Commercials on "free" Wifi WTF?

Between drive-throughs and people ordering fancy slushies while I wait in line, coffee shops have really pissed me off.  I should really start making my own coffee.

I went to Starbucks for a coffee and pastry yesterday.  Unlike most coffee shops which have "free" newspapers lying around, Starbucks doesn't, which left me to check the internet on my I phone while I drank my Grande dark roast.  I am not one of the those people I see a lot lately at Starbucks, usually sitting by themselves at a four person table with their laptop, obviously there for the long haul, but I do like to use their free internet while drinking my overpriced coffee and second rate pastry.

Not so free any more.  I found that their free internet is now sponsored by Travel Alberta and before I could access my internet I had to watch a 30 second commercial on my phone.

Aside from having to watch the commercial (which I have already seen on TV), why would my government spent $$$ preparing this video and then paying Starbucks $$$ to force me to watch it, all with the goal of getting me to visit Alberta, when I already live here?

Unfortunately I suspect we are going to be getting a lot more commercials with our free internet.  

If You Were Wondering Where I was on November 22, 1963.

It is really hard to believe it was 50 years ago.

I came home from school for lunch.  Our school was only a couple of blocks away from our house and so I walked home by myself at lunch and after school.  My mother who, like almost every mother on the block, didn't work always made lunch for my brothers and me.  I was in Grade I.  When I got home my mother told me that President Kennedy had been killed.  Although I was six and Canadian I sort of knew who he was.  We ate lunch and I went back to school.

Our teacher told us again that President Kennedy had been killed.  At about 2 o clock the principal came on the PA and told us that under the circumstances we should all go home early.  I don't remember being that happy about getting out early.

Later I remember watching the funeral.

Since then there have been many what ifs and conspiracy theories.

If you want a good what if, National Lampoon devoted a whole issue to it in 1977.

I suspect that JFK hadn't been assassinated, he probably would have won a second term during which time any honeymoon he may have had with the American voter might have ended and unfortunately we would had probably still ended up with Nixon, Reagan and the Bushes in the future.

Likewise I have read or heard all the conspiracy theories.   It seems I can't turn on History or Discovery channel lately without seeing another one.  Maybe I am fatigued by everything but I have come to believe that you had a serious nutcase Oswald, who just got off a lucky shot and maybe Jack Ruby was just really pissed off that the President died.  Maybe that is what they want me to believe.

Shouldn't have happened.  

K.I.S.S.

KISS as we all know stands for Keep It Simple Stupid (or Keep It Simple Sweetheart).  I first heard this in medical school from a surgeon who started his lecture by writing this on the blackboard.

Surgery is easy.

I am not saying anybody can do it but if you get into medical school, graduate, do a surgery residency and do enough of the basic procedures you should be able to function.  Most procedures have already been done before by somebody else, anatomy is relatively constant and tools have been designed to make things easier.  Not only that, you work with scrub nurses who can anticipate what you are going to do and anaesthesiologists who look after your patient for you and provide muscle relaxation.  Surgery should be really boring which is why historically surgeons have tried to make it more difficult by working when they are tired and doing unnecessary surgeries.

And then the laparoscope was born.

Laparoscopy was originally used by gynaecologists mostly for tubal ligations but also for diagnostic laparoscopies.  The anatomy of the uterus, tubes and ovaries is pretty simple and even in the old days, looking thru an eyepiece they could safely and effectively do their work.

It took general surgeons a little bit longer to get on the laparoscopic  bandwagon with the laparoscopic cholecystectomy.  Those of us who worked in the era of the introduction of the laparoscopic cholecystectomy remember this as a dark time in the anaesthesiology world.  Surgeons would go away for a weekend course where they operated on a pig or cadaver and would return raring to get onto the future of surgery.  They would show up in the OR usually with a rep from the company who sold the expensive equipment and a three hour ordeal of fiddling around would begin innevitably followed by the open cholecystectomy.  This would be repeated multiple times over the next year or so and usually multiple general surgeons were learning to do these so you can imagine the chaos in the OR, especially when they realized that it was affecting their elective time and started doing them afterhours.  There were also the common duct injuries, about 20% in the early stages requiring a long tedious repair by another surgeon.

Today laparoscopic cholie is the standard, most surgeons can run one off in about an hour as a day case and nobody would think of subjecting a patient to a subcostal incision.  There are a few problems with the laparoscopic cholie however.  Firstly the cholecystectomy rate has gone up since the introduction of the lap cholie. There are two reasons for this.  Firstly patients faced with the prospect of a painful subcostal incision may decide to just live with the occasional bout of gut grief.  A significant number of surgeries are for assymptomatic gall stones.  Secondly instead of a procedure which keeps a patient in hospital for several days, surgeons now have a procedure which is either a day surgery or at the worst an overnight stay.  And of course the old open cholies which kept patients in hospital beds for days, deterred surgeons from doing them as "emergencies" lest their elective cases be affected by "emergency" cases occupying their beds.  Not a problem with the laparoscopic cholie.  It is now a rare evening or weekend on call that I don't do at least one of these.  Therefore we are doing more cholies and more of them after hours.  And don't forget that even in the most skilled of hands this is a procedure associated with the occasional complication.  What about post-op pain?  It seems that laparoscopic cholie is still pretty painful maybe not as much as open but instead of getting morphine in hospital lap cholie patients go home with Tylenol with Codeine.

Having mastered albeit slowly the cholecystectomy surgeons moved on to other easy procedures that they could now make more difficult.

We have  laparoscopic appendectomy.  These can now be done in about an hour by a competent general surgeon longer if they let the second year resident do it.  Are they any better than the open appy.  Remember most good general surgeons could do these thru a keyhole incision which is about as long as the total length of the four little incisions necessary to do it laparoscopically.  And the length of stay and complication rate is the same as open which costs only one third as much.  At least laparoscopic patients can wear a bikini afterwards if you forget the ugly scar in the umbilicus.   Appendicitis as I tell surgeons is a medical disease now.

Laparoscopic hernia repair is now fashionable as well.  The problem with this type of surgery is that many of the patients who get hernia repairs are older patients with coexisting disease.  Patients you would like to do under spinal or local (or tell them to wear a truss for the rest of their lives).  Instead you end up fighting inflation pressures in the COPDer you are doing under general instead of spinal.  Plus you have to use mesh.  Being in practice many years, I have absorbed many hours of surgical teaching and remember the admonitions of staff surgeons in the 80s and 90s to avoid using mesh whenever possible due to risk of infection.  Either way hernia repair is a day procedure whether done locally or laparoscopically.  Laparoscopic hernia repair costs several times as much.

In the pain clinic I see a lot of post hernia pain.  While one would think this would be reduced with laparoscopic surgery, I still see a significant amount of post hernia pain in patients who had their hernia fixed laparoscopically.

Don't get me started on laparoscopic bowel resection.  The feeling is only now
returning to my bum after the epic-ally long procedure I did last week.  The purpose of laparoscopic surgery is surely to spare the patient an abdominal incision.  Except that the bowel has to come out somewhere which requires a 10 cm long incision to remove the bowel. So you get a surgery which takes twice as much time, done semi-blind and you still end up with a fairly substantial incision.  Incisional pain can be handled of course with an epidural which our surgeons don't like us doing when they get out the laparoscope.

Urologists have gotten into the act with laparoscopic nephrectomies and adrenalectomies.  (Technically as these are retro-peritoneal structures these are not laparoscopies).  We thankfully don't do them at our hospital so my only knowledge is from hearing of the horrendous complications like the urologist who got into the inferior cava doing a laparoscopic adrenalectomy.  Urologists have also gotten into robotic surgery with great gusto despite data suggesting that the complication rate is the same as the open procedure which is cheaper and takes less time.  Plus in order to do the robotic prostatectomy urologists want the patient in extreme head down position which has lead to significant post-op confusion and who knows what long term CNS changes.

Gynaecologists who of course pioneered laparoscopic surgeon have moved on from tubals and lysis of adhesions.  I have recently done two laparoscopies for bleeding ectopics who came to the OR shocky.  My first response when they got out the laparoscopic equipment was, "surely you can't be serious?"  but I am such a wimp.  Bleeding, especially arterial bleeding, looks 10X as bad blown up on the TV screen.  We also have the laparoscopic assisted hysterectomy which is really just a glorified vaginal hysterectomy.  Vaginal hysterectomy which was historically done blind had an incredibly low complication rate.  The last laparoscopic assisted hyst I did came back a few days later because her bowel had been perforated.  And this is just to avoid a Pfanensteele? incision.  I am waiting for my first laparoscopic Caesarian Section and don't think somebody isn't thinking about this.

I could rant on about all the other "minimal access" surgeries being done in other surgical specialties.

I am not against progress, if I had my gall bladder out, I would want it out laparoscopically.  Not so much my appendix and definitely not a hernia repair (I would have this under local).  The thing is, doing something just because it is neat, doesn't justify the procedure and sometimes there is a reason why things have been done the way they were done for many years.

If I collapse at work, here is a list of doctors that I don't want working on me.

Sadly all of us have such a list in our heads.

At the recent ASA meeting, I attended 2 separate ethics sessions which dealt with the same question.  If you know the surgeon is incompetent and the patient asks you, do you tell them?  The ethical answer is yes, however you could see how this would play out in the workplace should you actually do this.

A while ago I got a phone call from an exasperated colleague complaining about one of our surgeons.  This surgeon more or less restricted his practice to certain area but when on call takes on all comers.  My colleague pointed out that this surgeon had taken way longer than other surgeons to do a case with the result that that OR was now backed up with emergencies.  I had gotten the same impression so a day or so later I ran into the Chief of Surgery in the lounge and raised the question.  I obviously wasn't the first person to do so.  "His infection rate is the same as everybody else and his length of stay is the same too," spat out the Chief.  I later talked to the Chief of Staff, also a surgeon, and got the same answer.  Hmmm I thought if both of them know this surgeon's average length of stay and infection rate, maybe they had to look into it for some reason.

We had a now departed cardiac surgeon at the Centre of Excellence who was to say the least not very good.  Bad to the extent that several cardiac anaesthesiologists actually gave up doing cardiac anaesthesia rather than work with him ever again.  That's right cardiac anaesthesiologists actually gave up lucrative work because they didn't want to work with a surgeon.  (Some of them later rejoined on the condition that they not have to work with this surgeon).  One female anaesthesiologist said she felt like a murdress every time she worked with this surgeon.  One day a bunch of them were talking in our lounge about how bad this surgeon was, when I interjected, "Do you think you may be liable for working with him when you think he is incompetent?".  "That's an interesting question," replied the department chairman who had made a rare appearance to sit with the little people.  This is unlike this group of anaesthesiologists at another centre who had the cojones to refuse to work with a clearly incompetent cardiac surgeon and saved countless lives. 
The surgeon at the CofE continued to work on for a couple more years after this and is  now working somewhere in the US interestingly enough as an anaesthesiologist, as I found out on Google, which is surprising given his poor opinion of anaesthesiologists when he worked in Canada.

There are two components to surgery.  One is technical skill and one is judgement.  A surgeon may have perfect technical skills but very poor judgement and inappropriate surgery well performed can be as bad as appropriate surgery badly performed.

Incompetent surgeons come can be divided into groups.

Some surgeons are just plain incompetent.

Other surgeons learn early on that they cannot handle difficult cases and restrict their practice to a small menu of cases that they know they can do.  That is assuming there are any cases that they are able to do.   This works out especially if they work with someone who can occasionally bail them out.

The most dangerous surgeon is the surgeon who doesn't know he is incompetent.  Some of these are idiots who just blissfully ignore their bad results.  Quite a few of them a sociopaths who don't care about their bad results.  I suspect a large number of these surgeons actually know they are incompetent but have invested too much time and training and are working away waiting to get found out.  There is a subgroup who do some types of surgery quite competently but will attempt more difficult surgery with terrible results.  Quite often these individuals claim to be subspecialists in the very area they lack competence in.

A lot of us will actually tolerate an incompetent surgeon if he is pleasant to work with, works reasonably fast, doesn't do a lot of cases after hours and his cases don't come back to the OR too often.  The incompetent surgeon who is a complete asshole may get caught out sooner or conversely concerns about his work may be downplayed as "you are just complaining about him because you don't like him."  Or of course if he is a complete sociopath people including anaesthesiologists may be afraid to complain.

OKAY SO WHAT ABOUT INCOMPETENT ANAESTHESIOLOGISTS.

Yes they exist.  Some are globally incompetent, some may just have trouble with certain aspects of care like epidurals for example. When I first started out there were still a large number of anaesthesiologists with little or no formal training who had been grand-fathered in and were still working even in large centres.

Surgeons  like most bad anaesthesiologists because they rarely do regional blocks, art lines or central lines, they cut corners and never cancel cases except for the bad anaesthesiologist who has enough insight into his skills and only will do ASA 1 cases.  Further bad anaesthesiologists usually don't mind working after hours and will stay late.  Some surgeons know that the anaesthesiologist isn't really that good and just try to avoid him for their sicker patients.  Bad anaesthesiologists are either really nice guys so the nurses and the surgeons put up with the badness or they are real assholes and everybody is afraid to confront them.

Years ago there was an older anaesthesiologist whose skills had slipped which culminated in a surgeon finally refusing to work with him while on call.  This was a shock to everybody.  This individual did continue to work on for a few more years but wasn't allowed to take call, an imperfect compromise.  At our hospital we had to get rid of two anaesthesiologists about 5 years ago.  They had been there for years after training in another country.   It had been suspected for years that they less than competent but the surgeons loved them because they worked fast, never canceled cases for medical reasons and loved to work after hours.  Our department chief was forced to do a prolonged chart review of all their cases before he found enough evidence to hang them which he did and they retired.  All in all less than pleasant.