Sunday, April 9, 2017

Does one battle define a country?

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.

Tuesday, March 28, 2017

Drug Costs

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 that cost $100 used to be considered expensive, now $1000 to $10000 is not unusual.

Monday, February 27, 2017

End? of paper

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 possible to access just about all the blood work and X-rays going back 15 years.   In addition you can get every medication dispensed to the patient.  As well anything that is dictated in a hospital system is accessible.  I can't imagine how I lived without it.  However you still cannot access anything done in a private office and in addition there are quite a few physicians who handwrite their consults and admission histories.  Progress notes which are still handwritten are not available either.  Still way better than the old days when the patient would come in saying he was taking a blue and a green pill and wanted to discuss his MRI results which you didn't have.  NetCare is easy to get on in the hospital, less so outside of the hospital where you need a key fob and a lot of good luck to get on.  (I can access my own chart on NetCare, I'm not supposed to but I do, it is after all my medical information.  My family doctor was horrified when I told him this and set me up with a patient portal where I can access my records, legally but why should I have to memorize another set of log-ins).

Mostly where I have been using EMRs have been low volume practices and I am looking with some horror at my hospital clinic tomorrow where I typically see 24 or so patients.  The EMR people assure me that they will be on site and I have done the appropriate training and have set up the appropriate shortcuts that will make charting easier for me.

I have heard that EMRs have lead to dissatisfaction in doctors that have them, although doctors have a lot of reasons to be dissatisfied and in the 30 or so years I have been in practice I have never seen any doctor completely satisfied with all the aspects of his/her practice.  EMRs certainly are cumbersome, usually requiring multiple log-ins, and their tendency to randomly shutdown or kick you out of the system.  The EMR I am using today refused to let me write prescriptions under my  name, I got around this by printing the prescription under someone else's name and then crossing it out on the paper copy.  I have been assured this will be fixed today.  You do have to remember that paper charts were not the greatest either, trying to decipher your handwriting or looking for labwork that may or may not have been filed were definitely hassles not to mention the effect on patient care.

I have recently been doing a lot of medicolegals which mean a lot of chart reviews.  These have given me to opportunity to compare both paper and electronic charts.  Paper copies of electronic charts have of course the advantage of being legible.  The quality of the information is not better and potentially a little worse as I suspect a lot of doctors are typing with two fingers.  Most EMRs have shortcuts or macros available and I notice that these are being used quite a bit.  For example many family doctors have a macro for their yearly physical exam (notwithstanding the fact that nobody advocates a yearly physical, most patients seem to get one done, if only because the doctor can bill for it).  I have for example reviewed cases with severe neck or back pain, well documented in the progress notes who when they present for their yearly physical will have a completely normal exam documented on the obviously computer generated record.  This is I am sure going to cause problems when somebody less understanding than me reviews the chart.  I have also heard of instances in hospitals where people are cutting and pasting other people's consults or progress notes.  This is of course okay (if a little lazy) if the original information that was cut and pasted was valid, however the old saying garbage in/garbage out comes to mind.  False information, (alternate facts) of course persisted under paper charting as well.

The other issue I notice when I review medico-legal charts is the incredible volume of paper they can generate especially if the patient is admitted to hospital.  For example, at the hospitals in another city which has EMRs, each lab test is printed out on a separate piece of paper, likewise nurses notes.  This results in a huge chart, which if I get it in paper, means lots of turning pages and a high risk of paper cuts and repetitive strain injuries.  Lawyers tend to do fishing expeditions resulting in large amounts of irrelevant information.  I get paid by the hour so I shouldn't mind but the hours available to me are finite and I know that somebody is ultimately paying for this.  Logically when they get the request the hospital would give me a time sensitive log-in to their system for that one patient's chart so I can review on a computer.  It is after all the 21st century.

Fortunately or unfortunately an EMR for anaesthesia or AIMS as they like to call it seems to be years away.  We did spend a great deal of time getting ready for one about 5 years ago with multiple meetings however suddenly without even a whimper the whole process just ground to a halt. I don't see any sign of it restarting and I don't expect to be using it before I retire.

When people express fear or dissatisfaction about EMRs, I remember a story a specialist told me when I was a resident in Newfoundland.  He had started his career working in a remote community as a general practitioner in the 1960s.  When he arrived, he found that the clinic there did not keep any patient records.  He was appalled and told the staff that they would have to start keeping charts on patients, with the result that the entire staff resigned in protest.

Like all changes in healthcare, we will survive this and patient care might even be improved.


Monday, January 23, 2017

Bruce &. Me

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 a top 40 hit.  I didn't mind sharing him with others, it made me feel cool  thinking I had listened to him way back when.  "The River" is the soundtrack of the second half of medical school for me.

Bruce Springsteen wrote about working in factories, unplanned pregnancies and New Jersey.  He didn't write about growing up middle class in Victoria, going to good schools and going to medical school.  There is no way his music should have appealed to me.  It did though.

I finished Medical School, and went to Halifax to intern.  One day I was browsing in a record store on Barrington street and there it was, another Bruce Springsteen Album.  "Nebraska", so different from his other albums except possibly "Greetings...". I bought it and listened to it obsessively.  It became the soundtrack of my internship.   It was like the Bob Dylan album he should have been releasing at that time, except it was by Bruce Springsteen.       

I finished my internship and bummed around doing locums in the Maritimes.  I taped my Springsteen albums and listened to them on the tape deck in my in my car.  When I wasn't working, I used to drive around the backroads of Nova Scotia and New Brunswick just exploring.  Sometimes now when I hear a song off those albums I think about those drives.  I met my future wife and starting making trips back to Halifax where she lived from where I was, usually with Springsteen on the tape deck.

I got engaged in 1984 and Springsteen released "Dancing in the Dark".  Just a coincidence I'm sure.  Suddenly he was a superstar with Top 40 hits and MTV videos.  He started playing and selling out stadiums.  If I had been in Vancouver when he sold out BC place, I would not have been able to get a ticket. 

I got married, failed in general practice and went back east to Newfoundland to do a residency.  Springsteen also got married, just coincidence.  Mid-way through my residency he released "Tunnel of Love" a depressing if listenable album.  

Musically I was evolving.  I used to have a 30 minute commute to work, where I listened to the Rock FM station.  One day, I decided I could not take the talk and the bad music and switched to CBC FM which played classical music back then.  I pretty much exclusively listened to classical music for the next 5 years. A surgeon in the OR used to play the blues during his marathon cases.  I acquired a taste for the blues.  

I had my first child, finished my residency and got my first job in Fredericton.  I had another child and moved to Edmonton.  Somewhere around that time Springsteen released 'Lucky Town" and "Human Touch" simultaneously.  I of course bought them just like I used to buy Paul McCartney and Elton John's album when they came out, but the bloom was off the rose.  The first year I was in Edmonton, Springsteen came to Edmonton (without the E Street Band) and I didn't even try to go.  

I went to the Edmonton Folk Festival because I wanted to see Elvis Costello but stayed for the whole weekend.  I learned that folk music wasn't just a bunch of people singing Kumbaya, it was vibrant, interesting and it was the root behind the music I had loved in the past.  I started buying CDs from the Folk Festival CD tent and listening to CKUA, our province's public radio station which played that kind of music.  

Throughout the 90s Springsteen was a lesser part of my musical life.  I figured it was the natural order of things.  One can only be great for so long.  I had grown, he had grown.  I still bought the albums,  I bought his box set "Tracks".  My listening habits changed.  I got an MP3 player and started playing my, by then, large collection on shuffle.

Along the way, I had never heard Springsteen play live.  I interned with a fellow who had the fortune to see him play the El Mocambo club in Toronto in the mid 90s.  Actually he had seen him there for 2 consecutive nights.  His long shows were legendary.  I was jealous.

There is only one thing that I am thankful to George W. Bush for.  In 2002, I was going to Cannes on a Big Pharma junket when Bush Jr., decided to invade Iraq in search of weapons of mass destruction.  Because we all knew that Saddam controlled world terrorism I was afraid to fly and cancelled my flight.  Bruce Springsteen just happened to be playing in Edmonton during the time I was supposed to be getting brainwashed in Cannes and he hadn't sold out so my wife and I bought tickets.  They were just over $200 each, the most I had ever paid for a concert.  The tickets were general admission on the floor what used to be called festival seating. (In his book Bruce notes that early on his band never allowed festival seating for fear of a stampede to the stage).  We had to line up in cold sleet before being herded into the stadium where we were able to grab territory in front of the stage at about the blue line.  It was a long wait for the concert to start made worse by not being able to leave the primo real estate we were standing on.  

There is really no way to describe a Springsteen concert.  You really have to be there.  Being on floor relatively close to the stage, it felt like I was watching in the small club.  The entire E Street band was there and the whole affair felt like a giant party.  There were of course the 3 encores.  

I had a few months prior to the concert bought "The Rising" but had never really connected with the album.  When I heard the songs from the album performed, they suddenly made sense and the album was for a while an album I listened to a lot.

I left with my bond with Bruce restored.  It was an amazing experience.  

In the next few years, I reflexively bought the albums Bruce released regularity often at Starbucks.  They are for sure not as good as his first 5 albums.   Then again how many artists can claim to have 5 great albums.  Did we expect Einstein to come with another theory of relativity.  

Then as I mentioned above I read Bruce's biography over a couple of days after Christmas.  I have satellite radio and decided to to listen for a few longer drives.  The one thing that struck me which should have struck me earlier was what a good lyricist he is.  Many of his songs tell a story in a rhyming but never forced fashion which few song  writers including Nobel laureate Bob Dylan can boast of.  

It has been an almost 40 year journey during which I have grown from Top 40 pop to more eclectic tastes in music.  Bruce Springsteen has been an important part of that journey.

Monday, January 2, 2017

Up date on you're fired.

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.

Saturday, December 24, 2016

60 Christmases

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 years all posed in front of the mantelpiece.  Someone would set up a camera on a tripod and used a time release which never worked and the photo sessions went on forever until we got a workable picture (or so we would find out a week or so later when we got the photo back from the drugstore).  We never did send out a card with a family picture.

Christmas day was a day spent mostly in the living room playing with our toys. These stayed out on Boxing Day. December 27, my father usually went back to work and gradually the living room got tidied up until, sometime towards New Years, my mother told us to take our stuff to our rooms.

I remember my first Xmas away from home when I was an intern.  I was in Halifax and assumed that everybody in Canada outside of Victoria and Vancouver had a white Xmas.  The weather in Halifax that winter was a lot like what I had experienced in Victoria, maybe a little bit more miserable.   I had some hope Xmas eve when I looked out the window of the ICU and big snowflakes were coming down but they didn't stick or last and I believe I walked home the next morning in a drizzle.  Getting home, I opened the presents my parents had thought to send, had a bit of a nap before heading over to a friend's house for turkey dinner.  All in all it was a pretty good Xmas.

My first Xmas with my wife and each of the first Xmases with our two children are of course memorable. 

I had the good fortune to not have to work on Christmas day often in my career.  The first year of my residency my wife was working so I volunteered to work and we had the turkey on the 24th.  Work was as I remember quite light that day and I mostly watched TV all day and into the evening.   We brought in leftovers from the day before and my wife and I ate together in the cafeteria.  

One year before I started my residency I was doing a locum in Victoria and staying at my parents' house.  The clinic I was doing a locum for told me (they may have asked but I think they just told me ) I was on call from them and two other groups for the Xmas week.  This consisted of mostly answering phone calls, making house calls and making the odd ER visit.  They did give me the name of a physician who could cover for a few hours if I needed.  It came on the 27th that I decided I would really like to to have dinner uninterrupted and phoned said individual.   "Why do you need me to cover," he asked in an English accent.  "I would like to have dinner", I replied.  "As it happened", he came back, "I am going out for dinner and if it comes to between your dinner and my dinner, I am going to take mine."  I suppose he couldn't help himself, he was after all English. 

For most of the past 20 or so years our family have spent Xmas at the dacha and this has become our Xmas tradition.

Tuesday, October 25, 2016

End of Life

Image result for barbarian invasions movie
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 level, which I should have thought of).  She of course laughed in my face and at 0400 the page came, I went to the bedside, she handed me a syringe which I injected slowly and went back to bed.  At 0500, I got the page to pronounce death.  "Aren't you glad you got up to give him that injection IV instead of sc", the nurse said.  "What the hell was in that syringe you gave me,"  I replied.

The second episode was early or late in my career as a rural GP.  It was my first weekend in a small BC interior town and I was on call.  Friday night I got a call about a patient with ALS who was at home.  I made a house call and listened to his chest and he had pneumonia.  The one thing I remember was that he was watching the playoff hockey game and I remember thinking, "too bad he's not going to find out who wins the Stanley Cup this year."  Funny the things you think.  I prescribed some oral antibiotic and went home to watch the rest of the game.  Sunday evening I got another call and made another house call and he was really in a bad way.  I called the ambulance which took him to the hospital ER and I could see that he was not going to survive the next few hours.  At the same time his wife seemed quite adamant that everything be done which left me in a dilemma because everything that I had been taught told me that you don't ventilate ALS patients ever.  I called his family doctor who worked in the same clinic at home because I figured he knew the family well and could come in an talk with them.  "Oh" he said, "Do you need help intubating him?".  I muttered something like I didn't really think intubation was appropriate and besides we didn't have a ventilator at our hospital.  Anyway it looked like his wife wanted everything done so we called in a nurse, loaded him up in the ambulance and sent him to the referral hospital an hour away by road.

I talked to the nurse, who went with him, later and she said that they almost intubated him at the referral hospital before they realized that he had ALS and he died shortly after.

I think about how better the whole case could have played out, how he could have died at home surrounded by his family or at worst in the local hospital surrounded by his family instead of spending the last hour of his life in an ambulance.   He might have even been able to watch a little
hockey.

His wife came in the next week to see me and I told her how sad I was that her husband died and she shot me a look that said, "Fzck you" and asked for prescription for Valium which I gave her.

Shortly after that I decided rural (or for that matter any) general practice wasn't for me so I went in the anaesthesia where we don't have to deal with end of life issues except of course for the six months of IM I had to do which had some really interesting end of life issues, one of which I blogged on years ago.

Somewhere along the line the whole euthanasia debate got hijacked by the concept of "passive euthanasia" which was if you didn't try every single futile treatment, that was the same as giving someone a massive overdose of barbiturates or whatever.  So over the past 25 years we now have end of life patients in ICU, or getting futile surgical procedures.  One third of the beds in our ICU are dedicated to ALS patients now.

Anaesthesia is in fact quite often involved in end of life care as I will outline below.  This scenario or something similar is not uncommon.

Granny is dying of colon cancer at home.  She has been seen by the palliative care team and is doing great until she develops a bowel obstruction.  Instead of taking her to the hospital with the palliative care unit, where they know her, she gets taken to another hospital.  There the ER doc or the internist calls the surgeon who without seeing the patient agrees to do a laparotomy/enterostomy.  The patient is told she is having a quick general anesthetic where she will have the obstruction relieved by a small incision.  She is seen in the receiving area by the surgeon and you for the first time.  In the OR, of course the tumour is stuck to the abdominal wall and bleeds, or the surgical resident perforates the bowel and all of a sudden cachectic Granny has an incision from her pubis to her xyphoid and the you know she is not going to breath post-op.  You could call ICU but you can already hear the peals of laughter from them when you ask for a bed.  So you take her out to recovery on a ventilator and the recovery room nurses are really pissed off at you. (The surgeon is meanwhile telling the family that she is being ventilated because of the anaesthetic.)

The bottom line here is that other people on your behalf made promises they didn't have to keep, she was just having a quick case, she wasn't going to die today.  Had you seen her, you may have said otherwise but you weren't invited to the discussion.

The other issue is that Granny is a DNR or whatever you want to call it (we have a very complicated Goals of Care document in our region).  Technically you can just turn off the ventilator and watch her struggle for minutes to hours until the hypoxia/hypercarbia trigger the final lethal arrhythmia.  You could even sedate her a bit.  Nobody really wants to see that though. I've turned off the ventilator on organ donors enough but somebody that you talked to an hour so ago?  Not sure about that one.

The other scenario is the pathologic fracture and the ensuing tumour embolus.

This is not to say that either patient shouldn't get surgery.  A bowel obstruction or a pathological fracture can be pretty incapacitating.  The issue is that in that population there is a high risk of death or requiring ventilation post-op and this is something that needs to be discussed with the patient and their family and never is.  Granny for example might elect for an NG tube and a lot of morphine or a radiologist might be able to do something percutaneously.

When I was on the admin dark side, some people came to our Medical Advisory Committee to discuss the above Goals of Care document.  I took the opportunity to express my concern about these scenarios and the fact that we are never invited to these discussions.  "Yes, that is a problem," said the nice lady and went on to the next question.

The final issue is that having decided it is okay for doctors to kill people under circumstances how do we actually go about it.  Because as I blogged in respect to Capital Punishment it is really hard killing somebody when you really want to.   I mean those of us who do "monitored sedation" know how easy it is to make somebody apneic and occasionally cause a cardiac arrest but when you really want to kill somebody it may not be as easy as you might want.

As I understand currently the practice would be to administer large doses of oral barbiturates.  20-30 years ago getting barbiturates was easy.  About half the population were on them as sleeping pills.  We even gave them to pregnant women.  If you gave somebody a months supply of Seconal you usually gave them enough to kill themselves.  Now if I order a lethal dose of a barbiturate, the pharmacist is probably going to ask some questions.  He may even refuse to fill your prescription. (A significant number of pharmacists refuse to dispense the morning after pill, presumably these people may have some opinion on euthanasia)     That plus in some provinces barbiturates are on the triplicate prescription program.  Assuming that you have gone thru the proper procedures for physician assisted death, you won't necessarily get in trouble but you may get hassled.

Of course getting somebody who has a swallowing problem or who is drifting in and out of consciousness to swallow all those pills is going to be a little difficult.  That is why probably a lot of euthanasia is going to be intravenous which has its own issues because IV access is not that easy as I find out once a week or so. 
  
The other issue is that a lot of the euthanasia candidates are going to be narcotic tolerant which means you are looking at bigger doses.  Dose is a problem because you can give a huge dose and still not kill somebody.  (I remember a story in medical school which I hope is an urban legend about somebody who took a huge dose of horse tranquillizers and woke up days later on the stretcher on the way to have his kidneys harvested.)   I have a friend who is now a retired anesthesiologist in Holland who tells me of GPs coming to the OR to "borrow" some pancuronium and everybody knows what they intend to do with it.

Looking forward into our brave new world of legalized euthanasia or physician assisted death (because why use one word when you can use three) who is going to be doing the killing?

I think a lot of doctors are already thinking, I'm just going to call anaesthesia, they have all kinds of cool drugs and besides we already blame them when somebody dies.  I think most of the leaders in anaesthesia are trying to keep a low profile lest more people think that way which is too bad because we as a specialty should be part of this debate.

There are the evangelical physician advocates of PAD who are already active and will probably do a good job of it  although there are not very many of them.  Knowing doctors as I do too well, I predict the following scenario.

We have socialized medicine in Canada which means that doctors who euthanize patients will expect to be paid.  This means that a generous fee will be negotiated, because this has been mandated by a court decision provincial governments will pay whatever is demanded.  This means a certain class of doctors, who we all know, are going to realize that they can make a killing out of killing people and it is they who are going to be doing most of the PAD.