2015 in Review

I haven't been posting much in 2015.  There may be a lot of reasons for this.  Blogger fatigue, too much time on Facebook, maybe I finally got a life.  But for those who still read this here is 2015.

I started the year as I had done the previous 8 years on a Medical Mission to Ecuador accompanied by my wife who works as a nurse.  I was fortunate this time to have two colleagues from my department accompany me.  I have always recruited from other cities, other departments; this time it hit me, I work in the best department in the world why not invite some of them.  So I solicited the 4 or so people who I thought might be able to go and who could get along the surgeons and nurses, 2 of them said yes and so off we went.  

Our mission is to do total joints for hip dysplasia as well for Rheumatoid Arthritis and some osteoarthritis.  Before I first went, I had questioned the utility of doing such major and expensive surgery in a developing country as opposed to say spending the money on public health or something.  Thing is, most of these people are hugely disabled in country without much of a social safety net and there really isn't much short of a total joint replacement that is going to help them.  Of course there are more patients needing the surgery than we can do in a week so there is always the prioritizing and rationing aspect.

What I like most is the team aspect.  Many of the team go down every year and it is always great to work with them again.  Somebody asked once why I come back every year and I said because of the team.  Wrong answer?  I guess I was supposed to say because I wanted to help people which is supposed to be why I went into medicine.  

I think that coming on these missions has made me a better anaesthesiologist and physician.  One thing you learn in the developing world is how to do the best you can with what you have.  This is a very transferable skill to the developed world.   The other thing in a mission like this is that you see the planning and teamwork that goes into surgery, something we don't always appreciate in Canada.

Cuenca where we work has become like a second home to me and I told my wife that if the mission ever stopped, I just might keeping on coming.  

We often take a post mission vacation in South American but didn't do it this year and returned with most of the team following the mission.  

I once again rode in the MS Bike Tour with a team of my colleagues including this year a couple of OR nurses.  My wife and I had ridden this on our own and it was gratifying a couple of years ago when people approached me about forming a team which has increased in size.  We all ride a our own pace but we always meet a the rest stops and this year we rode as a team from the last rest stop to the finish on the second day, letting our slowest rider a 60 something lady who rode a mountain bike cross the line first.  I really recommend riding in the MS Bike tour in your area or sponsoring a rider or just donating, it is a first class event and the people who organize it are great, without the attitude we see so often associated with charities and volunteers.

I was also able to go on a group ride from Mt Robson to Clearwater in July.   This is a nice ride with a net elevation drop and only a few large hills.  We had a really nice group which is nice because group dynamics can make or break a ride.  This was organized through Mountain Madness which I cannot say enough good things about.

I have to reflect on how 10 years or so ago I started riding longer distances and how I have become what some people consider a serious cyclist and MAMIL even if my wife usually has to wait for me.  Some of the rides I have been on I could not have ever seen myself doing.  I was talking a year or so ago to one of my now team members who was concerned about the distance at MS Bike Tour.  "90 km," I told him, "is not a long distance."  Okay yes it is.

I had a little mini-sabbatical.  I felt sorry for one of the residents who had finished and didn't have a job so I gave him all my weeks in July and August and just did the pain clinic weeks.  On top of this I had a cycling vacation already planned in Slovakia followed by a 4 week educational mission to Rwanda.  Taking the extra weeks in the summer was just the tonic I needed; I typically take 3 sometimes 4 weeks but in a city with 7 months of winter, you really want to take advantage of our summer such as it is.  This also enabled me to take the above bike trip.  Most of the extra weeks I just spent at the dacha.

Our Slovakian bike ride was everything we had hoped for.  Technically we started in Budapest and finished in Kraków.   Budapest we had visited in 1999, when it was still quite shabby without a lot of restaurants and tourist infra structure.  It now has all of that and is a beautiful city to visit. 

Our in-laws joined us on the trip.  We had some adverse weather, climbed some huge hills, ate some great meals and stayed in some really nice places.  I strongly recommend this guided trip which can be booked through Freewheeling, a Canadian company or Greenways a Czech company.  We had a couple of days in Kraków after the end.  Kraków was a city I have always wanted to visit and it was everything I had hoped for. 

After Kraków my wife and I flew to Amsterdam, a city I now regret waiting 58 years to visit.  We had 2 fantastic days exploring Amsterdam before we went to the airport, I turned left and my wife went straight.

It was my second trip to Rwanda.  This is a teaching mission through the Canadian Anaesthesiologists Society International Education fund and is aimed at teaching Rwandan residents in anaesthesia.  I had  done this in 2011 and had left frankly a little disappointed and frustrated.  This was in a sense unfinished business for me.  

The educational aspect of the trip unfortunately proved to be another disappointment.  Part of the reason was the success of the program, there are more Rwandan staff anaesthesiologists (very gratifying since I trained some of them) than before so there is less for the Canadian doctors to do.  Another factor was that there are now American Volunteers through HRH who tend to be better funded plus HRH has donated equipment which tended to marginalize the Canadian volunteers.  In addition the teaching program had expanded to two other hospitals in Kigali which spread us very thin.  There were of course all the frustrations of trying to practice medicine or rather to teach others to practice medicine in the developing world and while there are issues of equipment and training there is still an issue of attitude which is a barrier.  I do sound negative however I did notice a lot of positive improvements in surgery and anaesthesia since 2011.

There were also distractions of not having water in our apartment most of the time and a major case of traveller's diarrhea which laid me low for a couple of days.  African toilets are pretty disgusting and the most disgusting ones are unfortunately located in hospitals.

I did take advantage of the tourist opportunities and visited Akagera National Park on the Tanzanian border which is Savannah land, the gorillas on the Congo border and Ngungwe National Forest which is the last untouched rain forest in the country and where I finally got to see a chimp up close.

I was quite happy to leave after 4 weeks which I told my wife were the longest 4 weeks in my life.  I did arrive home somewhat rested, refocused and was prepared to get on with things after 3 months mostly away from work.

Then as I already blogged I got fired as department head.  I should get over this but it has overshadowed the fall for me.

Soon after returning it was back to the airport and off to Las Vegas to see Jimmy Buffett in concert.  I had been a big fan in the late 70s early 80s but had sort of lost touch until a few years ago I bought his box set.  I was pleased to see he was still playing concerts, got tickets for this concert and my wife agreed to come.  We went to the pool party in the afternoon.  It was my first experience with his fans the Parrotheads.  The concert of course was fantastic.  

Vegas on the other hand is a bizarre artificial place whose sole purpose seems to be to extract as much money from you as possible.

In November we flew to Winnipeg for the Grey Cup which is Canada's football championship game.  Our home team was playing which was bonus although we had booked the trip and bought the tickets months ago.  Winnipeg is a way better city than its reputation and they put on a pretty good party.  Of course our team winning topped off the whole weekend.  

In December I went to New York ostensibly for the PGA meeting.  This was a popular meeting when I trained and worked in Eastern Canada but I had never gone to it.  I was able to fly on points in business class which is a bonus and my wife and I got to look around, walk the High Line, go to some decent restaurants and saw two musicals (Lion King and The Book of Mormon) before my wife flew home and I stayed for the rest of the meeting.

I got back from NY on December 15 worked a couple of days and then it was Christmas break and done to the dacha.   

The real highlight of 2015 was getting rid of two Conservative governments as in a shocker the NDP dumped the Conservatives in Alberta after 40+ years and then in the fall the Liberals dumped the federal Cons.  Okay I would rather have had the NDP beat the Cons and I hope the Liberals live up to their promises, something they haven't really done in the past but I would have voted for the Montreal Canadians against Harpo and it is great to feel good about being a Canadian again.

Overall a pretty nice year all told.  I think I will take it easier in 2016.  

Deposed

Almost two months ago, I got deposed, fired, terminated however you want to put it from my job as Department Head.  Officially I was told my term had ended (it hadn't actually) and I was not being renewed.  I was told they wanted somebody younger and who worked full time.

Firstly don't feel sorry for me.  I only got paid a very modest stipend that probably compensated me barely for lost clinical earning time and for the after hours work I did.  I am still working in my same clinical capacity only with a lot more freedom now that I have no more administrative duties.  I am sleeping better and drinking less.

Over the year or so prior to my dismissal I had noticed a chill in my relations with the administration.  The hospital had shaken up its administration meaning that some of long term relations I had with various people were no longer there.  In addition the shake up meant that some positions were vacant for up to a year which was a little frustrating.  I noticed that we had fewer meetings ( a good thing) but that the meetings we did have were meetings where things were announced as fait accompli with no opportunity to even discuss them.  I noticed that I seemed to be more out of the loop, I found myself eavesdropping on surgeon's conversations in the OR lounge to find out what was really happening.

When we did actually meet I found that any disagreement was looked on as bordering on treasonous and often taken personally.  After one meeting one person took me aside and asked me why I didn't like her?  I tried as best I could to be pragmatic and modulate decisions made by administration into something that could actually work in the real world.  This of course put me in conflict with my own department who are a lot less pragmatic than I am.

About six months ago I actually drafted a resignation letter but I thought that would just leave an power vacuum which the administration would exploit.  So I did what they said to do in all the administration courses I took (usually paying with my own money), I hired an executive coach (using my own money which I justified by saying it came out of my stipend).  I had four sessions which were interesting as a venting experience but was really not much help.  After 4 sessions that coach said she would follow up in a few months but I think she just gave up on me as lost.

I took some time off during the summer during which I had a long European vacation and did a one month medical mission.  By time off, I mean that I still answered emails and even attended some meetings by teleconference.  This gave me some time to reflect on what was going down and what I had to do.  I came back feeling that I knew what I had to do, that I could patch up things with administration and the directions we had to go in the next year.  I was actually excited about coming back.

There was the ominous request for a meeting with the Medical Director as soon as I got back.  I didn't sweat this; we meet every few months, I air my grievances, he airs his.  Nothing really gets accomplished.  This meeting about a week and a half after I got back, started with the usual pleasantries and I aired my list of problems.  This went on for about 20 minutes after which he told me that the medical administration was being re-jigged, that my term was up and that they wanted somebody younger and who didn't work part-time (I do chronic pain part-time although I am on site at my hospital 7.5 days out of 10.)  I was a little shocked both that it finally happened but more so in the calculated way it had just happened.  From the conversation I had gathered that I would stay on as care-taker chief until somebody was chosen but the next day the hospital announced by memo that although I was "held in esteem", I was no longer department head.  Having been given the uncharacteristic courtesy of reviewing the memo in advance, I was able to pre-empt this with my own memo.

The response of my department was one of outrage which was gratifying although I suspect some of that was that one of them would have to do it or worse, we would get somebody from outside.  An emergency staff meeting which I didn't attend was held and a letter was drafted.

Meanwhile I headed down to my dacha, walked along the river and stared at the mountains and by noon Saturday, it was all clear.  I could fight this, maybe "win" and live in a poisonous relationship with administration or I could just  focus on all the things I had had to let slide over the last five years (like writing this blog).  I composed a group email, stating that I no longer wished to be department head and that I was at peace with administration's decision.  I asked them to unite behind their acting chief and whoever was chosen to succeed me (almost two months later and no movement on that end).

It is unusual after being involved in the running of the department and aspects of the hospital to just be completely out of it.  I occasionally see down the hall somebody I used to meet with a lot who I never see anymore.  Some of the time I think how little I enjoyed the time spent with them.  A few weeks ago I arrived a little early and the OR committee was meeting next to the OR lounge and of course I used to attend those too.  My email inbox is now manageable size.  I occasionally hear of some problem and think how nice it is that I don't have to solve it.  I can exercise before or after work because I don't have any meetings.

I am still not sure what prompted my whatever you call it.  I kind of wish I had gone out with some outrageous, quixotic, act of defiance which people would talk about for years to come.

Last weekend my department had a nice what I called a "welcome back" dinner.  Speeches were made (actually just one speech) and I got some nice gifts.  I wonder, if the hospital changes its mind, do I have to give them back?

My new religion

I was in the pain clinic a couple of days ago hearing a patient tell me how his doctor wouldn't order a certain treatment because it was against the doctor's religion.  Already doctors are refusing to provide such services as birth control or referral for abortion citing religious reasons.  Some refuse to treat unwed mothers, some homosexuals.  

Since my parents let me stop going to church and Sunday school when I was 13, religion has not been a part of my life.  I have attended the odd wedding, funeral baptism or midnight mass but I suspect I have spent more time in churches as a tourist than as a participant.

But now that I realize I can actually refuse to do things I don't enjoy doing based on my beliefs, I think I just got religion.

Henceforth:

I am not going to observe isolation precautions.

God obviously loves antibiotic resistant bacteria because he makes so many of them.  So who am I to stop them from being fruitful and multiplying.  My righteous brothers and sisters on the wards are already helping this by allowing patients on isolation to go outside to smoke and visit the cafeteria.  Plus I think wearing yellow gowns is specifically proscribed in Deuteronomy or maybe Leviticus.

I am not going to do patients with no coverage (yes we have them in Canada),

I think the passage about render unto Caesar covers this.  I mean, how can I tithe if I don't get paid.  And for what you or  your Canadian relatives paid for you to fly to Canada for pro bono surgery, I am sure there is a little left over for my modest fee.  Plus if you came to Canada to ski or ride in the rodeo and didn't buy adequate travel insurance maybe you don't deserve to have your broken leg fixed.  And I really don't care if the surgeon also didn't get paid, because I expect in about half the cases he actually is getting paid.  Therefore if you want my services you better visit the money changers at the ATM in the hospital lobby to get some money to make the  appropriate offering.  Some people might get a warm fuzzy feeling from providing services for free to people but my righteous life gives me all the warm fuzziness I need.

Working on the Sabbath is out.

I haven't got this Sabbath thing down yet.  Is it Saturday or it is Sunday?   Never mind.  I won't work on either.  Nor on Statutory holidays or should I call them feast days.  Hmmm better think this one out....we get paid more to work on those days.  OK I will work those days, except when I am tired, hungover, something good is on TV, I don't like the surgeon or the slowest nurses are working.

No more emergency sections for breeches.

I'm not talking about the breech vaginal delivery gone wrong; I'm talking about the "stat" section for a persistant breech because they have either started labour or their membranes are ruptured.  Funny how these stat sections never happen during office hours.  If God wants you to come out butt first, you should come out butt first.  Besides if untrained birth attendants in the developing world can do a breech delivery, an Obstetrician with five years training should be able to.  

Because I am a righteous family guy, I get to go home when I want to and take vacation when I want to.

My kids are grown up but still it is the principle.

Obese patients violate my beliefs.

I am sure there must be something in the Bible about this.  We are blessed with a nice premium for patients with BMI over 35 so I will keep on doing those but the 45s and higher where you actually earn the premium are out. 

I am not going to fill out narcotic tracking forms.

Narcotics are one of God's gifts to mankind.  Besides as a righteous man of God, I would never misuse narcotics (and if you really to see what I may have given the patient, you can consult the holy anaesthetic record). 

No more futile surgery.

What can I say.  Who am I to try to interfere with God's will.

If you want me to come to a meeting before work you better provide breakfast and that breakfast better include bacon.

In my religion bacon is a sacrament, and if you expect me to get up half an hour early for a meeting to decide something you could have settled by email or phone call you better feed me.

I intend to live my life outside of work righteously as well.  For example some extreme religions do not allow their adherents to sit next to a woman on a plane.  Okay, it is an abomination for my legs to touch the seat in front of me.  Therefore the airline in the interest of religious freedom must allow me to have a bulkhead, exit or business class seat.  For no extra charge of course.  Also my religion prohibits me from sitting next to young children, people with body odour problems, people drunker than me or obnoxious people.  

I am sure in time I will find more ways in which society can ensure my life goes in as righteous a fashion as possible.  Stay tuned and God bless you all, except those of you who piss me off.

Reflections on a quarter century

25 years ago today or maybe it was yesterday I gave my first anaesthetic as a specialist.  I remember it was an oral surgery list.  I also remember my first patient was a Pediatric patient and I remember thinking how it was a good thing I hadn't looked carefully at the list the night before because I might not have slept well knowing I was doing a kid first.  Fortunately that child and the two other patients I did that day did well.

The child I would have induced with Halothane before starting an IV, giving a muscle relaxant (probably vecuronium) and intubating after which I would have maintained him with N2O, oxygen and halothane.

The two adults I would have used Alfentanyl, thiopental to induce and either succinylcholine or vecuronium to intimate.  I would have maintained with nitrous and oxygen and either isoflurane or enflurane.  Because the surgeon may have wanted induced hypotension, I may have used curare as my muscle relaxant.  Morphine would have been given for analgesia and I probably gave droperidol as an antiemetic.  Interesting how many of the drugs I used then are either no longer available or have fallen out of favour.

My machine would have been a Boyle machine.  No electronics, no software, driven by compressed gas and just as safe or safer than the $100K behemoth I use today.  To switch fron the bag to the ventilator, you manually disconnected the bag and connected the ventilator hose, remembering to close the APL valve.

The anesthetic circuit was the Bain circuit, with its necessary high gas flows which meant you went thru at least 1 bottle of isoflurane a day.  The circle circuit which had fallen out of fashion was just coming back into fashion.  Circuits were changed every case but there was no filtering.

Monitoring was with EKG, NIBP, pulse oximetry, and  ETCO2.  The latter two had only recently been mandated as standard.  There was no expired gas monitors.  Most of us figured that by dialling in a certain percent, we got a certain end tidal gas concentration.  Pulse oximetry had not been mandated in recovery yet.  Our recovery had one or two pulse oximeters which they put on whoever they figured needed it the most.

A significant number of patients were admitted the night before surgery which meant seeing them the night before after your list  and coming in Sunday evening.  At our hospital then, the person on call saw all the pre-ops which meant 10-20 patients on Sunday evening on top of doing emergency cases and I remember rounding at 2300 some nights. (When people complain about the pre  assessment clinic I remind them of this, but so few people remember having to do this that it doesn't work any more.)

Cholecystectomies, appendectomies, and hernias were still done open.  The laparoscopic cholie appeared early in my career ( initially three hours of farting around followed by an open cholie), the others later.

Over time things changed.  Propofol was introduced early on.  At first pharmacy refused to supply, then rationed it; I got into the habit of mixing it with Pentothal, I called this mixture President's Choice propofol.

Muscle relaxants came and went, rocuronium came and stayed, less so cisatracurium and pipicuronium. Curare disappeared soon after I started.  Pancuronium hung on until recently.  Atracurium and vecuronium, introduced while I was a resident are gone.

Sevoflurane and desflurane appeared in the mid to late 1990s.  I still don't think they are much better than halothane and isoflurane which have also disappeared from use.  So has enflurane.

The laryngeal mask airway was introduced early in my career.  Who remembers mask anaesthesia?  That was how we did short cases like D+C s and cystoscopies, holding the mask with one hand, and writing up the chart with the other.  Some of our older colleagues even did longer cases and had elaborate set ups with the black mask strap and tongue depressors to free up their hands.  (Periodically a resident comes across the mask holder and asks me what it was for).  The LMA has mostly supplanted the ETT in many of the cases I used to intubate although I am still a lot more conservative that some.

When I started well over half of Caesarian Sections were done under general.  Now GA is reserved for special exceptions and dire emergencies.  Some commentators are now saying we don't do enough GAs. Unfortunately in my time the section rate has increased from 15-20% to 30%.

My malpractice premiums were $9000 (14,600 in 2015 dollars) that first year.  I currently paid $8600.  I would like to think that this is because we are all better anaesthesiologists but I credit the pulse oximeter for most of this.

One constant in my career has been the drive to cut costs.  For the past 25 years, the mantra has been that health care costs are spiralling out of control.  With that logic they should now be consuming 200-300% of the total provincial budget or GDP however you want to express it.

One major change in anaesthesia and in medicine in general has been the increase in obesity.  On my fellowship oral exam, I remember being given a case of a morbidly obese lady presenting for a D+C.  I see at least one such lady every time I do the Gyne list.

Two things I thought were inevitable when I started have not come to pass.  Today as I have for the past 25 years, I charted on a paper chart.  Lots of places have an EMR; in my chronic pain practices I use an EMR at some but not all sites, but if you offer me good odds that I will not be exclusively charting electronically before I retire I will take them.  Secondly I am still billing exclusively fee for service.  I gave this 5 years maybe, when I started.  I will take the same odds that I will be billing fee for service until I retire.

Since my first day I have moved cities once and lived in 3 very different neighbourhoods in my current city.  I have fathered a second child, and watched 2 boys grow up.  I have gone thru 4 dogs.  I became an accidental chronic pain specialist.  After working unhappily at the C of E I now enjoy my life at my medium size Catholic Hospital.  I have gone into and survived administration.

When my wife learned I was blogging on this, she asked if I was nostalgic or whether I was happy with the way things had changed.

I am nostalgia for the way I felt during the first few weeks in practice when everything was a novelty, and you realized that after 4 years of training, you had made the right decision and you were competent at it.  You never get that feeling back.  I feel nostalgic for some of the people I first worked with who helped me out.  I also feel nostalgic for the little town in Atlantic Canada where I first worked for 2 years before I went to the Centre of Excellence.  I don't know how many times in the first few months, I wanted to call them and ask for my job back.  All in all I still think that the move was for the better.

Have things gotten better?

I do like the short acting drugs we have now although they are not always a short acting as we would like them to be and sometimes because we don't respect them we get into trouble.  Like the recent article in Anesthesiology suggesting that a significant number of patients still get discharged incompletely reversed from their intermediate muscle relaxant.  Pancuronium and curare we knew lasted a long time, so we used them sparingly.  If the surgeon complained about bucking while he was closing, we didn't give another dose.  It may be a good thing that patients are more awake post-op, however I wonder how whether the recovery room nurses appreciate the awake, anxious, painful patients we now drop off as opposed to the sleepy ones we used to.  No matter what anaesthetic you use, discharge is driven by things like policy, availability of porters and when the patient's ride shows up on time.  When I recently had a colonoscopy with sedation, I liked being able to walk out 15 minutes after the end of the procedure (I told my wife, "I've driven in worse shape then this.")

The greatest advance in anaesthesia is the pulse oximeter.  The ETCO2 is also a useful monitor and one I am glad to have.

With the medical system in constant crisis, I often wonder whether we are worse off.  I sometimes think that we are like the frog in the pot of water that is slowly being heated, and don't realize that we are being boiled alive because it is so gradual.

I like history and one of the advantages of growing old is to look back on how things have changed (and how things have not changed) ; how dogma becomes heresy and how heresy becomes dogma.

Looking forward to the next 25 years.

Good doctor, bad cop

When I was on the Big Pharma speaker gravy train, I used to give a lot of talks on prescribing opioids for chronic pain.  In one talk I remember saying that you had to be at the same time Rex Morgan and Sipowicz from NYPD Blue.  In retrospect I don't think I influenced a lot of doctors; most of them, I now realize, were there for the free meal or for the CME points.

While no one can agree on how or whether to treat chronic pain and the prescription of opioids is controversial there are certain facts or beliefs I still hold.  One is that a certain percentage of patients have pain that no amount of exercise, lifestyle changes, or chat therapy is going to help.  The second is that a certain percentage of patients do well on oral opioids.  The third is of course that some patients are in both groups.  

Oral opioids of course come with a price.  A certain percentage between 6 and 15% will become addicted to them.  Addiction is different from just using opioids, it is different from developing a tolerance to them and it is different from developing a withdrawal syndrome if you stop taking them.  This confusion always clouds any discussion of opioid addiction both in the medical and lay community.  The other issue is that a certain percentage of oral opioids leak out into the community where people buy and sell them for non-pain related issues.

The problem of course is that no matter how carefully I assess a patient, no matter how many addiction screens I administer, I can't predict with certainty whether a patient will become addicted to his medication or whether I am being duped and he intends to sell his OxyContin.  

To combat this, smarter people than me came up with the process of universal precautions.  The cornersone of the universal precautions is the urine drug screen.

 According to the gurus of universal precautions, everybody should get a urine screen on initiation of treatment and regularily.  This includes both the little old lady with a compression fracture and the oil field worker with the bad back.  Once you start administering UDTs however, you shift over from Rex Morgan to Sipowicz. 

Firstly no matter how nicely you explain it, asking someone to pee in a bottle before you prescribe them a medication starts your relationship off on a rather strained note.  A significant number of these UDTs are negative which means you have done them for no good reason.  The next issue is how you deal with the positive results.  

Probably the worst thing that can happen is that the medication you are prescribing is not even in the UDT which means the patient is not taking the medication and presumably selling it.  Some narcotics don't show up in generic UDTs, in our centre hydromorphone doesn't.  Most psychopaths are smart enough to at least take some of the drug they are getting from you and selling, so that doesn't happen very much.   Our lab tests for methadone metabolite, presumably some people just added the liquid methadone they weren't taking to their urine sample.  

What happens more frequently is that another substance shows up in the sample.  Marijuana is quite common.  Quite a few of the patients I see freely admit to smoking marijuana either recreationally or for pain reasons.  I used to smoke marijuana, all my friends in university used to.  Most of us just raise our eyebrows at this and go on.  Cocaine and amphetamine are a bigger concern and generally when these show up, it is time for a serious talk or to discharge them from your practice.  This is what I did recently when I discovered a patient of mine had had 3 recent positive tests while under the care of another doctor.  

Is it perhaps time to look at cocaine use as a marker for addiction.  Taking out the crack and meth heads, a lot of people who we call respectable use cocaine occasionally or regularily.  As has been observed, if it was not for the apetite for cocaine in the affluent class, it would not be worth importing.  Patients and physicians who treat these patients, have told me that cocaine use is part of the culture in the construction and oil field industries.  (Cocaine because it is cleared rapidly has become preferred to marijuana  in those industries that get job related UDTs)  I met someone a few years ago who told me he had brokered a cocaine sale between a friend of his and two anaesthesiologists who he didn't name but who worked (and still may be working)   at the hospital I was working at.  

The rationale of course for booting somebody over a positive test for cocaine is the assumption that they are selling their prescription in order to obtain cocaine.  There are of course other explainations.  Some of these people are working, something we who treat them are very proud of, and can afford many illicit substances.  Some have spouses or friends who are happy to share.  Some regretably use their meagre disability or social assistance income to buy their drug of choice (just as they do with cigarettes or alcohol).

Most of us in the medical profession have won the lottery in life.  With a few exceptions, we grew up in nice neighbourhoods, attended college and medical school unaware of how the majority of the population live or what their values are.   It shocked me to find out how some people lived their lives and I still impose my middle class WASP values on the patients I see.

Take double doctoring, a sure fire warning sign of drug abuse.  Turns out the doctor-patient relationship may mean something to doctors but it has never meant anything to patients.  In the small towns where I practised as an unhappy general practititoner most patients were happy to see just about every doctor in town.  Not just to get narcotics or sedatives.  They shopped around for second opinions, for antibiotics and for convenience.  In this time where so many patients have no family doctor and where doctors screen their patients and limit their practices, it is hard to think of a time when there was a glut of primary care docs and I remember angry fights between doctors over who the patient belonged to.  This still goes on.  When I review medicolegal charts it is not unusual for patients to be seeing doctors in two different practices over the same period of time.

A common scenario I see is where a patient's family doctor retires or moves away and they can't find anybody to either take them on as a patient or prescribe their meds.  There is a 1+ year wait list for the pain clinic so what they do in the interrim, they buy their drugs.  Why would you not buy something that has worked for you in the past, if you can't get it legally?  Or they borrow from somebody.  But who hasn't taken someone else's medication.  One time in medical school when I had a migraine, a well meaning classmate gave me some of her Fiorinal.  I didn't know what it was (it didn't work either) and I was a little horrified when later I found out what I had taken.  I used to see patients who were taking the antibiotics that had been prescribed for a family member and not finished.  I used to lecture them on this.  Then I was talking to a colleague, "Oh, I tell them to save the leftovers in case they get sick," he said.  What's a bigger societal problem, addiction or antibiotic resistance?   Think really hard about this.

And why do we treat some addictions differently from others.  Smoking for example is a risk factor for low back pain and for CRPS both of which I see in the pain clinic.  So why am I telling patients I won't treat them if they use cocaine which probably isn't hurting them but will treat them if they continue to smoke which actually is hurting them.  Obesity which could be said to be form of food addiction is a huge cause of chronic pain.  Even exercise is an addiction in some patients, some of who come to pain clinic but I see a lot more in the OR getting arthroscopies for their sore knees.  Even alcoholics tend to get a pass, unless they come in falling down drunk.

Like most things in medicine there are no easy answers to any of the questions and I guess as long as I continue to treat chronic pain I will have to continue on in my dual role.

Childhood Illnesses, a memoir

One of my oldest memories is the Christmas of 1959.

Christmas, 1959, was the Christmas I had measles.  I still remember seeing pictures of me at Christmas in my pyjamas with a blanket wrapped around me which was, then and now, all you could really do for measles.  I didn't suffer any ill effects and it wasn't until 20 years later in Medical School that I learned about all the bad things that could have happened to me.

As an aside, I have actually seen cases of measles in Canada.  One year, an entire cohort of children got vaccinated with a bum batch of vaccine which meant about 5 years later we had teenagers all the same age presenting with fevers and rashes and I finally got to see Koplik's spots.  All of the cases I saw were mild suggesting there was partial immunity.

By that time vaccination existed for polio, diphtheria and tetanus all very nasty diseases.  We were not that far removed from the polio epidemics of the early and mid 1950s.  We were constantly reminded of it by the kids in wheelchairs and the kids with leg braces some of whom attended school with us.  

Diphtheria is of course a really nasty disease, thankfully as a physician primarily working in the developed world, I have never seen a case.  I do remember reading in Kipling's autobiographical

"Stalky and Co." how the headmaster saved a child with diphtheria's life by doing some sort of 19th century intubation or tracheostomy.  Not sure whether this was based on a real incident or just something Kipling thought up.  Tetanus I have seen, usually in older adults some ending up on ventillators some not, at least one dying from it.

I remember going for my vaccinations as a toddler.  My mother would take me to the public health unit where a nurse would paint a rabbit on my arm with mercurochrome and stab the rabbit with a needle.  It still hurt although the ice cream cone afterwards almost made  it worthwhile.  Later, I get the Sabin vaccine which came on a sugar cube.

Vaccinations took place in the schools in Grades 5 and 10.  I believe it was possible to get a note from your parents exempting you but I don't think anybody did.  Why would they?  As I mentioned, we still had reminders of the polio epidemics all around us plus a lot of our parents had had a sibling, friend or classmate die of an infectious disease.

Along with vaccinations for diphtheria tetanus and polio, we were vaccinated for smallpox.  I was re-vaccinated for smallpox just before medical school in 1978, making me one of the last people vaccinated for it.

Vaccines for measles, mumps, rubella didn't exist when I was a child so I got to have them all along with chickenpox.

I got mumps at 3 or 4 which I remember as not all that bad, again treated by wearing pyjamas during the day.  I do remember my older brothers who got it the same time as I did were a little sicker.  Mumps has a lot of adverse consequences although more in adults.

Pertussis or whooping cough I got at age 6.  I don't know if I even missed school.  I did have to miss the swimming pool part of a friend's birthday party but not the dinner and ice cream after.

Chickenpox came at age 7, keeping my out of school for a few days (although this time I didn't have to wear pyjamas) and postponing my father's home made haircuts which I hated.  Chickenpox as I found it in medical school is highly contagious, one of my classmates who had never had it spent less than a minute in the door of the room of a child with chickenpox contracted it which means he wasn't allowed on the wards until the infectious disease department deemed him fit to do so.

Rubella I didn't get until age 17.  It was again a mild disease, fever and myalgias and I stayed away from school for a week or so.  Rubella of course can cause congenital malformations and I could potentially have infected somebody something I still wonder about.  Rubella was still fairly common when I was in medical school.

While living in university residence in 1976, I came down with a very severe flu, which years later I figure was probably the H1N1 strain, then called swine flu.  I missed a couple of days of classes and basically crawled to classes for another few days.  I have not ever been so sick.  I never sought medical attention, some people with the same thing who did, were promptly hospitalized.  

If it appears I am making light of all the vaccine-preventable diseases I had as a child, I am not.  I was shocked when in medical school I learned what could have happened to me as a child.  I often wonder how my mother who had been a nurse and who knew of the awful consequences of these diseases kept calm with sometimes 3 children sick with something.  As I have pointed out, this was still in the early antibiotic and vaccine era and many adults then had had somebody close to them die from an infectious disease so there may have been a fatalism that helped them get through. That same experience of premature death was why the parents of my generation embraced vaccines so enthusiastically.

We of course did a lot of things in the 1960s which we would never do now, like not wearing seatbelts and I like to think that as a society we have evolved. I continue to be disappointed.

I got profiled

I have been reading for some time now about the profiling of blacks and other visible minorities some just a hassle and some tragic.  I often think, how can the police be so stupid?   Then I thought about what happened to me 30 years ago and how it made me feel.  Now I didn't get arrested, didn't get frisked and suffered no consequences (one of us did which I will explain below).

The summer before I started medical school I was working for the forest service in Wells BC.  Nice little town, you should visit there; I haven't been back, for no specific reason.  There were 4 of us working up there and by accumulating overtime hours, which as casual staff we were supposed to take as time off, we were able put together a 4 day weekend, so we headed down to the coast where we were all from.

We left around 3 in the afternoon on a Thursday four of us in a beater car,and stopped for Chinese food in 100 Mile House.  I had a beer with supper, I can't remember if the driver did; it wouldn't have been more than one.  We kept on heading south passing Cache Creek on to the Fraser Canyon.

It was on the appropriately named Jackass Mountain that it happened.

As we proceeded on, going at or slightly above the speed limit, there was an RCMP cruiser parked along the side of the road.  As we passed it, somebody, maybe me turned his head to look back at it.  "Don't look back," said the driver, somewhat annoyed.  We all knew you never looked back at police cars because it invited suspicion.

Now we were all university or technical school students.  I became a doctor; I have lost touch with the other three, I am sure they all went on to become productive members of society.  We were just a little nerdy.  Our hair wasn't short but it wasn't that long.  And we were all white.

Within a minute of the look back, the cruiser was on our tail with the lights on.  We pulled over to the side and the driver got out his license and registration. As the cop walked over and stuck his head in the driver's side window I still remember what he said.

"You guys look suspicious, why do you look suspicious?"

He made us all give him our names.  I knew that legally I didn't have to do that but it was getting late and we just wanted to get down to the coast.  He asked a few questions about what we were doing and finally we were on our way.

At that time the Fraser Canyon highway went through rather than around every little town which of course meant slowing down from 80 km to 50 km, which most drivers didn't bother with.  So about 30 minutes later cruising through Boston Bar going with the traffic flow, our car , of all the cars going the same speed, got pulled over for speeding.  We figured the cop on Jackass Mountain had radioed ahead.

Because it was our driver's second speeding ticket that year, it cost him his safe drivers discount on his insurance, worth about $150 which he was a little pissed off about.  The other three of us suffered no consequences other than getting home a little later than planned.

I have thought often about that incident,  now almost 37 years ago, and how I felt and I can only feel sorry for those people for whom this is a weekly or daily occurrence.