Monday, March 31, 2014

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.

Sunday, March 30, 2014

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

Sunday, March 16, 2014

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.

Wednesday, March 12, 2014

Working 9 to 5

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.  

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.