I am a consultant. This means my job is to help other doctors with their patients. I am a little baffled by why other doctors perceive me as smarter than them in a least a very small way.
As a part-time chronic pain doctor, all my patients come to me by a referral.
Some chronic pain patients are very simple. I can take a history and examine them, come to a diagnosis and suggest or initiate treatment.
Most chronic pain patients are more complex. They have had a lot of procedures, medical trials and investigations. To properly assess this, I need to know what they have tried, for how long and in what dose. For example 100mg of gabapentin is a lot different than 3600 mg of gabapentin.
About a year ago, I saw a patient who had moved to town from another community. He had been getting injections with Botox from another doctor and wanted this continued as it seemed to have been working. He was however very vague about where or how much possibly due to a head injury or PTSD. Unfortunately the consult did not have much more than his name and healthcare number. A lot of times I can figure out what to do without my information. This patient wasn't one of those times.
Anyway I took the initiative to call the other doctor up and either discuss the patient or get the file.
This doctor as it turned out has the receptionist we all hate. She answered the phone, "Dr. X's office can you hold" and before I could reply, I was on hold. I put my phone on speaker and killed time for 10 minutes before I hung up and dialed again. The same thing happened. The third time I was ready and was able to interrupt her. I told her who I was, that I would like to talk to her doctor, that I knew she was busy and that I could give him a number to call at his convenience (GPs can actually bill the healthcare system for such phone calls). She just said, "well we're busy" and put me on hold again.
I therefore gave up trying to talk to this doctor or for that matter his receptionist. I dictated a letter and I asked for a copy of his records on this patient. I had told the patient that when I got the letter I would call him in for treatment.
Months passed. Every once in a while, usually while somebody else had me on hold, I would think about the case.
I came in this morning and found a handwritten note from the patient asking why several months later I had still not treated him. Apparently he had showed up the evening before in very bad humour and hassled the receptionist about why I hadn't seen him.
Any in a few weeks I will try to muddle my way thru a very unhappy patient.
Now in the 15 or so years that I have been seeing patients, this lack of documentation has been a major problem for me. When I worked at of CofE we actually designed a form where we asked for more information and would not book the patient until we had received the information. The thing is, most doctors offices have fax machines now; it is a simple matter to fax the rel event documents. It would take a secretary less than a minute. I know this because I frequently fax stuff myself (I thought it was neat when I learned to use a fax 10 years ago).
Almost worse than the family doctors are specialists who refuse to send you a copy of their consults when the family doctor either hasn't or can't send you a copy. Next to them are the family doctors who copy their entire chart so I have to sift thru the pap smear results to find the MRI report. Hospitals now seem to put their records on micro-film after about two years and actually ask you to come down and look for the records on the little micro-film viewer.
The monthly newsletter our friendly college puts out actually has a letters section. About a year ago, a family doctor actually wrote a letter to complain about the bad specialists who were demanding he send them information so that they could actually do a proper assessment on the patients he sent them. Now I would have thought that this would merit a public written tongue lashing from the registrar but it was in fact just published without comment.
(I should note that I did after I posted this (after I sent off an angry letter to the FP copied to the college) that I got an appologetic letter from the FP along with the info requested.)
Thursday, July 31, 2008
Monday, July 14, 2008
Bugs and Drugs
I have spent the last few days doing largely orthopaedic "emergencies". While this is good mindless work, it has entailed administering multiple doses of Ancef.
When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.
While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.
Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"
Anyway you get the impression that I find giving Ancef to be distasteful.
Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.
The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.
Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.
Which brings me to a case I did on the weekend amongst all the ortho cases.
This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.
Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.
All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.
Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.
Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.
On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.
No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)
Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.
When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.
While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.
Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"
Anyway you get the impression that I find giving Ancef to be distasteful.
Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.
The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.
Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.
Which brings me to a case I did on the weekend amongst all the ortho cases.
This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.
Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.
All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.
Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.
Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.
On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.
No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)
Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.
Wednesday, July 2, 2008
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 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".
Only so much niceness to go around
I was explaining to somebody in the non-medical field about how much abuse we received as students, interns and residents from more senior doctors. (I didn't tell her how much abuse I still get as a senior doctor). She said something like, "But I thought all doctors had to be nice!". So I explained the facts of life to her.
Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.
I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".
Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.
Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.
Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.
I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".
Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.
Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.
Sunday, June 1, 2008
Outed?
Webill contacted me about one of my posts.
She warned me that she had been able to come up with my identity in about 5 minutes from reading the post.
While I do post anonymously, I have never tried to hide things about who I am. I suspect anybody who knew me would be able to figure out who I am in about 5 minutes just by reading the blog and figuring out my nationality, province of residence, city, profession, subspecialty, political views, musical tastes, favourite hockey team etc.
I am not certain whether it is better to post anonymously and be outed or to post using my name or otherwise identifying myself.
Anyway I thank her for pointing this out; I am glad anybody actually reads my blog. I don't like to knit but my mother does (further clues to who I am).
She warned me that she had been able to come up with my identity in about 5 minutes from reading the post.
While I do post anonymously, I have never tried to hide things about who I am. I suspect anybody who knew me would be able to figure out who I am in about 5 minutes just by reading the blog and figuring out my nationality, province of residence, city, profession, subspecialty, political views, musical tastes, favourite hockey team etc.
I am not certain whether it is better to post anonymously and be outed or to post using my name or otherwise identifying myself.
Anyway I thank her for pointing this out; I am glad anybody actually reads my blog. I don't like to knit but my mother does (further clues to who I am).
Wednesday, May 7, 2008
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.
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.
Sunday, May 4, 2008
Hating the Habs
For me, after last night I can again enjoy the NHL Playoffs.
I am one of the millions of people across Canada who hate the Montreal Canadiens. I have nothing against Montreal, I love visiting there and Montreal Smoked Meat is one of the foods I live for. I have nothing against French people (Montreal actually has very few French players anymore).
Every year I live in dread of another Stanley Cup for Montreal (which has happened 12 times in my life).
My obsession is deep seated.
I grew up in a Habs household. Except when I was six, my older brother told me I wasn't allowed to hope for Montreal because that would be copying him. In a Habs household, hoping for the Leafs was out so I hoped for Chicago first because they had (and still have) the coolest logo in the NHL. Later when the Bruins started making the playoffs I cheered for the Bruins (and still cheer for them, except when they play Edmonton).
Off course being a Bruins fan, I have a lot to hate Montreal for. I like to think my hatred is justified on a wider basis as a hockey fan.
There are a number of legitimate beefs.
1. The arrogance.
After expansion, the Habs became a lot like Central Red Army. Most of the good players were concentrated on the Habs supported by some very good role players. It is well known how this came to be.
When the NHL expanded in 1967, the play was that every team would only be able to protect 6 players. This would have allowed expansion teams to draft second and third line players, in other words genuine NHLers. At the last minute Sam Pollock the Habs' GM pursuaded the other GMs that more players should be protected. So teams were able to protect 10 players (in addition to protecting another player for each player drafted). This meant the expansion teams were left with a few third line players, some fourth liners (at that time most teams only used three lines) and minor leagers.
Faced with a team with limitted talent, expansion GMs were now faced with trying to build a competitive team which would attract fans in cities like Oakland and St. Louis with limited hockey experience. Fortunately Sam Pollock was able to come to their aid. Sammie was happy to trade them over the hill players and minor leaguers for draft choices in the new amateur draft (Montreal also got to pick the first two players from Quebec as well). Montreal also was happy to trade players to the expansion teams who happily traded them back when Montreal needed them again. Usually a draft choice changed hands as well. Montreal even traded players to enable to teams to finish ahead of teams whose first round pick they had. On one occasion they traded a draft choice to prevent Boston from drafting a goalie (John Davidson).
The result was that Montreal in addition to winning the Stanley Cup almost every year got 4 first round draft choices. Some of these like Guy Lafleur, Steve Shutt adn Bob Gainey blossomed into stars. Worse were the first rounders who couldn't crack the Habs' line-up who ended up in the press box or the minors. This is at the time when there were at least 4 abysmally bad teams who could have used an NHL grade player. This is not to mention, the career damage to players who could have stepped into the NHL but instead spent 2+ years in the minors.
2. Habs fans.
These people are unfortunately the least knowledgeable and most obnoxious fans. I went to a Habs -Oilers game with my cousin who is a nice guy except when you let him dress up in a Habs jersey and take him to a hockey game. He complained bitterly over every call even the offsides.
Of course most people develop their hockey allegience as children when they first watch hockey. Of course for anybody who started watching hockey in the 60s or 70s, the Habs won just about every year. Now how much of a challenge is it to hope for a team that wins most of its games as well as the Stanley Cup.
The only bright side is that Leafs fans are almost as bad.
3. Refereeing
At the start of every Coach's Corner we get to see a very old clip of a much younger Don Cherry standing on the bench facing the crowd with his arms outstretched. The significance of that clip has been forgotten. Not by my however. Cherry was interviewed before Game 5 of the 1979 series with Montreal, tied 2-2 and predicted that the Bruins could not get a fairly officiated game in Montreal. This clip was taken after Boston's 4th minor penalty in the first period. Needless to say Montreal won the game.
We all remember Montreal players skating through centre ice, no player within 10 feet of him when suddenly his legs would go up in the air, the crowd would roar and the referee's arm would go up. Steve Shutt was a master of this.
Pat Burns after he left the Habs for the Leafs, commented after a Leaf's game, that the refereeing wasn't what he was accustomed to in Montreal.
4. Danny Gallivan / Dick Irvin
It was bad enough in the 70s having to watch Montreal just about every Saturday night (of course the option was Toronto or Vancouver) without having to put up with this dynamic duo. Danny's broadcast was more of a group fellating of the the Canadiens organization than a objective broadcast. Add to that Dick's nasal colour commentary and you wished the mute button had been invented. Back when Vancouver would play Montreal in Montreal, most of us turned the volume on our TVs (a primitive mute button) off and put on the Vancouver radio broadcast. When the Oilers and Flames joined the league which meant you hardly ever got Montreal home games on Saturday night, most of us in Western Canada kissed our TVs in relief.
5. Scotty Bowman
Scotty Bowman is a better than average coach. I give him this.
His main genius however is selecting which team to coach rather than any particular knowledge of hockey.
His record:
St. Louis Blues. Finished first in division and played in Stanley Cup Final (record 0-12) in bizzarre set-up where all 6 expansion teams played in the same division.
Montreal Canadiens. 1971-2 Took over team that had just won Stanley Cup. Finished in 3rd place and eliminated in the first round. 1972-3 Won Stanley Cup next year only because Bruins were decimated by defection to WHA. 1973-4 without Ken Dryden finished second, lost in first round. 1974-5 with Ken Dryden lost in second round.
1975-9 with team that had the advantage of having 4 first round picks for the preceding 4-5 years won 4 straight Stanley Cups. (Harry Neale could have won at least 3 with that line-up). Even the Canadiens are so unimpressed with Bowman that they chose Irving Grundman over him to succeed Sam Pollock.
Moves to Buffalo as coach-GM. Takes team that was a guaranteed dynasty to a series of early playoff exits.
Pittsburg. Takes over Stanley Cup champions after Coach Bob Johnson dies and wins one and only one more Stanley Cup.
Detroit. Joins team as coach AFTER team had already been assembled taking advantage of the NHLs ridiculous free agency rules and with a payroll double some teams. Wins a few but surprisingly not that many Stanley Cups.
Bowman's chief talent aside from chosing which team to coach was his mastery of the referees. This included inviting referees to a video session showing the penalties they should have called against Boston in the previous game (imagine any profesional league in the world allowing this) and as coach of Buffalo getting the NHL to suspend Tiger Williams for alledged slashing Bowman even though nobody saw it and it was not shown on any video replays of the game. I also remember his whine after Buffalo tied the game on a powerplay goal (and won in OT) that that the referee had promised him he would not call any penalties in centre ice.
I am one of the millions of people across Canada who hate the Montreal Canadiens. I have nothing against Montreal, I love visiting there and Montreal Smoked Meat is one of the foods I live for. I have nothing against French people (Montreal actually has very few French players anymore).
Every year I live in dread of another Stanley Cup for Montreal (which has happened 12 times in my life).
My obsession is deep seated.
I grew up in a Habs household. Except when I was six, my older brother told me I wasn't allowed to hope for Montreal because that would be copying him. In a Habs household, hoping for the Leafs was out so I hoped for Chicago first because they had (and still have) the coolest logo in the NHL. Later when the Bruins started making the playoffs I cheered for the Bruins (and still cheer for them, except when they play Edmonton).
Off course being a Bruins fan, I have a lot to hate Montreal for. I like to think my hatred is justified on a wider basis as a hockey fan.
There are a number of legitimate beefs.
1. The arrogance.
After expansion, the Habs became a lot like Central Red Army. Most of the good players were concentrated on the Habs supported by some very good role players. It is well known how this came to be.
When the NHL expanded in 1967, the play was that every team would only be able to protect 6 players. This would have allowed expansion teams to draft second and third line players, in other words genuine NHLers. At the last minute Sam Pollock the Habs' GM pursuaded the other GMs that more players should be protected. So teams were able to protect 10 players (in addition to protecting another player for each player drafted). This meant the expansion teams were left with a few third line players, some fourth liners (at that time most teams only used three lines) and minor leagers.
Faced with a team with limitted talent, expansion GMs were now faced with trying to build a competitive team which would attract fans in cities like Oakland and St. Louis with limited hockey experience. Fortunately Sam Pollock was able to come to their aid. Sammie was happy to trade them over the hill players and minor leaguers for draft choices in the new amateur draft (Montreal also got to pick the first two players from Quebec as well). Montreal also was happy to trade players to the expansion teams who happily traded them back when Montreal needed them again. Usually a draft choice changed hands as well. Montreal even traded players to enable to teams to finish ahead of teams whose first round pick they had. On one occasion they traded a draft choice to prevent Boston from drafting a goalie (John Davidson).
The result was that Montreal in addition to winning the Stanley Cup almost every year got 4 first round draft choices. Some of these like Guy Lafleur, Steve Shutt adn Bob Gainey blossomed into stars. Worse were the first rounders who couldn't crack the Habs' line-up who ended up in the press box or the minors. This is at the time when there were at least 4 abysmally bad teams who could have used an NHL grade player. This is not to mention, the career damage to players who could have stepped into the NHL but instead spent 2+ years in the minors.
2. Habs fans.
These people are unfortunately the least knowledgeable and most obnoxious fans. I went to a Habs -Oilers game with my cousin who is a nice guy except when you let him dress up in a Habs jersey and take him to a hockey game. He complained bitterly over every call even the offsides.
Of course most people develop their hockey allegience as children when they first watch hockey. Of course for anybody who started watching hockey in the 60s or 70s, the Habs won just about every year. Now how much of a challenge is it to hope for a team that wins most of its games as well as the Stanley Cup.
The only bright side is that Leafs fans are almost as bad.
3. Refereeing
At the start of every Coach's Corner we get to see a very old clip of a much younger Don Cherry standing on the bench facing the crowd with his arms outstretched. The significance of that clip has been forgotten. Not by my however. Cherry was interviewed before Game 5 of the 1979 series with Montreal, tied 2-2 and predicted that the Bruins could not get a fairly officiated game in Montreal. This clip was taken after Boston's 4th minor penalty in the first period. Needless to say Montreal won the game.
We all remember Montreal players skating through centre ice, no player within 10 feet of him when suddenly his legs would go up in the air, the crowd would roar and the referee's arm would go up. Steve Shutt was a master of this.
Pat Burns after he left the Habs for the Leafs, commented after a Leaf's game, that the refereeing wasn't what he was accustomed to in Montreal.
4. Danny Gallivan / Dick Irvin
It was bad enough in the 70s having to watch Montreal just about every Saturday night (of course the option was Toronto or Vancouver) without having to put up with this dynamic duo. Danny's broadcast was more of a group fellating of the the Canadiens organization than a objective broadcast. Add to that Dick's nasal colour commentary and you wished the mute button had been invented. Back when Vancouver would play Montreal in Montreal, most of us turned the volume on our TVs (a primitive mute button) off and put on the Vancouver radio broadcast. When the Oilers and Flames joined the league which meant you hardly ever got Montreal home games on Saturday night, most of us in Western Canada kissed our TVs in relief.
5. Scotty Bowman
Scotty Bowman is a better than average coach. I give him this.
His main genius however is selecting which team to coach rather than any particular knowledge of hockey.
His record:
St. Louis Blues. Finished first in division and played in Stanley Cup Final (record 0-12) in bizzarre set-up where all 6 expansion teams played in the same division.
Montreal Canadiens. 1971-2 Took over team that had just won Stanley Cup. Finished in 3rd place and eliminated in the first round. 1972-3 Won Stanley Cup next year only because Bruins were decimated by defection to WHA. 1973-4 without Ken Dryden finished second, lost in first round. 1974-5 with Ken Dryden lost in second round.
1975-9 with team that had the advantage of having 4 first round picks for the preceding 4-5 years won 4 straight Stanley Cups. (Harry Neale could have won at least 3 with that line-up). Even the Canadiens are so unimpressed with Bowman that they chose Irving Grundman over him to succeed Sam Pollock.
Moves to Buffalo as coach-GM. Takes team that was a guaranteed dynasty to a series of early playoff exits.
Pittsburg. Takes over Stanley Cup champions after Coach Bob Johnson dies and wins one and only one more Stanley Cup.
Detroit. Joins team as coach AFTER team had already been assembled taking advantage of the NHLs ridiculous free agency rules and with a payroll double some teams. Wins a few but surprisingly not that many Stanley Cups.
Bowman's chief talent aside from chosing which team to coach was his mastery of the referees. This included inviting referees to a video session showing the penalties they should have called against Boston in the previous game (imagine any profesional league in the world allowing this) and as coach of Buffalo getting the NHL to suspend Tiger Williams for alledged slashing Bowman even though nobody saw it and it was not shown on any video replays of the game. I also remember his whine after Buffalo tied the game on a powerplay goal (and won in OT) that that the referee had promised him he would not call any penalties in centre ice.
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