Hey I wore a poppy this year.

I think it was last year that I blogged about why I wasn't going to wear a poppy.  I did wear one this year.  This was partly under duress but mostly because of some reading and some deep thinking over the year.

The duress part.  The adult band I just joined played a "Lest we Forget" concert last Saturday and we were told to put a poppy on our suits.  40 or so years of band-geekdom have led me to blindly accept the commands of my conductor and I wore a poppy on the left lapel of my suit, which I learned is the correct way to wear it with suit.

However I put a poppy on my winter coat today when I went out.

During the last year or so I have read a couple of books about WWI and have thought about my two grandfathers who fought in that war.

For Christmas last year I got Margaret MacMillan's excellent book, "The War That Ended Peace."  All senior politicians in the world should be locked in a room and not let out until they have read this book (they may need to make a comic book version for Republicans and Canadian Conservatives).  As I read it, the central thesis of the book is that none of the great powers in Europe really wanted to go to war but they were all convinced that the other countries did and so gradually and inevitably everybody went to war.  The WWII is really just the end-game of WWI, the Cold War was the end game of WWII and all the little and bigger wars since then are really just the end game of the Cold War.

Just recently I read "Into the Silence" by Wade Davis.  This book is about the first 3 Everest expeditions culminating in the disappearance (and death) of Mallory.  About a quarter of the book however describes the first world war which had a marked effect on the mountaineers almost all of whom were veterans that war.  This is one of most vivid descriptions of the horrors of the first world war.  Events like patrolling no man's land and stepping on rotting corpses or of horribly maimed and unidentifiable dead being thrown into mass graves with orderly crosses being placed on top to give the illusion that the soldiers were buried intact in individual graves.  He also talks about the British Commander General Haig who lived the war in a French chateau miles away from the Front, which he never visited.

I grew up in the 1960s when there were still a lot of WWI veterans alive and when practically everybody's father had served in WWII.  I read a lot of war literature in that time and the impression I got of conditions for soldiers in WWI is a lot different from what we read in Davis' book or in many of the excellent books about WWI which are now being published.

The impression most of us, as children got of WWI was that it was a pleasant war with smiling soldiers who sang, "It's a long way to Tipperary" and met French girls.  The trenches were pleasant safe places and if conditions were a little rough, they were not that much rougher than your last Scout camp.  If a lot of people were killed, came back missed parts of their body or with minds that didn't function like they did before, that was a side issue.

I have been thinking a lot lately of the two grandfathers I never knew.  Both my grandfathers survived but didn't survive WWI.  One grandfather was in the first chlorine gas attack of of WWI.  He was later blinded when a grenade blew up in his face.  He returned to Canada later moved back to England, was trained as a masseuse, got involved with British Fascist party and died of respiratory disease in the 1930s.

My other grandfather was wounded at Vimy Ridge.  He too had been gassed earlier in the war.  He married an English nurse and moved back to Nelson where he had lived before the war, surviving on his army pension.  Like my other grandfather he suffered from chronic respiratory disease having been gassed, contracted TB and died along with his wife in the 1930s.

My parents never talked much about their fathers.  I never even saw photographs of them until I was an adult.  My mother had her father's medal ribbons (her brothers had the actual medals) which I took to show and tell once a year.  I do remember once when my brothers and I were talking about WWI, my mother saying, "if it wasn't for that war my parents would both be alive."

I still think about what lead my grandfathers to enlist.  One grandfather had already been in the British army serving in South Africa and Afghanistan.  It is a little unclear how he ended up in Vancouver where he enlisted but it is quite likely that he was at loose ends and maybe welcomed a return to the military.  My other grandfather was a miner, so I am not sure what lead him to enlist.  I suspect that compared to mining in the early 20th century, a military life seemed pretty pleasant; steady salary, 3 square meals and a warm place to sleep.  Plus you were joining the British Army which had a pretty good record of success since the American Revolution.  People talk about King and Country, however I wonder how patriotic Canadians in that era were.  There was of course peer pressure and of course a sense of adventure.

The other thing I have been thinking about is how disconnected we are now from the military.  Unlike WWI and WWII which were fought by teachers, farmers, clerks and miners who returned to their jobs after the war, the army now predominantly composed of career soldiers who enlist as teenagers.  We now see where the army is a family profession with sons and daughters serving because their father served.  (There is true, a reserve army as well.)  This leads to the army being disconnected from the community.  This makes it all the easier for politicians to order them into danger and unfortunately makes all of care a little less because we really have no connection with them.

I often think of how the 20th century would have unfolded without WWI.  I get the impression the world or at least Europe might look a lot the same as it does now.  I also get the impression things just might have been a lot better.  No Hitler, no Stalin for example but who knows what other monsters might have arisen.

I remember in the early 1990s when the Cold War ended looking forward to a peaceful 21st century where all the resources devoted to killing people could be turned towards the betterment of our planet and our species.  How horribly wrong I was.

So when I wore my poppy today, I wore it for the poor soldiers like my grandfathers who endured horrible conditions in a stupid war, for the relatives who lost or got back damaged loved ones, and for the civilians in the war zones whose lives were turned upside down.

And the poppy-wearing -war -mongering- politicians and generals can go fuck themselves.

Guess what, I now work in a client service area.

I have been sparring with our administration over accreditation and "high alert" medications something about which I have blogged about and will again in the future.  Apropos to that I was able to obtain a copy of the accreditation standards that our administration is using as a club to beat us with.

Right away, I came across the term "Client Service Area" which refers to the operating room where I work sometimes but also presumable refers to the wards in the hospital and the clinics and most likely also to the Tim Horton's outlet in the cafeteria.

Like the title of this blog says....I used to be disgusted.....

Okay I Finally Have to Say This, I Hate People Who Bring Carry OnLuggage on Planes

Disclaimer.  I ocasionally do not check luggage.  I do this in two circumstances.  If I have a very short trip overnight or back and forth the same day, I bring a small bag with a single change of clothes, toothbrush and shaving stuff.  I put this in a backpack or duffel bag which can be squished into the overhead or under my seat (not just to be considerate but because that is what I am probably going to have to do.).  The second is when I am on a medical mission and all my checked luggage is medical supplies so I have several days worth of clothes jammed into a carry on bag.

I have known this for years but it only became crystalized yesterday after hearing the young man one row back of me complain the entire flight because they had made him check his bag because there was no room in the overhead.  We were sitting at the back of the plane so he would have gotten to board first had he not been goofing around and yes it pisses me off when people in the front put bags above my seat but hey, as he told everybody in ear range, he had a four hour stop-over in Vancouver plenty of time to collect his baggage.

For about the past ten years now just about every flight I have been on has taken off late because of problems stowing everybody's carry on.  At the end of the flight it takes forever to deplane because of the reverse, people taking their steamer trunk out of the overhead where it has become wedged or trying to get to the back of the plane against the traffic flow to collect the steamer truck they stowed above somebody else's seat.  I remember being in the Toronto airport around midnight waiting for my baggage after a flight which left an hour late because of having to stow hand baggage and thinking, "those assholes who made the flight late are already in bed".

I have obviously spent a lot of time analyzing this and I can't help but observe that most mid-large size planes actually have enough overhead space to allow every person on the flight to stow one piece of carry on luggage.  If there is not enough room, it is because multiple people have stowed more than one bag especially because I only use the overhead compartment in situations like the first paragraph, this means they have ignorred all the warnings and signs about hand luggage and that the airline staff have ignorred this.  This is probably because the airline staff would rather deal with one obnoxious passenger than multiple but my obnoxious friend above has a point, why is everybody else's luggage more important than his?

You can of course or some will blame the airlines for charging extra for the second (or first)  bag and for not having enough baggage handlers.   I have never understood why the airlines now conscious about fuel costs have not figured out that a piece of luggage weighs the same whether it is stored in the belly of the plane or in the overhead compartment.  Actually I have figured it out, it is a naked cash grab.  (The United Airlines flight I took back from Ecuador last year realized that the flight was full and there was going to be carry-on rage and kindly offered to check a second bag for free something I took advantage of as this is one of the two situations when I bring a carry on bag).  Slow delivery of your baggage to the carousel is another issue but I expect airlines are using the excuse that everybody carries their luggage on anyway so they can get away with fewer baggage handlers.

And of course we have people who insist on carrying on way more hand baggage than they are allowed and get away with it like the obnoxious sociopath in Live Strong apparel who sat next to me on a flight from Kigali to Nairobi.  He and his buddy had apparently paid (bribed) the gate agent to allow them to carry on all their expensive video equipment.  He then tried to stiff the gate agent who came on the plane and wouldn't let us take off until the fee (bribe) was paid.  We were of course already 2 hours late.  While he was doing this he made everybody take their carry on out of the overhead compartments so he could put his stuff in and what he couldn't fit he stashed behind the seat in front of him spilling over into my leg room.  Another loser on a flight from Washington to Chicago who was in business class with us was actually allowed to carry on a duffel bag almost as big as what we in Canada call a hockey bag.

Another thing that galls me is people who don't check luggage when going on vacation.  Sure I can see if you are going on a short trip, that you can get away with a small amount of clothing and sundries, but I am been amazed on travelling to vacation destinations to have passengers on board who have managed to stuff 1-2 weeks of clothes into a carry on bag.  Or it could be that they couldn't fit all their stuff into their 50 lb of checked luggage.  Either way anti-social.

I went cycling in France with a corporate lawyer from Washington who told me he wanted as his epitaph, "Never checked luggage".  He also insisted on sprinting off every morning and riding a couple of km ahead of the group, stressing out the guide, smoking cigars before dinner and only drinking the duty free scotch he had bought over from the US until one hotel in Normandy told him he was not allowed to bring his own liquor onto their terrace.

If you aren't willing to put yourself in the line of fire, shut the fzck up.

There has been a lot of concern expressed in the media and by our politicians about the situations in the Ukraine and in the Middle East and talk of sending troops including those from Canada.

I am pretty disgusted about what is happening in either locale although there are two sides to every story and we are pretty consistently only hearing one side.  I also don't want to engage in a history lesson, although if people studied the history of those areas, they might think twice about sending in troops.

Actually if our politicians had studied the history of those regions at any time over the last 75 or so years ago we might not even be where we are now.

However:

If you feel really strongly about military action in the Ukraine or the middle East and are under 40 years of age (according to the website there is no upper age limit), you should enlist in the army so you can go over there and fight.

Or if you are over 40, you should strongly encourage/force your children to enlist, they can join at 17 with your permission.

Otherwise:

SHUT THE FZCK UP!

Just had to get that off my chest.

Reefer Madness: Hopefully But Probably Not the Last Word

It took at little time but Anonymous has replied to my screed on medical marijuana.  Part of the reason I blogged on this was to initiate reasonable debate on this issue.  In addition in the interests of brevity I did not include a lot of information or arguments.

I have commented on his comments:

 Cannabinoid studies should not be confused with medical marijuana (smoking the whole leaf). How many medications do we smoke? Think about it; If the lungs were the best method then why not nebulize like albuterol.

Not sure whether the lungs are the best method to administer drugs but as I pointed out, since 1846 we have administered general anaesthetics through patients lungs.  I also pointed out that there were objections to smoking including lung damage and risk of fire.  Vapourizers are available, (they are expensive) and I have read that e-cigarettes are being used to smoke marijuana.  Aside from the being safer from the fire point of view, it is questionable whether vapourizing marijuana is any less harmful to the lungs.Further as I pointed out, many patients use extremely small amounts of marijuana.

Also, why include all the other non-useful components of the leaf...we don't do that with opium poppy or any other drug for that matter.

We actually still use opium.   Just about every patient at our site who gets a cystoscopy procedure gets an O and B suppository.  Further opium has been used within my career.  Pantopan which is an extract of opium with the "tar" removed was widely used up until at least the late 1990s.  For all I know it still may be used.  It was the opioid of choice in the burn unit in Vancouver when I was a medical student and on the orthopedic service in Halifax when I was an intern.  It was considered to be superior to morphine or meperidine for bone pain and to have a euphoric effect.  It was still used as a pre-med when I was a resident including by our ultra-paranoid professor.  Some anaesthesiologists, mostly Brits, used it instead of morphine intraoperatively. 

There are reasons why combinations of similar drugs might work better than a single pure drug like perhaps working at different sub-types of receptors or affecting metabolism.  For example in Europe you can get a combination of Morphine and Oxycodone in a single pill. 

In the case of marijuana it appears that a second cannabinoid cannibidiol (CBD) may be synergistic with THC both in analagesic effect and also in reducing side effects.  This is why Sativex has a 1:1 mixture of THC and CDB and why most of the commercially available forms of medical marijuana now specify their THC:CBD ratio.  Now if we have evidence that a second cannabinoid promotes the action of THC, could it be possible that 3rd or 4th cannabinoids might also have a role?

Further, oral cannabinoids exist as treatment (e.g. Marinol).

Marinol is no longer available in Canada.  The manufacturer withdrew it because of low sales.  It was very expensive ($20 per pill) and was not covered under any drug plan.  Nabilone (Cesamet) on the other hand while expensive is covered on our province's drug plan.  I prescribe nabilone widely for a variety of pains. It is a useful drug to try in small amounts in cannabis naive patients.  Some patients who have gotten relief with medical marijuana do get good relief of their symptoms with nabilone.  Many however find that nabilone is not as effective as marijuana or that they get worse side effects.  It has actually been suggested that nabilone may antagonize the effects of medical marijuana by acting as a competitive blocker.

Marijuana does work well orally however because of the bio-availability larger quantities are required, which is a problem with something that was illegal and is now expensive.  It is possible to improve the bio-availability in many ways, including buying this book, or one of the many other ones now available.  You used to be able to download a book on PDF but I guess nothing is free now.  One of my patients practically has a chemistry lab in his kitchen.

Sativex a mixture of THC and CBD from a cloned plant is available in a buccal spray in Canada.  It is unfortunately expensive and not covered under any drug plan, therefore it never caught on although I think it is still a promising product.

So, if you want to promote the use of cannabinoids than more power to you. But you should focus on the pharmacologic properties and appropriate delivery of the drug, like we do with every other drug.

I think I covered this in my previous two posts but apparently not.

Most of us in the pain business would rather we had a pharmaceutical grade cannabis product that we could prescribe to patients either in oral form or as a spray (okay we do have Sativex).  As I mentioned in my previous posts it reflects poorly on the academic pain community and the pharmaceutical industry that with longer than 13 years to work on this we do not have a plethora of products.  In fact with the exception of one evangelical person, nobody in Canada has really done any clinical research on this.  A major factor is of course that it is practically impossible to do any research in cannabinoids in the US which is unfortunately where most of the new drug research for Canada is done.

13 years ago others and I could have stuck our heads up our asses and ignored this issue, like so many people did, but we tried to work with patients to try to get them the best treatment with the limited resources we have.

Reefer Madness part two

Medical marijuana has its boosters and detractors.  I have rarely seen a topic in medicine so polarized.

The following points have been raised by one side or the other.

From the medical establishment.

There is no evidence of the efficacy of medical marijuana

Actually there is considerable evidence of the efficicacy of cannabinoids in both pain and spasm both in human and animal studies.  Cannabinoids have in fact been thoroughly studied, possibly more than many classes of drugs.  The mechanism of action is quite well understood.  There has only been one study comparing smoked marijuana with placebo but this is a reflection of the difficulty of studying a drug which is illegal in most of the world.  This study was by the way positive in favour of smoked marijuana.  

The percived lack of evidence is more of a sad reflection on the academic pain community and the pharmaceutical industry who have had 13 years to test marijuana for pain but have with a few exceptions sat around twiddling their thumbs or pontificating.

Further if we look critically at the evidence for many conventional treatments they too are quite weak.  Even the best treatments for pain have a NNT of 3 or higher which simplistically means that they don't work in over 2/3 of patients.  Then we have to look at the large number of drugs that are used off label for which no studies have been done, the drugs that are used in pediatric patients and the drugs that are used in the frail elderly; neither children or frail elderly get included in clinical trials.  And of course we have to look at the treatments which have never been tested because, well, we've always done it that way.

The potency of medical marijuana is variable and unpredictable.

This would almost be a valid argument if conventional drugs had pharmacokinetics and dynamics which were constant from person to person.  But we all know that isn't true.  If we for example give 10 mg of morphine IV to a group of similar 70 kg individuals we know that we can expect a variety of responses.  Some people will get sleepy, some nauseated, some itchy.  Some will get good analgesia, some will get no analgesia.  This applies to most drugs which is why when things are critical we measure blood levels as we do with antibiotics, digoxin and many anticonvulsants.  Further as we all know and practise in anaesthesia, we titrate to effect.  

This also assumes that bioavailable is constant for the same drug.  We also know this isn't true, there are huge differences in bioavailability between generic and brand name drugs.  This is of course a major problem with drugs like Coumadin and Digoxin.  

The current requirement to obtain drug from a registered supplier also means that patients can get marijuana of known potency.  Not that I like to praise any policy derived by our Canadian Tea Party.

Smoking is harmful

Hard to argue with this one.  Except.

As every anaesthesiologist knows one of the best ways to deliver drugs is through the lungs.  A lot more drugs would probably be administered by this route if a reliable delivery system could be devised.    Smoking while harmful does deliver vapour to the lungs.

It is also possible to purchase a vapourizer to vapourize the marijuana.  This may or may not be safer than smoking.

Patients who smoke marijuana for pain typically smoke way less than do recreational users.  Many patients will only take one or two puffs and typically less than 2 grams a day are necessary.  Interestingly enough our government allows patients to have up to 5 grams a day.

It is possible to take marijuana by the oral route as well.  Because of the reduced bioavailability higher doses are necessary which can be a problem with a drug which is controlled tightly and now fairly expensive.  There is an interesting book, "Cooking with Cannabis" available for free download on the internet.

We have many good treatments for pain, marijuana should not be necessary

Except we don't.  Most of the drugs we have either don't work or are not tolerated in large proportions of patients (this also applies by the way to marijuana).  Some like opioids are extremely controversial.  Multi-disciplinary pain clinics have long wait lists, are expensive and quite frankly really aren't that efficacious.  (At a seminar I gave to a group of pain physicians years ago, I asked if anybody had ever seen somebody benefit from a rehab program.  Only one person had.)  Interventional treatments are great for the interventionalist's bank account but are of limited benefit for patients.  

Further marijuana or any treatment should not be a stand alone treatment but should ideally be a part of an inter-disciplinary approach to pain involving many modalites, focused on the patient.  I also believe in the Easter Bunny.

Marijuana can cause psychosis.

This is based on a retrospective observational study looking at the developement of schizophrenia in teenagers using marijuana.  Funny how observational studies are okay when they justify somebody's agenda.  The saying correlation does not imply causation applies here, and it is quite likely that teenagers with the early symptoms of schizophrenia might be tempted to try marijuana, easily available in most high schools to relieve these symptoms.  Notwithstanding this, I will not authorize it for teenagers (easy for me because I only see adults).  

Conventional drugs are not innocuous either.  NSAIDs cause GI bleeding and renal failure with prolonged use.  Acetaminophen cause liver and kidney disease.  Anti-depressants cause weight gain.  Opioids cause endocrine abnormalities and have been shown to produce loss of grey matter.  I could go on.  

Cannabinoids may be effective but we should wait until more research is done and until the pharmaceutical industry comes up with a pharmaceutical product.

Again, how much more research do we need?  Marijuana has been sort of legal in Canada for medical uses since 2001 and have we seen any new products?  (Oh I forgot, we don't do pharmaceutical research in Canada.)    The only recent cannabis derived product to come out is Sativex which was developed in Britain.  Some pharmaceuticals may have something in the pipe as it were.   While most of Big Pharma is inherently evil, most of use would welcome the opportunity to be able to prescribe something made by Pfizer or Eli Lilly.

Doctors are being forced......

No they are not.  If they chose to write a prescription, they can if they don't they can refuse, just like they can refuse any service which is not life or limb threatening.  This applies by the way to other requests that may be made by patients.  It is the failure of physicians to act as responsible gatekeepers which helps to maintain the ongoing crisis in healthcare.

And from the advocates of medical marijuana:

Marijuana is a natural medicine.

Actually the marijuana smoked today bears very little resemblance to that smoked 100 or even 30 years ago.  Todays marijuana is the product of breeding and cloning to maximize the amount of THC.  It is for the most part grown hydroponically using who knows how many chemicals.  If you want to consider that natural, go ahead.

Marijuana was widely used as a medicine prior to being made illegal.

Not really a great endorsement.  Strychnine, arsenic and mercury were also widely used as medicines.  Marijuana based preparations were used in the 19th and early 20th century.  They didn't persist largely because they didn't work that well.  Further they were not used in Western medicine prior to their introduction from India in the mid 19th century. 

Marijuana is a wonder drug, a panacea

When I used to give talks on chronic pain management, the first thing I would tell the audience is that there are no panaceas.  This applies to marijuana.

In closing

We don't have a lot of good treatments for chronic pain and most of us in the business welcome any addition to our tool box.  Most of us don't like the way medical marijuana came about, by a court decision, we would rather the government had shown some leadership there.  We are stuck with a bad process and those of us who have chosen to authorize or prescribe are trying to do what is best for our patients.  

It would certainly be refreshing to get a dialogue free of hyperbole because this is not going away.

Reefer madness part 1

Early on in my career trying to treat people with chronic pain, people would tell me that the only thing that worked for their pain was smoked marijuana.  Of course people told me lots of other things that were the only thing that worked for their pain including alcohol, cocaine, injectable Demerol and 30 percocet a day.  I of course told them sorry I couldn't comply with their request.  Marijuana was illegal but as I told patients, if you believe it helps your pain, do it discretely.

Marijuana is still illegal in Canada.  The law is enforced with a certain lack of vigour and consistancy across the country.  Despite this Canada spends between $500 million and $1 billion dollars a year, arresting, proscuting and punishing people for possession of marijuana.

In 2001, courts in Canada decided that it was unconstitional to bar patients from using marijuana for their pain and the government of Canada was forced to design a process by which patients could receive medical marijuana.  This initially involved the signatures of 2 specialists and allowed the patient to grow his own supply, designate a supplier or buy from the government.  

One day in 2001 I got a phone call from the Public Relations department of the hospital.  "Would you like to be interviewed by the CBC?", they asked.  "You cannot however mention the hospital".  The interview was as I should have suspected on medical marijuana.  The regulations had at that time not been finalized, I had never actually prescribed marijuana to any patient and my only knowledge was what I had read or seen at meetings but I figured any publicity is good publicity and so I was interviewed live on the afternoon radio show at 1700 hours.  End of story?

Not really.  On Monday my wife phoned me at work,  "Your interview is on the CBC national radio news".  I was subsequently interviewed by both local papers and got to have my second 15 minutes of fame.  

Keep in mind that I still had not prescribed marijuana to any patient.

I soon started getting phone calls from patients desperate to get the authorization forms filled out yesterday.  I explained that they would need to have a referral from another doctor and that I had a wait list.  After about a year, I started noticing a certain type of new patient showing up.  These were usually men, men with pony-tails under leather ball caps.  They usually had some vague pain complaint, had not really tried anything else for their pain except marijuana which I could usually smell on them.  I patiently explained, that the regulations as I understood them only allowed medical marijuana after other treatments had been trialled and failed and offered to start these treatments.  That was usually the last I saw of them.  

At that time I practised at the Centre of Excellence in a an academic pain clinic with 3 other doctors.  Shortly after the new regulations came into effect, The Professor at a staff meeting sternly forbode us to sign any authorizations.  I felt that this was curious as he professed to be all about research and this was virgin research territory plus the publicity for the clinic but I kept my mouth shut lest I be verbally castrated which was (and still is) how he dealt with differences in opinion.

For the next year or so, I politely explained to all patients, legitimate or not that I could not fill out the authorization.  That was until a patient I had seen years ago came to see me.  He had what we called failed back syndrome after back surgery with quite severe pain and spasms.  He had been using marijuana which he grew in his house which had lead to his arrest.  He had not really had any treatments since the epidurals I had tried years earlier and so I explained that we actually had lots of great treatments now and that he should try them.  Not surprisingly the first two gave him severe side effects and no relief which sadly is true of most of the wonder drugs in chronic pain.  At that point, I just said shag it and signed the damn forms.  

At that time I had an out in that I worked in another clinic so I just directed the patients to that clinic away from the scrutiny of The Professor.  And I continued there in a small way.  I started doing talks on cannabinoids for Valeant which markets nabilone (Cesamet) in Canada.  I was very cautious with patients, I treated them like any other consult, I listened to their story, examined them and if there were treatments they hadn't tried, I suggested that they try them.  Wherever possible I tried to get them to try nabilone a cannabinoid which is available by prescription and covered under our provincial drug paln or Sativex which is not reimbursed.

A few doctors saw business opportunities in medical marijuana and set up clinics specifically for the authorization of medical marijuana.  Most of these clinics charged $400 for completion of the paperwork, some even allowed you to be interviewed by Skype.

Patients came in a variety of presentations.  Many were sketchy but had a legitimate problem, quite a few were straight-laced folks with intractable pain who had tried somebody's marijuana out of desperation and some were just plain crazy.

In the interim, the Canadian Tea Pary came into office and the idea of people smoking marijuana recreationally or otherwise gave them dyspepsia.  Their hands were tied however by the court decision and so they had to keep the program.  They did however find a way to modify it in a way to make medical marijuana less available as well as reward well connected businessmen.  Effective last April, patients can no longer grow their own or designate a supplier but must buy from a Government registered supplier of which there are about 10.  Doctors rather than fill out the paperwork, must now write a "prescription" which the patient can they send to one of the companies who will then courier the week.  This has upset many long term medical marijuana users who previously grew their supply but now have to spend money with one of the suppliers.  The suppliers are for the most part slick operators with nice glossy brochures, they now sponsor pain meetings and I met my first detail man the week before last.

The change in regulations also sparked responses from both the medical societies and regulatory bodies.  From a physician point of view, the new regulations are actually better.  The "prescription" which I now write is a lot shorter and less complicated than the form I used to have to fill out.  Further just as doctors chose in the past whether or not to fill out an authorization, doctors can now chose whether or not to "prescribe" medical marijuana.  This didn't stop our College (Medical Board) from publishing regulations and demanding that doctors register with them; something they hadn't done between 2001 and 2014.  The Canadian Medical Association or at least the miniscule fraction of the profession that attends its annual meeting condemned the smoking of any plant material.

As someone who has been in the Medical Marijuana trenches for over a decade opinions are extreme on both sides and I wish to comment on and maybe refute some of the myths in my next post.

Dangerous medications or how I saved the 5 cc fentanyl

Hospitals, as we know, are dangerous places and most of us know of ways that we at least think would make things safer.  The problem is that most of these would involve spending money or would interfere with somebody's agenda.  So instead our hospital like most hospital focuses instead on creating solutions for things that aren't really problems.  This is not unique to hospitals, governments do this as well.

A significant source of badness in hospitals is when somebody injects the wrong drug.  This can range from innocuous to catastrophic. Another variation is when a more potent concentration of a drug or electrolyte is injected by somebody thinking they are injecting the lower concentration (often unaware that the higher concentration exists).

I went to a meeting a few months ago.  We were discussing what were called high alert medications and opioids were on the table which is why I attended.  There were a number of highly placed nursing administrators and a few pharmacists present and like most people who actually don't have to work for a living they were very pleasant and friendly; maybe a little surprised that a doctor showed up (if only because they had scheduled the meeting in the middle of the day, just for that purpose).  Specifically the 50 mg per ml morphine, the 10 mg per ml hydromorphone and incongruously the 5 cc fentanyl ampoule were on the chopping block.  Somebody high up in administration for various reasons wanted these medications gone except in various situations.

The first two are pretty much no brainers.  Obviously injection of 50 mg of morphine or 10 cc of hydromorphone could be catastrophic.  On the other hand many cancer patients are getting injectable narcotics by clysis requiring these highly concentrated solutions.  So either restrict them to palliative care units or keep them in pharmacy until they are needed.  Nice idea except that cancer patients also show up on medical or surgical wards and they are often admitted after hours when the hospital pharmacist is tucked into his bed.  We weighed this for most of an hour and I'm not sure what we actually decided.  The high concentration morphine and hydromorphone typically come in large bottles while regular strength comes in single dose ampoules which should alert all but the most brain dead nurse or physician.  Logically suggesting that people actually read the labels before they draw up medications makes sense but we all know about human factors analysis and not giving people a change to screw up.  I suggested why not put some harmless dye in the high potency narcotics like we do with 4% lidocaine.  Nobody thought that was a good idea although in about two years somebody will take credit for it.

We then went to the 5 cc fentanyl.  I don't use fentanyl much but some people do and like most doctors I don't like being told that a medication that has been used for at least 30 years can't be used anymore. Fentanyl is almost exclusively given by anaesthesiologists in the OR, by emergency room nurses or doctors and by ICU nurses usually to intubated or at least closely monitored patients.   First they kept on called this a high potency formulation.  Calmly and politely I explained that, no,  the 5 cc fentanyl has the same concentration as the 2 cc fentanyl.   I can see that giving 250 mcg of fentanyl when you only wanted 100 mcg could cause a problem for the patient, but unless you are someone who believes that the correct dose of any drug is one ampoule, this is unlikely to happen.  I then explained that we frequently use more than 100 mcg of fentanyl to induce anaesthesia and that while we could break open multiple ampoules of 100 mcg, this could lead to drug errors, injury to staff and problems with counts.  They then asked me what safeguards I proposed so that we could use the 5 cc fentanyl.

What I should have said was:  we go to medical school and then do 5 years of post graduate training, and we understand the pharmacology of fentanyl.  Further we are of moderate intelligence and can tell the difference between a 5 cc ampoule and a 2 cc ampoule.  I really should have said this but atypically for me I didn't take this obvious set-up.  Instead I mumbled the obvious that these patients were always monitored, that they was always an anaesthesiologist present and that the patients were usually intubated and ventilated shortly after the fentanyl was given.  

This went over well and the pharmacist filled out the appropriate exemption form.  I left the room thinking I had saved the 5 cc fentanyl.

About a week later, I came home late in the evening and did something I should have learned never to do.  I checked my email.  There was a form from our "quality" department which stated that our request for the exemption for the 5 cc fentanyl had been rejected because they did not have sufficient details about how we actually administered the fentanyl.  It has signed by the Head Stasi of Quality, (HSQ)  a lady I know all too well.

I had a fit.  I tossed and turned all night.  

What really pissed me off was that HSQ who signed the rejection had spent half a day in the OR with me because she wanted to see how we handled medications in the OR.

So first thing in the morning I wrote a letter.  I reminded the HSQ that she had spent a morning in the OR with me and had she not notice that I, not the nurses, the surgeon or porters,  injected all the medications.  I pointed out a lot of other stuff too.  I was maybe a little rude and condescending but in a controlled and logical fashion.  I then actually sat on the letter for about 3 hours, read it again decided everything was perfectly true and widely broadcast it by email.  

About an hour later I got a call from the head of Pharmacy who was apologetic.  Half and hour later, the Chief of Staff, a surgeon called me. "Why didn't you go through me, " he asked, "Don't you think I could have helped you?"  "Actually, " I said, "no I don't think you could have helped me."

Anyway we still have the 5 cc fentanyl.  And the HSQ was moved off the narcotic file so I at least temporarily no longer have to deal with her. 

We have now  turned to other "high alert" medications.

First came hypertonic saline.  About 10 years ago at other hospital a patient died of hyponatremia after a prolonged TURP.  It probably would not have made a difference but because it was the evening, there was nobody in pharmacy to get any hypertonic saline.  Consequently all OR's that do TURPs have hypertonic saline in their Pyxis.  How quickly people forget.  Our safety Stasi wanted to make hypertonic saline a patient specific medications meaning we would have to have to write an order and call pharmacy if we wanted hypertonic saline.  This required multiple exemption forms (one for the OR  and one for recovery room) to be filled out.  I realize all the bad things that can happen if you inject hypertonic saline by mistake, which is why I don't want it in my cart but keeping it in the Pyxis makes sense.  Anyway I filled out the form explaining that hyponatremia was a severe condition, the treatment of which was time sensitive, that we know what we are doing (I didn't actually say that) etc, etc.

They have also moved on the Magnesium Sulphate 5 g per 10 cc.  Some of my colleagues and I like to give 2-5 g and Mg to patients in the OR.  We believe it is analgesic and there is some evidence to this.  It is also a good anti-hypertensive and anti-arrhythmic.  Further I use it in the Pain Clinic on a completely non-evidence based basis.   Pharmacy who cite over-work whenever you ask to them to do something were proposing to put Magnesium into 100 cc mini-bags.  Another exemption form to be filled out.

Calcium Chloride/Gluconate had also been deemed dangerous.  Calcium disappeared from ACLS years ago although it is still on the crash cart.  We do use in in massive transfusion which I had to remind them we usually can't predict plus it is a pretty good inotrope in a pinch.  (It will also reverse the hypotension you get with  Magnesium if you inject it by mistake)  Pharmacy's solution was to draw up Calcium into syringes which would be stored in Pyxis. It is of course as easy to inject a pre-filled syringe (possibly easier) by mistake as it is to draw up a drug from a bottle and inject it and I could have pointed this out but they were on a mission and I can live with this one.

The euthanasia size bottles of Potassium Chloride disappeared years ago, now we have 10 MEq of KCl in 100 cc.

While I was writing this, I was reminded of something which happened about 10 years ago.  In an emergency room to the south of us, a nurse gave a patient 10 mg of hydromorphone instead of 10 mg of morphine leading to the patient's death on the way home from hospital.  When you think of it, this involved drawing up 5 cc instead of 1 cc, except that there is a 2 mg per ml morphine so one can sort of see the confusion.  (I am wondering if some well meaning administrator figured that the 10 mg morphine was dangerous and replaced it with 2 mg)  Our medical protective association, whom I (mostly my government actually) pay thousands of dollars a year to, came out with an atypically idiotic statement that hydromorphone was a dangerous drug.  Another physician and I had to write them a letter stating that hydromorphone doesn't kill patients, people kill patients (or something to that effect).

Yes ma'am I really am a doctor.

I was doing my penance in the pre-assessment clinic today.  A patient came in who was booked for a stone removal at the end of the week.  I introduced myself as Dr. BH from anaesthesia.

"Oh," she said, "you're just anaesthesia, I thought I was going to see a doctor."

"Actually", I said, "I am a doctor."  And what little bedside manner I have evaporated.  It was a frosty visit.

This is of course a problem in the US where nurses can give anaesthesia as my blogging colleague Great Zs has pointed out. 

I also loved the scene in "Deadwood" where a lady had to have a D+C for her miscarriage and one of the prostitutes, Trixie administered the ether.  This is a picture of her relaxing in the OR lounge after a tough case.

In Canada and in most of the British Commonwealth, anaesthesia has been the exclusive purview of physicians since the 19th century.  This didn't however stop our hospital from recently trying to buy an information pamphlet on surgery, which informed the patient that their anaesthesiologist could be a physician or a nurse.  I pointed out the flaw and I hope it disappeared.

I should be used to this now, I have been in the business for 24 years, not counting residency.  Sometimes I can even joke about it.  Like the time a patient in the OR about to go to sleep asked me if I had to go to medical school.  "No just Grade 11," I said, injecting the propofol.

Doctors and their beliefs

As usual I am a little behind the news cycle but two interesting stories have recently come up in Canada.

In the first two women in two different cities went to walk-in clinics to get their birth control pills filled.  They were either told by the physician they saw or in one case by reading a sign posted that the physicians would not prescribe birth control because of their personal beliefs.  There are two ways you can deal with this.  You can come back another time, go to another walk-in clinic, or get a family doctor.  You can also if you want post a nasty review on Rate MDs.   Or you could go to the press which is what both of them did.

This caused a big uproar with multiple stories and letters to the editor.  Many lay people felt that the physicians should have prescribed the BCP and that the women's rights had been violated.  Issues like the public funding of medicare, and  the subsidization of their education were raised.    Physicians who did comment sort of stickhandled around the whole issue.

There are several moral reasons why one might not prescribe birth control.  The Catholic Church prohibits it all together so if you are a devote Catholic physician you probably shouldn't prescribe it.  Some extremists believe it may lead to sex outside of marriage and refuse to prescribe it on that basis (if you went to medical school and haven't figured out that a lot of unmarried people are having sex, maybe you are a little dense).  There is also the whole abortion issue.   While the pill is believed to work by inhibiting ovulation, I seem to remember that another proposed mechanism was that it inhibits implantation which is technically abortion.  Another doctor I know claims he won't prescribe because it is too risky a drug to prevent what he believes is a normal physiological event (pregnancy).  

It is not therefore a new thing for physicians to refuse to prescribe birth control.  The general practitioner who delivered our second son refused to prescribe it.  He and his wife also a physcian, taught natural birth control.  They weren't terribly good advertisements for it as they had about 6 kids.  Not prescribing birth control wasn't an issue for us, he was otherwise a really good doctor.  

Now personally I think the two physicians in this case were being a little stupid and I can't believe that this happens in the 21st century.  (Actually much of what has happened in the 21st century I can't belive happened in the 21st century.)  Medicine is however an art not a science, most of us go on our beliefs which hopefully are formed on science.

Family docs have a lot of stupid beliefs.  Many of them believe that upper respiratory infections are caused by bacteria and must be treated by the most expensive broad spectrum antibiotic around.  Others believe that codiene will work for all pain no matter how severe.  Others believe it is not necessary to examine patients in order to arrive at a diagnosis.  I could go on.  These beliefs are at least as bad as not prescribing birth control. 

But I wonder if during the physicians in question's family practice "residency", did anyone point out the obvious economic benefits of prescribing the birth control pill to young women.  It has been a while since I was in primary care and I last wrote a prescription for the birth control pill in 1986 but here goes.  I used to love when women came for a refill of their birth control pills.  Even one counselled them about safe sex and warned about signs of DVT, we are talking about a 5 minute visit.  True you should probably do a Pap smear and cultures for STDs (actually they can test urine for it) but you can get them to schedule another appointment.  Young women on the BCP make great patients because they are mostly healthy.  Eventually they will get pregnant, if you do obstetrics you can follow their uncomplicated pregnancy; or you can refer them to OB.  After the birth you will get several years of well-baby care.  In addition by default, you get their husband who is also healthy and will present every couple of years for some minor problem.  It will be about 20-30 years before they will make you think.   This is exactly the patient a young family doctor wants in his or her practice.

In Canada the morning-after pill can be dispensed without a prescription by a pharmacist.  Shortly after the law came into effect a "researcher" for the CMAJ visited several pharmacies in rural Alberta posing as a patient trying to get the morning-after pill and was turned down by most of them.  This "study" was published in the CMAJ, incurring predictably the wrath of the Pharmacy community and when the editorial board stuck by their story the Board of CMA who charge me hundeds of dollars to belong fired the editorial board.  I don't recall being asked whether I wanted the board fired (or which board I wanted fired).

Abortion is of course another issue.  We used to do the odd abortion at the Centre of Excellence.  We had at least two anaesthesiologists wouldn't do the anaesthetic.  That was no problem, we simply swapped lists for that case.  Now our health authority contracts them out to private facility where they are done under local.  When I was in general practice, I worked briefly at an office in Northern New Brunswick.  The first thing I noticed was that the waiting room was plastered with anti-abortion posters.  The clinic did prescribe the pill, there were lots of samples around.  One day a distressed university student came to see me.  She was pregnant and adamantly wanted it terminated. I then and now support the right to abortion but I was in a quandry where I was in what I thought was an anti-abortion clinic.   Just to show how old I am, at that time, if you had money it was easier to get an abortion in the US than in Canada.  It was in fact not possible for patients from our community to get abortions in our province (the hospitals that did them, would only do them for their immediately catchment area)  so it was necessary to refer her to a clinic in Bar Harbour Maine.  I realized if I phoned from the clinic, it would appear on the long distance bill and I might be in trouble.  So I went home at lunch, phoned the clinic from home (long distance was not cheap then) and arranged the abortion.  A couple of months later when I knew one of the docs in the clinic better, I asked him what he would have done.  "All of us in the clinic send patients down there," he said.  The anti-abortion posters were in the waiting room because these are the type of people you don't want to say no to.

The hospital where I interned in OB did abortions.  Most of these were first trimester abortions done as day surgery but they did the odd second trimester abortion by saline induction which as I found out is quite unpleasant.  These patients usually generated a few calls to the intern for various problems.  The other two interns on the service refused to see abortions which meant I ended up dealing with the problems.  As I told one of them when she told me she didn't feel she had to see patients having an abortion, "I can't believe you would refuse to see a patient in distress".

But religious beliefs affect other areas of care not association with birth control.  Take end of life care for example.  Just how heroic or not heroic attempts to prolong life for a few days are often influenced by the doctor's religious belief sometimes going beyond the patient's or his family's stated belief.

The second issue involved a Caucasian woman who visited a private fertility clinic in Calgary to get inseminated.  She asked to be inseminated with the sperm of a non-Caucasian patient.  The doctor refused stating, "we don't do rainbow babies".   This caused the predictable storm, most fertility programs in Canada stated they don't have such a policy and the clinic in Calgary has back-tracked; they are now saying it was just a misunderstanding.

I think most of us would think, it the lady wants a mixed race baby so be it.  I am sure an ethicist can probably take this simple quandry and make it much more complicated.  

I sometimes think the world would be a happier place if we were all encouraged to mate with somebody of a different skin colour so that in several generations we were all the same shade of brown  .  Having said that I married a women with similar skin colour to mine and am quite happy with my marriage (not because of her skin colour),  

I wonder how the non-white sperm donors who perhaps donated sperm intending it to go to somebody with their skin colour and who now find out it is going to help white women make designer babies feel about all of this?  Of course most sperm donors don't really want to come forward or attract attention to what they do.  

When artificial insemination was in its infancy, our of our Obstetricians was a local pioneer.  He collected a lot of his sperm from medical students who we all know are genetically superior.  He paid $70 for a course of two donations two days apart which in 1980 was serious cash for a student.  I never did it, nor and nobody I knew admitted to it;  there were rumours about some of our class who were making big bucks in the insemination game.  (We did a skit about it at skits night)  Donors were matched with the spouse of the recipient by "race", blood type and eye colour.  We were assured that the process was anonymous, the identity of the donor would be kept in case of genetic problems later but that there would be no way of the recipient or offspring ever finding out.  That promise was of course not worth anything, about 20 years later, some of the offspring started to want to know who their natural father was.  I am not sure of the outcome of that one.  I can just imagine  at 42 years of age, a 20 year old showing up claiming to be my son after I joylessly inseminated his mother 20 years earlier.   Imagine explaining to my 8 and 10 year old children where their half brother came from.  

It's tough killing somebody when you really want to.

When I like to impress people about my job, I tell them that I have enough drugs in my anaesthetic cart to kill somebody several times over.  The last person I told this to said, "Thanks for not doing that."

This is why I read with interest and quite a bit of disgust about the series of botched executions in the US.

As a disclaimer I oppose all killing including by the state.  There is no question that what murderers have done is beyond reprehensible.  I feel that killing somebody years or decades after the actual event lowers our society to a place lower than the murderer.  As a teenager I read Truman Capote's "In Cold Blood".  The theme of the book was that while what the two murderers did was wrong, so was their execution many years later.  That's what I think Capote was getting at, he could have just been trying sell a lot of books.  There are some murderers for whom I wouldn't lose a lot of sleep seeing them executed but it is a question of degree and how heinous does a crime have to be before deciding to execute somebody.

Canada has not to its credit executed anybody since 1962 and abolished the death penalty in 1976 replacing it with life with no parole for 25 years for first degree murder.  Between 1962 and 1976 many murderers were sentenced to death, the government let them sweat while their appeals were exhausted, then commuted the death sentence to life imprisonment.  Prior to 1962, Canada had an automatic death sentence for murder and strung people up with great gusto.  The reason for relaxing the death penalty originally was not out of concern that it was wrong but rather that there was concern that juries were acquitting defendants rather than see them face the death penalty.  Canada started sentencing people to 25 years before parole 38 years ago which means that there are a significant number of people convicted of first degree murder walking the streets in Canada.

Periodically one of our right wing politicians brings up bringing back the death penalty.  The common theme is, "but we won't hang people anymore, we will just execute them by lethal injection."

So while large percentages of the American and Canadian population support the death penalty, their support is hinged on the perception that that actual execution  is humane and most importantly it is done out of sight.

Our forebears on the other hand treated executions differently.  They were painful and  long, usually occurring  within hours to weeks of the actual sentence.  They were also for the most part done in public.  There were also no appeals.

As society changed fewer crimes were punishable by death, executions were moved indoors, viewed by only a few witnesses and replaced by methods thought to be more humane.  Methods like the electric chair, the gas chamber and lately lethal injection were all felt to be more humane. (Actually Thomas Edison invented the electric chair to demonstrate how dangerous AC electricity was; Edison favoured DC current.) Appeals were added to make sure the judge and jury actually got it right.  And along the line, most countries and quite a few US states banned the death penalty.

About 30 years ago when some US states started contemplating lethal injection, I suspect most anaesthesiologists thought very hard about just how much drug it would take to kill somebody and what combination would they use.  I suspect some anaesthesiologists were asked formally or informally what they would recommend.  The combination of pentothal, pancuronium and potassium was arrived at.  I am still not sure what doses they used.  Pentothal on its own as many anaesthesiologists have found out is lethal on its own, however the pancuronium and potassium provide the coup de grace.

This seemed to work quite well until pentothal was no longer available in the US (or for that matter Canada).  As I have blogged in the past, pentothal was a perfectly good drug, not as good as propofol still a drug a lot of us would still like to have the option of using.  This caused a problem for executioners in the US because the only source of pentothal is from the EU, all of whose governments have banned capital punishment are not enthusiastic about supplying a drug whose only purpose is to kill people.  Pentobarb widely used in euthanizing animals has been considered but it is not approved for use in humans (it might kill them?) plus nobody knows what dose is lethal or even amnestic in humans.

This lead to an attempt to get propofol which apparently is no longer manufactured in the US with almost disastrous results as the EU threatened to cut off the supply to the US until the supplier begged the state which had obtained the propofol thru underhanded methods to return it.  Propofol which is more cardiostable and less of the respiratory depressant than pentothal might not even be that good a drug.

Therefore I gather midazolam which is still made in the US has been used in at least two botched executions, one execution in combination with hydromorphone.   The touted advantage of the the midazolam/ hydromorphone combination is that it can be given IM if venous access is a problem.  Of course IM injection is unpredictable especially in someone who is peripherally shutdown because they are after all about to die plus to give a lethal dose you would have to inject large volumes.  Combinations of benzos and narcotics are as we all know frequently lethal when you actually aren't trying to kill somebody but apparently work less well when you are trying to.

But it would seem that as soon as it was apparent that getting a good execution cocktail was no longer easy, that state legislatures would just say, "look we've tried as hard as we can to find a pleasant way to kill people but we just can't so why don't we just get rid of this death penalty thing and lock them up for life without parole."   Aside from the fact that the death penalty isn't a deterrent (murderers either don't expect to get caught or don't care if they get caught) and the fact that by conservative estimate 1/25 persons on death row is actually innocent, would this make sense?

Lost in this whole discussion is why the US with a population of 317 million has to import drugs?  If this leads to anaesthetic drugs once more being manufactured in North America and we can start to forget about shortages or impending shortages I just might not be that opposed to capital punishment. 

Bloody stupid

About 2 or years ago a patient, lets call him Patient A was having surgery at the Big Downtown Hospital (BDH).  For various reasons intraoperatively it was deemed that he needed blood and so the anaesthesiologist drew blood for cross match.  This was put into the appropriate tube and handed to the nurse.  Shortly after, things got better and it was decided that Patient A didn't need blood after all.  The nurse put the tube on a ledge in the operating room.

The next case was Patient B.  Intraoperatively it was decided that Patient B also needed blood.  The nurse (maybe the same one or a different one) saw the tube of blood on the ledge, assumed it had been drawn from Patient B, put Patient B's sticker on it, filled out the appropriate forms and sent the sample to the blood bank.

Fortunately for Patient B when the blood bank ran the blood sample they checked against Patient B's records and discovered that Patient B had not only been typed in the past but that his blood type was different from the sample that was sent to the blood bank which was of course Patient A's blood.

A certain tragedy was averted.

Now there were obviously a few procedural issues about collecting blood samples in the operating room at the BDH that needed to be addressed and certainly the nurse(s) and the anaesthesiologist involved in this case needed to be taken out to the woodshed on this.  Unfortunately we don't take people out to the woodshed anymore when they screw up.  Instead we get bodies like this involved.

Therefore instead of meeting with the individuals involved, presenting this at the local QA committee and developing or reconfirming a policy of properly identifying blood samples drawn in the OR, multiple high paid individuals, mostly removed from clinical practice got to pontificate about this for several weeks and finally arrived at policy, which we we all learned of for the first time when it was announced as a fait accompli.

Henceforth a type and screen done must have a second confirmatory blood sample drawn to check the blood type if the patient has not previous had a blood type. This doesn't just apply to samples drawn in the operating room where this event occurred, but also to samples drawn by the lab, who already have fairly rigourous procedures for identifying patients and labelling samples.  Hematology also announced that rather than routinely collecting this second sample in elective cases that needed it, they would not because they were too busy and that it would anaesthesia's responsibility to collect the second sample (not withstanding the fact that it was anaesthesia drawing a blood sample which caused this problem in the first place).  But don't worry said hematology, if because of time pressure it was not possible to send the second confirmatory sample they would send O negative blood.

This is somewhat moot in that many patients have had a blood type done in the past including every obstetrical patient who has had prenatal care.  Further as the hematologist pointed out to me only a small fraction of patients who get a type and screen actually ever get transfused.  And as he kept repeating, it is not like the patient will not get blood, they will just get O negative blood.

This was not reassuring for me or my colleagues.  Most of us feel that we have enough to do at the beginning of the case without having to check whether the patient has had a previous blood type, draw the blood and fill out the forms.  With newer transfusion guidelines, we let patients bleed down to what were previously considered dangerous hemoglobins which means when we need blood, we need it now.  Most of us consider giving O negative blood a sign of failure, an admission that we were not properly prepared or vigilant enough.  There is also of course the issue of the supply of O negative blood if we are going to be giving it out willy-nilly for purely bureaucratic reasons.  Being O negative myself, I wonder what happens if I get into a car accident driving home from work and there is no O negative blood available because they gave it to other patients.  (The hematologist assured me that as a man it would be perfectly safe for me to get O positive blood).

I have never seen an ABO transfusion reaction in my career, nor am I aware of any in any hospital where I worked.  I have however been in multiple situations where blood was needed and was not immediately available for various reasons and it is sickest feeling mainly because even if it wasn't your fault, you always blame yourself, you should have called earlier etc.

Our hospital's hematologist was very good during all this.  This policy was arrived at with minimal if any consultation of front line physicians.  I watched him come to our department meeting and patiently explain the policy which I could pretty much see he didn't agree with but had to implement.  Some of our guys gave him a rough ride.

Things seemed to have calmed down now after months of shouting matches over the phone between members of my department and the blood bank and we are finding a way to work with this policy.  (I seem to spend a significant amount of time as department head figuring out how to do end runs around stupid policies.)  No one seems to be harmed by it (except for patients getting an extra stick) and nobody seems to be benefiting from it.

This is what happens when anaesthesia doesn't control who sets up their machines.

Somebody sent me these photos of ET CO2 tubes gone astray.  OR administrators think that anybody can set up an anaesthetic machine.  Usually this means the nurse who is orienting to the OR, the casual who works once a month or quite often the student nurse gets to attach the circuit to the anaesthetic machine before the case.  

Hmmm what's this little tube with a female Luer lock on the end.  Where does it go?  No problem just find a male  Luer lock to attach it to.  Doesn't really matter where.  Just attach it.

ET CO2 tube connected to anaesthetic mask.

ET CO2 hose connected to Sevo drain.

Another post from Great Z that I wish I could have done myself.

Welcome to my life.

We agreed to work stupid hours, they agreed to pay us stupid amounts of money

I recently posted on this.

As it happened I attended a recent meeting of our provincial medical society and this whole issue was front and centre.

At the meeting the deceased father gave a moving but rational presentation on the events following his son's death.  He has tried to put a positive face on his son's death that maybe this can prevent other events or near events.  We learned that his son was an engineer and a pilot in other words an intelligent individual not some yahoo.  Not that that should have made any difference to how he was treated.  We also learned that he did indeed die of a pulmonary embolus.  What he didn't say was what the emergency room doc who saw him the day before did to rule out a DVT.

Their take on the whole mess can be found here.

This generated much discussion.  Much discussion was of course on looking for passive ways of improving communication and what almost nobody wanted to say was that unless we go back to the way we practised 20-30 years ago, we can expect similar events.  One younger doctor did say that the doctors who graduated with him, universally expect to make large amounts of money for as little work as possible.  That was when the President, an old GP came up with the statement in the title, which is essentially the social contract between doctors and society.  His point was that you can't get rid of one stupid without getting rid of the other stupid.  Part of the problem is the fact that 100 or so years ago we did agree to work so hard, which is why we have never set up systems to deal with problems during the day and after hours because there was never any need to because the hard-working doctor was always available.

In face as people started to want to work less stupid hours they were able to do so because other people were still willing to work stupid hours and pick up their slack.  GPs got out of the emergency rooms because other doctors were willing to work there leading in time to the specialty of emergency medicine.  They got out of hospital medicine because specialists were willing to look after their patients for them.  They got out of obstetrics because obstetricians could do normal deliveries for them.  As specialists got sick of working, the hospitalist was invented meaning that really two doctors are now getting paid for what one doctor used to do.   Medicentres enable docs to see large number of patients over a fixed shift with no long term follow-up.  Specialists started to hive off the lucrative and easy parts of their practice, leaving the rest of the work for their not so smart (or more ethical) specialist brethren.

Remuneration is not a problem.  We now have after hours premiums and retainers for being on call that I could only have dreamed of 30 years ago.  

Not to complain but anaesthesia is one of the few specialties that actually works harder now than they did 30 years ago and we haven't figured out how to get hospitalists to do our work for us.  A lot of us feel guilty the odd time we have to let a resident do an after hours case by himself (those of us who have residents).   

The interesting thing about this case is that 30 years ago, not being able to contact his urologist would have been moot.  He would have called the hospital switchboard or visited the emergency and would have been seen by the urology resident or by the rotating intern on the surgical service.  Rotating interns are of course extinct and urology residents now take call from home.  House staff worked really stupid hours for not so stupid money in the old days.  Not saying that that was right and I support to a degree the more relaxed lifestyles residents have today.  Problem is that as residents eased out of the medical workforce, especially the after hours work force, nobody thought who was going to pick up the slack and it certainly wasn't going to be the consultants.

Interesting times and it will be interesting to see how the medical profession in Albertafigures its way out of this problem or whether it is forced to do something by outside forces.  It is again quite possible that we will just weather the storm until the next outrage.

Working 9 to 5

http://www.hqca.ca/assets/files/December%202013/Dec19_ContinuityofPatientCareStudy.pdf

This is a very long document however the chronology is summarized on Page 6.

This unfortunate,now deceased, man developed a mass in his testes for which he consulted a physician at a walk in clinic on two separate occasions months apart.  On the second occasion he was referred to a general surgeon.  After 3 months he had not heard from the general surgeon's office but developed back pain for which he consulted the same physician (you know where this is going).

He was sent for a battery of tests which showed something ominous.  An urgent CT of his pelvis was ordered and performed.  When he didn't hear about the results he went back to the walk-in clinic but was told that the doctor who ordered the test no longer practised there and he was given an appointment to see another doctor who at the radiologist's suggestion ordered an ultrasound of the scrotum, making the diagnosis of testicular cancer.

He was referred to a urologist who worked in a multi-urologist practice grandly called an Institue of Urology (this seems to be an affectation of urologists, our city's group also calls itself an institute).  Unfortunately far from being an institute, this institute, like the one in our city is just a bunch of doctors who share office space.  It turns out that the urologist he had been referred to was on a long vacation and nobody was looking at his referrals to see if there might be something urgent like a testicular mass.    This, our patient found out when he phoned the urologist's number and got a recorded message.  Another urologist was located and surgery was performed urgently with follow up scheduled at the local cancer centre.   Two months passed between the presumed diagnosis of testicular cancer and the actualy surgery.

Two days later our patient noticed swelling of his legs.  After not being able to reach his surgeon (or presumably whoever was on call for the Institute) he went to the emergency where the ER doc ignorred the red flags of leg swelling in a post-op patient with cancer and sent him home where he died suddenly the next day.

The report doesn't say what the autopsy found,  My money is on a pulmonary embolus but what do I know?

I can be a little smug about this because I am an anaesthesiologist and we don't have to deal with patient care issues like this.  Trust me, if there was a way to blame anaesthesia for what happened here, we would have been blamed.

This report hit the press a month or so ago and generated some outrage until people forgot about it and started worrying about important things like Justin Bieber and the Olympic Games.  

The story re-emerged last week when the Registrar of College (medical board) issued this rebuke to the whole medical profession in our province. 

This was followed up by a letter to all physicians saying the same thing.

Like most catastrophes there was a chain of small mistakes resulting in a huge fatal mistake.

1.  The patient went to a walk-in centre.  This may be because he didn't have a family doctor or maybe just because his family doctor wouldn't give him an appointment when it was convenient for him.

2.  Instead of thinking, "hmmm testicular swelling in a young man... rule out testicular cancer", the walk-in doctor referred him to a general surgeon.  Now in the old days, some general surgeons did urological procedures and this is probably still the case in the developing world which is where the walk-in doctor is most likely from.

3.  Presumably instead of having his receptionist call the office to arrange an urgent referral, he just faxed an illegible referral form which the general surgeon's secretary couldn't read and so just put it on the pile with the rest of the illegible referral forms.

4.  After discovering that the man probably had (mostly likely) metastatic cancer, instead of then getting on the phone to a urologist or an oncologist, walk-in doctor #2 faxed in an illegible referral note to the a urologist at the Institute.  Presumably nobody was looking at this fellow's referrals.  On the other hand did they even have a mechanism for triaging really urgent referrals.  Probably not.  And of course trying to get any specialist on the phone is next to near impossible.

5.  Not knowing exactly how he presented to the ER and what degree of leg swelling he had or what investigations the ER docs did, it is hard to comment on what happened there.  At the very worst,the ER doc may have just thought, "OK he is seeing the oncologist tomorrow, he will take care of this."  Because you know, getting a venous doppler, phoning the urologist or starting someone on heparin is a such a drag.

Canada has socialized medicine.  What we really have are hundreds of physicians practising independently, the only commonality being the single payer.  While the government and individual physicians are spending milions on EMRs, these unfortunately do not talk to one another.  It is quite likely that even if the emergency room doctor worked at the same hospitall where the surgery was done, the operative report might not have been available to him on the computer because it hadn't been typed yet.  The urologist's consult would definitely not have been available.

The headline above was that our registrar reminded doctors that medicine is not a 9-5 job which unfortunately may come as a surprise to many doctors.  He also took the time to reminisce about his long ago career as a general surgeon and the excellent coverage he provided.  I actually worked with him 15 years ago, before he bailed for what lead to his  current job, and for a general surgeon he did provide pretty good care to his patients.  He didn't mention however, that he worked in a teaching hospital where his house staff fielded, screened and triaged all his calls for him.  He might have seen into the future how house staff coverage was going be eroding and that might have been why he bailed.

I have been practising for 31 years now and maybe I am looking back at the past with rosy glasses but it seems that we used to communicate better and actually try to serve our patients a little better.  There may be reasons for this.

There is the whole boomer, Gen X and Gen Y thing and how they look at life differently.  I could expound on this but others have done so more eloquently.

More and more there has become more of a divide between primary care docs and specialists.  Primary care docs used to work in hospitals, they largely don't now.  Primary care docs and specialists used to train together at least as junior staff.  Now primary care docs and specialist train in their individual silos with no interraction.  There used to be more respect between the groups.

Finally the licensing bodies have gradually over the years lowered the bar in what is considered standard on communication between doctors and after hours coverage.  While I suspect most people are already in the process of changing this, I can predict pretty safely that if I call most family doctors' and quite a few specialists' phones after hours, I will get a recorded message directing me to call 911 or go to the emergency.  Further many patients that I see in the pain clinic tell me that their doctor has gone on vacation with no replacement.  This used to be only patients from rural areas with small numbers of doctors, increasing I see it in patients from the city.  A couple of summers ago, one of the medical clinics in the town where I have my dacha placed an ad in the local paper announcing they were closing their office for all of July and August.  There was no suggestion where their patients would be going.  Who can blame them, when you live in a resort community what a drag having to work?  Likewise patients have told me that they have shown up at their family doctors office, only to find he has left town permanently.

Further complicating matters is the fragmentation of care.  Patients have slices of their care provided by various specialties and subspecialties.  There is very little communication between them.  They obtain their urgent care from a walk-in clinic where they see a different doctor every time.  It may be fine to parcel out pieces of the patient but conditions overlap and who is in charge when the shit hits the fan?  I am guessing the answer is "not me"

We talked about this at our Medical Advisory Committee meeting last Friday.   A couple of the surgeons stated that their patients had been admitted to hospital with complications of surgery and they had never been notified.  They only found out when the patient showed up for a follow-up visit or didn't show up because they had died.  A pulmonary specialist complained that patients he was following would be admitted to internal medicine and he was not called.   A lady from admin who was there, stated that yes, they had known for years it was a problem and that not calling a doctor who might actually know something about the patient's condition frequently prolonged the patient's hospital stay.  She didn't say why admin had not tried doing something.

Anyway it strikes me that the horse has long left the barn on this and I am interested in how our licensing body is going to play this out.  I am attending the semi-annual representative forum of our provincial medical society this weekend and it should be interesting.