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Preview: I used to be disgusted, now I try to be amused

I used to be disgusted, now I try to be amused



Alarmed to discover he is now considered middle aged, a burned out cynical male anaesthesiologist ( and physician) expounds on life, medicine and anaesthesiology.



Updated: 2018-04-20T07:10:00.086-06:00

 



Leaving Chronic Pain

2018-03-26T09:14:43.538-06:00

Sometime last month was my 25th anniversary of my first pain clinic.  I was at the Centre of Excellence, and the person doing the Pain Clinic went on to better things.  The Professor told me I could do the Pain Clinic until they found somebody smarter than me to do it.  Problem was there was nobody smarter or stupider and 25 years later here I am, although not at the CofE.  I should have had a party, moreover somebody should have thrown one for me.A couple of weeks ago, I gave notice that in March 2019, I will be giving up most of my chronic pain practice and become a more or less full time anaesthesiologist  again.  Like many decisions there was no “last straw” moment, it was a series of small things.One reason is that despite everything we complain about, being an anaesthesiologist is a pretty good gig, if only for this reason.  When you see the hospital in your rear view mirror at the end of the day, unless you are on call, you know you are finished.  No phone calls from the ward, patients, pharmacies or other doctors.  If for some reason you want to go on a long vacation, you don’t have to arrange coverage and you know that you won’t spend your first two weeks back, putting out all the fires that started while you were away.I have been pretty good about setting boundaries and have a great colleague who covers me when I am gone.  Patients expectations about availability are less too, I get a lot fewer calls now.  Still I have voicemail and a fax which go to my email which I check even on vacation and the hospital switchboard has my cell number.   I could ignore them because switchboard is supposed to know when I am away and my voicemail greeting usually says I am away and who is covering but I still feel guilty, even when the problem is not one of my creating.  For example I spent a great deal of time on my 60th birthday dealing with a patient who had messed up big time.  I did this after the pharmacist from the PCN pain clinic emailed me to say he needed urgently to speak with me.  Okay why was I checking emails on my birthday?  Because that’s what I do.I met a pain specialist from another centre about 10 years ago at an anaesthesia meeting.  "I'm thinking of going back into anaesthesia", she said, "I want to retire soon and I can't handle the demands of my patients."  Sounded strange at the time; most people give up anaesthesia and the call involved to do chronic pain, I almost did a few years ago.  This encounter did plant the germ of this idea in my head.The biggest thing however is that I realized a few months ago that I have lost my compassion.   I no longer have patience for people who won't try do anything to help themselves, I no longer want to hear about problems that I have no way of solving.  90% of my patients are good people who try do everything possible and I have a treatment that might help them or is helping them.  Like most things in life, it is the other 10% that take up most of my time, that leave me feeling drained at the end of the clinic.  I don't want to be seen as blaming patients for their misfortune, its just that quite a bit of the time I have nothing to offer and don't really want to hear about it anymore.  So often I want to say, "YOU have a problem, what are YOU going to do about it?"Pain medicine and medicine in general have changed over the last 25 years that make it less attractive to practise.  25 years ago most of my patients had a family doctor, moreover they had a family doctor to whom I could make recommendations that they would follow.  Now when I get a referral, I get the sense that the family doctor has washed his hands of this patient.  That is of course if the patient has a family doctor and a significant number don’t.Paradoxically we have way more physicians doing chronic pain than 25 years ago.  This should make it easy.  It doesn't.  25 years ago, I was almost always the first person to see a patient. [...]



Getting Older

2017-12-18T13:23:46.856-07:00

My father once told his grand daughter, my niece that he was not really old, he was just older.We are all getting older.  I celebrated my 60th birthday this summer.  This was a quiet celebration as have been most of the previous 59.  That is what happens when you have a summer birthday.  I did take a lot of time off this summer and went on two fabulous bike tours, so I guess I did have a nice birthday.My parents are also getting older.  My father is 93 and my mother 88.   My father retired at 61 although he did some consulting after.  My parents had a very active retirement (although my mother as a housewife may not have noticed any retirement).  They traveled quite a bit; driving all over BC, Alberta and the Western US.  They also visited us quite a few times when we lived on the East Coast.  They toured Europe and Britain.   My father kept on gardening and with the extra time on his hands his garden became more elaborate.They were however getting older.  One by one their siblings died until I have only one surviving aunt.  My father started to develop all the health problems, prostate cancer, atrial fibrillation (diagnosed by his urologist, most likely a publishable event), cataracts and an abdominal aneurysm repaired electively.  He also developed significant osteoarthritis in his knees which for some reason his family doctor didn't want to refer him to ortho for.  By the time I did the doctor thing and got an orthopod I knew to see him, all the above problems had presented and the orthopod prudently declined to operate.  My mother however remained in fairly good health and was with it.  While her mother died of TB in the 1930s, she had aunts on both sides who lived well into their 90s so I was anticipating a long life for her.  As my father became more and more crippled by his osteoarthritis, she became more and more his legs.My parents continued to live in the house that they had lived in since 1960,  This was a single story house with a finished basement.  My mother cooked as cleaned as she had all their marriage, my father worked in his garden and did the yard work.  A few years ago, my mother disclosed to me that she wasn't sure that they could handle the house but that my father loved his garden and didn't want to move.  The garden was becoming smaller and less elaborate and shortly after his 90th birthday my father decided that this was his last garden.  They were getting a little help thru homecare and through Veterans Affairs.Meanwhile my mother who suffered from macular degeneration, developed what might have been retinal detachments (I don't know for sure, the opthamologist wouldn't return my calls).  Last spring she told me, she could no longer read.  My mother loved to read as do I.  I felt very bad for her.I had started visiting my parents every couple of months a few years ago.  I no longer had all the weekend sports and it didn't seem that expensive to fly to Victoria any more.  It was a nice trip, I would stay in a hotel and visit all my favourite places.  We would go out for dinner and my mother usually cooked lunch and occasionally dinner if I was leaving later on Sunday.Last June (2016) I visited my parents and had a very nice visit.  My mother made us lunch and on Sunday because I had a later flight, she made a nice Sunday dinner.  She was at that time having the vision problems but the house was clean and they were nicely dressed.I came back in August.  Again everything seemed okay.  I arrived mid morning, we had tea and then my mother made lunch.  We went out for dinner on Saturday.  Sunday I drove them out in the country and we went to a nice restaurant for lunch.  I was flying home around supper and told them I would eat at the airport on the way home.So it was that around 1500, having tea my mother said to me, "you know if you had more education, you could get a better job".&nbs[...]



You break it, you buy it

2018-03-26T09:17:05.518-06:00

I saw 4 patients that morning.  2 of the patients were young men who were cancer survivors.  Unfortunately combinations of surgery, radiation and chemotherapy have left them with disabling neuropathic pain, which in both cases prevents them from working.Naturally if you read the progress notes from the Cancer agency you will read glowing, back patting descriptions of the success of their cancer regimen.  Both men are going to survive.The problem is that both of them have severe pain, and nobody really wants to address it.  Despite what you may read in the American and sometimes in the Canadian media, cancer patients actually get quite good care in Canada with a huge infrastructure of nurse practitioners, social workers, psychologists and patient navigators.  If you are dying of cancer, you will go into a similarly endowed palliative program.  This is as it should be; when my cells start acting in an antisocial fashion, I want it all there for me.If you are "cured" of cancer however you enter the dismal world of the Canadian healthcare system with its waiting lists and silos of care.  Unfortunately if you have chronic pain nobody really wants to take ownership of you, least of all the oncologists and surgeons who caused the problem in the first place.  This usually leaves it to chronic pain "specialists" like me who are stupid enough to still want to see these patients.  We are usually not talking about narcotics here although that is what they frequently need; anticonvulsants or antidepressants are often effective but I frequently see a patient who has gone for the 18 months or so my wait list is, without trialing them at all.When you think about it, it takes a special kind of sociopath to leave a patient in pain as a consequence of their treatment, (even if they did save the patient's life) and not feel responsible to at least do something to try and help the patient or at least direct him to someone who can.  Back surgeons are of course big offenders in this regard.Working in my other life as an anaesthesiologist I see the other face.  As I work in a big city hospital, in what could sometimes be seen as tertiary care, a lot of the work we do in OR, is as a consequence of surgery done at other sites, usually out in the country, often by somebody who had no business doing that complexity of surgery but also alarmingly from within the city.  I often pity my general surgery colleagues who get stuck with complications of gynae or urological surgery.  Talking about podiatrists to one of our orthopods is a sure fire way to generate a long rant.We anaesthesiologists of course get to tag along on these little misadventures because they almost always end up in the OR, usually after hours, occasionally bumping the enjoyable list you thought you had, often in ICU with 20 infusion pumps going or with MRSA, VRE, XYZ etc.  I remember early in my career noting that I had worked until 0400 all on complications of surgery done at other sites.And we all love to hear of the patient with the post-spinal headache in the ER, who had her baby at another hospital or who had a misadventure with a lumbar puncture. My chronic pain side is not immune.  I get to struggle with the patients put on megadoses of narcotics by other people, those on big doses of benzos and of course the sloughs from my colleagues who have exhausted their repertoire of lucrative blocks and now want me to manage their patient medically.Complications are a consequence of medicine and modern medicine is really just a bet that the benefits of the procedure or treatment outweigh the adverse effects, transient or permanent.  This is a bet patients frequently lose.   Sometimes the adverse effects are something we can deal with ourselves, sometimes in the best interest of the patient, some else is better able to deal with it.  It would be nice if there was some mutual respect and communication.[...]



Does one battle define a country?

2017-04-09T17:14:30.137-06:00

Today is the 100th anniversary of the Battle of Vimy Ridge which we are told established Canada as a country.

Just to establish my bona fides; my grandfather was in the Battle of Vimy Ridge.  Unfortunately he died in the 1930s and I never knew him; I only have one photo of him.  He was wounded there which eventually along with being gassed earlier in the war lead to his premature death.  He did meet my mother an English nurse who he married and brought back to Canada.  It could be said that without the battle of Vimy Ridge, I wouldn't be here.  In fact if you take into the fact the butterfly effect, the world might be very different without the battle of Vimy Ridge.

Vimy Ridge was the first battle entirely fought by Canadians.  Not entirely, there was a British General Lord Byng.  Lord Byng later became Governor General of Canada.  Notwithstanding the battle of Vimy Ridge, it would be another 20+ years before a Canadian could be trusted to be Governor General.  Lord Byng's wife, Lady Byng is much more famous: she donated the trophy given yearly to the most gentlemanly player in the NHL.  Those of us interested in constitutional law will remember Lord Byng in another context.

I haven't read much about the Battle of Vimy Ridge but the underlying principle of the battle seemed to be that if you bomb the shit out of the other side and aren't terribly worried about casualties (a large reason why Canadian rather than English or French troops were in the battle) you will win more often than you lose.  The battle was of questionable significance in the long run.

The thing is however.....

The First Nations have been in the territory which became Canada for 10,000 plus years.  The first (non-Viking) European contact was in 1497.  The first permanent settlement in the early 1600s.  The boundaries essentially established after the American Revolution.  A lot of history, a lot of people lived and died to create was is now Canada.

So can you really boil all that down to one battle even if my grandfather was there.




Drug Costs

2017-03-28T11:27:35.203-06:00

We had a little breakfast presentation by the Sugamadex people last Friday.  Not a bad breakfast and an okay talk by one of their scientific people, a little dry.Unfortunately any discussion of a drug basically comes down to, "can we afford it; will the hospital put it on formulary?"  The answer came about 50 minutes into the talk, after we had finished our breakfast and were on our second cups of coffee.  The answer was $100.  That is for the smallest dose, the dose for mild-moderate block, the dose that some of us depending on circumstances don't even reverse.  If you go for deep block, like when your resident listens to the surgeon's whining and gives rocuronium while they are closing, multiple by two.  If you want to immediately reverse rocuronium like for example when you give 50 mg to the guy with no chin and realize you can't intubate him (and can barely bag him), you are talking serious cash.Now neostigmine is not the nicest drug in the world.  I consider it the most dangerous drug in my drug cart.  Surprisingly pharmacy who insist on putting high alert stickers on my midazolam compartment haven't figured that out yet.  It is considerably cheaper however although the price is said to be going up due the Merck buying the licences off all the generic companies who used to make it. Sugamadex is with a few little wrinkles a better drug than Neostigmine, just as a Ferrari is a better care than my VW Jetta.  My VW Jetta gets me to work on time however.I have no idea how much it costs to make Sugamadex, even taking into account the inflated R+D costs companies claim they have to pay.  I suspect it isn't anywhere near $100.  Currently they are selling almost no drug at all in Canada.  The question comes, is there a price where the company can make a profit which balances with the hospital paying a little bit more for what is a better drug, which might actually save money by shortening recovery room stays and reducing complications.  I should have asked but I bet I wouldn't have got a straight answer.Incomplete reversal of muscle relaxants seems to be getting a lot more attention in the literature and at meetings, some of which I suspect is being driven by the makers of Sugamadex and their stable of tame physicians who can write articles and speak at meetings.  I trained at the tail end of the pancuronium-curare era, which gave me a healthy respect for muscle relaxants.  The problem is of course, I suspect we see more incomplete reversal now than we did with pancuronium, if only because people have lost their respect for muscle relaxants.  I have learned that adding a muscle relaxant probably increases your complication rate.  I do a lot more cases with a LMA spontaneously breathing now, I still use sux and quite often if I am just intubating to protect the airway, I don't bother with a non-depolarizing agent, unless the patient is bucking or the surgeon is whining.   Even when using a non-depolarizer, I tend to be sparing in how much I use and quite often if I don't need muscle relaxation have the patient spontaneously breathing or on pressure support by the end of an hour.The Sugamadex people have cottoned on to the fact that hospitals are not about to pay $100 for a drug, at least not for an anaesthetic drug, no matter how good it is.  The spin last Friday, was getting it indicated for high risk populations like the frail elderly, sleep apnea and high BMI patients.  Probably a good idea, however unless the hospital polices it, you are going to get indication creep.  If you need it for the BMI 45, what about the BMI 44 and so on.  Of course regulation could lead to you trying to call the on call pharmacist at 0400 because you want to use Sugamadex.  Neither very good options. I was talking later that day with the surgeon and was discussing our morning rounds.  He observed that where a drug[...]



End? of paper

2017-02-27T11:09:17.628-07:00

There are two things that,  if in 1983, you had told me I would still be doing in 2017, I would have called you crazy.The first is billing fee for service.The second is charting on paper.The end may be in sight however.  Last Friday's pain clinic at my main hospital site was the last before the electronic medical record rolls out.  Fortunately I only work alternate weeks so my hope is that all the bugs will be sorted out next week.  There is a huge team of people involved in setting this up.  I attended a meeting with about 10 of them in a large war-room with white boards all over the wall.  I wonder if the money spent on this might be better spent elsewhere.I work at a variety of sites and so have been exposed to 4 different EMRs all of which are entirely different from each other.  Fortunately the EMR I will be using in a week or so is one I already use at another hospital, which means that I already took the mandatory training and did all the privacy and security stuff.  The IT people who are supervising the whole process keep on referring to me as a star.  I also get invited to "physician champion" meetings which I never attend.  Sorry, guys I already know the system and I am the only person in my department. It is interesting how the logistics of a paperless system affect your practice.  For the first few months we have been advised to book fewer patients as charting can be expected to take longer.  The other issue is that we are nowhere near the end of paper.  At one place I work which has an EMR,  a parallel paper chart is kept, at another they insist on printing out my most recent note for me to read every visit.  I keep on telling them that I can read the electronic chart but they insist on it.  In addition because none of the 4 EMRs can communicate, if you want records from one practice the only recourse is to print out the record and send it where it is scanned into the other record.  All lab and imaging reports are now available on the provincial electronic record but they still insist upon sending me paper copies as well. Canada has a socialized medical system which means it should have been easy to set up a universal electronic medical record.  For example if I see a patient with headaches, I should be able to pull up the neurologist's consult.  If however I want a copy, it will most likely be a paper copy mailed or faxed to me, often not available when I am seeing the patient.  Larger HMOs in the US have a single medical record, as do  the doctors in one small Canadian province. As I blogged a few years ago, we had an issue where multiple miscommunications lead to a patient's testicular cancer diagnosis and treatment being delayed and the patient ultimately dying.  This lead to a lot of hand-wringing and promises to fix the system.  Much of this could have been solved by an integrated EMR which nobody including me, seemed to have the balls to suggest.  Our medical society is trying to set up a secure electronic portal where doctors can communicate with each other confidentially (except for the NSA and the Russians of course).  The problem is of course that such a system is of no use unless there is close to 100% buy in and I don't see that happening because for most doctors miscommunications are someone else's problem.  I have never really seen the problem with just using email.  Is it any less secure that faxing.  How often have you found someone else's fax stapled to one of your faxes.  Anyway I have a personal fax which emails me a PDF.  When someone tells me they can't email me something because of confidentiality issues, I tell them "Just fax it to me".  They do and the faxed gets emailed to me.  I don't point out the contradiction. Our province has a flawed but wonderful system called NetCare where it is poss[...]



Bruce &. Me

2017-02-13T11:12:25.903-07:00

I just finished reading Bruce Springsteen's autobiography "Born to Run".  It is not just a recitation of his personal history, it is a very introspective and philosophical book.  More articulate people than me have reviewed it.Before we started getting our music on iPods, satellite radio and oldies stations, music was the soundtrack of our lives.  Often times now when I hear a song from the seventies or early eighties, even the sixties it will evoke a memory of a period in my life or even a specific event.  It was simpler then, a song or and album was released, you listened to the song or the album on the radio, maybe you bought it and listened to it heavily, then another song or album came out. I still remember where I was the first time I heard of Bruce Springsteen.  It was in the lunch room at the Lake Cowichan Forest Service research station where I worked as a field hand.  It was the summer between high school and university.  I can't remember whether it was Time or Newsweek I was reading, he was on the cover of both.  I remember not being that impressed.  I hadn't heard any of his music, there was a lot of good music our there in the mid 70s.  I had, a few months earlier bought Bob Dylan's "Blood on the Tracks", an album that transformed my musical tastes permanently and I could not believe any artist could be better.  Many of the artists of the 1970s like Paul McCartney and Elton John were still at the top of their games.Notwithstanding the success of the album Born to Run, Springsteen got very little airplay in Vancouver either on the AM top 40 stations or on the "album oriented" FM station I listened to.  He got very little play on the Seattle FM stations I occasionally listened to.  In the subsequent years I read stories about him.  He seemed a little different.  He had a saxophone in his band; nobody had saxophones in their bands.  In retrospect listening to Born to Run, it was so different from what passed for Rock and Roll in the 1970s that I can understand his lack of exposure.  I bought Bruce's album "Darkness on the Edge of Town" in 1978, the summer I got accepted to medical school.  I don't remember why I bought it, I think somebody told me that it was a good album and so I picked it up.  I think I bought Dylan's "Street Legal" around the same time.  Never really listened to that one as much as I listened to "Darkness".1978 was a dark time for music.  Disco had taken over the dance floors and the radio stations.  Rock and roll was heading down the toilet.  Paul McCartney was releasing mediocre albums, soon to become bad albums, likewise Elton John.  The Eagles had peaked with Hotel California.  Fleetwood Mac followed up "Fleetwood Mac" and "Rumours" with "Tusk".  Dylan was about to enter his Christian phase with the accompanying bad albums.  The Band had just (temporarily) stopped touring and releasing new music.  It was a dark time to be a rock and roll fan or for that matter a folkie.  It was maybe for this reason I reached out and bought a Springsteen album. I remember listening to "Darkness" as a life changing, least a musical life changing moment similar to what I experienced when I first heard "Blood on the Tracks".  Darkness became the soundtrack of my first year in Medical School.  I spread out, I bought "Born to Run".  Later I bought "Asbury Park" and the "Wild, the Innocent...".  Bruce still wasn't getting a lot of airplay in the late 1970s.  Then came "The River".  Some have criticized it as too long, a double album that could have been edited down to a single album.  No way.  Every song was a great song, the album worked conceptually, when that was important in an album.  Springsteen also moved into the mainstream with that album with [...]



Up date on you're fired.

2017-01-02T19:29:01.339-07:00

I posted on this last year.

It appears that this has been resolved and nobody is getting fired.

I did read a long statement with all the appropriate buzzwords by the Head of the Section of Anaesthesia in BC.

This doesn't really state who blinked, if anybody, although I suspect it was the docs who did the bending over.



60 Christmases

2017-01-02T19:21:59.163-07:00

Seems like every year brings some type of milestone event.  While I haven't reached 60 yet, this Christmas will be my 60th.  I don't remember the first two.  The third was the Christmas I had measles which I previously blogged about.  I have memories of that Xmas although they may be enhanced by the photos in the family album I have seen many times.  My first two Xmases were not documented perhaps with a 4 and 16 month old plus two other youngsters my parents may have had other priorities besides taking photos. I remember most of the other Christmases although some merge into one another.Growing up in Victoria, white Xmases were rare, rain was not uncommon and quite often we had quite a pleasant day.  These were a bit of a drag as your mother would shoo you outside to play when all you really wanted to do was to play inside with your toys.  An exception was the Xmas when I was ten and got a bike.  I had asked for one, I really needed one as the hand me down I was riding was too small for me and frequently needed to be fixed, but I didn't know whether I would get one.  On Xmas morning I got a note from "Santa" in my father's handwriting telling me he couldn't get my gift down the chimney but that I could find it in the basement.  Down in the basement was a black Raleigh 3 speed.  That Xmas I took advantage of the un-Canadian weather in Victoria to ride around the neighbourhood.My parents were always generous with presents, given that we had 4 children.   Presents were usually something we needed like my bike and when we asked for something in the fall we were usually told to wait for Xmas.  This usually worked out.  We never got clothes for Xmas; my parents believed it was their duty to clothe us and clothes were not gifts.  We of course also got a lot of a silly and fun stuff.  On the 24 my brothers and I usually went downtown to buy presents for each other with the allowance money we had saved.  This usually meant a budget of $1 per person and it was an interesting time time to find a gift in that range.  My parents of course always bought other presents for us and there were presents from the relatives.My mother who I think (hope) loved Xmas spent most of December buying presents and baking.  She also made Xmas dinner single handedly.  This included fruitcake which she started in November.  She made enough that we could eat it all year.  When we got married, my wife at my insistence, made fruitcake until we both came to the conclusion that nobody actually likes fruitcake.  There was of course Xmas pudding which is almost as bad as fruitcake which my mother made lots of and we ate all year round.Xmas dinner came with the crackers which came with a little toy and a funny paper hat which we always wore throughout supper and into the evening.I stopped believing in Santa Claus when I was 7 and a kid in our class who was a year older told me.  I should have figured it out.  I had stopped believing in the Easter Bunny already.  I remember when I was younger, my mother told me I couldn't get out of bed as I might scare Santa and lying in bed with a full bladder in the early morning afraid to leave my bed.   I also remembered going to see Santa at the Bay and being scared.  Santa who was a little gruff, noted when I got on lap, "I saw you in line and you looked scared, why is that?"  I worried for the rest of the season that I had upset the Big Guy.We always had a family picture taken at Xmas.  Initially we all posed under the tree holding our favourite toy and in one photo you can see me pointing the toy gun I got at the camera.  Later after somebody sent us a Christmas card with a family portrait, my mother decided that we would do the thing and we for y[...]



End of Life

2016-10-25T14:21:05.287-06:00

The final scene from the movie "The Barbarian Invasions"A year or so ago courts in Canada ruled that people have a legal right to what was then called assisted suicide and is now called physician assisted death but what is what used to be called euthanasia.  They gave the government a year to come up with a law.  Our former Tea Party government diddled around with this and it fell on our new government to come up  with a law.  The law they have come up with is predictably unpopular with both sides of the argument which some people would interpret as that it must be a pretty good law. I generally disapprove of whatever you call it but as soon as you make arbitrary statements, all the what ifs come into play and these issues are rarely black and white but are rather shades of grey. I could expound further on the ethical issues but all kinds of other people who are able to use terms like beneficence and non-malfeasance and actually understand what they mean are already expounding in the medical and lay press.  I work in a Catholic hospital.  While the Catholic church has historically had no qualms about killing heretics, Muslims, Jews, or Protestants; the idea of ending the suffering of somebody with a terminal condition seems to stick in their craw.  This is problematic because our sister hospital has 95% of the palliative care beds in the region.  We are assured by our medical director not to worry because most of the PAD will be delivered in the patients' homes because apparently  in the universe he lives in, patients still die at home.This does give me an opportunity to muse about my experience with end of care.The concept of euthanasia is not by the way a new one.  I remember having a discussion of it in Grade 10 English class of all places Anyway as an intern I was towards the end of 8 unhappy weeks on Internal Medicine when we had an unfortunate patient admitted to our service in the evening.  This poor man had been otherwise well until a few days ago when he developed back pain and as we like to say, his bone scan lit up like a Christmas tree.  He had some type of untreatable cancer in his bones and he was deteriorating rapidly.   Now no death is really a good death but we could say that he had had an active life almost up to the end, unaware of what was going on in his bone marrow and that by presenting late in his disease, he was spared weeks of chemotherapy hell.  I doubt he or his family saw it that way.The medical resident (actually a second year family practice resident) told the patient and his family that there was nothing that could be done and that we would keep him comfortable with morphine until the cancer took it's course. That was when one of his daughters yelled, "what you are talking about is euthanasia!" and ran out of the room. Nowadays that would generate an ethics consult, a palliative care consult, a week of chemo and possibly an ICU stay but in 1983 we didn't do that so he got IV morphine which was a relatively new concept then.  Instead of just running an infusion or having the nurse give the med IV (the patient might die?) the intern had to inject 10 mg of morphine every 4 hours.  That meant every 3rd night that was me.  On a q4h schedule, that meant a midnight and 0400 injection.  Generally you were up and around at midnight but at 0400 you were generally trying to catch a few minutes of sleep.  After almost 2 months on 1 in 3 call you would sell your mother for a few extra minutes of sleep.  As it happened I was on call on the above patient's last night on earth and after the midnight injection, I asked the nurse if she might consider a sc injection.  (From a pharmacokinetic point of view, sc injections would give a more steady state morphine lev[...]



I am (or I guess I am not) a leading physician of the world.

2016-10-25T13:56:54.433-06:00

This fellow had a similar experience to me and blogged on it.In case you are interested in becoming a leading physician of the world, here is the website. I am not sure how I got into this but it may have been while wasting time on  Linked In or I may have responded to a random email.  I must stop doing this.Anyway I got a phone message today, informing me that they had reviewed my information and I was now a leading physician of the world, as long as I phoned the toll free number they left me.  I had a hole in my clinic and so I phoned the number and after some time on hold, I talked to a lady who went over all my information and asked me some questions, like to what did I attribute my success.  I am not actually certain whether I am in fact successful or what I attribute any success.  I suspect being born white, and English speaking, into a middle class professional family at a time when University tuition was affordable had a large amount to do with it. As the clock ticked away on the phone call, I was beginning to wonder how an organization devoted to the noble cause of identifying the leading physicians of the world supported itself.  I soon found out as the nice lady started asking my about whether I wanted the platinum or diamond plans and the costs of these.  I realized what I should have know all along that I was being scammed.  I therefore told the nice lady that while 10 minutes ago, I had not been busy, I was now busy and that perhaps she could email me the info.  She didn't want to do this and so I hung up on her so never got to hear about the gold plan like my cardiology colleague, let alone the silver or bronze plans which no doubt exist.Anyway I have failed again to grasp the brass (or was it platinum or diamond) ring and will have to content myself with being an ordinary physician. [...]



The Demedicalization of the Caesarian Section.

2017-02-27T11:12:57.361-07:00

First off, I am not in favour of natural childbirth.  I am interested in history so when I visit places that have a history, I occasionally visit graveyards.  I am always struck by the number of young women buried next to a newborn baby, because the mother and baby died in childbirth.  In Cuba when this happens, the baby is buried with the mother between her legs.  This is natural childbirth and if we want to accept mothers and babies dying as a natural occurrence, we should embrace this.  Having said all this in my lifetime the Caesarian Section rate has gone from 20% to 30% with very little decrease in maternal or foetal morbidity or mortality.  It is at the same time well documented that materanal morbidity is increased with caesarian section versus vaginal delivery. I was on call recently and did quite a few sections which gave me some time to reflect on this.We do almost all our sections under regional nowadays.  This is a major change from when I was a resident where the majority of Caesarian Sections were done under general.  We would always see the patient the night before and try to convince them to have their section under epidural which was how we did them then.  Now patients are told by OB they are having their section under spinal and it is very rare to have a patient demand a general (some "experts" in OB anaesthesia think we now do too few GAs).  Sections under general anaesthetic were always a major stressor at least as a resident and even as a junior staff.  The patient would be awake in the room, the OR team scrubbed and the belly prepped and draped.  You would pre-oxygenate the patient and the nurse would apply cricoid pressure after which you would inject a pre-set dose of pentothal followed quickly by succinylcholine.  You would then attempt to intubate the patient, this was made difficult by the fact that you had to work with the drapes and one hospital where I trained made things especially difficult by insisting on using the ether screen.   ("Fortunately ", we didn't have a pulse oximeter for most of my residency; it was probably when we and the OB saw how low the sats went that regional began to be pushed more aggressively.)  The pregnant airway is as we are all told more difficult and I shudder to think of giving GAs to the BMI 60 patients we routinely see now for sections.  The fact that a significant number of these GAs were in the middle of the night or you had had to drop everything and rush up to do it added to the stress.As I mentioned sections are now done exclusively under regional and it must be at least two years since I did a GA section.  After we put in the spinal or top-up the epidural, the patient is draped, the block tested and then the father is invited to come and sit at the head of the bed.  This is not always the husband/father, it could be the mother, a sister or a friend.  I remember on occasion having two people in the room but I suspect infection control has blocked that. Under regional, the sections are little more relaxed as there is not the race to prevent baby from getting some of mom's general anaesthetic drugs and in 5-10 minutes we have a baby.This is when what I call the "love-in" starts.  Everybody's IQ drops about 20 points, everybody coos how beautiful the baby is, the father is invited over to the bassinet to cut the cord, photos are taken etc.  Our hospital now does skin to skin.  Such a beautiful and special moment.  Except.....The mother still has a large abdominal incision and a big hole in her pregnant highly vascular uterus.  There is still the matter of getting the placenta out which may or may not be easy.  And there are little issues[...]



First Do No Harm

2016-09-18T09:34:25.732-06:00

There was recently an article published in a leading newspaper, referring to opioids, entitled "First Do No Harm".  I have discussed is this in the past and may again in the future, however the use of this adage struck me. I first heard this adage way back in medical school referring to anaesthesia and the fact that anaesthesia contradicts this principle.In fact when the urologist discovers after the patient is asleep that the patient passed the stone already or the orthopod after the patient is asleep realizes that maybe he should have examined the patient or at least looked at the X-ray  and all the patient needs is a cast, I reassure them.  "Anaesthesia is good for you", I tell them.  I hope this makes them feel better but  most surgeons have no conscience anyway.The fact is in medicine that we are constantly exposing patients to harm in the hope that we will make them better.   We are in effect betting the ill effects of a treatment versus the likelihood of helping the patient.The House of God had it down with rule XIII:THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.This of course isn't always in the patient's best interest either although is probably in their best interest more often than we think. For example how often do you hear an doctor justify a procedure or test by saying, "I didn't no what else to do" or "Well I had to do something".  I have been guilty of this back when I was in general practice, in the pain clinic and quite often in anaesthesia when things are going south, how often do we try something random which we know probably won't work.  Here's some questions to ask yourself.1.  Based on your assessment is the patient going to die within the next few hours without treatment?2.  Do you have any idea of what is going on and will either the test you order help make the diagnosis or does the procedure or treatment at least have a reasonable chance of stabilizing things.  But speaking of aphorisms, what about the Hypocratic Oath.  A patient advocate asked me about this oath a few months ago in connection with an op-ed he was going to write.  "First", I explained to him, "Many doctors, including me, have never taken the Hypocratic Oath."  Some schools have an elaborate oath taking ceremony.  My school didn't.  Am I a worse doctor for that?  "Secondly, " I went on, "there are multiple versions circulating including a modern version."  "Thirdly", I pointed out, "Many of the things proscribed in the Hypocratic Oath are actually part of medicine, like cutting for stone, administering noxious substances (chemotherapy, anaesthetics) and abortion (controversial but still part of medicine). ". The Hypocratic Oath also has things like treating your teacher(s) for free.  We have socialized medicine in Canada and I work in a city where I didn't train, but that doesn't mean I would be interested in treating pro bono the 100 or so physicians who taught me.About 20 years ago, I bought a handsomely bound of the "Aphorisms of Hypocrates" which now sits in my bookcase along with some of the other handsomely bound historical books from the same series.  And I read the Aphorisms.  I can tell you that if you practised in the Hypocratic fashion, it is a question of who would get you first, the licensing body or the lawyers.  I often wonder why we place such importance on the thoughts of somebody who practised over 2000 years ago.  I do like reading the history of medicine if only because seeing how wrong prominent physicians were in the past, puts into the context the modern practice of medicine. I think we need to spend less time worrying about doing no har[...]



Things that make my work worthwhile

2016-09-13T11:27:17.450-06:00

My wife just read my last blog post.  "You sound like a crabby old man" she said.  Well for a number of years I worked with a lot of crabby old men (and a few crabby old women); sadly or not many of them have retired and there is a niche that needs filling because just as mosquitos and wasps are important parts of the ecosystem, COM just might be an essential part of the OR ecosystem.About 2 years before I left of CoE, things were at a low point and morale was horrible in our department.  While the causes were at least to me pretty obvious, the solution was to hire a consultant to find out what was wrong.  I am not sure whether our department or the hospital paid for it.  Anyway those of us who wanted to meet with him were allowed a one on one meeting which I enthusiastically signed up for.  As most people who are earning $400 an hour are, he was quite pleasant.  So for about 30 minutes I detailed everything I thought was a problem with the operating room, the surgical service and the anaesthetic department.  At the end of this rant, he asked me, "why do you still work here?".   I thought about it and said something to the effect that I had been there for 10 years, I knew the place, I liked most of my co-workers and that I really hoped that things would get better.  I didn't say that I wasn't really sure I could get a job anywhere else, that the case mix at the CoE was so different from other sites that I wasn't sure that I could handle a different case mix and that I realized that the grass was not necessarily greener elsewhere.  A report which I never saw was duly produced, some minor cosmetic changes were temporarily introduced, things continued to get worse and I decided that maybe in fact I could handle the case mix at another place and that the grass was greener elsewhere.  The one thing I remember about coming out of the meeting with him, was how good I felt having let it all out to somebody besides my poor wife.But there are all lot of things about my work that make it all worthwhile.  Not in order of importance by the way.  1.  The sight of my hospital in my rear view mirror at the end of the day.  (Okay it gets better.)2. Being part of a team.  Sometimes we don't feel like it but we are part of a team and we can't function without each other.  That doesn't mean we always get along or have to get along but it is great to work towards a common purpose every day.  It is great when for example we get a heavy urology list and we all work through it together, finishing on time or when we all work together on a really sick or dying patient.  3.  OR nurses.  I have worked with these men and women for 30 years now counting my residency.  I still find it incredible the way they can handle multiple surgical instruments, and complex electronics flawlessly, anticipating the surgeons' next moves.  On call I find it amazing that the same team of nurses can flawlessly go from a complex Ortho case, to a general surgery case and then to a urology case all with radically different equipment and requirements.   Or if I ask for a piece of equipment I maybe use once every 3 years, they can usually find it.4. The jokes.  OR humour is probably the funniest and most inappropriate humour around which is why I can't give any examples.5.  Patient contact.  We don't get much of it in anaesthesia but we get more than we are given credit for.  I really like talking to patients pre-op going over their history and explaining things.  I know I am sometimes brief and perfunctory.  I even like the stupid patients or the ones who clearly aren't pa[...]



Things that really bug me

2016-09-13T11:25:01.589-06:00

Some of the people at work complement me on my relaxed laid back demeanour.  I would rather they complemented me on how intelligent and handsome I am but I have to take whatever complements I get.   Under that calm exterior lies a smouldering pit of resentment.  Let me air my grievances.1.  Electric beds.  Not electric OR beds, but I will get to those.  I am talking about the electric beds from the ward.  It does make sense to reduce the number of times patients are transferred and so some patients go to and/or from the OR on these beds.  Except, these beds are never at the same height as the OR bed which means plugging them into an electric outlet.  Of course they come with ridiculously   short power cords (short enough not to reach the wall but not short enough to not trip over) which means finding an extension cord so that they can be plugged in.  Did I tell you most of the beds in our hospital now have two plugs both of which have to be plugged in, so now two extension cords.  Aside from the fact that we really don't need two more things to trip on in the OR there is a potential electrical hazard here.  When I was a resident we had to learn about electrical safety and it seems that by law most devices in the OR are elaborately grounded to prevent shock to the patient and staff.  And apparently if you use an extension cord, this exposes the patient to micro or macro shock.    (Like I said, I learned about electrical safety, I didn't say I understood it.).  Oh and the new beds come with a piercing alarm which goes off if the bed is unlocked while plugged in, like for example when you are pushing it towards the OR table so you can move the patient.   A lot of this could be fixed if the beds came with batteries which our OR beds do and which the hospital beds in the hospital in Ecuador where I sometimes work do (the floor nurses would still forget to charge it) or if they allowed the option of manually raising and lowering them without plugging in the bed.Electric OR beds I for the most part like.  I miss strengthening my legs pumping up the table.  I don't miss wrecking my back bending over to crank the handle.  The only problem I have is with the surgical princesses who insist on moving the bed up and down side to side every 5 minutes.  Cuts into my phone call, Internet and of yeah monitoring the patient time.2.  IV poles with more than 4 legs.  Space is limited in the OR.  OR tables are rectangular as are beds and stretchers. This means that the right angle of the IV pole with 4 legs fits in nicely against these objects saving space during cases or when you are taking the patient to recovery room or ICU.  Life was good the universe was in balance.  25 years ago the first 5 legged IV poles appeared.  Now they seem to have taken over.Sadly this picture is typical.  Look at them:  three  5 legged poles (and in the background a lonely 4 legged pole)Proponents of these claim they are less likely to tip over.  As we all know, if you load enough infusion pumps, blood warmers etc onto on of these, they can and will tip over especially if you add a urology size bag of fluid or two.   They will tip over most likely because some clumsy oaf like me trips on the legs.  And suggesting that adding legs makes them more stable shows a lack of knowledge of geometry because as I learned in Grade 7, three points define a plane which is why for centuries milk maids use three legged stools because they don't tip over.  Not to mention tripods.3.  Infusion pumps.  Okay I use infu[...]



More idiocy from Infection Control

2016-08-10T10:50:41.115-06:00

A couple of recent experiences on call thanks to our tireless infection control department.

A few months ago a patient presented for surgery.  A year ago she had Vancomycin Resistant Enterococcus.  This was cleared and she had negative cultures.  So she presents in the ER requiring emergency surgery, can't remember what, maybe a hip fracture.  Whoever did her history and physical noted that she had VRE.  Had can of course be present or past tense.  Notwithstanding her negative cultures on goes the yellow gown and we have to go into full paranoia mode in the OR.  Before the case, I ask the charge nurse, "can't we just call infection control and explain and get the isolation precautions lifted?".  No of course because it is the weekend and infection control doesn't work on weekends.  Silly me.

To our credit both the surgeon and I ignored the precautions which means there are probably multiple incident reports floating around.

Next a month or so ago the charge nurse informs me that the surgeon has booked a cholecystectomy.  But.... the patient has been to a hospital outside of Canada and by hospital policy has to be treated as a possible antibiotic resistant carrier.

So I am trying to imagine in what third world hell-hole she found herself in hospital.

Answer:

Phoenix Arizona.



Doctor do you ever make mistakes?

2016-05-31T18:19:02.849-06:00

A few weeks ago a patient asked me an intelligent question.He was in the OR, the checklist had been done, IV started, monitors on and he had even had a sniff of midazolam.  That was when he looked up and asked me, "tell me doctor, do you ever make mistakes?" The circulating nurse was at the head of the bed and heard this, so I had to answer.  Here's what I said, "yes I make mistakes but I try to detect them early and fix them right away."  And then I gave the rest of my induction cocktail.   After he was asleep, I said to the nurse, "any doctor who thinks he doesn't make mistakes is dangerous?"This made me think about the nature of mistakes.  During my time as site chief I was of course involved in QA or QI and dealt with a lot of mistakes but never really got a handle on the best way to deal with them.   We read all the time about patients dying as a result of medical errors.  So let's look at mistakes.Giving the wrong drug is an obvious mistake.  This can be like giving adrenaline instead of atropine, or phenylephrine instead of oxytocin; two mistakes I have heard of.  This is unfortunately too easy with lookalike drugs and the tendency to change suppliers on a weekly basis.  A few years ago I was having dinner with a bunch of other site chiefs and we started talking about the drugs we had heard of injected intrathecally by mistake.  These included ondansatron  (the only thing that happened was a failed spinal) and tranexaminic acid which should have caused a problem but didn't fortunately.  These are situations where you inject something other than what you thought you injected.There are also times when you inject a drug which turns out to be a mistake.   Obviously these would include giving a drug to which the patient is allergic to, giving Pentothal to someone with porphyria or succinylcholine to somebody with MH.  Giving way too much of a drug to a little old lady could also be considered an error, one I think we have all committed.  There are errors of judgement.  Giving a muscle relaxant to a difficult airway is one such case.  This is often a judgement case; the previous neck dissection is pretty obvious, the person with a small chin not so much.  Some errors of judgement are immediately obvious.  Others only become obvious on reflection either by yourself or frequently by somebody else who is reviewing the case.   Sometimes things look a lot more obvious in retrospect.  There are of course errors of omission.  Missing something in the patient's history.  Not making sure you have the right equipment or not noticing the blood pressure dropping to mention a few.There are of course times when you do something because you think it is the right thing to do and it isn't.  Take giving metoprolol for high risk surgery, or tight glucose control.  Remember flecainide and tocainide?  (Actually those were over 25 years ago most people don't).  One of my staff when I was an intern insisted on running IV lidocaine on our MI patients; the worst tongue lashing of my career came when I failed to restart the lidocaine after somebody stopped it.  Turns out IV lidocaine actually increases mortality.  Still waiting for the apology.  Then there is homonal therapy.  There are lots of treatments which we are still using that are going to be shown to make the patient worse.  My money is on proton pump inhibitors as the next culprit.There are also complications of medical care that may or may not be due to mistakes.  We accept wound infe[...]



Oh by the way it's called Medically Assistance in Dying Now.

2016-05-22T19:55:43.342-06:00

Afterall why use one good word (euthanasia) when you can use 4 words especially when you get a pretty good acronym out of it (MAID).



I Call Bullshit

2016-04-15T06:17:45.369-06:00

I don't often call out patients.  Something about bedside manner that we sort of learned in medical school.  But a recent encounter with a patient makes me think maybe we should all do it more often.I was sitting in a multidisciplinary assessment of a patient in a clinic where I work sometimes.  Now I believe many of this patient's concerns about her condition are quite valid and I have a lot of sympathy for her plight. She was going on about how for health reasons she only buys food directly from farmers she knows or eats game that her husband and she hunt or is hunted by people they know.  I have no problem with this.  I like to buy some but not all of my food at farmers markets often paying 50% more and while I don't hunt, I am not against hunting and if somebody offers me game I always take it.  I should support somebody who is trying to be pro-active about their health.  Except.....She smokes 2 packs of cigarettes a day despite now having COPD.  I had been letting my colleagues run the interview until the alarm from my BD became too loud in my head.  5 years of administration has increased my BT but this was too much."If you are concerned so much about what you eat," I said, "why do you continue to smoke, given all the harmful chemicals in cigarette smoke."  She replied that she had smoked for 30 years and was unable to stop.  The visit went on and I don't believe she came back for a follow-up.  OK, I am busy enough and maybe I couldn't have helped her anyway.  I also appreciate how difficult giving up smoking is, because really with all the evidence about how dangerous it is to your health, everybody who is capable of stopping has.  A few years earlier, I had another almost identical  patient and never challenged her on this but maybe I should have.  This encounter made me think however.  Are we hurting patients by not challenging them on their beliefs or behaviours.A good example is the resurgence of vaccine-preventable diseases.  Now many of the patients/parents are not going to listen to reason, however how many family docs or paediatricians knew of patients in their practice, who had not been vaccinated and never challenged this because calling bullshit goes against our concepts of bedside manner plus you depend on the income from their office visits (and if you are in a small town, the visits of their friends and relatives).   Sure, most of them wouldn't have listened but maybe a couple would have.   Call bullshit. Obesity.   Look I weighed myself yesterday and I am pretty upset with what I found, not that I am going to forgo the Chinese buffet for lunch today.  But when your BMI 60 patient tells you, they do know why they can't lose weight because they don't eat anything, why not tell them that just to maintain that weight they need to consume 6000 calories a day and unless they have evolved to develop the capacity to photosynthesize, something is obviously going into their mouths.  And when they say they can't exercise because of their knee or back pain, tell them that exercise doesn't work without caloric restriction.  I have a lot of sympathy for fat people because I am one of them and I know how easy it is to gain weight and how difficult it is to keep it off but the odd person does this successfully and if you don't challenge them they might not get started.  So call bullshit. Drug allergies.  A few years ago while still department head, I got a letter from our Patient concerns offic[...]



Reefer Madness Part 4 and Another 15 Minutes of Fame.

2016-04-09T17:09:45.827-06:00

I just attended the annual meeting/course put on by the Canadian Consortium for the Investigation of Cannabiniods which I joined a couple of years ago.  I have prescribed/authorized medical marijuana for patients since 2001.  I do so in the context of my chronic pain practice and with some hesitation. A week or so on what must have been a slow news day our local paper announced in a front page headline story that a medical marijuana clinic was opening in our city.  Having commented on medical marijuana in the past, I had a feeling that I was going to be hearing from the Fourth Estate pretty soon.  While I do provide authorization for medical marijuana in appropriate patients,  I have a jaundiced view of medical marijuana clinics.  Over the past few years patients have informed me that for $400 a clinic somewhere else in Canada will give them a "Skype interview" after which they will get an authorization for medical marijuana (under the old regulations) and usually are able to buy product from the affiliated grower.  https://medicalmarijuanaservices.ca/medical-pot-clinic-offers-doctor-visits-via-skype-metro/I am not sure what the Skype interview consists of; holding their wallet up to the camera on their computer maybe.  This is sleazy practice, and I usually offered to complete the paperwork for "free" if I think they are appropriate candidates.  There have been incidents like this:http://news.nationalpost.com/news/canada/how-one-doctor-made-500000-as-canadas-top-medical-marijuana-provider-until-police-came-knockingI also increasingly believe that chronic pain should be managed in a multidisciplinary fashion not in silos of care such as medical marijuana clinics or for that matter the block shops we have in our city.  Unfortunately opportunities for multidisciplinary management are difficult because while health care in Canada is "free", physiotherapy and psychology are not.  Further for lack of resources, I and the loosely affiliated group of physicians I practise with  have an 18 month wait list for consults which even by Canadian standards is excessive. Our thankfully former Tea Party government who were of course anti-drug were most distressed by the concept of anybody using marijuana but were bound by a court decision, so came up with a solution that is probably the one thing in their 10 years in office that actually worked.  Instead of patients trying to grow their own marijuana (which most of them were not very good at) buying it on the street or from the lone government approved supplier, growers would be able apply for licences to supply patients who would get "prescriptions" from doctors.  I had previously discussed this in another blog.  The advantage of this system is that patients can now buy cannabis from facilities that are inspected by the government and that the THC and CBD content of the product is known which allows doctors and patients to select products of known potency.  This has resulted in about 30 companies, some large and some small being able to provide medical marijuana and according to the man from Health Canada there are 2000 applications to become licenced producers.  Anyway, it wasn't long before I was contacted for an interview.  This came from a reporter from one of the free newspapers people read on the bus or in coffee shops.  A little down market from my usual encounters with the press but there is no bad publicity.   I basically told him what I had said above.  [...]



An-hockey-donia

2016-04-06T09:29:26.264-06:00

I recently realized that the season is almost over and I haven't watched a hockey game from start to finish.  Last Saturday I watched the beginning and end of the Toronto Boston game but turned the TV off for a leisurely supper before turning back on to watch Boston hang on for the win.  I didn't bother watching the second game of the Saturday night double-header.I used to love hockey.  As a child, teenage and young adult, I never missed a chance to watch a game on TV.  I had season tickets to our local NHL team for 4 seasons.  Now if I tune into a game, I quickly find myself looking to see what else is on either on other stations or Netflix.  If I watch a game, I am usually reading a book, the newspaper or on Facebook.  On the other hand, I still read the sports section, and check scores in the evening on my computer.   It is not a distaste for sports in general either.  I still watch the CFL and NFL.  I love watching the Olympics when they are on.  This comes at a time which should be the golden age of hockey watching with a game on TV just about every night of the week, and a minimum of 2 on Saturday night. If you look at the quality of play, the skaters are better, more mobile, faster.  I just can't seem to get excited.  I was trying to figure out where my passion had gone.  There are reasons; some of them are things that have bothered me for years, some are new.I know the NHL brass read my blog so.......The season is too long.Not a new problem but the season has in my lifetime gone from 70 to 84 games.  Way too many.  I remember in the 1970s the players union offering to take a 1/8 paycut to shorten the season to 70 games which the owners turned down. This doesn't explain why I don't seem intererested in October either.  The playoffs are way too long.The first year I watched hockey (1964) the playoffs ended on April 29.  I remember this date because instead of watching game 7 of Detroit-Toronto we had to go to dinner for my mother's birthday.  I also remember in 1968, my brother telling me that because of expansion, there would actually be hockey played in May.  Crazy I thought. Okay there were only 4 teams in the playoffs not 16, I understand.  But hockey in June.  Most of Canada and a significant amount of the US have 5-7 months of winter and the last thing we really want to do is to spend time indoors watching playoff games.  Its not just that there are twice as many rounds, it is the leisurely pace they seem to schedule games mostly to accomodate TV.  I remember in the 1970s they actually started the playoffs with 4 games in 5 nights (quite often with games 3 and 4 played Saturday night and Sunday afternoon).   That's right teams were often eliminated within a week of the playoffs starting.  Now there are frequently 2 or 3 nights in between games and frequently up to a week between series.  This is at a time when players are actually a lot fitter than they were in the 1970s. And, when the NHL added the fourth series in the mid 1970s it was initially a best of 3 series which was extended to a best of 5 series when they went to 16 teams in the playoffs.  And yes, there were upsets where an inferior team eliminated a better team just like there are with best of 7 series.  That's why we have playoffs otherwise we could just give the Stanley Cup to the regular season winner and we could all enjoy our springs.  Major League Baseball s[...]



You're Fired

2016-03-30T16:34:41.509-06:00

Most of us told the Medical School admission committee that we wanted to become doctors so we could help people.  This is of course true only in the sense that outside of the most evil, selfish person everybody wants to help somebody.  This is hard-wired in our biology and soft-wired in our upbringing.  There are much more easier and cost-effective ways of helping people than 4 years of medical school and 2-5 years of residency.People assume that we went into medicine to make a lot of money.  Again if we had wanted to make a lot of money, a much surer route would have been a Commerce/Business degree, Law or Dentistry.  Or I could have not taken my brothers' advice and gone into Computer Science (I would have graduated in 1979).The main reason most of us go into medicine is for the job security.  On that day in June in 1978 when I got my letter from medical school, I knew that unless I messed up badly, I was set for life.  Having said that, I have been out of work at times in my career usually only for a few weeks at a time when I was a family doctor.  When I finished my residency jobs for anaesthesiologists were thin.  I got one, but when I was sitting my oral exams I was the only person of the 8 who sat the exam on my day who had a job after residency.   Into the 90s residents who finished in our city endured months of locums, or picking up a day here and there before gradually sliding into a stable position.  Currently there are a number of specialists in Canada looking for work.  I met a former neurosurgery resident who switched to family medicine (where there are lots of jobs for now). who told me, all the surgery residents are told up front that only 50% of them can expect to get jobs when they finish.  The fact that so many of them soldier on in the face of such odds is a testament to their tenacity and love of surgery or perhaps just confirms what I have always felt about the intellect and insight of most surgeons.  However surely once you get a job, you can't be dislodged from it unless you really mess up?A couple of weeks ago a group of Anesthesiologists in British Columbia found out.  I do not know all the details and if someone will enlighten me I would love to publish it.  They had apparently a long and possibly acrimonious battle with their hospital over Obstetric coverage on call.  (They are not the only such hospital in BC, at one hospital the anaesthesiologists threatened job action, which didn't go so well for them.). This resulted in the hospital mailing to each anaesthesiologist a letter informing them that in one year's time their hospital privileges would be revoked.  The exact significance of this is unclear.  Someone I communicated with told me that probably the people who administration saw as trouble-makers would not be brought back (and that those who came back would come back on the hospital's terms which would I presume include agreeing to covering Obstetrics in the way the hospital wanted). .  There is still a bit of a shortage of anaesthesiologists in Canada.  The area is question is a nice enough if quite expensive place to live and from comments in the media, administration and the government do not expect to have any trouble finding scabs to work there should they fire a whole bunch of people.  (And if you think on principle, doctors, if the position is attractive enough, won't replace doctors who have been [...]



Unmasked

2016-03-30T16:32:18.632-06:00

When I was a teenager, I liked to watch professional wrestling.  I knew it was fake but as somebody told me, you will rarely see such good acting.  I used to watch every Saturday morning on CBC.  This was not the steroid fuelled, crotch grabbing, fancy hairstyle wrestling that became popular in the 1980s.  These were men with pot bellies usually wearing briefs and calf high boots.  There were the local wrestlers who were there all the time and a rotating cast of villains and heroes who came for a few weeks.  This included by the way a younger Jesse Ventura. One of the villains was a masked fighter named appropriately Mr X.  He teamed up with the other villains such as "The Brute".  He was also claimed to be an American and loved to insult Canada, not popular in the 1970s very nationalistic Canada.  It came that Mr. X was to fight "Gentleman Gene" Kiniski "Monday night at the Gardens". The Saturday morning broadcast (actually taped the previous Tuesday) served to promote the weekly card at "The Gardens" an arena somewhere in Vancouver.  There was a twist to the fight.  If Gene Kiniski who sported a crew cut and wrestled in briefs, lost, Gentleman Gene who was well into his fifties, would have to "hang up his tights".   If Mr. X lost he would have to remove his mask and reveal his indentity.  Now usually fights like that were set up to end in a draw so that nobody would have fulfill their end of the bargain but the people who scripted All Star Wrestling decided it was time to unmask Mr. X, who duly lost to Gene Kiniski, who wrestled for many years after.  As I read in the sports section of the Vancouver Sun, which actually covered pro wrestling, the following Tuesday afternoon, Mr. X was actually Guy Mitchell, a Canadian.  This probably wasn't his real name either but Guy Mitchell formerly Mr. X wrestled on All Star Wrestling for the next year or so as a hero.  As an aside Gene Kiniski owned a bar in Point Roberts which I visited years later.  This is a long winded introduction to announce that after 8 or so years of blogging anonymously I have decided to unmask, sort of.I started this blog about 8 years ago, sitting home on New Year's Eve on call but with no work to do, the family down in the dacha.  I originally intended to write about politics and life.  I had been a very active member of the left wing discussion forum "Babble".  A few months later, I started reading medical blogs and this interested me so I started writing about what I know.  I kept things anonymous, largely so that I would have freedom to write exactly how I felt without having to be confronted the next day at work by somebody I had inadvertently or intentionally insulted.  In addition, unlike most anaesthesiologists, I do some direct patient care and really wasn't interested in my patients Googling me and reading my blog.  I chose Bleeding Heart which was the name I used on Babble.  Bleeding Heart Liberal was a term I believe was used by Spiro Agnew or Richard Nixon although according to Google it originated in the 1930s.I could have done a better job covering my tracks.  I have lived and worked in enough Canadian cities that I could have convincingly pretended to work in one of them.  I really didn't think anybody was going to read my blog.  Very early on, somebody contacted me stating that she had been able, using hints I had [...]



Rascism and the duty to accomodate

2016-03-15T09:24:28.893-06:00

A couple of weeks ago a patient refused to let one of my colleagues give her an anaesthetic because of his race.  What race is not important although you can probably guess.  The surgeon was very much less than supportive of his anesthetic colleague and the case went ahead after my colleague switched rooms with somebody of an acceptable race.  One of the OR nurses was disgusted and refused to work on the patient and she swapped out of the room as well. Of course when pressed, the patient denied being racist; she said she just wanted to know what his qualifications were. In case she reads this blog, my colleague was born in Canada, attended medical school in Canada, did a Canadian residency and has a Canadian fellowship. Admin got involved and we got a meeting with the VP of Ethics and Spirituality (yes such a position actually exists). It was a good meeting.  He started out by bringing in the CMPA's statement on you to deal with requests based on race.  It is the usual bland unhelpful document that the CMPA puts out.  Essentially racism is bad but try to accommodate the patient anyway. He then brought out the hospital's policy which essentially said the same.  Historically this situation raised its ugly head when women from a certain religion refused to have male doctors look after them in Obstetrics (presumably male nurses too although these are rare in OB).  This is of course a problem because while the woman can go to female GP or OB; doctors do share call and take time off plus male residents also rotate through OB and are expected to deliver patient care.  The solution was to meet with the local leaders of said religion and also to consult said religion's holy book, which aside from some vague statements about modesty was fairly tacit about whether women could or could not have physicians of a different gender. Anyway periodically when up in the labour floor I will see a sign on the door stating no male staff.  I have been involved in 2 incidents personally.  The first was when I was doing a booked C section.  The usual practice at our hospital is that we see the patient for the first time in the OR, usually sitting up waiting for their spinal.  This is not ideal, but it is how we do things and nobody is stopping anybody from finding the patient in their room pre-op.  I walked around to face the patient and was struck by her facial expression.  When seeing patients pre-op you can see a variety of facial expressions, nervousness, fear, hope, happiness.  What I saw on this patient was hatred.  "She doesn't want a male doctor," said one of the nurses, "but we told her she had to have one."  L+D nurses have never heard of patient autonomy.  I mentioned that had they called me earlier, I probably could have swapped with one of the female members of my department.  Not that I should have to of course and the case went uneventfully.  About a month later I was finishing a C section when the nurse stuck her head in the door and told me I had a retained placenta next door for a GA as soon as I was finished.  The patient when I arrived in the room was quite upset at my presence (this doesn't happen normally) but again the nurses told her she was bleeding to death and I was the only available person. This lead to a discussion.  During the day you can usually find another person if the patient is un[...]



The Cancer Card

2016-03-03T09:36:29.736-07:00

A while ago while still site chief, I got embroiled in a dispute between a department member and a surgeon.  (Wow like that never happens).This was over a patient presenting for a mastectomy during the summer.  The patient was obese, had COPD and sleep apnea and now had a URTI.  My colleague listened to the lady's chest which apparently sounded gross, asked another colleague for an opinion as to what to do and then cancelled the case.  "What?", said the surgeon, "you can't cancel the case, she has cancer".  She cancelled the case anyway.  Letters ensued.  Now the real issue was that it was summer and the surgeon was about to embark on 4 weeks of vacation so it wasn't like he could do her next week but there are solutions, like for example asking one of his colleagues to do her next week.  I wasn't there and never got to listen to her chest which may have actually been the best it had ever been for years on that particular day.  Maybe I or another of my colleagues might have just bitten the bullet and gone ahead.  One thing I do know it this.  When you do a case against your better judgement and things don't go like you prayed they would, nobody thanks you.  Or as my former professor told me, "the object of anaesthesia is not to see what you can get away with."Later that year while still chief I was involved in mediating a problem between the administration and my department for which nobody has thanked me  (and which probably got me fired).In Canada we have waiting lists for surgery which can be anywhere from days to months.  This causes a lot of angst.  Surgeons generally prioritize cancer cases although not always.  So it came that there was a report in the local press about lung cancer patients dying while waiting for surgery.  Thoracic surgery is of course a little more complicated than other cancer surgery, especially as they insist on doing everything through a scope now, so OR times are long, they usually require ICU or some type of high intensity unit post-operatively etc, all of which limits the number of cases that can get done.  Typically I have found that when waiting lists are long, it is more than a question of available resources, it is also a question of failure to prioritize and quite often lack of organization often by the surgeon's office.  The other issue is that despite advances in surgery and oncology the outcome for lung cancer no matter how quickly and expertly it is excised is pretty grim anyway.  That is why I am glad I don't do thoracics anymore.  You would bust you ass for 2-3 hours trying to oxygenate the patient, not to mention the occasional massive bleeding and then read the obituary a few months later.Our health authority's response to this bad publicity was to announce extra money to do extra cancer cases.  Any type of cancer case, not just lung cancers.  This was not a problem for the other hospitals in the city which have unused ORs.  They did off course have to find anaesthesiologists which was a bit of a problem that nobody thought of but these were recruited.   Our hospital which runs at 100% capacity was a problem. Our hospital's solution was one that is becoming more frequent.  Extend the OR day by two hours to accommodate the additional cancer cases.  This sounds like an easy solution except for a f[...]