What I am really ready for is for people to stop asking me if I am ready for Christmas

I have noticed this trend over the past few years that people around Christmas will attempt to start a conversation or just acknowledge you by asking, "are you ready for Christmas?"  This will include patients, co-workers and people you have only just met, like the man who asked me in the hot tub at the Y tonight.

Just for the record I am ready for Christmas.  I don't have many responsibilities, just try to read my wife's mind and buy her presents of the approximate dollar value to what she buys for me. (I know you read this dear and I love you very much).   It took 3 after work epic shopping sessions but I may have succeeded.  In some ways I am excused by virtue of having to work until December 23.

I also love Christmas.  What's not to love about a week off, knowing the days are going to get longer, getting  and giving presents, being together with your family, being able to shamelessly overeat and drink.  I listen to the all Christmas music radio station and enjoy both the cheesy and ultra traditional songs.  I actually like eggnog.

What I can't understand is why people will ask other people they don't actually know that well or at all if they are ready for Christmas?  I know they are only trying to be friendly but is it any of their business.  For all they  know I may not celebrate Christmas, or may be horribly unready for it (and thanks for reminding me and adding to my stress).   But is Christmas something you have to be ready for or should it be something that just happens. I know those presents don't just buy themselves,the tree doesn't decorate itself and the baking doesn't just happen but have we taken what should be most wonderful time of year (this was playing on the radio as I typed this) and turned it into an event for which one has to be ready.

So.....wishing my a Merry Christmas or Happy Holidays or Winter Solstice is fine.  Just don't ask me if I am ready.  I am but just don't ask.

As an aside I went to a local production of Dickens' "A Christmas Carol" last week.  This is the third time I have seen it since moving here and I have seen it a couple of times elsewhere as well as various movie versions plus I read the book.  So I sort of know the plot.  I was wondering to my wife if maybe they were going to update the plot this year.  Like maybe Scrooge was going to remember his fiduciary duties to his shareholders,  tell Cratchit to pull himself up by his bootstraps while outsourcing his job after which of course he could award himself a huge year end bonus.

A Christmas Carol is more than a play about Christmas.   As I result of the 3 visitations, Scrooge starts to pay Cratchit a living wage, enabling him to purchase medical care for Tiny Tim and starts to donate to charities which in the 19th century were the social safety net.  Sadly most 19th century capitalists didn't do this and things got worse rather than better during the rest of the 19th century for the Cratchits and Tiny Tims.  There were a lot of gains in the 20th century but so many of these have been rolled back.

With that thought, have a Merry Christmas.

Majority Envy

My faith in the US was restored with the re-election of Obama last Tuesday.  Granted he has been a disappointment but one has to look at the alternatives.   I know a lot of the doctors who read this blog are disappointed but get over it. 

There are a lot of things about the US that I admire including, rock and roll, blues, bluegrass, NFL football,  and of course the Boston Bruins; however watching the recent election there I couldn't help noticing that with the exception of a few cases, the president actually gets a majority of the popular vote.  Granted there is the ridiculous electoral college but in most cases the president gets over half the vote and all the electoral college does is turn a narrow popular vote win into an electoral college landslide.

I have always admired the US political system with its checks and balances even if this has been perverted in the last decade or so.   There is a lot of the US system that is bad but as a Canadian, the saying people who live in glass houses shouldn't throw stones comes to mind.

Canada unlike the US has 3 and sometimes 4 political parties and our increasingly presidential-like Prime Minister is elected by our own version of the electoral college, the first past the post election of the House of Commons which allows people to win their seat with less than 50% of the vote (27% in one case).  This has assured that in my life-time only two Prime Ministers Diefenbaker in 1958 and Mulroney in 1984 have gotten over 50% of the popular vote.  In both cases these two got huge majorities in the House of Commons.  Pierre Trudeau, considered by some to be Canada's greatest Prime Minister won majorities with 45.5%, 43.2% and 44.3%.  He also got a minority win with 38.5 % and lost an election with 40.1%.  Jean Cretien managed to win 3 comfortable majorities with around 40% of the popular vote.  In other words Sarah Palin got a higher percentage of the popular vote than most Canadian Prime Ministers. 

I am painfully aware that not everybody shares my political views and I accept the fact that if more people vote for the other guy, he deserves to win and govern.  It does bother me that somebody who got less than half the votes gets to "win" the election.

As somebody else pointed out, a Prime Minister with a parliamentary majority is the closest thing to a dictatorship and our current Prime Minister has a very comfortable majority in the House of Commons with only 39.62% of the popular vote.  The opposition representing over 60% of the popular vote can do all they can but if our PM deviates from his legislative agenda, it is because his advisers have advised him that what he is proposing is not politically sound.  Oh yeah and I did I tell you he gets to appoint all the Senators as well?

Of course this all dependent on his Parliamentary caucus voting along with him.  Our Prime Minister is able to keep his troops in line by controlling things like cabinet appointments and other jobs that increase the income and prestige of the individual member.  He also is able to eject unruly members from his caucus effectively ending their chance of re-election and is able to block their nominations by refusing to sign their nomination papers.

The result of this system is that political parties know that the magic number for a majority is about 40% of the popular vote and they can tailor their platform to this minority of the population.  There has been a distaste among Canadian voters for proportional representation (which seems to work just fine in many of the world's democracies).  Most political parties realizing that they are unlikely to ever get more than 50% of the popular vote are not that enthusiastic about it either.

In effect a Canadian Prime Minister finds himself in the situation Obama found himself in after the 2008 election, controlling both the House and the Senate.  Looking at his first two years in office with his inability to get his legislative agenda through, I wonder how many current and former Canadian Prime Ministers were thinking, "what a wimp".

The most important article in the history of the NEJM

Thanks to Great Z s for posting this.

This is an interesting article although it would probably not get published nowadays due to not being randomized double blind and of course not getting consent from the ethics committee to do the experiments or from the patients involved to publish.

I was interested in the author's comparison of the effects of ether to the effects of Egyptian hashish.  Medical marijuana anyone?

Not wearing a poppy again this year.

As usual somebody has published my sentiments much more eloquently than I could.

I posted this in 2009.

I posted the Huff Post article on Facebook and one of my "friends" a physician I went to high school with who served in the military and is I believe still in the reserve commented, "Its for remembrance of sacrifice not glorification of war."  If only that was true.

Politicians like to trot out our gallant soldiers for political gain and probably have for centuries.  This is notwithstanding how badly they treat them when they aren't doing photo-ops with them.  Veterans benefits have been cut and the government actually spent a fairly large amount of money defending unsuccessfully a lawsuit from veterans who were only trying to get what they believed they had been promised.  Veterans affairs offices are being closed, however WWII veterans (average age 88) have been advised, "don't worry, here's an app you can download for your smartphone."

Our government is currently spending a great deal of money celebrating the 200th anniversary of the War of 1812 (hey Americans, did you know you lost?).   I enjoy history but wonder whether the money couldn't have been spent better or even just spent on a celebration of history that doesn't just justify the governments current policies.  Plus while we "won" the war, most of the fighting was done by British regulars and our Indian "allies" who the British on our behalf abandoned after the war.  But Washington was sacked and burned by British regulars on our behalf so we can still boast about that.  And the battle of New Orleans (which happened after the peace treaty was signed) produced a pretty good Rock song.

I am still hoping that in my lifetime we can find a way of settling disputes that doesn't involve killing people.

Celebrating Our Mistakes

This video is 19 minutes long but you should really take the time to watch it all.

Bill Chadwick who was a NHL referee before I was born, is alleged to have made an exchange with a doctor who sat close to the ice and like to heckle him.  Chadwick said something to the effect, "Yes doctor, I make a lot of mistakes; the difference is I don't bury mine".

I went to a Departmental retreat last Saturday.  The first one third of the retreat was on quality improvement.  Somebody said "we should celebrate our mistakes".   What a great concept, I would never have thought of that but I am still going to use it on my blog.

Years ago as a resident we had M+M rounds once a week.  Each staff at our local Centre of Excellence took the day in rotation and was supposed to present his cases.  If you were the resident who was involved in the event, you usually had to present the case.  You never liked to be the person who was presenting a mistake or a case that had not gone well but at the same time, it was a supportive environment.  Somebody usually said the same thing had happened to them.  And of all the teaching I got in residency, the M+M rounds were where I learned the most.

The CofE when I arrived there had a very active QI process.  Two nurses reviewed every single anaesthetic chart and reported variances to our four person QI committee.  This included trivial things like the blood pressure dropping on induction even if no harm came to the patient.  Typically one of the QI committee members would visit you in your room with a copy of the anaesthetic record and point out your errors.  If anything this exercise only taught me to fill in the valleys in my blood pressure.   We had another province-wide initiative.  If your patient died within 7 days of an anaesthetic you would get a summons to the Medical Records department to review the chart and fill out a form which was reviewed by a committee.  This was an interesting exercise because while sometimes you knew or suspected your patient was going to die, quite often patients died for no apparent reason.  At the same time the system was reactive not proactive.  It was punitive and not educational.

With the first reorganization of healthcare in the mid 1990s most of the QI activities ceased to exist.  The cost was cited but there was the suspicion that administration didn't want to know about what was going on because it might reflect on problems brought on by their policies and/or they might actually have to spend money fixing the problem.

The second blow to reporting and discussion of adverse events, was paranoia in the medical profession regarding the medico-legal implications of public confessions.  QI activities are supposed to be privileged which means that anybody who attends the meeting cannot be forced to testify on the case.  Changes to our provincial Evidence Act muddied the waters somewhat.  While we are reassured that QI discussions are privileged and cannot be subpoenaed, nobody wants to be the test case; our medical protective association has for years advised against participating in QI activities, if you think a legal action is imminent.  At the same time, administration while talking a great deal about quality and risk management, is in no hurry to support activities that might expose flaws in their agenda or force them to spend money to correct the flaws.

Our health region has a system called the Reporting and Learning System RLS, a computer based system whereby individuals can report adverse events and near misses.  I actually used it when this happened.   The problem with this system if that reports go into a black hole.  I am still awaiting a response to my report.

Making mistakes is of course the essence of how we learn in medicine and in life.  When I was a junior resident one of the staffmen liked to warn me over and over that one day I was going to make a serious mistake that would hurt somebody (I assumed he told every resident this and didn't think I was especially klutzy).  I got sick of hearing this and so one day I said to him, "How about I do it today so I can get it over with."  He didn't think this was funny.

When I was thinking about writing this blog, I was thinking about how I learned to ride a bicycle.  I didn't learn until I was 8 although I started trying much earlier.  I went through a lot abrasions both to my skin and my pride but one day I got on the bike and just start riding.  Maybe something clicked but more likely it was the sum of all the mistakes I had made trying to learn to ride a bike.  Parents in the 1960s were of course a lot more accepting of skinned knees and elbows.

Learning in medicine is the sum of experience, much of which is mistakes.  Some are obvious like blowing an IV or not being able to intubate; some have to be pointed out to you.  When you fail, you think of how you did it wrong and how you will try to do it right the next time.  When somebody criticizes you, you ask yourself, was that justified?  That is how we learn.  And it involves doing this on real live human beings.  Has anybody been to a simulation session that was even close to being realistic?

Of course many mistakes are only apparent to us and it is pretty easy to cover up or defend something especially if the atmosphere punitive not nurturing and supportive.  The problem is that when you don't confess your mistakes or when the system makes you defensive, you lose the learning opportunity the mistake gave you, as you replay the event over and over in your head what you did becomes more and more right.  Conversely by not being able to discuss freely your mistake, you may actually lose confidence in your abilities without the reassurance that your colleagues have had similar happening to them.  You also miss the opportunity of letting other people know of the pitfalls of doing what you did.

So if you are a non-physician reading this, you are thinking, all these mistakes in the name of training and experience;  is the system safe?  Well firstly, most mistakes are small mistakes.  There are of course single mistakes that can be catastrophic but the most serious adverse events are usually a cascade of small mistakes compounded by the failure to notice the small mistakes.  Small mistakes can be trivialized as is often the case when it is a system problem or minimized when it is an individual problem.  Failure to learn from mistakes, to take action so that the mistake doesn't happen again leads to serious adverse events.  So often the principle, no harm no foul exists in Medicine.

We are all human, we work on humans.  We are not perfect, our patients don't all present the same way.  That is the art of Medicine.  The doctor who realizes he is human, makes mistakes and learns from them is probably a pretty good doctor.  The most dangerous doctor is the one who thinks his shzt doesn't smell.

Sometimes however I just wish I could just say, "Doh".

No More Free Lunch

About a year ago, our administration banned what are known as drug lunches.

Anaesthesia who use a very limited menu of drugs, most of them now generic or with no real competition probably misses out on Big Pharma's largess and hospitality compared with other specialties.  We did however get the odd free lunch.

When BMS (Pentaspan) and Fresenius-Kabi (Voluven) were involved in colloid wars both reps brought very nice lunches to the OR lounge once a month or.  They were very tasty and we only had to listen to one company tell us how bad the other's product was.  Personally I didn't think clinically there was much difference, Voluven was easier to spike plus you could inject stuff in the bag so I used it.  When BMS showed the white flag, the Voluven guy kept on showing up with delicious lunches although he was now only competing with normal saline and Ringer's lactate. We also had Abbott, who market Sevoflurane.   The only competition with Sevoflurane is Desflurane which I also use but because we do a lot of cases with laryngeal masks at our hospital we use a lot of Sevoflurane.  There is a generic Sevo, coming up and while we are eating our lunches, the rep makes sure we are cognizant of the drawbacks of the potential generic competitor.

I appreciate the lunches, although I always eat too much and am sluggish during the afternoon.  From my point of view, they are a waste of time for the rep.  What colloid we get or what type of Sevoflurane we get is decided by someone in a room far away, who has never been near an OR and probably thinks Sevoflurane is a dietary supplement.  If I hang up a bag of Voluven instead of Ringer's Lactate it is because I think it is going to be better in the situation I am in.  The whole crystalloid-colloid thing bores me.  I earn a good living, I can afford to buy lunch.  I usually bring it from home.   I shouldn't be bothered by banning drug lunches.

Except.......

Our hospital does a lot of total joints and orthopedic trauma.  This means that everyday we have reps from the orthopedic hardware companies sitting in our lounge, walking around the OR and directing the nurses and surgeons in installing their expensive products.  The hospital even lets them park in the doctor's parking lot and gives them lockers.  There are at least 5 of them and assuming they all earn $100,000 a year, that's half a million dollars worth of sales force hanging out in our OR.  Do you think the companies that employ them are going to tell them to tell the surgeon to implant the most cost-effective hardware ?  That's why, instead of the old Moore's prosthesis which cost $300, people who haven't walked in years are getting the modular Moore at considerable extra cost.  This isn't enough, we are know doing total hip replacements in 90 year olds with broken hips.  The old DHS is of historical interest, everybody now gets a gamma nail.

And of course every OR committee meeting we hear about how many millions over budget we are, mostly due to the cost of orthopedic hardware.  But the real problem is that once a month or so anaesthesia  (used to) gets a free lunch!

Hi, I'm one of those guys who puts people to sleep

The medical mission I work with, has a dinner and silent auction every year to raise money.  We hire a local celebrity/ radio weatherman /newspaper columnist.  He is pretty funny and has some pretty coarse jokes.  I almost peed myself a couple of times.  And he mentioned us in his newspaper column.  Not at the top mind you but a little ways down.  And of course any publicity is good publicity.

In his column he says (bold type is my emphasis):

"On January 31st, some 50 volunteers from our city, including surgeons, dentists, those guys who put people to sleep (I can't say or spell the word), O.R. and recovery room nurses and other assistants, will once again travel to South America carrying hundreds of pounds of medical supplies in hockey bags."

Part of this is of course our fault.  We had to choose one of the more unpronounceable specialty names in medicine.  Otolaryngology is close but they had the sense to shorten it to ENT.

Anaesthesiology is 7 syllables.  "Those guys who put people to sleep" is only 8 and all in English and pretty easy to spell even for a Sun* Columnist.  TGWPPTS for short?

A few (actually many now) years ago the anaesthesia department at the C of E decided it needed an image change and was looking for a new name.  I suggested the Department of Patient Centred Wellness which for some reason wasn't accepted but they did change their name to the Department of Anaesthesiology and Pain Medicine.

A few years ago (okay many years ago) I did a mischievous thing to a patient.  He asked me how much training I needed to become an anaesthesiologist.  I said, "Grade 11" and put him to sleep seconds later.  He may still believe this.

But we all had a good time and raised lots of money.

* My son's Cub pack toured the Sun newspaper factory and my son asked me why we didn't read the Sun.  I told him only stupid people read the Sun.

Bullying

There has been a lot of attention to the issue of bullying in Canada after this video was posted followed shortly after by the poor teenager taking her life. The video is quite long but you really should watch it to the end.  She obviously made some poor choices but nobody deserves to be put in a place where taking one's life is the only way out.  This has resulted in more action than I can remember ever happening in response to bullying.  The provincial premier has commented and there is talking of new anti-bullying laws.  The police are investigating aspects of the case and the vigilante group Anonymous has posted on line the name and address of the alleged harasser.

As a serial victim of bullying, I am following this with interest.  As a child I was fat, not good at sports, I stuttered and I got good marks, which made me a natural target.  Moreover, my parents instilled in me that fighting was wrong, so I never fought back.  I certainly not the only child bullied at my school; as Ralphie in A Christmas Story observed society was divided into bullies, toadies and the bullied.
This was accepted as part of the natural order of things as a child.  There was always somebody weaker than you to whom you could be a bully or the toady to a bully.  Bullying could be physical or was often psychological, teasing and excluding from activities.

When I took ethology (animal behaviour) in university, it all made sense.  Human as everybody, except Republicans, know are primates.  Most of the higher primates have strong pecking orders with one dominant male and female; the rest of the tribe neatly ordered each one dominant over the one below.  We are possibly more intelligent than our chimpanzee and gorilla cousins and have evolved a more complex society.  The pecking orders still exist in the smaller divisions of our society and especially in our children and adolescents.  Bullying is unfortunately just the manifestation of our baser primate dominant-submissive relationships.  That doesn't necessary condone it, but it does explain it.  Much bullying goes beyond what is necessary for our inner primate and many of our natural alpha males and females live their life without having having to bully at all.

Anyway most of us down the dominance chain, learned our place we stayed out of the way of the bullies, toadied when necessary and that was how we survived childhood and adolescence.  In junior high and high school with more of us, we were able to form cliques where those of us in the lower or less high social stratas grouped in order to mutually shelter us from the alpha males and females.  These cliques often had their own social strata.

Teachers were often bullies themselves and quite often enabled bullies.  I remember in junior high, one of the track stars punched a projector nerd in the face.  Normally that would have resulted in a suspension from school, but that would have hurt our school's chance of winning the city track meet.  Therefore the principal announced that while what the track star had done was wrong, the service to the school he provided by running fast mitigated his crime.  (Our school didn't win the city championship that year....karma?).  There was also in our school a young man who was hated universally by both teachers and students.  I'm not sure why we all hated him; he was short and a little mouthy but that is hardly a reason.  I wonder now if his mouthiness wasn't just his way of dealing with how we dealt with him.  He moved away after a year.

Quite a while ago our high school class had it's 25th year reunion.  I was talking to the guy who organized the reunion and he was telling me about a friend of mine from high school who didn't come to reunion.  My old friend is now a professor at the local university.  When the organizer phoned the professor up to invite him to the reunion, the professor angrily told him never to try contacting him again.  A few years later, I was having beers with another friend I have known since Grade 5 and told him that story.  "Do you not remember," said my friend, "how badly all of us were treated in high school?"  I obviously had never thought this over or was perhaps more accepting of my place in society.

University seemed a reprieve from the whole tribal culture.  UBC where I went was not a big jock school, most of us were pretty ordinary nerds.  (I told my kids that Revenge of the Nerds is loosely based on my career but it really wasn't like that much)  What bullying went on in University was more of the psychological type.  There was of course hazing in the residence where I lived but this was fairly benign and we thought that this was something that brought us together as a tribe. Residence life was in some ways quite tribal but in a nicer way if you were prepared to accept that ways of the tribe. I never thought about how people who didn't want to accept the ways of the tribe lived.   Some professors and lab instructors were bullies but we worked around them.

Eventually I went to medical school.  I remember our first day, the Dean standing in front of us, telling us all how special we all were and how we were finally joining the exclusive brotherhood of medicine.  I had no idea I was about to enter a world of bullying worse than the worst high school, lasting 9 years (with a three year break for general practice).  Bullying and intimidation were the mainstays of teaching and patient care in that time.  This came from the super-competitive other students, professors, residents and nurses.  We sometimes got a sense of joy and relief watching another student being humiliated at rounds or teaching sessions; we all knew it could (and would) easily be us on the hot seat.  5 years ago we had our 25th reunion.  I always thought we had a really close class but even though the reunion was in Vancouver where a lot of the class had ended up, only 50 of 90 graduates attended.  I was astounded that people wouldn't at least come to part of an event that was taking place in their home town but then I realized that medical school may not have been the nicest time for many of them and that it may have been some of their classmates who contributed to that experience.

Internship and residency wasn't much better except that we now had medical students to pick on and as we got higher up the chain more lower level residents to deal with.  In fact the knowledge that we were now doctors and were getting paid to do what we did served to turn up the heat.  Anaesthesia was a little less hierarchical  (an internal medicine residents was amazed that as a senior resident, I took the same amount of call as the junior residents);  we only had to deal with OR nurses, staffmen and surgeons.  And, of course to remind us of what we were missing, 6 months of internal medicine.

I remember telling someone about what medical school and residency was like.  She was incredulous, "Aren't doctors caring, compassionate people?"  she asked.

Great Zs has blogged about bullying in training programs

The culture of bullying and intimidation never really ended with becoming a consultant.  I still think of the culture of blame I lived through at the Centre of Excellence.  If things have improved for me, it is merely that I am so close to being an alpha male, as to be immune to all but the most malignant bullies.  One of the problems with the whole culture of intimidation which still exists in medicine is that sometimes the only way to get anything done in a timely or reliable fashion is to go into bully mode yourself.   A medical school classmate of mine now a urologist observed a few years ago while we were drinking beers, that he likes to have the staff "slightly" afraid of him.  I was a little shocked but could sort of see where he was coming from. So many bullies in medicine bully to their advantage and quite a few of them have moved themselves into a position that no matter how much the hospital talks about respect and anti-intimidation measures, you know they are never going to be called onto the carpet.

I should have a snappy conclusion to this but I don't.   I am not sure what I went through or what others went through is as bad as it is today.  I am not sure how getting a wedgy relates  to having your boobs displayed on Facebook.  Thinking back about the school and playground bullying and the workplace bullying I experienced, it is hard to imagine having been able to tolerate the workplace bullying without having first had to deal with the play ground bullying.  Dare I say, it built character?  Bullying is in our nature, we can pass laws, hold workshops,  education campaigns and all we are going to do is shift the method of bullying.

We are after all just apes.

The Distracted Anaesthesiologist

The program director of our residency program who isn't given to long emails copied all the Site Chiefs on this long edict to the residents.  My comments are in normal text.

To all residents:

I have received numerous complaints from surgeons over the past year about anesthesia residents reading in the OR.  Typically these complaints come after a surgeon has had difficulty attracting a resident’s attention during the case, however, some have also noticed the increased use of iPads and iPhones during cases.  Please remember that the department and program policies are that residents should focus 100% on the patient and procedure.  Obviously if the staff is also in the OR and has requested that the resident read something that is different.  However, when your staff is absent you need to focus 100% on the patient and case! 

You may ask what about the staff?  There are many examples in the city of anesthesiologists doing things such as talking on the phone, wandering outside the OR, reading, working on their computers, reading the newspaper etc.    Three points here.  (1) You are not a staff who has spent years honing the ability to multitask and can respond to the surgeon’s requests even if concentrating on other things this related to the 10000 thing (2) All research done in multitasking demonstrates decreased effectiveness on all tasks.  Sure total productivity increases, but your ability to focus on the patient is decreased.  (3) Numerous adverse events have occurred in this city when the anesthesiologist was tied up away from the anesthesia work area.  Some of these have resulted in patients with permanent brain injury and/or death.  The CMPA considers it indefensible when the anesthesiologist is away from his/her work area. I can’t imagine how the hospital lawyers [who don’t work for you, ask me if you want to know more].   Lawsuits as a resident are bad.  Jail time is worse and can result in inability to obtain full licensure (yes, I have a case report of an anesthesiologist going to jail for being on the phone – 1995, Appeal File 6579, appealing ruling on file number QBCNJ148/93 J.C. Regina )

Note, I am not aware of any such incidents in our city.  The case where the anaesthesiologist went to jail involved him leaving the room to make a phone call, something that is a little worse (or just as bad depending on your outlook) than talking on the phone, texting or reading while in the room.)  Our PD doesn't define the work area.  Is the entire room the work area or is it just the triangle defined by the OR table, the machine and anaesthetic cart.

So, no matter what you see others do, no reading of any kind, even medical literature when you are looking after a patient on your own.  No iPad use, no texting or personal phone calls.  Place your cell phone on vibrate if you receive personal texts, emails or phone calls during the day and if there is an immediate personal concern ask for your staff to return.  You may answer your pager by cell phone if you in the anesthesia work area.   Please ask the nurse to answer your page.  If they give you sour looks just tell that that you have to focus on the patient and procedure.  As always, if you have issues with nursing or other ancillary staff, please inform me or the site chief of the hospital you are at.

Any questions?  I am happy to discuss this further.

Now obviously our program director must have gotten a real blast from some surgeons.  In my experience the only things surgeons really expect from anaesthesiologists or even have an interest in what we do are;

1. Get the patient asleep and awake as soon a possible.
2. Adjust the table and the lights.
3. Select music that they like at a volume that they like.
4. Know their place.
5. Realize that everything bad that happens to the patient is their fault.

I suspect most of the surgeon's angst is related to 1 and 2.  Anaesthesia residents are, as somebody else observed, expected to be able to work as fast and competently as a consultant within the first month of their residency as opposed to surgery residents who have five years (and the first two plus years of their consultant career) to get up to speed.  Unfortunately  they can't complain (actually they can and do)  about the extra 5 minutes the anaesthesia resident took putting in the art line when it takes their residents 20 minutes to close a 6 inch incision; ergo everything that went wrong today is because the resident was texting.   

Staff anaesthesiologists on the other hand at some point in their careers, not sure just when, develop an ability to  read, work on their lap-tops, book vacations,  and do complex negotiations over the phone while still monitoring their patients.  The fact is, there are a lot of things that are part of our job that distract us from vigilance.  These include charting, taking phone calls from recovery or the ward, getting ready for the next case, adjusting the table and the lights and teaching students.  Sometimes surgeons like to engage us in their conversation.  I've never heard a surgeon complain, "he laughed at my jokes."  When we are staring at the ceiling or out the window  because we are so bored, we probably aren't as vigilant.

We didn't have laptops, I phones or texting when I was a resident.  I did read a lot in the OR during long cases.  I usually carried at least one textbook, as well as journals, and some photocopied articles which I read during cases.  One day the staffman was reading Umberto Eco's "The Name of the Rose".  He went out for a break, telling me as he left,  "this is a really good book, you should read it.".  Which I did starting with the book he left in the room and I later bought it and read the whole book and my life is more richer for discovering Umberto Eco, than anything I learned during that craniotomy.  And I don't think the patient or the surgeon suffered.

Closing the book on my favourite bookstore

Appropriately for the times, I learned last week on Facebook that my favourite book store Greenwoods (I would post a link to the site but it will soon also be coming down so what's the point) is closing at the end of this week. According the owner, this is due to the sudden death of her co-owner brother but in some ways is due to the economics of the independent book store.

20 years ago when I moved here, I quickly discovered this bookstore.  At that time it anchored "The Avenue".  It was situated in a early 20th century brick building occupying the main floor and the basement.  It had a huge selection of books.  I like history and I usually headed straight down to the basement where the history section rarely leaving without buying something.  In the 1990s, it was usually packed on the Saturdays or Sundays where we usually visited.  It was at one point voted the best bookstore in Canada.

Time was not kind to Greenwoods.  In the late 1990s multiple Chapters outlets opened in the city including one down the street from them.  In 2001, their lease expired and they moved two blocks off the avenue into a smaller store in a strip mall.  Their old site was unable to find a tenant for at least two years after sitting empty like a missing tooth on The Avenue.  (This demonstrates the stupidity of the commercial real estate industry which would rather allow a building to sit empty than charge tenants a rent they can afford.)  In it's new location we visited much less frequently but still bought most of our books there.  Sometimes when I saw book I wanted based on a book review, I would order it from them.  A few times I even found a book in Chapters that I liked and got them to order it for me.

About a year ago, Greenwoods moved back to The Avenue into an old building albeit one smaller than their original building.  It seemed as if the universe had been restored.  Sadly the last time we were in, we noticed that there were hardly any books on the shelves.  My wife asked why and an employee said that one of the owners had died and everything was in limbo for a while.  And this week the other shoe dropped.

There are of course a number of reasons why the independent book stores are now going out of business.  These include the big box bookstores like Chapters (now Chapters-Indigo having merged with another big box bookstore).  I have never liked Chapters; I feel that they regard books as a commodity rather than as something worthy of reverence.  On-line sellers like Amazon have played a role and I am guilty of ordering books from Amazon or Chapters-Indigo on-line, something I justify because I usually use gift cards I get for completing on-line marketing surveys.  I even buy books from Costco.  E-books have been blamed and there may be some truth to this.  E-books of course can't safely be taken to the beach or read in the bath (something I have never done), plus of course a book doesn't need batteries or adapters when travelling, plus you can sit or step on a book without damaging it much.  It has been suggested on the other hand that things like cheap books from Big Box stores, on-line and e books may actually make books more accessible.  I certainly get the impression that people read less, there are 100 TV channels, movies for rent, video games and the internet  (where I am wasting time right now when I could be reading a book).

I have developed a relationship with books that may border on pathological.  I grew up in the 1960s in a 3 fuzzy black and white channel universe, and where it seemed to rain a lot which meant I remembered reading a lot.  My mother read to us every afternoon before I went to school but on completing Grade I, she told me that I now knew how to read and she would not longer read to me any more.  I embraced books enthusiastically.  A visit to the Public Library was a weekly event in our family.  I read through Enid Blyton and the Hardy Boys plus heavier fare.  My teachers always allowed us to read from the class library when we finished our classwork, this lead me to complete my work quickly so that I could have 10-15 minutes reading a book from the back of the classroom.  A good book has gotten me through many rainy days, waits and long journeys.

Our house was filled with books.  At that time if you joined the Book of the Month club, you got 4-5 free books if you agreed to buy a certain number.  My father had this scam figured out. If you bought the minimum number of books then quit, the average price per book would be quite low.  He would then rejoin either under his own name or under one of our names.  We acquired a considerable home library in that fashion, supplemented by paperbacks my parents bought a church rummage sales.  My father has, of course, never thrown away a book, although I notice every time I visit he is now trying to pawn 2-3 off on me.

I first learned the charm of book stores as a teenager visiting Munro's then located across the street from the Public Library.  I spent many hours browsing and not buying much there.  Munro's now sits in a magnificent restored bank building in the heart of the tourist district and I can never visit Victoria without visiting (and usually buying a book).  There is just the charm of seeing a book that might interest me, picking it up, flipping through the pages, looking at the illustrations, putting it down and moving on to the next book.  Something I can spend hours on.  Every city it seemed had it's own favourite book store like  Duthies in Vancouver (now gone for many years), and Greenwoods in Edmonton, newly deceased.  A visit to a book store is often one of the first things I do on visiting a new city.  Sometimes a book is a souvenir of where I have been like the History of Poland, I bought in the English language book store in Warsaw (and still haven't got around to reading yet).

Used book stores, I have never really gotten an appreciation for.  To me they appear sad places, almost orphanages of unwanted books, the hard covers bravely trying to look new in their wrinkled dust jackets.  I sometimes bring books I no longer want to our local used book store.  When going on a long journey I often buy used paper backs which I shed as I finish them.

So many things I had come to accept as being there have gone, favourite restaurants, stores and coffee shops.  I adapt, I go elsewhere develop new favourites, new interests.   We are fortunate to have another very good independent book store whose life may be prolonged by the death of its independent competitor. I will go there and after a few visits won't feel dirty or unfaithful.  

Whose patient is it anyway?

Spent another hour at our site's Medical Advisory Committee meeting on Friday which is essentially a circle jerk in which the doctors and the administration pretend that the doctors have anything to do with running the hospital.  At least breakfast was provided and wasn't too bad, although not quite up to the standards of some of our administrators.

Towards the end of the meeting an item came up where it seems that residents will only now be allowed to work 16 hours consecutively.  There was of course the usual concern about how we were going to run our hospital without all that cheep labour.  Then inevitably somebody  brought up the issue of if residents worked fewer hours, should not the length of their training be extended.

I had to respond to this.

"For the past 30 years," I said, "anaesthetic residents have not worked after being on call.  This means that the anaesthetic residency is about one year shorter than comparable residencies.  Yet if your life depended on being cared by:  a newly qualified surgeon, a newly qualified internist or a newly qualified anaesthesiologist, which specialty would you pick?"*

The answer is of course pretty obvious as most of the room acknowledged.  It is not quantity of training, it is quality of training.

What I should have asked, and might have asked if I hadn't had to leave to start working.

"How come hospitals with similar case loads to ours who have never had residents are able to deliver good patient care?"

And....

"Don't you guys get paid to look after your patients?"

We of course don't get residents on a regular basis in anaesthesiology at our hospital.

* Obviously for this hypothetical question, different scenarios for each specialty are possible.

How I spent my summer vacation

My wife who reads my blog pointed out that I haven't posted on my blog since July.

After going to Rwanda last year, I had planned a quiet summer with only a few weeks of vacation.  This was not to be and I had quite an eventful (in a good way) summer.

I went cycling in Quebec

My wife and I have now gone on a few cycling holidays with Freewheeling adventures an outfit based in Nova Scotia with tours all over the world.  I have been to the Czech republic and Mexico with them, my wife has done a few others.  We had a $500 gift certificate we had to use so decided to go to Quebec.  Originally my plan was to link this to the CAS meeting but we couldn't find a trip which coordinated with the CAS meeting, so no tax write-off.  We were able to use frequent flyer points for the flight and hey who says the Queen has to subsidize all your vacations.   On top of this my wife's sister and her husband from the US were able to come along.

We flew into  Montreal and stayed at our favourite hotel in Montreal, the Hotel Nelligan in Old Montreal, arriving in the evening and eating on their fabulous roof-top restaurant.  Sunday we had a little time to look around Old Montreal before getting a taxi to the train station and off to Quebec city by Via Rail.  Via Rail while nothing like the service in Europe I was to experience later in the summer is still pretty good.  We arrived in Quebec City had a short taxi ride to our hotel an pleasant "Auberge" in an old restored building, walked around Quebec City and had dinner.  My sister in law and her husband arrived around 2300, we took them out to the Old Town for a beer.  

I got to play tour guide the next day, showing them around Quebec City and boring them with my knowledge of Canadian history.  I only had to make up a few facts I wasn't sure of.  Around 1600 the van from Freewheeling came to pick us up and we got to meet our fellow cyclists, another American from Baltimore and an older (than us) couple from Waterloo, Ontario.

I could really bore you with what we did in detail the next five days; it was a fantastic trip, we stayed in some great hotels and ate like kings.  The weather was crappy but but instead of making everybody miserable, it brought the group together.  The trip was labelled green or easy; the longest we rode was 60 km and there were a few hills.  

On the last day we got dropped off at the train which we took back to Montreal, and our favourite hotel.  We rolled into Montreal and crossed the St. Lawrence River as the sun was going down and got to our hotel in time to hear the Canada day fireworks.  We flew back home the next evening.

We got the house re-renovated (still in progress)

I am beginning to learn that renovation is a two step process.  First you do the renovation and then a couple of years later, you redo of the stuff that the contractor didn't do (or wouldn't do) right the first time or that you didn't think you could afford when you did the renovation.  We renovated our house in 2008 at the crest of the biggest housing boom in history (followed by the biggest crash in history).  This of course meant that we considered ourselves lucky to even have a contractor (2 in our case) which meant paying a lot of money and generally sucking up to them.  About two years ago we noticed that the carpet upstairs was loosened and wrinkling.  This meant that we would have to move all our furniture out so someone could come and fix this.  Anyway I had this brilliant idea, why don't we get rid of the carpet and put in hardwood floors.  Then I had another brilliant idea, why not put in built in bookcases in my office.  This required dealing with a hardwood guy and a cabinet guy.  I had this vision of them actually working together so that on a given week of their choosing, we could get all the work done in close sequence preferably while we stayed down at the dacha.  Then again I still believe in the Easter Bunny.  Eventually we got a date for the cabinet installation with the hardwood installation booked safely in the future in case there were snags (which there weren't).

Now even in our oil-rich province, we are in a recession and it is safe to safe that there are not as many hardwood floors and built in cabinets being installed as there were in 2008.  Like maybe you have to be nice to the customer and act like you appreciate their business?.   For example I had to sign and initial a two page long contract by the hardwood company which mostly outlined what they would not do; we had to put down rather large deposits well in advance of the work being done and finally my wife had to wait around all day waiting for the hardwood to be delivered because they would only give us an 8 hour window and we were last on the list (apparently they have never heard of cell phones).  We do have the cabinets in and they look marvelous tomorrow the hardwood installers may just show up.  We had to hire movers to move our large heavy furniture into our garage and my wife and I are sleeping in the basement and coping quite well I must say.

I screwed up my shoulder

I had a week of vacation booked at the end of July/ beginning of August which I do to ensure that I will not be on call on my birthday which usually falls on the 3 day weekend.  I had  planned to spend the first weekend moving stuff from upstairs where the renovation was to take place but my parasite son who lives at my dacha needed his bike for a race so I had to leave Saturday with the bike.  My wife wanted to stay in town, presumably happy to have some time to herself.  I arrived in the early afternoon, my son took his bike then his brother and he took off for Golden for their race the next day.  They may actually have thanked me.

I tidied up the dacha, half-heartedly tried to deal with the weeds, took a nap, BBQed a steak watched some Olympics and went to bed, vowing to be more active the next day.

I arose to the beginnings of a sunny hot day and immediately I knew what I had to do.  I had to ride my mountain bike to Banff on an XC trail, eat lunch in Banff and ride home on the new paved trail along the highway.  There are two XC trails between Canmore and Banff.  The easier one, the Goat Creek Trail starts high above Canmore and while it is possible to ride from Canmore up the dusty dirt road, one usually gets dropped off.  As my children were away, this was not an option.  The more difficult one the Banff/Rundle/Riverside trail is easily accessable from Canmore but I remember it as a tree-root infested ordeal when I rode it many years ago.  Nonetheless, that was the route I decided to take.  I climbed up to the Canmore Nordic Centre, stopping for a coffee at the cafe there.  I made sure I texted my boys and my wife to tell her where I was going so that they would know where to look for the body.  You might think riding alone was pretty stupid and maybe it was but I figured it is a pretty busy trail, there is cell phone reception all the way and I was a much better rider than a few years ago.

I climbed up from the Nordic Centre along the wide trails arriving at the National Park Boundary in about 30 minutes.  Inside the park, the trail narrowed and headed downhill.  There were lots of tree-roots and rocks.  Occasionally I got off my bike to walk around some of the worse obstacles but gradually I gained more and more confidence.  From time to time my bike balked at tree root and stopped dead but I was always going slow so stayed on my bike.  As I said, I was gaining more confidence and probably going faster.  All of a sudden my bike hit a tree root, and stopped abruptly.  I didn't and sailed over the handlebars, landing on my outstretched right arm.  I felt my shoulder pop out and then pop in.  This was accompanied by significant pain which actually made me feel a little nauseous.  I sat down on a log, drank some water and paced around for a few minutes.  I was pretty sure my shoulder was back in, it was sore but I could move it thru a limited range of motion.  I decided to keep riding vowing to be more careful.  I didn't really have much choice, I was half way between trailheads and it was either ride or walk.

About 5 minutes later, I brushed a tree and fell over sideways.  As I pushed myself up with my right arm, I felt a searing pain and I could not move my shoulder at all.  SHZT.  It didn't look like it was going back in.  The circulation looked okay and there was no numbness or paresthesia.  Okay, I thought I am going to walk out to the trailhead, call a taxi and go the emergency in Banff.  Off I went pushing my bike with my left arm.  After about 5 minutes my shoulder decided to pop back in.  I walked and rode to the trailhead and then from there rode into Banff.  My shoulder was feeling pretty good all considered and I didn't relish spending time in the ER so I had and ice cream cone at COWS and rode back uneventfully along the paved trail 20 km back to Canmore where naproxen and beer awaited (I do not by the way advocate this analgesic combination although I remember it worked pretty well).

I took things pretty easy the next few days.  I flew to visit my parents for a couple of days, attended the Canmore Folk Festival and was back at work the next week.  It must of been my grimacing that got one of the Pain Clinic nurses to get an orthopod to see me and 10 days after the accident, I was in a sling.  Of course because I am right handed, I had to take it off to work.  It was and still is hard to get used to using my left arm.  I can only hope this is helping to develop my right brain.

I wore the sling on and off for the next week.  At the Edmonton Folk Festival I started noticing all the other people in slings, and felt a subtle solidarity with them.  (I was a little disappointed that by wearing a sling I didn't get to go to the head of any lines or sit in a special disabled viewing area)  Travelling around Europe hauling a saxophone and way too much clothing hasn't really helped.  I got back home and saw my orthopod in the coffee room.  We better get an MRI he said.  He even made me fill out the req.  I am still waiting for the MRI (this is Canada after all).

Did I learn anything?  I have learned that I will never ride single track again.  I have learned that at 55 you don't bounce back from injuries.  I no longer regard all the people I saw in the pain clinic with shoulder pain as wimps and complainers.

I went to Band Camp

Playing the saxophone was a dream of mine realized as an adult.  Fortunately or unfortunately the saxophone is irrevocably linked to jazz, a genre I have very little background or for that matter taste for.  This has not kept me from playing in two jazz bands and attending two jazz workshops.  Anyway a few years ago I figured that the only way to see if jazz and I were compatable was to get some intense experience.  Hence I googled "adult jazz band camps".   I came up with the Jazz Summer School an English outfit which runs a summer camp in a French chateau (along with a winter camp in Cuba).  I made the usual inquires and got put on their mailing list.

Time passed, I always had something else on.  I left my jazz band partly because of time and partly because I was frustrated at how badly I thought I was playing.

This summer I was going to attend the IASP meeting in Milan at the end of August.  Just after I registered, the mailout for Band Camp came along.  Hmmm, I thought this is just before my meeting.  I checked and there was a vacancy for a saxophonist, I was able to change my flights and I was heading off to band camp.  As the date approached I had the usual misgivings.... I suck at jazz, I suck at the saxophone, I won't know anybody there etc.  Injuring my shoulder and my impending renovation which my wife was going to have to deal with, played a part.

The camp is held at Chomerac.  Chomerac does not appear in any guidebooks nor does Privas the nearest large town.  The town is south and west of Lyon, a one hour taxi ride from the nearest train station at Valence.

I flew to Milan where the conference was to be, stayed a couple of days to get acclimatized and then caught the train for Lyon which left at 0607.  It was a pleasant trip through the Alps and in about 5 hours I was at the Lyon St. Exubery TGV station at the airport.  After a two hour stopover, from there it was a 30 minute ride on the TGV to Valence.  The course organizers had given me the names of two people who would be on the same train and and could share a taxi.  I looked at them on the platform but couldn't see anybody so I walked into the station where somebody seeing my saxophone case introduced themselves and soon 4 of us were heading in a taxi to Chomerac and the chateau.

For some stupid reason I had envisioned a castle but the chateau was a rather large 3 story building although one with turrets and arrow slits (probably ornamental I am thinking).  The course organizer, Clive was there to meet us and we sat at tables in the shade outside while he organized our rooms.  My room which I shared with one of the other campers was quite larger and one of the turrets had been made into a shower.  Gradually other people started to arrive.   Everybody seemed to know everybody, in fact there were only 3 of us who had never been. Some people were starting their second consecutive week.  Despite this, everybody was very friendly.

After getting organized, we had dinner at 1900 with carafes of wine on the table.  Although the "chef" was English, the food was excellent.  At 2100 we had a "play around".  It was a bit of a humbling experience as there were some excellent players with a good knowledge of jazz.  I did get up to play in a few blues jams and acquitted myself reasonably well.

As I said, I have been two weekend jazz workshops in North American.  These tend to be structured busy affairs where your face is sore at the end of the day.  This camp was much less structured with a lot of different teaching techniques.  We would have breakfast at 0800 and would start playing around 0900 either all together or in groups.   At 1300 there was lunch and you were theoretically free until 1630 when you got together with your small group which played the piece you had worked on for the whole group.   Between 1400 and 1630 as mentioned you were theoretically free however most people used that time to work on pieces they planned to play at the evening "cabaret".

After dinner at 1900, we had the evening cabaret where small group of 2-6 people played songs they had worked on in the afternoon.  Beer, and wine were available at cost during this session which went on until midnight.  The instructors would usually also play a set a some point.

All and all a very relaxing place out in the French countryside, overlooked by a large hill or small mountain.  There was a swimming pool to relax by.

On the Friday we played a concert for the villagers.  There must be very little to do in Chomerac because about 30 people showed up.

Overall it was a very positive experience and I may just come back next year.

I got to tour southern France and Northern Italy a bit

I was able to get business class on points which is really the only way to fly 8 hours.  With the help of the little blue pill I got about 3 hours of sleep and arrived reasonable refreshed.  When I leave North America to travel to Europe I usually take Melatonin at the time it is going to get dark where I am heading and I have found this makes a huge difference.

I took the airport shuttle to Milan which only cost 5 Euros and deposited me at the Central Train Station closed to where I thought my hotel would be.  The hotel didn't seem to be within walking distance so I got a taxi and paid 8 Euros for a 2 block ride.  After showering and changing, I took the metro to the Duomo area which is the massive Gothic cathedral and walked around the area.  It was a holiday in Milan and except for tourists the streets were deserted.  I ate supper at an outdoor cafe and took the metro back to my hotel.

The next morning I packed a small daypack with a change of clothes, checked my luggage and took the train to Como where I took a ferry ride to Bellagio and back and stayed overnight in Como returning to Milan the following afternoon to my original hotel.

I left for Valence and band camp the next day.

After band camp which ended on a Saturday, I had not made any arrangements until I was to return to Milan on Sunday, figuring I could spend Saturday looking around the area.  After talking to people, I decided to go the Avignon, so on Saturday I shared a taxi with the first group out.  On arriving in Valence, I found that there was a train to Avignon leaving in 10 minutes so I was able to get on it and was in Avignon by 1100.  I found the hotel I had booked on Expedia, dropped off my luggage and visited the Palais Des Papes and then the Avignon bridge.

I had to be at the Valence Ville train station by 1440, the next day in order to make my train to Milan.  In order to  do this it was necessary to take a bus to Avignon TGV station which is outside of Avignon and catch the TGV to the Valence TGV station and then catch a bus to the Valence Ville train station, where I could then catch the train I had booked a couple of months earlier.  Miraculously this complicated arrangement worked, depositing in at the Valence Ville station with enough to time eat lunch at an outdoor cafe across from the train station.  I then caught my train to Lyon airport and after a two hour stopover was on the train back to Milan arriving around 2200.  I took a taxi to my conference hotel.

The following day I had booked a cycle tour of Milan.  I find that the best way to see a city is on a bike.  You can cover way more ground than on foot and you miss a lot in a car or bus.  I had booked in advance with Bike and the City.  This is a really great tour which I would highly recommend.  The guide was very passionate about the history and architecture of the city.  Her English was pretty good despite adding a vowel to every word.

For the next 4 days I attended the IASP meeting which I found a little disappointing.  The IASP has recently gone to World Congresses every 2 rather than 3 years and 2 years doesn't seem to generate a lot of cutting edge material.  There was also the matter of it coming at the end of a pretty jam-packed trip.  I did have a couple of fantastic meals thanks to the pharmaceutical industry and one night a bunch of us participated in "appertivo".  Appertivo is a Milan tradition where buying a drink entitles you to eat at the buffet for the rest of the evening.

All good things had to come to an end.  I actually managed to last at the meeting until 1800 on Friday, after which I picked up my luggage and taxied out to the airport hotel, I had booked.  This, like many airport hotels was a bit of a disappointment.  The Russian dragon boat team was staying there so I anticipated a noisy time but they were pretty quiet.

I flew out of Milan at 0730.  I had the usual panicky  1 km run thru the Frankfurt airport to catch the flight I thought was boarding 10 minutes after we landed (it was an hour late).  After a 6 hour stopover in Toronto, I was home by 2100.

I managed to book the entire trip without the help of a travel agent.  I found the Rail Europe website incredibly helpful and two days after I booked my trains, the tickets were couriered to my home.  They did sell my two meal vouchers at 20 Euros which the train staff wouldn't honour but otherwise the service was great.  I booked all my non-conference hotels through Expedia.  There are lots of horror stories abounding about Expedia but I use them for most of my travel and have never had any trouble.  The Hotel Mini Tiziano where I stayed during the conference was booked thru the conference website.  In this respect I was lucky as the hotel was a 20 minute walk from the Congress Centre and close to a Metro station, bars and restaurants.  Many people found themselves having to take a 30 minute taxi ride every morning and evening.

No Matter What Fancy Italian Name You Give It, It is Still a Squishy

Coffee plays an important part in my life.  Not just the caffeine (I can give it up any time, I did for six months once).  I enjoy a good coffee shop, I even enjoy a mediocre one.  When driving long distances, I use coffee stops as an excuse to get out stretch my legs and use the bathroom.  True, I could do this at a gas station.

As it happened I was driving to my dacha; a 4 hour drive last Friday.  I had been on call Thursday night and despite a three hour nap Friday morning and a large latte, I was in desperate need of a coffee pulling into Dead Rear, 90 minutes into my drive.  DR has a newly minted Starbucks which I figured could provide me with the needed sustenance.  I was a little put off by the long line up inside but I had parked my car and anyway how long does it really take to serve a coffee.

Unfortunately as I learned during the next 15 minutes, the people in front of me were not ordering coffee (nor had the 10 or so people who had already ordered and were waiting for their drinks).  They were all ordering icy fruity drinks, drinks which take a long time to prepare.  After some time, I was able to talk to the barrista and order my "talle" dark roast.  "Oh that is so simple!" she said.

People, if you want a fruity slushy drink, there is a place you can go.

Several places you can go in fact.  Most gas stations and convenience stores have a squishy machine where you can actually serve yourselves.  You can actually mix flavours like my children used to.  And better still you will not piss me off by making you wait while you someone makes it for you.  I used to enjoy a squishy too, (until I found out how many calories they have) but I would no more buy a squishy in Starbucks, than I would buy coffee from a convenience store or gas station.

Vacation

Once again I am forced to poach one of Great Z's posts

A staffman when I was a resident advised me that he seldom took vacation for similar reasons that the Great Z mentioned.  When you are not working you are not earning money.  The first job I had, as I posted in a comment on the blog, required me to take 7 weeks vacation a year.  This was because of the way we staffed our department, with one person off on vacation all the time, 2 in the summer.  We were an income splitting group practice so you didn't notice that you weren't earning any money.  I left this group after 2 years and now I am in the situation where when I don't work I don't make any income.  This bothered me a lot when I first started out; I would be on vacation racking up credit card charges and thinking about the fact that I was racking up credit card charges and not racking up billable hours.  This was until one day, skiing mid-week on a beautiful day, it occurred to me how much I enjoyed not working and how much less I enjoyed working.  Now I typically take 7+ weeks of vacation; I just returned from one week and am already looking forward to my next one.  Occasionally we find ourselves overstaffed on a certain week and I almost always volunteer to take it off (I frequently have to fight for it, apparently a lot of people where I now work had the same revelation as I did).   I am lucky, I have a dacha I can head off to; quite often I just enjoy a staycation.  At the end of year, it never seems to make any difference in what I made.

As I told a surgeon years ago when he asked how I could afford to take so many weeks off, "How can I afford not to".

Ray Bradbury

As I once mentioned, I used to read science fiction but that was almost exclusively Arthur C. Clarke and the recently departed Ray Bradbury whose every work I devoured as a teenager either in books taken out from the library or paperbacks purchased with my allowance.  I grew up, stopped reading science fiction and hadn't read anything from him for years.

Calling Ray Bradbury a science fiction writer too narrowly compartmentalizes him.  Many of his short stories were not even science fiction, others were fantasy, a lot of them defied classification. It is unfortunately his connection with science fiction which has prevented him from being considered among the top American writers of his time.

Many people were exposed to Bradbury through being forced to read the Martian Chronicles in junior high; a good book if not necessarily my favourite.  It was his short stories which were the most masterful (the Martian Chronicles is a collection of somewhat related short stories).  His story, "A Sound of Thunder." about the perils of time travel stands out; this has been made into at least one bad movie which I saw riding home on the bus about a year ago.  Of course Fahrenheit 451 is a work that should be required reading  and a vision of society that 50 years later is becoming a bit too close for comfort.

About a year ago walking through Chapters during an exceeding quiet day on call, I saw a copy of his collection of essays, "Too Soon from the Cave, Too Far From the Stars" which I brought as my on-call book.  I really hadn't bought a book by him since the 1970s.  Sadly I rarely pick it up at work.  I did learn a lot about him especially his career as a movie writer which I never knew about.  I must get around to finishing it.

It is sad that Bradbury is no longer with us.  I hope the large body of work he left will remain and be read.

Do We Owe Residents a Job?

While attending the Resident's Research Day, a resident approached me and asked if he could meet with me.  "I am happy to meet with you, " I replied, "But if you are looking for job, I do not anticipate hiring anybody in the near future."  He still wanted to meet with me so we did a week later and I told him the same thing.  He already had a 0.5 position at a suburban hospital and was looking for something more.  I told him we could offer him locums on a weekly basis and that some people looked for people to do call on weekends.  He left a little disappointed and felt I little guilty that I couldn't help him out more.  Should I?

I went into my residency fairly confident that I would get a good job when I finished.  Things had changed by the time I finished and although I send my resume to just about every place I could conceivably work in, I got few nibbles.  I did end up getting quite a good job in a nice community for which I am grateful (and sometimes wish I never left).  When I did my fellowship orals, 4 other people did theirs at the same time as me.  I was the only one of the group of 5 who had a job after my residency.  Things got worse during the 1990s to the point that we actually tried to talk medical students out of anaesthesia as a specialty because there would be no jobs for them.  Suddenly things shifted, people died, people retired, people cut down, operating rooms opened and in the late 90s the residents who had gone into anaesthesia despite our warnings not to, had their pick of good jobs.  This persisted into this century until fairly recently.  Because of the perceived shortage, there was a doubling of residency positions.

The impression I get is that while in the larger centres, jobs are hard to come by; many of the larger "rural" hospitals are still hard to staff.  Every time somebody asks me for a job, I always ask them if they have considered any of the other hospitals outside of our city and our evil sister city.  They usually have some excuse.  These hospitals it is true, tend to smaller which means more call and the communities lack the amenities of the city.  These are hospitals however that were once places that specialists considered working in.  I remember in the early 1990s when a larger rural hospital posted a job, resulting in a feeding frenzy among the final year residents as to who would get it.  Rural hospitals do not really seem to looking for our residents either.  They seem to have gotten into the pattern of recruiting from overseas (mostly South Africa).  Our University Department recently had to assess the training of a SA anaesthesiologist going to work at a rural hospital 5 hours away.  Our chairman asked why this hospital had not tried to recruit any of the finishing residents, some of whom didn't have full-time jobs yet (assuming any of them would consider working there)?

The main problem is that operating room numbers have not kept pace with the population growth.  Our metropolitan area had 800,000 people when I moved here in 1992 and now has 1 million people.  Logically this should mean 25% more operating rooms.  There are in fact more or less the same number as in 1992.  Meanwhile we seem to do more "urgent" cases after hours.  We recently built a modest size hospital in suburbs; it has 4 operating rooms.  These will be staffed by GP-anaesthesiologists; there has as far as I know been no effort to have it staffed by specialists.  Our evil sister city, recently to great fanfare opened a brand-new hospital.  This new hospital will result in no net increase in operating rooms; rooms at other hospitals are being closed in order to allow it to use its brand-new ORs.

The problem of physician over-supply is not limited to anaesthesia.  Even in the 1990s certain specialties like neurosurgery, ENT and cardiac surgery turned out residents, knowing there would not be jobs for them in Canada.  Most of them went to the US which was able to absorb them quite well until recently.  A rational person would ask why we are training specialists for non-existent jobs or for jobs in other countries and there is of course only one rational answer.  For service of course.  We can't expect a cardiac surgeon to actually look after his patients can we?  Radiation oncology is now massively over-subscribed, a graduating resident wrote a lament recently wondering why this could not have been anticipated 5 years ago when he was applying for a residency.

A city our size could easily absorb to a point all the graduating residents.  We might all have to take a couple of extra weeks of holidays a year.  In time we might actually enjoy it and wonder why we didn't think of this earlier.

The question is:  "Do we owe our residents a job?"

University Tuition

Years ago, I used to give a lecture every year to the medical school on pain.  I felt evangelical about teaching medical students about pain then which made me overlook some of the downsides of which there were many.  The major downside was that I wasn't paid for my time,  and because I just can't interrupt the OR list for an hour to run over to the next building to give my lecture, I had to take the whole day off.  Further complicating matter was the medical school's habit of occasionally rescheduling the lecture on short notice.  I also had to attend curriculum meetings that lasted for hours and in a minute of stupidity agreed to sit in on a half day medical student case presentations.  Eventually I learned to work around the call schedule to minimize my income loss and having got a good Power Point presentation, I only had to make minor adjustments every year.  I think I actually enjoyed it a bit; I used to be one of those people who sat in the back row of the lecture theatre not paying much attention and now I was a real Medical School Professor.  I did this for 10 years.  For the last 2 or 3, I started hinting that many they should find someone else but they kept on asking me.

The last year I gave my lecture, just before I started, the class president asked if he could talk to the class for a minute.  The University had just raised tuition again and he and a group of students were planning to meet with the Dean to see if they could do anything about this.

I then started my lecture.

I prefaced by stating words to the effect that, I supported the students 100%, that tuition they were paying was ridiculous;  further that I was not getting 1 cent from the University to give the lecture, and that most of the doctors who did medical school teaching received no remuneration.  So I concluded, where was the money going?  Then I gave my lecture.

Nobody ever said anything, but my career as a Medical School Lecturer was over; I was never asked back.
Strangely enough about 3 years ago the University actually started paying me for teaching.  I don't teach much but I sleep soundly at night accepting the money.

Students in Quebec have recently gone "on strike" over what the mainstream press describes as modest tuition increases.  This has resulted in some violence which is of course widely publicized.  It has also resulted in some fairly draconian legislation by the provincial legislature which has brought out more people onto the street. Tuition even after the fee increases will still be the lowest in Canada.   One way to look at this is that tuition in the rest of Canada is too high not that tuition in Quebec is too low.  Regardless tuition still only covers a portion  of the cost of educating a student so you could look at it as tuition being a tax imposed on students (and their parents).  In effect it could be argued that increasing tuition prevents low income students from accessing a program which is still heavily subsidized.  Also Quebec is in the middle of another corruption scandal and folks are looking at how much government money ended up in various people's pockets and asking just why are the students being asked to pony up more money.

The increases are it is true just a couple of hundred dollars a year.  Put this in perspective.  Periodically (actually quite a bit over the past 20 years), the government will announce a tax cut.  Somebody will point out that the average person will only reduce his tax bill by a few hundred dollars as opposed to somebody in my income range who might save thousands of dollars.  Instantly that person will be attacked as an elitist who doesn't understand the value of a couple of hundred dollars to the working man.  I don't even mind having a couple of hundred dollars thrown my way.  So a couple of hundred dollars is a big deal.

Here is how old I am.  In my first two years of University, my yearly tuition was $428.  That is $1854 in 2012 dollars. In my third year, a 25% increase was imposed, raising the rate to $535.  And there were protests although nothing like is happening in Quebec.  It was after all the 70s, it was still possible to get a good summer job, and student loans and grants were generous. Medical school tuition was much higher but it only cracked four figures in my last year.  Consequently I graduated owing only $10,000 most it incurred in my last year and I got bored with dealing with the bank and paid it off during my first year in practice.

Tuition for Sciences at my old Alma Mater is now $4700, 2.5 times inflation.  Medicine is $16,000, over 6 X the inflation adjusted $1000  I paid in 1981. Are students getting an education that is 2.5 X better than in the 1970s let alone 6 X better?  I doubt it.

I now have one son graduated from University and one son still in school.  I was able to take advantage of the income attribution rules that those of us in the 1% have and set up mutual funds for them soon after their birth, which had a far whack of cash in (not as much as my investment adviser predicted) when they were 18.  When the government allowed RESPs with the $400 yearly grant, we put money in those.  On top of that our children won the odd scholarship and between that they have been able to attend University and graduate debt-free, not really have to work during summers or deal with the whole student loan BS.

Student loans are of course a whole form of welfare for the banks.  What a sweet deal that is.  The government pays the interest while the student is in school and if the student defaults, the government picks up the tab.  Where can I get a deal like that?

When I was "a student leader" during my time in University, I was invited to a dinner where the University president Dr. Douglas Kenny gave a talk.  Dr. Kenny had an interesting proposition that I have heard repeated a few times since then.  He proposed making University "free" or rather the students would automatically get their tuition and reasonable living expense covered.  When they graduated, or ceased going to school, they would start paying this back as a surtax on their income.  For example if we said the surtax was 5% to pick a number, and they owed $1000 in income tax, they would pay another $50 as a surtax.  This means that the investment banker or ophthalmologist would pay back their "loan" quite quickly whereas the philosophy major working at Starbucks would pay it back quite slowly.  Because it would be administered through the tax system, most of the student loan bureaucracy would be eliminated.  Variations on this have been proposed including free education in return for national service, something we already offer our military.

These proposals however make so much sense that there is very little chance that they will ever be accepted. 

Just a minor case

This is really sad. 

No I mean it, nobody should have to have gone through what this poor man's wife went thru; he shouldn't be a widower, his children should have their mother still.  And good for him for channeling his grief into trying to help others by educating and improving practices.

It does show something.

Surgery (and anaesthesia) are something to be respected.  From time to time I run into a patient who is scared shztless about his upcoming surgery.  These are for the most part ASA 1 or 2 patients having "minor" surgery.  I always tell them that it is quite normal to feel that way; surgery is something that should be respected.  Too many patients approach surgery with a cavalier indifference.  In the Pain Clinic I see a lot of people whose lives have been ruined as the result of surgery.  Without exception they all want another operation. We all see the patients in the Pre-assessment clinic or in the holding area who just can't seem to understand why we are asking them all these questions.  After all it is just a minor case.

We also get this response from surgeons when we suggest that the patient's diabetes needs to fixed or that the chest pain they have been having needs to be investigated, "Oh its just a quick case."

It is interesting watching the video, seeing what went down.   It appears as if she was having sinus surgery; a shared airway we all learned to respect very early in our residency.  I would have to question using a laryngeal mask although I realize many respected anaesthesiologists advocate this.  I like to have the airway secured while the ENT surgeon is messing around (while I know that they can and do accidentally extubate the patient).  Not that I don't like LMAs.  I use them for over half my cases but almost never in a head and neck case.  I suspect what happened in this case was that they couldn't intubate the patient so decided to go with a LMA, converting a Can't Intubate Can Ventilate airway to the much feared Can't Intubate Can't Ventilate airway.  I have never understood the logic of pushing a large LMA blindly down an airway you have already traumatized although I have done this myself and "got away with it". 

I have fortunately never been involved in a can't intubate, can't ventilate situation.  There has been the odd time when I thought I might be headed down that road but something intervened.  It is surprising that with an ENT surgeon in the room and the nurses even bringing in a trach set, nobody thought of doing a trach.  Of course I remember watching an ENT surgeon at the C of E doing a trach and thinking, "I hope my life never depends on you doing a trach on me!"

It is interesting that her widower works in the aviation industry, one industry that takes safety seriously (as I like to reassure myself before every take-off and landing.)  When it suits their agenda our administration is always exhorting us to imitate the aviation industry in our "quality" practices.  This is why we now have our safe surgery checklist.  There is a lot to learn from the aviation industry except that there is one huge difference.  If a pilot screws up badly, he dies along with his passengers. Therefore everybody, in the plane at least, has a real big incentive to make sure everything goes smoothly.  That doesn't include the ground crew or the air traffic controllers of course and we hear of the the odd suicidal pilot.  In contrast if you screw up in the OR, at the worst you may get a rough ride at M+M rounds, you might face an unpleasant interview with your chief, you might get a College complaint or you might get sued.  The bottom line is that in most cases you will be back to work.

But we have to remember that patients die during and after routine surgery from other causes.  They can succumb to an infection with sepsis, they can have a myocardial infarction or a pulmonary embolism.  These are for the most part unrelated to anaesthesia.  The difference is that there is usually very little hand-wringing when a patient dies from these causes although I would bet they are far more common than any direct anaesthetic related mortality.  It is however not possible to have most surgeries without an anaesthetic so why do we treat any anaesthetic death related or not related to competency differently.  Not that we shouldn't feel remorse or empathy when a patient has a bad outcome.  (Unfortunately the first thing most of us think about when this happens is "well at least it wasn't my fault".)

When people ask me what the risk of dying during anaesthesia is; I have a pat answer.  I tell them it is the same as being killed in a car accident on the way home.  One very anxious patient when I told her that replied, "Oh that is really high".  To which I replied, "You must be a really bad driver."