It is always refreshing to find out, after 20 years or so that you have been doing things wrong.
I arrived at work early last week to find out that the nurses were no longer making up IVs until the anaesthesiologist told them exactly what solution they wanted. Further questioning revealed that one day all three anaesthesiologists in our downstairs 3 room OR had refused the normal saline offered to them and had asked for Ringer's Lactate instead. It turns out that all three had attended an evening CME event that I obviously hadn't attended at which the key message was: "SALINE KILLS PEOPLE!!!".
Now when I was a medical student, much of our very limited education in anaesthesia was provided by Dr. Kenneth Leighton, a true gentleman and excellent role model. I remember one of Dr. Leighton's aphorisms:
Doctors who use Ringer's Lactate don't know what's in it and doctors who know what's in it don't use it.
Having said that, I used RL for most of my residency and early on in as staff if only because Saline was hard to find in 1 litre bags. Early on in my career at the CofE when the province, the hospital and the department were trying to save money, someone observed that Saline cost $0.40 less than Ringers so the switch was made. We used to have great fun, trying to figure out how many bags of Saline instead of Ringers we would have to use to pay for one more liver transplant. The practice however spread to the entire region and now I believe that until recently every first bag of crystalloid in the region is saline.
One of the advantages of getting older is the opportunity to observe changes in medical practice some logical, some not not.
I remember as a student intern seeing my first case of N,V &D in paediatrics. Back then these cases were admitted for IV therapy. Later somebody figured out oral rehydration. Someone had already started the IV so one anxiety producing act was out of the way. I did however now have to write the IV orders. I had my Sick Kids blue book and was perplexedly perusing the section on fluids and electrolytes. I was trying to calculate free water, sodium and other maintenances and deficits when I felt my brain starting to explode so I punted and paged the resident. He say he would be right down and would show me how to write fluid orders. What he actually did was say: this child weights 24 kilos, is 10% dehydrated for a deficit of 2.4 litres which we will replace over 24 hours equalling 100 cc an hour plus maintenance of 40 ccs for the first 10 kg., 20 for the next and 4 for the last 4 equaling 64 ccs making a taking rate of 164 cc per hour. Now for the selection of fluid. Why don't we just use 2/3 1/3. This was done and this child is presumably now an adult somewhere.
Years later when I started as anaesthesia resident in paediatrics, 2/3 1/3 was still the maintenance fluid. Early on in my residency, I had to present an M+M on a severely dehydrated child who had come to the OR. A friend of mine who had started earlier in another program had told me that residents no matter how junior were supposed to have read up on their cases and that those who clearly hadn't were come down hard on. Not wishing a public humiliation I immersed myself in fluids and electrolytes. Everything I read told me that while children handled sodium well, they did not handle free water well which to me meant that normal saline NOT 2/3 1/3 should be the maintenance therapy in pediatrics.
2/3 1/3 however remained the standard therapy in pediatric surgery for years after. It took one very dedicated anaesthesiologist at the CofE years and hours of meetings to persuade surgeons, nurses and his fellow anaes. that saline was the way to go.
The "SALINE KILLS PEOPLE" lecture was of course sponsored by one of our local starch suppliers who would much rather we use their product at $40 for 500 cc instead of $1-2 for a litre. I actually like to use a balance of crystalloid and colloid. I used to be an enthusiastic user of albumin until we found out it too was KILLING PEOPLE. We have two starches available and about once a month or so one or the other company brings in lunch to tell us how bad the other product is. To be quite honest, one company's bag is easier to spike and I use that product.
The bottom line I seemed to have learned is that people are pretty resilient and that no matter what you pour into them within reason most of them will normalize it. There are of course exceptions and what I can get away with in 2 hours in the OR doesn't necessarily translate into 2 weeks in the ICU.
I learned another thing from Dr. Leighton in medical school. At that time VGH had 2 separate ORs, the older Heather Pavilion OR and the newer Centennial Pavilion OR. Dr. Leighton told us (and it was true) that in the Heather Pavilion OR, saline was provided while in the Centennial Pavilion OR D5W was provided. The reason? Historically Centennial Pavilion had done private patients, while Heather Pavilion had done public patients. D5W is more expensive than saline so must clearly be better. Just another example of how rich people don't necessarily get better care. Also explains why 90% of the pages I got as a student intern on surgery were for low urine output post-op although I only just figured that one out.
Monday, May 3, 2010
Sunday, April 18, 2010
Paying For Healthcare
In the 25+ years I have practised medicine, I have rarely had to charge a patient for anything. While I bill each patient individually, my bill goes either to the provincial health plan, Workers Compensation Board or in the case of the military to Blue Cross.
25 or so years ago Canada passed the Canada Health Act. One of the provisions of the CHA was portability. This means that while health care is a provincial responsibility, one provinces coverage has to be honoured in another province. In response to this, 9 of the 10 provinces agreed to reciprocal billing. What this means is that if I see a patient from Saskatchewan, rather than sending a bill to Saskatchewan, I send the bill to Alberta Health which pays me and bills Saskatchewan on my behalf. This is done electronically and painlessly.
As I mentioned one province decline this arrangement. Quebec. This would be fine if I could easily send a bill to Quebec and expect to be paid. Unfortunately Quebec usually does not pay for its residents when they travel out of province, when they do they pay pitifully low rates, even less than what they pay their own doctors. I once got a cheque from Quebec for $7 for an evening emergency visit. I thought about sending it back, reasoning they obviously needed the $7 more than I did. Alberta however is a long way away from Quebec so I usually don't have to deal with this.
A couple of weeks ago while covering the case room, I got a phone call from the nurses. They told me that a young lady from Quebec was in labour, might need an epidural in the future, and possible might need a Caesarian Section. They asked my to visit the lady and tell her what the fees might be. Now her Obstetrician who is Quebecoise, speaks French knows who to phone in Quebec and what forms need to be filled out and had already arranged for HER fees to be covered. Naturally she hadn't done this for me or any of my colleagues.
Anyway I visited her and through an interpreter (she actually didn't speak French or English) that I would not deny her any essential service based on her ability to pay, but however a labour epidural is not an essential service and if she wanted to have one, it would cost her $100 which is what I get paid for an Albertan and this would have to be paid in advance. I told her that there would be other fees that I would invoice her for and that if she required a C/S it would cost $300 which is roughly what I get for a C/S. I did tell her that she would eventually get reimbursed for at least part of it. Now I didn't feel comfortable doing this but my time is valuable. If the OB had approached me and asked me nicely, I might have taken my chances with billing Quebec but while she was pre-arranging her fees, she didn't both asking about anaesthesia fees.
What happened, was that my intervention stopped the poor lady's early labour, she was sent home and I am sure one my other colleagues had to have the same talk with her sometime later.
25 or so years ago Canada passed the Canada Health Act. One of the provisions of the CHA was portability. This means that while health care is a provincial responsibility, one provinces coverage has to be honoured in another province. In response to this, 9 of the 10 provinces agreed to reciprocal billing. What this means is that if I see a patient from Saskatchewan, rather than sending a bill to Saskatchewan, I send the bill to Alberta Health which pays me and bills Saskatchewan on my behalf. This is done electronically and painlessly.
As I mentioned one province decline this arrangement. Quebec. This would be fine if I could easily send a bill to Quebec and expect to be paid. Unfortunately Quebec usually does not pay for its residents when they travel out of province, when they do they pay pitifully low rates, even less than what they pay their own doctors. I once got a cheque from Quebec for $7 for an evening emergency visit. I thought about sending it back, reasoning they obviously needed the $7 more than I did. Alberta however is a long way away from Quebec so I usually don't have to deal with this.
A couple of weeks ago while covering the case room, I got a phone call from the nurses. They told me that a young lady from Quebec was in labour, might need an epidural in the future, and possible might need a Caesarian Section. They asked my to visit the lady and tell her what the fees might be. Now her Obstetrician who is Quebecoise, speaks French knows who to phone in Quebec and what forms need to be filled out and had already arranged for HER fees to be covered. Naturally she hadn't done this for me or any of my colleagues.
Anyway I visited her and through an interpreter (she actually didn't speak French or English) that I would not deny her any essential service based on her ability to pay, but however a labour epidural is not an essential service and if she wanted to have one, it would cost her $100 which is what I get paid for an Albertan and this would have to be paid in advance. I told her that there would be other fees that I would invoice her for and that if she required a C/S it would cost $300 which is roughly what I get for a C/S. I did tell her that she would eventually get reimbursed for at least part of it. Now I didn't feel comfortable doing this but my time is valuable. If the OB had approached me and asked me nicely, I might have taken my chances with billing Quebec but while she was pre-arranging her fees, she didn't both asking about anaesthesia fees.
What happened, was that my intervention stopped the poor lady's early labour, she was sent home and I am sure one my other colleagues had to have the same talk with her sometime later.
Friday, April 16, 2010
Playoff beards
I know everybody in the NHL reads my blog so...
Think of the great moments in Stanley Cup History:
Jean Belliveau hoisting another Cup
Maurice Richard driving towards another goal
Bob Baun scoring in overtime
George Armstrong sliding the puck into the Habs' empty net
Bobby Orr flying through the air
Bob Nystrom tipping the puck into the net
Any one of Gretzky's or Messier's highlight moments.
They all have one thing in common. All clean shaven.
Playoff beards were a novelty. They have become old. You play for three hours every 2-3 days. You have lots of time to shave.
Think of the great moments in Stanley Cup History:
Jean Belliveau hoisting another Cup
Maurice Richard driving towards another goal
Bob Baun scoring in overtime
George Armstrong sliding the puck into the Habs' empty net
Bobby Orr flying through the air
Bob Nystrom tipping the puck into the net
Any one of Gretzky's or Messier's highlight moments.
They all have one thing in common. All clean shaven.
Playoff beards were a novelty. They have become old. You play for three hours every 2-3 days. You have lots of time to shave.
Reqiem for a Heavyweight
One of the things I get to do now as department head is to advise pharmacy on formulary additions and deletions. Today I got an email asking me to comment on whether we should keep Sodium Pentothol on the formulary.
Now Pentothal AKA Thio AKA STP has been used in anaesthesia since the late 1930s. Despite a bit of trouble after Pearl Harbour when its use in sub lethal doses by untrained personnel lead to allegedly more deaths than caused by the Japanese Pentothol was the undisputed champion of induction agents until the mid 1990s. There were challengers along the way, methohexital, ketamine, etomidate, alphathesin (which I would love to see formulated in intralipid), midazolam, sufentanyl and alfentanyl all came and were unable to supplant Pentothal as the dominant induction agent. Millions of people went to sleep (and woke up after) hearing, "You'll get a taste of onions or garlic...."
Propofol finally supplanted Thio. It wasn't easy though. I remember in the early 1990s when Propofol was first introduced. We presented it to our pharmacy committee who balked at the cost of $8 vs 50 cents for the equivalent dose of Thio. Propofol was unquestionably better but not 16 times better. At first pharmacy allowed that we could use it for Pentothal allergies or porphyria. Later they allowed us 6 vials per person per week. This lead to my practice of what I called "President's Choice" propofol (President's Choice was the house brand at a grocery chain) where I took 10 cc of propofol and topped it up with enough pentothal. It also lead to a lot of stealing from other people's carts.
It was later understood that while propofol was clearly better for day surgery, pentothal should be used longer cases. Gradually propofol became used more and more, pentothal less and less. A few years ago the multidose bottles of pentothal disappeared, leaving only single dose bottles which were a hassle to reconstitute.
Currently while propofol now generic costs $3 for 20cc the equivalent dose of pentothal goes for $14. The question was, whether we should keep pentothal. I felt that for a drug which is clearly not as good, only used on principle by a small group of diehards and which costs almost 5 times more, it would be hard to justify it. That doesn't mean I don't feel guilty about it.
Pentothal joins a large list of anaesthetic drugs which have fallen into the dustbin during my lifespan including Halthane, Enflurane, Isoflurane, Curare and Pancuronium (still available but only ever used to scare residents).
Tuesday, April 13, 2010
More Species of Anaesthesiologists
Burnttoast commented on my last post.
His work is really too good to left in the comments section; I have further commented in italics
Additions;
Dr. TrainedAtBigNameHospital Any conversation must include "When I trained at BIG NAME Hospital..." So why didn't they offer him a job?
Dr. Flirt whose main objective is to charm any attractive members of opposite sex. Usually must be paged to be found. Very useful guy, usually has at least one ex-wife, will take extra call.
Dr. StockMarket who would lecture daily on what a major killing his wise investments were making, often in the presence of those making a tenth of his salary. The recession was almost worth it, as it shut this stuff up totally. The interesting thing about these guys is that most of them work past their 70th birthday.
Dr. Perfect's sibling, Dr. PerfectFamily. Kids all utterly amazing from their Apgars of 15 to their brilliant grade school careers, a shoo-in for total Ivy scholarships in either academics or athletics. Spouse equally perfect. You wonder how they got stuck with someone like him. I used to not be able to stand working with these people or attending social functions especially the child-friendly ones they insisted on. They made me feel so inadequate as a parent.
Dr. WatchtheBoard. Obsessed with the flow of the OR schedule. (guilty of this myself) Some people bet the ponies, I like to forecast OR scheduling collisions. I usually try to fix them ahead of time.... Some colleagues of mine like to do this when on call on the basis that they feel the need to reduce (on enhance) their evening workload. Everybody who has cases dropped into or taken out of their room is not impressed.
Dr ShouldaHadaTrustFund. Doesn't like doing short cases. Doesn't like doing long cases. Doesn't like doing hearts. In America, these guys wind up supervising CRNAs. Not that they necessarily like doing it.
Dr. NotMe When on call, argues that call docs shouldn't be stuck with long difficult cases, because, they are on call. When on off list, argues shouldn't be stuck with long difficult cases, cause he is on off list. When neither, argues he shouldn't be stuck with long difficult cases because it may lengthen the work day. Probably a variant of ShouldaHadaTrustFund. Or Dr. Whiny.
Dr. Technical Carries a toolbelt. Knows specs of every monitor/machine ever built. Can fix anything. Unless it is biological ie human patient.
When do we get to do type surgeons??? (Evil of me I know)
Read this
April 12, 2010 12:35 PM
His work is really too good to left in the comments section; I have further commented in italics
Additions;
Dr. TrainedAtBigNameHospital Any conversation must include "When I trained at BIG NAME Hospital..." So why didn't they offer him a job?
Dr. Flirt whose main objective is to charm any attractive members of opposite sex. Usually must be paged to be found. Very useful guy, usually has at least one ex-wife, will take extra call.
Dr. StockMarket who would lecture daily on what a major killing his wise investments were making, often in the presence of those making a tenth of his salary. The recession was almost worth it, as it shut this stuff up totally. The interesting thing about these guys is that most of them work past their 70th birthday.
Dr. Perfect's sibling, Dr. PerfectFamily. Kids all utterly amazing from their Apgars of 15 to their brilliant grade school careers, a shoo-in for total Ivy scholarships in either academics or athletics. Spouse equally perfect. You wonder how they got stuck with someone like him. I used to not be able to stand working with these people or attending social functions especially the child-friendly ones they insisted on. They made me feel so inadequate as a parent.
Dr. WatchtheBoard. Obsessed with the flow of the OR schedule. (guilty of this myself) Some people bet the ponies, I like to forecast OR scheduling collisions. I usually try to fix them ahead of time.... Some colleagues of mine like to do this when on call on the basis that they feel the need to reduce (on enhance) their evening workload. Everybody who has cases dropped into or taken out of their room is not impressed.
Dr ShouldaHadaTrustFund. Doesn't like doing short cases. Doesn't like doing long cases. Doesn't like doing hearts. In America, these guys wind up supervising CRNAs. Not that they necessarily like doing it.
Dr. NotMe When on call, argues that call docs shouldn't be stuck with long difficult cases, because, they are on call. When on off list, argues shouldn't be stuck with long difficult cases, cause he is on off list. When neither, argues he shouldn't be stuck with long difficult cases because it may lengthen the work day. Probably a variant of ShouldaHadaTrustFund. Or Dr. Whiny.
Dr. Technical Carries a toolbelt. Knows specs of every monitor/machine ever built. Can fix anything. Unless it is biological ie human patient.
When do we get to do type surgeons??? (Evil of me I know)
Read this
April 12, 2010 12:35 PM
Wednesday, April 7, 2010
A Guide To Anaesthesiologists
A while ago I blogged on the various surgical personalities we all encounter. I really love slagging surgeons but lets face it, people who live in glass houses shouldn't throw stones.
Lets meet my department.
Dr. Perfect.
Dr. Perfect's shit doesn't smell and has never smelt. Every thing about his cases are perfect and only because he is doing them.
Dr. Cancel.
Dr. Cancel only likes to do ASA I cases. Anything else he will find some excuse not to do the case or he will make life so difficult for everybody involved including the patient.
Dr. Wallet.
Dr. Wallet can look down the OR slate and tell within $10 how much every person is going to make that day. AND he better be making more than everybody else! Dr. Wallet spends most of his days either complaining to the list assignor that he didn't get the most lucrative list or at the front desk trying to get cases moved into his room. Fortunately you will only have to deal with Dr. Wallet for a few years as he will soon leave your department to work in a private surgical suite.
Dr. Chatty.
Dr. Chatty loves to talk. This will include a long talk with the patient mostly unrelated to the patient's medical history or the surgical procedure before finally putting the patient to sleep. Usually Dr. Chatty has to be paged several times from the lounge where he is holding court.
Dr. Block.
Dr. Block loves regional anaesthesia. His enthusiasm for blocks is only matched by his lack of speed and ineptness in performing them.
Dr. Science.
Fortunately he only works in teaching hospitals. Dr. Science loves research. Unfortunately most of his research involves you doing your cases according his research protocol which means not doing things the way you find comfortable, having your case delayed by his research assistant and having to draw blood at intervals when you could be doing something useful like reading the paper. Dr. Science's papers are always published with himself as the sole author and no acknowledgments. He is always the co-author on all the research done by residents even if he didn't actually do any of the research.
Dr. Rambo
Dr. Rambo never has an easy case. Every of his (her) cases is the sickest patient being subjected to the worst horrendoplasty, brought back from the brink only through Dr. Rambo's skill. Dr. Rambo will give you a lunch break; when you come back your ASA 1 gall bladder has an art line, 7 French CVP and is on norepinephrine.
Dr. Bucket
Dr. Bucket carries a huge ice cream bucket filled with multiple ETT, stylets, bougies, syringes, minibags and who know what else. When you can't find a piece of equipment, you ask the nurses to search Dr. Bucket's bucket. There are variations including fanny packs and tackle boxes.
Dr. Whiny
Just like his surgical cousin, Dr. Whiny is never happy. If his list doesn't end precisely between 1500 and 1530 he will complain about working too long or not enough. Likewise call is either too busy or not busy enough.
Dr. Tightass
Dr. Tightass missed his calling as an internist. He rigorously interrogates each patient before surgery, and looks for lab work that hasn't been invented yet. Dr. Tightass's anaesthetic records are completely filled out on both sides to the point that you can't decipher anything anyway.
Lets meet my department.
Dr. Perfect.
Dr. Perfect's shit doesn't smell and has never smelt. Every thing about his cases are perfect and only because he is doing them.
Dr. Cancel.
Dr. Cancel only likes to do ASA I cases. Anything else he will find some excuse not to do the case or he will make life so difficult for everybody involved including the patient.
Dr. Wallet.
Dr. Wallet can look down the OR slate and tell within $10 how much every person is going to make that day. AND he better be making more than everybody else! Dr. Wallet spends most of his days either complaining to the list assignor that he didn't get the most lucrative list or at the front desk trying to get cases moved into his room. Fortunately you will only have to deal with Dr. Wallet for a few years as he will soon leave your department to work in a private surgical suite.
Dr. Chatty.
Dr. Chatty loves to talk. This will include a long talk with the patient mostly unrelated to the patient's medical history or the surgical procedure before finally putting the patient to sleep. Usually Dr. Chatty has to be paged several times from the lounge where he is holding court.
Dr. Block.
Dr. Block loves regional anaesthesia. His enthusiasm for blocks is only matched by his lack of speed and ineptness in performing them.
Dr. Science.
Fortunately he only works in teaching hospitals. Dr. Science loves research. Unfortunately most of his research involves you doing your cases according his research protocol which means not doing things the way you find comfortable, having your case delayed by his research assistant and having to draw blood at intervals when you could be doing something useful like reading the paper. Dr. Science's papers are always published with himself as the sole author and no acknowledgments. He is always the co-author on all the research done by residents even if he didn't actually do any of the research.
Dr. Rambo
Dr. Rambo never has an easy case. Every of his (her) cases is the sickest patient being subjected to the worst horrendoplasty, brought back from the brink only through Dr. Rambo's skill. Dr. Rambo will give you a lunch break; when you come back your ASA 1 gall bladder has an art line, 7 French CVP and is on norepinephrine.
Dr. Bucket
Dr. Bucket carries a huge ice cream bucket filled with multiple ETT, stylets, bougies, syringes, minibags and who know what else. When you can't find a piece of equipment, you ask the nurses to search Dr. Bucket's bucket. There are variations including fanny packs and tackle boxes.
Dr. Whiny
Just like his surgical cousin, Dr. Whiny is never happy. If his list doesn't end precisely between 1500 and 1530 he will complain about working too long or not enough. Likewise call is either too busy or not busy enough.
Dr. Tightass
Dr. Tightass missed his calling as an internist. He rigorously interrogates each patient before surgery, and looks for lab work that hasn't been invented yet. Dr. Tightass's anaesthetic records are completely filled out on both sides to the point that you can't decipher anything anyway.
Sunday, March 28, 2010
Excuse me, are you in line?
Having stood in various line-ups for many years I am all too aware of the all the bad behaviour that can occur in line-ups. The most common bad behaviour is the person who lets his friends in line or saves places for large numbers of people. There is of course a special place in hell reserved for the person who stands in line in the grocery store or Costco while his accomplice shops for the two of them.
I have noticed a new form of anti-social queuing (or should I call it non queuing).
I noticed this several years ago at our hospital. We have a kiosk which "proudly" serves Starbucks coffee rather than the week old swill available in the cafeteria. Consequently there are long line ups there all day. One day around 10 am I went to get a coffee. There were about 20 people in a long line that extended well out into the wide corridor. About 3 metres back of the that line, standing in a circle were 6 people who were having a conversation about something. I got into the back of the line, when one of them tapped me on the shoulder and said, "Excuse me we're in line". I meekly got in behind their circle. What I should have said was,"Why the hell don't you get in line then, preferably in single file"
Unfortunately this behaviour seems to have become quite widespread, where people seem to think that the proximity or the belief that they are in line, means they are in line. It is getting to the point the when I go to the convenience store, or coffee shop I will encounter somebody standing well behind the queue, sometimes facing the counter, sometimes not, but I know that if I stand at what should be the back of the line, I am going to get the shoulder tap or the glare. Sometimes these people will actually force people who have to stand in line behind them to stand outside or in the doorway. Another variation is the person who stands beside the line; is he in line, is he waiting for somebody in line; is he keeping somebody company. I can't tell.
I am not saying that everybody should be lined up pelvis to buttock. I have my personal space which I try to guard too (at the same time judging by how much I seem to get jostled now there seems to be less respect for personal space). I just wish that people would stand the hell in line. Is that too much?
I have noticed a new form of anti-social queuing (or should I call it non queuing).
I noticed this several years ago at our hospital. We have a kiosk which "proudly" serves Starbucks coffee rather than the week old swill available in the cafeteria. Consequently there are long line ups there all day. One day around 10 am I went to get a coffee. There were about 20 people in a long line that extended well out into the wide corridor. About 3 metres back of the that line, standing in a circle were 6 people who were having a conversation about something. I got into the back of the line, when one of them tapped me on the shoulder and said, "Excuse me we're in line". I meekly got in behind their circle. What I should have said was,"Why the hell don't you get in line then, preferably in single file"
Unfortunately this behaviour seems to have become quite widespread, where people seem to think that the proximity or the belief that they are in line, means they are in line. It is getting to the point the when I go to the convenience store, or coffee shop I will encounter somebody standing well behind the queue, sometimes facing the counter, sometimes not, but I know that if I stand at what should be the back of the line, I am going to get the shoulder tap or the glare. Sometimes these people will actually force people who have to stand in line behind them to stand outside or in the doorway. Another variation is the person who stands beside the line; is he in line, is he waiting for somebody in line; is he keeping somebody company. I can't tell.
I am not saying that everybody should be lined up pelvis to buttock. I have my personal space which I try to guard too (at the same time judging by how much I seem to get jostled now there seems to be less respect for personal space). I just wish that people would stand the hell in line. Is that too much?
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