tag:blogger.com,1999:blog-83256051844951379422024-03-14T01:28:22.179-06:00I used to be disgusted, now I try to be amusedAlarmed to discover he is now considered middle aged, a burned out cynical male anaesthesiologist ( and physician) expounds on life, medicine and anaesthesiology.Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.comBlogger347125tag:blogger.com,1999:blog-8325605184495137942.post-10341041112378934602021-03-27T11:47:00.002-06:002021-03-27T11:47:43.439-06:00Cancelled by Twitter<p> <span style="font-family: "Helvetica Neue"; font-size: 11px;">I haven’t been blogging much lately.</span><span style="font-family: "Helvetica Neue"; font-size: 11px;"> </span><span style="font-family: "Helvetica Neue"; font-size: 11px;">Twitter has for better or worse become my forum even if I usually only comment on topics, like, retweet and occasionally forward articles to Facebook.</span><span style="font-family: "Helvetica Neue"; font-size: 11px;"> </span><span style="font-family: "Helvetica Neue"; font-size: 11px;">I only have a few hundred followers.</span></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I got up this morning and checked my emails to find that my account had been suspended for offensive content. Further exploration found that this was due to a Tweet in a conversation about a month ago.</p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://lh3.googleusercontent.com/-osP1wba2FYU/YF9vkhIQ5JI/AAAAAAABEfo/s_cijgHOrEsMqfp91XyBQu0hzfCKrKOYwCLcBGAsYHQ/image.png" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1480" data-original-width="1222" height="240" src="https://lh3.googleusercontent.com/-osP1wba2FYU/YF9vkhIQ5JI/AAAAAAABEfo/s_cijgHOrEsMqfp91XyBQu0hzfCKrKOYwCLcBGAsYHQ/image.png" width="198" /></a></div><br /><br /><p></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I got in a discussion about a potential malaria vaccine. I made the flippant remark that more white people had to die for researchers to take malaria seriously. This is not an original thought, I have heard the same said about Ebola. We now have an Ebola vaccine and the research into this vaccine is one of the reasons why we have COVID vaccines sooner than predicted. There were 2 other people in this discussion, one a local university professor who tweets and comments in public, the other was another physician who I know quite well and occasionally have coffee with, although not in the last 12 months. It was pointed out to me that the life cycle of the malaria parasite is problematic for developing a vaccine, which I of course knew but I still think if we took malaria more seriously we might get if not a vaccine, treatments which are more effective and less toxic.</p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">You could read the Tweet except as a condition of my parole, I had to delete it.</p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Anyway somebody, weeks after the post , reported me or maybe a Twitter algorithm picked this up, and I was suspended for calling for the death of an ethnic group. This is of course a group that I was born into and still belong and I really have no wishes for any wide-spread cleansing of this or any other ethnic group.</p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I did appeal my suspension pointing out that my post was obviously sarcastic and not hate speech but Twitter quickly replied and told my post indeed was hate speech. By that time by randomly “pushing buttons” I had figured out that if I deleted the Tweet my indefinite sentence would become finite, so I did that and I will be let back on sometime today. In the interim I can still look at Twitter, I just can’t like, re-Tweet or of course post anything.</p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I do have strong opinions about things and I occasionally enter into discussions that begin to appear acrimonious. This is strange because most of the people I follow on Twitter have beliefs quite similar to mine. For example I recently opined that while balanced solutions like Ringers or Plasmalyte may not be as bad as Normal Saline, in the real world if you gave small amounts it really didn’t matter all that much. This touched many people’s nerves apparently. Yesterday I got into a discussion about shaming people for smoking which went off the rails pretty quickly. Mostly when I enter a discussion it is to make a joke which some people occasionally find funny and even re-Tweet.</p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I really do spend too much time on Twitter; I realize how unhealthy it is, however like many of my other unhealthy passions like beer, bacon and (as I found out a couple of years ago) biking I enjoy it to much to give it up. </p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p>
<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">If anything my cancellation has at least encouraged me to post to my long neglected blog.</p>Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-48773604418648873572020-10-28T11:09:00.001-06:002020-10-28T11:09:59.788-06:00Requiem for a heavyweight 2.<p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I don’t do much chronic pain direct patient care anymore but I do still work for one clinic in Northern Alberta. I got a call from the nurse a couple of weeks ago telling me a former patient’s family doctor was desperate to get in touch with me. I gave her my cell phone number and littering within 5 minutes he called me. It seems the former patient who was on oral Demerol for her headaches had been told by her pharmacy that oral Demerol was no longer available and he was wondering what he could prescribe. I told him any short acting opioid would be okay and it would be a bit of trial and error process. He asked if I could see her which I did recently.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">About two or so years ago we were told that injectable Demerol (meperidine) was temporarily not available and it seems temporarily has became permanent. It is always interesting when a drug which was so widely used is suddenly no longer available.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I like to use generic names but Demerol is so widely used that I continue to call it Demerol.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Demerol was apparently invented in Nazi Germany during the WW2 when supply lines for opium were cut. Not even the Nazis wanted their citizens to suffer pain. Methadone was also invented under the Nazis but never caught on as a routine analgesic although it became popular for treatment of addictions and is occasionally used for chronic pain or palliative care.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">By the time I was in medical school, Demerol was the drug of choice for surgical and other acute pains. My first day in clinical clerkship involved scrubbing on an abdominal hysterectomy back when holding a retractor was still exciting. Part of my educational experience involved learning to write post-op orders and it was then that I wrote my first order for “Demerol 75-100 mg IM q3-4 hours PRN”. (Technically clinical clerks couldn’t write narcotic orders but in practice we did.). That was the first of 100s of such orders I wrote during clerkship, internship and general practice.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">During emergency rotations of course I learned about the use of Demerol for migraine headaches. Most doctors covering emergency disdained Demerol but still used it for the migraine patients regular or not.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Oral Demerol was used a lot when I was in general practice. It was the second line when a more potent narcotic was needed or when the patient was allergic to codeine. There were of course other more potent narcotics like hydromorphone and oxycodone available but doctors seemed to prefer Demerol.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Like all medical students/interns back then we had no formal teaching in how to manage pain. We learned by watching when doctors did or what we were told to order. Kind of like today.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Entering my anaesthesia residency my whole attitude to Demerol changed. Anaesthesiologists in general had a distaste for Demerol. Part of that was that anaesthesiologists like to administer drugs intravenously and Demerol given intravenously inevitably knocked the bottom of the blood pressure as I learned after a few times giving it. Most of us preferred IV morphine or fentanyl in the the OR and IV morphine given by recovery room nurses in small increments. Once the patient left recovery room, they were back under the surgeon and the IM Demerol. A few anaesthesiologists preferred Demerol; a paediatric anaesthesiologist gave it IM to all her tonsillectomies. She claimed it worked better with fewer side effects. Demerol was also popular as a pre-med back when we gave pre-meds. A resident I trained with who had had a few surgeries told me how he liked to entertain himself while waiting for surgery by watching things crawling up the wall after his Demerol pre-med.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I never quite figured out why people used Demerol to be quite honest. Explanations I heard included:</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Less sedation.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">More sedation (when you wanted sedation)</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Less nausea</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Less addicting</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Morphine is only for cancer patients.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Morphine causes histamine release (true but rarely clinically significant)</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">I have been administering narcotics for quite a long time now both for acute and chronic pain; orally and intravenous and the one I have learned is that I cannot predict what effects patients will get from any given narcotic nor what side effects they will get. </p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Having said that Demerol has a few negatives. The big one is its active metabolite normeperidine which causes seizures. I first became aware of this while on the Pain Service at the Centre of Excellence. We followed all the PCA patients and we used either morphine or Demerol. Morphine was more common but we had a steady number of Demerol PCAs for morphine “allergies” or in a lot of cases patient/nurse/surgeon preference. I noticed when patients got up to 400 mg every 4 hours (which is a lot, I know) patients got very twitchy and it was time to get them off the Demerol.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">While it is popular to blame Purdue and OxyContin for use of narcotics in chronic pain patients, narcotic use was actually quite common when I started working in the Pain Clinic in 1993. While most patients were on some type of codeine preparation, a significant number of patients took Demerol usually by mouth but there were a small number who got regular injections in the ER, their doctors’ office or alarmingly a few who injected at home. And I would say almost 100% of the patients on Demerol were happy with it and did not want to stop. People often forget that when OxyContin came on the market in 1995, a lot of the patients switched to it were on injectable Demerol.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">Oral Demerol has to pass through the liver first so normeperidine levels tend to be higher with oral Demerol and I saw a few seizures in chronic pain patients. What always amazed me how the patients wanted back on (and usually got) Demerol. One patient reluctantly came off after her third seizure.</p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">At the same time there were a small number of patients for whom Demerol was really the only thing that worked. I was at pain meeting in the late 2000s and was sitting a table with a number of our province’s eminent pain specialists. The conversation turned to Demerol and I asked them if they had seen any patients for whom Demerol was the only thing that worked and every single eminent pain specialist nodded his head. </p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 13.1px;"><br /></p><p style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;">One of the advantages of getting older is others seeing how dogma becomes heresy and heresy become dogma, is seeing how drugs that were such as important part of medicine just gradually fade away. Aldomet and of course Pentothal come to mind. And now Demerol.</p><div><br /></div>Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-36102338208686704182020-04-30T12:20:00.000-06:002020-04-30T12:20:09.592-06:00Happy Birthday Mom<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">As usual I am late.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My mother would have been 91 yesterday had she not died last summer. She had aunts on both sides of her family who lived to be close to 100, so I always thought she would be one of those bright ladies living on to 100 or later. Sadly she developed dementia around her 88th birthday and slowly declined.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">While clearing my electronic schedule which has been decimated by the COVID crisis, I noted my mother’s birthday. I deleted it. It was a recurring event so my computer asked me if I wanted to delete all future events so I did that. I felt a little sad but really she isn’t going to be having any more birthdays.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Of course on facebook, yesterday a picture I had taken of her 3 years ago appeared. It was her 88th birthday and the picture was taken at the Oak Bay Marina where I always took my parents when I visited them in Victoria and of course for special occasions. My parents were by then in a seniors home and it was already apparent that she going to have to go into a higher level of care. By then my mother couldn’t read the menu and forgot anyway what she said she wanted so I just ordered what I figured she wanted. She didn’t have much of an appetite and mostly pushed her meal around her plate. This was the last time I ever took my parents out to supper or for that matter ate at the Oak Bay Marina. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I did repost the picture on Facebook and a lot of people “liked” it which should make me feel better I guess.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">About 3 and a half months later we had to place my mother in what is called a “reminiscence unit” at another seniors facility which meant separating my parents for the first time since 1952, although my dad moved into the same building in different room a few months later.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Just over a year from that birthday picture my father fell, broke his hip and died of complications. The first time I visited my mom, she of course asked what had happened to her husband and I told her he had died. She got sad and then forgot about it, so every time she asked from then on, I just said he was resting which he sort of was.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Later my mother fell and broke her pelvis, which I thought was going to be the end of her but she was discharged back to the home, used a wheelchair for a while and then actually learned to walk with a walker, something that had been thought impossible due to her dementia and her fragility. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I tried to visit every month. It is no hardship to visit Victoria. I would visit for an hour in morning, go somewhere for lunch and spend an hour in the afternoon. She of course never remembered the morning visit. If I stayed overnight, I could visit again the next morning.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Last July, I saw her for what was the last time. We had what I remembered as a nice visit, given that by that time she didn’t know who I was.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Last summer in August just after I had surgery for a facial smash, I got a phone call that my mother was in hospital with a perforated bowel. I talked to the emergency room doctor and we agreed on no surgery. She lingered on a few days and finally died in the afternoon on a Sunday. I was after my surgery in no shape to travel. I reassured myself that we had had a good visit in July and that she was no longer suffering.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My wife and I visited Victoria later that year on our way to Bella Coola. I had to reflect on how weird it was to visit Victoria and not visit my parents. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Some people will say she is in a better place. My mother was not terribly religious. She made us go to church and Sunday school and even taught Sunday school because that is what everybody did in the 1960s. Our whole family stopped going to church when I was 13. I suspect she was an atheist so she didn’t believe in an afterlife. I remember her saying that you live on through your children.</span></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-47372656395760507552019-12-30T17:23:00.000-07:002019-12-30T17:23:14.584-07:00Nepotism, a memoir and apologea<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Despite what some people will tell you I have said, I had never gotten a job based on my own merits prior to graduating from medical school. Most of the jobs I have gotten since medical school were based on the fact that nobody else was available or that the other applicants were really horrible. I accept this.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I worked 6 summers prior to and during medical school. Every single one of those jobs was due to nepotism. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My father worked for the Forest Service. He had without any nepotism risen very high in the hierarchy on his own merit. This did not stop him from resorting to nepotism for all four of his sons.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My oldest brother started the tradition with a summer job as a compassman in the Inventory Division of the Forest Service. This lead to his switching from an Economics Major to a Forestry Major much to my father’s joy and he had a brilliant career as a Forester. After a couple of years he got a summer job outside of the Forest Service away from my father’s shadow and had a long career in the private sector.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Brother #2 who was heading for a long career as an Engineer worked summers in the Forest Service Engineering Division, a posting he was qualified for.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">It was then my turn. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The summer of 1974, the NDP government had a robust summer student program both in the public sector and thru subsidies in the private sector. This lead to me in the summer of 1974 finding that all my friends had summer jobs. No problem. I went to my Dad and asked if it was possibly there might be a job for me? And there was. The research division was looking for a summer student who could write computer programs. I had taken a course in computer science and was quite good at it There were very few high school students who could do this. I believe that the job required you to have finished Grade 12. No problem, said my Dad, we will tell them you have finished Grade 12. This meant back dating my date of birth. And I got the job. (The clerk who did the payroll picked this up on my first day on the job but by then I had the job.)</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I always thought the research division was a separate division but actually it was part of my Dad’s division, something I only learned a few years later.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I therefore spent the summer of 1974 writing computer programs using FORTRAN, compiling data and other duties around the office. The research division was situated in an old James Bay House which had been converted to offices (the house is still there although no longer used by the government). I had much to learn about the ways of the civil service and didn’t pace myself so by early August I had finished everything I was supposed to do. I did a few jobs around the office for a couple of weeks before getting sent on in the field on a survey crew. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The field work we were doing was fairly interesting. Douglas fir clones from various areas had been planted in different environments and we were measuring how well they were thriving in their new home. This meant measuring a height and the width of the trunk 1/3 up the height of the tree. (These trees were about 4’ tall at that point). This sounds esoteric but with climate change has become more relevant and I read an article in The Walrus about the very research I was helping out with about a year ago.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The first place we went was to Ladysmith which is 45 minutes north of Victoria. We could have probably commuted from Victoria except that where we were working was a further 30 minutes on logging roads from Ladysmith. Therefore we were going to stay in a motel in Ladysmith. Outside of school trips this was my first time away from home. My mother gave me a self addressed letter so I could write home.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">In addition to having my hotel paid for by the Queen, we also got $16.50 per day for meals which meant that in 1974 you could eat steak for dinner every night, which of course I did.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">As aside, just as an example of how easy it was to get a summer job, one of my co-workers was a guy named Dennis, a hippy-drifter type from Ontario, who the crew had hired after meeting him in a bar the week before.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The trip to Ladysmith involved my first trip to a BC beer parlour. One day after work the crew chief announced we were going to the bar. I knew I was underaged but I just followed along. This was a classic BC beer parlour. No windows, circular tables covered in terricloth. Strong smell of 20+ years of spilled beer and cigarette smoke. We sat down the waiter came over. I was uncertain how to order beer. No matter, the waiter dropped off two draft beers for everybody in the group. We all threw one and two dollar bills on the table. The waiter picked up what he was owed and gave on change from a change dispenser on his belt. My first experience of many beer parlours. One might say the moment my life went south. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">After we finished up in Ladysmith there was more in Sooke, where we could live at home although it was an hour drive each way. And of course there was the stop in the beer parlour on the way home. In Sooke the 15 year old on the crew got busted and sat out in the truck while we drank in the bar (17 year old me didn’t get asked for ID).</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">It was overall a pretty good gig. I calculated that I made $3.60 and hour at a time when the minimum wage was $2.25 an hour. I banked most of it and didn’t buy anything expensive except for a Texas Instrument SR 50 calculator.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The next summer I was back in the research division, this time at the research station at Lake Cowichan. 7 of us, 5 guys and 2 women lived in the bunkhouses during the week. We had an old school camp cook who made the most amazing suppers. The work ranged from boring to heavy physical labour. We swam in the lake, and played tennis or soccer in the evening. We also spent quite a bit of time in the Riverside Bar in Lake Cowichan. Again with my living expenses covered during the week and living at home on the weekends, I banked almost everything except for what I spent on beer. Those two summers enabled me to go to UBC in Vancouver instead of living at home and attending UVic.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The three summers between University years where spent in the Cariboo; Quesnel, 100 Mile House and Wells. The first two summers I worked in what was call a “Regen” crew. Our job was to visit clear cuts and take samples to find out whether the clear cut was regenerating naturally. (Spoiler alert, they hardly ever did). This involved setting plots and measuring whether there were any new trees in the plot. To do this we walked kilometres over clear cuts, stepping over or around rotten logs and stumps. Rain or shine. The last year was similar except that we were surveying areas where the cedar had been logged in the 1960s leaving the other species.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Away from Victoria, the Forest Service was a paramilitary organization with a rigid hierarchy of Rangers, Deputy Rangers and Assistant rangers. There were those of us who didn’t have a title including the summer crews and we were always reminded where we stood in the hierarchy. Aside from the Regen crews there were also Fire Suppression Crews who worked much harder than we did but also due to getting overtime, made more money. We were supervised by a Ranger, although our four man crew had a crew chief as well who was slightly higher on the hierarchy than us.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Again I’m not complaining , but this was a paramilitary organization and were lots of assholes and bullies within the Ranger staff and unfortunately a lot from within the the crews itself. Years later I reflected on how this prepared me for life. Working in a rigid hierarchy with lots of bullying and intimidation? Sounds a lot like medical school and residency and maybe those summers were good for something besides the money.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">What was it like being the boss’s son? Well first of all, my father had the sense to hide me in the Cariboo away from Victoria. Also there was a lot of nepotism in the government at that time so there were lots of someone’s son or daughter working summers. My first summer in Quesnel, there was one other son-of besides me. I ran into them all the time, I had heard my father mention their fathers name or had met them at a social function when I was younger. My dad shares the same name as popular sitcom star. One of the people on my crew phoned to ask who he would be working with. “Oh, you’re working with _______’s son” and he thought he was working with the son of the sitcom star.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The other factor was that a lot of people never realized I was a son-of. I worked a long ways from the headquarters in Victoria, most people had no idea who the division head was.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">In between second and third year university I interviewed for a job with the inventory division. The interviewer had been my brother’s boss and the entire interview told me what a great worker my brother was. I of course got offered a job but turned it down. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">And aside from the job and the pay check, I never got any special favours. I worked in small interior backwaters away from the amenities of Vancouver and Victoria. I never became a crew chief. One summer I was on a special project for a month but that was more because I had been there the previous two summers and knew the area. I like to think I did a pretty good job as well. I am a bit of a Type A personality (more A-) and like to do things better than everybody else. Plus I knew if there were issues, it was going to get back to my Dad and he would kill me (actually he wouldn’t have but the guilt trip he would have laid on would have made me want to die).</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Periodically I met someone older who’d knew my father. These were mostly people who liked him and spoke highly of him. I’m sure there were people who didn’t like him but they never spoke to me. I remember working for someone who had worked with my dad in the 1950s named Florian Tugnam who went under the name of Tuggy. One of the nicest men I had ever met. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Prior to my second summer in the Cariboo my father got shuffled out of his job and he wasn’t my boss anymore. I worked two more summers in Reforestation. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">After my first year of medicine I decided I wanted to spend the summer in Victoria and work in a hospital, so I got a summer job as a nurses aide at the Royal Jubilee. Actually I didn’t, there were cutbacks and I got laid off before I even started. I pounded the pavement for about a week before my father got impatient and found a vacancy and I worked another summer in the Forest Service, this time in Victoria.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Of course by then I had entered the world of nepotism in medicine. Our class of 88 had about 10 offspring of doctors. Some of them were academically quite strong and would have gotten in on their own merits. A few had significantly lower marks coming into medical school. Some of them had lived lives of privilege, boarding schools in Switzerland or summer vacations in Europe. Some despite their physician father had worked part-time or summer jobs throughout university. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">One tragic case of nepotism was my friend Phil. Phil was an English major who wanted to be a writer. Phil’s father was an ENT surgeon in Vancouver, his brother graduated first from John Hopkins Medical School. Pressured by his father to apply to medical school, Phil went through the motions and to his horror got accepted. There may have been phone calls made by his father. Phil did manage to get through medical school and internship. He died of a drug overdose in 1990.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The children of doctors didn’t really benefit much more throughout medical school. Having mom or dad as a doctor doesn’t really help you much with anatomy. We did later have a lot of subjective marks based on oral exams and clinical evaluations so some of them may have benefitted because their examiner or preceptor knew their parents. I wasn’t really obsessed with marks in medical school. I was for the most part on survival mode, trying to pass and acquire the knowledge I figured I would need to practise.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We had a pretty close class, we got to know each other well and I became friends with a lot the children of doctors. Sure they drove nicer cars, didn’t have to work during the summer (nor did I after second year), and lived in their parents’ nice houses in the Vancouver area usually with a pool. We had year end pool parties at 3 such houses. And I certainly was no working class hero. My father wasn’t a doctor but he was a well paid civil servant. We lived in a nice area of Victoria, I went to a really good public high school.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I do remember that we had a rural doctor elective between second and third year. To assign people we had a lottery and a draft of the various placements. Some of the doctors children didn’t bother with the draft. Their father arranged a placement with an old colleague. I suspect the same thing happened with fourth year electives.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Specialty training is of course a hot-bed of nepotism. Some programs like ophthalmology don’t even try to hide it. Urology in our city has a dynasty now into its third generation. The match of course hasn’t changed that. There was a story a few years back about how the head of the cardiac surgery program in Vancouver intentionally left their position vacant so that his son who had trained off-shore could get a position in the secondary match. Our program recently matched a child of one of the staff. The program directory felt it necessary to send out a memo explaining that everything was above board and that she had been ranked on her merits (which is probably true.)</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The interesting thing is that being a doctor no longer gives your children a free or reduced effort ticket to medical school. Getting into medical school which was pretty competitive when I applied has become hyper competitive and I suspect the evaluation process is probably more rigid and fairer. Therefore a lot of doctors children are attending medical school off-shore. This of course means these people will need to get into a residency in Canada, not an easy task if you didn’t go to medical school here, which is I suspect leading to a lot of phone calls, begging and arm twisting by concerned doctor parents.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was talking a while ago with a surgeon. His son was attending medical school in city where he worked. His son had decided to apply to the same surgical sub-specialty. He was a little anxious about this. He felt his son was going to held to a higher standard than the other residents.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I should mention that most children of doctors I have encountered in their training have been thoroughly professional individuals who don’t (overtly anyway) demand special treatment. There has been of course the odd entitled asshole but these are so uncommon that they stand out.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">In private practice of course who you know is really important when getting a job; a little less so now that we have shortages of many specialties. You can’t really fault someone for taking a family member into their practice which is after all their practice. This is a little less faultless when hospital privileges or operating room time is involved. We have in our department 2 children of anaesthesiologists. We didn’t hire them because of their bloodlines. Frankly we were desperate and were happy their fathers had spoken so warmly of our hospital. They are by the way both excellent. We also have 3 children of surgeons working at our site in the same specialty.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">A small town in New Brunswick I worked in had a dynasty of doctors, the third of which was working there. The local High School was even named after them. People weren’t knocking down doors trying to practise medicine in this particular town and looking back it was nice that the third generation of the dynasty decided to come back because he certainly may have had opportunities elsewhere. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Nepotism is rampant outside of medical. Look at how many businesses are named _______and sons. Again you can argue if you own the business, you can hire who you feel like. Except of course when this leads to your business becoming inbred to the point where it collapses leading to job losses and ripple effects in the economy. Eatons in Canada is a good example of that.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Politics is heavily nepotistic. Our Prime Minister is an example. He might very well have risen to where he is on his merits. I don’t really think so. (Not that he is an exceptionally good or bad PM). In BC WAC Bennett passed the leadership to his son who had never been involved in politics. Nobody questioned whether there was a better person for the job and he served for 3 terms as premier. In the US we have the Bush dynasty, the Kennedy’s and who knows how many other family dynasties. Winston Churchill may have been Britains greatest Prime Minister, but he probably wouldn’t have gotten a start in politics without his politician father. It is a funny thing that after crawling out from under a hereditary aristocracy, we still think that bloodlines are important in our politicians.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The word nepotism comes from Renaissance Italy. Illegitimate sons of Popes were referred to as nephews (nepos) and given jobs in the Vatican.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">In times of yore, of course power was inherited. This made sense when kings were supposed to be descended from gods or at least divinely ordained. Of course the son’s of kings were often not the strongest individuals or the best to lead. The Roman Emperors recognized this and would adopt a strong general who could then succeed them. Medieval Poland had an elected monarchy. The Holy Roman Emperor was elected although by the end of the Renaissance the position become a Hapsburg inheritance. The first Hapsburg Emperor was elected because it was felt he could be easily dominated. That didn’t work out well. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The earlier Romans and the Athenians didn’t have kings. The Roman republic elected two Consuls for a year who had imperium for that year. The Roman republic was of course heavily nepotistic and who your ancestors were was very important in how you did politically. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The thing is that we all try to use what advantages we have. I didn’t get to where I am because my father got me well paying summer jobs. Growing up in a middle class family, attending good public schools and having parents who stressed education was way more important. Is that fair to someone who didn’t have those advantages? And of course when faced with a number of candidates to chose from, who wouldn’t chose someone who they knew or whose father they knew, all things being equal. Fair? Not really. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We try to do the best for our children. I got my brother, an engineer , to give my son a summer job. None of my children went into medicine so I have not had the opportunity to exert what influence I might have. I once vowed I was not going to be one of those doctors but I know faced with a child wanting to go into medicine, I probably would have been. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">As an aside, the well paying summer jobs we used to get largely no longer exist. The whole concept that you can give someone good job and maybe do something useful at the same time seems to have gone by the wayside. Summer students now work for much smaller salaries and top this up with huge student loans. </span></div>
<br />
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-9210106536949630322019-11-08T13:59:00.003-07:002019-11-11T12:45:48.954-07:00My fall and later rise.<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">On August 8 I was injured in a major bicycle accident which required surgery. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My wife and I go to the Edmonton Folk Festival every year. I have only missed 3 festivals since 1995. Since moving to our current home in the West End, we have usually ridden our bicycles. It is 12 km each way on quiet roads or paved trails. This means riding home in the dark or twilight. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We went as usual this year for the Thursday evening concert. We left a little late, wanting to avoid the line-up to get in. We don’t do the tarp run. With only two of us we can usually squeeze in between tarps. We arrived, got our weekend wristbands, bought a program and walked up the hill, finally finding a good place to place our tarp. We then went to the beer garden and had one beer each. It was a sunny humid day. “Are you going to have another beer,” my wife asked. “No”, I said “lets go have dinner.”. We both ate Ethiopian food sitting on the grass. The first act which we weren’t interested in was already playing on the stage. We then walked back to our tarp where we watched the second and third acts, both of whom were quite good. It was my plan to leave after the third act and miss the final act. The festival is 4 days and you have to pace yourself. Plus we could see the weather deteriorating to the west of us.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We walked back to the bike lock up to pick up our bikes. It had rained a lot over the previous days and there were swarms of mosquitos and I got quite a few bites before we left. We cycled thru Cloverdale and took the pedestrian overpass and then started cycling west along the trail. As we passed the Riverboat area, a wedding party was just dispersing. The first flashes of lightening were showing to the south and west. We kept on, my wife riding ahead as usual. To get home we had to cross the Saskatchewan river via the Low Level Bridge. This meant going on the underpass under the bridge in order to cross on the correct side of the bridge. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">There is a small downhill going to the underpass. As I started to descend, I ducked my head as I always do going under bridges. I thought to myself, I don’t have to do this, there is lots of room. I could see my wife ahead almost at the other end of the underpass. There was a bright lightening flash. That is the last thing I remember.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I do remember going into a dream state. I first dreamed I was back at the bike lock-up, then that we were cycling on River Valley road (about 1 km away and where we were heading). Next I was awake on the ground talking to my wife. I was bleeding from my face. I remember saying I could ride home but my wife told me I had to go to the hospital which as I became more with it made more sense. My wife called a taxi and quite quickly one came. It was a minivan so we threw my bike in the back and I got in. My wife decided to cycle home and drive to the hospital. I was bleeding moderately heavily, she gave me the blanket we had sat on to put over my face.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was starting to be more alert. I realized I had facial fractures. My teeth were pushed back in my mouth. I figured I might had a skull fracture and maybe even be bleeding intracranially. At points in the short taxi ride I felt drowsy but forced myself to stay awake. We shortly arrived the University Hospital ER. The fare was about $15, I gave the driver $20, given that I had probably bled over his cab. He really was a nice guy who was quite concerned about me. He brought my bike to security in front of the ER, who I remember were generally disinterested in looking after it.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I then went to triage. There was one person in front of me. When it was my turn, I explained what had happened. I was then sent to register and then directed to the waiting room. This was quite full and I had to squeeze into a chair between two people, holding the blanket over my bloody face. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">In the 10 or so minutes in the waiting room I was able to reflect at what I had done to myself and what effect it might have on my life. I figured I had knocked out my front teeth. I most likely had facial fractures, possible some neurosurgical problems. I had been knocked out. I was going to need surgery I was not going to be able to work for an as yet unknown period of time. Given that I had a head injury would I even be able to go back to work. Would I be able to or want to ride a bike ever. Would I be able to play the saxophone? (I actually thought that).</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was eventually summoned into the back where I was taken into the trauma room with its resuscitation equipment, radiolucent bed and overhead X-ray (keep in mind I had been sent back to the waiting room by triage). I remember the nurse who walked me back as very kind and compassionate. Not at all like the ER nurses I used to work with, or read on Twitter. An IV was inserted, blood was drawn and X-rays were taken. A very nice ER doc came in trailed by a medical student. He went thru as thorough trauma assessment including rolling me over. They gave me ketorolac for pain and to my surprise it actually worked (they promised I could have something more potent if necessary). I shortly went over to CT to have facial and head CT. “Aren’t you going to look at my neck?”, I asked. The ER doc explained that I didn’t have any neck pain and had walked in. Makes sense. The techs in CT were also really nice and professional. After CT I was moved back to another area of the ER. Somewhere in that time my wife had arrived, having ridden home. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I lay in the cubicle for a couple of hours. I was fully awake and was aware that I was most likely out of major danger. My wife had brought my phone which she had taken from me at the accident scene. I had the prescience to email and cancel an appointment I had the next day. At some point we looked at my helmet. I’m not sure how it came with me. It was broken at the front, which made sense with the facial fractures. We tossed it in the garbage. I feel a little bad about this. It is an inanimate object but it did save my life and while I had only had it for a couple years, it had sat on my head for some pretty epic kilometres of biking.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My GP had signed me up for the patient portal so I could legally look at my blood work. I started getting emails in the ER telling me I had blood results, which I was able to log in and see. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Eventually the ER doc came and told me that I had no intracranial problems but had multiple facial fractures. He had phoned plastics who would see me the next morning. I could go home.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Oh and do you mind if the student sutures your only facial laceration.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I sutured lots of facial lacerations as a student so I said it was okay. He somewhat clumsily set up the suture tray, injected local and put in a few stitches. I noticed that rather than instrument tying he was hand tying each knot. We chatted while he was doing all this. He was from Victoria like me but we went to different high schools (a generation or so apart). The ER doc came back and asked if I wanted something for pain. I said I preferred Percocet over Tylenol 3 and I found a rare ER doc with a triplicate pad, so I got a prescription for 30 and 5 tablets to go. My wife got my car from parking and picked me up in front of the ER and she drove me home.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Because of the swelling I was told to sleep with my head elevated she set me up on the couch in my office with lots of sheets and towels to keep the blood off. I didn’t sleep. Too wired, too worried about the intracranial bleed I was sure I had. I keep on telling myself, you had CT of your brain, everything is okay. I had Percocet but was scared to take it. Eventually around 0600 I went back to my own bed and slept on a couple of pillows until about 0900 or so when my wife woke me because it was time to go back to the ER.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We checked into the ER again and told them that we were meeting plastics. We were directed back to the waiting room. This was quite full and the only seat was next to a disheveled “gentleman” stinking of cigarettes and possibly alcohol. At one point he bought a cellophane wrapped sandwich and tossed the wrapper on the floor. A burly man sitting kitty corner to us wearing a Boston Bruins ball cap yelled at him to pick it up and I thought I was going to have a ringside seat to an ER fight. Infrequently, people were summoned into the ER to be seen. To be honest most of them didn’t look very sick. It was sickest people who seemed to be ignored including the young lady moaning and holding her abdomen. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">After about an hour a junior plastics resident came down to see me. He did a more thorough exam than the ER did. He looked somewhat unimpressed at my sutures from the last night. He said he would talk to his chief resident. Back to the waiting room where more or less the same crowd were still sitting there. A couple of hours later I met a more senior resident who told me that I would be admitted to hospital for surgery the next day but could go home over night on a pass. I was told to wait to see the chief resident, who came down later with the staff surgeon. I was quite relieved to see the staff surgeon. I had worked a lot with him when I worked at the centre of excellence. He explained that I had quite bad facial fractures and what he would do to me. He said that he could do my case in his elective time the following Wednesday but recommended that we try to get it done over the weekend on call.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Before I could go home however I had to be admitted to my bed so I could go out on pass so I had to wait another hour or so in the waiting room which was becoming old. First I was told that my bed was ready but they were waiting for a porter. I asked if I could just walk over there but was told it wasn’t allowed. Finally a porter arrived and we walked towards the ward. She got lost and I had to guide her to ward, where I was admitted and then sent home. My wife showed up with a milkshake and we drove home.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was really tired by this time and I remember falling asleep sitting upright watching the football game on TV.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The next morning we got up bright and early and went to the ward where I was shown my “bed”. My “bed” was what they called an “overcapacity” bed which meant it was a stretcher in between two beds in room designed to have two beds. (Apparently they have not figured out how to put bunk beds in hospital rooms), Both my room mates were long term residents of the plastics ward. I was told that I was likely to be the second emergency case done at around 1000. Around 0900 a nurse came into start an IV for the OR. I have been out in the sun a lot this summer and my hands were little leather-like, as well while I had tried to drink lots, I was a little dry. She failed, as did the 2 nurses who tried after her. The third attempt struck a nerve and I got a shock down my arm. I got a little cross. I was sick of my little bed so I wandered out to the lounge in the atrium. Out there one of the plastics residents came but to tell me that I was further delayed but she at least bought a glass of ice water and a nurse bought a glass of juice. For the rest of the afternoon I alternately read, looked at my phone and occasionally wander around the atrium. At around 1600, I was getting a little tired so went back to my “bed” and actually was able to go to sleep. Someone tried to get me to eat supper but I told her I wasn’t supposed to eat. At 1800, a nurse came out and told me that my surgery was cancelled that day. I was a little relieved. Based on my experience I was looking at a 6 hour surgery and I wasn’t enthusiastic about coming back after midnight after facial surgery. My wife came and picked me up and we went to Booster Juice and then home. On the way home, the ward phoned me and told me that they thought I could get done first if I came in a 0615 Sunday am. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We showed up at 0615 the next day and I went back to my “bed”. It quickly became apparent that I wasn’t going to be first on the list. Around 1100 a plastics resident told me that I might get done later in the day. I told him I preferred to wait at home and could get back to the hospital in 15 minutes if necessary so I went back home. Later in the afternoon I was advised that because of 5 transplants being booked they wouldn’t be doing me on Sunday and could I come back Monday am.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">No doubt the Centre of Excellence was busy Saturday and Sunday but I have worked enough weekends to know how the emergency slate is gamed and nobody wants to follow a 6 hour plastics case. To his credit and my detriment, my surgeon wasn’t very good at this gaming. It is difficult to argue about transplants, although they never seem to be an emergency between 0800 and 1700 Monday thru Friday.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was figuring this all out. Monday am I phoned the ward and told them that I was staying home and they could call me when my case was booked. Later Monday I got a phone call telling me that there was no chance I would get surgery on Monday but I was now booked in elective time Tuesday afternoon. This was a bit of a relief. I now knew more or less when I was going to have surgery. I had gotten use to the way my face was, I wasn’t having much pain, I had Percocet and was enjoying my diet of milkshakes, smoothies and beer. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I went back to the plastics ward Tuesday. Maybe they felt sorry for me, but I now had a private room with a window. A nurse came in and put an IV in my antecubital fossa. I waited reading a book I had started and checking my emails and Twitter. Some time after noon, two porters showed up with a stretcher and I was off to the OR.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Aside from colonoscopies I have never had a general anaesthetic. Aside from having had 5 days to think about this, I had some reasons to be anxious. It had been 13 years since I worked at the CofE and the anaesthetic department had turned over quite a bit. I knew as a facial smash I might be a difficult intubation. And then there was the impending 6 hour surgery. I told myself that from my point of view I would be asleep the whole time but I was still nervous. I worried about coughing on the tube, nausea and pain. As we got into the OR I looked for nurses I knew from before. I was wheeled into their receiving area where a nurse interviewed and checked my chart. A nurse who used to work at my hospital came in and talked to me which I appreciated greatly. (I occasionally see someone I know waiting for surgery and go over to talk to them; I never realized how appreciated it is).</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">After a while, first the surgeon and then the anaesthesiologist came to talk to me. I had never met the anaesthesiologist although she told me she had trained in our program. She told me that I would be intubated nasally. I had figured that with maxillary fractures, I would be getting intubated orally but I guess they have to be able to look at the alignment. The surgeon had told me that I probably wouldn’t but might be wired shut at the end. I wondered how I would respond to waking up like that. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was pushed into the room. I could see the scrub nurses setting up. My CT scan was on the viewbox but without my glasses I couldn’t make out details (not that I could with glasses). Lying supine, I saw my anaesthesiologist pushing the Glidescope into the room. That should have made me feel anxious but at that point I wasn’t caring much and I figured she was just being safe. I had told her not to modify her usual technique for me. She told me she was injecting midazolam. I had had midazolam before for colonoscopy and know what a potent amnestic it is. I knew I had a few seconds of consciousness left. I remember about 20 seconds.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Seeming seconds later, I was in the recovery room. I was extubated. I couldn’t believe how awake I was. I had a little pain but no nausea. I looked at the clock and it was just after 1900. That took a while, I said. The nurse asked if I wanted something for pain and I said yes. She gave my 0.6 mg of hydromorphone and told me I had gotten 2 mg in the OR. What seemed shortly after I was told that I was going back to ward. When I looked at the clock however it was after 2000. Being pushed back to the ward, I saw my wife waiting for me in the hall. I was so happy to see her.</span><br />
<span style="-webkit-font-kerning: none;"><br /></span>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-Fpql5MhKLlI/XcXpDYNRWmI/AAAAAAAA_3k/aU1tDyrpa7Yhv6q1b2sGJCvEIjxtBt4QwCKgBGAsYHg/s1600/005131B3-7C94-47AA-8C6C-93D6A6947C2E.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1600" data-original-width="901" height="320" src="https://1.bp.blogspot.com/-Fpql5MhKLlI/XcXpDYNRWmI/AAAAAAAA_3k/aU1tDyrpa7Yhv6q1b2sGJCvEIjxtBt4QwCKgBGAsYHg/s320/005131B3-7C94-47AA-8C6C-93D6A6947C2E.jpg" width="180" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">I looked a little like Ali after the Joe Frazier fight</td></tr>
</tbody></table>
</div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was finished surgery but was not out of the woods yet. There had apparently been problems with my nasal intubation and both nostrils were clogged with clot. Not withstanding my nose bleed they still gave my low molecular weight heparin (but said I couldn’t have NSAIDS). The intermittent compression machine they put on my legs kept me awake as well. I really didn’t feel that tired however after my general anaesthetic. The IV infusion pump periodically alarmed as well. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Morning came and the plastics housestaff came in, the 3 residents I had already met plus 2 medical students. One of the residents told me I had been a difficult intubation. Apparently because of my size, (6’5”) a regular ETT barely gets from my nose to the vocal cords. This presumably explained the nosebleed. They said I could go home after a CT of my facial bones and that the IV could come out. The anaesthesiologist had put another IV in my saphenous vein (I do that too sometimes) which was affecting my mobility. I decided to disconnect the IV. There was an extension with a needleless connector so I just unscrewed it. The pump was still running. I know how to shut off an IVAC pump but I figured it might wreck the charting so I called the nurse. A nurse came fairly promptly and I got a lecture about not playing with the IV. The same nurse came back about 10 minutes and apologized, saying she didn’t know I was an anaesthesiologist.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">A breakfast tray arrived with a muffin and a box of bran flakes. It had now been about 5 days since I had eaten anything solid. “They expect me to eat this?”, I thought. I soaked the bran flakes in milk and gingerly ate them and the muffin which I broke into small pieces. I really didn’t feel like eating but I knew if was part of my recovery. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Later in the morning I went over to CT by wheelchair. The CT techs were so pleasant and that scan took about a minute. A CT scan when I was a resident took about 30 minutes. Then back to the ward. A friend who still worked at the CofE came over to visit, we chatted along with my wife who had arrived from home. I was told that my CT scan was read and was okay but the surgeon wanted to see me. I was getting a little tired of my room so we walked out to the atrium where we bumped into him and he gave me some final instructions. “You really are in hurry to get out of here”, he said. “Sorry,” I said, “I hate this place.” A little ungrateful perhaps because overall they had been so good to me. I think what I meant was I want to get home and start getting better.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">We drove back about 15 minutes to my house. I was still suffering the effects of the concussion and the general anaesthetic. Everything was moving so quickly, I didn’t think I would have been able to react to it all.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">The next few days seem a blur. I am not the busiest person but now I was in enforced inactivity, my only job was to get better. I spent most of the next 4 or so days reading, looking at my I Pad and having random naps. A few times I went out in the car with my wife. Things were still moving to fast for me. The first two nights I really didn’t sleep. This was probably the effect of the anaesthetic and possibly also due to the dexamethasone I had been given. The second night home, I became obsessed about a peri-operative MI. I remember thinking, “I am going to die tonight.” I had Zopilcone but was scared to use it, my face was still swollen, my nose was plugged and I was worried about obstructing. Later I started using the zopiclone which gave me a deep sleep for 3 hours after which I slept fitfully often until 0800 or 0900. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Eating was still painful and I didn’t have much of an appetite. My wife cooked some delicious meals for me that I could eat on my soft diet. I regret I didn’t appreciate them more because they were really good. The surgeon had left wires in my mouth in case he had to wire my jaw (he didn’t have to) and one of them was irritating my gum. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">On Thursday after surgery my brother phoned me. My 90 year old mother had been taken to the hospital with abdominal pain. I talked to the ER doc in Victoria and it appeared that she had perforated her colon. I knew that this would be fatal and I told him to just keep her comfortable. I wondered about flying to Victoria to “say goodbye” but I knew I was in no shape to travel. Maybe if my surgery had been done on the Saturday like it was supposed to have been done. My mother died on Sunday. The team in Victoria did as good a job as they could trying to keep her comfortable but with the peritonitis she must have had along with her dementia, it must have been a horrible 3 days for her before she finally died.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I did visit my mother in late July and was able to spend a few hours with her. I tried to comfort myself that I had said my goodbyes but I still regret not being able to see her one more time.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">On Saturday my wife suggested that we go and visit where I had crashed 9 days earlier. We went to the farmers market first. I still had a lot of facial bruising. As it happened we ran into someone I knew so had to explain what had happened. We then drove to the other side of the Low Level Bridge, parked and walked across. I wondered if I would get anxious returning to the site but I felt okay. Almost immediately looking at where I had gone down, I could see why. The pavement was rutted and broken off at the right side of the trail. I must have hit the edge of the trail where it was broken and slammed down hard. I felt a little better. I don’t remember the impact but had always worried that I had done something stupid and that was why I crashed. Now I felt a little angry that the city could leave a busy paved trail in that condition.</span><br />
<span style="-webkit-font-kerning: none;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-H74uJaJ-xkA/XcXpWBu_PII/AAAAAAAA_3s/TQzaNu9-Bmcnt0fA_mn4IDOlPTvVRsWzwCKgBGAsYHg/s1600/IMG_2217.HEIC" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://1.bp.blogspot.com/-H74uJaJ-xkA/XcXpWBu_PII/AAAAAAAA_3s/TQzaNu9-Bmcnt0fA_mn4IDOlPTvVRsWzwCKgBGAsYHg/s320/IMG_2217.HEIC" width="320" /></a></div>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-UAdYAMFEXcM/XcXpWEGDgFI/AAAAAAAA_3s/U2ffUreVsskOFW8wttEG4JkzZkwY7UytACKgBGAsYHg/s1600/IMG_2220.HEIC" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://1.bp.blogspot.com/-UAdYAMFEXcM/XcXpWEGDgFI/AAAAAAAA_3s/U2ffUreVsskOFW8wttEG4JkzZkwY7UytACKgBGAsYHg/s320/IMG_2220.HEIC" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The scene of the crime.</td></tr>
</tbody></table>
<span style="-webkit-font-kerning: none;"><br /></span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">By Monday one of the wires which was digging into my gum was really starting to bug me. My surgeon had told me that he would be on vacation but that I could contact the on call plastics thru the hospital switchboard. I figured however that would just result in being told to go to the ER and wait and frankly I had spent enough time in the ER. I thought about asking one of the plastic surgeons at my hospital to look at it. Wednesday morning I woke around 0600 and had a revelation. The plastics house staff round at 0600, I could phone the ward and ask to speak to them or leave a message. I did that but the nurse I talked to was very protective of the doctors although I did get him to take a message. He did have a good suggestion, dental wax. I googled dental wax and sure enough London Drugs carried it. I finally felt good enough to to drive and headed over there just after opening and picked up some dental wax. Later in the morning one of the plastics residents called me and said my surgeon, who it turned out wasn’t yet on vacation , could take out the wires in the surgery clinics. I did this later in the afternoon. At the clinics I met a nurse who had worked in the Pain Clinic years ago when I was at the CofE and we got to chat a bit and I got the wires removed except for the ones holding my upper incisors in.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">It was Tuesday that I finally woke feeling almost normal. It was a beautiful late summer day and I knew I wanted to go for a walk. That morning I walked with my wife and the dogs down into the river valley to the zoo. Walking along the dirt path beside the river was such a healing experience. We had coffee at the coffee shop outside the zoo before walking home. This involved a climb out of the river valley and I was relieved that my conditioning hadn’t suffered much. We did this walk every day for a few days. I started looking at the step counter on my phone and tried to make the 10,000 step maker every day.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My work in chronic pain had made me aware of the risk of PTSD after an accident I had so almost as soon as I got home from hospital I called the medical association’s Physician and Family Support line and got an appointment with a psychologist. Because it was the summer I wan’t able to get in right away but did get an appointment for Thursday. I drove down to the office just off Whyte Avenue. I was feeling really good. I was out of the woods, I was going for walks every day and was driving again. The psychologist and I sort of talked for about 30 minutes when it was clear that I was doing pretty good. I sort of apologized for wasting his time. Apparently getting knocked out so you don’t remember anything is a good thing. On the way home, I stopped and bought a new bike helmet. </span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I went to the Eskimos football game the following day Friday. It was not a very good game and my wife and I left in the 4th quarter. It was dark when we left. I park at a nearby hospital where I have reciprocal parking privileges. Driving home in the dark with the traffic and the bright lights brought back memories of my taxi ride to the hospital just over 2 weeks earlier. A cyclist wearing dark clothes and no helmet crossed the road in front of us and this upset me for some reason. Maybe I wasn’t as good as I had made myself out to be.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">It was around then that my wife noticed some redness in the skin around my nose. It looked a bit like a skin infection. I figured there was a plate underneath. I have of course seem some horrendous post-surgical infections and had views of my face sloughing off. By then we had gone down to the dacha in Canmore to see if some mountain air would pick me up. Fortunately there was a walk in clinic open on the Sunday so I went there shortly after opening time and saw a doctor who it turned out was a former next door neighbour. I was started back on antibiotics. (When I saw my plastic surgeon later, he didn’t think I had an infection but told me to finish the prescription).</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Gradually recovering, the question was when exactly could I go back to work. I had been told it would take 3 weeks to recover. After two weeks I felt a lot better but I still had some facial swelling. As it had turned out, I injured myself with 2 weeks of vacation left. Worst vacation ever. (We had planned to take in the Salmon Arm Roots and Blues festival the following weekend but obviously didn’t go.)</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I was supposed to work the week before Labour Day and be on call 3 times over the Labour Day weekend. That obviously wasn’t going to happen. My colleagues really pitched in and all my work slots were filled within a few hours of me posting that I wouldn’t be able to work. It turned that because of a family problem with another anaesthesiologist we were short staffed the week before Labour Day. I actually volunteered to work. My offer was prudently ignored.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">Eventually I decided that I would do my scheduled work the Tuesday after Labour Day. I am self employed, as they say, I have to eat what I kill. I have significant savings so I could probably have stayed out longer. It was more that I felt I was ready and was worried about losing my skills if I stayed out longer. I was already taking most of October off, if I missed September that would be a long time off. That was in addition to all the time I had taken off in the summer.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I had suffered a big knock to the head and I was worried about cognitive effects. I keep on going over drug doses in my head and imagining scenario and what to do. I felt I was ready cognitively.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">My first day back was a single all day flap. That was great for me, just 1 IV to start, 1 airway and then a lot of sitting. I got thru that. The next day was a urology list with about 8 cases and I sailed through that. I was back.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I have more or less recovered now. I still have some facial numbness and I will need dental work on my front incisors, hopefully only being capped. My teeth are a little mis-aligned and chewing is still difficult. A pleasant side effect of not enjoying food as much was a 15 lb weight loss. After the surgery my face was numb and dysesthetic, so I didn’t want to shave. I now have a beard and my wife even likes it.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">I still think how fortunate I was. If I had not been wearing a helmet I may likely have died. The transplant unit was across from the plastics unit and I think how bits of me could have been living across the hall in other patients. I was glad I was riding with my wife; quite often I have ridden home from the Folk Festival alone. I am glad I didn’t have to rely on the kindness of strangers.</span><br />
<span style="-webkit-font-kerning: none;"><br /></span>
<span style="-webkit-font-kerning: none;">And what about the Canadian Healthcare system? Sure I had to bunk with 2 other people in a room designed for 2 and I waited 5 days for surgery. But I got seen in the ER right away, I had 2 CT scans and I major surgery and the only things I paid for was $20 for the taxi and a few dollars here and there for OTC meds. What a great system and yet politicians and sadly quite a few doctors want to blow it up. Shame on all of you.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br /></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">And I remember how nice everybody was to me, the emergency nurse, the emergency physician, the CT scan staff, plastic surgeons, the floor nurses and of course the anaesthesiologist and the OR staff. Sometimes in my career when I was tired, busy or frustrated I haven’t been the nicest to patients and I regret that now.</span><br />
<span style="-webkit-font-kerning: none;"><br /></span>
<span style="-webkit-font-kerning: none;">I really have to thank my surgeons. I like to make fun of surgeons but the care I got from the whole team was fantastic.</span></div>
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none;"></span><br />
I have to thank my anaesthetic colleagues who are the greatest colleagues anybody could ask for. I had to miss work during the summer and was on call on a long weekend. In Edmonton we have a very short but nice (not this year so much) summer and people gave up days off in the summer for me. And they picked up every day within hours of it being posted.</div>
<br />
<div style="font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;">And of course my wife. She was so calm in the face of what was a really serious injury. She let me recover slowly with no demands. There were times when I just wanted to be left alone and she did that too. And of course the great food, from the smoothies before surgery to the delicious soft diet food after.</span></div>
<div>
<span style="-webkit-font-kerning: none;"><br /></span></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-15915788159903262892019-04-29T06:38:00.000-06:002019-04-29T06:40:29.664-06:00The Board<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I trained as a medial student and intern in 3 different labour suites, caserooms whatever you</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">The unifying feature of caserooms was the The Board.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">While The Board slightly varied between sites, there were constants. The patient’s name, attending physician, Gravida and Parity, gestation and dilatation. There was usually room for other info such as pre-eclampsia or VBAC. It was such a valuable source of information for seeing what was going on and predicting workload. The Board when I was junior was a blackboard with chalk. Lately it is a whiteboard. Such a low tech but effective way of communications.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"><br /></span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">At Vancouver General Hospital which did OB in the early 1980s, the medical students had to keep The Board up to date, which meant constantly having to bother the nurses about what the dilatation was (they didn’t tell you when they did vag exams, because you might want to do it yourself, which after all was one of the reasons you did an OB rotation) lest you get yelled at by the crabby soon-to-be-former OB resident. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">When I came to my current medium size Catholic hospital 13 years ago the board had become more streamlined than what I remembered. Dilatation and gestation were not charted, but it at least had the patients name, attending physician, gravida and para. They also wrote a big E next to the patient if there was an epidural. Very useful for anaesthesia when you came in on call. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Something as effective and elegantly simple as the board was bound to come to an end of course.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Several years ago, I was called for an epidural and looking on the board saw that her last name was 3 letters long. I went into the room but noticed she had a different name more than 3 letters long. Back to the desk I went. No I was told the 3 letters are the first three letters of her name which for privacy purposes we are now only allowed to use. I rolled my eyes and did the epidural. Of course as I commented many people nowadays have 2-3 letter last names, plus it is highly likely that you will have 2 people in labour at the same time who share the first three letters of their last name (McDonald/McDowell. Chan/Chang). Other people whose opinion counted more than mine must have weighed in because they started putting on the full name again. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">About two years ago I got called for an epidural. At our site they never tell us the patient’s name only the room #. “Room 5 wants an epidural” they tell me. I walked past The Board and noticed that the patient had the same last name as one of the obstetricians. Of course when I walked into the room the patient had another name. It turns out that for privacy now they were now only posting the name of the doctor on The Board. Twice as it turns out under patient and under physician. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">The day before yesterday I walked onto the ward and The Board had shrunk to about 1/3 of its size. “Why is The Board smaller?”, I asked. “Its an accreditation standard, “ I was told. I am not sure why it should matter at all to the accreditors but apparently it does. The Board is now literally tiny. Whereas you used to be able to stand back of the nursing station and read it, you now have to go right up to it.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">This presumably is in the name of privacy. My mother always told me if you had nothing to hide, you didn’t need any privacy. I wonder how many patients really cared about their names being flashed up on The Board. People after all pay to put birth announcements in the newspaper. Labours are live-Tweeted, Facebooked and Instagrammed. Plus I am sure in the past if people wanted the anonymity, they were accommodated with a pseudonym. And if you’ve figured out that your husband’s mistress is in labour at this hospital you can probably find out which room she is labouring in.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">At the same time, we actually have made labour a group activity. It is not unusual to have multiple family members in the room, or hanging around the hallways (usually talking outside the call room) while the mother is in labour. I frequently have to ask for all but one of them to leave when I do the epidural. (As department head, I had to deal with a complaint about one of my colleagues doing just that). My father on the other, even if he had wanted to, was not allowed to see any of the births of his 4 children, which may explain why I grew up so messed up. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">And there is the issue of depersonalization. I seem to remember during my OB rotations that I actually knew the patient’s name. Now most patients are referred to by their room number. I even find myself writing the room number on the patient label I collect for billing so I can tell them apart.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<br />
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Of course in the 21st century we could have replaced The Board with something electronic that might even be an improvement but I’m not holding my breath on that</span></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-5156820876042449382019-04-29T05:45:00.002-06:002019-11-08T15:18:08.611-07:00Why I stopped subscribing to my local newspater.<div dir="ltr" style="text-align: left;" trbidi="on">
The Edmonton Journa didn’t publish my letter but I have a blog:<br />
<br />
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">My wife and I cancelled our subscription to the Edmonton Journal.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Since moving to Edmonton in 1992, we have subscribed to your paper. I remember it as an excellent paper with balanced coverage of local, national and international news and issues. The large Saturday and Sunday editions were a true joy to read, taking several hours.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Over the last few years, the quality of the paper has declined, there is no longer a Sunday edition and the size of the paper has decreased to the point where the flyers deposited in our mailbox along with the paper are often larger in size. In addition the national and international news and opinion section has been outsourced to the National Post. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Worse was the behaviour of the Journal during the election and in the run up to the election. On at least two occasions the UCP was allowed to buy full page ads on the front page of the journal giving the impression that this was news not advertising. During the election various PACs were allowed to buy full page ads in the news section of the paper. In addition the Journal endorsed the UCP which is really not surprising although disappointing.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I realize that papers depend on ad revenue to survive and am not naive enough to expect that advertisers and owners of newspapers will always agree with me. I realize that their coverage of news of their editorial opinions will always subtly reflect the bias of the owners and advertisers. I have always enjoyed reading the other point of view if only to mentally rebut it (and occasionally agree with it). The Journal in the past has always presented a diversity of opinions and tried to present both sides of the story. It is clear however that the promotion of a single agenda is now being blatantly pushed not only in editorial content but also in the way that news is being presented. This is reflected in the Journal ignoring certain stories and by presenting opinion as news.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">For the past few years, I have noticed that the Globe and Mail’s coverage of Alberta and Edmonton issues is more thorough and balanced than that of the Journal. The Journal has now become a newspaper which features the worst aspects of the Edmonton Sun and National Post. Quite frankly most days, now I find myself going straight to the comic section which is actually still quite good.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I have read newspapers since shortly after learning to read. As I mentioned above, I still find the Globe and Mail to be a high quality source of information and entertainment. Recently while visiting Victoria, I read the Times-Colonist and was thoroughly impressed with quality of the journalism.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Newspapers have been observed to be under siege with competition from the internet and other platforms. I have always preferred to read a paper and I suspect that a significant number of people do not read newspapers any more not because of the internet but because the content in newspapers has become so awful. </span></div>
<br />
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-61939275429658581412019-04-09T09:17:00.001-06:002019-04-09T09:17:34.457-06:00Sometimes you write a really good letter but don’t send it.<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">About a year ago I applied for a licence in my neighbouring province (where I was born, went to school and worked for a while). This was an interesting experience which I should blog about some time. The caper was in addition to having to get a criminal records check, having to be fingerprinted. This was because apparently a sex offender has the same birthday as I do. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"><br /></span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I quixotically phoned the agency, knowing that it wouldn’t change anything but I needed to yell at someone on the phone. They were very polite; it was like I wan’t the first person and I went down to my local police station and good fingerprinted. Interestingly enough, so many people need to get fingerprinted now that our police force has a free standing office which does nothing but fingerprint people. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"><br /></span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-stretch: normal; line-height: normal;">
<span style="font-size: 14.666666984558105px;">And I wrote this letter. </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"><br /></span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">“Thank you for your letter and for the time your two employees took trying to explain it on the phone. It is nice to know that I am not suspected of being a sex offender.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">For your information, I was born in British Columbia, grew up, attended medical school there and practised medicine there. I have practised in Edmonton since 1992 and have been at my current hospital since 1996. I have lived in my current house for over 10 years. I have paid both federal and provincial income taxes as well as property taxes. I have a drivers licence. I recently renewed my passport for 10 years. (I provided a notarized copy to the CPSBC). I have a Nexus card. It is my understanding that every year I have had criminal records check through the CPSA. I also had one when I got a visa to go to Rwanda to volunteer teach. I show up in Google searches of my name. It is not like I have hiding for the past 40 or so years.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I accept however the possibility that during this time, I may have lived a double life involving nefarious activities under another name leading to my acquiring a criminal record. It is also possible that I continued to work and raise a family while incarcerated. An alternative explanation might be that I used my time while incarcerated to learn how to construct a time machine which I used on release to travel back in time and create a new identity.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Seriously I think that people who exploit the vulnerable especially those who abuse children are the lowest form of humanity and if by getting fingerprinted, I could prevent one such incident of abuse, I would happily get fingerprinted every day. The truth is that this policy is not about protecting the vulnerable; it is a make work project for the public safety industry and a cash cow for the RCMP and local police forces. Even the nice lady who spoke with me on the phone acknowledged that this policy has resulted in a huge increase in the number of staff needed to maintain it and one wonders how many nurses or police officers could be employed with the money necessary to employ these people. The other and more concerning issue is that policies like this are primarily designed to give the appearance of doing something about the problem rather than actually doing anything about it.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<br />
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">It further needs to be noted that saying, “we’re only enforcing policy” is a somewhat empty excuse when you are the ones who made the policy. It also sounds very much like “we are only following orders”, an excuse that was deemed invalid around 1945.”</span></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-51613629295421289222019-01-07T09:26:00.000-07:002019-01-07T09:26:15.701-07:00Do I feel guilty about getting drunk the day my father died.<div dir="ltr" style="text-align: left;" trbidi="on">
While I'm not necessarily proud of going on the wine tour on my father's last day on this earth, I am not ashamed also.<br />
<br />
Would I have been ashamed if in an alternate universe, he had not broken his hip but rather had had a huge myocardial infarction or stroke on that day while I was out wine touring. <br />
<br />
As I said, it still bothers me that he died alone but I got to see him the week he died and spent a lot of time with him during his last two years alive. I would rather remember him as he was when he was younger because the last two years weren't really that great for him or for us for that matter.<br />
<br />
While anaesthesia doesn't get involved in end of life very often, I did do general practice for 3 years and also anaesthesiologists get to do 6 months of internal medicine so I saw my share of death watches where the entire family assembles around the bed of a dying parent or grandparent in various stages of awareness and pain. Overall, I didn't get the impression that anyone, patient or family got any comfort from the practice.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-16629393174230479822019-01-04T11:30:00.000-07:002019-01-07T08:43:50.184-07:00Thoughts on my father's death.<div dir="ltr" style="text-align: left;" trbidi="on">
My father died last June 2. He was 94 and it shouldn't have been unexpected. As I was to find out, it was still difficult.<br />
<br />
I go on a few medical and teaching missions nowadays. In 2011, I went with CASIEF to Rwanda for 4 weeks (a total of 6 weeks away between pre and post-cations). My parents were pretty old by then, so I believe I told them, if something happened while they were away, I was not coming home. Therefore every time I visited and left my parents it was like I was saying goodbye forever.<br />
<br />
Between placing my parents in various levels of care over the past 2 years I have been visiting about every month, which is more than I saw them when I was attending university in Vancouver, a ferry ride away.<br />
<br />
Anyway I was on my way to the Canadian Pain Society meeting in Montreal. On arriving in Montreal, I turned on my phone and my brother had texted me to tell me that my father had fallen and broken his hip. We were still in the airport. "Do you want to fly back?" asked my wife. No, I said, it won't make any difference. He will have surgery in the next couple of days which he may or may not survive and whether I am there or not will not make any difference. And besides I had said my goodbyes. I kind of had the sense that this was it. He was going to die within a couple of weeks or it would be the start of an inevitable downward decline.<br />
<br />
After some consideration, I decided that after returning to Edmonton, the Friday, I would fly to Victoria on Saturday to visit Saturday and Sunday. I had a busy next week planned. A medicolegal in Calgary on Monday, Pain Clinic in Grande Prairie Tuesday and Wednesday , a medicolegal in Vancouver. Thursday and one in Kelowna on Friday. Now I could have cancelled all this but really it really wouldn't have made any difference would it? I phoned the ward regularly during the week I was in Montreal.<br />
<br />
So I flew out to Victoria Saturday am, rented a car and went straight to the hospital. My father had had surgery by then. I never ever learned whether he had a hip pinning or a hemi-arthroplasty or whether it was a GA or spinal. He was in a private room and was pretty delirious. He did recognize me. It was very interesting because in between bouts of delerium he actually made sense and was talking about politics which he loved doing. He had a bundle of newspapers which he clutched tightly, not letting the nurses take from him. I also went and visited my mother. She kept on asking where he was and I kept on telling her he had broken his hip.<br />
<br />
I visited again on Sunday. The nurses said he had had a bad night and he was lying in bed but recognized me. I spent a little time with him and then drove back to the nursing home to see my mother. I asked the staff at the nursing home if it would be okay to bring her over. I had mixed feelings about this. She was already not terribly able to walk even modest distances and I would have to park and walk over to the hospital with her. The other thing that worried me was what I would do if she refused to leave my father's bedside. Nevertheless, I took her, we walked slowly over to the hospital and up to my dad's room. By this time the nurses had hoisted him into a chair and he was in a deep sleep. We say there for almost half an hour, my mother and I. At one point my father opened his eyes but didn't seem to recognize us and went back to sleep. After half an hour, my mother said, "that's not my husband is it?" and we left, stopping for coffee and a snack at the coffee shop in the lobby.<br />
<br />
I returned my mother to the nursing home and spend a little time before leaving. I had a flight in the late afternoon and so had lots of time. I could have visited my father again but I thought what difference really would it have made. I figured he had survived the first few days of injury and surgery, the delirium would resolve and he would be eventually starting a long (and most likely futile) rehab program.<br />
<br />
I later flew to Calgary, then to Grande Prairie, to Vancouver where my wife met me and then to Kelowna where I had a medicolegal Friday. My son lives in Kelowna and we had planned to spend Saturday in Kelowna and leave in the evening. My son works Saturday so we couldn't visit with him that day but took him and his girlfriend out to dinner Friday.<br />
<br />
My wife suggested we do a wine tour Saturday and we found a taxi driver who did private tours and who would take us to the airport afterwards. We were just on the way to our first winery when my brother phoned me. My father was apparently now septic from at UTI with decreased blood pressure. He gave me the pager number of the hospitalist. I paged her and she phoned back right away. By that time we were outside of our first winery. She confirmed what my brother told me, I confirmed his resuscitation status and suggested that if he didn't respond to modest amounts of fluids not to do anything.<br />
<br />
We went into my first winery. "I hope you don't think," I said to my wife,"I am being callous by tasting wine when my father is most likely dying." She didn't think so.<br />
<br />
Wine tours are really just an excuse for getting drunk during the day and we did that quite happily and I am may have even forgotten about my father. At one point our driver suggested we visit a craft brewery which we did. Outside the tasting room, my phone went off. It was the hospitalist. My father's blood pressure was now worse, falling to as little as 40 systolic. I told her that I understood and that he would probably die. I then phoned my brother and told him, I didn't think my father would live out the day. I am not usually good by the way at predicting deaths.<br />
<br />
For some reason I decided to taste a flight of beers and I ordered them and took them out to table outside. Then it hit me, my father was going to die. I started crying. People were looking at me. I got myself together and then tasted my craft beer. Why waste it. <br />
<br />
We finished our tour and went to the airport. We flew to Calgary. At the Calgary airport while waiting for my plane to Edmonton, I phoned the unit. The nurse said my father was hanging in there.<br />
<br />
Sometime while I was in the air between Edmonton and Calgary my father died. My brother left a message on my phone which was on airplane mode.<br />
<br />
It doesn't bother me that my father died. He was 94 and had never adapted to nursing home life or my mother's dementia. He had a great life including 33 years of retirement on a comfortable pension. It does bother me that he died alone although I don't know that it would have made any difference or whether in his last hours he would have even noticed the company. I don't know what goes on in peoples minds while their body is shutting down; I hope that during the hours he was unconscious before he died, he was having visions of his childhood in Sussex or meeting my mother for the first time.<br />
<br />
My father requested that he not have a funeral. Some people I talked to thought that it was weird and that we should have something but we didn't. My brother got him cremated which is what he wanted. I assume he has the ashes.<br />
<br />
I went to visit my mother a few weeks later. The staff had told her that he had died but of course she forgot this after getting quite upset. She of course kept on asking me where he was. I told her over and over he was resting. At one point she said, "What is he resting from?". "Arguing" I replied because that is what he loved to do and she actually laughed. When I went into my mother's room the book "Silk Roads" was on table in her room. I gave that book to my father the previous Christmas. He like to read in my mother's room. I really enjoyed the book. I hope he got far into it.<br />
<br />
<br />
<br /></div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-16905549343845369602018-12-26T16:35:00.002-07:002018-12-26T16:35:38.188-07:00How I Stopped Worrying About Giving Up Chronic Pain<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I decided last March to give up chronic pain. I blogged about it. I am now down to my last few clinics. I had continued to agonize about whether I was making the right decision. Until last Friday’s clinic.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">The last pain clinic before Xmas is always interesting. People bring in baking, candy and occasionally liquor. (I have for years thought about asking them to donate to charity instead but this of course presupposes they would even give me a gift.). On the other hand it is a littler busy and you end of dealing with a lot of prescription faxing because people need early releases or realize their prescription is going to run out over Xmas.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Three things on an otherwise good day just pissed me off.</span></div>
<ol>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: 11pt;"></span><span style="-webkit-font-kerning: none; font-size: 11pt;"> One of my patients has been going to the local block shop where she has been getting blocks. I have no idea what type of blocks or where because they never send me reports. I may have referred her there, it wouldn’t matter, they hardly ever send me their consults. Anyway she told me she was getting rhizotomy and she had been told to take 2 weeks off after it. Then the capper. She brought her disability form which they had told her to have me fill out. I was a little shocked and told her I didn’t fill out those forms. I told her to take them to her family doc, which I am not proud of. I should have told her to take them back to the block shop. She left disappointed, maybe angry. Probably the last time I will see her.</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: 11pt;"></span><span style="-webkit-font-kerning: none; font-size: 11pt;">Next I get an email from my PCN pain clinic pharmacist. Another patient had a rhizotomy at the same block shop. This time I had referred her there. This made her pain worse rather than better. Funny how nobody doctors or patients considers that that might happen when you apply radio frequency current with a large needle. Anyway the block shop was refusing to prescribe any analgesics. After initially refusing myself on the basis of “you break it, you buy it”, I thought better and faxed in a prescription for hydromorphone. If you think that this is just a problem with one particular block shop; actually this is the best block shop It is mostly physiatrists, they actually examine patients. Just about everybody gets a block though. Did I mention her family doc has taken 14 days off over Xmas with nobody covering her practice?</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: 11pt;"></span><span style="-webkit-font-kerning: none; font-size: 11pt;">Later that day a patient I see sporadically came in. He has a very complex pain and psych history. So his psychiatrist decides this is a good time to wean him off all but one of meds. Yes this includes narcotics but also included a lot of psych meds. Surprise, surprise his pain is worse and I am supposed to sort this out the Friday before Xmas when I’m going to retire in 3 months. “Did you tell this to your psychiatrist, “ I asked. Turns out he had seen the psychiatrist 2 days earlier but they had only talked about his mood. I suggested that he go back to his psychiatrist and ask to go back on his meds. As if this is going to happen before January. I have nothing against deprescribing, I think it is good idea sometimes as long as you are prepared to admit when it isn’t working. I know there are 2 sides to every story and his psychiatrist might have had a very good reason to want to wean him off. I of course don’t know because he never bothered sending me a copy of his notes. And he can’t say he didn’t know I was involved in his patient’s care, because I sent him a copy of my last progress note. I could try to phone him except that in 25 years I have never gotten through on the phone to a psychiatrist nor has one ever returned my calls. Not to mention it is Friday, Friday before Xmas.</span></li>
</ol>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">Hey I know that disability forms are a pain to fill out and most of us think if a patient tells his employer he needs time off, they should within reason believe them. I also know that our colleges and people like David Juurlink have made the prescription of narcotics dirty. The point is when you accept care of a patient you should take responsibility for their disability forms and for the complications of your treatments. You should also communicate with your colleagues.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">I thought that I was giving up chronic pain because I had lost my compassion. In fact I now realize that it is the whole medical environment that has finally. Not administrators, EMRs or lack of resources. It’s the whole “not my problem “ attitude that has malignantly affected medicine. Every week some patient tells me about their latest interaction with a physician, it could be their family doc or a specialist, and I think of how ashamed I am to be a physician. To be fair, there are some doctors who give their chronic pain patients excellent care, with whom it is possible to work with. The thing is, that these doctors are now so uncommon that they stand out.</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal; min-height: 13.1px;">
<span style="-webkit-font-kerning: none; font-size: 11pt;"></span><br /></div>
<br />
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-size: 11px; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none; font-size: 11pt;">So I will mostly be spending the rest of my career working almost exclusively with surgeons. I have written and thought a lot about surgeons, some of it in jest. Surgeons are economic with the truth, a little arrogant, tardy and make me work when I would rather not. But...surgeons give a shit about their patients at least for the time under surgery and frequently for a few days before and after their operation.</span></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-85879512732014951352018-09-05T20:19:00.001-06:002018-09-05T20:19:31.837-06:00First days of medical school<div dir="ltr" style="text-align: left;" trbidi="on">
With getting older comes all sorts of anniversaries. I started medical school 40 years ago today.<br />
<br />
There were the prelims of course, getting the letter of acceptance sometime in June, writing back to accept their offer and I believe there was a deposit cheque involved. There was also a trip over to Vancouver to pick up the microscope they said we had to buy. I quit my summer job a week early much to my father's distress; everybody except him thought I needed a little time before starting medical school.<br />
<br />
Starting was simpler than for some. I had been at UBC for 3 years of undergrad already; I only applied to one school and planned to be either starting medical school or finishing off my degree. I had a room in the student residences. My friends had got a house off campus; I preferred to have the familiarity of residence and the ability to roll out of bed and walk to my classes instead of dealing with traffic or buses.<br />
<br />
My recollection is I went over by bus and ferry on labour day. At UBC the week after labour day was registration week, a week of drunken debauchery before classes started the following week. No registration week for the medical school. Classes started the day after labour day.<br />
<br />
So it was on September 5, 1978 that I found myself in a lecture theatre in the Woodward Building sitting in my usual seat at the back, looking around wondering if I knew anybody in my class. As people filed in, I recognized a few faces from lectures and labs and even somebody I didn't know all that well but had gotten drunk with a couple of times. I had a negative opinion of what I thought would be my future classmates. I expected a serious, hard working, cut-throat group of people. I expected the next 4 years to be a busy, hard and socially very boring time. (The summer before I started I was introduced to a visiting fiance of a co-worker as a medical student. "Oh," she said, "I know a few medical students....I don't like any of them." Great, I thought I've known you for a minute and you've already insulted me.)<br />
<br />
Negative thoughts notwithstanding it was an exciting time, the culmination of three years of undergraduate always with a goal of getting into medical school. We were welcomed by the Dean who informed us that we were the chosen people and welcomed us to the great fraternity of medicine. We were then registered, and photographed. I am not sure whether we had further classes that day. There was a trip to the bookstore to pick up all the texts they said we needed, including the anatomy trilogy written by our Professor of Anaesthesia. I also bought an ugly short white lab coat.<br />
<br />
I went to the Pit (the student bar at UBC) that night and ran into my old friends and got little drunk which meant starting my first anatomy lab the following day with a bit of a hangover, which I would not recommend but I survived the day.<br />
<br />
Thursday afternoon was the useless touchy-feely course we took in first year and we were divided into groups of 8. The 8 of us sat in the room and some older adult asked us to tell the group something about themselves. It was a round table and the talk started to my right so I got to talk last. That was not good. The first 6 had all had incredible lives, attending schools overseas, volunteer work and they all knew exactly what kind of doctor they wanted to be (and that kind of doctor was not an anaesthesiologist or a general practitioner). Fortunately the person to my left, turned out to be a down to earth person, with an ordinary life, actually from Victoria although from a different high school. Then I told my boring life story and we went on to something else.<br />
<br />
Later that Thursday we had a tour of VGH lead by 4th year medical students who seemed so incredibly cool, followed by a party in the Medical Student Lounge on 10th avenue. This party was by tradition put on by the second year class who had survived first year. They were, as I later learned, by UBC standards an intense group. Talking to them was somewhat anxiety provoking as they told us about the amount of work we could expect to do in first year (which was mostly true) followed by telling us that second year was worse (which it wasn't). This was very depressing but we had Friday morning off and the beer was cheap, so I got to have a few and made some friends in my class and I remember in the early morning a bunch of us heading off to Bino's on Broadway for pancakes before somebody drove me back to the campus. This was to be the first of many drunken parties in medical school. <br />
<br />
Friday afternoon the first week was our 3 hour Biochemistry lecture and I was most impressed when Dave, my new dissecting partner loudly announced that the lecture would be continued in the Pit. It just happened to be the night of the second Ali-Spinks fight which was on the big screen and it was great to see Ali regain his title. Between that and running into my old friends, I think I closed the Pit down. Medical school was not looking bad.<br />
<br />
First year was heavily weighted on Anatomy with 3 or more dissection labs a week, along with a histology lab and 2 hours lectures 3 days a week. It became apparent that most of us were in grave danger of failing anatomy if (or even if) we didn't work our buns off. This was memorization of trivial details on a scale none of us had ever encountered. It was, I am sure, humbling for all us, accustomed to being at or near the tops of our classes to have to shift into survival mode. The whole stress of the situation seemed to bring everybody together perhaps in the same way basic training brings together soldiers. We spent so much time together in those days as we all had same lectures and same labs. We usually ate lunch and had coffee together, and frequently drank together. People started inviting the whole class to house parties. <br />
<br />
Our class was the largest ever at UBC with 88 students. There were supposed to be 100 but they weren't able to expand the anatomy lab to fit that number (which may have been galling to the 12 people who found themselves left on the waiting list the day after Labour Day). Also a first we had 33 women which was most ever at UBC.<br />
<br />
I think back now on how little I knew of what was ahead. I knew nothing of details like specialization, certification exams or what was involved in being on call. I had no idea what an anaesthesiologist was. The only one I was aware of was the morose Australian on MASH, who always seemed to say, "Oim losing 'im Hawkeye". Looking back it is interesting of how little we were prepared for the world we were going to go into or that in which we live today.<br />
<br />
I believe all but two of our class graduated although it took some more than 4 years. One poor fellow failed anatomy and the summer supplemental anatomy course and was turfed. The other developed schizophrenia in second year which was fascinating but depressing to watch. We all went away to internships, did locums, residencies, settled down in various parts of country, a lot of the class eventually washing up in the lower mainland. We had a 5th, 10th, 15th, 20th and 25th anniversary. Only about 40 people attended our 25th anniversary in Vancouver, surprisingly given the number who lived in the area. Nobody bothered organizing a 30th or 35th (maybe they did but didn't invite me). Two of my classmates work in my city. I used to see one, a neurosurgeon, a lot when I worked at the Centre of Excellence. The other a psychiatrist, I last ran into over 10 years ago. At least 3 of our class have died including my good friend Dave and also Phil who was in my dissecting group. (The fourth member of our dissecting group, contacted me a few months ago on LinkedIn and introduced herself as the other surviving member of our group.)<br />
<br />
40 years on now, I can just look back to the excitement, the fear and the relief of those first days in medical school.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-40515441388874922132018-03-25T15:07:00.000-06:002018-03-26T09:14:43.538-06:00Leaving Chronic Pain<div dir="ltr" style="text-align: left;" trbidi="on">
Sometime last month was my 25th anniversary of my first pain clinic. I was at the Centre of Excellence, and the person doing the Pain Clinic went on to better things. The Professor told me I could do the Pain Clinic until they found somebody smarter than me to do it. Problem was there was nobody smarter or stupider and 25 years later here I am, although not at the CofE. I should have had a party, moreover somebody should have thrown one for me.<br />
<br />
A couple of weeks ago, I gave notice that in March 2019, I will be giving up most of my chronic pain practice and become a more or less full time anaesthesiologist again. Like many decisions there was no “last straw” moment, it was a series of small things.<br />
<br />
One reason is that despite everything we complain about, being an anaesthesiologist is a pretty good gig, if only for this reason. When you see the hospital in your rear view mirror at the end of the day, unless you are on call, you know you are finished. No phone calls from the ward, patients, pharmacies or other doctors. If for some reason you want to go on a long vacation, you don’t have to arrange coverage and you know that you won’t spend your first two weeks back, putting out all the fires that started while you were away.<br />
<br />
I have been pretty good about setting boundaries and have a great colleague who covers me when I am gone. Patients expectations about availability are less too, I get a lot fewer calls now. Still I have voicemail and a fax which go to my email which I check even on vacation and the hospital switchboard has my cell number. I could ignore them because switchboard is supposed to know when I am away and my voicemail greeting usually says I am away and who is covering but I still feel guilty, even when the problem is not one of my creating. For example I spent a great deal of time on my 60th birthday dealing with a patient who had messed up big time. I did this after the pharmacist from the PCN pain clinic emailed me to say he needed urgently to speak with me. Okay why was I checking emails on my birthday? Because that’s what I do.<br />
<br />
I met a pain specialist from another centre about 10 years ago at an anaesthesia meeting. "I'm thinking of going back into anaesthesia", she said, "I want to retire soon and I can't handle the demands of my patients." Sounded strange at the time; most people give up anaesthesia and the call involved to do chronic pain, I almost did a few years ago. This encounter did plant the germ of this idea in my head.<br />
<br />
The biggest thing however is that I realized a few months ago that I have lost my compassion. I no longer have patience for people who won't try do anything to help themselves, I no longer want to hear about problems that I have no way of solving. 90% of my patients are good people who try do everything possible and I have a treatment that might help them or is helping them. Like most things in life, it is the other 10% that take up most of my time, that leave me feeling drained at the end of the clinic. I don't want to be seen as blaming patients for their misfortune, its just that quite a bit of the time I have nothing to offer and don't really want to hear about it anymore. So often I want to say, "YOU have a problem, what are YOU going to do about it?"<br />
<br />
Pain medicine and medicine in general have changed over the last 25 years that make it less attractive to practise. 25 years ago most of my patients had a family doctor, moreover they had a family doctor to whom I could make recommendations that they would follow. Now when I get a referral, I get the sense that the family doctor has washed his hands of this patient. That is of course if the patient has a family doctor and a significant number don’t.<br />
<br />
Paradoxically we have way more physicians doing chronic pain than 25 years ago. This should make it easy. It doesn't. 25 years ago, I was almost always the first person to see a patient. Now quite often they have already seen one or more chronic pain specialist. Quite often they are still seeing someone else (I saw a patient a few years ago who was seeing 4 other chronic pain doctors; she was quite disappointed when I told her I didn't think there was any point in my following her as well). This would be nice if I actually had the records from their previous doctor so I could see if I had anything else to offer but that is the exception not the rule. Moreover some of my colleagues have developed boutique-type silo practices where they offer single modalities, usually interventional treatments. Quite often the patient is still getting these treatments but the expectation is that I will prescribe medication for them. Or one of my colleagues has started them on some toxic cocktail of multiple classes of drugs that I am supposed to unravel and continue. And with all this expertise floating around we should be able to work together in the patients' best interest? What universe do you live in?<br />
<br />
So why don't I, as somebody suggested, just carve off the parts of chronic pain practice I enjoy and forget about the rest? If only it was so easy to tell in advance who was going to be easy and who wasn't. And the easy patient of course so easily becomes the hard patient. I have for the last few years been more selective in screening out referrals and in my new consults so that I am accumulating fewer patients I know I can't help with the resources I have available. But I have never been comfortable telling a patient that just because I can't do some lucrative procedure doesn't mean I can't try to help you.<br />
<br />
It is hard to talk about chronic pain without mentioning the opioid crisis or epidemic whatever you want to call it. I still prescribe opioids for chronic pain, although not in the industrial doses some of my colleagues prescribe. So far I have escaped scrutiny from our medical licensing body. Every quarter I do get a list of patients who are over the recommended dose which I read with some interest. Talking however to some of colleagues who have undergone scrutiny and have had to pay 10s of thousands of dollars in "costs" of the investigation or fees to attend remedial courses scares me a little bit. I am less than 5 years from retirement, slowly building up my nest-egg. I look at some of my patients and think, "is patient X, the hill I want to die on?"<br />
<br />
And of course with increased scrutiny from the licensing body, a significant number of referrals I get are dumps of patients who have gotten onto these industrial doses not to mention a number that are doing well on a reasonable dose and the expectation is that I will take them over in my solo part-time practice. Which of course I do because I am an old school doctor, who doesn't want to see patients go through narcotic withdrawal.<br />
<br />
Narcotics still confuse me and I have no idea what the right answer is. I have mentioned above, that I have reluctantly acquired a number of patients on whopping doses of opioids. Most of these people seem to look okay. Their function like most chronic pain patients is not the best although I periodically find somebody who is actually working. Most of them are quite happy on the massive doses they are taking; they don't want to see a psychologist or attend a rehab program and they definitely don't want to come off their meds.<br />
<br />
On the other hand I read a lot in the medical literature and on Twitter (where I get most of my medical info now) about all the bad effects of narcotics, and there is no doubt that there is some truth in all of this. The question is where is the balance because as somebody who follows a lot of patients on narcotics, clearly some of them benefit greatly from them with little or no adverse effects. Further I have seen a number of ugly cases of forced weans that ended up in my clinic. Our Workers Compensation board has recently become evangelical about weaning off opioids, at least once a month I have to spend 20 or minutes consoling a distraught patient who has been told they have to go to a clinic in a city 3 hours away to be weaned off their meds. They all think I have some magic clout with WCB.<br />
<br />
Just something I don't want to be bothered with anymore.<br />
<br />
In fact these patients are the most difficult for me to abandon. I hope to transfer those with understanding GPs back to their GP. Some of the complicated ones I am referring to some of my colleagues and my colleague who is taking over my clinic time will take over some. Our licensing body told me that as long as I gave them 3 months notice, I had no obligation at all to arrange follow up.<br />
<br />
Chronic pain still confuses me. I still don't know what causes back pain or neck pain. I could be one of those people who says, "yes it's definitely your facet joints and every three months I will inject steroids into those joints or maybe just burn the nerves" but I know its not that simple. So I end up offering what I think might work, usually in my case trigger point injections and an antidepressant but feel like an idiot for doing so. I should be telling them to exercise and lose weight, like that will ever happen.<br />
<br />
Patients often ask me about some bizarre symptom they are having. "Is this normal?" they say. "No", I reply, "it is not normal but it is not unusual." I have learned that patients have these symptoms, they are real; if they're making it up, that too is pathology worthy of treatment; and that in most cases I can only guess at the psycho-physiological mechanism behind it.<br />
<br />
The lack of supportive infrastructure is another factor. I usually go to a pain meeting once a year where I hear presentations from psychologists and physical therapists and I come home excited and ready to help my patients. That is until I try to refer and find that my patients can't afford any of this and the very few practitioners in the public field have exclusion criteria that effectively excludes all my patients. Long ago at the CofE one of my colleagues came back from his Pain Fellowship (at Boston College, not Harvard as he now tells everybody) to join me in practice. "Where," he asked me, "do I refer somebody for inpatient rehabilitation?" I was polite and supportive. I didn't roll on the floor laughing. I told him that no such program inpatient or outpatient existed and that he better learn to live with that.<br />
<br />
Periodically we get to meet with our regional admin. They usually tell us how much they support what we are doing and then we don't meet again. A couple of years ago when I last got invited, I was a little punchy. "Are you going to be giving us more resources, " I asked, "because if you aren't I really have no interest in attending any more meetings". And I didn't. It is not just not having new resources, it is not being able to access existing resources that bugs me. And it just galls me to see all the new programs that have sprung up for chronic diseases while we have been told there is no more money for chronic pain.<br />
<br />
Things are a little better now, we do have self management programs and also some exercise programs. Thing is, these are all by self-referral and the likelihood of the passive fix-me-now pain clinic patient phoning the number and driving across the city (because they are never central) to attend one of these programs is close to zero.<br />
<br />
Anyway, while I sometimes lie awake at night wondering if I am doing the right thing, blowing up 25 years of practice, I told somebody I was retiring (from chronic pain) and it felt pretty good. Maybe somebody will throw a party for me.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-24122524286620342742017-12-18T13:23:00.001-07:002017-12-18T13:23:46.856-07:00Getting Older<div dir="ltr" style="text-align: left;" trbidi="on">
My father once told his grand daughter, my niece that he was not really old, he was just older.<br />
<br />
We are all getting older. I celebrated my 60th birthday this summer. This was a quiet celebration as have been most of the previous 59. That is what happens when you have a summer birthday. I did take a lot of time off this summer and went on two fabulous bike tours, so I guess I did have a nice birthday.<br />
<br />
My parents are also getting older. My father is 93 and my mother 88. My father retired at 61 although he did some consulting after. My parents had a very active retirement (although my mother as a housewife may not have noticed any retirement). They traveled quite a bit; driving all over BC, Alberta and the Western US. They also visited us quite a few times when we lived on the East Coast. They toured Europe and Britain. My father kept on gardening and with the extra time on his hands his garden became more elaborate.<br />
<br />
They were however getting older. One by one their siblings died until I have only one surviving aunt. My father started to develop all the health problems, prostate cancer, atrial fibrillation (diagnosed by his urologist, most likely a publishable event), cataracts and an abdominal aneurysm repaired electively. He also developed significant osteoarthritis in his knees which for some reason his family doctor didn't want to refer him to ortho for. By the time I did the doctor thing and got an orthopod I knew to see him, all the above problems had presented and the orthopod prudently declined to operate. My mother however remained in fairly good health and was with it. While her mother died of TB in the 1930s, she had aunts on both sides who lived well into their 90s so I was anticipating a long life for her. As my father became more and more crippled by his osteoarthritis, she became more and more his legs.<br />
<br />
My parents continued to live in the house that they had lived in since 1960, This was a single story house with a finished basement. My mother cooked as cleaned as she had all their marriage, my father worked in his garden and did the yard work. A few years ago, my mother disclosed to me that she wasn't sure that they could handle the house but that my father loved his garden and didn't want to move. The garden was becoming smaller and less elaborate and shortly after his 90th birthday my father decided that this was his last garden. They were getting a little help thru homecare and through Veterans Affairs.<br />
<br />
Meanwhile my mother who suffered from macular degeneration, developed what might have been retinal detachments (I don't know for sure, the opthamologist wouldn't return my calls). Last spring she told me, she could no longer read. My mother loved to read as do I. I felt very bad for her.<br />
<br />
I had started visiting my parents every couple of months a few years ago. I no longer had all the weekend sports and it didn't seem that expensive to fly to Victoria any more. It was a nice trip, I would stay in a hotel and visit all my favourite places. We would go out for dinner and my mother usually cooked lunch and occasionally dinner if I was leaving later on Sunday.<br />
<br />
Last June (2016) I visited my parents and had a very nice visit. My mother made us lunch and on Sunday because I had a later flight, she made a nice Sunday dinner. She was at that time having the vision problems but the house was clean and they were nicely dressed.<br />
<br />
I came back in August. Again everything seemed okay. I arrived mid morning, we had tea and then my mother made lunch. We went out for dinner on Saturday. Sunday I drove them out in the country and we went to a nice restaurant for lunch. I was flying home around supper and told them I would eat at the airport on the way home.<br />
<br />
So it was that around 1500, having tea my mother said to me, "you know if you had more education, you could get a better job". Hey I know I'm just an anaesthesiologist. She then asked me where I lived and who I was married too. Thinking back over the weekend, I began to suspect she had not known who I was all weekend. I left feeling somewhat shattered.<br />
<br />
Monday I phoned home hoping to talk to my father. My mother answered the phone, recognized my voice and we talked for a few minutes before I was able to talk to my father. He confirmed that she had been acting like that for some time now. I contacted my brothers and one of them who had visited earlier in August, confirmed that she had been acting like that when he visited. He also revealed that she had been falling over as well.<br />
<br />
Concerned about (but secretly hoping it was) a subdural, I phoned her family doctor, got a locum told her the story and the locum was able to arrange a CT scan in uncommon speed for a GP. This was normal except for atrophy.<br />
<br />
A family meeting was convened with two of my brothers and me. My parents or rather my father agreed that it was time to move to some type of facility. My father has a good pension and they had considerable assets so a private facility was available for them<br />
.<br />
I am not going to go in detail all of what has gone down in the last year except that it was about 10 months that I never again want to experience. My mother now lives in a "reminiscence unit", which is a locked ward for patients with dementia and a tendency to wander. Reminiscence is a nice euphemism for a place inhabited by people who can remember events from the 1930s but can't remember the names of their children or what you told them 5 minutes ago. My father as of a couple of weeks ago lives in the same building on a different floor. He is allowed to visit my mom but can't take her off the unit.<br />
<br />
As it happened just over 6 months ago, we got a phone call that my mother in law was in the emergency with back and leg pain and not really able to walk. Again not going into all the nuts and bolts of what went down but she is now in a nice facility in Burnaby having moved out of her condo.<br />
<br />
Life as my father or maybe it was somebody else observed doesn't come with a users manual and I have learned more about getting older than I ever wanted to. In no particular order.:<br />
<br />
<b>Seniors care is very expensive and somebody is making a lot of money off it.</b><br />
<b><br /></b>
My parents are currently spending between $10 and $20K a month for the rather nice place they are currently living. My mother in law who had much less assets was after some time eligible for subsidized care. However when we first placed her in her first assisted living facility she had to pay a significant extra amount of money to have someone dispense her medications and bath her. This is despite the fact that the person providing the service is probably getting paid the minimum wage for the time spent providing the service. This is also the case for the nice people who look after my parents. There is a RN in their building but I suspect she is getting less than she would be getting by working in a hospital.a<br />
<br />
<b>Not all nursing homes are created equal.</b><br />
<b><br /></b>
I of course should have known that that. We found a nice seniors home for my parents in their neighbourhood with a room available within 6 weeks. My wife, then I suddenly realized that this was totally not the right place for my mom but the wheels were in motion and so that was where my parents went. We told the administration right up front my mother's mental state realizing we might sabotage the move and to their credit they were very accommodating especially for a for-profit facility. <br />
<br />
There are in fact multiple levels of care, which overlap and some are available in the same building some are not. Researching this was very complex. This may mean divorce by nursing home.<br />
<br />
There are of course public and private facilities to consider as well. It is interesting that in Canada, everybody gets treated equally in the healthcare system (not really) but that where and how live as senior is so dependent on your income or what programs you are eligible for.<br />
<b><br /></b>
<b>Staying in your home might be important but a lot of people can't do it.</b><br />
<b><br /></b>
The mantra since I was in medical school has been to keep seniors in their homes and we go to elaborate lengths to do this, not necessarily sometimes in the best interest of the elder or their support people. My father really wanted badly to stay in his house which complicated things incredibly and my brothers and I (most me) tried to figure out scenarios where both my parents could stay in their home. My parents are quite well off, money would not have been an object; however on thinking things over there was no way they could have possibly stayed in their home, even with the best of help. This did not stop me from feeling like I had let the team down.<br />
My mother in law on the other hand was an inpatient and it became clear that she could not go back to her condo. She was eligible for subsidized care, however when we approached people about that we were advised that she could not go directly to subsidized care from hospital; she would have to go home first, fail her trial of home care and then go to subsidized care. We had the means to put her in a non-subsidized care facility from which she was able to apply to the lovely subsidized care facility she currently lives in. Had she not had the means to go into a private facility, however she might still be involved in a Mexican standoff where they say she has to go to her home but she can't possibly go to her home. I am pretty sure that scenario is being played out in lots of hospitalized seniors.<br />
<br />
<b>Rather than being pro-active the system is set up for seniors to fail.</b><br />
<b><br /></b>
Even 30+ years ago when I came out in practice, they were talking about the silver tsunami although they may not have had such a catchy name.<br />
<br />
In Canada we have socialized medicine, every person has a health care number, almost every person has some contact with the health care system, every person pays income tax or receives some form of government assistance, a great deal of seniors pay property tax. In other words there is a huge repository of demographic information available.<br />
<br />
So why are we so surprised every time we have a senior with failure to thrive? Why do we wait for seniors to end up in an acute care bed or the ER. Why aren't we proactive? It is quite likely for example that if I hadn't visited my parents that particular month, nobody would have realized just how far my mother had declined. Sure, you can say the family should have some responsibility. This ignores the reality that living in the same city you grew up in is the exception not the rule and that the children of seniors are mature adults who have jobs, look after their own kids and not infrequently have health issues of their own.<br />
<br />
When I was department head, I had to attend Medical Advisory Committee meetings. Most of those meetings involved various members of the administration telling us about the crisis of seniors in the ER or on the hospital wards. Once I piped up, something to the effect that why don't we look upstream and try and prevent these people from ending up in a place they and we don't want them to go to. Nice idea, said someone in a suit and we went on to the next topic.<br />
<br />
What about geriatricians. Geriatricians exist. The problem is they largely work in hospitals where they see people who have already failed the system or in hospital clinics where after being on a long wait list you can get assessed. Not out in the community putting out fires like they should be. <br />
<br />
Family docs? Both my parents had pretty good family docs. The problem is that it is very difficult providing the type of care seniors need in a fee for service system, while looking after the rest of your sick and not so sick patients.<br />
<br />
<b>Not everybody ages at the same rate.</b><br />
<b><br /></b>
I sort of knew this but visiting my parents in two different seniors' home brought it home to me. The seniors' population is a heterogenous group with very different needs. Closer to home, this means that a couple may not age at the same rate. My mother for example doesn't recognize me, my father's mind is still as sharp as every. This leads to the phenomena of divorce by nursing home where because of different care needs a couple cannot stay in the same facility. My parents are lucky enough to now live in the same building but in different rooms on different floors.<br />
<br />
Even individuals don't age at the same rate. I was astonished by the precipitous decline in my mother's mentation even though she may have been hiding it well. The swift decline form a fully functioning individual to something way less than that, constant catches family and the healthcare system off guard. It shouldn't.<br />
<br />
A week or so ago, a pain clinic patient asked me if I was going to retire. "Not right now", I said, "but I just turned 60 and things can change in a hurry."<br />
<br />
<b>Have I learned anything from this?</b><br />
<b><br /></b>
My parents' generation largely didn't deal with this because people died at younger ages from infections or from heart disease or cancer for which there were fewer treatment options. Therefore faced with their own fragile longevity they have no idea what to do because they never had to deal with elders in the same predicament when they were young.<br />
<br />
I am starting to learn and hopefully plan my own senescence. <br />
<br />
Firstly, I assume that at some point I will not be able to drive. By that time I will probably lack the insight into this so it is better to quit well before I am forced to. This also means living in a place where the services are within walking distance (which also might be a problem) or that there is good public transport. <br />
<br />
I am going to need medical services. I have a good family doctor. For the rest of you, this means if you don't have a family doctor, you better get one who is a lot younger than you. Preferably one who isn't an idiot and who works more than 3 days a week. When choosing what town I am going to live in, I now have to factor in what medical services are available locally. This is important if I want to retire overseas as I often threaten to do.<br />
<br />
There is of course planning my home and will I be able to live in it in the future. Better figure out how you are going to climb those stairs when you have generalized osteoarthritis or heart disease. The necessary renovations are going to cost money and despite what my financial advisor tells me, I know I am going to have less of that in retirement. I joked when visiting seniors homes about, "see you in 10 years" but maybe it is more realistic to go into a home when you want to, not when you have to.<br />
<br />
There is of course the whole advanced directive thing. I am pretty health right now and barring metastatic cancer or something like ALS I would probably like a little CPR. Problem is that by the time I shouldn't be getting a little CPR or the related trimmings, I may not have the insight. Better discuss this with somebody sensible now. Make sure they are prepared to advocate for you because there are quite a few doctors out there who are prepared aggressively treat you, based on their religious belief, hospital policies or the irrational fear of being sued.<br />
<br />
<b>In closing</b><br />
<b><br /></b>
As my parents started to push 90, believing that longevity is genetic, I rejoiced in my potential long life. <br />
<br />
Not so sure about that now.<br />
<br />
<br />
<br />
<br /></div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-81891350125296216742017-05-11T14:27:00.001-06:002018-03-26T09:17:05.518-06:00You break it, you buy it<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
I saw 4 patients that morning. 2 of the patients were young men who were cancer survivors. Unfortunately combinations of surgery, radiation and chemotherapy have left them with disabling neuropathic pain, which in both cases prevents them from working.<br />
<br />
Naturally if you read the progress notes from the Cancer agency you will read glowing, back patting descriptions of the success of their cancer regimen. Both men are going to survive.<br />
<br />
The problem is that both of them have severe pain, and nobody really wants to address it. Despite what you may read in the American and sometimes in the Canadian media, cancer patients actually get quite good care in Canada with a huge infrastructure of nurse practitioners, social workers, psychologists and patient navigators. If you are dying of cancer, you will go into a similarly endowed palliative program. This is as it should be; when my cells start acting in an antisocial fashion, I want it all there for me.<br />
<br />
If you are "cured" of cancer however you enter the dismal world of the Canadian healthcare system with its waiting lists and silos of care. Unfortunately if you have chronic pain nobody really wants to take ownership of you, least of all the oncologists and surgeons who caused the problem in the first place. This usually leaves it to chronic pain "specialists" like me who are stupid enough to still want to see these patients. We are usually not talking about narcotics here although that is what they frequently need; anticonvulsants or antidepressants are often effective but I frequently see a patient who has gone for the 18 months or so my wait list is, without trialing them at all.<br />
<br />
When you think about it, it takes a special kind of sociopath to leave a patient in pain as a consequence of their treatment, (even if they did save the patient's life) and not feel responsible to at least do something to try and help the patient or at least direct him to someone who can. Back surgeons are of course big offenders in this regard.<br />
<br />
Working in my other life as an anaesthesiologist I see the other face. As I work in a big city hospital, in what could sometimes be seen as tertiary care, a lot of the work we do in OR, is as a consequence of surgery done at other sites, usually out in the country, often by somebody who had no business doing that complexity of surgery but also alarmingly from within the city. I often pity my general surgery colleagues who get stuck with complications of gynae or urological surgery. Talking about podiatrists to one of our orthopods is a sure fire way to generate a long rant.<br />
<br />
We anaesthesiologists of course get to tag along on these little misadventures because they almost always end up in the OR, usually after hours, occasionally bumping the enjoyable list you thought you had, often in ICU with 20 infusion pumps going or with MRSA, VRE, XYZ etc. I remember early in my career noting that I had worked until 0400 all on complications of surgery done at other sites.<br />
<br />
And we all love to hear of the patient with the post-spinal headache in the ER, who had her baby at another hospital or who had a misadventure with a lumbar puncture. <br />
<br />
My chronic pain side is not immune. I get to struggle with the patients put on megadoses of narcotics by other people, those on big doses of benzos and of course the sloughs from my colleagues who have exhausted their repertoire of lucrative blocks and now want me to manage their patient medically.<br />
<br />
Complications are a consequence of medicine and modern medicine is really just a bet that the benefits of the procedure or treatment outweigh the adverse effects, transient or permanent. This is a bet patients frequently lose. Sometimes the adverse effects are something we can deal with ourselves, sometimes in the best interest of the patient, some else is better able to deal with it. It would be nice if there was some mutual respect and communication.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-57020878532736094672017-04-09T17:14:00.000-06:002017-04-09T17:14:30.137-06:00Does one battle define a country?<div dir="ltr" style="text-align: left;" trbidi="on">
Today is the 100th anniversary of the Battle of Vimy Ridge which we are told established Canada as a country.<br />
<br />
Just to establish my bona fides; my grandfather was in the Battle of Vimy Ridge. Unfortunately he died in the 1930s and I never knew him; I only have one photo of him. He was wounded there which eventually along with being gassed earlier in the war lead to his premature death. He did meet my mother an English nurse who he married and brought back to Canada. It could be said that without the battle of Vimy Ridge, I wouldn't be here. In fact if you take into the fact the butterfly effect, the world might be very different without the battle of Vimy Ridge.<br />
<br />
Vimy Ridge was the first battle entirely fought by Canadians. Not entirely, there was a British General Lord Byng. Lord Byng later became Governor General of Canada. Notwithstanding the battle of Vimy Ridge, it would be another 20+ years before a Canadian could be trusted to be Governor General. Lord Byng's wife, Lady Byng is much more famous: she donated the trophy given yearly to the most gentlemanly player in the NHL. Those of us interested in constitutional law will remember Lord Byng in another context.<br />
<br />
I haven't read much about the Battle of Vimy Ridge but the underlying principle of the battle seemed to be that if you bomb the shit out of the other side and aren't terribly worried about casualties (a large reason why Canadian rather than English or French troops were in the battle) you will win more often than you lose. The battle was of questionable significance in the long run.<br />
<br />
The thing is however.....<br />
<br />
The First Nations have been in the territory which became Canada for 10,000 plus years. The first (non-Viking) European contact was in 1497. The first permanent settlement in the early 1600s. The boundaries essentially established after the American Revolution. A lot of history, a lot of people lived and died to create was is now Canada.<br />
<br />
So can you really boil all that down to one battle even if my grandfather was there.<br />
<br /></div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-20118998310789597102017-03-28T11:27:00.001-06:002017-03-28T11:27:35.203-06:00Drug Costs<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-c86-oZ73LIk/WNqc63EfGRI/AAAAAAAAy9s/owrfHK58PZEcoYMbCuImDqOhyTOQYEwnQCLcB/s1600/download.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://2.bp.blogspot.com/-c86-oZ73LIk/WNqc63EfGRI/AAAAAAAAy9s/owrfHK58PZEcoYMbCuImDqOhyTOQYEwnQCLcB/s1600/download.jpg" /></a></div>
We had a little breakfast presentation by the Sugamadex people last Friday. Not a bad breakfast and an okay talk by one of their scientific people, a little dry.<br />
<br />
Unfortunately any discussion of a drug basically comes down to, "can we afford it; will the hospital put it on formulary?" The answer came about 50 minutes into the talk, after we had finished our breakfast and were on our second cups of coffee. The answer was $100. That is for the smallest dose, the dose for mild-moderate block, the dose that some of us depending on circumstances don't even reverse. If you go for deep block, like when your resident listens to the surgeon's whining and gives rocuronium while they are closing, multiple by two. If you want to immediately reverse rocuronium like for example when you give 50 mg to the guy with no chin and realize you can't intubate him (and can barely bag him), you are talking serious cash.<br />
<br />
Now neostigmine is not the nicest drug in the world. I consider it the most dangerous drug in my drug cart. Surprisingly pharmacy who insist on putting high alert stickers on my midazolam compartment haven't figured that out yet. It is considerably cheaper however although the price is said to be going up due the Merck buying the licences off all the generic companies who used to make it. <br />
<br />
Sugamadex is with a few little wrinkles a better drug than Neostigmine, just as a Ferrari is a better care than my VW Jetta. My VW Jetta gets me to work on time however.<br />
<br />
I have no idea how much it costs to make Sugamadex, even taking into account the inflated R+D costs companies claim they have to pay. I suspect it isn't anywhere near $100. Currently they are selling almost no drug at all in Canada. The question comes, is there a price where the company can make a profit which balances with the hospital paying a little bit more for what is a better drug, which might actually save money by shortening recovery room stays and reducing complications. I should have asked but I bet I wouldn't have got a straight answer.<br />
<br />
Incomplete reversal of muscle relaxants seems to be getting a lot more attention in the literature and at meetings, some of which I suspect is being driven by the makers of Sugamadex and their stable of tame physicians who can write articles and speak at meetings. I trained at the tail end of the pancuronium-curare era, which gave me a healthy respect for muscle relaxants. The problem is of course, I suspect we see more incomplete reversal now than we did with pancuronium, if only because people have lost their respect for muscle relaxants. I have learned that adding a muscle relaxant probably increases your complication rate. I do a lot more cases with a LMA spontaneously breathing now, I still use sux and quite often if I am just intubating to protect the airway, I don't bother with a non-depolarizing agent, unless the patient is bucking or the surgeon is whining. Even when using a non-depolarizer, I tend to be sparing in how much I use and quite often if I don't need muscle relaxation have the patient spontaneously breathing or on pressure support by the end of an hour.<br />
<br />
The Sugamadex people have cottoned on to the fact that hospitals are not about to pay $100 for a drug, at least not for an anaesthetic drug, no matter how good it is. The spin last Friday, was getting it indicated for high risk populations like the frail elderly, sleep apnea and high BMI patients. Probably a good idea, however unless the hospital polices it, you are going to get indication creep. If you need it for the BMI 45, what about the BMI 44 and so on. Of course regulation could lead to you trying to call the on call pharmacist at 0400 because you want to use Sugamadex. Neither very good options. <br />
<br />
I was talking later that day with the surgeon and was discussing our morning rounds. He observed that where a drug that cost $100 used to be considered expensive, now $1000 to $10000 is not unusual.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-20699076726431732642017-02-27T10:50:00.002-07:002017-02-27T11:09:17.628-07:00End? of paper<div dir="ltr" style="text-align: left;" trbidi="on">
There are two things that, if in 1983, you had told me I would still be doing in 2017, I would have called you crazy.<br />
<br />
The first is billing fee for service.<br />
<br />
The second is charting on paper.<br />
<br />
The end may be in sight however. Last Friday's pain clinic at my main hospital site was the last before the electronic medical record rolls out. Fortunately I only work alternate weeks so my hope is that all the bugs will be sorted out next week. There is a huge team of people involved in setting this up. I attended a meeting with about 10 of them in a large war-room with white boards all over the wall. I wonder if the money spent on this might be better spent elsewhere.<br />
<br />
I work at a variety of sites and so have been exposed to 4 different EMRs all of which are entirely different from each other. Fortunately the EMR I will be using in a week or so is one I already use at another hospital, which means that I already took the mandatory training and did all the privacy and security stuff. The IT people who are supervising the whole process keep on referring to me as a star. I also get invited to "physician champion" meetings which I never attend. Sorry, guys I already know the system and I am the only person in my department. <br />
<br />
It is interesting how the logistics of a paperless system affect your practice. For the first few months we have been advised to book fewer patients as charting can be expected to take longer. The other issue is that we are nowhere near the end of paper. At one place I work which has an EMR, a parallel paper chart is kept, at another they insist on printing out my most recent note for me to read every visit. I keep on telling them that I can read the electronic chart but they insist on it. In addition because none of the 4 EMRs can communicate, if you want records from one practice the only recourse is to print out the record and send it where it is scanned into the other record. All lab and imaging reports are now available on the provincial electronic record but they still insist upon sending me paper copies as well. <br />
<br />
Canada has a socialized medical system which means it should have been easy to set up a universal electronic medical record. For example if I see a patient with headaches, I should be able to pull up the neurologist's consult. If however I want a copy, it will most likely be a paper copy mailed or faxed to me, often not available when I am seeing the patient. Larger HMOs in the US have a single medical record, as do the doctors in one small Canadian province. <br />
<br />
<a href="http://theblogofbleedingheart.blogspot.ca/2014/03/working-9-to-5.html">As I blogged a few years ago</a>, we had an issue where multiple miscommunications lead to a patient's testicular cancer diagnosis and treatment being delayed and the patient ultimately dying. This lead to a lot of hand-wringing and promises to fix the system. Much of this could have been solved by an integrated EMR which nobody including me, seemed to have the balls to suggest. Our medical society is trying to set up a secure electronic portal where doctors can communicate with each other confidentially (except for the NSA and the Russians of course). The problem is of course that such a system is of no use unless there is close to 100% buy in and I don't see that happening because for most doctors miscommunications are someone else's problem. I have never really seen the problem with just using email. Is it any less secure that faxing. How often have you found someone else's fax stapled to one of your faxes. Anyway I have a personal fax which emails me a PDF. When someone tells me they can't email me something because of confidentiality issues, I tell them "Just fax it to me". They do and the faxed gets emailed to me. I don't point out the contradiction. <br />
<br />
Our province has a flawed but wonderful system called NetCare where it is possible to access just about all the blood work and X-rays going back 15 years. In addition you can get every medication dispensed to the patient. As well anything that is dictated in a hospital system is accessible. I can't imagine how I lived without it. However you still cannot access anything done in a private office and in addition there are quite a few physicians who handwrite their consults and admission histories. Progress notes which are still handwritten are not available either. Still way better than the old days when the patient would come in saying he was taking a blue and a green pill and wanted to discuss his MRI results which you didn't have. NetCare is easy to get on in the hospital, less so outside of the hospital where you need a key fob and a lot of good luck to get on. (I can access my own chart on NetCare, I'm not supposed to but I do, it is after all my medical information. My family doctor was horrified when I told him this and set me up with a patient portal where I can access my records, legally but why should I have to memorize another set of log-ins).<br />
<br />
Mostly where I have been using EMRs have been low volume practices and I am looking with some horror at my hospital clinic tomorrow where I typically see 24 or so patients. The EMR people assure me that they will be on site and I have done the appropriate training and have set up the appropriate shortcuts that will make charting easier for me.<br />
<br />
I have heard that EMRs have lead to dissatisfaction in doctors that have them, although doctors have a lot of reasons to be dissatisfied and in the 30 or so years I have been in practice I have never seen any doctor completely satisfied with all the aspects of his/her practice. EMRs certainly are cumbersome, usually requiring multiple log-ins, and their tendency to randomly shutdown or kick you out of the system. The EMR I am using today refused to let me write prescriptions under my name, I got around this by printing the prescription under someone else's name and then crossing it out on the paper copy. I have been assured this will be fixed today. You do have to remember that paper charts were not the greatest either, trying to decipher your handwriting or looking for labwork that may or may not have been filed were definitely hassles not to mention the effect on patient care.<br />
<br />
I have recently been doing a lot of medicolegals which mean a lot of chart reviews. These have given me to opportunity to compare both paper and electronic charts. Paper copies of electronic charts have of course the advantage of being legible. The quality of the information is not better and potentially a little worse as I suspect a lot of doctors are typing with two fingers. Most EMRs have shortcuts or macros available and I notice that these are being used quite a bit. For example many family doctors have a macro for their yearly physical exam (notwithstanding the fact that nobody advocates a yearly physical, most patients seem to get one done, if only because the doctor can bill for it). I have for example reviewed cases with severe neck or back pain, well documented in the progress notes who when they present for their yearly physical will have a completely normal exam documented on the obviously computer generated record. This is I am sure going to cause problems when somebody less understanding than me reviews the chart. I have also heard of instances in hospitals where people are cutting and pasting other people's consults or progress notes. This is of course okay (if a little lazy) if the original information that was cut and pasted was valid, however the old saying garbage in/garbage out comes to mind. False information, (alternate facts) of course persisted under paper charting as well. <br />
<br />
The other issue I notice when I review medico-legal charts is the incredible volume of paper they can generate especially if the patient is admitted to hospital. For example, at the hospitals in another city which has EMRs, each lab test is printed out on a separate piece of paper, likewise nurses notes. This results in a huge chart, which if I get it in paper, means lots of turning pages and a high risk of paper cuts and repetitive strain injuries. Lawyers tend to do fishing expeditions resulting in large amounts of irrelevant information. I get paid by the hour so I shouldn't mind but the hours available to me are finite and I know that somebody is ultimately paying for this. Logically when they get the request the hospital would give me a time sensitive log-in to their system for that one patient's chart so I can review on a computer. It is after all the 21st century. <br />
<br />
Fortunately or unfortunately an EMR for anaesthesia or AIMS as they like to call it seems to be years away. We did spend a great deal of time getting ready for one about 5 years ago with multiple meetings however suddenly without even a whimper the whole process just ground to a halt. I don't see any sign of it restarting and I don't expect to be using it before I retire. <br />
<br />
When people express fear or dissatisfaction about EMRs, I remember a story a specialist told me when I was a resident in Newfoundland. He had started his career working in a remote community as a general practitioner in the 1960s. When he arrived, he found that the clinic there did not keep any patient records. He was appalled and told the staff that they would have to start keeping charts on patients, with the result that the entire staff resigned in protest.<br />
<br />
Like all changes in healthcare, we will survive this and patient care might even be improved.<br />
<br />
<br /></div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-56284559773961117482017-01-23T18:22:00.001-07:002017-02-13T11:12:25.903-07:00Bruce &. Me<div dir="ltr" style="text-align: left;" trbidi="on">
<div>
I just finished reading Bruce Springsteen's autobiography "Born to Run". It is not just a recitation of his personal history, it is a very introspective and philosophical book. More articulate people than me have reviewed it.</div>
<div>
<br /></div>
<div>
Before we started getting our music on iPods, satellite radio and oldies stations, music was the soundtrack of our lives. Often times now when I hear a song from the seventies or early eighties, even the sixties it will evoke a memory of a period in my life or even a specific event. It was simpler then, a song or and album was released, you listened to the song or the album on the radio, maybe you bought it and listened to it heavily, then another song or album came out. </div>
<div>
<br /></div>
<div>
I still remember where I was the first time I heard of Bruce Springsteen. It was in the lunch room at the Lake Cowichan Forest Service research station where I worked as a field hand. It was the summer between high school and university. I can't remember whether it was Time or Newsweek I was reading, he was on the cover of both. I remember not being that impressed. I hadn't heard any of his music, there was a lot of good music our there in the mid 70s. I had, a few months earlier bought Bob Dylan's "Blood on the Tracks", an album that transformed my musical tastes permanently and I could not believe any artist could be better. Many of the artists of the 1970s like Paul McCartney and Elton John were still at the top of their games.</div>
<div>
<br /></div>
<div>
Notwithstanding the success of the album Born to Run, Springsteen got very little airplay in Vancouver either on the AM top 40 stations or on the "album oriented" FM station I listened to. He got very little play on the Seattle FM stations I occasionally listened to. In the subsequent years I read stories about him. He seemed a little different. He had a saxophone in his band; nobody had saxophones in their bands. In retrospect listening to Born to Run, it was so different from what passed for Rock and Roll in the 1970s that I can understand his lack of exposure. </div>
<div>
<br /></div>
<div>
I bought Bruce's album "Darkness on the Edge of Town" in 1978, the summer I got accepted to medical school. I don't remember why I bought it, I think somebody told me that it was a good album and so I picked it up. I think I bought Dylan's "Street Legal" around the same time. Never really listened to that one as much as I listened to "Darkness".</div>
<div>
<br /></div>
<div>
1978 was a dark time for music. Disco had taken over the dance floors and the radio stations. Rock and roll was heading down the toilet. Paul McCartney was releasing mediocre albums, soon to become bad albums, likewise Elton John. The Eagles had peaked with Hotel California. Fleetwood Mac followed up "Fleetwood Mac" and "Rumours" with "Tusk". Dylan was about to enter his Christian phase with the accompanying bad albums. The Band had just (temporarily) stopped touring and releasing new music. It was a dark time to be a rock and roll fan or for that matter a folkie. It was maybe for this reason I reached out and bought a Springsteen album. </div>
<div>
<br /></div>
<div>
I remember listening to "Darkness" as a life changing, least a musical life changing moment similar to what I experienced when I first heard "Blood on the Tracks". Darkness became the soundtrack of my first year in Medical School. I spread out, I bought "Born to Run". Later I bought "Asbury Park" and the "Wild, the Innocent...". Bruce still wasn't getting a lot of airplay in the late 1970s. </div>
<div>
<br /></div>
<div>
Then came "The River". Some have criticized it as too long, a double album that could have been edited down to a single album. No way. Every song was a great song, the album worked conceptually, when that was important in an album. Springsteen also moved into the mainstream with that album with a top 40 hit. I didn't mind sharing him with others, it made me feel cool thinking I had listened to him way back when. "The River" is the soundtrack of the second half of medical school for me.</div>
<div>
<br /></div>
<div>
Bruce Springsteen wrote about working in factories, unplanned pregnancies and New Jersey. He didn't write about growing up middle class in Victoria, going to good schools and going to medical school. There is no way his music should have appealed to me. It did though.</div>
<div>
<br /></div>
<div>
I finished Medical School, and went to Halifax to intern. One day I was browsing in a record store on Barrington street and there it was, another Bruce Springsteen Album. "Nebraska", so different from his other albums except possibly "Greetings...". I bought it and listened to it obsessively. It became the soundtrack of my internship. It was like the Bob Dylan album he should have been releasing at that time, except it was by Bruce Springsteen. </div>
<div>
<br /></div>
<div>
I finished my internship and bummed around doing locums in the Maritimes. I taped my Springsteen albums and listened to them on the tape deck in my in my car. When I wasn't working, I used to drive around the backroads of Nova Scotia and New Brunswick just exploring. Sometimes now when I hear a song off those albums I think about those drives. I met my future wife and starting making trips back to Halifax where she lived from where I was, usually with Springsteen on the tape deck.</div>
<div>
<br /></div>
<div>
I got engaged in 1984 and Springsteen released "Dancing in the Dark". Just a coincidence I'm sure. Suddenly he was a superstar with Top 40 hits and MTV videos. He started playing and selling out stadiums. If I had been in Vancouver when he sold out BC place, I would not have been able to get a ticket. </div>
<div>
<br /></div>
<div>
I got married, failed in general practice and went back east to Newfoundland to do a residency. Springsteen also got married, just coincidence. Mid-way through my residency he released "Tunnel of Love" a depressing if listenable album. </div>
<div>
<br /></div>
<div>
Musically I was evolving. I used to have a 30 minute commute to work, where I listened to the Rock FM station. One day, I decided I could not take the talk and the bad music and switched to CBC FM which played classical music back then. I pretty much exclusively listened to classical music for the next 5 years. A surgeon in the OR used to play the blues during his marathon cases. I acquired a taste for the blues. </div>
<div>
<br /></div>
<div>
I had my first child, finished my residency and got my first job in Fredericton. I had another child and moved to Edmonton. Somewhere around that time Springsteen released 'Lucky Town" and "Human Touch" simultaneously. I of course bought them just like I used to buy Paul McCartney and Elton John's album when they came out, but the bloom was off the rose. The first year I was in Edmonton, Springsteen came to Edmonton (without the E Street Band) and I didn't even try to go. </div>
<div>
<br /></div>
<div>
I went to the Edmonton Folk Festival because I wanted to see Elvis Costello but stayed for the whole weekend. I learned that folk music wasn't just a bunch of people singing Kumbaya, it was vibrant, interesting and it was the root behind the music I had loved in the past. I started buying CDs from the Folk Festival CD tent and listening to CKUA, our province's public radio station which played that kind of music. </div>
<div>
<br /></div>
<div>
Throughout the 90s Springsteen was a lesser part of my musical life. I figured it was the natural order of things. One can only be great for so long. I had grown, he had grown. I still bought the albums, I bought his box set "Tracks". My listening habits changed. I got an MP3 player and started playing my, by then, large collection on shuffle.</div>
<div>
<br /></div>
<div>
Along the way, I had never heard Springsteen play live. I interned with a fellow who had the fortune to see him play the El Mocambo club in Toronto in the mid 90s. Actually he had seen him there for 2 consecutive nights. His long shows were legendary. I was jealous.</div>
<div>
<br /></div>
<div>
There is only one thing that I am thankful to George W. Bush for. In 2002, I was going to Cannes on a Big Pharma junket when Bush Jr., decided to invade Iraq in search of weapons of mass destruction. Because we all knew that Saddam controlled world terrorism I was afraid to fly and cancelled my flight. Bruce Springsteen just happened to be playing in Edmonton during the time I was supposed to be getting brainwashed in Cannes and he hadn't sold out so my wife and I bought tickets. They were just over $200 each, the most I had ever paid for a concert. The tickets were general admission on the floor what used to be called festival seating. (In his book Bruce notes that early on his band never allowed festival seating for fear of a stampede to the stage). We had to line up in cold sleet before being herded into the stadium where we were able to grab territory in front of the stage at about the blue line. It was a long wait for the concert to start made worse by not being able to leave the primo real estate we were standing on. </div>
<div>
<br /></div>
<div>
There is really no way to describe a Springsteen concert. You really have to be there. Being on floor relatively close to the stage, it felt like I was watching in the small club. The entire E Street band was there and the whole affair felt like a giant party. There were of course the 3 encores. </div>
<div>
<br /></div>
<div>
I had a few months prior to the concert bought "The Rising" but had never really connected with the album. When I heard the songs from the album performed, they suddenly made sense and the album was for a while an album I listened to a lot.</div>
<div>
<br /></div>
<div>
I left with my bond with Bruce restored. It was an amazing experience. </div>
<div>
<br /></div>
<div>
In the next few years, I reflexively bought the albums Bruce released regularity often at Starbucks. They are for sure not as good as his first 5 albums. Then again how many artists can claim to have 5 great albums. Did we expect Einstein to come with another theory of relativity. </div>
<div>
<br /></div>
<div>
Then as I mentioned above I read Bruce's biography over a couple of days after Christmas. I have satellite radio and decided to to listen for a few longer drives. The one thing that struck me which should have struck me earlier was what a good lyricist he is. Many of his songs tell a story in a rhyming but never forced fashion which few song writers including Nobel laureate Bob Dylan can boast of. </div>
<div>
<br /></div>
<div>
It has been an almost 40 year journey during which I have grown from Top 40 pop to more eclectic tastes in music. Bruce Springsteen has been an important part of that journey.</div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-15325283674448524802017-01-02T19:29:00.000-07:002017-01-02T19:29:01.339-07:00Up date on you're fired.<div dir="ltr" style="text-align: left;" trbidi="on">
<a href="http://theblogofbleedingheart.blogspot.ca/2016/03/you-fired.html">I posted on this last year</a>.<br />
<br />
It appears that this has been resolved and nobody is getting fired.<br />
<br />
I did read a long statement with all the appropriate buzzwords by the Head of the Section of Anaesthesia in BC.<br />
<br />
This doesn't really state who blinked, if anybody, although I suspect it was the docs who did the bending over.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-83871041145806179052016-12-24T17:47:00.001-07:002017-01-02T19:21:59.163-07:0060 Christmases<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-cl5406gAbMI/WGsKHD3EaPI/AAAAAAAAyxY/J2iOsBmr0DQq6A0Cz28IImU2L-GhZX-EACLcB/s1600/xmas%2Bstory.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="224" src="https://3.bp.blogspot.com/-cl5406gAbMI/WGsKHD3EaPI/AAAAAAAAyxY/J2iOsBmr0DQq6A0Cz28IImU2L-GhZX-EACLcB/s320/xmas%2Bstory.jpg" width="320" /></a></div>
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.<br />
<br />
<div>
<div>
I remember most of the other Christmases although some merge into one another.</div>
<div>
<br /></div>
<div>
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.</div>
<div>
<br /></div>
<div>
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. </div>
<div>
<br /></div>
<div>
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.</div>
<div>
<br /></div>
<div>
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.</div>
<div>
<br /></div>
<div>
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.</div>
<div>
<br /></div>
<div>
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.</div>
<div>
<br /></div>
<div>
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.</div>
<div>
<br />
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.<br />
<br /></div>
<div>
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.<br />
<br />
My first Xmas with my wife and each of the first Xmases with our two children are of course memorable. </div>
<div>
<br /></div>
<div>
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. </div>
<div>
<br /></div>
<div>
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. </div>
</div>
<div>
<br /></div>
<div>
For most of the past 20 or so years our family have spent Xmas at the dacha and this has become our Xmas tradition.</div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-54816047248473766082016-10-25T14:21:00.000-06:002016-10-25T14:21:05.287-06:00End of Life<div dir="ltr" style="text-align: left;" trbidi="on">
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><img alt="Image result for barbarian invasions movie" class="irc_mi i61mbnhyqWgU-pQOPx8XEepE" height="451" src="https://4.bp.blogspot.com/-RO-ojPjrY_4/UTM1y9b0GCI/AAAAAAAADO4/aIOVGxK5HqQ/s1600/barbarian-2.jpg" style="margin-left: auto; margin-right: auto; margin-top: 85px;" width="800" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The final scene from the movie "The Barbarian Invasions"</td></tr>
</tbody></table>
<br />
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. <br />
<br />
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. <br />
<br />
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.<br />
<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
This does give me an opportunity to muse about my experience with end of care.<br />
<br />
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 <br />
<br />
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.<br />
<br />
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. <br />
<br />
That was when one of his daughters yelled, "what you are talking about is euthanasia!" and ran out of the room. <br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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<br />
hockey.<br />
<br />
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.<br />
<br />
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, <a href="http://theblogofbleedingheart.blogspot.ca/2010/02/judge.html">one of which I blogged on years ago.</a></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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. <br />
<br />
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.<br />
<br />
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.)<br />
<br />
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.<br />
<br />
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.<br />
<br />
The other scenario is the pathologic fracture and the ensuing tumour embolus.</div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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. <br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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. <br />
</div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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.</div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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?</div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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.</div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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.</div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
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. </div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br /></div>
<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<br /></div>
</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-51297972835389948132016-10-25T10:58:00.000-06:002016-10-25T13:56:54.433-06:00I am (or I guess I am not) a leading physician of the world.<div dir="ltr" style="text-align: left;" trbidi="on">
<img alt="Image result for hippocrates" class="rg_ic rg_i" data-sz="f" name="thUwnIYKGKMZIM:" src="data:image/jpeg;base64,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" style="height: 196px; margin-left: 0px; margin-right: 0px; margin-top: -2px; width: 173px;" /> <br />
<br />
<a href="https://theskepticalcardiologist.com/tag/leading-physicians-of-the-world/">This fellow had a similar experience to me and blogged on it.</a><br />
<br />
<a href="http://www.theleadingphysiciansoftheworld.com/">In case you are interested in becoming a leading physician of the world, here is the website. </a><br />
<br />
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.<br />
<br />
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. <br />
<br />
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.<br />
<br />
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. </div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-39003981965141864382016-10-25T10:34:00.000-06:002017-02-27T11:12:57.361-07:00The Demedicalization of the Caesarian Section.<div dir="ltr" style="text-align: left;" trbidi="on">
<img alt="Image result for cesarean section historical" class="irc_mi ihlcMfbYqv8I-pQOPx8XEepE" height="372" src="https://www.nlm.nih.gov/exhibition/cesarean/images/asclepius.jpg" style="margin-top: 125px;" width="700" /> <br />
<br />
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. <br />
<br />
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. <br />
<br />
I was on call recently and did quite a few sections which gave me some time to reflect on this.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.....<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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. <br />
<br />
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.<br />
<br /></div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com0tag:blogger.com,1999:blog-8325605184495137942.post-54258062450632924422016-09-13T11:38:00.001-06:002016-09-18T09:34:25.732-06:00First Do No Harm<div dir="ltr" style="text-align: left;" trbidi="on">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. </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">I first heard this adage way back in medical school referring to anaesthesia and the fact that anaesthesia contradicts this principle.<br>
<br>
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.<br>
<br>
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.<br>
<br>
The House of God had it down with rule XIII:<br>
<br>
<b><i>THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.</i></b><br>
<br>
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. </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">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. </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">Here's some questions to ask yourself.</div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">1. Based on your assessment is the patient going to die within the next few hours without treatment?</div><div dir="ltr" style="text-align: left;" trbidi="on">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. </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">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. </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">"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." </div><div dir="ltr" style="text-align: left;" trbidi="on">"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). ". </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">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.</div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">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. </div><div dir="ltr" style="text-align: left;" trbidi="on"><br></div><div dir="ltr" style="text-align: left;" trbidi="on">I think we need to spend less time worrying about doing no harm and more time stopping using outdated and irrelevant aphorisms.</div>
Bleeding Hearthttp://www.blogger.com/profile/11654470738092202883noreply@blogger.com7