Saturday 29 November 2014

Thursday 27 November 2014

House call part 2.

This is the final part of a two part post.  Read part 1 first.

      All three occupants of the room froze. I clutched my medical bag, with its considerable variety of drugs, tightly in my hands.  No one attempted to open the door. Again a loud knocking, this time more insistent, demanding an answer. I was just on the point of quickly opening the door, walking down the corridor and getting into the still running car,(we used to do that at 40 degrees below zero!) when with a loud crack, the front door flew open.  Two men stood in the doorway.  I sized them up quickly. One tall, fairly well dressed, tough looking, the other fat and rather shabby. I noticed that as the short, fat one burst into the room, his jacket swung open revealing a holstered gun.  Tomorrow's Leader Post headlines flashed in front of my eyes. "Young Physician shot in Drug Shootout"  I clutched my house call bag firmly in my hands. (If they got that, it was going to be over my dead body!) I decided that it was now or never. I pushed past the two men hoping they would be so busy with the occupants of the rooms they wouldn't bother with me.  I walked briskly down the corridor, head down, making for the car, with its engine running, warm.  I knew once I got there I would have no problem. I glanced over my shoulder - my god,they were after me!  I broke into a trot,and so did they! I felt a heavy hand laid upon my arm as I was spun around. The small shabby man's hand went to his holster. I wondered whether to run for it.
      "Sgt. Sam O'Hanlon, Regina City Police Dept.,"he said. "Afraid you got caught up in a drug bust,doc." He shoved his police department badge under my nose. "I just have to establish for the record that you didn't leave any narcotics at this address, so that when we lay charges they can't say that it was just stuff the doc left." 
         "No, I didn't leave anything," I said.
         "We may have to call you for evidence, doc." 
         I nodded "Okay ,will that be all."
        "Yeah,that's all, doc".
           I walked out to the car. It was warm and cozy, as I drove home.  I parked my car in the carport,and plugged in the block heater. I crept up the stairs so as not to waken the baby. On the landing I removed my clothes,slipped into the bedroom and felt the cozy warmth emanating from my wife. As I snuggled up beside her she stirred.
       "Have you got to go out,darling?" she asked.
       "No" I said.

Sunday 23 November 2014

A Deadly Habit.

      "A Deadly Wandering" by Matt Richtel is a true story that I recently listened to as one of the Audio books that I regularly go to sleep to, instead of taking sleeping pills.  I find that many audio books are quite soporific and lull me gently to sleep.  This one kept me awake. It dealt with a phenomenon  that I learned was 'Distracted Driving'.  This particular book dealt with a horrible disaster that took the lives of two men in the prime of their lives and almost destroyed the life a decent young man who initially didn't even realize the role that texting while he was driving played in causing the catastrophe.  If you chose to read the book, what I have told you won't spoil it for you.  This caused me to investigate that phenomenon and I was surprised by some of the things I discovered.  Distracted driving is defined as impaired driving  as  drivers' judgement is compromised when they are not fully focused on the road.  The list of the distractions are many, some obviously much worse than others.  Texting is probably the worst of these activities but there are many others.    The ubiquitous GPS  on every windscreen or dash, cell phone, maps, eating, drinking. applying make-up and even reading can all be powerful distractions.    Texting, takes the cake, driving while texting is six times more dangerous than driving while intoxicated, according to the U.S. National Highway Traffic Safety Administration.  They report that sending or receiving a text, take the driver's eyes off the road for an average of 4.6 seconds, the equivalent, when traveling at 55 miles per hour, of driving the length of an entire football field while blindfolded.  Not many folks would choose to do that!
   Texting in cars and trucks causes over 3000 deaths and 330,000 injuries per year in the U.S. according to a Harvard Center for risk analysis study.
   Fines, license suspension and dangerous driving charges may result.  So can sudden death.

Monday 17 November 2014

Generic drugs and patient safety!

     Although physicians and patients have been repeatedly assured that the government's bulk purchases of generic drugs are as safe and well monitored in their production as those of the original  pharmaceutical manufacturer, a recent investigative journalism piece by the Toronto Star would make it appear otherwise.  The Star states that most of their information came from the FDA which inspects Canadian manufacturers both in Canada and abroad. The information was made available to the Star under the U.S. freedom of information laws.  The Star uncovered that while the FDA is transparent because of the freedom of information laws, Health Canada is secretive and does not give any information of the problems that it finds during individual inspectionsSome of the manufacturers are in India and China.  Cases of hidden or altered test data have been revealed. It would appear that Health Canada is giving the least information that it can.  This hardly inspires confidence; all of this information has to be easily available to anyone who requires it.  This particularly applies to prescribers, dispensers and to health care workers, anything less amount to negligence.  Not that the major drug companies are blameless but they are more transparent and the FDA does frequent and apparently thorough investigation and follow-up.   They have a great deal to lose if they do not rapidly conform. By all accounts the FDA are much more rigorous and hold the companies to account in a manner that Health Canada does not.
     The Ministry of Health has a major responsibility to oversee that its purchases not only save money, but to make sure that Canadians are not put at risk.  The first step is transparency.
 If you think this matters, make a comment or drop me a note at

Tuesday 11 November 2014

House-call - A Winters Tale.

        It was 3 am, in January, in Saskatchewan.  The phone call stated the patient was in acute abdominal pain.   As one of the new boys at the bottom of the ladder at the Medical Arts Clinic, we young docs had the privilege of making most of the house calls for the multi -doctor, multi -specialty clinic.  Some house calls were entirely appropriate and greatly appreciated and some were like the one I describe below...............
        I loosened my down parka and and felt the body heat it had captured waft past my face. It was 30 degrees below zero and that's what I was dressed for, so inside the the apartment block I felt uncomfortably hot.
        I decided to try knocking one more time then I was going home. I banged on the door loudly this time,confident that it would not be answered. It was.
        The man who opened the door was dirty, disheveled and smelled of booze."Come in,Doc"he slurred.  I hesitated and then walked into the sparsely furnished, dimly-lit room. I looked around. The room was shabby and untidy with a torn, shapeless sofa, on which a woman of about thirty-five reclined. She was clad in a black slip and not much else, held a smoking cigarette in her hand and took a deep drag on it before she spoke. "Am I ever glad to see you, doc"she said. 
        "Good evening"said I "I'm Dr Smith, what seems to be the trouble?" 
        " I was to see one of the doctors in the clinic the other day and he said I have gall-stones,and if I get the pain again I am to call up the doctor on call for a shot of Demerol.  I've been in terrible pain all night" she said.
             "Why did you wait until three o'clock in the morning to call me?" I asked. 
             "Oh,I didn't want to bother you,doctor"she said. 
             I tried to suppress my sigh.  ."Okay, step into the bed-room and I'l examine you." 
            "Oh, I don't think I need an examination right now, just give me the shot and I'll come into the office tomorrow for a check-up." I looked at the woman, apart from looking tired and dissipated, it was obvious that she was in no distress.
            I was young, but not inexperienced, having assessed the situation, I now decided the time had come to be firm. This woman was obviously looking for drugs. I hadn't decided exactly what her relationship was with the shabby looking man.
           He was now sitting in the room's solitary armchair chatting incoherently either with himself, or to me.. He was mumbling away and all I caught caught was "Party in  Seattle and then this guy pulled out a gun.." 
           I decided it was time to be firm, deal with the situation and get out of the apartment as soon as I could.  I ignored him and turned to the patient.
         "You either let me examine you or I'm leaving without prescribing anything.  You don't seem to be in any pain right now" 
          She looked as though she was about to tell me to fuck off but then seemed to think better of it.
           "Well,if you could just leave me a few demerol or talwin pills in case the pain comes back during the night, then I'll come into the office tomorrow for an examination" 
            I was about to tell her I was leaving nothing and goodbye and if the pain came back she could go to the emergency room, when there was a loud knock at the door.

If you want to hear the end and most exciting part of this story, just tune in next week!!

Saturday 8 November 2014

Who Nose?

            This morning I had a visit to my otorhinolaryngologist (ENT specialist) .  As I parked my car I took an outdated copy of The Economist to read while I was waiting.   As fate would have it, I opened it on an article on 'Longevity and the sense of Smell'.  I found out out that the loss of the sense of smell may predict a shortened life span.  It transpires that it may forewarn of neurodegenerative diseases such as Parkingsons Disease, Alzheimer and certain other neurological disorders.
             My ENT guy is a young man and I thought it would be appropriate for me to quiz him as I had done to generations of family medicine residents during my academic days.
              "Did you know that low olfactory acuity portends a curtailed lifespan?" I asked innocently.
               He smiled, "yes it does, amazingly enough.  When  I  was in  training if someone became anosmic or hyposmic, we checked out their nose and if that was okay we reassured them and sent them away.  Now we usually investigate them extensively, up to and including a brain scan. 
               He rattled off a few of the possible diagnoses.   I was glad he passed my test!
               When I got home I looked up the list of differential diagnoses for loss  of the sense of  smell.
               There are 76  listed!

Tuesday 4 November 2014

The Humble House Call.

       I used to make house calls.     Making house calls was an integretal part of  general practice.  It would have been unthinkable to tell a mother of a baby with a high temperature to take her kid to the emergency department at two in the morning in the prairie subzero temperatures, or any other time for that matter, other than for a genuine emergency.  Doctors knew their  patients and assessed the information over the phone and  had to make the decision whether to make a house call or to turn over and go back to sleep.  It was often a difficult decision to make. If the patient sounded ill it was easier to get up and go and assess him, than to leave it until office hours the next day.  Just sloughing off the patient with a "go to emergency " didn't help much when there  were no full  time physicians in the emergency room and the doc was just going to get another phone call from the ER nurse.  Quite apart from that, physicians had a sense of obligation to their patients that caused them to  respond to their distress and to try to solve the patients' problem rather than  the physician's.  Of course, this all pre-dated the 'Health Care Industry'. I know all this sounds pretty corny, but that's  the way it  really was.
       House calls achieved a rapport that social workers, psychologists and psychiatrists are unable to replicate (at great expense).  Something, much more important than a prescription for a respiratory infection or tonsillitis , took place during those visits. A glance around the home was often more informative than half an hours history taking.  It was easy to understand why some kids were recurrently arriving in the office with infected eyes, ears, noses and throats.  It became easier to understand why certain patients were showing up repeatedly, week after week, the so-called frequent flyers.  It gave insight into some of the  problems financial and otherwise that some had to deal with.  Most important, it gave an insight into the family dynamics, healthy or otherwise that family physicians deem to be so important.  It focused on the environment in which disease and disorder, mental and physical, so commonly originates.It also tended to create a bond between patient and physician that few other contacts apart from obstetrical delivery did.  (In those days most of the obstetrics were carried out by family docs).
       So why was this important aspect of the doctor - patient allowed to wither away?  
        There are three main reasons:
                                   1. Time.  Doctors practices almost always were based in the  neighbourhood where their patients lived, so it was possible for a doctor to make a house call, often on the way to work  or  the way home without it taking an inordinate amount of time.  The demographics of family practice have changed.
                                   2. Money. Despite the time and effort required to make house calls the administridiots who plan the budgets decided on a fee schedule that was grossly inadequate.  The last time I looked, it was more expensive to have a consultation with a plumber.  That therefore, was a de facto decision to discourage home visits by physicians.   This decision, far from saving money, generated huge costs, because many patients particularly the elderly, opted to be looked after at home when they knew the physician would visit as frequently as nece4ssary and monitor their needs..
                                    3.Technology.  As we have become more reliant on laboratory investigations to make our diagnosis physicians are often afraid to make a diagnosis without a batch of (sometimes unnecessary) investigations, lest they be accused of not exercising due diligence.  This results in the defensive mode of practice and the tendency to over-investigate almost everything..   Thus, it became increasingly  acceptable, with a grain of truth, to respond to requests for a house-call with "we're going to need some tests so go down to emerg".  Now, with full time ER physicians,  the family doctor is off the hook!
                                   All of the above are remediable if the right people were in charge.

     Come back next week you want to read an account of a real live house call of yesteryear!

Sunday 2 November 2014

Ebola and the spoilt brat

          This incredibly self centred nurse who's amazing hubris allows her to speak as an authority on Ebola, which she certainly is not, is illustrative of the extraordinary attitude that everyone's opinion carries equal weight.  She has the unmitigated gall and brazen effrontery to challenge the most knowledgeable experts and to pretend that she knows the unknowable and is prepared to take the small risk that she could unleash an epidemic.   She is doing this because she felt that she was not treated with sufficient deference, felt unappreciated and demeaned by the poor facilities that were available to her by the stumbling, fumbling workers and policy makers who were doing  their best to try and avoid spread, knowing full well where the  blame would be placed should things go wrong,  She was more interested in challenging the protocols that though unpopular and inconvenient, may prove to be the safest thing to do.  Encouragement by jounalists and lawyers likely played some part. She is a poor example of a health care professional and it is likely that her behaviour will influence other health care workers to put their personal comfort ahead of the welfare of the public.
          No doubt the book will be appearing soon.