Monday, November 28, 2011

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.

Sunday, November 20, 2011

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.

Thursday, November 17, 2011

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?

Wednesday, November 16, 2011

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.

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.

Monday, November 14, 2011

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.

Thursday, November 3, 2011

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.