Role Models

One of the questions I ask prospective residents when I interview them is, "who are your non-medical role models?" Just to get them talking, nothing at all to do with their potential as an anaesthesiologist.

I have recently asked myself, who were my role models?

I can think of a few, my parents, a few teachers and....

My old scout master.

Scouting was a huge part of my childhood and adolescence. I was in Cubs, Scouts and Venturers from the time I was 8 until I graduated from high school. The most formative years were however from 11-14 when I was in scouts.

Our scout master liked to be called by his first name. In the 1960s having an adult who let non-adults call him anything other than Mr. was unusual. His first name was Dave and I will call him that for the rest of this blog.

Dave was born in England and had moved to Canada with his parents as a young adult. He was still not married and lived with his parents. Dave ran the scout troop. Other adults and few older teenagers helped out from time to time but it was Dave's show.

We had our meetings every Thursday evening. These were incredibly well organized evenings chock full of several interesting activities all planned by Dave. Every Saturday morning he came to the scout hall for those of us who wanted to pass tests or earn badges. Every couple of months we had a hike on a Saturday or Sunday. We also had weekend camps about three times a year and in the summer we had a 9 day camp in the mountains.

Dave was a real hiking and camping enthusiast. He was big into light weight camping where you packed in all your gear. The idea was to be as comfortable as possible while still carrying in almost everything. We often had over 30 people per camp so every camp was a major military operation supervised by Dave.

Periodically we had "wide games" which were huge operations based on variations of "capture the flag" or a treasure hunt. These were also elaborately organized and some of them must have taken days to set up.

Dave's effect on the troop was such that our troop had over 40 scouts at a time when Scout troops all over the area were folding.

Dave also helped out perioidically with the Venturers, was involved in the local hiking club and was involved as a Big Brother.

Dave was soft spoken, when not in scout uniform (which he wore with short pants and knee socks) he was always well dressed. There was a story that he broke up with a rare girlfriend because she wore jeans to his parents house. He drove a Rover. He was an enthusiastic landscape photographer and had an SLR camera which weren't very common in the 1960s (and was the first thing I purchased when I finally had money). If you had a problem, he was always willing to talk things out and could be very philosophical.

As I said he was a huge influence on my life. I wish I could say that this was the start of a life-long commitment to camping, hiking and mountaineering; sadly while I enjoy looking at mountains, I don't really like climbing and I enjoy my bed too much.

I went up to Venturers at 15 (I stayed an extra year in Scouts, I liked it so much). About a year later, Dave who worked for the government was transferred to another town. He got right into the local Scouting movement and the next summer his new troop had a joint summer camp with his old troop.

I last saw him when I was 20. I was coming home for a break from my summer work and was on the ferry home. He was also visiting his parents. We sat together and talked for the whole trip. It was like two old friends talking together. I have never seen him since.

I went to medical school, kicked around in various places in Canada and I was living in Eastern Canada when I heard that he had been charged and pleaded guilty to sexually abusing one of his scouts. He spent some time in prison. I was out of the province so I missed any media coverage and I have lost contact with just about all of my scouting buddies. I have talked it over with my older brothers who preceded my in Scouts. One says there is no way he was guilty; the other says, of course he was guilty. My father believes he pleaded guilty in order to prevent the child who accused him from having to testify and be cross-examined. I have a hard time believing anybody would willingly go to jail as pedophile.

Now looking back, maybe it should have been obvious. We have a quiet soft spoken man who lives with his parents, is heavily involved in Scouting and Big Brothers, doesn't have a girlfriend, and likes to take pictures. Perfect profile of a pedophile? This was the 1960s; there were lots of men like him and they were largely respected in the community. When I was writing this blog, I googled him and all I could find a was an award for distinguished service to scouting in 1969.

All I can say is he never touched me (maybe I was lucky) and I never ever heard anything untoward about him from any of my friends although being diddled by your scoutmaster isn't something teenagers brag about. One time in Venturers we were hiking up in the mountains and we came across him camping with his Little Brother. In 1973 we didn't think that was unusual.

About 5 years ago our scout troop had a reunion. It was on a weekend and while I wasn't working, it would have meant flying there so I didn't go. I just thought it would be a whole lot of people I had nothing in common with anymore trying to make conversation. The whole uneasiness about Dave played a role. One of my brothers attended and said it was a lot of fun and that Dave was there.

About a month later, I got a letter from Dave. He said that he was now retired and living with his wife(!) on one of the Gulf Islands. I meant to write hime back to tell him what a good role model he had been for me but the letter disappeared into a black hole on my desk and I never did write the letter. I lost his address too.

I attended a workshop on hypnosis last spring and we talked about forgiveness. The speaker said it is possible to forgive somebody without condoning what they did. I cannot condone anybody who uses a position of authority to hurt somebody, especially a child. I can forgive him however for what he did to that child and for the doubts he has raised about my whole Scouting experience.

I Was a Medical Criminal Part III

Just a note that after venting on my blog, I did what someone described as the closest thing an Englishman will do to rebelling, I wrote a letter. I wrote a letter to the chief of staff for the region.

A few days later, his executive assistant phoned me and wasn't really helpful BUT a month later I actually got a signed letter from the Chief of Staff himself, appologizing for the whole incident.

So I am no longer an medical records criminal.

Am I a Luddite

Technology was supposed to make life simpler for us. In some ways it has. I would never want to go back to submitting my billing on paper; paying my dues on-line is easier and of course if I wasn't writing this stupid blog, I would actually feel obliged to do some work.

A couple of new technological hurdles are making me wonder however.

At a recent staff meeting, a member raised a concern about our new anaesthetic machines. Apparently in our case room we have the newest generation Drager machine. It is in the case room because for some reason Ob-Gyn "paid" for it. The problem with this machine is that if it is turned off, it takes literally 30 minutes for the software to boot up.

So don't turn it off you say.

Unfortunately for infection control reasons all operating rooms are terminally cleaned once a day which means moving all the equipment into the hall. This means unplugging the anaesthetic machine which unlike my laptop, doesn't have a back-up battery. (My laptop also plays music and surfs the internet unlike my anaesthetic machine.) Therefore unless somebody turns it back on, when you show up at 0300 for the prolapsed cord, the machine will not work. Now there is a process where you can "hot boot", the machine however the manufacturer warns that after 10 hot boots, the software will be damaged.

Our department has exclusively Drager machines in the main OR which also have a boot up process after being unplugged but it is possible be randomly pushing at buttons to bypass this.

Does all this software make anaesthesia safer. No.

Gather round children while Grandpa tells you about anaesthesia in the olden days.

We had machines that were essentially copper pipes with valves. They were driven by the compressed gas from the central supply or from the O2 cylinder. And they were safe. If the compressed O2 failed, the N20 which was held open by the gas pressure also shut off, and a loud whistle sounded. There was a mechanical link which automatically reduced the N2O when the O2 flow was reduced and in addition it was impossible (on most machines) to completely turn the O2 off. You didn't need to plug them in to an electrical socket which meant you could if you were stupid enough or where forced to, move them with the patient to another room using the O2 cylinders. Oh yeah the O2 also drove the ventillator.

Now the greatest advance in patient safety in my lifetime was the invention and adoption of pulse oximetry. Not newer more elaborate machines that need to the plugged in to the wall socket and have finicky software. Not to mention those annoying alarms. Talk about crying wolf.

A year or so ago I went down to Ecuador. While there I went over to another hospital to do a case. In the room we were given I encountered an old Ohio machine. Some people would have fled the room in horror but I had actually used a similar machine, I was able to inspect it quickly, ascertain that it was in working order (and I am not very good with machines) and I knew that with a pulse oximeter, I would be able to give a very safe anaesthetic. Later that evening I recounted my adventure to a slightly younger anaesthetist who recoiled in horror at using a machine that in his words should be in a museum.

The second issue was the new Smart Pumps our hospital now has.

These are computerized infusion pumps designed to prevent medication errors. During the early fall nurses had to attend inservices lasting several hours to learn to use these machines. As anaesthesiologists we alone amongst physicians have to adjust these pumps we tried to get an inservice. I spent a great deal of time with the company explaining why we needed a full inservice (instead of just looking at them between cases which was what they offered). As it turned out I had to miss the inservice so I still in the dark about how to adjust these pumps. Again do these expensive and time consuming pumps improve patient safety.

No.

Will still there be medication errors?

Yes.

This reminds me that my wife who recently recertified as a nurse actually had to learn how to calculate flow rates by counting drips. She asked my about this. I told her it showed just how long it had been since most academic nurses had actually been in a hospital because nobody does that anymore.

Transferring your stress

I attended a meeting last weekend. It was a pain meeting but one of the talks was on "stress management in the pain provider". It was a talk I looked forward to when I looked at the program first thing in the morning. The presenter is a physician who works for the medical association's physician help program and in addition writes articles that I have always enjoyed reading.

I was disappointed.

Right from the start, this doctor (who is younger than me) stated that his practice was currently restricted to weekend locum coverage and surgical assists. During the talk he casually mentioned his interesting travels, his winter "retreat" in the New Mexico desert and the fact that he never works on his wife's birthday.

So.......

The solution to stress for all of us is:

Work part-time but also only chose work that you really like when you feel like it.
Take lots of vacation.

Now I work more or less full-time both as an anaesthesiologist and also as a chronic pain doctor. This is by choice, anaesthesia is one of the specialties where part-time work is a viable option. I also take between 6-10 weeks of vacation depending on how things shake out. Sometimes my work is stressful, I can't say for sure whether it is more or less stressful than 25 years ago.

But imagine now if all the doctors decided they were going to work part-time and only do work that suited them. Aside from needing 2-3 times more doctors, what about the patients and work that doesn't suit anybody. Who sees these patients.

Our expert in stress is not alone however. There are becoming more and more doctors who are working part-time, refusing to take patients with chronic diseases, refusing to work evenings or weekends (in fairness our expert apparently only works weekends which are a pain but you do get paid more). This is causing more stress on those of us who are old school and believed that you take the good cases with the bad and that real doctors still work evenings and weekends.

Anyway I hope our expert in stress is able to put his honorarium to good use and maybe he can do fewer weekends or maybe take off his neighbour's birthdays. I hope he is thankful to the taxpayers who subsidized his education so that he can work part-time,to mention the individual who didn't get into medical school so that he could, and the physicians in his community who have picked up his slack.

And I am no further along in managing my stress

I Was a Medical Records Criminal II

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

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

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

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

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

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

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

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

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

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

I was a Medical Records Criminal I

People go into various specialties for various reasons. Now while almost all the potential residents who I interviewed said they had chosen anaesthesia because of their interest in physiology and pharmacology, I am sure that people my generation who largely came out of general practice what rank one factor at or near the top of their reasons:

NOT HAVING TO DEAL WITH MEDICAL RECORDS!

Sadly I didn't learn and went into chronic pain management which of course means dealing with a lot of medical records and also dictating notes.

As you can guess from a previous post, I like lots of information when I see a patient (most times I would just settle for any information). When I was in general practice or working in the ER one of the things that drove me crazy was having to deal with a recently discharged patient presenting and having no discharge summary (or for that matter any records) to help figure out the usually distressed often comatose patients. Patients have certain expectations. When they present to the hospital where they were recently hospitalized they expect that the doctor will actually be able to read their chart. When of course you don't have the discharge summary and have to rely on the nurse notes and illegible progress notes, it is not their beloved doctor who is the stupid one, it is you.

With that in mind, I have always dictated my notes soon after seeing the patient. This is a practical matter. If you ask me in the evening about a patient I saw in the afternoon, I usually can't remember. And that is before I start drinking!

I work in a regionalized health authority. This has meant working in multiple hospitals. Almost 10 years ago our health authority assimilated a small suburban hospital. To make a long story short, for some reason I ended up doing fluoroscopically guided blocks in their OR. They were easy to deal with unlike the CofE where I then worked. Now when you do something in the OR you become the surgeon which means dictating an operative record. It also means signing that record. Now our health authority has always sent our dictations with "DICTATED BUT NOT READ" where the signature should be. This is a little embarassing when you make a big mistake in your dictation or when you dictate while in a bad mood and say something you really shouldn't have said. Despite that fact that your words are now widely disseminated, you are required to physically sign the report. Most medical records departments have made this easy for me by sending my dictations to me in an envelope to sign so that I don't have to go down to medical records. Anyway nowadays we have electronic signature where you read your masterpiece online, press a button and VOILA it is signed.

For some reason my otherwise flexible and helpful suburban hospital has always required me to actually go to their medical records department and sign their charts. They are for some reason which nobody can explain not part of the E-signature program even though their charts are available on-line just like every other hospital. I normally sign the charts on the days when I am out at the hospital doing procedures, which as it happens hasn't been very frequent lately so I had accumulated about 25 unsigned charts. These dictations as I mentioned had by that time been available on-line and had been mailed to the referring doctors including me.

So about a month ago, I got a phone call from the medical director's office saying that I had been kicked off staff at my little suburban hospital for not signing my charts in a timely fashion. But, because we are all part of the same happy family, this meant that I was also off staff at every hospital in the region which meant that my pain clinics were going to be cancelled. The only escape would be for me to sign my charts by midnight which meant driving 30 minutes each way to the hospital. I resigned myself to spending 60 minutes driving that evening in order to keep my priveleges. As I left the hospital though I got a phone call from the medical director's office stating that there had been a mistake by a new secretary and because I hadn't received a registered letter that I couldn't be kicked off staff but could I complete my charts by the end of the month.

Anyway about a week later, I drove out and spent about 10 minutes signing the charts.

More on the Edmonton Folk Festival

About a year ago I published a blog on the EFF. Someone actually read it and made the comment below which I thought I should publish it in my blog.

"For a bunch of hippies, they act in a remarkably selfish, grasping, up-tight, whinging, unfriendly way.

I've been to many hundreds of outdoor and indoor music events but never one like this. I'm not sure if it's common to be as unfriendly and rude to someone who is merely trying to enjoy the same event as you, and who isn't intruding on your space.

We showed up for the evening acts, having purchased an evening-only ticket (full day tickets aren't available, only tickets for the whole weekend).

On arrival we found that this bunch of grasping people had all laid out 10 to 15 foot wide tarps all over the whole seating area, some only had two or three people or chairs on them. This meant that latecomers or evening-only people like ourselves, were meant to stand way at the back miles from the stage.

I suppose the other option was to go to one of the prescribed 'dancing' areas- who has ever heard of a dancing area at a live show? If you want to dance... dance.

We squeezed ourselves into a gap between two tarps somewhere in the middle of the crowd, and had to put up with dirty looks and comments- heaven forbid we sit too close to someone elses staked out seating area.

I will never go back to this festival or any similar one, I've never seen such an unfriendly un-communal attitude from people at an event like this.

At most rock shows you can sit, stand, and dance wherever the hell you like. If you want to stand and the people around you are dancing, move further back. If you want to sit, find somewhere where you can see. "
Now when we go to an event we want to have as good a view of the stage as possible. There are a number of ways a deciding who gets the best seat. Some venues charge more for better seats, some have lotteries, some are first come first serve. The EFF has a combination of a lottery and first come first serve. Except of course the lottery is fixed.

The second thing we want is in outdoor festivals we want to actually be able to reserve a spot where we can leave our stuff and where we can go for pee without losing our place. (At the Bruce Springsteen concern where I had standing room on the floor, I had to stand in one place for 90 minutes to hang on to my somewhat prime spot; this would not have been justified for a lesser artist) That is why the EFF and other festival allow people to plant tarps or chairs etc. The EFF actually restricts tarp size to 8 feet by 10 feet although I didn't see any volunteers out with a tape measure.

Now over the last few years as my correspondent noted, I have been seeing a lot of
big tarps with very few people on them. For example on Saturday night my wife and I sat next to two large tarps. One was never occupied at any time during the day. The other had two people on it for about two hours during the evening concern after which they left. I don't go in the tarp run anymore and since only my wife and I go, I am usually able to get a decent seat just by looking for small spaces that the tarp runners didn't stake out. I do tend to come early in the day however. On occasion where I have come later and squeezed in most people have been polite so on behalf of the whole EFF community I appologize for the assholes my correspondent sat between.

Now in defence of the EFF, they do ask people to do their best to allow people to the people with evening tickets to squeeze in before every evening concert. They also ask people not to dance except in the dance area at the side of the stage. If you want to dance, your view of the band shouldn't matter. Quite frankly if you allow people to get up and dance, it means that everybody stands up and you have to stand up for the whole concert. They have been much less rigid about this in past years.

Anyway despite everything the EFF is the highlight of my summer and I hope my correspondent comes next year. He should buy a weekend pass though, because it is the workshops that are worth the money.