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.  




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

Image result for hippocrates

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.

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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 type 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 like amniotic fluid emboli and pre-eclampsia.  Further the OB is probably going to exteriorize the uterus which means that means that your patient is going to get nauseous and if the block is the least bit patchy, uncomfortable.  She may also get hypotensive from the spinal and from the blood loss.  In other words, your patient is not out of the woods and may need your attention still.

This happened to a colleague of my a few years ago.  I don't remember exactly what happened but he felt he needed some help with the patient and so asked for assistance from one of the nurses.  The love in was still in process and the nurses ignored him accidentally or intentionally.  This lead to him raising his voice (his version) or yelling (their version) and he got written up and had his wrists slapped.  I wasn't there and only heard his version so I can't really comment.

This is a difficult issue to discuss because a Caesarian Section is life saving for the mother or the baby in some circumstances.  Just how often is the question.  Certainly not 30% of the time.  A lot of women really wanted have the perfect labour and delivery and push out their baby and when in their best interests we have to section them, they may feel that they have failed and we don't want to reinforce this.  At the same time we read about the "too posh to push" mothers who chose to have a section rather than even attempting vaginal delivery.  There are probably variants of this and I imagine discussions going on in the OB office where the prospective mother states her concern about the difficult labour of her sister, friend or mother and states that if things look like they are headed that way, she wants a section.  I am not sure whether these discussions happen, I strongly suspect that they do and a significant number of "failure to progress" or "non-reassuring tracing"  sections are as a result of these discussions.

The demedicalization of the Caesarian section, benefits mostly the OB who no longer feels guilty (assuming they are capable of that) when she does a questionable section, because she wants to get back to her office, go for dinner, not have to hand off the patient etc, doesn't have to worry about depriving the mother of a wonderful birthing experience because after all a section is a birthing experience with mom awake and the father or whoever invited to participate.  

My argument is that by making the Caesarian Section less medical, more routine and more pleasant we are making it too easy and maybe we need to find some type of balance.  Not holding my breath on that.

Tuesday, September 13, 2016

First Do No Harm

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 harm and more time stopping using outdated and irrelevant aphorisms.