Merry Christmas or Whatever You Want to Call It

I am sheathing my sarcasm for the holidays.

Hope to return with a vengeance in 2014.

Controlled substances

I attended a meeting last week.  There were about 20 people at the meeting including the administrator of the hospital, the chief of staff and just about every mid-level administrator.  Scheduling this meeting no doubt took at great deal of time because they wanted everybody to be able to attend.  This even cancelled it once because one person couldn't be there.

There are a lot of important issues facing our hospital right now.  We are in an old poorly constructed building where elevators freeze and pipes burst regularly.  Our emergency is plugged up with patients waiting to be admitted because there are no beds available.  Our operating room has been told it has to cut $800,000 from its budget (without cancelling any cases apparently).  All good reasons for a large meeting of the minds.  None of these were what the meeting was about however.

The purpose of the meeting was to discuss the hospital's Controlled Substances Policy.

Anaesthesiologists are alone among physicians in directly administering narcotics to patients as opposed to giving an order and having a nurse administer narcotic.  We give short acting narcotics like fentanyl and remifentanyl for induction and maintenance of anaesthesia and we give longer acting agents like morphine or hydromorphone for analgesia.  We give drugs by bolus, we give them by infusion, intravenously, epidurally or intraspinally.  We also use controlled drugs like ketamine.  Some other drugs we use are not (yet) controlled but are prone to abuse like propofol and midazolam.

When a nurse wants to give a controlled drug, she has to get the drug from a locked cabinet (usually after tracking down the nurse who has the keys), count what is in the locked cabinet usually with another nurse, write the drug in the narcotic book, give the drug to the patient and if the full dose isn't given, the wastage must be verified again witnessed by another nurse.  This is while the patient who was told not to ask for analgesia until it was REALLY necessary is writhing in pain, pushing the call button.

At our hospital we do things a little differently in the OR.  At the beginning of the day, based on what I think I will need, I log into our Pyxis machine and sign out whatever I think I will need for the day.  I generally leave them on top of my anaesthetic cart.  I do write down what I give to the patient on the anaesthetic record but when I want to discard any drug, say for example I only give 5 mg or a 10 mg morphine amp, I just throw it in the sharps container without any witness.  Quite often I may split an ampoule between 2 or more patients.  Remifentanyl for example I dilute to 100 mcg per cc and use 50-100 mcg on induction using of course a clean syringe for each patient.  I like remifentanyl infusions, to save time I often mix up a whole bunch at one time and then divide it amongst patients.  I could just use a separate 1 mg remifentanyl ampoule for the 100 mcg dose on each patient at $40 per ampoule but somewhere in my pedigree there was a Scotsman who reminds me that this is wasteful.   In addition the drug shortages we have recently experienced makes it all the more attractive not to waste drugs.

At various times in various hospitals I have had to fill out narcotic sheets where we write the patient's name (or use a sticker) and write  down what we gave them.  Most of us gave this up when we found out that nobody actually read these sheets.  Besides we already document the dose on our anaesthetic record.

At the end of the day I could sign the drugs I didn't use back into the Pyxis but why bother?  I just lock them in my locker and use them the next day.  This is by the way legal in Canada for physicians.

Propofol and midazolam are supplied on my anesthetic cart at the beginning of each day and restocked as necessary.  Because we spotted somebody (not an anesthesiologist) flitting around the ORs one evening probably sniffing gas, we now secure our anaesthetic carts with a plastic tie, just in case somebody is helping themselves to the odd vial of propofol or midazolam.  (We decided not to lock them because we know the key will inevitably be lost.)

At some hospitals a narcotic kit is dispensed containing a sampling of various narcotics that can be used during the day.  This entire kit can be signed back in so that pharmacy can keep track of what has been used.  Stocking these kits is very labour intensive for pharmacy who hate them which is why we don't use them at our hospital.

Apparently a couple of times a week, there is a discrepancy between the amount of drugs dispensed, the amount returned and what is left in the Pyxis, which is a headache for nursing and pharmacy but up until now not for me.  I have no idea of what type of skulduggery is necessary to resolve these discrepancies and really don't intend to try to find out.

All this is causing dyspepsia for the Stasi lady from our quality department who is behind these meetings.

The result of the meeting was that we all lost an hour of our lives and came no closer to the solution.  Most people gently pointed out that doing anything like what the Stasi-lady wanted was clearly impractical and most likely impossible.  Pharmacy pointed out that they would need more resources if the letter of the law was to be followed.  I pointed out the impracticality and futility of charting wastage of narcotics in a busy OR.  We will meet again sometime in the future when 20 or so people can find a mutually acceptable spot in their timetable.  I expect to be able to string this out until I retire.

Aside from it being the law, what is the big fuss?

Drug diversion certainly is a problem although probably less of a problem than some people would make it out to be.  Drug use is a problem in a small minority of anaesthesiologists although we are apparently more likely to abuse injectable narcotics than our colleagues who don't have the same access. (I interview prospective residents and I have not yet met somebody who said that he wanted to go into anaesthesia because of the easy access to narcotics.) Abuse of injectable narcotics has three issues.  There is first the illegality of it, second the effect on the health of the abuser and most importantly the effect on patients of being cared for by an impaired anaesthesiologist.

When anesthesiologists are caught, as has been pointed out over and over again, it is not because of tight narcotic controls and documentation; it is because of behavioural changes. Narcotic addiction is a horrible problem but alcohol abuse and addiction is probably a worse problem among physicians.  The biggest cause of impairment in physicians is fatigue, something I have never heard administration expressing any concerns about.

The bottom line is, you do have have to trust people a little but at the time realize that they can and will screw up and be vigilant against this.

Lost among this discussion is the patient.  We give narcotics for a reason.  We give morphine for pain because despite all its downsides we haven't yet found a better way to deal with pain.  We use the fentanyl family because they blunt the response to intubation and are cardio-stable.  Just how important these properties are is questionable but most of us like them.  Remifentanyl with its short half life is a great drug for induction and maintenance of anaesthesia.  Any time you make narcotics harder to use, a significant proportion of docs and nurses will just say, "to hell with it" and not use them which means that the patient will suffer.

As I said to somebody as we left the meeting, "the hospital has way worse problems than this.""

Commercials on "free" Wifi WTF?

Between drive-throughs and people ordering fancy slushies while I wait in line, coffee shops have really pissed me off.  I should really start making my own coffee.

I went to Starbucks for a coffee and pastry yesterday.  Unlike most coffee shops which have "free" newspapers lying around, Starbucks doesn't, which left me to check the internet on my I phone while I drank my Grande dark roast.  I am not one of the those people I see a lot lately at Starbucks, usually sitting by themselves at a four person table with their laptop, obviously there for the long haul, but I do like to use their free internet while drinking my overpriced coffee and second rate pastry.

Not so free any more.  I found that their free internet is now sponsored by Travel Alberta and before I could access my internet I had to watch a 30 second commercial on my phone.

Aside from having to watch the commercial (which I have already seen on TV), why would my government spent $$$ preparing this video and then paying Starbucks $$$ to force me to watch it, all with the goal of getting me to visit Alberta, when I already live here?

Unfortunately I suspect we are going to be getting a lot more commercials with our free internet.  

If You Were Wondering Where I was on November 22, 1963.

It is really hard to believe it was 50 years ago.

I came home from school for lunch.  Our school was only a couple of blocks away from our house and so I walked home by myself at lunch and after school.  My mother who, like almost every mother on the block, didn't work always made lunch for my brothers and me.  I was in Grade I.  When I got home my mother told me that President Kennedy had been killed.  Although I was six and Canadian I sort of knew who he was.  We ate lunch and I went back to school.

Our teacher told us again that President Kennedy had been killed.  At about 2 o clock the principal came on the PA and told us that under the circumstances we should all go home early.  I don't remember being that happy about getting out early.

Later I remember watching the funeral.

Since then there have been many what ifs and conspiracy theories.

If you want a good what if, National Lampoon devoted a whole issue to it in 1977.

I suspect that JFK hadn't been assassinated, he probably would have won a second term during which time any honeymoon he may have had with the American voter might have ended and unfortunately we would had probably still ended up with Nixon, Reagan and the Bushes in the future.

Likewise I have read or heard all the conspiracy theories.   It seems I can't turn on History or Discovery channel lately without seeing another one.  Maybe I am fatigued by everything but I have come to believe that you had a serious nutcase Oswald, who just got off a lucky shot and maybe Jack Ruby was just really pissed off that the President died.  Maybe that is what they want me to believe.

Shouldn't have happened.  

K.I.S.S.

KISS as we all know stands for Keep It Simple Stupid (or Keep It Simple Sweetheart).  I first heard this in medical school from a surgeon who started his lecture by writing this on the blackboard.

Surgery is easy.

I am not saying anybody can do it but if you get into medical school, graduate, do a surgery residency and do enough of the basic procedures you should be able to function.  Most procedures have already been done before by somebody else, anatomy is relatively constant and tools have been designed to make things easier.  Not only that, you work with scrub nurses who can anticipate what you are going to do and anaesthesiologists who look after your patient for you and provide muscle relaxation.  Surgery should be really boring which is why historically surgeons have tried to make it more difficult by working when they are tired and doing unnecessary surgeries.

And then the laparoscope was born.

Laparoscopy was originally used by gynaecologists mostly for tubal ligations but also for diagnostic laparoscopies.  The anatomy of the uterus, tubes and ovaries is pretty simple and even in the old days, looking thru an eyepiece they could safely and effectively do their work.

It took general surgeons a little bit longer to get on the laparoscopic  bandwagon with the laparoscopic cholecystectomy.  Those of us who worked in the era of the introduction of the laparoscopic cholecystectomy remember this as a dark time in the anaesthesiology world.  Surgeons would go away for a weekend course where they operated on a pig or cadaver and would return raring to get onto the future of surgery.  They would show up in the OR usually with a rep from the company who sold the expensive equipment and a three hour ordeal of fiddling around would begin innevitably followed by the open cholecystectomy.  This would be repeated multiple times over the next year or so and usually multiple general surgeons were learning to do these so you can imagine the chaos in the OR, especially when they realized that it was affecting their elective time and started doing them afterhours.  There were also the common duct injuries, about 20% in the early stages requiring a long tedious repair by another surgeon.

Today laparoscopic cholie is the standard, most surgeons can run one off in about an hour as a day case and nobody would think of subjecting a patient to a subcostal incision.  There are a few problems with the laparoscopic cholie however.  Firstly the cholecystectomy rate has gone up since the introduction of the lap cholie. There are two reasons for this.  Firstly patients faced with the prospect of a painful subcostal incision may decide to just live with the occasional bout of gut grief.  A significant number of surgeries are for assymptomatic gall stones.  Secondly instead of a procedure which keeps a patient in hospital for several days, surgeons now have a procedure which is either a day surgery or at the worst an overnight stay.  And of course the old open cholies which kept patients in hospital beds for days, deterred surgeons from doing them as "emergencies" lest their elective cases be affected by "emergency" cases occupying their beds.  Not a problem with the laparoscopic cholie.  It is now a rare evening or weekend on call that I don't do at least one of these.  Therefore we are doing more cholies and more of them after hours.  And don't forget that even in the most skilled of hands this is a procedure associated with the occasional complication.  What about post-op pain?  It seems that laparoscopic cholie is still pretty painful maybe not as much as open but instead of getting morphine in hospital lap cholie patients go home with Tylenol with Codeine.

Having mastered albeit slowly the cholecystectomy surgeons moved on to other easy procedures that they could now make more difficult.

We have  laparoscopic appendectomy.  These can now be done in about an hour by a competent general surgeon longer if they let the second year resident do it.  Are they any better than the open appy.  Remember most good general surgeons could do these thru a keyhole incision which is about as long as the total length of the four little incisions necessary to do it laparoscopically.  And the length of stay and complication rate is the same as open which costs only one third as much.  At least laparoscopic patients can wear a bikini afterwards if you forget the ugly scar in the umbilicus.   Appendicitis as I tell surgeons is a medical disease now.

Laparoscopic hernia repair is now fashionable as well.  The problem with this type of surgery is that many of the patients who get hernia repairs are older patients with coexisting disease.  Patients you would like to do under spinal or local (or tell them to wear a truss for the rest of their lives).  Instead you end up fighting inflation pressures in the COPDer you are doing under general instead of spinal.  Plus you have to use mesh.  Being in practice many years, I have absorbed many hours of surgical teaching and remember the admonitions of staff surgeons in the 80s and 90s to avoid using mesh whenever possible due to risk of infection.  Either way hernia repair is a day procedure whether done locally or laparoscopically.  Laparoscopic hernia repair costs several times as much.

In the pain clinic I see a lot of post hernia pain.  While one would think this would be reduced with laparoscopic surgery, I still see a significant amount of post hernia pain in patients who had their hernia fixed laparoscopically.

Don't get me started on laparoscopic bowel resection.  The feeling is only now
returning to my bum after the epic-ally long procedure I did last week.  The purpose of laparoscopic surgery is surely to spare the patient an abdominal incision.  Except that the bowel has to come out somewhere which requires a 10 cm long incision to remove the bowel. So you get a surgery which takes twice as much time, done semi-blind and you still end up with a fairly substantial incision.  Incisional pain can be handled of course with an epidural which our surgeons don't like us doing when they get out the laparoscope.

Urologists have gotten into the act with laparoscopic nephrectomies and adrenalectomies.  (Technically as these are retro-peritoneal structures these are not laparoscopies).  We thankfully don't do them at our hospital so my only knowledge is from hearing of the horrendous complications like the urologist who got into the inferior cava doing a laparoscopic adrenalectomy.  Urologists have also gotten into robotic surgery with great gusto despite data suggesting that the complication rate is the same as the open procedure which is cheaper and takes less time.  Plus in order to do the robotic prostatectomy urologists want the patient in extreme head down position which has lead to significant post-op confusion and who knows what long term CNS changes.

Gynaecologists who of course pioneered laparoscopic surgeon have moved on from tubals and lysis of adhesions.  I have recently done two laparoscopies for bleeding ectopics who came to the OR shocky.  My first response when they got out the laparoscopic equipment was, "surely you can't be serious?"  but I am such a wimp.  Bleeding, especially arterial bleeding, looks 10X as bad blown up on the TV screen.  We also have the laparoscopic assisted hysterectomy which is really just a glorified vaginal hysterectomy.  Vaginal hysterectomy which was historically done blind had an incredibly low complication rate.  The last laparoscopic assisted hyst I did came back a few days later because her bowel had been perforated.  And this is just to avoid a Pfanensteele? incision.  I am waiting for my first laparoscopic Caesarian Section and don't think somebody isn't thinking about this.

I could rant on about all the other "minimal access" surgeries being done in other surgical specialties.

I am not against progress, if I had my gall bladder out, I would want it out laparoscopically.  Not so much my appendix and definitely not a hernia repair (I would have this under local).  The thing is, doing something just because it is neat, doesn't justify the procedure and sometimes there is a reason why things have been done the way they were done for many years.

If I collapse at work, here is a list of doctors that I don't want working on me.

Sadly all of us have such a list in our heads.

At the recent ASA meeting, I attended 2 separate ethics sessions which dealt with the same question.  If you know the surgeon is incompetent and the patient asks you, do you tell them?  The ethical answer is yes, however you could see how this would play out in the workplace should you actually do this.

A while ago I got a phone call from an exasperated colleague complaining about one of our surgeons.  This surgeon more or less restricted his practice to certain area but when on call takes on all comers.  My colleague pointed out that this surgeon had taken way longer than other surgeons to do a case with the result that that OR was now backed up with emergencies.  I had gotten the same impression so a day or so later I ran into the Chief of Surgery in the lounge and raised the question.  I obviously wasn't the first person to do so.  "His infection rate is the same as everybody else and his length of stay is the same too," spat out the Chief.  I later talked to the Chief of Staff, also a surgeon, and got the same answer.  Hmmm I thought if both of them know this surgeon's average length of stay and infection rate, maybe they had to look into it for some reason.

We had a now departed cardiac surgeon at the Centre of Excellence who was to say the least not very good.  Bad to the extent that several cardiac anaesthesiologists actually gave up doing cardiac anaesthesia rather than work with him ever again.  That's right cardiac anaesthesiologists actually gave up lucrative work because they didn't want to work with a surgeon.  (Some of them later rejoined on the condition that they not have to work with this surgeon).  One female anaesthesiologist said she felt like a murdress every time she worked with this surgeon.  One day a bunch of them were talking in our lounge about how bad this surgeon was, when I interjected, "Do you think you may be liable for working with him when you think he is incompetent?".  "That's an interesting question," replied the department chairman who had made a rare appearance to sit with the little people.  This is unlike this group of anaesthesiologists at another centre who had the cojones to refuse to work with a clearly incompetent cardiac surgeon and saved countless lives. 
The surgeon at the CofE continued to work on for a couple more years after this and is  now working somewhere in the US interestingly enough as an anaesthesiologist, as I found out on Google, which is surprising given his poor opinion of anaesthesiologists when he worked in Canada.

There are two components to surgery.  One is technical skill and one is judgement.  A surgeon may have perfect technical skills but very poor judgement and inappropriate surgery well performed can be as bad as appropriate surgery badly performed.

Incompetent surgeons come can be divided into groups.

Some surgeons are just plain incompetent.

Other surgeons learn early on that they cannot handle difficult cases and restrict their practice to a small menu of cases that they know they can do.  That is assuming there are any cases that they are able to do.   This works out especially if they work with someone who can occasionally bail them out.

The most dangerous surgeon is the surgeon who doesn't know he is incompetent.  Some of these are idiots who just blissfully ignore their bad results.  Quite a few of them a sociopaths who don't care about their bad results.  I suspect a large number of these surgeons actually know they are incompetent but have invested too much time and training and are working away waiting to get found out.  There is a subgroup who do some types of surgery quite competently but will attempt more difficult surgery with terrible results.  Quite often these individuals claim to be subspecialists in the very area they lack competence in.

A lot of us will actually tolerate an incompetent surgeon if he is pleasant to work with, works reasonably fast, doesn't do a lot of cases after hours and his cases don't come back to the OR too often.  The incompetent surgeon who is a complete asshole may get caught out sooner or conversely concerns about his work may be downplayed as "you are just complaining about him because you don't like him."  Or of course if he is a complete sociopath people including anaesthesiologists may be afraid to complain.

OKAY SO WHAT ABOUT INCOMPETENT ANAESTHESIOLOGISTS.

Yes they exist.  Some are globally incompetent, some may just have trouble with certain aspects of care like epidurals for example. When I first started out there were still a large number of anaesthesiologists with little or no formal training who had been grand-fathered in and were still working even in large centres.

Surgeons  like most bad anaesthesiologists because they rarely do regional blocks, art lines or central lines, they cut corners and never cancel cases except for the bad anaesthesiologist who has enough insight into his skills and only will do ASA 1 cases.  Further bad anaesthesiologists usually don't mind working after hours and will stay late.  Some surgeons know that the anaesthesiologist isn't really that good and just try to avoid him for their sicker patients.  Bad anaesthesiologists are either really nice guys so the nurses and the surgeons put up with the badness or they are real assholes and everybody is afraid to confront them.

Years ago there was an older anaesthesiologist whose skills had slipped which culminated in a surgeon finally refusing to work with him while on call.  This was a shock to everybody.  This individual did continue to work on for a few more years but wasn't allowed to take call, an imperfect compromise.  At our hospital we had to get rid of two anaesthesiologists about 5 years ago.  They had been there for years after training in another country.   It had been suspected for years that they less than competent but the surgeons loved them because they worked fast, never canceled cases for medical reasons and loved to work after hours.  Our department chief was forced to do a prolonged chart review of all their cases before he found enough evidence to hang them which he did and they retired.  All in all less than pleasant.
 

Good thing that Hypocratic Oath.

There is a Doonsbury cartoon about 30 years ago, based on Henry Kissinger's CABG surgery.  In the cartoon the surgeon is talking with Kissinger a day or so post-op.  He notes that during the surgery he was holding the heart of somebody who had condemned thousands to death.  He said, "Then I thought of my Hypocratic Oath and sewed you up".  Kissinger replies, "Good oath that".

A couple of months ago while working I went out to see a patient for a procedure.  His name seemed familiar so I thought that he might have been a patient I had seen before or even somebody I might have have met socially.  I asked him that and he said he didn't remember meeting me.

It was only after I put him to sleep that I realized the man who had placed his life in my hands was the insurance assessor I wrote about here.

I told the staff in the room about him and what he had put me through but at the end of the case I took him to the recovery room and went on with my business (I even gave him something for nausea) and presumably a day or so later he went on with his business and I hope to god we never meet one another again.