A Blog I Wish I Had Blogged

Great Z's blog post on how to be a good anaesthesiologist needs to be read. A touch sexist (if true) but right on the money.

How Much Longer Are Your Going To Be?

I realized how much this question bothers me the other night while on call.

I can usually estimate how long it is going to take me to do most things. It is trying to estimate how long the surgeon is going to be that gets on my nerves. Like as if I can actually control that. I would love to be able to control surgical times, I fantasize about implanted chips or scrotal clamps that give shocks or tighen up if the surgeon is working slowly.

The other night it was the Case Room calling just after surgical incision (and just after I had told the second call to go home) to find out how long we would be as they had a C-Section they "needed" to do. They were of course very vague about how urgently they "needed" to do the C-Section. For all I knew and for all they were prepared to tell me it could have been a prolapsed cord or just someone who wanted their child born that day for astrological reasons (don't laugh, we have done at least one C/S for those reasons).

It is not just the Case Room. Other surgeons frequently phone into the room asking to speak to me to find out how long their colleague is going to be.

I could ask the surgeon. If it is shortly after incision, they will answer that they don't know until they actually see what is involved. Or they will give me an estimated time which I will then have to decide whether to multiply by 2 or 3 times based on their past performance. Some surgeons are a little sociopathic and actually slow down or let the resident do the case when they know, they are going to get bumped.

More often as the evening witching hour approaches it is just another surgeon trying to decide whether the case which was urgent a few hours ago can now wait until tomorrow.

I should know better; I was a little rude to our Case Room. I told them I could no more predict how long the surgeon would take, then they could predict who would need a labour epidural and when.

The Needle and the Damage Done?

One of the most onerous tasks lately as department head (or site leader as we say in newspeak) has been the implementation of what our leaders call "Safety Engineered Devices". These are essentially needles that cap or blunt themselves automatically to prevent needle-stick injuries.

As an anaesthesiologist I should be in favour of these devices. After all for a living I for the most part stick sharp things into people, take them out and dispose of them. As such I am at high risk for needle-stick injury. In fact I blogged about my last needle-stick. Early on in my career I read a depressing article where someone calculated a 1 in 3 chance of an anaesthesiologist being infected with HIV during his career. This gloomy article was based on 3 needle-sticks a year and assumed a population incidence of HIV that we have fortunately never reached in North America. Wearing gloves does not of course prevent needle-sticks, it may in fact increase the risk.

Our most recently foray into safety actually originated with our Ministry of Labour which in our province is in charge of Occupational Health and Safety not the Ministry of Health. Legislation was passed and we are now approaching the July 1 deadline. This has meant multiple emails, multiple meetings and I cannot pass anyone in my department in the hall without getting an earful.

Why do we hate these so much? Most of these devices were introduced 3-5 years ago. The hypodermic needles in order to have their built in blunting or capping devices are incredibly bulky. This is not much of the problem with the larger needles that we use to draw up drugs (although we hate them too). The smaller needles that we use for infiltration or occasionally nerve blocks are cumbersome to use, and the extra bulk often makes it difficult to see the needle tip, something most of us like to see as we are sticking it into somebody. Fortunately with some needles it is possible to break of the capping device which I do, although I was informed last week, I can be fined for doing so.

Worse are the intravenous needles. These either come with a spring loaded blunting device which shoots up the needle hopefully after (but frequently during) the intracath insertion. The other variety has a spring loaded device that withdraws the needle back into the hub like a reverse switchblade.

3 years ago we were given the first variety. Even accounting for a learning curve, they were terrible. The needles were blunt, the catheter did not slide easily, they were bulky and the flashback chamber was small. Within days because of complaints the old IVs appeared in the OR but the nurses on the floors were forced to use them which meant that patients came down to OR with bandages all over their arms from failed attempts.

With the deadline looming however, a better safety IV appeared, the BD Insyte with its retractable needle. While they are a little bulky, they seem to be something I at least can live with especially as we already use the old BD Insytes and are used to them. We are assured we can use them, I suspect they may suddenly disappear in a year or so and we will be left with a less user friendly needle.

Fortunately, as there is no "safety engineered device" available, epidural, spinal and nerve block needles are for now exempted. Interestingly enough acupuncture needles are not. It is possible to apply for an exemption which I did last week for all our "dangerous" sharps and we are assured that these exemptions will be granted although only for six to 12 months at a time which should help the pulp and paper industry.

It is only a matter of time before the companies that make both types of devices realize that there is no point in manufacturing a cheaper device when they can with the government's blessing sell a much more expensive device.

More ludicrous has been the search for a safety engineered scalpel. With 3 weeks to go to the deadline, no such satisfactory device, has been found and as far as I can see they aren't even trialing one. I was going to suggest that they just use box-cutters.

One issue nobody has raised so far is the cost of all this. I learned this last week at a meeting. The SED hypodermic needles currently cost 26 cents a unit versus 2 cents a unit for the old device. I suspect the gradient for the intravenouses is even higher. These may be only a matter of a few cents however think how many needles get used every year. For example in our late (and I am told futile) H1N1 vaccination blitz SED needles were exclusively used. So say in our province one million people were vaccinated, the means that $260,000 rather than $20,000 was spent on needles alone. At the meeting I was informed that while we are trying to cut healthcare costs in other areas, when it comes to SED's money is no object.

I like to protect myself and don't really like the needle-stick experience I seem to get every couple of years with its paperwork and blood drawing. Worse I would hate to have a nurse or other colleague stabbed by one of my needles. I wish that this whole initiative was driven by a concern by worker safety but I think it is being driven by an occupational health and safety industry that is farther and farther removed from the realities of the workplace.

Work relationships.

This is an interesting article which puts a different perspective on this story.

For the rest of the world who don't get news from Canada, a brigadier general from Canada was recently relieved of his command in Afghanistan after admitting to having sex with a subordinate officer. When you are a brigadier general I suppose you are limited to having sex with Lt. Generals, Major Generals and of course plan old Generals. The fact that he was married to a different woman adds to this. He was at 42 the youngest general in the army and could have had a promising career ahead. On the other hand he was also court martialed for accidentally shooting himself around the same time which says something about what it takes to advance in the Canadian Forces.

I am quite happy to have one less Canadian soldier in Afghanistan.

Leah McLaren points out however that without workplace romances, many of us would be celibate and many would have never got married.

I have been married for 25+ years to a nurse. Most of my close friends from medical school are married to nurses. I met my wife in a social setting, however it was a medical party. I have never gone out with any nurse that I met at work. I would like to say that this is because I deeply respect nurses as fellow healthcare workers but that would be bullshit. It was not for lack of trying, but I was held back by a number of factors.

1. I am usually inept around women.
2. The idea of working with someone for 4 or more weeks after being turned down has never appealed to me.
3. Most nurses hate me within a few hours of working with me.
4. I am too frigging busy at work and I suspect most nurses are too. If I have nothing to do, the last thing I want to do is hang around the ward hoping to make time. If I am not on call, I would rather be home, if on call I would rather be sleeping or watching TV.

I have often heard doctors describing their on call sexual exploits. Again I wonder when they found the time (or the woman). I can remember two occasions when it might have highly theoretically been a possibility for me. Both times my beeper started smoking for the next 3-4 hours effectively losing any highly theoretical opportunity for on-call sex.

The other interesting subject is whether a doctor who "dates" a nurse is making use of her subordinate role to him. I would suspect most residents and quite a few staff physicians would argue that at least in teaching hospitals it is the reverse. Doctors are completely subordinate to nurses!

Fluid Wars

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.

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.

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.