some administrator is already looking at the total joints done at our hospital and soon we may have some vacant OR time. I am only the Site Leader for anaesthesia, no need to let me in on this.

But what happens if other specialties demand their own separate hospital. Cardiac surgery already has their own. Why not a hospital for laparoscopic cholies, one for hernias etc the list could go on. Are we going to see the general hospital become a thing of the past, or a just a dumping ground for stuff that can't be safely outsourced to a fancy new building?

Why I Support the Occupiers

Other than the loss of much of my retirement income, the current financial crisis has not really hurt me much. I work in the healthcare sector, people keep on getting sick, having surgery and ending up in chronic pain. Our province is buffered from economic reality by virtue of sitting on top of large amounts of oil and gas. Moreover Canada's banks didn't collapse if only because successive governments ignored the advice of business sector and didn't deregulate our banks. (It will take at least a few years before the Canadian Tea Party which currently governs us figures people have forgotten and moves to deregulate everything that moves.)

Yet I am behind the thousands of people who are occupying Wall Street, Bay Street and central business cores across the developed world.

Much of this is because I am proudly a Bleeding Heart liberal who never backed away from a chance to challenge the MAN even if I have become part of the MAN. While this is a good time to be rich in North America and I believe I could now be called rich, it is hard to ignore what is happening to our fellow men. It is also hard to ignore the war on the middle class that has gone on for the past 25 years. It is hard to not be disgusted at the super-rich. How much money do you actually need?

But more it is just a feeling that Wall Street, the Stock Market and the whole financial services sector just need a good spanking and those of us who should have done this about 10 years ago and certainly should have in the last three years have just stood by kind of like the soccer mom at the playground repeating to her spoiled child, "Oh that is so inappropriate." when what the kid needs is good swat.

I have had a long relationship with the "Stock Market". As someone who is self employed I don't have a pension plan. Doctors could have negotiated a really good one years ago but our leadership said there wasn't any need because we could do better with the Stock Market. It is therefore necessary to put away money. You can only put so much in a registered retirement savings plan which our financial advisers tell us nowhere near enough to retire on so it is necessary to have other savings. Having read "The Wealthy Barber", I began to pay myself first and put away 10% of my earnings. In its wisdom our government taxes capital gains and dividends at a lower rate than interest so it is necessary to invest in the stock market usually through a mutual fund. There are a lot of doctors who eschew investment funds and are happy to regale you with their investment secrets, however most of them are in their 70s and still working.

The first thing I noticed was that although my mutual fund claimed to be earning 10+% per year, the money fund wasn't growing anything like that. I never really asked any questions because you don't question the stock market. Next we have the Dot.com stock market crash, followed a couple years later by the Enron stock market crash, and after a few years of "stability" and growth this latest market meltdown.

I used to be disgusted by all this but now I am merely amused (hey what a great name for a blog). I have long ago given up retiring at 55; 65 is a fantasy and I am cautiously optimistic about 75. Not that I am complaining, I like my job. There is of course the resentment that I did everything right and still haven't come out much ahead. Sheep-like, every month by direct deposit so much goes into my RRSP, so much goes into my mutual fund. Every six months or so I meet with the frat boy who manages my portfolio and we rearrange the deck chairs. I could of course put it into interest bearing funds and earn 2% which sounds low until you look at the negative return on your mutual fund statement. Besides I am actually not allowed by law to put my corporate investment accounts into interest bearing funds.

What has always fascinated me is the mystique behind the Stock Market which really is just the sale of small pieces of large and not so large companies. The share price is based on the companies assets and their earnings or potential earnings. Theoretically if you hold a number of companies over time, the average value of the companies will only grow as much as the economy grows. Shares of companies fluctuate for sometimes a good reason and sometimes no apparent reason. Money can be made by betting on these fluctuations. I have always been amused by the stock market responding to current events positively or negatively even when the event in question could really have no conceivable effect on the value of companies. It was like the stock market was a living person who sat in a room stating "we are /are not amused". This was followed by the slavish devotion of governments trying to keep the stock market happy.

More sinister was the way companies could increase their stock value by hurting people. Close a plant for example and your value goes up. I always thought the purpose of a company was to make things. Even more sinister is the way people are able to make money by betting against the share values. What conceivable use can this have in our economy.

The results is that I have figured out that the stock market is essentially a glorified Ponzi scheme and a form of legalized gambling. It depends on suckers like me sending in my monthly withdrawals in the hope that I can retire some day while the insiders get insanely wealthy. Which they do whether or not the markets actually go up or down.

In the run up to all this latest madness we of course had the Real Estate bubble which hasn't quite broken in Canada. This meant that my former house appreciated at least 2.5 times what it cost me to build it in 1998. That would be great if I could move somewhere with lower housing costs. Usually places that have lower housing costs have lower costs because nobody wants to live there. Of course if my wife and I have the good taste to die before we sell the house, my kids are in for an unearned windfall. What concerns me however is the fact that a house or even a condo is quite possibly out of reach for my children. Joking about them living in our basement at age 40 doesn't seem so funny any more. And who really made all the money in this housing bubble? The banks and the realtors of course.

But what infuriates me was that the government actually had the opportunity to come out of this ahead. Imagine if they, instead of bailing out the banks, had actually taken over the failing ones. A government owned bank imagine, what we could do with that. Our province which is not quite North Korea (except for only having one political party) has had its own government owned bank since the 1920s. It takes money deposited in the province and for the most part loans it out within the province. Quite a few of these loans are shady ones to friends of the government. The auto companies likewise. The government could have bought every share of GM for a fraction of what it cost to bail them out. Wow imagine a government owned car company that made cars people actually wanted to buy. Safe cars that got good gas mileage.

Some people have said that instead of occupying places people should get involved in the political system. Good idea except consider that our Canadian Tea Party got a majority government which is the closest thing you can get to an absolute dictatorship with only 40% of the vote. They are currently merrily dismantling programs that took most of the 20th century to achieve. All the opposition can do is talk, the government with it's majority in the house will pass the legislation and they know that keeping their 40% base happy will guarantee re-election. No wonder fewer and fewer people vote. Every four years I make a trip to the polls to vote against my Conservative candidate. It doesn't matter, she gets 60% of the vote.

A lot of conservative pundits are downplaying the protest. "After all things are not as bad as the Great Depression," they say. My parents grew up in the depression as did a lot of their friends and I used to hear, growing up, a lot of nostalgia for the Depression years. But frankly is that the best they can do; sure things are bad now but things were a lot worse in the Great Depression. Like haven't we learned anything in the succeeding 70+ years about how we really don't want to go thru that again?

Or the other objection: things are a lot worse in the third world economically and politically. Again, isn't it better to do something about the way things are spiraling down before we become part of the third world. Isn't it better to complain about the erosion of our democracy while we still have one?

And sure some of the protesters are the people we see at every protest, some of them are vegetable rights people and some of them are not very clean, have piercings and funny haircuts. I suspect (I haven't gone down to my local occupation) that there are a lot of people who are fed up with the way society is going and frustrated with the inability to effect any change through political channels. And you have to admire how peaceful and well-behaved everything has been.

I am a student of history and have read about a lot of popular movements. Many were crushed, some fizzled out, some were co-opted and some went horribly wrong. I am pessimistic but at the same time optimistic that this surely is the start of good things to come.

Yet another thing I learned while on the toilet

Whilst in my "office" this afternoon I picked up a copy of the Bathroom Reader and opened it at random. There was a page of quotations from Mark Twain. One caught my eye.

"Every time you stop a school, you must open a jail."

Sounds like our politicians should spend more time reading in the bathroom.

Follow up on the environment in Healthcare

I found this site (courtesy of Steve Duckett of all people)

Apparently I am not the only one concerned about the environmental footprint of healthcare.

Out out damned spot

I have a confession. I used to read Science Fiction. Not the pulpy stuff but quality writers like Arthur C. Clarke and Ray Bradbury. I especially like Bradbury who doesn't always write science fiction. It is one of his non-SF pieces that I just thought about.

The story is about somebody who after a disagreement with a friend or acquaintance murders said individual. He prudently decides that he must remove all evidence that he was in the house and starts wiping every surface he may have touched. He of course keeps on remembering places he may have touched and so has to wipe these off and so on and so on. The result is of course that he never leaves the house and is still there the next morning when the police come to arrest him. The last thing he does as he is lead out handcuffed, is to wipe off the door-knob.

This unfortunately reminds me of the hand-washing campaign at our hospital.

Hospital acquired infections are not nice and anti-biotic resistent ones are even worse. Anything we can do to prevent these is a motherhood issue and hand-washing is a pretty simple and cheap solution. Our zone went through an audit of hand-washing several months ago and our hospital did not do well with of course doctors leading the way. This sounds really bad until at an executive meeting I learned (for the first time) the rules that we are supposed to follow.

It is not enough to wash your hands after seeing a patient, you must also wash your hands before you see the next patient even if all you do is walk from one bed to next without even picking your nose. Even if you have no intention of touching the patient you must wash before and after. If you wear gloves, you must wash before putting on the gloves and after "doffing" the gloves. (It is so nice to see an archaic verb like doffing come back into use.) Miss a single step and you are non-compliant. Because of this a lot of well meaning docs failed the test.

Because you now have to wash your hands twice for each encounter, visualize this. If I see 24 patients in the pain clinic and see them an average of two times each visit, that is 96 hand washes in 7 hours (13.71 hand washes per hour). I could do this more because hand sanitizer bottles are conveniently placed by every door in the hospital and being slightly obsessive compulsive I actually stop and wash my hands.

To help with our compliance, bottles of hand sanitizer are appearing on walls all over the hospital. Many of these are empty which is a good thing because people are washing their hands but a bad thing because you have to look for another one to wash your hands before the hand washing Stasi see you. Our receiving area on the other hand doesn't have room to put a hand sani dispenser at every cubicle, a single dispenser has to do for 7 cubicles. (They had to take them out of the emergency department of our inner city hospital because people were drinking the alcohol gel).

Hand sanitizer doesn't work for C. diff of course and we don't know who has this but we are going to just forget about this for a while.

Private doctors offices which is where most of the doctor patient interractions occur are of course exempt from this well intentioned madness and in some offices like the one I am working in today, you actually have to go way out of your way to wash your hands. I recently saw a patient at a private office and referred her to my hospital pain clinic where the nurses somehow discovered to their horror that she was MRSA positive and wisked her off to the isolation room where she was placed in the magic yellow gown.

Stethoscopes are another issue. Wiping your stethoscope with hand sanitizer which I do apparently doesn't work and it is necessary to use another anti-septic. Unfortuately this anti-septic eats plastic so they have not yet made any recommendation about what you do with your stethoscope. Fortunately most doctors have forgotten what exactly a stethoscope actually is so we don't have to worry in that respect.

Thinking of all the times you forgot to wash your hands,all the times other people forgot to wash your hands and the surfaces all of you touch has made me feel like Bradbury's character. Who for example knows what germs are on this keyboard I am typing this on. We can eliminate a lot of germ transmission but even the best intentioned most OC person is going to slip up.

Packaging

I lost the little adapter that enables me to plug in my I phone directly to a wall outlet. As I knew I was going to be in the hospital all night and would probably need to charge my phone, I headed off to the mega mall to get a new adapter which I found no problem.



Here is the charger above. Not a great photo and I should have put a ruler or something next to it but most of you can figure out how big it is.

Here above is the charger before I took it out of it packaging and below is the packaging which I recycled.

This kind of reminds me of a clip from Curb Your Enthusiasm.

I handled this in a more mature fashion than Larry did but why does everything we buy now have to come in a hard to remove plastic case which is often 2-3 times bigger than what we bought. The worse case was the USB stick I bought at Costco that came encased in a plastic cases that was 30 cm long and 20 cm wide. I suppose that one reason for packaging a small item in a large package is to prevent shop-lifting. There are other approaches like for example hiring more staff.

Just Friday I was looking at the large garbage can in the Pain Clinic. I typically fill this to the rim by the end of a clinic. I trained using reusable epidural trays and I never want to go back to that (on the other hand the reused needles were so blunt it was impossible to get a wet tap) but do we really need all this packaging. I have a number of patients with intrathecal pumps who come in every 1-2 months for a refill. The kit we used to fill the pump comes in a box 20 by 20 cm. This holds a 22 gauge needle, a filter, a 60 cc syringe and a narrow bore tubing I use to empty the pump and refill it. It also comes with an instruction manual in multiple languages that is the size of a small paperback novel. All the packaging and literature goes straight to the garbage.

Another anaesthesiologist told me how in their hospital the German company that makes pedicle screws used in back surgery had been bought by an American company with the result that the size of the packaging actually tripled in size. Germany many years ago forced companies to reduce the size of their packaging. Just about all our surgical equipment comes in elaborate plastic cases. Some of them are quite useful. You see them around the OR used to store things. Nurses bring them home sometimes; I have brought home the odd piece of OR plastic. Most of them go straight to the garbage from where they are trucked to the incinerator. No recycler will touch them, they could have some nasty bug on them. Which reminds me, when I came to the CofE they had an incinerator in the building that burned all their medical waste. Drapes, syringes, needles all went into the same bag, somebody took them downstairs and they were burned, heating the building in the winter we were lead to believe. That was of course too good to be true and now by government edict all medical waste has to be separated and trucked 200 km south to a waste disposable facility owned by some well connected people.

A Ugandan doctor who visited our OR years ago was appalled at how much we threw out. In Ecuador we bagged our garbage to be disposed of by the hospital but realized that the local OR nurses went through it looking for things they could re-use. We started separating our garbage to help them out.

In my first job a senior staff member religiously scoured the garbage for things he could re-use. Periodically an award in his name was issued for a particularily creative re-use of what would otherwise be medical waste. For example tubing used in opthamology was re-used as ETCO2 tubing. (I wonder how many prions were transferred).

There was an article in the recent Medical Post which I am ashamed to admit I read ( it was in the lounge and I was bored okay?) This outlined the large amount of waste particularily with orthopedic cases and the environmental cost. We are big offenders in anaesthesia and maybe we should be taking the lead in this.

Adventures in Automobile Service Land

I recently leased a car which I am overall happy with.

Except:

At the beginning of last month the radio died. This was the stock radio which is standard on that make of car and it has a CD player also standard. Car stereos are no big deal anymore. I figured it was a loose connection and so I (my wife actually) phoned the dealer to make an appointment to get it fixed. The service department asked us ,"Did we know that we are due for scheduled service at 8000 km". We didn't actually because the service manual says 15000 but that's okay, I like my car to work properly and I feel sorry for the poor car dealers who make a lot of money servicing the cars they sell in this recession, even if they were partially responsible for it.

On the appointed day, a Friday, I dropped my car off at 0700. I phoned just before noon in the delusion that I might be able to pick it up at lunch and of course it wasn't ready. Around 1500, the service guy phoned and told me that my radio definitely didn't work but that they were going to have to order a new radio and would I mind coming in next week. I asked them why they just didn't take a radio out of one of the new cars on the lot and he explained they weren't allowed to do that. He did it in a patronizing way that made me feel like I was stupid for even suggesting that as a possibility. They should have the radio by Monday and I could bring my car in.

Problem.

I am going on vacation taking that car; now not only do I not have a radio but I have to make another trip to the dealer.

I phone the Monday after my vacation and get referred to the parts guy who says my radio still isn't in. He also lets slip that they actually didn't order one on the Friday the car was in the dealer but waited until the following Monday. I get pissed off, ask to speak to the general manager and actually get to talk to the comptroller who on hearing my story is apologetic and offers to facilitate things.

Tuesday afternoon I get a message that my radio is in. I ask if I can bring the car in after work. They agree reluctantly and I drive to the dealer. I bring a book because I know I am going to have to wait. After about an hour or so, a flustered employee comes out to tell me that the radio they received also doesn't work but they took a radio out of a new car on the lot and I am free to go.

OK so why didn't you just do that 10 days ago?

While I am waiting, a receptionist comes out to tell a man in the waiting room that they dropped his car off the lift and it is damaged but don't worry they will get the damage fixed and pay for a rental car. I hear him phone his boss to tell him he is going to be late for work. I feel a little sheepish getting so worked up about my radio.

On the other hand maybe the dealers pay actors to sit in the waiting room with sad stories so you feel bad about complaining about the lousy service. I wouldn't put it past them.

Overpaid Porters

Cataract surgery when I was in medical school was a 2 hour surgery under general anaesthetic with a 7 day recovery in hospital. Anyone who operates on eyes of course deserves to be well paid and ophthalmologists were even in those days. This blog by the is not a complaint about ophthalmology although I could probably rant about that for a while.

Cataract surgery is now a 15 minute procedure done under topical anaesthetic. The ophthalmologist still gets the same fee in inflation adjusted dollars which I promised above not to complain about.

When I arrived in my current city, cataracts were done under retro or peribulbar block with the anaesthesiologist providing the block. We had a nice deal in those days where the anaesthesiologist got a minimum of one third of the surgeon's fee which is a nice chunk of change for a day's work. That's why they were known as retro-dollar blocks. I never learned to do them where I trained and as I tell anybody who asks, "there are some places even I won't stick a needle.". Fortunately we were in a revenue sharing group and there was no reason for me to learn to do them. Times changed, some cataracts were farmed out to private clinics and the rest of them centralized in another hospital. Because a small group of individuals were in the process of cornering the market on cataracts, the province's anaesthesiologists actually voluntarily reduced the fee and the extra money went to other areas.

The joke among ophthalmologists in that era was that while they were capable of doing the blocks themselves, if the anaesthesiologist wasn't present, who was going to push the stretchers in and out of the OR?

Several years later I did a locum in a hospital in another province that still did cataracts. The fee schedule in that province was such that you couldn't make large amounts of money so I actually got to do the list. This list was entirely under topical. The ophthalmologist explained how to do the topical. For 8 hours I put in various eye drops and lidocaine jelly into seniors' eyes and pushed them in and out of the OR. It was a pleasant day, I felt like a bit of slut getting paid to do it and I joked with the nurses that I was just an overpaid porter.

Somewhat apropos as our department recently started doing endoscopy sedations. We started this gradually and just this month made the leap to full-time coverage of endoscopy. Sedating endocopies is an interesting process with the older patients, intensely stimulating parts of the procedure followed by less stimulating times, the high turnovers and the shared airways.

One of the gastroenterologists typifies the old joke about the definition of a colonoscope (a long black tube with an asshole at each end). This fellow has enthusiastically been using propofol for the past few years. He claims have done this uneventfully for years although the first thing I noticed when I first work in endo was how good the nurses were at bagging patients. He did agree to having us sedate his patients. This goodwill lasted about one session after which he "fired" our department, sending off a poison pen letter accusing us of all kinds of unsafe practices. One of his parting shots called us "just overpaid porters". What was worse for me, was the loud and vocal opposition from a small number of department members who believed that sedating a patient was an abuse of their considerable skills. Our GI friend didn't help much here.

The problem of course with anaesthesia is that we make it look so easy. This leads to things like GI, ER and sundry other specialists merrily sedating patients everywhere in the hospital. Drugs like propofol which have a large margin of safety are even more dangerous if only for the false sense of security they give the doctors. One thing I have learned over the years is that a good general anaesthetic is better than a bad sedation. We now have some short acting options which enable us to more safely sedate patients. The "more safely" is as I mentioned as safer or easier also means less respected or less feared. As site chief for anaesthesiology I feel I am responsible for all anaesthetics given in the hospital including those given by non-anes.

There is as I am becoming aware, a turf war in the US between endoscopists who believe they can safely sedate patients while looking up their bum and anaesthesiologists who say they can't. There is a little self-interest in both. In a private system it is cheaper for the patient or the insurer not to have an anaesthesiologist. At the same time endoscopy sedation offers employment for anaesthesiologists and generally a pleasant decently paid day. Our health region recently wanted to trial a servo system that would enable endoscopists to 'safely' sedate patients. They wanted anaesthesiologist to participate in the trials which we politely declined. There are of course studies both pro and con which largely depend on the bias of the person who ordered the study.

As we get better sedatives there are a lot of cases we currently do under general which could be done with local and sedation. Turf is an issue here. The operating room is "our house". If say, a surgeon wants to do some or all of his cases under local, this can be a loss of income. We can stay in the room "monitoring" and portering the patient or we can cool our heels at home or in the lounge. In eastern Canada where I first worked and trained, local cases were almost exclusively done in a local room where surgeons worked while nurses gave sedation. Occasionally we got a stat call to the local room but it usually worked out okay.

I like to think that by sedating patients I can achieve a perfect balance between comfort and safety. One of my mentors as a resident used to lecture me and the difference between being a professional and a technician. When one tries to get the best possible outcome for the patient you are being a professional. If you just show up and squirt in a little propofol, you are being a technician. I hope I am being that I am not just another overpaid porter.

My 9/11 post

After 911 we had the opportunity to show the Muslim world how Christians can turn the other cheek (not that 2000 years of history have shown the Christians have ever done that).

911 was the day that as a Canadian I felt solidarity with Americans. On that day we were all Americans.

So what the hell went wrong?

Cyclist kills pedestrian / Man bites Dog

A couple of days I confessed in my blog that I occasionally ride on the sidewalks. This prompted a lecture in comment soon after. I always glad people read my blog.

Almost around the same time I read this in the Globe and Mail. An editorial no less. I obviously missed the original story.

I must of course offer my condolences to the family and friends of the unfortunate gentleman.

While I do ride on the sidewalks, I am always aware of the fact that pedestrians have the right of the way, which is why I generally ride as slowly as it is possible while staying upright and if there are lots of pedestrians I either get off my bike and walk or I brave the traffic. I would never think of riding fast enough on a sidewalk to kill anyone, I can barely ride that fast anyway.

But what the Globe failed to mention was how many pedestrians are killed by cars every year and how many cyclists are killed every year by cars. I was able to find it on the internet in about 10 seconds. In 2009, it was 307 pedestrians and 41 cyclists. Multiply this by 10 to get the American numbers. These certainly didn't warrant an editorial, if there were articles, they were buried on the back pages. Not all the drivers are charged and if they do get charged they often plead to something lesser and get a wrist slap months later. There was no hand-wringing about how this is a tragedy and how can we prevent this.

Interestingly enough I did get yelled at once for not riding on a sidewalk. Our city actually permits riding on sidewalks in certain locations where traffic is heavy. So it was that one Sunday afternoon I was riding along one of these routes. The trail/sidewalk was crowded with people jogging or walking so I decided to ride on the road which was not that busy. Within seconds a pick-up truck (of course) pulled up alongside me, slowed down and the driver rolled down his window to yell at me for not riding on the sidewalk.

I saw this video on Facebook recently. Here it is on You-Tube

That's all I'm saying.

Bike Rage

One of my staff was riding his bike to work the other day on the road as is his right. He was passing a shopping centre when a car turned left in front of him with the result that he broke her windshield with his head and sustained some soft tissue injuries. Fortunately he had a helmet on and didn't break anything. To my surprise when I phoned him, ostensibly to see if he was okay but in reality to see whether he would be able to work, he expressed remorse that he had broken the lady's windshield. He also told me that she had been looking into the sun and couldn't see him (as a general rule I don't drive when I can't see where I'm going which has so far kept me out of any serious accidents.)

I used to ride my bike down the same street to get to work before I moved. I still ride down it occasionally. I told him that I always rode that particular stretch of road on the sidewalk. He told me he never rides on the sidewalk.

I am not a serious bike rider but I do enjoy riding to work whenever I can. Typically when I drive to work, I arrive at work feeling tired and yet stressed out. When I ride or walk to work I arrive feeling wide awake and almost euphoric (maybe because I survived another bike commute?). While our city does have some bike paths and some designated bike routes, for the most part riding anywhere within city limits is a combination of service roads, side streets, riding cautiously in traffic and unfortunately riding on the side walk. I also ride across crosswalks sometimes. I know that under the motor vehicle act, I am equal to a car and am not supposed to ride on sidewalks. On the other hand, I am not protected by one ton of steel and I really don't want to end up on somebody's windshield or under their front tire and the fact is we have some pretty bad drivers. Besides nobody walks on the sidewalk anymore.

Currently we have some great paved bike paths in our city. Unfortunately most of them end abruptly forcing you to rejoin the road. Our city does have an ambitious plan for bike paths all over the city. Ambitious, as in expensive which means that it will never get done.

Worse than the bad drivers are the drivers who have a hate on for cyclists. A couple of years ago I was riding on a side street designated as a bike route. This runs parallel to a major street which is quite busy and so many drivers use it as a short cut (me included). I was riding along minding my own business when I hear, "Get off the road you asshole.". Just then a car passed me and in case I missed it, he repeated it. He drove on ahead but had to stop at a stop sign, where I caught up to him. I knocked on his window. "Do you want to step out of your car and call me an asshole?", I asked him. I am not an aggressive person but I felt empowered. Besides I could see he was a senior (meanior) citizen half my size and I figured I could probably kick his butt. He looked terrified quickly locked his door. Through the glass he started yelling at me about what was I doing riding down the middle of road (I wasn't). I gave his door a kick, not hard enough to dent it but hard enough to make an impact. He quickly turned left and sped away.

That is probably the worst episode I have been involved with. I have of course been yelled at many times, sometimes for riding across crosswalks or doing rolling stops which I know are wrong but hey it is only my life I am endangering. Many times the driver's rage has been existential. As I told my wife after a pick-up driver honked at her, "you have to remember his drive to work (in the city) in his big pick-up is probably the best part of the day in his pathetic life and you ruined it by forcing him to slow down."

This is not an isolated attitude. Our local tabloid paper actually printed a letter from someone declaring open season on cyclists who ride on the road.

One of the prominent members of the local riding community who my son knows, is much more aggressive. Any driver who misbehaves is chased down. While cars can drive faster than bikes, they too have to stop at lights and he can generally catch them although it may take several blocks. I can imagine the shock and surprise of the motorist on being accosted by an rather large angry cyclist. This is may be a little extreme.

Even pedestrians with whom we should feel solidarity are selfish when we have to co-exist on the shared trails. I have a bell on one of my bikes; I haven't gotten around to getting one for my other bike but I yell loudly, "on your left" as I approach them. Despite this I get a number of snarky looks and remarks as I pass; quite a few refuse to yield. One fellow on hearing our bell actually lurched across the trail in an attempt to block us. As we passed he yelled , "you know I have the right of way!". About 75% of walkers and runners now are listening to their I-Pod, you could have an airhorn and they wouldn't hear you. (MEC sells a bike air horn but my wife won't let me buy one). Dog walkers still haven't learned that if your dog hasn't figured out that it needs to stay out of the way of bikes or worse if it is aggressive toward bikes, there is a device called a leash which the dog should be wearing even though you might be in an off-leash area. Toddlers are a challenge too. Some people find it quite cute watching them zig-zag across the path. I used to too when I had toddlers. They make me very nervous when I am on my bike trying to get past them. Not that I advocate leashes.

This was a victory for those of us who have been bullied by malicious drivers. The driver in this case, an emergency physician had a habit of braking suddenly in front of cyclists. They had complained to the police in the past without avail but with this happened, charges were laid, the doctor was in true American Justice fashion perp-walked from the ER and eventually jailed.

Stop Complaining, You Got to Play in the NHL

Recently a number of currentand former goons and tough guys have died from suicide, drug overdose or other causes. This is of course tragic for the players, their families and their friends. This has resulted in a lot of soul searching regarding the role of players whose main role in the game is to fight. It has also resulted in a lot of whining from current and former goons about the stress of the role they had to play.

I have never liked fighting in hockey. I remember the exact time when I decided that. It was during the 5th game of the 1972 Bruins Rangers Stanley Cup Final. This game was a classic which the Rangers won 2-1. At one point a fight broke out, I don't remember betweeen who but I do remember thinking that this was interrupting what was a classic game and how stupid it was.

Many years later when I had seasons tickets I remember a game between Edmonton and St. Louis. Midway through the second period, George Laraque came out for Oilers and Tony Twist for St. Louis. They lined up next to each other. The crowd started cheering, the morons with seats behind the glass started pounding on the glass and of course Twist and Laraque dropped the gloves and had a fight. Both got 5 minutes and the game went on. I remember thinking, "What did that just accomplish". I don't think Laraque and Twist had been on the ice together that game so they had no reason to be angry with each other.

The NHL has always had its' fighers. John Ferguson, Dave Schultz, Wayne Cashman, Gordie Howe, Eddie Shack, and later Bob Probert. The difference between these fighters and the current group of goons is that these guys actually played regular shifts. Gordie Howe of course was the leading career goal scorer for years, most of these guys scored 20 goals a season Bob Probert scored 40 goals one season. (Probert is one of the recent deaths, however he had substance abuse issues as a player and died of a heart attack which may or may not have been related to his fighting history.) Philadelphia, the Broad Street Bullies won two Stanley Cups but these had more to do with the goaltending of Bernie Parent than the intimidation factor.

Sometime in the late 70s some teams started keeping a goon on their bench. This player would play a few minutes a game usually to start a fight with the other team's goon or one of their tougher players. This was in the place of a player who could actually play the game, which meant that many marginally talented players spent their career in the pressbox or the American Hockey League so that a team could keep a goon on the bench.

I am not going to go into the pros and cons of fighting. What bothers me is the current series of sob stories in the media by current or former goons about how difficult it was to fight, how they dreaded games etc. One goon lamented that he was paid the minimum $500,000 a year on which he claimed to pay 50% in taxes (he needs to get a better accountant).

OK guys.

I grew up wanting to play in the NHL. My two sons wanted to play in the NHL. Every Canadian playing organized hockey wants to play in the NHL. Only 1 in 10000 kids in organized hockey every makes the NHL. You got to play in the NHL. Moreover you got to play at the expense at some other player with way more talent than you. You got paid more than the Prime Minister. You certain made or are making more than you would be if you weren't playing hockey. So shut the fzck up. Or you can quit or maybe even learn to skate and see if you can make it on your ability to play hockey.

Hours of work

"The problem with one in two call is that you miss half the interesting cases."

Anon
This article caught my eye.

To summarize, an arbitrator in Quebec has ruled that the 24+ hours shifts some residents still have to work are unfair and have to stop. This ruling of course only applies to Quebec but will no doubt reverberate across Canada. There is no question that long hours and lack of sleep affect performance and judgement. We all know that, we just haven't figured out how to deal with it.

This debate has been seriously brewing for at least 10 years. In our program junior housestaff are allowed to go home after 1200 when they have been on call. Peer pressure usually prevents them from doing this. The innevitability of reduced work hours for trainees has been extensively discussed in academic forums and the conclusion has been that in order to allow residents to work shorter shifts it would be necessary to add 1-2 years onto their 5 year residency.

Anaesthesia on the other hand has allowed residents to go home post-call since before I started training. Some programs now even have 12 hours shifts. Anaesthesiology trainees do 3 years of anaesthesia during their 5 year residency getting their post call days off. They also do 6 months of ICU which also allows them to go home after call. Assuming anaesthesia trainees when they are working work as hard as other residents (judging from the condition of the patients coming to the OR they work way harder than surgery residents), this means that anaesthesia residents get about 20% less clinical exposure during their residency than do surgery or medical residents. That is one whole year.

Consider this however:

If your life depended on the skills of either a newly qualified surgeon, a newly qualified internist or a newly qualified anaesthesiologist who would you pick?

Any anaesthesiologist would of course pick the anaesthesiologist. I suspect however a significant amount of surgeons and internists would also pick the anaesthesiologist. It is quality of training not quantity of training that matters.

When I was a resident I got involved with what was called the Interns and Residents Association and what I called the Residents Union. We negotiated things like salaries and work conditions with the hospitals and the government. Late in my residency our contract was up for renewal. We realized that because of the economy we were not going to get any more money so we decided to negotiate terms of work. At that time we were required to come in for 4 hours on Saturday morning so getting rid of that was a no-brainer. We then moved on to call frequency. At the time we were restricted to maximum of 10 days in 30 (1 in 3) call. We decided to go to maximum of 1 in 4 call. Most services at that time actually did less call than that, the surgical and some internal medicine services being the exception. I sat on the University's Residency Training Committee and attended a meeting where that proposal was discussed. At that meeting there were dire predictions of the collapse of patient care and loss of training opportunities from the staff physicians there. There were also a few threats. The Head of Orthopedics said and I quote, "Any resident who won't do 1 in 3 doesn't get to pick up the knife." We eventually backed down and only got rid of the Saturday mornings.

It was as they said however a fait accompli and now residents only do 1 in 4 call, the collapse of the medical training system has not yet happened.

We do learn a lot of medicine at the bedside. We also have to deal with emergencies some of which happen after normal working hours. Unfortunately forcing trainees to deal with patient care when they are tired is not educational, it teaches them a lot of shortcuts to deal with the problem now in a way that you can get back to bed or watching TV. A lot of advice I got from kindly residents as a student intern dealt with just that, how to defer or patch up the problem until someone else can take care of it. It also makes patients the enemy for destroying your sleep and your sanity. It took me a few years to get over that.

Another issue often raised is the issue of hand-over and continuity of care. It is felt that if residents work shorter shifts patients will suffer as information is not passed on. Nobody has ever commented on what happens now in the evenings when residents go home, leaving everything to the on call resident or on weekends when only the on call staff show up. In most services there is no sign out. When I did general internal medicine for 3 soul destroying months, I recognized quite early that around 1900, I would start getting pages about patients on other services with fairly significant and complex medical problems; patients I knew nothing about. I also learned that if I phoned the attending physician I would get yelled at. Therefore I approached the head of medicine and suggested that around 1600 the housestaff have a signover rounds where these complex patients could be discussed. This was of course rejected as the 30 or so minutes required would take the housestaff away from more important work.

Fortunately nurses who actually do sign over patients between shifts knew something about the patient, something which probably saved my, and more importantly the patient's butt, more times than I can think of.

In retrospect a big part of the opposition to sign over was the whole concept that you shouldn't leave a complex patient which meant you were often expected to stay well into the evening if you had somebody in trouble, rather than signing the patient over to the physician who was eventually going to have to look after your patient anyway because sooner or later you were going to go home and the patient was not going to suddenly get better. Of course the person you were signing over to would have worked as long as you had already that day, probably a little bit harder and wouldn't it have been nice to be able to sign over to someone who was just coming in relatively fresh. What a concept.