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.