Wednesday, 10 July 2019

Ancient Obstetrics!

Obstetrics-the state of the art 70 years ago!


   When I started learning how to deliver babies there was no ultrasound, there were no fetal monitors, x rays were considered dangerous and not very precise. Epidural anesthesia was unheard of. Most deliveries that were considered to be uncomplicated took place at home.
   I recall coming into my office one Monday morning to find an X-ray pelvimetry report on my desk that stated, "There is gross disproportion between the baby's head and the pelvic inlet. This delivery will require a Caesarian section."
   In fact I was called at three o'clock on Saturday morning and barely got there in time for the delivery which proceeded without difficulty.
   Medical students in the world famous Rotunda Hospital got rigorous hands-on training, much of it in the slums of Dublin, 'on the district' as home deliveries were called. The 'delivery suite' might be half of a one room apartment with a sheet divider crudely hanging so as to divide the room in two. The pregnant woman and the 'delivery team were on one side of the sheet, while the husband and the kids (often several) were on the other side.
   Behind the screen was the bed, often sagging and dirty and cleaning that up and preparing it for the forthcoming event was one of the duties of the medical students - usually under the watchful eye of the midwife, who ruled us with an iron fist. The bed needed to be stripped and a rubber sheet placed on top of the mattress and well tucked in so that the mattress, which may have to last a long time would not be destroyed with blood and amniotic fluid. To stop the fluids overflowing , on top of the rubber sheeting several layers of newspaper to sop up the excessive fluids. Over this was placed a single sheet on which the pregnant woman would lie and eventually give birth.
   In those days, Caesarian Section carried a substantial risk and women often laboured for a long time. It was before the philosophy of "Never let the sun set twice on a contracting uterus" and it was not unusual for a woman to be in labour for two or three days or more, with all the attendant risks.
   Once contractions started the husband or one of the kids would jump on their bicycle and race to the hospital. None of these patients had telephones.
   "My wife (or Mammy) is going to have the baby. Send the doctor right away."
   What they got was a midwife and a couple of students. The midwife was in charge and we were there to evaluate the situation. Was the woman actually in labour? Was the baby's head engaged (down into the birth canal)? What position was the baby in?
   She taught us how to do the initial evaluation, how to do a proper pelvic examination, how to talk avoiding embarrassment for oneself and the patient. If the woman was not in well established labour the midwife would go on her way with a comment that she would be back in an hour or two after she called on some other patients in the vicinity who had recently given birth to see how they were feeling.
   "I don't think she'll be doing much for a while but if the is any problem there is a public phone just half a block away and you can call the hospital for help. ".
   This was long before the day of the cell phone and none of the patients had telephones. So two or three of us terrified students were left in charge barely aware of which orifice the baby might pop out of.
   The midwife made sure we were instructed in the patient's medical history
particularly her obstetrical history. She would instruct and supervise each of us (2 or 3 students) in doing a pelvic examination emphasizing the need to assess cervical dilation and the necessity to determine the fetal position.
   "She's not very dilated, is she?" inquired the Midwife. I had no idea.
   "Er. I don't think so,". I tried to sound as though I at least had some idea of what I was doing.
      "What about position?"
      "Er. I'm not sure." I said stupidly.
      She told me what I should looking for.
      And so it went. We students learning all about the dramatic high forceps maneuvers in rare complicated cases that we would never be called upon to do, by high powered hospital Actor-specialists and learning the vital common everyday obstetrical skills which we would need as GPs from the midwife.
    We also learned a great deal about life in the slums of Dublin and the influence of the Roman Catholic church that caused the poor and unfortunate to become even more poor and unfortunate. Ten, eleven, twelve and even thirteen children was not uncommon. I once delivered a woman of her seventeenth child and more than once I cared for a woman and daughter about to give birth at approximately the same time.


Come back in a couple of weeks and I'll take you with me on one of those adventures!
      

 


Thursday, 27 June 2019

The Pool without John.

 

  The pool without John ain't what it used to be.  Sure, I know lots of good folks and am friendly with a few but that exceptional relationship only occurs a very few times in the life of lucky people.  
   His son phoned me a couple of weeks ago to say that the hospice where John died was having a memorial evening and reception in memory of those who had died recently.  He invited me to attend and I did.  I know all his five children and they marveled as do I at the closeness of our late-life friendship.  Not many people are fortunate enough to forge such a friendship at our advanced age.
"We all wondered how two such different guys could have such a close relationship?" his daughter said to me at the  reception.  It's true.  He was an observant Christian (though I was never able to find out to exactly what specific order).   I am an non-observant Jew, so we had some good religious discussions.  He used to say to me ,"If you are right I have nothing to lose, if I'm right you're in big trouble!"
  In politics he leaned left, I leaned right.  We discussed those topics too, occasionally generating more heat than light, but that didn't matter either.  We discussed other things too, that I'm not going to tell you about here and we were never, ever, Politically Correct.
  We had a lot of laughs.  He told me cop stories, I told him doc stories and we were old enough to laugh at our youthful mistakes and misadventures that had long since ceased to be sources of embarrassment.  When recounting stories of some of the things that didn't work out he would say, "failure, the second best lesson!"
   Most of those discussions took place in various inexpensive restaurants nearby wherever we had been swimming. (see above photo) For a while I took notes and when the waitress inquired what I was doing John would tell them, "my friend is a blog writer, he's probably going to write up your restaurant."  Needless to say, he didn't tell them that my blog only had a half-dozen followers!
   Given his talent for exaggerating a little in his story telling, John, whose surname was Dell, would maintain they were not exaggerations at all, they were just 'enDELLishments.  
   Sometimes when we were lunching out my daughter in Toronto would phone.  I would immediately lose the phone while they chatted away for a few minutes.  John and Rena never met, but when his son was playing in a production of 'Les Mis' in To, he presented Rena and Bill with tickets.
   In the last few months when he wasn't up to swimming we played a lot of pool.  He was quite a good pool player despite having very poor vision in one eye.  When he played a particularly brilliant shot, he would turn to face me and triumphantly announce,"Not bad for a blind man!"
   Despite multiple medical disorders, he never complained, (except to swear mildly when he couldn't do something he thought he should have been able to)  He continued planning and doing for as long as he could. 
   In true Churchillian fashion he never surrendered; he never gave up.
   
    






























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Sunday, 16 June 2019

Pool Fools

We Pool Fools develop a strange, almost family-like relationship. We look out for each other and if someone doesn't show up for a while we ask anxiously:
"Have you seen X recently?"
We are not all old and not all hypochondriacal but we are mostly sufficiently 'with it' to recognize that a common reason for failing to show up is inability due to death or disease.
Now, don't get me wrong. We are not all living in fear of a visit of the Grim Reaper. Far from it. Most of us will do justice to our visit from him, when he catches up with us. No, we want to know that our erstwhile friends haven't found a better swimming pool or, (perish the thought), a more fascinating group of swimmers / bathers to immerse themselves in the water with.
As I stepped into the pool today I encountered a woman of about my own age who was a regular swimmer.
"How are you doing?" I asked.
"Oh not too bad," she answered. "It is getting a little harder to drag myself out of bed and get my joints moving. She laughed and added, "I think I'm going to try a little marijuana."  
She wasn't joking.
"Better be careful, " I said. "Some of it can be pretty strong nowadays".
"Oh my friends and I have researched it pretty well." she explained. "Some of them have tried it out already. The just use the mildest stuff. They seem to think it's quite good. I haven't tried it yet."

None of us had seen Laura for months. She was well known to most of us. She was an exceptional swimmer with a lot of style who had put in forty laps of stylish and energetic swimming three days weekly. Not bad for a woman
with grown up grandchildren! Then I spotted her, but instead of cutting gracefully through the water as was her style, she was exercising carefully in the slow Lane and moving with great difficulty and discomfort.
"What happened to you," I asked. She looked awful.
"I was in an accident," she said. "I was nearly killed."
"What happened ?" I asked.
"We were going on a Trans Canada trip and I was riding on the back of his motorcycle," she said.
I gulped, (silently I hoped), at the prospect of this Grandma, no matter how young, riding pillion on a motorcycle on a cross Canada trip.
"We turned off the highway to check into a hotel, when the bike skidded out from under him and I flew off the back and that's all I remember. "
"You're lucky!" said I.
"Yes," said she, " I fractured vertebral bones in my neck. The doctor said I was really lucky that I didn't damage my spinal chord and become paraplegic! I'd rather have been killed outright than that."
"You were very lucky."
"Yes, I'm going to get a hundred per cent recovery no matter how hard I have to work!"
"Good," I said, noting that she had a long way to go . I moved on so she could carry on with her program.
I swam a few lengths and was just getting into my stride when Rick waved at me from two lanes to my right.. "Hey!" he yelled, "Haven't seen you for a while. Come over here and have a chat."
I sidled over two lanes. Rick likes to stay in the swimming lanes out of the line of vision of his athletic wife, pumping weights in the glass-walled exercise room upstairs from where she is able to keep an eye on him.
"She gets quite upset if she sees me just sitting chatting. She doesn't think I should stop swimming at all!"
Rick, probably in his early seventies now, went to University in the States on a football scholarship. He had done well but ended up with significant musculo-skeletal damage to his knees and ankles. He has difficulty walking but is quite comfortable pottering around in the water but is not committed to actually exercising. His wife keeps a strict eye on him to make sure he keeps moving, so he stays out of her line of sight as much as possible! I didn't keep him and just continued doing my laps.
 
Swimming laps can get boring at times so I have a few projects additional to elucidating the biographies of my fellow swimmers to keep me occupied while I complete my mandatory 'time'. I adhere to this quite obsessively, knowing full well that if I started wittling it down it would dwindle down to nothing in no time.
One of my favorite occupations is checking my cognitive prowess to reassure myself there is no significant deterioration setting in. I like to check my mathematical skills which were never great. As I watch the digital clock I do various calculations centering around how many seconds I have been swimming so far and how many more to go. Unfortunately the sequence sometimes breaks down mid-calculation and I have to start over again...... And again! When I succeed a couple of times I quit while I'm ahead and move on to something else, after congratulating myself appropriately.
I find learning a poem that I have been fond of particularly rewarding and useful. Firstly it is rewarding in and of itself, secondly, it is very much more impressive at Pen Club, when trying out someone's latest pen purchase to scribble a quatrain or two of Omar Khayyam rather than the traditional "The quick Brown fox jumps over the lazy dog."
My other diversion is thinking about my next blog.   I have four or five regular readers who I would not want to disappoint.
  So, thinking about my next blog content, Marathon Man and Dutch Jane spring to mind. I haven't seen them for a while.
So, perhaps next week - or next month, I'll tell you about them!!
Be sure to come back!! Or not!






Saturday, 8 June 2019

A WW2 Hero.



D - Day and other WW2 Heros.

   I remember in 1944 when I was nine years old, my mother's distress when she received the news that her first cousin Monty Rosenfield. had been killed in the battle of Anzio in Italy. Monty had already been wounded and awarded the M M, the highest award for bravery a non -commissioned office could get no matter how valiant his actions. A few months later, as soon as he recovered he volunteered to return to the front line, when he could easily and honorably have served his country in a safe environment.
   Monty was only nineteen when he left Manchester to join the International Brigade to try to save Spain from its fascist Church supported dictator, Francisco Franco. After resisting the British attempt to prevent him ('non intervention') he trekked over the Pyrenees to join the British Battalion. He was wounded while fighting to save Spain from a dictatorship that lasted for two generations.
   At the beginning of WW2 although volunteering for active service Monty, a corporal in the British Army was obstructed from serving overseas until the International Brigade protested this as discrimination.
 After his return to the front lines by his own insistence, this courageous man gave up his life for Britain, for Jews and for the 99 per cent in another act of bravery.
   I never met Monty but I remember hearing about him from  our mother when he was killed in action at Anzio in 1944.  He had been wounded previously and I remember hearing how he joined the International Brigade and went to Spain to fight the Fascists.
I remember his brother Arnold (known as 'Arkie) who was a newspaper reporter and subsequently editor of one of the English Daily newspapers.   He came to visit us when he was working on some story  in Dublin and I, about sixteen at the time, was fascinated having a real live reporter telling us entertaining stories behind the stories.  I also remember him tossing back a Scotch or two Dad poured him (just like they did in  the movies!)
   Monty was awarded the MM (Military Medal for bravery) and I believe another medal posthumously.
   I became interested in the environment in which  he grew up and found:
           A PhD research thesis on  Manchester Jewry, which I found very interesting and gave some acute insights as to what it was like to be a young Jew growing up in  Manchester at the time
  • BTW, Another WW2 hero in  the Family was Arthur Cowan, RAF  pilot who died in an air crash AFTER the war.  He's buried in Dolphin's Barn Cemetery in Dublin.  
  



Tuesday, 4 June 2019

Conscience & Medicine.

Here is an email I received just last week:

Dear ,


How would you like it if the government forced you to act against your conscience?

In the past, we could have this argument in an abstract way, likening that kind of behaviour by the state to totalitarian regimes that are distant to us in both geography and history. Today, however, this kind of tyranny is being forced upon the health-care workers of Ontario thanks to the highest court in the province.

The Court of Appeal for Ontario ruled on May 15th that doctors have to give referrals for euthanasia and abortion even if it goes against their deeply held religious or moral beliefs.

We pray that this diabolical ruling gets appealed and defeated at a higher court, but if it stays in force, it means that doctors across the province will need to refer their patients for abortions and euthanasia, thereby (in a very real way) taking part in these heinous acts.

TAKE ACTION: DEMAND CONSCIENCE PROTECTION LEGISLATION

We need to demand that the lawmakers in the House of Commons, our members of parliament, take this decision out of the hands of activist, left-wing judges, at least partially, and pass legislation to protect doctors from being forced to violate their consciences

Campaign Life Coalition recently launched an Action Alert Email campaign in support of MP David Anderson’s private member’s bill, C-418. This law will make it a criminal act, punishable by incarceration, for employers to coerce health-care workers into participating in euthanasia, including by forcing them to refer patients to another doctor who is willing to kill the patient.

You can visit our website, and, in under a minute, write your MP to ask that they support The Protection of Freedom of Conscience Act. This much-needed bill is expected to be debated around May 29th.

There are many great health-care professionals across the country who are deeply opposed to abortion or euthanasia for religious and ideological reasons. Unfortunately, because of this latest court decision, these good folks will have to find work in other professions in order to live with a clean conscience.

Conscience rights matter and so does your voice. Click here to send your email now.

For life,

Jeff_Gunnarson_sig_275px.jpg

Jeff Gunnarson
National President
Campaign Life Coalition
www.campaignlifecoalition.com



Campaign Life Coalition · Canada
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   Well, how would you like it if the Government asked YOU -  no forced you, to act against your conscience?  Perhaps, like many, you wouldn't care.   But you better realize that once your Doctor is no longer allowed to exercise his conscience, you are not going to like it at all.   Conscience is what keeps people, including physicians on the straight and narrow.  It is what makes people undertake responsibilities that they might otherwise avoid.  It is the judge that sits on our shoulder and adjudicates whether what we do is right or wrong.  It is a cruel mistress and regardless of what the man-made laws of the land dictates it will punish relentlessly those who do not take it into account.  Most, but not all of us, can discriminate between right and wrong.  When the mob wants something, whether it is marijuana, freely available late-term abortion or physician dispensed death (and that's just the beginning!) they will do everything in their power to get what they want.  When people of conscience stand in their way, they will do anything to undermine them.  Not satisfied with physicians whose morals prohibit them from  being a part of this movement, the rulers and the legal system wants to coerce physicians to submit or to get out of the profession.  (an arbitrator actually said that.)
   The  Government and the administridiots who serve them are determined to suppress anything that might undermine their nefarious plans in the interests of cost cutting and votes.  They will be quite happy to humiliate and expel from the profession  anyone who dares to stand up to them, particularly when principal and ethics are the motivators.  The Health Care system has been turned away from  its humanitarian 'raison d'etre' into a political vote gathering game.

The Court of Appeal for Ontario ruled on May 15th that doctors have to give referrals for euthanasia and abortion even if it goes against their deeply held religious or moral beliefs.


Canadian Medical Association Journal: 191 (22)From the Canadian Medical Association Journal.
Guidelines for withdrawal of life sustaining measures and Medical Assistance in Dying. Figure 1:

This is just the beginning. Amazingly, most folks don't seem to care until it involves them or their family. Comment if you have an opinion. Don't say I didn't warn you !!

Sunday, 26 May 2019

Don't shoot the Doctor!

   Just about five years ago I started warning you.   I warned you that euthanasia would be the thin end of the wedge.  I warned you that if you let the lawyers and administridiots decide that taking life is permissible, then they would want physicians to do the slaughtering just as they do with babies.  Politicians and administridiots, many of them lawyers are legislating when it is appropriate to take life.  Ours is a profession, dedicated to the preservation of life and the amelioration of suffering even when we can't cure the disease.  The Supreme Court of Canada, has just told physicians if you can't make your conscience acquiesce to what we tell you to do then you are free to seek another job!   If you won't kill people because the State tells you  it is what you need to do for the good of the 'State', Medicine is not for you!  Find another job.
   I warned you it wouldn't be long before scraping a few fertilized cells from the uterus would become morally equivalent with killing a newborn.  It has.
   I warned you that the indications for euthanasia would become unrecognizable and they have.  It is no longer acceptable to even use that word.  It slipped to 'assisted suicide' for a while, before that too became politically incorrect.   Now, ridiculously it has become MAID -Medical Assistance In Dying.  (After all, what sane person wouldn't like a maid?)
   The politicians and the administridiots are often very smart.  They start off cautiously when they support a new position assuring us their only motive is 'serving the people'.  Very often it is the bottom line they are concerned with..   It is very expensive to keep old people alive sometimes and if we can so easily dispose of neonates (the newly born) surely we shouldn't be too squeamish about helping the elderly on their way.  After all, they've had a long life and if they want to feel really good about it they can donate their organs while they are still alive.  Surely death by organ donation is as noble as one can get.
   Now let me give you one more warning.   Nepotism trumps everything, including money.  Even talking (or writing) about cannibalization indicates that's what some folks are thinking about.  After all, if my thirty four year old son needs a heart and your eighty year old father has one - hey folks, let's be reasonable, why should we spend a fortune on  someone who has had a good life and is going to die soon anyway.  "Let's give the 'old guy' a comfortable death," they say and give my son (who  happens to be a high-ranking civil servant who has served the state all his life) the break he deserves.   After all, he has so much more to offer the State.
   The 'Elites' are much more concerned with their own health, both physical and financial, than they are with yours.  I worked in the system for long enough to realize that when the CEO of the Hospital or whatever brought the deputy minister down to the 'Department' to introduce him  to  the Department Head, there was often another agenda.
   That's enough warnings for today, but fear not, I  have plenty more, not least of which is what will happen if the administridiots remain successful in determining the future role of physicians!
   If you are a patient or about to become one soon, don't read this blog.  It may kill you -sooner!
    
 

Tuesday, 21 May 2019

A failing health care system.

   When I decided to emigrate to Canada, it was partly because I felt that I could live with her Health Care System.  I had been an Assistant General Practitioner in a practice in THE London, where I  worked for a group of physicians I liked and respected.  They reciprocated the feelings, at least based on the references they gave me.  (I still read them with some pride fifty-eight years later!).  They offered me a partnership arrangement, based on the prevailing arrangements of the day, which  I rejected.   One of the issues that prompted me to emigrate was the increasing influence of the administrators of National Health Service of Great Britain, not only on the delivery of health care, but on the quality of that care.
   Friends and colleagues have often asked me over the years why I decided to come to Canada.  particularly those who know of my close family relationships in the U.S.  The answer is relatively simple.  I  felt that Canadian medicine represented the best of the British and of the American system, while avoiding the worst of both.   Alas my opinion has changed over the years as I have seen the steady deterioration brought about by the politicization of health care.   We have gone from being one of the best systems in the developed world to becoming one of the most poorly rated.  The Canada Health Act has condemned Canadians to mediocre medicine at best, to shameful neglect at worst.  Furthermore the hubris of elected officials has assured that Canadians have been prohibited from seeking health care privately as is available in most of the developed countries in the world.  For the most part that has forced patients who are dissatisfied with the public system to go outside the country or to seek one of the low-profile sources that manage to exist because the prohibitions imposed by government are being challenged in the courts.  Unfortunately, the administridiots now control medical care and have turned it into a political game in which votes come first and patient care comes last.
   All of which is the introduction to one simple example I am  going to  share with you.  Because, even in this age of pseudo-respect for confidentiality, nothing is private, I will avoid identifying persons in this story that a friend of mine shared with me very recently.  The following account does not presume to record the actual clinical events in detail, but rather to give an overview of  my interpretation of what Rose told me took place.
   It was approaching midnight when Rose heard a loud clatter coming from the bedroom.   It was unusual  for Tom to still be clattering around at this time of night, so she went  into the bedroom to see what might be going on.  She was not a person who panicked easily, but when she saw her husband spasming on the bedroom floor, she panicked.  Even under those circumstances she reacted quickly and efficiently.  She called 911 and ran to his side to help in any way she could.  By then, he had stopped seizing.   The emergency response was timely and appropriate and Tom was taken to the nearest ER for management.  Rose was not allowed to accompany him  in the ambulance, so despite being thoroughly shaken up, prepared herself to drive to  Emergency to be at her husband's side.   
   Fortunately her neighhbour had been disturbed by the ambulance and came rushing over to help.
   "I think Tom has had a stroke  and they are taking him to  the Emergency Room.  They won't let me ride in  the ambulance so I  am going to drive right over there now." said Rose.
   "You can't  drive anywhere in the state you're in.  Let me grab my coat and I'll drive you to the emergency room."
   She dropped Rose off by the entrance.  Rose went in and introduced herself . The Doctor had seen Tom and had arranged an emergency CT scan as well as X-Rays and blood work.   Many hours later, when the tests had been completed and  interpreted, the doctor came over to talk to Rose.
   "Your husband has two tumours," he said, "one in the brain, the other in his lung."
   " Oh my God, what do we do now?" she asked, deeply distressed.
   "He needs to be evaluated by a neuro-surgeon and we are going to set up an appointment.  Meanwhile you can take him home now and we'll be in  touch with you regarding the appointment."
   "Will someone be seeing him tonight?" she asked.
   "Oh no," said the doctor.  "We will have to arrange an appointment.  You can take him home now and we'll be in touch with you."
    Rose felt a surge of panic welling up inside her."What if he has another seizure when I take him home?" 
   "We have started him on anti-convulsants and I will write you a prescription to keep him on, so that will probably keep things under control for the moment.  If he did have anything further in the meantime just bring him back here."
   Shaken badly Rose called a taxi and took her husband home so she could worry herself sick about him.
   A week went by and Rose had heard nothing. She had to phone the Emergency Department and her family doctor who knew nothing about the event.  
   When I talked to Rose a few days later she finally had a date for the appointment which had not yet taken place. Her stress level remained as high as one would expect.
  Now let me tell you how this would have been managed in the 'bad old days' when  I was a family doctor:
  The patient would have phoned the clinic her family doctor worked in, where a member of the group was on call on a twenty-four hour roster.  The patient would  have been patched through to the on- call doctor who would have met the patient in Emergency, examined him and prescribed what was necessary. This patient would undoubtedly have been ADMITTED to the hospital for observation and management and would have been seen as an emergency consultation by the neuro-surgeon in the morning,   Meanwhile, the family knew the patient (yes, I still call them patients!) was at least in a setting where immediate attention would be available if necessary.  Thus the patient was in a safe place where he would be appropriately monitored and the family/caregiver was relieved of some of the stress in a high stress situation.   
   These changes have come about because the administridiots that the Government put in charge of health care are more concerned with votes and appearances than with patients and they know it is easy to download the blame to the doctors and nurses and other health care workers on whose shoulders the whole system is carried.  

Many people share stories like this one with me. If you have one you'd like to share, contact me.  Obviously no identifying data would be published.