The Needle and the Damage Done

Most people locally consider me to be a needle guy. I have aquired a reputation as somebody who gives everybody who comes into the clinic some type of needle. I think that is unfair. I do a lot of nerve blocks of various types for patients most of whom come in for repeat injections. Most of these people seem to be happy with their treatment (the other ones post on RateMDs). I also do a lot of medication management including narcotics and methadone. Most of these patients once stabilized I see infrequently and some have been transferred back to their GP.

I still however feel guilty everytime I stick a needle in somebody. I attend all these pain meetings and I know I should be sending them to non-existent multidisciplinary programs. In fact I actually now work in a so-called multidisciplinary pain clinic and almost 100% of the internal referrals are to stick a needle in somebody.

I also do acupuncture. I took a long course which involved some training in traditional Chinese medicine but like most people I just stick the needle where it hurts. Quite frankly I consider acupuncture to be an equivalent treatment to trigger points, however when I do acupuncture I am an open minded practitioner of complementary medicine whereas when I do trigger point injections, I am a money grubbing needle guy.

On the weekend past, I attended a course on fluoroscopically guided injections. I have never done a lot of these mainly due to the inability to access fluoro which the radiologists guard jealously here as if they paid for those expensive machines out of their own pocket. I will be getting more access in the future so I decided I better actually get some training.

At the meeting we learned all kinds of different blocks. What disturbed me was the whole time, I was thinking, "How many of these can I do in a day and how much can I bill for them". (When you go to American Meetings, there is usually about half a day devoted to billing, further some interventional textbooks have chapters on billing). More disturbing was that everybody else taking the course was thinking the same thing.

Now I have been treating chronic pain for over 15 years (longer if you include my 3 years of general practice) and I still haven't figured out what causes back or neck pain, nor what is the best way to treat it. My more recent training has not enlightened me on this.

I can only hope the way I treat back and neck pain will be governed by what I think is best for the patient, and not how much I can get paid or how many fluoro slots I have to fill.

Privacy

Yesterday and today I am on call which means covering the case room. Now a universal feature of caserooms since I was a medical student in the last millenium was "The Board".

"The Board" was a then a blackboard, now a whiteboard with every labouring patient's last name, status including dilatation, station, NPO status, epidual and whether they were being induced.

In the interest of privacy now, the patient's last names have been replaced with only the first 3 letters of their name. This caused a problem for me right away when I arrived in the morning. The first three letters of the only patient with an epidural made up a name that is not common. So in I went saying "high Ms. , I'm Dr. BH" and then went out to the desk to find her chart. After I couldn't find her chart I asked, "who has Ms <3 letter word name>'s chart" and after getting blank looks, "who has room 5's chart". One of the nurses handed me a chart with a six letter last name and when I said no I want <3 letter word>'s chart; they looked at my like I was stupid and told me that they were only putting the first 3 letters of the patient's name on "The Board". I never asked how they proposed to deal with patients whose last name only had 2 or 3 letters something increasingly common now (or two patients with similar three letters).

Most medical and surgical wards used to have boards with everybody's names on and what bed they were in. Alternatively the name was on the door so you could at last walk around looking for the patient you had to see. Unfortunately boards have gone by the way and in several hospitals now there are no names on the door either. This forces you to look for the chart (which if it is in the rack is filed by room number) or ask the ward clerk or a nurse.

At the same time we are very concerned about proper identification of patients to prevent the wrong treatment being done to them. Now I think everybody has had the experience of going in to see the wrong patient and realising half way through talking to them that you really should be talking to someone else. When one wants to estabilish a therapeutic relationship with a patient, the least auspicious way to meet them for the first time, has to be to enter the room and go straight for their arm band to see who they are. Yet with names not on the door, or the patients bed, in patients who are deaf, demented or half asleep, that is now the only way of ensuring you are actually talking to the right patient.

At the same time most units allow patient and their visitors to use the phones at the desk. Of course what are usually sprawled all over the desk for everybody to see. Charts of course, so the patient or their visitors can read whatever is in their visual range. (Maybe that's why nobody writes progress notes anymore).

Very few names are unique anyway. If I see a name on a door that is the same as someone I know, I just assume it is someone with the same name. Occasionally much to my surprise it is someone I know. I once ran into the contractor who built my house while on Pain Rounds. The name didn't ring a bell and people surprisingly don't look the same with an ng tube. I was talking to him when he interrupted me and said, "I built your house". I didn't tell him it was a good thing for him that I didn't give him his anaesthetic.

A number of years ago we had a victim of a gang related assault in our trauma unit. The staff were somewhat concerned that someone was going to come in to finish him off so as this was still when there were names on the door, instead of putting his name on the door, they put his hospital number.

Great...

I'm a gang member assigned to finish him off and I learn what ward he is on. So I sneak around the ward and there are 19 rooms with a name on, and one with a number on. I wonder which room I should chose.

I grew up in (what was by today's standards) a small house with three brothers (and two parents). My mother always said, "If you don't have anything to hide, you don't need privacy".

So please put my name on the door.

Information I really shouldn't be posting on my blog (but that is too juicy not to)

When I worked at the CoE there was a surgeon whose ego was the inverse of his height. Now he was not a modest guy so you can guess he was quite short. He compensated for this by wearing ridiculous cowboy boots with heel lifts and I know everybody (even some short people) made jokes about his height mostly behind his back. Now I am reasonably tall but I have come to realise that outside the NBA, NFL and CFL this is largely a world suited for short people so I couldn't really see what the "big deal" was.

Despite this surgeon's lack of physical attributes he had quite a successful life. (The operative word is had as I will explain below).

He became a successful surgeon, helped pioneer a few new procedures, was well respected in the community (if not by his colleagues), and was a successful political fund raiser for the ruling party. He was incredibly wealthy, had a huge house, and drove what he described as (after one of the nurses' daughters rear-ended him) the most expensive car in the province.

All was not rosy in his life. About 10 years ago he ran away from a long marriage to a woman who had put him through medical school, bore his children, etc to marry a sales rep. This didn't seem to affect his standing in the community, in fact even before he remarried he was in the social pages accompanied by his new wife-to-be. At his second wedding, his adult children from the first wedding picketed the ceremony and he had them arrested.

Now about 3 years ago I heard that he was going to take the whole summer off to have surgery. He was at that time of the age where people get prostate or colon cancer or require joint replacements so I didn't think much of it. That was around the time I left the CofE.

We were talking one day about him in the OR at my new place and somebody said that the reason he had taken the summer off was to have his legs lengthened in New York. The procedure had not been done. Just the fact that he had even considered such a procedure caused much amusement, although this would not have been out of character for him.

A couple a weeks ago someone came out and told everybody that he had actually gone ahead with the leg lengthening in the US. This is by the way called the Ilazarov procedure and is usually used for leg length discrepancy or occasionally for children of short stature. While this procedure is done on adults (particularily in adults who can afford it), there is generally a cut off at age 50 simply because you stop healing well, forming bone and rehabing well at that age. Being 50 myself, that is a little depressing. Apparently in the US, being able to afford a procedure can take years off your life (in both senses unfortunatley).

To make a long story short, he did terribly. His recovery was complicated by pulmonary emboli requiring an ICU stay, he has an infection, non-union and 60 year old nerves not liking being stretched, has developed causalgia which to my (and his?)relief is being treated by one of my colleagues and not by me.

Personally I blame myself. I should have never made all those short jokes.

But seriously....after the snickering about the shear audaciousness of a mature successful man undergoing mutilating surgery for a slight increase in his height, I really had to feel genuinely sorry for him. Not sorry for the predictable complications but sorry that he felt that his life was not perfect enough that he had to improve himself.

Another issue that came up is the issue of confidentiality. Yesterday in the surgery lounge this was the topic of conversation all day with people hearing the story and getting on the phone to someone they knew with, "did you hear about...".

Technically as a hospital patient, his condition should only have been known to his caregivers. While perhaps because of his actions over the years he has done more than most people to make his personal life less private, in his time of personal crisis, even if this came from a totally irrational decision on his part, he is entitled to privacy.

Still we all love gossip and this is a juicy story.

Stethoscopes

In the election we had last month, a local emergency physician ran and won for the ruling Conservative party. Now I have no issue with a physician running for a party that has eviscerated health care in the province; nor do I have any issue with the fact that physicians who go into politics are innevitably an embarassment to the profession; nor even with the fact that if a physician gets into a position of power they are never a friend to the profession.

What I have an issue that his campaign photo was a head and shoulder shot of him wearing an OR green top with his stethoscope hung over the back of his neck. This large photo is, as far as I know, still adorning a bus shelter I drive past too often. It is saying look at me, I am a doctor, I am cool, I save lives.

The old image of a doctor is of course a stethoscope dangling from the neck like a neck tie (which doctors innevitably wore in those days). I often wonder how often they snagged their stethoscope on something.
When I first started going to into hospitals as a medical student, nurses slung their stethoscopes around their necks which most doctors carried their stethoscopes in the pocket of their coats. (Surgeons never carried a stethoscope why would they?)

Gradually people started slinging their stethoscope over the back of their necks. Even I did. We thought it looked cool. Except you still snagged it on things plus the rubber irritated your neck (some people had cloth sleeves made for that purpose). In fact after a while with everybody doing it, it was no longer cool so I stopped as did most people and my stethoscope went back into my pocket. Somewhere along the way, I lost it or it was stolen. I now borrow stethscopes when I need one and I rely on the ETCO2 for tube placement (I still make medical students and residents listen!)

The image of a doctor used to be, a clean white coat, shirt, tie and nice pants. (These doctors were by the way always male). There seems lately to be a trend where doctors are photographed wearing OR greens and with a stethoscope or further props. The stethscope is after all only one of many tools a physician uses. Why didn't he have his picture taken using an otoscope, or a rectal glove?

Anyway why should it matter whether he is a doctor as to whether he will be a good member of the legislature. And certainly there are better ways to advertise your professional qualifications than to have your photo taken wearing your stethoscope.

Whiplash

I spend half my time doing chronic pain management. This has meant spending more time associating with lawyers than anyone should have to. Most of this is related to motor vehicle accidents. I don't really mind doing it; for my patients I feel that I can help them by making their medico-legal reports as timely, balanced and accurate as possible. I have a smaller number of medico-legal referrals. These are very interesting to do and the best thing is that I get to make lots of recommendations knowing there is absolutely no way I will ever have to follow-up on them.

Automobile insurance premiums have increased dramatically this millenium. This for the most part due to the insurance industry's poor investment track record and also because they can. I don't really want to discuss this much in this post. A couple of years ago in order to reduce costs, the Alberta government legislated a $4000 cap on "pain and suffering" which was supposed to reduce premiums. A judge recently ruled this cap unconstitutional so we are waiting to see what our newly re-elected government does.

A few observations on whiplash:

1. Nobody actually knows what causes it.
There have been all kinds of studies and some people say it is due to damage to cervical facets, some people say it is due to muscle damage and of course some people say it doesn't exist.

People don't die immediately from whiplash; autopsy findings on people who die in MVAs are not reliable because the forces are entirely different. I did see a case report on an autopsy of someone who committed suicide shortly after an MVA but that is a single case.

There are no really good models to reproduce whiplash. Animals are no good, there are no animals who are the same size as humans and walk upright. I have seen studies with human volunteers but these are carefully controlled studies and of course there are limits on what you can do to a volunteer. There are studies done with cadavers but we all know that even a freshly dead person feels very different from a live person.

Imaging is not very useful. There is never any bony damage, soft tissues show up poorly on even the most sophisticated types of imaging. Imaging of muscle will show structural but not functional abnormalities.

Bogduk "proved" by doing diagnostic blocks that it is damage to the facets that causes whiplash, however only 30% of his subjects passed his rigorous blinded blocks which makes you wonder what caused the pain in the other 70% of his patients with neck pain.

Now you would think that with such a large public health problem, especially one that has such an impact on the bottom line of the insurance industry that we would like to figure out why people get this condition. Unfortunately the only way to do this is to do a huge cohort study where you can look at as many people as possible with whiplash and follow them thru their course, doing a standardized workup and standardized treatment. This unfortunately requires the cooperation and involvement of the insurance industry which immediately taints the whole process plus most people's lawyers will advise them not to participate. This is exactly what happened to a colleague of mine when she tried to do such a study.

2. Getting rear-ended is not physiological.

Human beings are slow moving. This is probably what forced us to become intelligent in the first place. A sprinter who runs 100m in 10 seconds is running at 36 km per hour. This is of course the fastest speed a highly trained human can run under perfect conditions and only for a short period of time. Most of us move slower. This means that the collisions that we have experienced and survived over our evolution have been a signficantly lower speed than even the slowest car. Actually probably the fastest collision speed humans experienced would have been falling from a height which beyond a certain height is bone breaking if not fatal.

While sitting in your car, you are somewhat protected from the moron who runs into you, your body is still going to have to absorb a lot of the impact. In a sense you are being exposed to an impact that humans have only had to absorb and walk away from over the last 100 years.

In North America we typically don't investigate rear end collisions unless there is significant damage to the car. In Australia they apparently investigate all collisions and a researcher by looking at the crash records found that on the average, the speed of rear-enders with pain was 15 kph higher than rear-ender without pain.

Now add to that, the fact that there is a good chance that the vehicle that hits you is likely to be a SUV, which is much heavier than the cars we drove in the 60s, plus because they are higher the impact point is going to be higher.

3. What about seat belts?
No doubt seat belts prevent deaths in head on collisions and there is absolutely no way I would ever advocate not wearing one. Having said that, there is a theory that seat belts in particularly shoulder belts may actually increase the incidence of whiplash (maybe we should release them when stopped at traffic lights.)

4. Headrests
Most people don't have their headrest at the right height, further taller people cannot get their headrest high enough. But the only way apparently a headrest can help you is if you are leaning back against it at the point of impact. Who does that at intersections. You are looking to the side at traffic, waiting for the light to change, fixing your make-up etc.

5. The legal/insurance complex
Everybody is insured or supposed to be. In a rear end collision the rear-ender not the rear-endee is always in the wrong correct? Apparently not.

Say for example I am rear ended. I just need some analgesics and I have to take some time off work to attend physio. So after everything is said and done, I ask my rear-ender's insurance company to reimburse me for my trouble and lost income. To do this, I have to hire a lawyer who will deal with the insurance company's lawyer and eventually years later if I don't just say shag the whole thing, I might get some money.

The above is a simple claim. Suppose I can't work and/or require more treatment.

This is where the lawyers start to really earn the big bucks. Joining them shamefully are certain physicians of which I occasionally am one. All the treating physicians will be asked to submit a report for which they will be reimbursed handsomely. My medical association says I can charge $400 per hour for such reports, some people charge more.

Then we bring in the IME. This stands for Independant Medical Exam. This is of course not independent, and barely medical. Most IMEs are done by elderly physicians as a way of financing a comfortable retirement. A few younger physicians have gotten into the game in a big way. Now if your retirement or your medical practice depended on the insurance industry (who pay for most of these IMEs) whose side do you think you are going to take, especially when you have a diagnosis as nebulous as whiplash (remember as above we don't even know what causes it). Many patients get several IMEs which judging by the volume of paper generated are costing well over $10K eacg. The Plaintiff's lawyers will also order at least one IME to rebut the other IMEs. I do about one of these a year which with the amount of paper I have to review means that I frequently end up charging more than $10K which the lawyers pay quite happily.

Another thing that really amazes me is the slowness of the process. Occasionally I get behind and let things slide but I rarely get any angry phone calls or letters asking why the hell haven't I finished yet.

Meanwhile, the poor patient is often not working and trying to scrape through why he awaits his eventual settlement. It is not unusual for these things to drag out 7 years.

These cases rarely go to trial. They are almost always eventually settled and the patient gets something. The lawyers in negotiating the settlement will always make sure their costs are covered.

Now as I mentioned, because the driver who caused the accident is always at fault, he will have been paying higher premiums for several years by that time.

Another factor of the endless exams that the patient must go through is describing the accident over and over again. Just about every IME I read has a detailed description of the accident. One thing we have learned about post-traumatic stress syndrome over the years is that the worst thing to do is to describe the event over and over again. Talking is okay in a therapeutic setting with a therapist who knows what he is doing, but the IME is not a therapeutic setting.

6. Most of the these are not simple taps from behind at an intersection.While we talk about "whiplash" most of the patients I deal with in the pain clinic where in much more complex collisions. If they were stuck from behind, they were usually struck at higher speeds and by a vehicle much heavier than those. In fact most of the more severely injured patients I see were T-boned or in head on collisions. Therefore there is almost always an element of PTSD. PTSD is by the way not a sign of weakness but is a consequence of the accident.

7. There is no green cure

That is one of the most pervasive myths in the medico-legal field. Patients do not get better after their settlement. Firstly most of them don't get a settlement. They either give up or they lose due to the "IME's". The rare patient who gets a settlement doesn't get better. Trust me, I have followed some patients from shortly after their accident until years after their settlement.

8. These people are not faking their symptoms to get some money

Many of these people are not working. In only a small percentage of cases is anybody getting any benefits until they get their settlement. Some have lost their houses. Quite a few of these people are on welfare. When they are getting benefits, it is quite often long term disability from work rather than anything related to their accident. Quite a few are on CPP disability. Now anybody who is going to put their life on hold for the 7 years it takes to get a settlement is suffering from some severe psychopathology (of course that's what people say about them anyway).

I have over the years heard about whiplash scams. The operative word is heard just like I've heard about alligators in the sewers. I'm sure it does happen. In fact one of my wife's cousins disconnected her brake lights so that she would get rear-ended. I have heard about incidents where a car was rear-ended and suddenly 5 "passengers" jumped into the car. I have heard of places in such cars being sold. But that is just that, I have only heard; I have never seen any verification. This is, by the way, insurance fraud which our judicial system takes a very dim view of.

Another resource the insurance industry uses is the private detective videotape. I had been following a patient with a whiplash associated injury for about 2 years when I got a copy of an IME which referred to a videotape which proved that she has faking her symptoms. My first impulse was anger, that this patient had pulled the wool over my eyes. In fact what happened that one of the private dicks would let the air out of her car tires and they would then videotape her trying to change her tires. This happened so often she finally joined the automobile association. On the eve of her trial, I actually got to see the videotape. It basically showed her struggling to change her tire with one hand for about half and hour,after which she got out an air compressor, inflated her tire and drove to a garage. Nothing in the video conflicted what she had said about her symptoms. Yet I met another doctor who had been involved in her treatment who, based on what she had been told about the video, now thought she had been faking all along. The other tactic is the edited videotape. One patient I saw was under surveilance for 8 hours out of which 20 minutes of tape were produced. Hardly a representation of his ability to function.

Now I did see a videotape of a patient where after viewing the tape, I told her lawyer that based on what I saw, I would be uncomfortable testifying on her behalf. The video was by the way taken in a very sneaky fashion and it was apparent that they may have tampered with her car as well.

And by the way what do we tell patients in pain management programs? We tell them to live as normal a life as possible, to do everything they possibly can. We do this knowing that somebody might be watching them. (WCB are also great videotapers in this province as well).

9. The adversarial system feeds this whole thing.

For various reasons, auto insurance is mandatory. You could look at this as medicare for the car. Suppose in the 1960s the government instead of bringing in medicare had just made health insurance mandatory. Say if you are having crushing chest pain and your doctor says you have angina. Instead of having your CABG right away, you have to go to a whole bunch of IMEs by your insurer, you get videotaped out walking; "proving" you don't have angina. 7 years later your estate might actually get the funding for your CABG. Kind of what Michael Moore described in Sicko.

Why not replace this system with a no fault system. The current rabble of IME hired guns would be replaced with true Independent Medical Examiners, certified by the Provincial Licensing Bodies instead of the weekend courses they currently take.

That would for the most part cut out the lawyers and about 2/3 of the IMEs currently done. The private dicks could go back to staking out cheap motel rooms or whatever they do.

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.

More Shame

A couple of weeks ago a patient came into get her medication refilled. This is a patient who had a stroke a couple of years ago and while she more or less recovered, she was left with a thalamic stroke and post-stroke pain. This is among the worst pain patients can suffer with and usually responds poorly to anything.

She was already on OxyContin when I saw her. After trialing a few things, I trialed her on methadone. When I trial patients on methadone, I always ask the family doc to agree to get a methadone licence to follow the patient indefinitely. I do this so that my clinic doesn't fill up with methadone patients and I can actually see new patients. Her family doctor agreed.

On this visit, the patient brought a letter from her old family doctor which basically said that he was changing the way he was practising and that she would have to find a new doctor. She was actually able to find a new doctor, who surprise, surprise, told her he would look after her other medical issues but would not prescribe OxyContin (which means he will never prescribe methadone I suspect).

Like the title of this blog says, I use to be disgusted, now I try to be amused so I took this in stride as the new face of medicine and I suppose I have married another patient.

Today in the newspaper, presumable in response to complaints there was an article on this doctor with a testimonial from the head of the college of family physicians praising him for modifying his practice and discharging 500 patients at "random".

Like I say, I used to be disgusted.