Good apple, bad apple

I had an interesting experience last week which shows the good and the bad of customer service.

I didn't get a computer until 1991 when I finally could afford one and when I needed one for billing.  At that point I had to make a choice between PC and Apple.  I had had to make a similar choice between Beta and VHS a few years earlier, fortunately choosing correctly.  I asked a few computer savvy docs and it really appeared that Apple was going the way of Beta and so I chose a PC.

Probably thousands of MBA thesi have been written explaining why Apple got their butt kicked by PC in the 1990s and I am not going to enter into that discussion.

This has lead to a succession of PCs including the laptop I am typing this on.  I have over the years spoken with people who use Apple and they are enthusiastic almost evangelical about their computers.  I even briefly considered getting one after getting fed up with Dell but I am a creature of habit.

I even resisted getting an i Pod when they came out.  I got a Creative Zen instead which while not as compact as the i Pod is in my opinion a much more versatile MP3 player.  I did finally get an i Pod about 6 or 7 years.  This iPod has lasted up until now, I keep on waiting for it to die but it won't.  4 years ago I got an i Phone 3 and when it died an i Phone 4 which I currently still have.  Both these interface quite nicely with my PC although I had a little trouble getting my iPod to sync with my current laptop.

I had a little Dell netbook which I used for traveling and to take to work until it became so unreliable that I stopped using it.  I wanted something smaller than a laptop for work and travel so I started looking for a tablet.

A couple of Xmases ago after my wife told me she didn't want an i Pad, I gave her one anyway and fortunately she loved it.  My kids on the other hand tell me that iPads are over-priced and that there are cheaper better tablets available.  This left in a bit of a quandary as to what to get so I asked the Chinese guys in my department and they told me with impeccable logic, that since I already had an iPod, iPhone and my wife had an iPad, it made sense for me to also get an iPad.  Besides I thought, I will be able to share charging cables.  With that in might I proceeded to the Apple Store, bought an iPad air, gave it to my wife who presented it to me for Xmas.

And very nice it was.  Within half an hour of getting it on Xmas day, I had my email set up and my schedule and contact list was synced with my iPhone.  I was able to download versions of all the apps I had on my iPhone.  And I soon loved my iPad as much as one can love an inanimate object.  No love is perfect.  It used a different power cord than my iPhone and my wife's i Pad and as we found out when we visited South America, only an Apple charger will work which meant the travel USB charger I bought didn't work and it was just fortunate that for some reason I threw one of the Apple chargers in my bag.   Also the word processing soft wear is not as good as Word or Open Office and an iPad is more or less useless without Wifi and our hospital is about the only site in the developed world without Wifi.

I started using it all the time, I watched Netflix on it, during the Olympics I streamed the CBC feed onto it.  Next to the iPad my laptop seemed like something from the Stone Age (not far off as it runs Windows 8).

Then one day as I was multitasking while watching TV, I absent mindedly pressed on the screen and I felt a tactile sensation like the sensation one gets on breaking a thin film of ice.  And when I looked down this is what I saw.

No problem.

The iPad is less than 2 months old, it is still under warranty and I have the receipt because the Apple Store emails the receipt to you.  Off to the Apple Store in the mega mall I go.  Arriving at the Apple store I was able to flag down an employee, not always an easy thing, and I explained my situation.  He directed me to a table when 4 other people were sitting or standing and waiting my turn, I explained my situation again.  The employee pushed a laptop in front of me, told me to log in using my Apple ID and when I logged on, told me to make an appointment.  "You mean I came down here just to make an appointment?," I asked.  Grumpily I made an appointment.

The next afternoon I was back at the Apple Store in the mega mall at the appointed time.   I flagged down an employee and was directed to the "Genius Bar" where about 5 other people were sitting.  20 minutes after my appointment time (not complaining I am a doctor after all), a technician came out and looked at my iPad.  The following conversation ensued:

Technician :  "Interesting, I have never seen a crack pattern like this."
Me:  "Must have been a flaw, "
Technician: "Tell you what, since you didn't buy the extended warranty (for $200), I can give you a new one for replacement cost of $300."
Me: "Surely after 2 months it is still under warranty"
Technician:  "The warranty doesn't cover damage from impact"
Me: "From my thumb?"
Technician: "Sorry".
Me: "Can I speak to the manager?"

After 10 minutes somebody about the same age as the technician comes out with a badge saying manager.  I always suspect that when somebody asks to see the manager, somebody just goes into the back room and changes their name tag.

Manager:  "If you had bought the extended warranty, we would have replaced it for free, less a deductible"
Me:  " You mean if I had been stupid (or prescient) enough to spend one third of the price of the iPad on a warranty, I still would have had to pay more money?"
Manager:  "That is correct.  Do you want us to get you a new iPad for $300 plus taxes".
Me:  "I can get a tablet from another company for $300 so why should I pay you for another tablet when I paid you $600 two months ago and now the screen is cracked?"
Manager (almost speechless at my logic):   "That is up to you sir."
Me:  "Well, I also have an iPhone and an iPod and when they die, I will be dealing with a different manufacturer."
Manager:  "That is too bad."

I slunk home thru the mega mall with my damaged iPad.  I was really pissed and at the same time a little sheepish about how I had spoken with the Apple employees.   I doubt they get paid very much and probably a lot of them are over qualified for what they do plus they are only following company policy.  I make a good living, paying $300 for a new iPad is not going to bankrupt me especially as a member of the 1%, my corporation actually owns it and can write it off.

Getting home I went to the Apple site and lo and behold there was a toll free phone number to call, it was one of those annoying voice response phones but after about 2 minutes I actually got to talk to a human with a North American accent who when I explained what had happened, called his manager who asked my to email him the picture I had taken, which I did using my iPhone and he actually phoned me back about 10 minutes later and told me I could have a new iPad.  I suspect this had more to do with my demographic than  any sense of fairness and justice.   "What do I do now, " I said.  "There is a note on your file, " he said, "just go back to any Apple store and they will give you new iPad".  I actually made an appointment online for the next day.

I was a little nervous about this because the only assurance I had was the verbal assurance from someone who said he was a manager but when I arrived at the Apple Store at 1600, next day, I was quickly directed to the back of store where a nice Apple employee gave me a new iPad, helped me set it up and made sure I didn't lose any of the data on my old one before we erased my old one and I walked out of the store happy and relieved. 

Olympic reflections

The Olympics are almost over for another 4 years, time to reflect.

1.  Isn't hockey better with no fighting?  True, these are elite players and the stakes are high but just the same, no interruptions for fights, scrums etc.  Many of the players playing in the Olympics occasionally drop the gloves so it is not a matter of non fighters being chosen.  Further the general managers who chose these players are the same GMs who argue that it is necessary to have a least one spot on the roster for a player whose only role is to fight.

2.  Bigger ice doesn't necessarily make for a more exciting game or more goals.  Not that it wouldn't be nice to see a bigger rink in the NHL.

3.  These athletes actually compete in the 3 years between Olympics but nobody watches them.  We have 2 all sports networks in Canada.  Half the time when I turn them on, they are showing Poker.  And lets not forget that many of these athletes we fall in love with and take for ours every four years struggle to support themselves and train for the four years in between Olympics.

4.  Olympic medal standings.  Note how these get manipulated.  If you are leading in gold medals you rank the countries in order of golds.  If you are leading in total medals you rank in order of total medals.  Logically it would be 3 points for gold, 2 for silver and one for bronze.  Or why not include top ten performances.  There are no actual official medal standings so why even post them?  This article has an interesting slant on medal counts.

5.  Are all medals equal?  Some sports like downhill skiing and long track speed skating are a single run against the clock.  Some are multiple heats leading to a final.  Some have back door routes.  Some are tournaments with playoffs.  (In hockey you could lose your first 3 preliminary games, still make the the playoffs and almost upset Canada as Latvia almost did)  Some are invidual, some are team.  Some are in sports that only a few countries excel in or even participate in.  Some are in sports that most countries participate in.

6.  Men (and women) in blazers.  Its about the athletes!

7.  Already talked about judged sports.  They have to go even if it costs Canada medals.  On the other hand by diverting the resources expended on "sports" like ice dancing into real winter sports which Canada being a cold snowy country should excel at we actually might start picking up medals.

8.  Really like seeing the Americans lose in hockey.  It just never gets old.  And we are going to hold you to that:

Scored of the Rings

The Olympic Slogan is supposed to be higher, faster, stronger.  How about higher, faster, stronger, better judged.

There are a lot of things that bug me about the Olympics but judging has to be the thing that bugs me the most.  There is the politics, the unfairness, and the fact that most of us don't understand how events are judged.

At the top of this blog is a photo of Nadia Comaneci and one of her perfect 10s.  No doubt she was the best gymnast at the 1976 Olympics.  It turns out however her perfect 10s were engineered by the Soviet Union who figured that awarding her 10s would raise everybody else's scores enabling  the Soviets to win the team medal in gymnastics.   

It is hard to not notice that many of the events Canada now wins medals are in judged sports.  Does this mean that Canada's athletes are better or do we just play the international judging politics better than we used to.  

True non judged events like hockey do have referees and there is some judgment involved but most high level sports have tried to make that professional level referees are now doing the games.  

The bottom line:  Any sport that does not involve getting somewhere sooner, going longer, going higher, lifting more or scoring more points doesn't belong in the Olympics.  This by the way includes boxing.  Remember the Seoul Olympic boxing?  Other fighting sports have actually developed objective scoring so maybe some of them can stay.  

Eliminate the judged events and more room is open for other events that aren't in or extending existing events.  Ski mountaineering, telemark skiing, and snowshoeing would be easy candidates for addition. Some of the judged sports might be able to modify their sports to make them more objective.

Figure skaters, halfpipers and aerialists are are skilled athletes no doubt.  So are skateboarders, ballroom dancers and stock car racers none of whom I really want to see in the Olympics. Figure skating and ice dancing don't do anything for me but some people find them beautiful to watch.  I enjoy my local symphony but I don't expect see it at the Olympics.

But just because many people and I personally don't enjoy watching sports like figure skating or gymnastics doesn't mean they still can't be in the Olympics.  Just not as a competitive sport.  Sort of an Olympic Ice Capades or Olympic circus.

The Flu

Just before Christmas a lady came in to have a baby at our hospital.  She was sick with the flu and when they sent off the appropriate tests, it was found that she had the much dreaded H1N1.  In to isolation she went.  This shouldn't really be a problem though because our hospital provides free flu shots which include H1N1 and it is practically impossible not to get one.  If you phone staff health they will actually come to where you are and stick you.  Unfortunately only 24% of our labour and delivery nurses bothered getting vaccinated this season.  That meant that all the un-vaccinated nurses who were exposed to this case were sent home. Some of the remaining un-vaccinated nurses got vaccinated.

Labour and delivery nurses are of course a unique subset; some of them belonging to the placenta-eating- breast feed until 5-unpasteurized-organic-anti vaccine crowd.  What was more interesting was that vaccination rates weren't that much higher including amongst some of my colleagues.

I haven't asked everybody but at least 3 people had not been vaccinated (including one who was potentially exposed).  One didn't get the vaccine because she already was having a flu-like illness when they were doing the vaccinations (I did too but I got mine once the symptoms resolved), one told me that the flu vaccine was just for old sick people and one wouldn't tell me why.

As we started getting more and more cases the administration issued an edict.  All staff must either:

1. Have been vaccinated for at least two weeks.
2. Have been vaccinated for under two weeks and take Tamiflu if they were exposed to the flu
3. Take Tamiflu.

If they didn't want to do that they were not supposed to work.  The Christmas closure was just about to start which meant we would only have on call coverage for 2 weeks and I really didn't want to have to find people to work.  I forwarded the memo.

I immediately got an email and phone call from a staff member.  He was planning to work several days over Xmas, he did not want to get vaccinated, he had picked up Tamiflu but didn't want to take it.  I could have been a hardass and told him that he couldn't work which would have meant finding somebody to do his call (this would have inevitably been me) but I kind of wimped out and told him that while I couldn't see what he had against vaccination as long as he had the Tamiflu I was prepared to close my eyes.  I suspect I was not the only "supervisor" who did this.

Christmas came and went (uneventfully staffing wise) and the cases of H1N1 piled up.  We now have 9 ventilators occupied by H1N1 patients at our hospital which means that aside from our anaesthetic machines, there are no more ventilators in the hospital.  Other sites are in similar straights.  Cardiac surgery (gasp) is being cancelled at the Centre of Excellence because the perfusionists are ECMOing people.

Despite all this according to the latest memo only 47% of staff at our hospital are now vaccinated.

Our neighbouring province to the west well before this outbreak mandated that all HCWs either had to be vaccinated or wear N95 masks during flu season.  Most people after wearing an N95 mask for more than 5 minutes will run to the nearest vaccination station.  N95 masks of course don't filter out viruses but apparently are considered better than (or as good as) nothing.

It is an interesting ethical question whether an employer can compel employees to have an invasive medical procedure or take a drug.  No doubt this will be the source of many seminars and journal articles for the next decade.

There are of course some people who defend not getting a flu shot by saying that they actually don't work.  Not being an epidemiologist, it is hard for me to interpret the various studies and of course you can always find something to split hairs on in any study no matter how well designed.  The CDC believes they work.  Anecdotally, I have gotten a shot every year since the late 1990s and I believe I get fewer flu-like illnesses every winter.  This could also be because I wash my hands more than I used to, wear a mask sometimes, take cold FX, my kids not long attend the viral incubators known as public schools and I have been exposed to most of the flu viruses in previous seasons (including H1N1 which I believe I survived in 1976).

Then of course there are those who refuse to take the vaccine citing potential harm.  One of my colleagues tells me of the nurses in a large ICU in another city who refuse the vaccination because one of their colleagues years ago got Guillian Barre around the time she was vaccinated.  This is notwithstanding that there is a baseline spontaneous rate of GBS in the community.  Other people claim they get a flu-like illness associated with the vaccine and I have actually experienced that although nothing like the flu-like illnesses I used to get.  There are of course the tin foil hatters and conspiracy theorists some of whom work in the hospital.  Just about everybody who works in a hospital from the cleaners to the internationally renowned sub-specialist considers himself an expert in health care and the adage "a little knowledge is a dangerous thing" is most apt.

We vaccinate health care workers for three reasons of course.  Reason one is so they don't transmit influenza to patients.  Reason two is so they don't catch influenza from a patient and reason three is so they don't get influenza and call in sick.

Influenza is not the only illness that can be transmitted to patients although it is probably much more contagious than other viral or bacterial illnesses.  Patients acquire bacterial infections like C Diff and MRSA in the hospital all the time and the vector is most often a staff member.  URTIs which can be quite unpleasant can be transmitted easily to patients.  This orthopod gave up surgery after he believed he gave Hepatitis B to a patient although most people, including me, figure he probably didn't unless he had sex with the patient or bleed profusely into the open wound.  With HIV now considered a chronic disease, I expect there are probably a significant number of HIV positive physicians scattered around North America.  I doubt medical school admission committees or hospitals are allowed to ask.  Transmitting HIV through casual contact is pretty unlikely but I could see the dollar signs in lawyers eyes should a patient believe he contracted HIV while under the care of one of these doctors.

While it is a nice thought to think that hospitals really care about their employees' health and don't want them to catch infections from patients; having now been in administration for almost 4 years, I can tell you that hospital administrators care as much for their employees as 19th century factory and mine owners cared for theirs.  Administrators love to talk about employee wellness as long as no money is spent, no political agendas are disrupted and they get to go on a retreat somewhere nice to talk about employee wellness.  Administrators feel just the same way about physicians by the way.

It is hard to believe but doctors and other healthcare workers actually used to catch serious illnesses from patients and die from them.  (In some cases after intentionally contracting the disease to test a hypothesis or a new treatment).  This was considered a sacrifice justified by the prestige and financial security of being a doctor.  I am not sure what the justification was for less prestigious and financially secure workers like nurses was.

So it really comes down to preventing staff from getting sick with the associated sick leave and overtime costs, which is the real motivation behind vaccinating staff.  Administrators were even honest about this in the 1990s when the first mass vaccinations of staff were done.  In fact while staff in a hospital probably shouldn't come in at all when they are sick, this of course leads to sick leave and in all the meetings over the past 20 or so years devoted to cutting costs, sick leave is frequently raised as a significant cost that has to be reduced.

As of now 10 patients have died of H1N1 in our province and given the number on ventilators we can sadly expect a few more.  This has lead to a rush on vaccination with long line-ups and shortages of vaccines.  Any premature death is tragic but in 2012 the most recent year for which we have statistics there were 345 traffic fatalities which averages out to about the same number of traffic fatalities  in the same space of time as we have had 10 H1N1 deaths.  Strangely I don't see people lining up to take defensive driving courses.

Aside from H1N1 which smites people in the prime of life, most of the people who die from Influenza A and B are elderly with chronic illnesses.  I do not mean to be disrespectful to seniors because I am becoming one all too rapidly but Influenza really just takes people who are hovering on the brink and gives them a gentle nudge over into the abyss.  Effectively influenza has taken over the role bacterial pneumonia had as the "old man's friend'.   The problem is that while we all know we can't do anything for these people, we insist on trying which means spending large amounts on futile treatments we all know won't work.  Or worse we sometimes take somebody who might have done just fine at home (or not) admit them to hospital where we give them something like C Diff which really does push them to the edge of the abyss.

In a few months we will be past flu season and we will forget everything we should have learned this flu season and in the past few flu seasons.

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.