Things that make my work worthwhile

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bad Work Habits 2

I read during cases

Now last year I interviewed propective anaesthesia residents (I did this year too). We ask them all kinds of stupid questions that have nothing to do with their suitability to safely deliver an anaesthetic in 5 years time but are more geared towards, can we not stand this person at all or do we like him just a little more than the others. Anyway one of the questions somebody else asked dealt with how you deal with long cases. The prospective resident answered something about this is a good time to bring the laptop into the room. When we discussed this poor fellow at lunch, the program director promptly stated, "well he is not getting a residency in our department." I looked at another interviewer who I know also reads during cases and we rolled our eyes. I feel sorry for the program director who has to wittle 50 applicants down to a short list for 5 positions but....

I read during cases, I frequently bring in my laptop, I write letters and I make a powerpoints. I have written several published book reviews and one CME article for an anaesthetic journal and I largely have done these while a patient was under anaesthetic. I don't just restrict my reading to anaesthesia and pain material. I read the newspaper, occasionaly books and magazines.

I am not sure where I fall safety wise in the anaesthesia community. I think I am around the middle. I know that obsessive-compulsive-wise I fall near the bottom (We had a very OC anaes. at the Cof E named Gray, the residents and nurses called me "the Anti-Gray"). I am not ashamed of this, I am rather proud. Over the years I have had the odd patient who didn't do well, I have made mistakes which hurt patients one of which I blogged about on this blog. One thing I can say is that I have never hurt a patient by reading or innattention. In fact some of my near misses have been while teaching residents and medical students. While I would like to, I am not going to (and cannot) stop teaching them.

Anaesthesia is for the most part boring, this used to frustrate me until I realized what the option to boredom was. Reading keeps me alert, the sheer guilt of reading forces me to look at the monitor more regularily, and keep the chart up to date. This is rationalizing I know; I stand guilty.

Bad work habits 1

This being the New Year and resolution time, I feel I should confess some bad habits that I have acquired. I have no intent of changing them but talking about them makes me feel good.

I leave the room while patients are asleep.

Not just when I have a resident and we don't have anesthetic assistants or nurse anesthetists in Canada. From time to time I just get up and leave the room!

This is the cardinal sin of anaesthesia. From day one of our residency it is beaten into us, thou shalt not leave the room. Sleeping, staring up at the ceiling, talking to people with your back to the patient are okay. Reading is slightly frowned upon (I will comment on that in the future).

Our medical protective association considers this such an egregious violation of the standard of care that they will settle any case where this happens out of court. The courts have over the years taken a very dim view of this. Even the criminal courts have taken a dim view of this; about 15 years ago an anaesthesiologist who had a patient die while he was out of the room taking a phone call spend 6 months in jail. This by the way didn't prevent him from getting another job and as far as I know he is still working somewhere.

Now I only go out of the room when I have to, I minimize the time I am out of the room and I try to pick "safe" times in the case. I will give you examples of when I leave the room.

1. Bathroom breaks.

When my kids were younger they brought home all kinds of nasty viruses from daycare and school. This usually resulted in my having to sprint to the nearest toilet every once and awhile. I also confess to having a weak bladder. I am sure I should never have been offered a residency in anaesthesia. I compound this by drinking way too much coffee. I used to work in a teaching hospital. Unfortunately residents no longer think letting staff anaesthesiologists pee is educational. Of course many of my bathroom breaks were sudden and unscheduled.

2. Finding equipment and drugs.

Even after 18 years as a staff anaesthesiologist I still don't anticipate very well what I am going to need or the piece of equipment isn't in my cart and I didn't check. I could ask the nurse to go fetch the equipment but I learned at the CofE how useful that is. Usually I know where I can find it and can get it quicker myself.

When I was a resident, I was in my last year and the staff was "letting" me do a AAA by myself. For some reason we did not keep more than 1 litre of fluid in the room at that hospital and while there were bags and bags of crystalloid in the hall, it had been beaten into my that I could not leave the room, so I asked the nurse to get me another litre. She promptly went to the intercom and paged the staff back to the room. When he arrived quickly figuring something had gone wrong, she told him "I am not spending the entire case fetching things for him (pointing at me)"

3. X-rays

OR nurses and X-ray techs believe that anaesthesiologists are immune to the effects of radiation. At least that is why I think they never bring in an X-ray gown for me. Therefore if they are only shooting a few shots I generally step out into the hall. Actually one of my near misses occurred doing just this. I had taken over a case from someone else, it was an ortho case and they were doing X-rays at the end of the case so I wandered out into the hall for a few minutes. When I came back in the room, the heart rate was 20. I never figured out why that happened but I could be in jail right now.

4. Food and coffee

Cases frequently run over lunch. Infection control frowns on eating in the rooms. Actually I quite frequently fervently eat my sandwich in the room. I have on occasion got nurses to bring coffee and a muffin into the room for me (I paid of course).

5. Recovery room

You take the patient into recovery room, he is completely stable, you go out pee, have coffee eat, chat to your next patient put him to sleep and ....that is inevitably when your previous patient starts to circle the drain. The courts have said, "Thou shalt not leave thy patient". My conscience says I should weight the risks and do what is best. Of course if I think my patient in the OR is stable and can be left I will go to recovery. I have done this a few times in a career, fortunately not often.

There was a case quoted where someone left his patient in the OR because his patient in recovery had arrested. While he was in the recovery room, his patient in the OR arrested. He was undoubtedly unlucky or a really bad anaes. The judge no doubt prompted by "expert witnesses" said that what he should have done was bring the patient from the recovery room into the OR. In what universe did they live in?

Anaesthesia is of course the one specialty where the dogma of total dedication to one patient only applies. During my residency, I had to do six months of internal medicine. I remember several times where I was with a sick patient I felt I couldn't leave and was called for a more trivial problem. I usually explained that yes I would be by sometime but that it would not be for a while because I was with a sicker patient. This was usually followed by a phone call from the nursing supervisor ordering me to attend the other case and in one case a letter. (I never somehow figured out how to lie and say, yes I'm on my way).

Anyway it would do the profession good, if we got off our high horse and went from a total prohibition of hallway time to a harm reduction strategy. We could say in what cases it is acceptable to leave a patient, for how long and what type of contingencies we should use (tell the nurse?, tell the surgeon?).

Meanwhile I continue to live on the edge.

I Was a Medical Records Criminal II

When I wrote the previous post, it brought to mind some other brushes I have had with medical records.

When I first finished my internship I went to do locums at a medium sized city in Atlantic Canada. I worked there for 10 months. Even then I was pretty compulsive about medical records and dictated all my histories and discharge summaries promptly or so I thought.

When I left I phoned up medical records, told them I was leaving town and could they get all my charts together because I wanted to finish them before I left. Like I said I was pretty conscientious then.

I worked in another community for about six months and then left the province for greener pastures. A few months after arriving in greener pastures I got a letter from the medical director stating that I was deficient in completing multiple charts and that they would be reporting me to the Medical Board unless I forthwith reported to their medical records department. I wrote a polite letter back stating that I was now on the other side of the continent, that I had actually tried to complete everything before I left, that they could have tried to contact me while I actually lived only an hour away and that despite everything if they sent me the charts I would be happy to try to complete them.

In time I received a large bundle of charts. Many of these were charts belonging to people who I had done locums for who figured it must have been me who looked after the patient in question (in most cases it wasn't). I also found out that many specialists had a little trick of transferring patients back to their family doc on the day of discharge, thus making the family doc responsible for the discharge summary. I was stung pretty badly there, worse because in most cases I never even knew the patient was in hospital and had usually never met them. I also learned for the first time that the hospital had a policy that when you assisted on a hysterectomy (which I did quite a bit) you had to write a consult agreeing that the procedure was necessary. (Imagine me as a very young GP telling the Gynecologist, "you leave that uterus in!")

Anyway I completed them as best I could and sent them back and I never heard back from the hospital again.

The first hospital I worked for as an anaesthesiologist had a very activist medical record department. We anaes don't do a lot of dictating but we do as it turns out give a lot of verbal orders which eventually have to signed. The hospital had a two week cut-off after which you were off staff and you were supposed to keep up on it which meant visiting medical records to see if you had any charts.

Now at this hospital there was a computer screen at the doctor's entrance and you were supposed to log-in every time you came in the hospital so that switchboard would know you were in the hospital. This was of minor importance when you were on call because you couldn't here overhead pages in the OR or caseroom and if switchboard didn't know you were in the hospital they wouldn't try to look for you. This on one occasion resulted in an orthopod yelling at my wife on the phone because she didn't know where I was and I had forgotten to log in. Anyway after that I always tried to log in.

One evening I was coming in to do some type of "emergency" and tried to log-in only to be told I couldn't log-in because I had been kicked off staff for not signing my verbal orders. For a second I thought, this is great, I'm going home and someone else can do this emergency. But I didn't, I worked on illegally. Actually a couple of days later, I mentioned this to the Chief of Staff who told me, "actually it didn't mean you were really off staff", which of course made me wonder what exactly it did mean and why did they even bother.

Another story someone told me around that time is kind of funny. This doctor was driving thru a rural community and was listening to the local radio station when, leading off the local news was the announcement that a doctor he knew had been suspended from staff at the local hospita. He of course contacted his colleague to find out what had happened and was told, "Oh, I just got behind on my charts, I'm not really off staff".

Lab Work

I wish I had learned more in medical school.

I did learn, what should have been a very valuable lesson, quite early on during the laboratory medicine part of our pathology course. What I was taught was:

Don't order any investigation where the result (positive or negative) will have no influence on the management of the patient.

With that knowledge in hand out I went into the world.

I learned another thing along the way.

If after talking to and examining the patient, you have not the foggiest what could be wrong, no lab test is going to help you.

Now if you read this blog, you will know that collecting blood for the lab was one of my most favourite parts of internship. Through sheer stupidity I actually used elective time to do orthopaedics thinking I would actually learn something useful. Now on ortho, every admitted patient (and back then there was very little day surgery and no same day admission) whether he was 19 or 90 got a laboratory panel of 24 tests known as the SMAC. This required 5 tubes of blood to be collected. So on my first or second day, I asked the resident, "why do we do so many tests on apparently healthy patients?". He looked me in the eye and said, "Anaesthesia wants them". Naturally all these patients were admitted after 1500 when the lab blood collection went home, which left the blood collection to the interns.

Of course "normal" results are in fact the range that 95% of healthy assymptomatic patients fall into. This means that 5% of otherwise normal patients will have an abnormal result to a test. If you order 24 tests, there is an absolute certainty that at least one will be abnormal. These abnormal tests have to followed up on which of course means more blood work.

Now did "Anaesthesia" really want them. Apparently not as I learned a few years later when I read the guidelines for routine lab work. Here are the current ones:

Now I was able to find these in about 30 seconds because I know where to look for them. If I had googled pre-operative blood work it is little more complicated but by simply looking up the guidelines of your national anaes. society, it should be quite easy. Or you could ask your anaesthesia department.

But why do I even give a shit?

1. I pay taxes

Most healthcare is publicly funded in Canada. A significant amount is publicly funded in the US. I want my tax dollars spend on treating patients not on lab work! As an aside, much of the blood work in my province is done by a private company. Do you thing they have any interest in reducing lab work?

2. Healthcare is a zero sum game

Even in the US, there is a finite amount of money that can be spent on healthcare. That means money spent in one area is money that will not be spent in other areas. Every dollar spent on unnecessary lab work is a dollar that could be spent on something useful like chronic pain.

3. It holds up things.

How often has your day in the OR been disrupted by a cancellation or postponement due to an abnomral lab test that shouldn't have been ordered that has absolutely no bearing on the patient's ability to tolerate surgery. Just the same, you have to cancel the case, or wait while the test is repeated or the necessary follow-up tests are done. Many years ago I saw a patient who had been cancelled a month ago because of an abnormal gamma GT that someone had ordered pre-op. It was elevated so she was cancelled, went for the million dollar work-up which was of course normal and was re-booked. Of course somebody ordered the gamma GT again which was still elevated. Remembering from my time in family practice that this test is a marker for alcohol abuse (or use?) I asked her if perhaps she might have had a glass of wine the night before her testing and lo and behold she said yes. I put her to sleep and she survived despite her abnormal lab test.

4. It delays necessary lab work.
A classic example is the PT/PTT. Nobody would deny the benefit of these tests in following response to anti-coagulant therapy. There are also important in the management of an evolving coagulopathy or in monitoring whether a patient has been off his anti-coagulants long enought to do surgery or stick a needle in. Except...when you order the stat PT/PTT you really need, it is going to be queued up behind all the "baseline" PT/PTTs that have been ordered. Therefore you are going to get back your PT/PTT long after you have already bit the bullet and given the FFP your patient may or may not have needed.

5. Nobody looks at it or does anything about it
Sadly, that is the case. We order all this stuff and it gets filed in the chart and nobody looks at it. This includes abnormal lab work which frequently isn't followed up on. Chest X-rays are the classic which are often ordered pre-op and reported on post-op. As I found out as a resident, actually going to X-ray and looking at the CXR is no help. The one and only time I tried that, the tech at the film library laughed at me. Actually at our hospital, CXRs are available on-line now if I could just find the time to fill out the stupid form, make up a password etc. EKGs of course go off to be reported by the cardiologist which means they sit on someone's desk until look after the surgery.

6. Surgeons actually think lab work is a substitute for a proper history and physical.
The last time I cancelled somebody as medically unfit, the surgeon's whine was, "But I ordered a cardiogram". Further people think that lab work is a static thing, like the fact that the patient's K was normal on admission, means his K is still normal after he's been vomitting for 3 days.

7. Politicians know we order too much lab work and use it as a stick to beat us on the head when we complain about lack of funding in other areas. "The ER is full of patients waiting to be admitted?. That's because you doctors order too many blood tests".

8. It leads to more unnecessary testing and interventions

I have a personal story here. My first born was born at term after an uneventful labour and was normal size for gestation. Despite this somebody decided he needed to have a blood glucose done. It was something like 3.0 which would be low for an adult but normal for a full-term neonate (because of this episode the normal range for neonates of 2.5-3.5 which of course I had to know for my recently completed written exams has stayed in my mind). Of course the lab reported that number as low using the adult range, so the first thing the nurses did was to feed him some glucose and water. This meant when my wife woke up a few hours later with swollen boobs, our son didn't want to feed. It also meant he got an extra heel prick the next day to see if his blood glucose was still "abnormal".

I fought the lab and ... hey I won this time

One of my favourite tasks as an intern was acting as the after hours (and frequently during hours) blood collection service. Right up there with IVs and manual disempactions.

We all remember being called to draw blood from a patient. The patient was either:

1. A little old lady covered in bruises on all four limbs from IV and blood collections.
2. A heavy smoker with no veins.
3. A child on chemo with a severe needle phobia.

So after multiple stabs and tears you would fill the multiple different coloured tubes that the nurse handed you. An hour later you would be paged back to the same patient to draw more blood because:

1. There wasn't enough blood in the tube
2. There was too much blood in the tube
3. You collected blood in the wrong coloured tube (I used to fill one of each colour just in case)
4. The specimen was not properly labelled
5. The sample was "hemolyzed".

Of course it is over 25 years since I was an intern so I should have gotten over it by now. I still of course collect blood from patients under anaesthesia, and very rarely get called to the floor because no-one else can get blood. I also collect blood from nurses who got a needle stick which brings me to my story.

Now for several years I have resolved to wear gloves when starting IVs but this year I actually started doing so. The other day I went to start on IV on my first patient of the day. He was a little difficult and I had to try a second time but I got the second IV in. I am not the neatest person but I do make a point of being responsible for my own sharps. I picked up the two IV needles with me gloved hand and walked back towards my sharps container. That was when I felt a little prick (not the surgeon) and when I took off my glove I could see a little break in the skin.

Oh shit.

The patient had no obvious risk factors and no visible tattoos. Nevertheless I felt that I should draw blood from him and myself. At our hospital we have a needlestick protocol. You get a ziplocked bag with two tubes, one for the patient and one for you. There are two reqs one for the patient and one for you. You put everything in the same bag and it goes off to staff health.

The patient was still under some I drew some blood from a vein and put it into one of the tubes which I labelled with a sticker. I put his sticker on the req. Finding somebody to draw blood from me was harder. The OR nurses didn't want to do it. Recovery room nurses are good at drawing blood but the req had written across it in handwriting "please do not ask recovery room to draw blood". I finally found another anesthetist between cases. I labelled the tube with my name, filled out the req including my name, my date of birth and my healthcare number. Everything, mine and patient's blood went into the ziplock bag and off to staff health. Now as I was labelling my tube, I thought back to those happy times as an intern acting as the afterhours blood collection and recollection service.

Not much to my surprise, I got a call from the staff health nurse about 30 minutes later stating that the lab would not process my sample because it was not labelled properly. I suggested maybe she should call the lab and straighten things out with them as there were only two samples in a zip-locked bag and one was labelled with the patient's label, the other one had my name it. She asked if I was concerned about the patient's risk factors. I asked if she had never heard of universal precautions?

Now I could have just found somebody to draw another sample, but hey it's my blood, my integrity was violated to get the sample, they should process it. So I phoned the lab director who actually had heard about the fuss already. He said he would bring the sample to the OR and I could label it properly. About five minutes later he phoned back saying that the lab tech had told him, there was no way even if it was relabelled that they would process it.

I asked him, "Are you a physician?" He said "yes". I asked "and you have done a pathology residency?" Yes again. So says I. You have over ten years of post high school training and you are letting someone who graduated from a two year technical school telling you what you can do.

One hour later, he brought the tube to the OR and we relabled it.
2
Score: Lab 217 BH 1. But at least I'm on the board.

And by the way the patient was negative.

Death on the table

We recently had a death in the OR. Actually the patient died in the ICU afterwards but it was essentially a "table-death". This was a laparoscopic gall bladder in an octagenarian. She had an uneventful OR and then arrested in the recovery room. I didn't do the case but responded to the alarm, stayed for while until I figured there was enough help, so went on my way. Anyway she had a complex but no pulse which lead me to think she might be bleeding. After some rescuscitation they took her back to the OR where there was bleeding in the retroperioneum around the pancreas that nobody had noticed. She as I mentioned later died in the ICU.

This reminded me of a few things.

The first thing that came to mind was something that happened to a staff anaesthetist where I trained. This individual was not a very good anaesthetist. He however felt that he was the best anaesthetist around. This is a bad combination. He wasn't really fun to work with as a resident. (Aside from being a pompous twit, he had a nasty habit of poking you in the shoulder to make his point; nowadays laying hands on a resident would land you in the Dean' office.)The event in question however happened about 2 years after I finished. By that time I gather there had been a few other episodes.

He was doing a laparoscopic cholie around the time that surgeons started doing laparoscopic cholies and those of us who worked in that era remember what a dark time that was(3 hours of farting around followed by an open cholie). I gather during the case, the blood pressure continued to fall and fall. He asked the surgeon if there were any problems and of course the surgeon said no so on they went until the patient died.

My former "mentor" was told soon after that it was time he retired. This was before the autopsy showed a belly full of blood which the surgeon had failed to notice. Unfortunately my mentor had to keep retired while the surgeon is to my knowledge still working and hopefully learned something that day.

I have unfortunately over the years had a few deaths in the OR and few people that expired shortly after. Most of these have been predictable, ruptured aneurysms of both types, traumas and of course the ICU cases sent to the OR to be euthanized (this patient is going down the tubes and we can't think of anything to do so lets operate on him). Self flagellation comes naturally to anaesthesia and we always wonder if there was anything we could have done differently and looking back over the years, I don't think there was except maybe I could have run away.

The wierdest thing about a table death is that you usually have to start another case right after. Either you are on call or this case bumped into your elective list or it was in the middle of your elective list. So after an hour or so to clean up the mess and do the paper work, back in the saddle. Strange.

Several years ago, we had a province wide committee on peri-operative deaths and it was an interesting exercise. Essentially if a patient died within two weeks of surgery you had to come down to medical records, review the chart and fill out a form. Many of these were of course patients you knew died or you thought were going to die but you got the odd patient who just happened to die a few days post-op for no apparent reason. As I say it was interesting (and easier than reading the obits and looking for names you recognize.) This initiative stopped during our time of health care reform and downsizing in the mid 1990s when the province and hospital admins got worried that death might be attributed to their restructuring efforts.

Excuse me, aren't you on call?

A couple of days ago, a patient of mine in the pain clinic had a seizure. This was after an epidural steroid injection. I didn't use any local except for skin infiltration. Like many epidural steroid injections he was olders. In addition he was a diabetic and a smoker.

After I checked my own pulse and reassured myself that I hadn't done anything wrong (unless you believe epidural steroids are inherently wrong), I thought what the hell is wrong here. So the differential included:

1. A sycopal epidode because of pain followed by a seizure secondary to cerebral hypoxia.
1a. In a diabetic smoker a sycopal event associated with cardiac ischemia.
2. Seizure secondary to a cerebral mass lesion exacerbated by increased ICP during epidural injection.
3. Electrolyte abnormality
4. Hypoglycemia
5. Others that I haven't thought of.

Although the seizure only lasted about 15 seconds and he wasn't very post-ictal afterwards I felt that he probably warranted further investigation and probably some observation. So I paged internal medicine on call.

The internist answered my page right away and I told him the clinical scenario. His response was, "well I don't know when I'm going to have time to see him". He told me to order some blood work and if everything was normal to send the patient home with no follow-up.

I was somewhat astounded. This wasn't a newer physician but one of the older more "respected" members of the medical staff.

I have some empathy for internal medicine. I spent 3 months on a general internal medicine service as a resident. They tend to be a dumping ground for every type of medical problem without a lucrative procedure attached; for those people who don't have much wrong with them except that they can't be sent home etc. They make a lot less than their procedurally inclined colleagues. Fine that is a problem that is at least 20 years old. I shouldn't be put out because you haven't figured out how to deal with this.

It strikes me that general internal medicine like family practice before them is in the process of getting out of the hospital and in general in looking after sick patients at all. I am told that most of them now only round 3 times a week on their inpatients which of course means that their patients don't get discharged as quickly which has meant medical patients spilling over onto surgical beds. Instead as family practice focuses more on looking after patients who really don't have anything wrong with them, internal medicine is sliding into the niche of looking after patients who only have a little bit wrong with them but are getting paid consultant rates for doing so.

Take the traditional pre-operative medicine consult. This was a cash cow for internists in the past with every consult ending with, "Fit for surgery, avoid hypoxia and hypotension." Now less than 10% of those consults were actually necessary or useful but now we very often can't even get those 10%.

I brought this up with the chief of my department who suggested reporting this to the licensing body. I am mulling it over but I really can't bring myself to rat out another doctor for only following what has become a trend in medicine.

So I put it on my blob

My Jehovah's Witness Story

It seems everybody has their JW war story. Here is mine.

A couple of years ago when I still worked at the CofE I was on call for neurosurgery and was called in one Saturday morning to give an anaesthetic for an aneurysm clipping. The patient was already intubated and had lines in (I call this plug and play). We put in the head pins started the surgery and I got down to reading the Saturday paper occasionally glancing at the monitor.

A former resident called neurosurgical anaesthesia " a gall bladder with mannitol". Despite all claims to the contrary neuroanaesthesia is dead easy. Various anaesthetic drugs have some effect on ICP and CBF and I did learn all these things during my residency. If you think too much you will be anaesthetizing all your patients with lidocaine and pancuronium because those are about the only drugs that don't do something bad. However after a while you realize that the neurosurgeons could not give a shit about what drugs you use, as long as the patient doesn't move, the brain is relatively slack and the patient wakes up when the surgeons wants them to (either right away or several days later). Further the patients either do well or badly and it has nothing to do with what you did (which doesn't stop the surgoens and worse still your colleagues from pointing the finger at you)

I was well into the sports section when somebody phoned into the room to tell us that they thought that the patient might be a Jehovah's Witness. Now aneurysms rarely require blood products (except for giant aneurysm and when those rupture you may as well just turn off the ventillator and go for coffee). So I did what the surgeon should have done before the case, I read the chart. I didn't find the blood refusal form but I did find a personal directive naming her sister as her power of attorney. Around that time somebody talked to her husband who stated that he wasn't aware that his wife was JW but that they had only been married for 6 months. Soon after I was told that the sister was on the line. By this time the aneurysm had been clipped. I told the sister that it was a moot point at this time but that given that her sister obviously wasn't a practising JW anymore would she consider allowing her brother-in-law to permit his wife to accept blood products. She of course refused at which point a man (presumably the father) came on the line and asked why we wouldn't use alternatives. I explained that we actually always used alternatives unless we felt that the patients life was in danger and hung up. The cranie was closed; another JW bullet dodged.

Not quite.

Around 1800, I got a phone call stating that I needed to come in for another cranie in this patient due to bleeding. Before I drove in I suggested they might want to contact the hospital lawyer about the possibility of giving blood products but nobody took my advice. The surgeon did talk to the sister who was still insistent on no blood products.

I was never clear on why the re-bleed occured. At the time it seemed that the patient had somehow become hypothermic and had developed a hypothermic coagulopathy. Her temperature was 33 and using all the resources at my command, I just couldn't seem to raise it. A quick internet search suggested that platelets might work in this situation but of course we couldn't give them. I of course can't rule out poor surgical technique and hemostasis. Anyway the surgeon poked around, cauterized and clipped for about 2 hours before closing up and we went off to CT to see whether we had accomplished anything. The CT showed a hematoma as big as the one we started with and we shipped her off to Neuro ICU presumably to die.

Now I of course felt sorry for the patient who may have died and at best would have been left brain dead. I also feel sorry for the husband whose wife of six months was now not the woman he married and hopefully was still in love with. All this because of the whim of his sister-in-law who, if he didn't know that his wife was JW, he probably had never met. Now many faiths have beliefs that are completely irrational, I am not going to give examples, you know who you are. It just seems that JWs consume a proportion of health care resources way in disproportion to their numbers. Consider everytime you have a JW coming in for major blood losing surgury, say a hip revision or liver tumour. These cases usually become a major military operation. There are usually consultations between multiple surgeons, hematology, ethics etc. Sometimes they even consult anaesthesia. The patient if he survives will have an ICU and hospital stay at least twice as long as normal.

Now you might ask, shouldn't we in a perfect health care system be prepared to do everything the patient wants to get him thru surgery. Yes, except that healthcare is a zero sum game. Service given one patient is service denied to another patient. If you spend an extra day in ICU, that is another patient whose surgery is cancelled, or who has to be looked after on the medical ward instead of the ICU or who has to transferred to another city or is on a ventillator in the recovery room.

Now somewhere in Richard Dawkins' book "The God Delusion" he pointed out that we are much more tolerant of irrational or stupid beliefs when a religion is attached to them.

Suppose I am about to undergo surgery where major blood loss is expected. Now I hate the Montreal Canadiens with a passion. I have decided that I will not accept blood from a Habs fan. Because the Canadian Blood Agency does not ask whether you like the Habs (which is in my mind WAY WORSE than paying for sex) I will not accept blood from them. Directed donation even if it were allowed would be out because I cannot be sure that my blood might be contaminated with a Habs fan's blood.

Even the biggest Bruins fan of a surgeon would flatly refuse to operate on me. There would be no meticulous planning, no ICU stay, no ethics consult. There might be a psychiatric consult.

An extreme example?. Only a question of degree. Afterall ethicists often justify the JW refusal blood by citing less extreme examples of other faiths (Catholics refusal of abortion, Jewish refusal of autopsy). It works both ways.

More on the CoE

I published several months ago a long diatribe about why I left the CoE.

Anyway several people either left or reduced their committment after me, which left the department which in addition to their total inability to recruit anybody left them severely short of staff. This lead to them actually having to cancel ORs because there weren't enought anaesthesiologists. Now cancelling lists is not a new thing at the CoE. They cancel them all the time because of lack of nursing, because the surgeon was up all night transplanting, because there are no beds, because the single horrendoma booked in a room was cancelled etc etc. This is done frequently with very little angst. Of course when you find out a 0600 you aren't going to work, this hits you in the pocket book. (This is assuming there actually have the courtesy to call you at home which is unusual, they normally wait until you show up or better still make you wait for 2 hours before they decide they can't do anything.) It was when I found I was actually happy when I found my list was cancelled that I realized that maybe I should leave.

But when they have to cancel cases because of no anaesthesia it suddenly becomes a crisis.

So they brought in two academic anaesthesiologists to do yet another external review. I have no idea of what this two charged but I'm sure it was worth their while. They produced a long report. The first half of the report where they went over all the problems at the CoE could have been written by me, except the my spelling and grammar would have been better. The second half where they proposed solutions was completely out of touch with reality. The bottom line was that instead of seeing how they could make the CoE a more attractive place to work at, they focused on how they could make the other places in the city less attractive.
The other interesting thing was that they came all the way out to Edmonton and didn't bother speaking with any of the anaesthesiologists who actually left who might have some insight into the situation.

Of course they could have just stayed home and read my blog. I wouldn't have charged them.

I got sued part 2

Actually maybe things didn't go that well. As the case wore on, she required more oxygen to keep her saturation up. In retrospect, the rotten food I should have sucked up was probably getting past my et cuff.

So I decided to keep her intubated, get a chest X-ray and call ICU.

I took her out to recovery and put her on a ventillator there and called ICU who sent their fellow over right away. As it turned out her oxygenation got worse in the next few minutes and her CXR was gross.

To make a long story short, she spent several months in the ICU, a few more in hospital but was actually discharged with no new deficits. Not that spending a few months in ICU is necesartily a good thing.

I had a somewhat unpleasant meeting with my chief, (who you may recall was the individual who was able to see the patient in a relaxed un-hurried fashion in the preassessment clinic and failed to document the patient's achalasia) and called the Canadian Medical Protective Association.

Several months later the patient's father called me up and asked to meet with me regarding what had happened to his daughter. I called up the local lawyer on my case who advised me to only meet with a lawyer present. I phoned the father back and told him, this. His response was, "Is this how you doctors handle things?" I often think if I had just met with him I might have avoided legal action (or least shifted blame onto the surgeon and my chief). A few weeks later he called me up and asked if he could photocopy the chart. As patient charts are legally the property of the patient, I told him to go ahead. Unfortunately the hospital refused to let him photocopy the chart which lead to me receiving a letter from his lawyer. Strike two.

Time passed. In my province at that time you had only one year to file a lawsuit. As eleven months rolled by, I began to feel good about myself again. At eleven months and two weeks I got served! Along with the surgeon, and the hospital. Curiously my chief managed to escape.

About 2 years later I had what is called an examination for discovery. This is a process in civil suits where you sit down and the other lawyer questions you. Your lawyer is present, but does not ask questions; he may interupt to clarify and he may by hand or eye signals caution you on answering a question. The plaintiff is usually present, although there is no requirment that she be there.

This of course involves taking a day off work although in anaesthesia one can do this by working around the call schedule. The other side of course cancelled the first session on short notice and we had to reschedule.

Now as I have said, there were mitigating factors; the bottom line is that I screwed up. I could have and should have dug deeper asked more questions of the surgeon and patient. I should have got the chart back from the surgery resident. I should have cancelled the case after the induction. I should have checked for a suction. Blah, blah, blah. I should have done all these not so I wouldn't get sued, but rather to prevent a patient would was told she was coming for a simple short stay surgery that would solve her problems forever from spending months in the ICU, a fate I would wish on no-one (even my chief).

The other lawyer of course missed all this in his two hour interogation. The examination ended with the curious question, "Did you give her chlorine" to which I answered no.

Now there were a few other problems. As I mentioned the patient was deaf-mute. She also had a variety of pre-existing neurological problems which of course nobody bother documenting pre-operatively. Also in the ICU as they began to wean her off her sedatives, she developed twitching, which the neurologist said was due to "anoxic brain damage". Although the patient required high concentrations of oxygen and other ventillatory support she was never even hypoxic, let alone anoxic.

Eventually the case was settled out of court for a low six figure amount.

The only consolation when something bad happens to one of your patients, is that you learn something that will help future patients, and the institution may make changes that may prevent future events. I have done achalasia patients since uneventfully and I now know what a "Heller's Myotomy" is. I can even google it now:

http://www.gpnotebook.co.uk/cache/2087387177.htm

Years later I was talking to the scrub nurse in that case and I learned why I had a student nurse helping me. At that time, in the Centre of Excellent, each service had its own head nurse in the OR. Some of the head nurses actually helped out. The head nurse in this case usually didn't. On that particular day because they were behind and were busy setting up for this laparoscopic procedure, they asked the head nurse if she could help me get the case started. Her response was to send the student nurse in to "help" me. I gather that when her bosses in the OR asked her why she didn't help me, she said it was because she didn't like me. At that time I had worked at the CofE for 3 months and had never worked in her room so I must have managed to piss her off in the first couple of hours that day. She retired a couple of months later. This says something about the institutional culture at the Centre of Excellence. Normally when you give an excuse like "I didn't help him because I don't like him", the usual response would be "I don't care whether or not you like him...your job is to help him". As it was one of the items discussed with my chief at the unpleasant meeting I mentioned above was the fact that according to my chief after 3 months all the nurses hated me. Well I certainly wasn't too impressed with the nurses around that time.

I Got Sued Part 1

A few weeks ago while channel surfing I came across the movie "The Verdict" with Paul Newman. I first saw this movie in 1984.

The movie is about a lawsuit against an anaesthesiologist.

The "facts" in the movie are that the plaintiff came into hospital to have her baby and was "given the wrong anaesthetic". Essentially the patient had eaten just before she came into hospital to have a baby and was given a general anaesthetic with a mask during which she vomitted, aspirated, had a cardiac arrest was rescuscitated but was left in what we call a vegitative state.

The movie doesn't say what type of operation she had.

Assuming she had a caesarian section, there was no right or wrong anaesthetic in 1983 or now. The standard of care for a caesarian section under general since the 1960s would have been to intubate the patient. A mask anaesthetic would have definitely been the wrong anaesthetic. Pregnant patients are assumed to have a full stomach regardless of how long they have fasted and stomachs empty much more slowly in pregancy.

Now up until the 1960s or later, it was fashionable to give women heavy sedation approaching or exceeding general anaesthetic for labour and this is what may have happened. Judging from the clothing and hairstyles however, the movie is set in the early 80s/late 70s.

I am constantly amazed that producers are prepared to spend millions on a film without asking a specialist in the field, "Is this a plausible scenario?"

This however is not about reality in the film industry, it is about my brush with the medico-legal system.

Actually it was 14 years ago and I believe it was settled at least 10 years ago. I was reading Dr. Sid Schwab's blog and he talked about how he got sued years ago so I thought I should relate my experience.

Firstly I fully admit that while there were extenuating circumstances which I will detail, there were actions that had I followed them, the whole mess would not have happened. The bottom line is I have always accepted full responsibility for what happened.

It happened a few months after I joined the staff at the centre of excellence. I have been in practice for just over 2 years at the time. Statistically anaesthetists are at their most dangerous in their first 3 years of practice. (Some people think that more experienced anaesthetists are just better covering up their mistakes.)

Anyway as I have mentioned in a previous post, I had already by then realized that I did not fit in at the centre of excellence and that I would probably never fit in.

When I was a resident and in my first years of practice, when a patient needed to stay in hospital after their surgery, they were admitted the night before and they were seen the night before by the anaesthetist assigned to the room. This meant up to an extra hour of (unpaid) work after your list had finished not to mention the Sunday night visits. This was we all belived the cross anaesthetists had to bear. Now it was around that time, the hospitals in the name of saving money decided that patients could be admitted on the day of surgery. This meant that they were seen in advance of their surgery at a Pre-operative Assessment Clinic (PAC) by one anaesthetist who was assigned there that day. That lucky person would see all the patients, review the lab work and fill out the anaesthetic form. Hopefully if there was a potential problem, that would be relayed to whoever was supposed to do the case. At that time a copy of the anaesthetic form would be faxed to the office the day before so you had some idea of what you were doing.

Anyway, the day before I looked at the slate and saw that one of my cases was a "Laparoscopic Heller's Myotomy". Even with a medical degree, five years of medical training and over two years clinical practice, I had no idea what that was. Nor did anybody in the office. I suppose I could have gotten a surgical textbook and looked it up (I did several months later and even some surgical texts didn't use that term). Or I could have phoned the surgeon's office and talked to him. But I didn't. I figured I could talk to the patient the next day, read the chart and I would be able to figure out what I could or couldn't do. (Nowadays I would just Google Heller's Myotomy but back then Al Gore had only just invented the internet).

Complicating matters was that the surgeon was probably the most clumsy incompetent surgeon at the CofE. There are many clumsy and incompetent surgeons and many of them know their limitations and stick to hernias, lumps and bumps. Then there are those who don't know their limitations. This surgeon, widely known for his incidental splectomies was one of the later group. Worse still, he had jumped onto the laparoscopic bandwagon well in advance of many of his colleagues.

Anyway on arrival in the room, I asked the nurses if they had any idea what our second case was. They too had no idea. So we asked the surgeon when he came in. He mumbled something like, "just like a laparoscopic cholie, no problem". Our first case was a breast biopsy which unfortunately needed a frozen section which took much longer than planned, so we were already running late. All this time I was thinking no problem, I'll talk to the patient and read the chart and I can do this next case.

On dumping my first patient in the recovery room, I went out to the receiving area but my second patient wasn't there yet. Quite often I will see the patient in the operating room but I distinctly remember telling the nurse in receiving, " call me when the patient gets there". Then I went to have coffee.

The next call I got was from the room telling me that the patient was in the room. No problem, I can read the chart and talk to the patient there. Except.....

Because patients don't come in the night before, the surgery residents also don't get a chance to read the chart and the surgery resident had taken the chart somewhere to read it. And...

The patient was deaf-mute and no family member had accompanied her.

No problem. One of my colleagues must have been able to talk to the relatives, read the chart in the PAC. So I got the anaesthetic record (which hadn't been faxed over the day before). She had been seen by the chairman of the department, an eminent academic anaesthetist. To be honest there wasn't much on the chart just a couple of meds, no allegies and a note that the patient was deaf-mute. Nothing to get the spidey senses tingling. Now I have learned since and probably knew then that the more eminent an academic anaesthetist is, the less competent they are. But I figured, okay we're dealing with something like a laparoscopic cholie in deaf-mute but otherwise health person.

So we set up to induce anaesthesia. I had a student with me that day, somebody I had worked with for a couple of days. This was a smaller room and we had the two monitor towers on each side of the bed so there was only room for one person at the head of the bed. Since my student was going to intubate,that was him. When we start anaesthesia, there is supposed to be a nurse whose only responsibility for those few minutes is to help us. There was a female nurse-looking person standing at the side of the bed where the nurse usually stands.

So I inject the drugs and after waiting a few seconds, my student goes to intubate. First thing he says is "I think we need suction". So I ask him to get away from the head of the bed because there is not room for two of us because of the monitors and I take a look and her entire mouth is full of some gross whitish material. That was when I discovered that my lovely assistant was a student nurse who had never helped start a case and that she had not got a suction ready. (The nurses get the suction ready for each case, but I admit it is my responsibility to check for its presence).

At this point, the surgery resident wandered into the room with the chart, looked into her brimming oro-pharynx and said, "Isn't achalasia gross?"

ACHALSIA!!!!!!!

Achalasia is a condition where the muscles in the esophagus that are supposed to propel food down towards your stomach don't work. This results in solid food accumulating in your esophagus where it basically decomposes leaving you with a massively dilated esophagous full of rotten food. This patient I learned later had a particularily bad case to the point where she had to sleep sitting up or else all this rotten food would go down her lungs.

Usually patients like this are admitted to hospital several days in advance and all the rotten food is sucked out and they kept on a liquid diet.

Now when you screw up like this, no matter how extenuating the circumstances are, when you should be thinking, "how can I help this poor person?", your first thoughts are, "boy am I in shit!"

So I pushed the student aside waiting for the real nurse to set up a suction, sucked out the oro-pharnynx and intubated. Fortunately the patient's oxygen saturation remained okay and she was not broncho-spastic. I called for a broncho-scope and looked down into her lungs. There was a little bit of "staining" in the parts of the lung I could get to with the bronchoscope which I tried to suction out as best I could.

At that point I should have cancelled the case. The patient had aspirated she was stable but she could get worse during the case and once we started, it might be difficult to stop. I didn't do that though. I felt so bad that my telepathic powers had failed to pick up what the patient had and what the surgeon planned to do that I felt I had to make things up by continuing on with the case. This is very irrational but that is how you think when things like this happen.

At the very least, I should have suctioned out the 2 or so litres of rotten food in her esophagous to keep it out of her lungs. (An endotracheal tube is only partial protectiona against aspiration.)

After that, the case went pretty good.

Why I left the Centre of Excellence

15 months ago I left the large teaching hospital I will call the "Centre of Excellence" to practise at a smaller community hospital. I had worked at the CofE for 14 years. People often ask me why I left. There was no single reason; it was a series of small reasons. Taken individually they seem petty, as a whole they are a powerful reason.

1. I never fit in there.

When I was a resident I worked at a hospital that was similar to the CofE. I vowed I would never ever work in such a hospital. After my residency I worked at a community hospital in New Brunswick. Problem was, my wife and I are both from BC and I began to pine for BC or least Western Canada. In addition the New Brunwick government was in financial straits in the early 90s and was cutting money from health care like crazy. This not only affected my income but actually increased the number of hours I had to work for less pay. Now at that time, they was a glut of my specialty in Canada so when I got an offer to work at the CofE, I forgot about how much I hated that type of hospital and jumped at it. Within a month I knew I had made a major mistake but I had already spent a lot of money and time moving and besides there weren't a lot of jobs in Canada. In addition when I moved, I told my wife this would be our last move ever.

2. Personality Cults

I am an anaesthesiologist. I realize that patients don't come to the hospital for anaesthesia, they come for surgery. However I soon realized that at the CofE there were actually "personality cults" approaching worship of most of the surgeons. The problem was many nurses worked exclusively in one single sub-specialty while you rotated between rooms. This actually hurts rather than improves care as nurse tend to overlook flaws in the surgeons while focusing on your flaws real or imagined. For example a few years ago a surgeon left his resident to do a mediastinoscopy undersupervised. When the resident biopsied the pulmonary artery (actually he didn't but with the amount of bleeding that was what we thought) the surgeon could not be found. After several anxious moments another thoracic surgeon came from his office. It turned out the surgeon had actually left the hospital. I felt this had to be reported and when we discussed it at the next staff meeting several others had had the same thing happen with this surgeon so it was reported to the medical director and the surgeon was hauled on the carpet for a "corrective interview". Naturally I didn't work in that room again for about six months. I was expecting a frosty reception my first time back but to my surprise (maybe not) it was the nurses and not the surgeon who were frosty. I should mention that this surgeon is now on a forced leave of abscence.

There have of course been less egregious episodes. Like the nurse hissing, "I'm helping the surgeon!" when I asked for help with the severely burned patient.

3. Face-offs
This isn't about hockey. Our hospital does a lot of major head and neck surgery. We call those face-off because they take the patient's face off for cancer and reconstruct. These cases last about 16 hours. They don't require a lot of work once the case starts and always go to ICU post-op so they are not terribly intellectually stimulating.

The problem is that during those 16 hours, you have to eat and pee. This requires you to ask for another anaesthetist to come into your room to take over the case briefly. Most anaesthetists will do this for one another as a courtesy. The CofE has residents as well so they can often take over the case. Recently residents no longer regard helping another colleague to be educational so that route has been closed. There also seemed to be a lack of respect within the department so people would not automatically ask if you needed a break. This meant that around 1400 you were basically phoning around begging for a break so you could pee. We discussed this at multiple staff meetings without any resolution.

Long cases like this are not new. In the "old days" you would do about one a month. At the CoE they do 3 a week. This is in addition to the odd long Plastics or Neurosurgery case. The major head and neck cases used to be thought of as a cross you had to bear in order to do the lucrative ENT short cases. In our city however all the lucrative cases are done at another hospital. Go figure.

Usually one of the on call people takes over the case around 1600. There had been a tendency to assign the second call to that room which meant the lucky second call person gets to do the whole sixteen hours. Of course this means one of the on call people is now finishing an elective case from the day during the evening instead of doing emergency cases.

Add to that the personality cult among the nurses in that room.

4. Major cases
When I came to the CofE we actually did minor cases. Then the regional health authority decided that the CofE should be a pure "tertiary referral centre" and all the minor cases were moved to other hospitals. This means most of the cases are 3-5 hours long with the usual problems peeing and eating. It also means that cases often run into the evening without warning and the second call can't take over your case because he is in the face-off (see above). In addition many of the cases are in patients with a bad prognosis which is bad for morale.

Somebody has to do these cases (well actually some of them would be better off not being done). It just shouldn't be the same people all the time.

Also as people started to leave and it became hard to recruit staff, the chairman recruited a number of staff with questionable skills and qualifications. So guess who gets to do the few low intensity cases we have because they can't be trusted with sick patients?

5. Lack of help

I would think I am at the top of the scale of self-sufficiency for doctors. I can do most things without much assistance. There are a number of things that require an extra pair of hands. Also sometimes somebody has to go and fetch equipment or drugs solely because you can't leave the patient. Oftentime equipment is stored in a location where only somebody else knows how to find it (sometimes I think they do this intentionally).

When I interviewed for the job at the CofE they raved about their anaesthetic techs. I was actually looking forward to having somebody to help me. Unfortunately the techs work mostly in the cardiac rooms and are of very little help in other rooms. I found them very unhelpful.

Because we have techs however, most of the nurses were reluctant to help out. Many of them when I asked for help would go to the intercom and page a tech who never came. Sometimes a tech would come, open the door a crack push in the piece of equipment you needed and leave. Sometimes they would actually come in the room, look around and leave.

As low intensity surgery was moved out of our hospital, the need for the techs became greater, however the level of service did not improve, if anything it got worse.

Over the years I learned how to function without much help. When the hospital started renovating the OR, everything was moved and moved again which meant I couldn't find anything.

In contrast when I did locums or when I worked at other hospitals in the city I was amazed at the level of assistance I could get.

For the last couple of years, if I had to do a major case the next day I would lie awake at night worrying about how I would get throught the case with no help. One thing that always bothered me was that there were certain types of cases we did a lot of like for example liver resections but every time I did such a case, I would have to come in first thing in the morning and ask individually for every piece of equipment I would need to safely do the case.

This was brought up multiple times at staff meetings, and the chairman's (he only works in the cardiac room) was "we get excellent service from our techs".

My "Colleagues"
The CofE has a lot of anaesthesiologists whose shit doesn't stink. I noticed this from about the first month. I would sit in the lounge and hear people talking about the horrendoma they had done and how it was only thru their skill that the patient pulled thru.

I felt very inferior until I realized that I was doing the same cases as them and that my patients were pulling thru if only because no matter how incompetent you or surgeon are, it is very hard to kill somebody.

There were and still are a lot of people there I like. Over the years quite a few people came in who I didn't really like, some of the people I liked left and so on. I used to come to department social functions early on. I stopped going after a while, if somebody asked me, I said," its bad enough having to work with you". After a while, I realized that I wasn't joking.

When I started thinking about working at the community hospital, I thought about the anaes. who already worked there and realized how much more I liked them (and till like them after a year).

Lack of Respect
There are two types of respect.

The first type of respect is a type you have to earn. I know that I have to earn that respect and I don't take that as a given.

The second type of respect is the basic respect that everybody is entitled to regardless of their station. I like to think I try to treat everybody with respect. Maybe I haven't always done that but I always try now.

That second type of respect was totally lacking at the CofE. And for that matter forget about trying to earn the first type of respect.

It was only after working at other hospitals that I learned that I was actually an important member of the team whose input was important.

The declining standard of care

"Back when I was a resident" teaching hospitals functioned on the backs of residents, interns and medical students who worked their buns off. Staff physicians and surgeons did very little patient care and the nursing staffs tended to be more helpless than in a community hospital. It was soul-destroying work and I am glad that residents don't work as hard as they used to.

Except.... if they don't do the work, somebody has to do it. That means that the staff surgeons have to start earning their generous fees and that the nurses have to learn that the solution to every problem is not to page someone (because that someone is not going to answer that page anymore).

Unfortunately the slack is not being picked up. Problems are being missed, patients are coming to the OR on an emergent basis for problems that could have been picked up earlier and dealt with electively or not at all, patients are coming to the OR inadequately investigated or inadequately rescusitated. Charting is attrocious especially on the medical side. I find it disgraceful that I have to rely on the nurses' notes to find out what is going on and even then these are frequently less than adequate.

This happens to a lesser extent at our community hospital but in general the surgeons seem more vigilant and insist on a higher quality of care from their residents.

Disorder in the Operating Room

When I first came we had a clinical director who directed the flow of cases in the operating room Things worked out quite well. Then the health authority decided we didn't need one.

Now we have a clerk at the desk who manages the flow of cases. When a surgeon wants to book an emergency that involves disrupting a room, instead of talking to a physician or even a nurse who might be able to tell when he is lying, the clerk simply gets on the phone and disrupts whatever room she feels like. If you are involved in one of these so-called E1 emergencies, you of course have no idea of what you are getting into because of course the surgeon does not talk to you.

Unbelievably this was raised at staff meetings and nobody thought it was important although a few months after I left, they actually did change the system and now you have to talk to an anaesthetist to book your case.

We also have transplants. I have a lot of problems with transplants but then again I am just one needle stick away from needing a liver transplant so I will shut up. The problem is they typically harvest the donor starting in the evening which means that the heart, liver and lung transplants start after midnight so that come 0700 we have 2-4 anaesthetists who are not available to do their scheduled list. Instead of trying to deal with the problem (do the harvests earlier in the day so that the transplants are in the evening or do the harvests at night and the transplants first thing in the day), we came up with a solution where we have to take turns being the person who has to find 2-4 individuals to work the next at 2300 hours. So after working all day, you get to spend about an hour at 11 pm finding somebody to work the next day.

The transplants also screw up the OR slate incredibly the next day plus on weekends trauma cases get backed up.

There are actually some good people there

I don't mean to be entirely negative. There are a lot of really good people there who are disgusted by what has happened to their hospital and continue to labour on because of loyalty.