Monday, October 31, 2011

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).

Sunday, October 23, 2011

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).

Thursday, October 20, 2011

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?

Wednesday, October 19, 2011

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 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.

Saturday, October 15, 2011

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.

Wednesday, October 12, 2011

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.

Thursday, October 6, 2011

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.