Why I Went Into Anaesthesiology

As I mentioned, I interviewed new prospective residents about a month ago.

I didn't ask people why they wanted to be an anaesthesiologist (instead I asked them why they thought it might be a bad idea to go into anaesthesiology). The stock answer to why they wanted to become an anaesthesiologist seemed to be something about being interested in the physiology and pharmacology involved with anaesthesiology.

That wasn't why I went into anaesthesiology.

One day during my clinical clerkship, I was "assisting" on an open cholie. "Assisting" involved retracting the right costal area with the infamous Deever retractor (eager beaver with the deever). This of course meant you couldn't see anything which was afterall the justification for you actually being in the OR. In addition because you couldn't see anything you couldn't see whether you were actually helping, which meant you were constantly being nagged about this with the volume and sharpness of the nagging going up as the case went on and your arms got tired. Plus in those days, it was actually acceptable to hit students which meant the odd rap across the knuckles with a needle driver.

Anyway I was in the midst of one these ordeals when I looked over the drapes. There was the anaesthesiologist sitting in his chair with his feet up, doing his crossword.

And I said right then, "that's got to be a good job!".

Yet another reason to be ashamed to be a doctor

A number of years ago, a lady came to me with a diagnosis of fibromyalgia. She was in significant pain, was on long term disability and had tried all the usual nostrums for fibromyalgia.

After some discussion I put her on a small dose of methadone. Because methadone blocks NMDA receptors, the theory is that it might be a good medication to try in fibromyalgia.

Now I have not been able to duplicate this success with many other patients but she did fabulously. Her pain decreased, she slept better, she was more functional. She had at that time been off work for many years so going back to work was not really in the cards and her disability insurer didn't seem too unhappy with that.

Over the year or so I followed her, she increased her medication slightly but stabilized on less than 10 mg per day. Her family doc who did palliative care and had a methadone licence then took over her care again.

About a year ago I got a new referral to see her. The letter said that her family doc, had retired and that her new doc didn't have a methadone licence.

Methadone licences to treat pain are relatively easy to get in our province; in addition it is possible to get a licence to treat only one patient. I phoned her doctor and told him I would send a letter supporting his application for a patient specific licence. He said he really didn't want to do that.

Several months later I actually saw the patient again.

She told me that since her old family doc had retired, she had been making the rounds of family docs who were taking new patients. All of them flatly refused to see her after learning she was on methadone even though it was clearly for pain and not for addiction. The last guy, the one who referred her to me said he would be happy to look after her medical concerns but would not prescribe methadone or any narcotic for her.

While certainly prescribing narcotics is controversial and little bit of a hassle, here we have a patient who is on a stable dose of medication that is clearly benefiting her and yet we have a series of doctors who refuse not only to look after her pain but refuse to even take her on as a patient.

I can think of a few medical conditions that are a lot more of a hassle to deal with than a patient on a stable dose of narcotics. Insulin dependent diabetes and anticoagulation come to mind. I wonder how many doctors turn down those patients. (Sadly I suspect quite a few).

As I said in my referral letter, "this is a sad reflection on the medical community".

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

Primary Envy

There are a lot of things about America and Americans that I admire. This includes the Blues, Rock and Roll, and the Sopranos to mentions three things that come to mind. Having watched the still ongoing primaries however I am envious.

Now while many of us don't like the party system, the bottom line is that while occasionally independent candidates do well at the constituency level, nationally most independent candidacies are quixotic runs by wealthy men who can afford to do so. (Ross Perot with all his money failed to get a single electoral vote in either election; he did probably help Clinton get in at least once for which we are grateful.) It is not possible to get elected President, Prime Minister, Premier, Chancellor, Dictator for Life without the nomination of a political party.

In Canada, our party leaders who are the closest thing we have to presidential nominees are chosen thru a much more byzantine system. Stephan Dion, the leader of the Liberals could very likely be the next Prime Minister, if not this election, the next. Lets look at how he got there.

Each federal riding gets a certain number of delegates to the leadership convention. In addition party officials get a certain number of delegates but it is the votes from the individual ridings that make a difference. To be able to vote for a delegate, you must be a member of the party and live in that constituency. In the old days party members were committed supporters of the party, who met regularily, attended policy conventions, raised money and worked their asses off at election time. Their reward was that they got to nominate the candidate for their riding and also for delegates at leadership conventions. A large constituency association would have less than 100 members.

Some time in the past 25 years, someone figured out that if you wanted to nominate your candidate or elect your slate of delegates, all you had to do was to sign up some more members who would vote for your people. For example when I was in university, a girl I knew a little was busy getting drunk when two men in suits walked up to her and started talking. They eventually asked her if she knew anyone living in the same residence as she did and she named names. The result was that about two weeks later I received a fully paid up membership in the Liberal party and an invitation to vote in the upcoming nomination meeting. I was more principled at that time.

This has now gone way beyond the point of approaching university girls and meetings to nominate candidates or to elect leadership delegates now routinely have over 1000 members. What will happen is that the various candidates will try to sign up as many new members as possible. While I got my membership paid for me, theoretically the new member is supposed to buy his own membership. These have become ridiculously cheap usually in the $5.00 range.

With the need to sign up hundreds of delegates, talking to drunk girls in bars while fun is terribly innefficient. What you need is to be able to sign up a whole lot of members at the same time. So what most Canadian politicians do now is they go to evangelical churches, Sikh temples, or immigrant groups. Sometimes, as did Brian Mulroney in his leadership battle with Joe Clark, they simply go to a homeless shelter and bus in the inhabitants, new membership card in hand, to the nomination meeting.

So this is what the various candidates for the Liberal leadership did. They all signed up as many members as they could. These members showed up to the delegate selection meeting to vote for a slate of delegates committed to their candidate. Because each riding elects its delegates on a winner-take all basis, this means that frequently a candidate with between 30 and 40% of the members would get 100% of the delegates.

At the actual convention no candidate got 50% on the first ballot so that meant that as less successful candidates where elimated, they would endorse one of the remaining candidates which would mean most of their delegates would go to that candidate.

In this fashion, the Liberals elected their leader who has a good chance of being Prime Minister sometimes in the next year.

The Conservatives are slightly different. Rather than elect slates of delegates at the constituency level, each member gets to vote directly for the leader. I seem to remember that the votes may be weighted by province or constituency. The process is the same however; each candidate tries to sign up as many new members as possible.

A leadership campaign should be a time when there is a discussion of policy and people can chose who they vote for based on the strengths of the candidate. I have been watching the speaches of the candidates in the US primaries on CNN and while I am not naive enough to believe that these glowing words will translate into acutal action it certain is inspiring. In Canada however while leadership candidates actually make speaches, have townhall meetings, debates etc, we all know the real action is at the churches, temples and homeless shelters where votes are being signed up en mass. When the leadership race ends so does the involvement with the party. I doubt many of them even vote for the party they joined. (Some of them can't vote, most parties allow landed immigrants and minors to vote).

Back in 1992 the Albert Conservative party elected a new leader. Rather that having a nominating convention as they had in the past, they announced that anybody who purchased a $5.00 membership could vote. The winner would become premier. As you probably have figured out now, I have never and will probably never vote Conservative. But the novel experience of being actually able to directly vote for the premier was too good to resist and so I paid up my $5.00 and voted in the election and again 2 weeks later in the run-off. I never renewed my membership but I got phone calls and written material from the party for years afterwards.


Now there are a lot of problems with the primary system in the US (the huge expenses, the length, the way a small pluralty becomes magnified into a major victory) but the bottom line is that in most states every person who wishes to vote is able to vote for the nominee of his party (and in some states for both parties). They don't have to pay $5.00 although they may have to register. And they sure don't get bothered with phone calls and mail afterwards.

And for that I am envious.

Getting Back To Skiing's Roots

I recently spent a couple of days at Whitewater Ski Resort near Nelson.

http://www.skiwhitewater.com/

Most ski hills have become real estate developements where skiing exists only as a backdrop to the condo and golf course developement and where trophy wifes walk around in fur lined "ski suits" walking or carrying small dogs.

I am by no means a great skier, I prefer the groomed runs, I ski moguls poorly out of boredom, I have a fear of being buried in an avalanche and never venture outside the ropes (the idea of actually climbing a hill in order to ski down it doesn't appeal to me). Still WOW.

Whitewater is a small ski hill with only two double chairs. It is however situated in the middle of what is amazing backcountry skiing. Everywhere you look all you can see are non lift serviced peaks covered with powder and ski tracks.

The lodge is old, and there is absolutely no real estate developement or night life around the hill. Definitely no golf course. The prices are reasonable, the staff are friendly.

In short everything that is good about skiing.

Pre-Natal Classes

I have been involved with obstetrics for many years, first as as family doc, then as an anaesthetic resident and lately as a sometimes obstetrical anaesthetists. I actually enjoy obstetrics; I think it is the perverse fascination of dealing with a condition that will never ever happen to me (as opposed to urology for example).

While many people talk about the "miracle of childbirth" however I have to disagree. Firstly childbirth is a completely physiological condition and necessary for the survival of the species. Secondly just about every mammalian species does it; most of them do it much more efficiently and with less fuss that do homo sapiens. Grizzly bears actually have their cubs while they are asleep which unfortunately doesn't do much for their disposition.

But face it, pregnancy, labour and delivery are disgusting processes. Labour for example turns normal pleasant women into desperate, screaming monsters. Normal caring husbands are turned into helpless by-standers. The vaginal delivery process is a miasma of shit, urine, amnitotic fluid frequently with meconium and mucous. 20-30% of women end up having a caesarian section which has got to be the most brutal inelegant operation ever divised; the obstetrician cuts thru multiple tissue layers as fast as he can, rips the baby out, passes him/her off and closes only slightly less quickly. If you don't get a section, there is a good chance your baby may be hauled out by his head using a device which has been used since medieval times (forceps). Even in the 21st century, previously strong healthly women bleed to death, succumb to massive infections, or seize uncontrollably.

None of the above however exists in the alternate universe of the prenatal class.

Prenatal classes teach us that labour is a pleasant process where "tightenings" or "discomfort" can be breathed away aided of course by the husband who will be a willing partner in the whole event which of course will end in the painless delivery of a normal health baby.

I really don't have anything against pre-natal classes; I believe a little knowledge can sometimes be a good as opposed to a bad thing and that is, despite what my wife remembers, I went willingly and cheerfully to our prenatal classes.

I didn't plan my first baby very well. In fact I was at the end of six months of doing 1 in 3 internal medicine call when the conception allegedly took place so I have no recollection of when I found the time or energy. It turned out that my written fellowship exams were in September which was when the pre-natal classes my wife wanted to take started. I of course told her that there was no way I was taking any time away from stuffing my head full of the useless information I thought would be needed to pass my exams. My wife got angry and threatened to hire a labour coach whatever that was. We were able to compromize on classes that started in late October which meant that if our baby was early, we would be without the full benefit of the prenatal classes. I was certain in that contigency we could manage.

So one evening we showed up to a classroom at the hospital for our prenatal classes. Our class had all the usual sterotypes; the perfect couple, the young man with a mullet and his pregant girlfriend, and of course the Expert.

The Expert was a CRNA which is called a LPN in most of the country. Quite early on she introduced herself as an expert on most aspects of healthcare including of course obstetrics. I make a point of not introducing myself as a physician unless for some reason it has to be brought up, my wife likewise did not introduce herself as a registered nurse.

I really enjoyed the prenatal classes, honestly. I hardly ever rolled my eyes and participated in all the exercises. Things went well until the instructor found out that not only was I a doctor but that I was an anaesthesiology resident. Consequently she asked my if I could give a talk on epidural analagesia and also anaesthesia for caesarian section.

I would really rather have not done it but having been asked, I felt that as the now public face of the specialty, I should do a good job. I spent a great deal of time preparing what I thought was a balanced talk that focused on the labour epidural as being only part of a spectrum of labour analgesia and presented what I thought was the information they would need to know about Caesarian section. I made overheads and on the pre-natal night I presented my talk.

It was the worst experience of my life!

As I went on and on, the stunned rapturous expressions faded into frowns and then scowls. I finished my talk and the Expert immediately said, "Well I'm not having one even if I have to have a section." The teacher asked her why, and she stated, "its just not natural." Someone else asked why we wouldn't let the husband in for sections under GA which I didn't have a good answer for (otber than why would you want to to watch a stranger pry your wife's mouth open and try to ram a tube down her throat?). I had mentioned the remote risk of paralysis with an epidural and the husband of the perfect couple asked me something along the lines of "if the incidence of paralysis is 1 in 10000 and say a million are done every year in NA, does that mean there are 100 women paralyzed every year?". The guy with the mullet asked me if it was true that we sometimes put tubes in the baby's lungs because he sure didn't want to watch that happen. The teacher then felt she had to mention that she had in fact invited me and it had not been my idea to present and we adjourned for our nutrition break.

At the nutrition break my wife and I stood by ourselves while everybody looked at me with hatred from as far away in the room as they could get. I had introduced a breach between the alternate universe of the prenatal class and the universe we unfortunately live in.

That may have been the last prenatal class I had to go to. My wife's water broke the next week, she went into labour. I arranged for an epidural and we eventually had a forceps delivery. The baby in question is now 18, in university and, I would like to add, has a 4.0 average.

A year or so later my wife got pregnant. By that time I was a staff anaesthesiologist. I delayed bringing up the topic for a while but finally asked her if she wanted to go to prenatal classes again.

And she said no.

Why do we blame politicians for giving us what we asked for.

We are in the midst of a provincial election and healthcare which is a provincial responsibility has become a major issue.

Well over 10 years ago our government in an attempt to control the "spiralling" costs of healthcare imposed arbitray cutbacks of 25% on the healthcare sector. This meant beds closed, nurses laid off and cuts in the fees of those groups of physicians who were less well polically connected. This was accompanied by a cut in medical school positions across the country because we all knew that health care costs were proportional to the number of doctors and cuts in nursing schools (not that anybody really wanted to go into nursing knowing that there were no jobs). There was even a move at the CofE to replace most of the nurses with "smart-aids" who could be hired off the street, trained on the job and only require a high school education, if that. The CofE actually paid a consultant 7 figures to come up with that one.

Now the chickens have come home to roost.

The large cohort of older doctors that existed in the early 90s are retired, the newer graduates do not want to work the crazy hours the older docs did, a whole generation of nurses has been lost and the population is larger older and as, if not more, demanding.

Now our current Premier was handed this mess by his predecessor. Many people are saying that his government deserves to be brought down for their lack of forsight. Now I am not to going vote for him but I suspect that his party will get back in on the backs of the evangelicals, who make up 30% of the population, and the rural voters who distrust the city folk.

But essentially what the Conservatives give us except what we wanted?

In the 1993 election Ralph Klein, the conservative premier campaigned on "Brutal" cuts in public spending. His Liberal opponent campaigned on "Savage" cuts to public spending. Ralph Klein won narrowly we got "Brutal" instead of "Savage" cuts to public spending.

During his first full term in office Ralph Klein eviscerated the healthcare system among other areas the goverment was involved with. He was re-elected twice with increased majorities each time. He actually got more than 50% of the vote and I believe once got close to 60% of the vote. These numbers are unheard of in Canadian politics (our current Prime Minister got 37%). So in other words a whole lot of people agreed with what he was doing.

During that time I would see patients pre-operatively and they would complain about how long they had waited and how many times they had been cancelled. I used to say, "You shouldn't have voted for Klein". They would then go into a tirade about how they had always voted Liberal. In most cases they came from rural areas where the Conservative candidate usually gets about 70% of the vote. So you can conclude that only Liberal voters get sick.

Now in his last election Ralph Klein actually lost seats. The main reason he lost seats was because an even more right wing party took votes away from him. In other words there were people who wanted even more brutal or savage cuts (maybe medieval cuts).

Now I hope like hell that the Cons lose the election preferably in a Richard Hatfield-like fashion but people should remember that the Cons only gave people what they wanted.