Thursday, March 31, 2011

Why Do Coffins Have Galvanized Nails?

1. So oncologists won't pry them open to try to give chemotherapy
2. So nephrologists won't pry them open to try to dialyze them
3. So orthopods won't pry them open to try to fix their hip.

Choose one or all of the above.

I only read the National Post when somebody leaves it around and I am really bored, however this is quite interesting in a depressing way of course.

This of course reminded me of where I trained. We had an oncologist who liked to give his last dose of chemo in the morgue. This combined with the lack of balls of our intensivists meant that on occasion half the ICU were patients with terminal cancer. Our local nephrologists weren't much better.

I had to do 6 soul-destroying, spirit-breaking months of internal medicine during which I had to deal with quite a few of these dilemmas. At that time the older people I was seeing tended to have had large numbers of children. I observed a truism: the children who still lived in the area and had cared for their parents tended to be quite reasonable about extraordinary measures; the children who had moved away were usually very unreasonable and wanted everything done. I am trying to think of an exception to this but I can't. There were as in this case, more malevolent motives

My son is studying bio-medical ethics which for some reason doctors don't have to study. I told him my simple ethics test: "Don't do anything to a patient you wouldn't do to yourself or to a member of your family." A little simplistic, however I have applied it retrospectively to most of the ethical situations I have found myself in over the last 29 (!) years and it seems to more or less work for most of them. (Abortion is an exception; I believe in abortion, some doctors don't) Many times of course what I would do if it were me is not necessarily what the patient wants or more frequently what the family wants but I think if I or preferably somebody else actually sat down and gave the hard facts, I think a lot of people would come around.

The thing is, judging from my coffee room conversations with other doctors, most of them don't want aggressive measures should they have some horrible terminal disease or for that matter some horrible injury that leaves them with a diminished quality of life. Granted I don't drink coffee with a lot of oncologists or nephrologists. With these beliefs however we submit our patients to weeks to months of what must be living hell in the belief that that is what they want. As I mentioned a long time ago one of my least favourite things to hear a surgeon say is, "I don't want to do this case but the family is insisting on it."

Part of my job now as Site Leader is to sit on a QA committee with the Chief of Surgery and some high powered nursing administrators. Some time ago we had a unfortunate (maybe not) 95 year old drop dead in our recovery room after his IM nailing. He had a DNR order which the anaesthesiologist quite correctly respected. Cases like these are always interesting because by hospital policy DNRs are suspended when a patient comes to the OR. The correct response here would then have been to pound on his chest for some time. Nobody was critical of how the case went down, the reason I presented the case was to ask the question of whether it was even appropriate to try to fix his hip and if so could it have been done in a simpler fashion than the gamma nail, which is the method du jour of fixing hips now, especially as his demise was probably due to a marrow embolus from the IM nail.

We seem to get into a few dilemmas like this in our like OR as we do a steady number of IM nails for pathologic fractured femurs. These have a significant incidence of tumor embolism which is almost always universally fatal. This has lead to complaints against members of our department for both over-rescuscitating and under-rescuscitating depending on the attitude and the grief of the surviving relatives. A lot of this could be avoided by having the orthopod actually talk to the family but hey, these are orthopods.

Aside from the ethical issues involved here the article points out that there are financial issues in play as well with a significant amount of health care dollars going into the last six months of care. Of course we all know what happened when they tried to talk about this in the US. Death panels anyone. Sounds like a plan.

Sunday, March 20, 2011

It is Indeed a Special Moment the First Time Your Son Injures Somebody

All the commentary about head shots and concussions in sports have brought back repressed memories from my years as a hockey dad.

Now men like to hit each other or fight. You only have to watch young children playing to appreciate this. This is also apparent in other species where it is not necessarily limited to males. Consequently we have sports like hockey football and boxing. This is not a North American phenomena, we also have rugby and hurling.

I only played one year of organized hockey. My parents gave all kinds of reasons including, the early ice times and the fact that I was not very good. This is despite the fact that in 1977 when I would have been eligible to play in the NHL, all the teams were drafting big guys who couldn't skate and at 6'5" I would have been the tallest player in the NHL (you can check on this if you want). I should get over this but I won't. This trauma is why when my oldest son announced at age 7, that he desperately wanted to play hockey I did nothing to stand in his way.

Of course having 2 boys, you can't just put one in hockey without putting the other in hockey and so little brother had to go in as well.

Little brother had a different personality from big brother, he was one of those cute kids who skates around in circles oblivious to the puck. This was fine at the Tom Thumb level where he had kids who would actually play the game for him but as he reached novice where he was put on a team with kids of similar ability, it became painful.

Hockey in our province is non contact until age 11 at which time body checking is permitted. I wish we could say that we were mortified but actually we were quite proud that this was an area of the game in which number 2 son excelled. Body checking gave him a role on the team, his interest peaked, he actually started scoring goals and playing at the outdoor rink. And of course he injured players. Many players I learned don't watch Don Cherry and don't appreciated that you don't cruise across the blue line with your head down. Thanks to Don Cherry our son realized that players would do this and many of his worst hits came on those players. Now my son was not a dirty player, many of his hits were to the head which was legal then but they were with his shoulder not with his elbow. He got a penalty every couple of games unusual unrelated to hitting. In his second and final year of contact hockey he was badly mis-tiered at the beginning of the season which meant he played with and against a number of players in their first year of contact hockey.

The carnage every week was incredible. I remember seeing a player skate out of the corner, head down and my son laying him out; I saw the legs buckle, the player slump the ice and the other team's trainer sprinting across the ice. Meanwhile number 2 son was getting high fives at the bench and I had never been so proud of him. At the end of season party one of parents came up to my son and said, "Thank you for protecting my son".

Body checking is an integral part of hockey just as tackling is an integral part of football or rugby. Most 11 year old kids in minor hockey want to body check.

Sadly my son also suffered a number of concussions in minor hockey. Some of these were inflicted by his own team in practice as some players wanted to see how tough he was. A few were in games, at least one skiing.

My number two son is in University now and doing well. He no longer lowers his shoulder into people's heads. He just skis and bikes off cliffs.

Friday, March 11, 2011

At the Centre of a Scandal

Rarely does one find oneself actually having worked in what is shaping up to be a major political scandal.

Thoracic surgery at the C of E was a poor cousin to cardiac. This was unfortunate for them as they shared beds and operating time and guess who won out there.

About 5 years into my tenure at the C of E a new thoracic surgeon was recruited. Now at the C of E at that time there was only room for one thoracic surgeon which as you can see could potentially cause some problems.

The fellow they recruited was a local boy who trained at another centre and had done some training over in Britain. He was technically not a bad surgeon, he was a little whiny, he liked to operate at night etc. Despite some interpersonal problem I had with him early on, we actually got along, and I actually enjoyed working with him. After a few years, he started to complain about things like not being able to recruit other thoracic surgeons due to lack of OR time (which meant he had to be on call every night), and his beds being filled by cardiac surgery patients meaning that he often had cases canceled due to no beds. He also couldn't get beds in the cardiothoracic ICU, the hospital wouldn't open a step down unit which was all most of his patients needed. He also complained about being on call every night because the hospital couldn't or wouldn't recruit another thoracic surgeon. Briefly a city wide call schedule was instituted but the other surgeons in the city soon tired of working at the C of E at night.

Suddenly he was gone. The story which I only heard today was that one day he arrived to find the locks on his office changed and the chief of surgery and two security guards waiting. He was escorted from the building.

In his place was a wise man from the East, a thoracic surgeon recruited from Toronto. He seemed to be a nice guy a first, he was fast, and didn't always want the lung down. Soon it became apparent there were problems with him. His judgment seemed a little questionable; we started seeing his patients on ventilators in recovery; he insisted on operating on patients we wanted to cancel, he left residents in the room and couldn't be located when the shzt hit the fan. At the same time suddenly we got a step down unit, there never seemed to be cancellations of thoracic cases and two more thoracic surgeons were recruited.

Rumours then started flying about how this wise man had been recruited to evaluate the whiny one's practice and being told, " Oh by the way how would you like to work here?"

Things rapidly went south, the two other thoracic surgeons moved to other hospitals mainly because they didn't like working with the wise man from the east. I left the C of E. I think that the prospect of working with the wise man was a major factor in my leaving. About a year after I left, I got a memo stating that the wise man was taking a leave of absence. He has never returned from this.

Why am I digging up more dirt on the C of E.

This fellow a physician member of our legislature has been making accusations of cover ups of cancer deaths on the wait lists and pay-offs to physicians. My first impulse was that even our health authority and government aren't that malicious. Then I thought about the whiny one. And today this appears on the front page of my local paper .

The whiny one of course sued and according to scuttlebutt around the OR today got between 8 and 12 MILLION dollars in an out of court settlement. No wonder he is smiling.

And here I was at the centre of it all. Sad to think of how many nurses 12 million could have paid for.

Sunday, March 6, 2011

Unmasked Sort Of

I started this blog in a moment of boredom on New Year's eve 2006. I was on call, my family were at the dacha, there were no cases on and the case room was quiet. I sat at home. There is never anything good on TV on New Years eve so I started fooling around on my computer and that was when I started this blog.

I never thought it would amount to much but I kept on writing. Gradually people started commenting, I saw other blogs were linking to mine and I kept on writing. Some of posts I have written, I am really proud of; a lot are petty or stupid.

Throughout that I never told me wife. Until yesterday. I had always intended to tell her but as the months went on and I still hadn't told her, it got harder. While I write anonymously, I have given out so many hints that anybody who reads the blog can figure out who is writing it pretty easily if they know me. I was worried she might actually stumble on it that way. Anyway I told her on the way to dinner yesterday and after dinner she read most of my posts some of which I explained to her. She reacted pretty well on the whole. I never had told her about the problems I had during my internship, nor about my sexual harassment complaint. We of course went through my lawsuit and my bad marriage with the C of E together.

This blog was sort of like a perverse diary where you hide it from your family but the entire Web is able to read it. Not anymore.

By the way as she is probably going to read this: She is an amazing woman who has been a constant source of support through all the shit I have been through and all the shit I have put my family through.

Friday, March 4, 2011

Ending My Silence on the King's Speech

There are a lot of good movies out lately and so when my wife announced on date night that she wanted to see the King's Speech I was a little hesitant but I went and thoroughly enjoyed it.

I stutter. Many fellow stutterers have writen about this, much more eloquently than I can.

This, as I remember started in Grade I. I probably started before that but with the reading out loud, you have to do in Grade I it became apparent. My Grade I teacher alertly picked this up and I was started on speech therapy that year which lasted until Grade 5. Once a week an old English lady, Miss Crickmay would appear at the door of our classroom and another student and I would go for our weekly speech therapy sessions. This mostly consisted of reading from our readers and being told not to talk loudly and read slowly. The sessions stopped after Grade 5. I believe I had broken her spirit.

I went thru a lot of teasing throughout school. I remember in Grade 1 we would have the morning and afternoon role calls. As the teacher called out our names we would have to say, "Good morning Mrs. Murphy" or "Good afternoon, Mrs. Murphy". That instead of just saying "here" or "present". I could easily say "good afternoon"; "good morning" was a daily ordeal. In Grade 2 I was actually placed in the dummy reading group until the teacher realized that I could read better than anybody in the class. I went to the same school from Grades 1-7; as I got along, the other students knew that I stuttered, the teasing stopped; some other students came to my defense if somebody imitated me or laughed.

Junior high was another matter. Only half our school when to that Junior High and there were three other feeder schools. A whole new group of students to whom I was going to have get to know. My solution was to clam up. I only spoke when spoken to and stuck with my small group of friends. I believe that as a result of this I missed a lot of socialization during adolescence. I still have a hard time making conversation, people find me aloof. I really wanted to learn French in junior high so I took an enhanced course. Part of the reason may have been that I felt I could be more fluent in another language. As I found out I stutter in French although not as badly as in English probably because I have to speak slower and think more in French. Nonetheless, French class became an ordeal.

When I was in high school there was a televised quiz show for high schools called Reach for the Top. I am especially good at trivia, so much to everybody's, but not my, surprise I made the team in Grade 11. I have only recently thought of how stressful this must have been for my parents. Their stuttering son on TV at 7:30 in the evening, broadcast province-wide. Fortunately for some reason I usually don't stutter under pressure and the one word and short phrase answers required for these shows never bothered me.

Notwithstanding Miss Crickmay's efforts I did come to a truce with my stutter but it is an uneasy and frequently violated truce. Soft S's and C's are difficult as are H's and W's. For example scissors is a word I have a hard time saying (I actually bought my own as an intern so I wouldn't have to ask the nurses). Worse are the times when I just self destruct, the words stop flowing, I grimace, my tongue protrudes from my mouth. These come without warning; I can be in the middle of a conversation and without warning the attack will come. I do a lot of speaking now, I have learned that after about half an hour this may happen. I have learned to have a glass of water handy more to use as a prop while I wait to reset. I like King George and Winston Churchill try to avoid words I know I cannot say. This is frequently awkward, in medicine with its most precise terminology it is often impossible to avoid certain words. Like King George, I don't stutter when angry and I can swear. I like to sing in private. I went thru my fellowship oral exam completely fluently, I have no idea how or why.

Alcohol of course makes it worse. I hold my liquor rather well except when it comes to speaking when I frequently appear way drunker than I am. Coffee is another villain. I try to avoid coffee when I have to give a talk. I stutter more when I am tired. There is an obsessive component to it, certain situations make me stutter more.

Public speaking is another source of stress in my life. I dreaded the presentations we had to give in medical school; presenting a case in a small group was never a problem (except that I tend to be very to the point which a lot of people don't like). When I was a resident we had to present a lot more. I suddenly found that I enjoyed it. I loved researching a topic and breaking it down to a way that an audience could understand. I was also able to structure it in a way that I could actually present it effectively. I now do a lot of talks for the medical school and mostly for Big Pharma. For the most part I am able to get through them. Early on I remember giving a talk for the dental class on head and neck pain and all of a sudden self destructing, limping to a finish. I was never invited back. Nonetheless I have spoken at two national meetings as an invited speaker, something I am still very proud of.

I now attend a lot of meetings. Depending on how I am feeling, I may or may not participate in the discussion. Sometimes this has been to my detriment, I often actually have something useful to say. I frequently now send letters or emails after the meeting; I just thought of this I say, although I probably thought about it during the meeting. I often think about how if I had spoken up at staff meetings when I was at the Centre of Excellence, that I might have changed the way things went. Nah.

A few years ago I resolved to kill the beast once and for all and attended weekly sessions at ISTAR. I found them helpful but at the end I got the impression that I was as good as I was ever going to get and that there were people worse than me. Still I highly recommend them to anybody. By the way they are always looking for donations.

Interractions with patients are interesting. People will think I chose anaesthesiology as a specialty where I would not have to talk to people. Everybody knows, don't they, anaesthesiologists never talk to patients. As such my choice of chronic pain is questionable. I was never a good family doctor; my stutter might have contributed to it. It may have made me appear less sure of what I was telling patients. It made me more direct and to the point which some people like, most don't. In certain practices I worked in, the doctor's practice was to call the patient in from the waiting room. Certain names of course I have trouble saying. At work, sometime asking for stuff is difficult; I am known as someone who is fairly self sufficient, I would rather just get something myself. When this happened my ever supportive chairman suggested that I had not more thoroughly interogated the surgeon or asked for help because of my stutter. I don't think so but what if?

I realize this is a handicap but that I am more fortunate than people who are blind, deaf or have a mobility problem, many of who have overcome their problems to go on to great things. On the other hand it is handicap not always accepted by society. I remember being always being told to speak slowly and other hints. I was told that I could stop stuttering as if I really wanted to just keep on doing it. As a teenager I remember thanking my father for something and being told, "you can thank me by stopping stuttering."

Stuttering of course runs in the family. The gene has apparently even been localized. My father stutters although he mostly overcame it, my younger brother (but not my other brothers) stutters. I have a cousin I have never met who stutters. Painfully for me, my son also stutters although after a year long ordeal of speech therapy he controls it much better than do I.

I thank the writers and producers of the King's Speech for bringing out the problem I share with so many other people. I suspect however this fascination will only last a few years and we will continue to go on as before. Meanwhile I have my blog.