60 Christmases

Seems like every year brings some type of milestone event.  While I haven't reached 60 yet, this Christmas will be my 60th.  I don't remember the first two.  The third was the Christmas I had measles which I previously blogged about.  I have memories of that Xmas although they may be enhanced by the photos in the family album I have seen many times.  My first two Xmases were not documented perhaps with a 4 and 16 month old plus two other youngsters my parents may have had other priorities besides taking photos.

 I remember most of the other Christmases although some merge into one another.

Growing up in Victoria, white Xmases were rare, rain was not uncommon and quite often we had quite a pleasant day.  These were a bit of a drag as your mother would shoo you outside to play when all you really wanted to do was to play inside with your toys.  An exception was the Xmas when I was ten and got a bike.  I had asked for one, I really needed one as the hand me down I was riding was too small for me and frequently needed to be fixed, but I didn't know whether I would get one.  On Xmas morning I got a note from "Santa" in my father's handwriting telling me he couldn't get my gift down the chimney but that I could find it in the basement.  Down in the basement was a black Raleigh 3 speed.  That Xmas I took advantage of the un-Canadian weather in Victoria to ride around the neighbourhood.

My parents were always generous with presents, given that we had 4 children.   Presents were usually something we needed like my bike and when we asked for something in the fall we were usually told to wait for Xmas.  This usually worked out.  We never got clothes for Xmas; my parents believed it was their duty to clothe us and clothes were not gifts.  We of course also got a lot of a silly and fun stuff.  

On the 24 my brothers and I usually went downtown to buy presents for each other with the allowance money we had saved.  This usually meant a budget of $1 per person and it was an interesting time time to find a gift in that range.  My parents of course always bought other presents for us and there were presents from the relatives.

My mother who I think (hope) loved Xmas spent most of December buying presents and baking.  She also made Xmas dinner single handedly.  This included fruitcake which she started in November.  She made enough that we could eat it all year.  When we got married, my wife at my insistence, made fruitcake until we both came to the conclusion that nobody actually likes fruitcake.  There was of course Xmas pudding which is almost as bad as fruitcake which my mother made lots of and we ate all year round.

Xmas dinner came with the crackers which came with a little toy and a funny paper hat which we always wore throughout supper and into the evening.

I stopped believing in Santa Claus when I was 7 and a kid in our class who was a year older told me.  I should have figured it out.  I had stopped believing in the Easter Bunny already.  I remember when I was younger, my mother told me I couldn't get out of bed as I might scare Santa and lying in bed with a full bladder in the early morning afraid to leave my bed.   I also remembered going to see Santa at the Bay and being scared.  Santa who was a little gruff, noted when I got on lap, "I saw you in line and you looked scared, why is that?"  I worried for the rest of the season that I had upset the Big Guy.

We always had a family picture taken at Xmas.  Initially we all posed under the tree holding our favourite toy and in one photo you can see me pointing the toy gun I got at the camera.  Later after somebody sent us a Christmas card with a family portrait, my mother decided that we would do the thing and we for years all posed in front of the mantelpiece.  Someone would set up a camera on a tripod and used a time release which never worked and the photo sessions went on forever until we got a workable picture (or so we would find out a week or so later when we got the photo back from the drugstore).  We never did send out a card with a family picture.

Christmas day was a day spent mostly in the living room playing with our toys. These stayed out on Boxing Day. December 27, my father usually went back to work and gradually the living room got tidied up until, sometime towards New Years, my mother told us to take our stuff to our rooms.

I remember my first Xmas away from home when I was an intern.  I was in Halifax and assumed that everybody in Canada outside of Victoria and Vancouver had a white Xmas.  The weather in Halifax that winter was a lot like what I had experienced in Victoria, maybe a little bit more miserable.   I had some hope Xmas eve when I looked out the window of the ICU and big snowflakes were coming down but they didn't stick or last and I believe I walked home the next morning in a drizzle.  Getting home, I opened the presents my parents had thought to send, had a bit of a nap before heading over to a friend's house for turkey dinner.  All in all it was a pretty good Xmas.

My first Xmas with my wife and each of the first Xmases with our two children are of course memorable. 

I had the good fortune to not have to work on Christmas day often in my career.  The first year of my residency my wife was working so I volunteered to work and we had the turkey on the 24th.  Work was as I remember quite light that day and I mostly watched TV all day and into the evening.   We brought in leftovers from the day before and my wife and I ate together in the cafeteria.  

One year before I started my residency I was doing a locum in Victoria and staying at my parents' house.  The clinic I was doing a locum for told me (they may have asked but I think they just told me ) I was on call from them and two other groups for the Xmas week.  This consisted of mostly answering phone calls, making house calls and making the odd ER visit.  They did give me the name of a physician who could cover for a few hours if I needed.  It came on the 27th that I decided I would really like to to have dinner uninterrupted and phoned said individual.   "Why do you need me to cover," he asked in an English accent.  "I would like to have dinner", I replied.  "As it happened", he came back, "I am going out for dinner and if it comes to between your dinner and my dinner, I am going to take mine."  I suppose he couldn't help himself, he was after all English. 

For most of the past 20 or so years our family have spent Xmas at the dacha and this has become our Xmas tradition.

End of Life

The final scene from the movie "The Barbarian Invasions"

A year or so ago courts in Canada ruled that people have a legal right to what was then called assisted suicide and is now called physician assisted death but what is what used to be called euthanasia.  They gave the government a year to come up with a law.  Our former Tea Party government diddled around with this and it fell on our new government to come up  with a law.  The law they have come up with is predictably unpopular with both sides of the argument which some people would interpret as that it must be a pretty good law.

I generally disapprove of whatever you call it but as soon as you make arbitrary statements, all the what ifs come into play and these issues are rarely black and white but are rather shades of grey. I could expound further on the ethical issues but all kinds of other people who are able to use terms like beneficence and non-malfeasance and actually understand what they mean are already expounding in the medical and lay press. 

I work in a Catholic hospital.  While the Catholic church has historically had no qualms about killing heretics, Muslims, Jews, or Protestants; the idea of ending the suffering of somebody with a terminal condition seems to stick in their craw.  This is problematic because our sister hospital has 95% of the palliative care beds in the region.  We are assured by our medical director not to worry because most of the PAD will be delivered in the patients' homes because apparently  in the universe he lives in, patients still die at home.

This does give me an opportunity to muse about my experience with end of care.

The concept of euthanasia is not by the way a new one.  I remember having a discussion of it in Grade 10 English class of all places

Anyway as an intern I was towards the end of 8 unhappy weeks on Internal Medicine when we had an unfortunate patient admitted to our service in the evening.  This poor man had been otherwise well until a few days ago when he developed back pain and as we like to say, his bone scan lit up like a Christmas tree.  He had some type of untreatable cancer in his bones and he was deteriorating rapidly.   Now no death is really a good death but we could say that he had had an active life almost up to the end, unaware of what was going on in his bone marrow and that by presenting late in his disease, he was spared weeks of chemotherapy hell.  I doubt he or his family saw it that way.

The medical resident (actually a second year family practice resident) told the patient and his family that there was nothing that could be done and that we would keep him comfortable with morphine until the cancer took it's course.

That was when one of his daughters yelled, "what you are talking about is euthanasia!" and ran out of the room.

Nowadays that would generate an ethics consult, a palliative care consult, a week of chemo and possibly an ICU stay but in 1983 we didn't do that so he got IV morphine which was a relatively new concept then.  Instead of just running an infusion or having the nurse give the med IV (the patient might die?) the intern had to inject 10 mg of morphine every 4 hours.  That meant every 3rd night that was me.  On a q4h schedule, that meant a midnight and 0400 injection.  Generally you were up and around at midnight but at 0400 you were generally trying to catch a few minutes of sleep.  After almost 2 months on 1 in 3 call you would sell your mother for a few extra minutes of sleep.  As it happened I was on call on the above patient's last night on earth and after the midnight injection, I asked the nurse if she might consider a sc injection.  (From a pharmacokinetic point of view, sc injections would give a more steady state morphine level, which I should have thought of).  She of course laughed in my face and at 0400 the page came, I went to the bedside, she handed me a syringe which I injected slowly and went back to bed.  At 0500, I got the page to pronounce death.  "Aren't you glad you got up to give him that injection IV instead of sc", the nurse said.  "What the hell was in that syringe you gave me,"  I replied.

The second episode was early or late in my career as a rural GP.  It was my first weekend in a small BC interior town and I was on call.  Friday night I got a call about a patient with ALS who was at home.  I made a house call and listened to his chest and he had pneumonia.  The one thing I remember was that he was watching the playoff hockey game and I remember thinking, "too bad he's not going to find out who wins the Stanley Cup this year."  Funny the things you think.  I prescribed some oral antibiotic and went home to watch the rest of the game.  Sunday evening I got another call and made another house call and he was really in a bad way.  I called the ambulance which took him to the hospital ER and I could see that he was not going to survive the next few hours.  At the same time his wife seemed quite adamant that everything be done which left me in a dilemma because everything that I had been taught told me that you don't ventilate ALS patients ever.  I called his family doctor who worked in the same clinic at home because I figured he knew the family well and could come in an talk with them.  "Oh" he said, "Do you need help intubating him?".  I muttered something like I didn't really think intubation was appropriate and besides we didn't have a ventilator at our hospital.  Anyway it looked like his wife wanted everything done so we called in a nurse, loaded him up in the ambulance and sent him to the referral hospital an hour away by road.

I talked to the nurse, who went with him, later and she said that they almost intubated him at the referral hospital before they realized that he had ALS and he died shortly after.

I think about how better the whole case could have played out, how he could have died at home surrounded by his family or at worst in the local hospital surrounded by his family instead of spending the last hour of his life in an ambulance.   He might have even been able to watch a little
hockey.

His wife came in the next week to see me and I told her how sad I was that her husband died and she shot me a look that said, "Fzck you" and asked for prescription for Valium which I gave her.

Shortly after that I decided rural (or for that matter any) general practice wasn't for me so I went in the anaesthesia where we don't have to deal with end of life issues except of course for the six months of IM I had to do which had some really interesting end of life issues, one of which I blogged on years ago.

Somewhere along the line the whole euthanasia debate got hijacked by the concept of "passive euthanasia" which was if you didn't try every single futile treatment, that was the same as giving someone a massive overdose of barbiturates or whatever.  So over the past 25 years we now have end of life patients in ICU, or getting futile surgical procedures.  One third of the beds in our ICU are dedicated to ALS patients now.

Anaesthesia is in fact quite often involved in end of life care as I will outline below.  This scenario or something similar is not uncommon.

Granny is dying of colon cancer at home.  She has been seen by the palliative care team and is doing great until she develops a bowel obstruction.  Instead of taking her to the hospital with the palliative care unit, where they know her, she gets taken to another hospital.  There the ER doc or the internist calls the surgeon who without seeing the patient agrees to do a laparotomy/enterostomy.  The patient is told she is having a quick general anesthetic where she will have the obstruction relieved by a small incision.  She is seen in the receiving area by the surgeon and you for the first time.  In the OR, of course the tumour is stuck to the abdominal wall and bleeds, or the surgical resident perforates the bowel and all of a sudden cachectic Granny has an incision from her pubis to her xyphoid and the you know she is not going to breath post-op.  You could call ICU but you can already hear the peals of laughter from them when you ask for a bed.  So you take her out to recovery on a ventilator and the recovery room nurses are really pissed off at you. (The surgeon is meanwhile telling the family that she is being ventilated because of the anaesthetic.)

The bottom line here is that other people on your behalf made promises they didn't have to keep, she was just having a quick case, she wasn't going to die today.  Had you seen her, you may have said otherwise but you weren't invited to the discussion.

The other issue is that Granny is a DNR or whatever you want to call it (we have a very complicated Goals of Care document in our region).  Technically you can just turn off the ventilator and watch her struggle for minutes to hours until the hypoxia/hypercarbia trigger the final lethal arrhythmia.  You could even sedate her a bit.  Nobody really wants to see that though. I've turned off the ventilator on organ donors enough but somebody that you talked to an hour so ago?  Not sure about that one.

The other scenario is the pathologic fracture and the ensuing tumour embolus.

This is not to say that either patient shouldn't get surgery.  A bowel obstruction or a pathological fracture can be pretty incapacitating.  The issue is that in that population there is a high risk of death or requiring ventilation post-op and this is something that needs to be discussed with the patient and their family and never is.  Granny for example might elect for an NG tube and a lot of morphine or a radiologist might be able to do something percutaneously.

When I was on the admin dark side, some people came to our Medical Advisory Committee to discuss the above Goals of Care document.  I took the opportunity to express my concern about these scenarios and the fact that we are never invited to these discussions.  "Yes, that is a problem," said the nice lady and went on to the next question.

The final issue is that having decided it is okay for doctors to kill people under circumstances how do we actually go about it.  Because as I blogged in respect to Capital Punishment it is really hard killing somebody when you really want to.   I mean those of us who do "monitored sedation" know how easy it is to make somebody apneic and occasionally cause a cardiac arrest but when you really want to kill somebody it may not be as easy as you might want.

As I understand currently the practice would be to administer large doses of oral barbiturates.  20-30 years ago getting barbiturates was easy.  About half the population were on them as sleeping pills.  We even gave them to pregnant women.  If you gave somebody a months supply of Seconal you usually gave them enough to kill themselves.  Now if I order a lethal dose of a barbiturate, the pharmacist is probably going to ask some questions.  He may even refuse to fill your prescription. (A significant number of pharmacists refuse to dispense the morning after pill, presumably these people may have some opinion on euthanasia)     That plus in some provinces barbiturates are on the triplicate prescription program.  Assuming that you have gone thru the proper procedures for physician assisted death, you won't necessarily get in trouble but you may get hassled.

Of course getting somebody who has a swallowing problem or who is drifting in and out of consciousness to swallow all those pills is going to be a little difficult.  That is why probably a lot of euthanasia is going to be intravenous which has its own issues because IV access is not that easy as I find out once a week or so. 
  

The other issue is that a lot of the euthanasia candidates are going to be narcotic tolerant which means you are looking at bigger doses.  Dose is a problem because you can give a huge dose and still not kill somebody.  (I remember a story in medical school which I hope is an urban legend about somebody who took a huge dose of horse tranquillizers and woke up days later on the stretcher on the way to have his kidneys harvested.)   I have a friend who is now a retired anesthesiologist in Holland who tells me of GPs coming to the OR to "borrow" some pancuronium and everybody knows what they intend to do with it.

Looking forward into our brave new world of legalized euthanasia or physician assisted death (because why use one word when you can use three) who is going to be doing the killing?

I think a lot of doctors are already thinking, I'm just going to call anaesthesia, they have all kinds of cool drugs and besides we already blame them when somebody dies.  I think most of the leaders in anaesthesia are trying to keep a low profile lest more people think that way which is too bad because we as a specialty should be part of this debate.

There are the evangelical physician advocates of PAD who are already active and will probably do a good job of it  although there are not very many of them.  Knowing doctors as I do too well, I predict the following scenario.

We have socialized medicine in Canada which means that doctors who euthanize patients will expect to be paid.  This means that a generous fee will be negotiated, because this has been mandated by a court decision provincial governments will pay whatever is demanded.  This means a certain class of doctors, who we all know, are going to realize that they can make a killing out of killing people and it is they who are going to be doing most of the PAD.  

I am (or I guess I am not) a leading physician of the world.

This fellow had a similar experience to me and blogged on it.

In case you are interested in becoming a leading physician of the world, here is the website.

I am not sure how I got into this but it may have been while wasting time on  Linked In or I may have responded to a random email.  I must stop doing this.

Anyway I got a phone message today, informing me that they had reviewed my information and I was now a leading physician of the world, as long as I phoned the toll free number they left me.  I had a hole in my clinic and so I phoned the number and after some time on hold, I talked to a lady who went over all my information and asked me some questions, like to what did I attribute my success.  I am not actually certain whether I am in fact successful or what I attribute any success.  I suspect being born white, and English speaking, into a middle class professional family at a time when University tuition was affordable had a large amount to do with it.

As the clock ticked away on the phone call, I was beginning to wonder how an organization devoted to the noble cause of identifying the leading physicians of the world supported itself.  I soon found out as the nice lady started asking my about whether I wanted the platinum or diamond plans and the costs of these.  I realized what I should have know all along that I was being scammed.  I therefore told the nice lady that while 10 minutes ago, I had not been busy, I was now busy and that perhaps she could email me the info.  She didn't want to do this and so I hung up on her so never got to hear about the gold plan like my cardiology colleague, let alone the silver or bronze plans which no doubt exist.

Anyway I have failed again to grasp the brass (or was it platinum or diamond) ring and will have to content myself with being an ordinary physician.

The Demedicalization of the Caesarian Section.

First off, I am not in favour of natural childbirth.  I am interested in history so when I visit places that have a history, I occasionally visit graveyards.  I am always struck by the number of young women buried next to a newborn baby, because the mother and baby died in childbirth.  In Cuba when this happens, the baby is buried with the mother between her legs.  This is natural childbirth and if we want to accept mothers and babies dying as a natural occurrence, we should embrace this. 

Having said all this in my lifetime the Caesarian Section rate has gone from 20% to 30% with very little decrease in maternal or foetal morbidity or mortality.  It is at the same time well documented that materanal morbidity is increased with caesarian section versus vaginal delivery.

I was on call recently and did quite a few sections which gave me some time to reflect on this.

We do almost all our sections under regional nowadays.  This is a major change from when I was a resident where the majority of Caesarian Sections were done under general.  We would always see the patient the night before and try to convince them to have their section under epidural which was how we did them then.  Now patients are told by OB they are having their section under spinal and it is very rare to have a patient demand a general (some "experts" in OB anaesthesia think we now do too few GAs).  Sections under general anaesthetic were always a major stressor at least as a resident and even as a junior staff.  The patient would be awake in the room, the OR team scrubbed and the belly prepped and draped.  You would pre-oxygenate the patient and the nurse would apply cricoid pressure after which you would inject a pre-set dose of pentothal followed quickly by succinylcholine.  You would then attempt to intubate the patient, this was made difficult by the fact that you had to work with the drapes and one hospital where I trained made things especially difficult by insisting on using the ether screen.   ("Fortunately ", we didn't have a pulse oximeter for most of my residency; it was probably when we and the OB saw how low the sats went that regional began to be pushed more aggressively.)  The pregnant airway is as we are all told more difficult and I shudder to think of giving GAs to the BMI 60 patients we routinely see now for sections.  The fact that a significant number of these GAs were in the middle of the night or you had had to drop everything and rush up to do it added to the stress.

As I mentioned sections are now done exclusively under regional and it must be at least two years since I did a GA section.  After we put in the spinal or top-up the epidural, the patient is draped, the block tested and then the father is invited to come and sit at the head of the bed.  This is not always the husband/father, it could be the mother, a sister or a friend.  I remember on occasion having two people in the room but I suspect infection control has blocked that. Under regional, the sections are little more relaxed as there is not the race to prevent baby from getting some of mom's general anaesthetic drugs and in 5-10 minutes we have a baby.

This is when what I call the "love-in" starts.  Everybody's IQ drops about 20 points, everybody coos how beautiful the baby is, the father is invited over to the bassinet to cut the cord, photos are taken etc.  Our hospital now does skin to skin.  Such a beautiful and special moment.  Except.....

The mother still has a large abdominal incision and a big hole in her pregnant highly vascular uterus.  There is still the matter of getting the placenta out which may or may not be easy.  And there are little issues like amniotic fluid emboli and pre-eclampsia.  Further the OB is probably going to exteriorize the uterus which means that means that your patient is going to get nauseous and if the block is the least bit patchy, uncomfortable.  She may also get hypotensive from the spinal and from the blood loss.  In other words, your patient is not out of the woods and may need your attention still.

This happened to a colleague of my a few years ago.  I don't remember exactly what happened but he felt he needed some help with the patient and so asked for assistance from one of the nurses.  The love in was still in process and the nurses ignored him accidentally or intentionally.  This lead to him raising his voice (his version) or yelling (their version) and he got written up and had his wrists slapped.  I wasn't there and only heard his version so I can't really comment.

This is a difficult issue to discuss because a Caesarian Section is life saving for the mother or the baby in some circumstances.  Just how often is the question.  Certainly not 30% of the time.  A lot of women really wanted have the perfect labour and delivery and push out their baby and when in their best interests we have to section them, they may feel that they have failed and we don't want to reinforce this.  At the same time we read about the "too posh to push" mothers who chose to have a section rather than even attempting vaginal delivery.  There are probably variants of this and I imagine discussions going on in the OB office where the prospective mother states her concern about the difficult labour of her sister, friend or mother and states that if things look like they are headed that way, she wants a section.  I am not sure whether these discussions happen, I strongly suspect that they do and a significant number of "failure to progress" or "non-reassuring tracing"  sections are as a result of these discussions.

The demedicalization of the Caesarian section, benefits mostly the OB who no longer feels guilty (assuming they are capable of that) when she does a questionable section, because she wants to get back to her office, go for dinner, not have to hand off the patient etc, doesn't have to worry about depriving the mother of a wonderful birthing experience because after all a section is a birthing experience with mom awake and the father or whoever invited to participate.  

My argument is that by making the Caesarian Section less medical, more routine and more pleasant we are making it too easy and maybe we need to find some type of balance.  Not holding my breath on that.

First Do No Harm

There was recently an article published in a leading newspaper, referring to opioids, entitled "First Do No Harm".  I have discussed is this in the past and may again in the future, however the use of this adage struck me. 

I first heard this adage way back in medical school referring to anaesthesia and the fact that anaesthesia contradicts this principle.

In fact when the urologist discovers after the patient is asleep that the patient passed the stone already or the orthopod after the patient is asleep realizes that maybe he should have examined the patient or at least looked at the X-ray  and all the patient needs is a cast, I reassure them.  "Anaesthesia is good for you", I tell them.  I hope this makes them feel better but  most surgeons have no conscience anyway.

The fact is in medicine that we are constantly exposing patients to harm in the hope that we will make them better.   We are in effect betting the ill effects of a treatment versus the likelihood of helping the patient.

The House of God had it down with rule XIII:

THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

This of course isn't always in the patient's best interest either although is probably in their best interest more often than we think.

For example how often do you hear an doctor justify a procedure or test by saying, "I didn't no what else to do" or "Well I had to do something".  I have been guilty of this back when I was in general practice, in the pain clinic and quite often in anaesthesia when things are going south, how often do we try something random which we know probably won't work.  

Here's some questions to ask yourself.

1.  Based on your assessment is the patient going to die within the next few hours without treatment?

2.  Do you have any idea of what is going on and will either the test you order help make the diagnosis or does the procedure or treatment at least have a reasonable chance of stabilizing things.  

But speaking of aphorisms, what about the Hypocratic Oath.  A patient advocate asked me about this oath a few months ago in connection with an op-ed he was going to write.  

"First", I explained to him, "Many doctors, including me, have never taken the Hypocratic Oath."  Some schools have an elaborate oath taking ceremony.  My school didn't.  Am I a worse doctor for that?  "Secondly, " I went on, "there are multiple versions circulating including a modern version."  

"Thirdly", I pointed out, "Many of the things proscribed in the Hypocratic Oath are actually part of medicine, like cutting for stone, administering noxious substances (chemotherapy, anaesthetics) and abortion (controversial but still part of medicine). ". 

The Hypocratic Oath also has things like treating your teacher(s) for free.  We have socialized medicine in Canada and I work in a city where I didn't train, but that doesn't mean I would be interested in treating pro bono the 100 or so physicians who taught me.

About 20 years ago, I bought a handsomely bound of the "Aphorisms of Hypocrates" which now sits in my bookcase along with some of the other handsomely bound historical books from the same series.  And I read the Aphorisms.  I can tell you that if you practised in the Hypocratic fashion, it is a question of who would get you first, the licensing body or the lawyers.  I often wonder why we place such importance on the thoughts of somebody who practised over 2000 years ago.  I do like reading the history of medicine if only because seeing how wrong prominent physicians were in the past, puts into the context the modern practice of medicine. 

I think we need to spend less time worrying about doing no harm and more time stopping using outdated and irrelevant aphorisms.

Things that make my work worthwhile

My wife just read my last blog post.  "You sound like a crabby old man" she said.  Well for a number of years I worked with a lot of crabby old men (and a few crabby old women); sadly or not many of them have retired and there is a niche that needs filling because just as mosquitos and wasps are important parts of the ecosystem, COM just might be an essential part of the OR ecosystem.

About 2 years before I left of CoE, things were at a low point and morale was horrible in our department.  While the causes were at least to me pretty obvious, the solution was to hire a consultant to find out what was wrong.  I am not sure whether our department or the hospital paid for it.  Anyway those of us who wanted to meet with him were allowed a one on one meeting which I enthusiastically signed up for.  As most people who are earning $400 an hour are, he was quite pleasant.  So for about 30 minutes I detailed everything I thought was a problem with the operating room, the surgical service and the anaesthetic department.  At the end of this rant, he asked me, "why do you still work here?".   I thought about it and said something to the effect that I had been there for 10 years, I knew the place, I liked most of my co-workers and that I really hoped that things would get better.  I didn't say that I wasn't really sure I could get a job anywhere else, that the case mix at the CoE was so different from other sites that I wasn't sure that I could handle a different case mix and that I realized that the grass was not necessarily greener elsewhere.  A report which I never saw was duly produced, some minor cosmetic changes were temporarily introduced, things continued to get worse and I decided that maybe in fact I could handle the case mix at another place and that the grass was greener elsewhere.  

The one thing I remember about coming out of the meeting with him, was how good I felt having let it all out to somebody besides my poor wife.

But there are all lot of things about my work that make it all worthwhile.  Not in order of importance by the way.  

1.  The sight of my hospital in my rear view mirror at the end of the day.  (Okay it gets better.)

2. Being part of a team.  Sometimes we don't feel like it but we are part of a team and we can't function without each other.  That doesn't mean we always get along or have to get along but it is great to work towards a common purpose every day.  It is great when for example we get a heavy urology list and we all work through it together, finishing on time or when we all work together on a really sick or dying patient.  

3.  OR nurses.  I have worked with these men and women for 30 years now counting my residency.  I still find it incredible the way they can handle multiple surgical instruments, and complex electronics flawlessly, anticipating the surgeons' next moves.  On call I find it amazing that the same team of nurses can flawlessly go from a complex Ortho case, to a general surgery case and then to a urology case all with radically different equipment and requirements.   Or if I ask for a piece of equipment I maybe use once every 3 years, they can usually find it.

4. The jokes.  OR humour is probably the funniest and most inappropriate humour around which is why I can't give any examples.

5.  Patient contact.  We don't get much of it in anaesthesia but we get more than we are given credit for.  I really like talking to patients pre-op going over their history and explaining things.  I know I am sometimes brief and perfunctory.  I even like the stupid patients or the ones who clearly aren't paying attention to me.

6.  Hitting the sweet spot.  The time when every thing goes right, when you ask the patient to open his eyes as the dressing goes on and he does; and he seems comfortable and not nauseated.  Or when you get the spinal first pass.  Doesn't happen every case or it wouldn't be special.  

7.  My co-workers.  I already mentioned the OR nurses.  I get to work with a great group of anaesthetic colleagues and while the only time we get to work together is when the shit is hitting the fan, I really appreciate the support and cameradery we have.  Sure the surgeons really piss me off sometimes but I  do know that some of the stunts they pull are done with the patient's best interest in mind.  I should also mention all the other nurses, techs, clerks and orderlies I work with most of whom are great to work with. 

8.  Recovery.  Should have mentioned these nurses earlier.  Doesn't get the glamour of places like ICU, but the way these nurses can anticipate problems, pick up problems early and move quickly when the shit hits the fan is positively amazing.  They have saved my ass so many times.

9.  Being an anaesthesiologist.  Within a month of my residency starting, I knew this is what I was born to do.

10.  My lifestyle.  OK the surest way not to get an anaesthesia residency is to mention that we have a good lifestyle.  But we do.  No start up expenses, low overhead, fixed start to the day, when you are finished for the day you are finished for the day.  Easy to work part-time.  Sure there are specialties that have a nicer lifestyle but we have the satisfaction of doing a good job while we are at work.

Things that really bug me

Some of the people at work complement me on my relaxed laid back demeanour.  I would rather they complemented me on how intelligent and handsome I am but I have to take whatever complements I get.   Under that calm exterior lies a smouldering pit of resentment.  

Let me air my grievances.

1.  Electric beds.  Not electric OR beds, but I will get to those.  I am talking about the electric beds from the ward.  It does make sense to reduce the number of times patients are transferred and so some patients go to and/or from the OR on these beds.  Except, these beds are never at the same height as the OR bed which means plugging them into an electric outlet.  Of course they come with ridiculously   short power cords (short enough not to reach the wall but not short enough to not trip over) which means finding an extension cord so that they can be plugged in.  Did I tell you most of the beds in our hospital now have two plugs both of which have to be plugged in, so now two extension cords.  Aside from the fact that we really don't need two more things to trip on in the OR there is a potential electrical hazard here.  When I was a resident we had to learn about electrical safety and it seems that by law most devices in the OR are elaborately grounded to prevent shock to the patient and staff.  And apparently if you use an extension cord, this exposes the patient to micro or macro shock.    (Like I said, I learned about electrical safety, I didn't say I understood it.).  Oh and the new beds come with a piercing alarm which goes off if the bed is unlocked while plugged in, like for example when you are pushing it towards the OR table so you can move the patient.   

A lot of this could be fixed if the beds came with batteries which our OR beds do and which the hospital beds in the hospital in Ecuador where I sometimes work do (the floor nurses would still forget to charge it) or if they allowed the option of manually raising and lowering them without plugging in the bed.

Electric OR beds I for the most part like.  I miss strengthening my legs pumping up the table.  I don't miss wrecking my back bending over to crank the handle.  The only problem I have is with the surgical princesses who insist on moving the bed up and down side to side every 5 minutes.  Cuts into my phone call, Internet and of yeah monitoring the patient time.

2.  IV poles with more than 4 legs.  Space is limited in the OR.  OR tables are rectangular as are beds and stretchers. This means that the right angle of the IV pole with 4 legs fits in nicely against these objects saving space during cases or when you are taking the patient to recovery room or ICU.  Life was good the universe was in balance.  25 years ago the first 5 legged IV poles appeared.  Now they seem to have taken over.

Sadly this picture is typical.  Look at them:  three  5 legged poles (and in the background a lonely 4 legged pole)

Proponents of these claim they are less likely to tip over.  As we all know, if you load enough infusion pumps, blood warmers etc onto on of these, they can and will tip over especially if you add a urology size bag of fluid or two.   They will tip over most likely because some clumsy oaf like me trips on the legs.  And suggesting that adding legs makes them more stable shows a lack of knowledge of geometry because as I learned in Grade 7, three points define a plane which is why for centuries milk maids use three legged stools because they don't tip over.  Not to mention tripods.

3.  Infusion pumps.  Okay I use infusions all the time and would hate to go back to the situation like when I was in medical school where nurses counted drips to figure out how fast the infusion was going.  (My wife when she re-certified for nursing had to learn about drip counts; "nobody does that anymore," I told her.). I certainly don't object to having some medications run thru infusion pumps and I can see that in fragile patients and children, making sure they don't get too much fluid is important.

What really bugs me is the 20 year old with the fractured ankle who comes down with his IV running through an infusion pump.

And do they have to be so freaking complicated.  This is the 21st century.  I am a PC guy but when I got my i phone, I had it figured out and running within minutes.  Why do we now have to have hour long inservices on these pumps before we can use them.  Do people not realize that this is inherently dangerous?  Nowadays when an ICU patient comes down with 10 of these running, I usually try to ignore them, occasionally starting my own IV line.  This would be fine except the ICU nurses always set the VTBI (volume to be infused) to a low number so it will run out during the OR and the alarm(s) will go off forcing me to deal with it.  I think they do it intentionally.  

And can they trust people?   Why is everything locked up.  We got new PCEA pumps for OB recently.  We actually got to play with them at rounds before they went into service and liked  them (not that it would have made any difference if we hated them, they were already bought).  So a couple of weeks ago I decided I would use it on a patient, the pump was now inside a plexiglass locked case which not only made it difficult to read the screen but required a key which the nurses took 10 minutes to find.  Plus in addition to a key to lock the case, there was a second different key on the pump which the nurses also had to find.  

Do they actually think malicious relatives are going to turn up granny's infusion?

4.  This:

If you are concerned about your diet, just don't eat the doughnut or the muffin.  Don't just eat the top of the muffin or cut out half or, as somebody  in the above pictures did,  2/3 of the frigging doughnut.  Because despite all the lectures and posters on hand hygiene,  I know where your hands have been and  the type of person who would do this to a muffin or doughnut is the type of person who doesn't wash his hands, so you think I or anybody are going to eat the fraction of pastry you left behind?

4.  People who drink but don't make coffee.  You know the scenario.  You drop your patient off in recovery, see your next patient and in the remaining 5 minutes before they call you, head to the OR lounge for a coffee to warm you up and keep you awake for the next case.  Except there is no coffee left.  You look around the lounge and just about everybody has full cup so...one of them took the last coffee and didn't bother making another batch.  You could (and probably will) make another batch but you know this is going to be the time when your room turns over quickly.  Making coffee is not difficult.  Most of you went to medical school.  It doesn't take that long.  If you drink the last drop of coffee making another fzcking batch.  OK?

This by the way also applies to the first person in the lounge in the morning.  If you drink coffee, make the first pot.  Don't just sit there and when I arrive ( and I am never first) say morosely, "there's no coffee."

This applies to medical students, residents and sales reps who drink our coffee.

5.  Arm boards.  You would think by now they would have designed an arm board that attaches and detaches easily from the OR table?

6.  Residents, medical students.  Okay I was both a medical student and resident at one time, but I was much smarter, cooler, and hardworking.  Plus less klutzy.  This applies mostly to surgical staff.  I figure by now I have spent a year of my life watching students and residents painfully close incisions.  This applies to anaesthesia as well although our residents are way better and now the only medical students we see are thinking of applying to anaesthesia so actually know something.  Actually we at our place see residents so infrequently that largely I would just rather do my room by myself thank you very much.

Fellows are by the way just as bad and quite a few fellows clearly decided to do the extra year of training because they forgot to learn how to operate during the previous 5 years.  For some of them no amount of training is going to ever make them into surgeons.  

7.  The constant gaming of the "emergency list".   I know we can't just restrict our after hours work to life and limb threatening cases but when you can predict your on call workload based on what surgeons are on call things have gone too far.  Maybe things haven't changed , maybe I am getting older and crabbier.  Most of my 5 years as dept. head, I spent fielding phone calls:  from the anaesthesiologist on call complaining about what the surgeon(s) had booked; from the surgeon demanding that I call in a third anaesthesiologist to do the "emergency" case he had booked 4 days ago that had now been bumped by a real emergency.  

More idiocy from Infection Control

A couple of recent experiences on call thanks to our tireless infection control department.

A few months ago a patient presented for surgery.  A year ago she had Vancomycin Resistant Enterococcus.  This was cleared and she had negative cultures.  So she presents in the ER requiring emergency surgery, can't remember what, maybe a hip fracture.  Whoever did her history and physical noted that she had VRE.  Had can of course be present or past tense.  Notwithstanding her negative cultures on goes the yellow gown and we have to go into full paranoia mode in the OR.  Before the case, I ask the charge nurse, "can't we just call infection control and explain and get the isolation precautions lifted?".  No of course because it is the weekend and infection control doesn't work on weekends.  Silly me.

To our credit both the surgeon and I ignored the precautions which means there are probably multiple incident reports floating around.

Next a month or so ago the charge nurse informs me that the surgeon has booked a cholecystectomy.  But.... the patient has been to a hospital outside of Canada and by hospital policy has to be treated as a possible antibiotic resistant carrier.

So I am trying to imagine in what third world hell-hole she found herself in hospital.

Answer:

Phoenix Arizona.

Doctor do you ever make mistakes?

A few weeks ago a patient asked me an intelligent question.

He was in the OR, the checklist had been done, IV started, monitors on and he had even had a sniff of midazolam.  That was when he looked up and asked me, "tell me doctor, do you ever make mistakes?" The circulating nurse was at the head of the bed and heard this, so I had to answer.  Here's what I said, "yes I make mistakes but I try to detect them early and fix them right away."  And then I gave the rest of my induction cocktail.   After he was asleep, I said to the nurse, "any doctor who thinks he doesn't make mistakes is dangerous?"

This made me think about the nature of mistakes.  During my time as site chief I was of course involved in QA or QI and dealt with a lot of mistakes but never really got a handle on the best way to deal with them.   We read all the time about patients dying as a result of medical errors.  So let's look at mistakes.

Giving the wrong drug is an obvious mistake.  This can be like giving adrenaline instead of atropine, or phenylephrine instead of oxytocin; two mistakes I have heard of.  This is unfortunately too easy with lookalike drugs and the tendency to change suppliers on a weekly basis.  A few years ago I was having dinner with a bunch of other site chiefs and we started talking about the drugs we had heard of injected intrathecally by mistake.  These included ondansatron  (the only thing that happened was a failed spinal) and tranexaminic acid which should have caused a problem but didn't fortunately.  These are situations where you inject something other than what you thought you injected.

There are also times when you inject a drug which turns out to be a mistake.   Obviously these would include giving a drug to which the patient is allergic to, giving Pentothal to someone with porphyria or succinylcholine to somebody with MH.  Giving way too much of a drug to a little old lady could also be considered an error, one I think we have all committed.  

There are errors of judgement.  Giving a muscle relaxant to a difficult airway is one such case.  This is often a judgement case; the previous neck dissection is pretty obvious, the person with a small chin not so much.  Some errors of judgement are immediately obvious.  Others only become obvious on reflection either by yourself or frequently by somebody else who is reviewing the case.   Sometimes things look a lot more obvious in retrospect.  

There are of course errors of omission.  Missing something in the patient's history.  Not making sure you have the right equipment or not noticing the blood pressure dropping to mention a few.

There are of course times when you do something because you think it is the right thing to do and it isn't.  Take giving metoprolol for high risk surgery, or tight glucose control.  Remember flecainide and tocainide?  (Actually those were over 25 years ago most people don't).  One of my staff when I was an intern insisted on running IV lidocaine on our MI patients; the worst tongue lashing of my career came when I failed to restart the lidocaine after somebody stopped it.  Turns out IV lidocaine actually increases mortality.  Still waiting for the apology.  Then there is homonal therapy.  There are lots of treatments which we are still using that are going to be shown to make the patient worse.  My money is on proton pump inhibitors as the next culprit.

There are also complications of medical care that may or may not be due to mistakes.  We accept wound infections as a consequence of surgery but we know that some surgeons have higher infection rates or other complications.  

We often now talk about system errors as cause of adverse events in the OR but we have to accept that sometimes the adverse event is entirely due to human error and no system would have prevented what happened.  Looking at the individual, we have to then assess whether this was just a bad day or is this part of a pattern of multiple errors.  Sometimes we respond to what was an individual error by initiating cumbersome systems that will not prevent or mitigate the error.  

Some mistakes have immediate and serious consequences.  Some mistakes make cause consequences if they become part of a sequence of other errors or events.  Some (most) mistakes have no consequences at all.  For example if you forget to make sure you have a suction, that is only a problem if the patient vomits at the beginning or end of the case.  When to tell a patient of a mistake where there are not consequences or even when there are is tricky.  A few years ago at another hospital a staff anaesthesiologist was working with a medical student who after starting the IV hooked up the sux drip (remember those) instead of the IV.  The staff noticed this right away, but not before the patient became apneic.  The patient was put to sleep right away.  The staff however felt that he had to explain what had happened, to the patient who had no recollection of the event.  The result was that the patient sued him, claiming among other things sexual dysfunction, apparently a little known consequence of awake paralysis.   When deciding whether to disclose your mistake, you will get conflicting advice.  If you contact your malpractice carrier, in Canada the CMPA, you will be advised to talk to nobody about the case.  On the other hand hospitals have disclosure policies and our hospital has "disclosure coaches" who can help you to disclose the event to the patient.  This is probably less benevolent than it is about shielding the hospital from liability.  Then there is the question of how serious do the consequences to the patient have to be before you disclose.  Certainly if you are seen as covering up the mistake, things are not going to go well for you.

When I was a resident we had weekly M+M rounds which were public at which we presented our mistakes or how we got out of situations caused by other people's mistakes.  It was accepted that the discussion was privileged and could not be used in court.  These were the most educational rounds of my residency, especially as frequently a resident in the audience was put on the spot which forced you to come prepared and think.  Now we don't have M+M rounds or have them infrequently because people are scared that they are no longer privileged and could be used in legal proceedings.  Our legal department has not been able to give us a straight answer on this.  A year or so ago we had an obstetrical disaster with a good outcome.  Our OB department agreed to discuss the condition in joint rounds as long as we did not present the case.  When I was site chief, I would hear about something that had happened in the OR and would approach the individual(s) involved to get something in writing which they often refused even though as our department's rep on the surgical QI committee,the information was clearly privileged.  Our "quality" department was less than helpful here.  

But what about mistakes.  A few simple rules.

1.  Try to recognize them early on.  This means constantly questioning what you do.  No matter how good you are, you are going to make mistakes and some of them may unfortunately be catastrophic. 

2.  Fix them right away if you can. This is as opposed to covering them up.

3.  Own up to them.  That can mean disclosing them as above or just accepting that you made a mistake.  When I re-started adult band, my conductor told us that there was a convention that if you played a wrong note, you should admit it.  You can save a lot of rehearsal time by just saying, "I played an F# instead of F".  If you own up to a mistake, you might find that others have made the same mistake and you might all learn from them as below or at least others may be more vigilant about making the same mistake.  At the same time don't beat yourself up about them.  Move on.

4.  Learn from them.  You are still going to make the same mistake twice or even three times but you should learn something and even change your practice a bit.  On the other hand don't make ridiculous practice changes as the result of a small mistake or uncommon situation.  Where I first worked we had an OB who did not use cautery because when he was a resident, a single patient got a burn.  Stat sections with him were an interesting experience.

5.  Support your colleagues who make mistakes (this excludes surgeons and internists who you should always try to nail).

Oh by the way it's called Medically Assistance in Dying Now.

Afterall why use one good word (euthanasia) when you can use 4 words especially when you get a pretty good acronym out of it (MAID).

I Call Bullshit

I don't often call out patients.  Something about bedside manner that we sort of learned in medical school.  But a recent encounter with a patient makes me think maybe we should all do it more often.

I was sitting in a multidisciplinary assessment of a patient in a clinic where I work sometimes.  Now I believe many of this patient's concerns about her condition are quite valid and I have a lot of sympathy for her plight. 

She was going on about how for health reasons she only buys food directly from farmers she knows or eats game that her husband and she hunt or is hunted by people they know.  I have no problem with this.  I like to buy some but not all of my food at farmers markets often paying 50% more and while I don't hunt, I am not against hunting and if somebody offers me game I always take it.  I should support somebody who is trying to be pro-active about their health.  Except.....

She smokes 2 packs of cigarettes a day despite now having COPD.  

I had been letting my colleagues run the interview until the alarm from my BD became too loud in my head.  5 years of administration has increased my BT but this was too much.

"If you are concerned so much about what you eat," I said, "why do you continue to smoke, given all the harmful chemicals in cigarette smoke."  She replied that she had smoked for 30 years and was unable to stop.  The visit went on and I don't believe she came back for a follow-up.  OK, I am busy enough and maybe I couldn't have helped her anyway.  I also appreciate how difficult giving up smoking is, because really with all the evidence about how dangerous it is to your health, everybody who is capable of stopping has.  

A few years earlier, I had another almost identical  patient and never challenged her on this but maybe I should have.  

This encounter made me think however.  Are we hurting patients by not challenging them on their beliefs or behaviours.

A good example is the resurgence of vaccine-preventable diseases.  Now many of the patients/parents are not going to listen to reason, however how many family docs or paediatricians knew of patients in their practice, who had not been vaccinated and never challenged this because calling bullshit goes against our concepts of bedside manner plus you depend on the income from their office visits (and if you are in a small town, the visits of their friends and relatives).   Sure, most of them wouldn't have listened but maybe a couple would have.   Call bullshit. 

Obesity.   Look I weighed myself yesterday and I am pretty upset with what I found, not that I am going to forgo the Chinese buffet for lunch today.  But when your BMI 60 patient tells you, they do know why they can't lose weight because they don't eat anything, why not tell them that just to maintain that weight they need to consume 6000 calories a day and unless they have evolved to develop the capacity to photosynthesize, something is obviously going into their mouths.  And when they say they can't exercise because of their knee or back pain, tell them that exercise doesn't work without caloric restriction.  I have a lot of sympathy for fat people because I am one of them and I know how easy it is to gain weight and how difficult it is to keep it off but the odd person does this successfully and if you don't challenge them they might not get started.  So call bullshit.

Drug allergies.  A few years ago while still department head, I got a letter from our Patient concerns office.  Apparently a patient had presented for surgery with multiple anaesthetic "allergies".  Instead of trying to give an anaesthetic with the 3-4 remaining drugs she was not allergic to yet, my colleague called bullshit resulting in a complaint.  (In my response I called bullshit on the surgeon, who should have had this taken care of before the patient reached pre-op holding.  Sure as a urologist, he probably didn't talk to her but with these patients the "allergies" are usually the first thing they tell you about.)  Likewise my colleague who argued with a patient about her morphine allergy.  He got written up despite giving the patient dilaudid intra-operatively.  Then there is the adrenaline allergy which I saw a couple of weeks ago.  The patient said it makes his heart beat fast.  What happened of course was during an adventure in the dentists' chair a little or a lot of local with epi went intravascular, as happens even with good dentists, and instead of manning up and telling the patient this, the dentist took the cowardly route and told the patient he had an allergic reaction.  So if this patient actually has a real anaphylactic reaction under my care, am I going to go searching around for vasopressin or whatever else might work?   No of course, I am going to call bullshit and use adrenaline.  Likewise the local anaesthetic  "allergies" after a misadventure in the dentists' chair.  Penicillin allergies?  Years ago I almost killed a child with vancomycin because of a "penicillin allergy"  ( it was my resident but I am old school and take responsibility for what trainees under my supervision do).

And of course when the patient mentions how great his chiropracter/naturopath/homeopath is, call bullshit and remind them that when they have a medical problem at 3 am it won't be any of those 3 seeing them.  This also applies to conventional practitioners.  When you patient refuses to take your medication because of something the pharmacist told him, remind him that you went to university the same number of years as the pharmacist BEFORE you went to Medical School.  (I call bullshit on myself here; I only did 3 years of undergrad before going to Medical School).  Having said this, I do work closely with pharmacists and have gotten a lot of good ideas from them.

Surgeons who want to do cases after hours because patient has cancer.  Sorry unless it's an obstruction or a pathological fracture.  I already blogged on this.  Doing the surgery tonight or on the weekend makes no difference to your patient's survival and I am sorry that your patient got cancelled earlier because they misunderstood the NPO instructions or they had medical issues or as is usually the case, your list ran over because you still haven't figured out how slow you really are but after hours is for broken bones, appendicitis etc.  Likewise the guy who presented with renal colic 2 weeks ago but is now pain-free and afebrile; not an emergency.  I call bullshit.

Surgeons who game what after hours prioritization system you have decided to use so that they can do their cases when it is convenient for them.   Surgeons who bring in cases off their wait list to make their on call financially worthwhile.  I call bullshit.

And of course admin.

I now wish that during all the meetings I attended, instead of staring at the ceiling and feeling the spirit ebb from my body, I had just kept on chanting bullshit, bullshit, bullshit.

I call massive C Diff, enterococcus filled bullshit on just about everything Infection Control does.

No money for anaesthetic machines but you want to put a Pyxis in every OR.  I call bullshit.

Calling bullshit on admin, as I found out doesn't work which is why I have all this free time to write a blog.  Not that I discourage it. 

Reefer Madness Part 4 and Another 15 Minutes of Fame.

I just attended the annual meeting/course put on by the Canadian Consortium for the Investigation of Cannabiniods which I joined a couple of years ago.  I have prescribed/authorized medical marijuana for patients since 2001.  I do so in the context of my chronic pain practice and with some hesitation. 

A week or so on what must have been a slow news day our local paper announced in a front page headline story that a medical marijuana clinic was opening in our city.  Having commented on medical marijuana in the past, I had a feeling that I was going to be hearing from the Fourth Estate pretty soon.  

While I do provide authorization for medical marijuana in appropriate patients,  I have a jaundiced view of medical marijuana clinics.  Over the past few years patients have informed me that for $400 a clinic somewhere else in Canada will give them a "Skype interview" after which they will get an authorization for medical marijuana (under the old regulations) and usually are able to buy product from the affiliated grower.  

https://medicalmarijuanaservices.ca/medical-pot-clinic-offers-doctor-visits-via-skype-metro/

I am not sure what the Skype interview consists of; holding their wallet up to the camera on their computer maybe.  This is sleazy practice, and I usually offered to complete the paperwork for "free" if I think they are appropriate candidates.  

There have been incidents like this:

http://news.nationalpost.com/news/canada/how-one-doctor-made-500000-as-canadas-top-medical-marijuana-provider-until-police-came-knocking

I also increasingly believe that chronic pain should be managed in a multidisciplinary fashion not in silos of care such as medical marijuana clinics or for that matter the block shops we have in our city.  Unfortunately opportunities for multidisciplinary management are difficult because while health care in Canada is "free", physiotherapy and psychology are not.  Further for lack of resources, I and the loosely affiliated group of physicians I practise with  have an 18 month wait list for consults which even by Canadian standards is excessive. 

Our thankfully former Tea Party government who were of course anti-drug were most distressed by the concept of anybody using marijuana but were bound by a court decision, so came up with a solution that is probably the one thing in their 10 years in office that actually worked.  Instead of patients trying to grow their own marijuana (which most of them were not very good at) buying it on the street or from the lone government approved supplier, growers would be able apply for licences to supply patients who would get "prescriptions" from doctors.  I had previously discussed this in another blog.  The advantage of this system is that patients can now buy cannabis from facilities that are inspected by the government and that the THC and CBD content of the product is known which allows doctors and patients to select products of known potency.  This has resulted in about 30 companies, some large and some small being able to provide medical marijuana and according to the man from Health Canada there are 2000 applications to become licenced producers.  

Anyway, it wasn't long before I was contacted for an interview.  This came from a reporter from one of the free newspapers people read on the bus or in coffee shops.  A little down market from my usual encounters with the press but there is no bad publicity.   I basically told him what I had said above.  I said for reasons above that the medical marijuana clinic would have very little impact on the treatment of chronic pain.  I also said that what should have been the headline was the distressing lack of resources for treating chronic pain.  Further I said that while I hoped the physician starting the clinic had the noblest of motives, many people in the past had exploited the vulnerable chronic pain population.

The interview lasted about 10 minutes of which a few sentences made the article.  You can probably find it on Google but I am not going to help you.  It did state that I said there was no need for new physicians to prescribe medical marijuana because there were already enough in our city which I don't think I said. 

The entrepreneur/physician got to comment the the next edition of said free newspaper in which he claimed in messianic fashion that our city had been selected of all the cities in Canada because there was a need for doctors to prescribe medical marijuana.  I don't really think we are better or worse than anywhere else in Canada and he may have other motives for adding to his chain of clinics such as availability of office space or maybe he has a girlfriend in our city.  

I must say I only read these articles fully on line just now while writing this blog.

My next interview request came from CTV and they wanted to interview me on TV.  I took a media relations course a long time ago and the one thing that stood out was using the interview to advance your agenda.  Unfortunately when they contacted me I was on my way to Toronto to attend the above meeting but we agreed that maybe I could be interviewed by Skype in Toronto which I agreed to and I spoke with the reporter on phone and basically told her what I had told the free newspaper reporter only having had time to reflect in more polished form.

I was subsequently contacted by CBC French who wanted an interview which I did on the phone in English from Chilie's in the Calgary airport where I was having a beer and a burger before flying to Toronto.  I was on a roll by then and gave what was probably the best interview of my life.  Too bad I don't listen to CBC French.

Just before my plane took off, I got an email from CTV stating that they were going to cancel the interview because of lack of time.  I suspect the real reason was they realized that I wasn't going to talk about medical marijuana (which is sexy) but was going to talk about chronic pain (which is not sexy except when people smoke dope).

As I have said during this time I was getting ready to go the CCIC meeting in Toronto and just happened to look at the program and discovered that my entrepreneur friend was one of the speakers. Interesting, I thought I will at least get to put a face to name.  I was a little worried because as above I maybe hadn't been that positive about his little business and he had probably read my comments.  I went to two talks by him and he is pretty smooth and I am not sure what to make of him.  I probably should have taken him out for a beer (or smoked a doobie with him) to welcome him to our medical community.

The only blowback I got during the meeting was at lunch on the second day when someone sat down at my table looking at my nametag and said, "Oh you're the guy who thinks your city doesn't need a medical marijuana clinic."  I said something about how it was a 10 minute interview and they had taken out a few sentences and the moment passed.

Otherwise it was a great meeting with some really good talks and I learned a few pearls.  Unfortunately the meeting was essentially preaching to the choir although there were some people who were really pro cannabis.   It would certainly be nice if the people who oppose medical marijuana attended meetings like this and maybe we could have a dialogue.  

The other interesting thing was that the meeting was heavily sponsored by medical marijuana companies and there was a pharmaceutical trade show.  No free samples though.

An-hockey-donia

I recently realized that the season is almost over and I haven't watched a hockey game from start to finish.  Last Saturday I watched the beginning and end of the Toronto Boston game but turned the TV off for a leisurely supper before turning back on to watch Boston hang on for the win.  I didn't bother watching the second game of the Saturday night double-header.

I used to love hockey.  As a child, teenage and young adult, I never missed a chance to watch a game on TV.  I had season tickets to our local NHL team for 4 seasons.  Now if I tune into a game, I quickly find myself looking to see what else is on either on other stations or Netflix.  If I watch a game, I am usually reading a book, the newspaper or on Facebook.  On the other hand, I still read the sports section, and check scores in the evening on my computer.   It is not a distaste for sports in general either.  I still watch the CFL and NFL.  I love watching the Olympics when they are on.  

This comes at a time which should be the golden age of hockey watching with a game on TV just about every night of the week, and a minimum of 2 on Saturday night. If you look at the quality of play, the skaters are better, more mobile, faster.  I just can't seem to get excited.  I was trying to figure out where my passion had gone.  There are reasons; some of them are things that have bothered me for years, some are new.

I know the NHL brass read my blog so.......

The season is too long.

Not a new problem but the season has in my lifetime gone from 70 to 84 games.  Way too many.  I remember in the 1970s the players union offering to take a 1/8 paycut to shorten the season to 70 games which the owners turned down. This doesn't explain why I don't seem intererested in October either.  

The playoffs are way too long.

The first year I watched hockey (1964) the playoffs ended on April 29.  I remember this date because instead of watching game 7 of Detroit-Toronto we had to go to dinner for my mother's birthday.  I also remember in 1968, my brother telling me that because of expansion, there would actually be hockey played in May.  Crazy I thought.

Okay there were only 4 teams in the playoffs not 16, I understand.  But hockey in June.  Most of Canada and a significant amount of the US have 5-7 months of winter and the last thing we really want to do is to spend time indoors watching playoff games.  Its not just that there are twice as many rounds, it is the leisurely pace they seem to schedule games mostly to accomodate TV.  I remember in the 1970s they actually started the playoffs with 4 games in 5 nights (quite often with games 3 and 4 played Saturday night and Sunday afternoon).   That's right teams were often eliminated within a week of the playoffs starting.  Now there are frequently 2 or 3 nights in between games and frequently up to a week between series.  This is at a time when players are actually a lot fitter than they were in the 1970s.

And, when the NHL added the fourth series in the mid 1970s it was initially a best of 3 series which was extended to a best of 5 series when they went to 16 teams in the playoffs.  And yes, there were upsets where an inferior team eliminated a better team just like there are with best of 7 series.  That's why we have playoffs otherwise we could just give the Stanley Cup to the regular season winner and we could all enjoy our springs.  Major League Baseball still has their first round as a best of 5 even with all the variation pitching brings in.  

So why not make the first two rounds best of 5 again?  Not likely as home teams make $1,000,000 plus for each playoff game and with no revenue sharing no team is going to give up that type of potential payday.

The problem is of course is that by the time the finals roll around, everybody has lost interest outside of the fans of the two teams in the finals and most likely even them.  Take 2012 when the NHL finally had the match-up they had dreamed off when they expanded, a team from New York (New Jersey actually) against a team for LA.  I remember turning on the TV one night.  "Oh are they playing hockey still?" I thought.  So why would you want to take your showcase, the two best teams in the league and put it on at a time when you have the best outdoor weather plus you are going against baseball?  I really can't wait to not watch what will probably be this year's Stanley Cup final LA or Anaheim vs. Florida.

The games are too long.

Common thread here.

The one thing I remember from my years as a season ticket holder is being bleary eyed the next morning after a game that went on for 3 hours.

Now to its credit the NHL has done something to reduced the length of the games.  Not enough though.

I remember again in the 1960s,  games ran 2 hours and 15 minutes or less.  In fact the CBC had a 15 minute program which followed Hockey Night in Canada.

There are lots of possible solutions.  Only allowing line changes on the fly, maybe even getting rid of faceoffs in certain situations.  Reducing commercials.  Yeah right.

 Gary Bettman

A face more punchable than Ted Cruz?  (Not that I advocate violence, a good wedgy would suffice.)

Interesting how you can pin the state of the game on one person.  It is hard to believe (actually not) that he has been commissioner for over 20 years.  Now his two predescessors John Ziegler and Gil Stein were not the greatest hockey guys and maybe some of us thought Bettman might be good for a few years before they got a real hockey guy to run things.

But here he is, still running things.  All he has accomplished is 3 work-stoppages including a whole season lost and the movement of two Canadian teams to the US.  

It just irks me to see him on TV at a game (an infrequent event because he rarely goes to games and I rarely watch now) sitting in the expensive seats or the owner's box looking at his Blackberry, not watching the game.  That and his periodically lecturing city councils about how they need to have a publicly funded arena to replace the perfectly good one already there.

And there is of course the ritual booing when he presents the Stanley Cup.  The most sacred moment in hockey spoiled.  I don't blame the fans, I would boo too.  Since you are not going to step down Gary, why not give us a break, let some hall of famer present the Cup.  Imagine Gordie Howe, Bobby Orr or Wayne Gretzky presenting the Cup.  

It makes one long for the days of Clarence Campbell.  True he did some stupid things, like not letting Vancouver in the initial expansion and not letting the expansion teams draft any players of consequence condemning fans to years of lousy hockey.  But... he was Canadian, he had been a referee, and he went to games including going to the forum in Montreal after suspending Rocket Richard.   Plus when he presented the Stanley Cup,  he then went to the dressing room and talked with the players in their underwear.  Can't imagine Bettman doing that.  

The current divisional line-up

Okay what type of league divides themselves 16/14 rather than 15/15.   This means the Western teams have an 8/14 chance of making the playoffs vs 8/16 in the East.  True the Western teams have a tougher travel schedule.  What it really is, is a giant fuck-you to the concept of expanding to Quebec, Hamilton or a second team in Toronto  when they go to 32 teams because there are clearly too many Eastern teams now.  Which means we will be getting a team in Las Vegas and some other Western city that the league will have to prop up just like they prop up Phoenix now.  Like was there no team in the Eastern Conference that could be moved over to the West?  Why not on rotation make one of the three New York City teams play in the West on a rotation basis so they can see what it is like to travel?   And, what is the point of having a wild card when the teams in each division have a different schedule.  

I have personally thought why not split the thirty teams into 3 conferences, either Western, Central and Eastern or Western, Northeast and Southeast.  Time zone and travel wise, makes more sense.  Playoffs may be a little tricky but it would work.

Some people have suggested a premier league like in soccer and while second division teams might be less of a draw, the knowledge that your team is actually competitive might bring out fans.  Having the top teams play more often would be great for TV.  And like the FA cup everybody could play for the Stanley cup at the end of the season (all the premier league and the top second division teams).

The shoot-out / overtime

Back when I watched hockey in the 1970s, games actually ended in ties.  (Montreal who won  the Stanley Cup in 72-73 had 16 tie games.)  I remember a lot of the time, you turned off the TV or left the arena and thought you had seen a pretty good game.  It is true that occasionally in the last 10 minutes of a tie game, teams just passed the puck back and forth between the blue lines but quite often the tying goal was also scored in the last 10 minutes.  

For no apparent reason however the NHL went first to a winner take all overtime.  That still left ties so they brought in the shoot-out after a 4 on 4 overtime.  I have said this before, the shootout is not hockey.  Now they have gone to 3 on 3 overtime again followed by a shoot-out.  A little better but still some games get decided in the travesty of the shootout.  Another factor is that the winner of the OT/ shootout gets two points, same as the team which wins in regulation time.  The loser gets a point which is fair because if you survive 60 minutes tied, you should be entitled to a point.  This of course means some games are worth 2 points and some worth 3.   At a time when teams make or miss the playoffs by one point this is pretty significant.  

So why not give 3 points to the winner, 2 for an overtime winner and 1 for an overtime loser like they do in international tournaments including the Olympics.  The NHL justifies this by saying that this keeps the playoff races closer.  Artificially closer.

So if you don't want ties, why not just play until somebody wins like they do in Baseball and Basketball (and hockey during the playoffs).  And if the shootout and 3 on 3 are so exciting, why not have a shootout competition or a 3 on 3 tournament?  Just don't destroy the sanctity of the game with a gimmick.

The rules / inconsistency of the refereeing.

As others have pointed out this season, the quality of refereeing in the NHL has been inconsistent.  Not at all what you should expect in the what is supposed to be the best league in the world.

And part of the problem is that the rules are so vague.  For example does anybody understand what the current rules are about the crease and contacting the goalie inside or outside the crease?  Why not makes rules which actually clarify what is and isn't allowed.  Again going back to the 1960s, the rules were pretty clear, all of both feet in the crease and the goal didn't count.  I certainly don't want to go back to the toe in the crease rule of the 1990s.  So why not have a smaller primary crease where you can't go at all and a larger secondary crease where you can't contact the goalie.  And not all goalie contact should be penalized.  Blowing the play dead is enough.

Further while goalies are important, expensive and only 2 are dressed for a game, why should they be immune from contact if they decide to play defence?  

Another thing that bugs me is when a player gets pushed into the goalie and that player gets a goalie interference penalty.  The play by play announcers always, say that the player should have made more of an effort to avoid the goalie.  Sure try doing that when you are off balance being pushed by a defenceman who weighs 50 lbs more than you.   The whole goalie interference thing is so subjective, one guy farts near the goalie and gets a penalty, somebody else skates thru the crease and takes out the goalie and a goal gets scored.

The other thing is whether the puck actually crosses the line.  You would think by now the NHL would have some type of sensor to determine  whether the puck is over the line.  Or else simplify it so that instead of the entire puck crossing the line, the puck just has to break a plane on a line which could be just behind the goalposts for example.  The NFL does this already.  

But there is just the inconsistency in how the game is called.  A penalty at one point in the game is not a penalty at another time in the game.  Even up calls.  No other major professional league does it.  

Other sports (except maybe soccer) bring in rule changes to make their game more exciting and more fair.  Hockey not so much.

Too many teams

From 6 to 30 in my lifetime.  Maybe there are 5X as many elite players as there were in 1967.  The main problem is that it is just too hard to keep track of them all, too hard to get excited about Columbus.  Sometimes I read about some player I have never heard off and they are talking about him being in the running for a trophy.  Baseball which also has a lot of teams at least divides them into two leagues with differerent rules and until recently no interlocking play.  Football has two conferences although they play interconference games.  Because the NHL decided that every team should play every team home and home, this means less games against rivals or other teams in your division.  So every season ticket holder gets to see Montreal and Toronto once a season; they also get to see Columbus once a season.  

Free agency/salary cap/ trade deadline

I am conflicted about this.  Maybe players are overpaid but they have to right to what the market will bear and the owners who all claim to be astute businessmen don't have to pay them.  On the whole I would rather watch an elite hockey player than an investment banker or a corporate lawyer.  It has however gotten to the point where the turnover of players every season robs many teams of their character.  This is opposed to the situation before the advent of free agency where the best teams at least made very few roster changes every season and the move of a star player from one team to another was a major story.  

And why do  GMs feel that they have to rebuild or gut their team the week before the trade deadline.  I suspect if you added the pluses and minuses of trades at the deadline, the ledger would be solidly on the negative side.  And if it is your team that is being gutted imagine how as a season ticket holder being told that your GM has given up on the team you shelled out thousands of dollars for tickets, even while they still haven't been mathematically eliminated yet.

Not sure how you deal with this.  Revenue sharing might be a good start.  

Canadian Teams

OK.  I do cheer for an American team which I have always justified by telling myselve and everyone else that their players are mostly Canadians.  

The lack of success of Canadian teams recently is somewhat upsetting, especially as Canada got skunked in the playoff department this time around.  In fact Canada hasn't won a Stanley Cup since 1993 although 4 teams have made the final since then.  Not much of a statistician but with 7 out of 30 teams we should be looking at a champion every 4-5 years.  

I'm not much of a Habs fan but given that they won about every other year in my youth,maybe the universe would be back on keel if there could be a Stanley Cup parade in Montreal along "the usual route".

 

I can and do embellish my old-fartedness by telling younger people that I actually remember the Leafs winning the Stanley Cup.  I in fact remember them winning two Stanley Cups and they won four in my lifetime.  

At the same time I wish the national media would remember that there are 7 teams in Canada not just the Leafs and the Habs.  

Goalies

This has been a topic of conversation a lot but the goalies even the not very good ones have become so big now that it is impossible to score on them.  It is interesting to think of putting someone like Ken Dryden who was pretty big for his time into modern equipment and trying to score on him.  He probably wouldn't have lost a game in his career.  (He only lost 50).  

The league has been talking about this for at least 10 years but haven't really done anything.  Here's a suggestion.  Why not replace the first baseman size glove they currently get with a catcher's mitt.  Lots of padding but smaller and harder to make difficult catches with.  And make the blocker smaller.  Just big enough to protect the goalie.  And their stick doesn't need to be as wide.  And again I remember in the 1970s goalies used to get delay of game penalties if they froze the puck unnecessarily.  The rule is still in place why not enforce it.

 

The rink is too small

Imagine if Major League Baseball played on the same size field as little league.  The NHL plays on a rink the same size as my kids played on at age 8.  Now watching international hockey with their bigger rink doesn't make for a more exciting game however players are bigger and faster now.  In my lifetime every NHL team has built a new arena including a new one in my home town, and they are still building them to the same size as when players were smaller and skated a lot slower.  (I could be wrong but I think the Saddledome in Calgary built for the Olympics was built to Olympic size and then reduced to NHL size).  Sure in the transition, we would have arenas of different size, but that would  just like when Chicago and Boston had smaller rinks and just like Major League Baseball parks now.