Saturday 31 January 2015

PFM (Pen for Men).

        Once there was a Fountain Pen, made by the Shaeffer Pen Company given the incredibly politically incorrect title of the "Pen For Men".  Despite the fact that we had a "Lady Patricia" pen  for women which was considered to be an artistic neat little pen, that many admired, the big bulky, PFM was considered by some to be a bit sexist.  
         I have a PFM and it was given to me by a patient.   I used to regard my patients as friends and ask them about their interests and some of them, obviously regarded me as a friend and were interested in my hobbies.   Tom, (let us call him that) said that he would like me to have his PFM as he was interested in horses, not fountain pens.
         Nowadays, any sort of gift from a patient is frowned upon and regarded as some sort of impropriety.  Tom and I had a sort of rapport and when he came to see me it was a different sort of visit than that which took place between a customer and his plumber.   
          One day, Tom's routine checkup revealed some red blood cells in  his urine ( a test that we did routinely in those days but that now is regarded as useless). I repeated it in  a few weeks and it still continued to show some red cells.  I went on to do the further investigations that were appropriate in those days, before ultrasound made many apparently innocuous investigations possible,  and the test, an intravenous pyelogram, showed a suspicious lesion.   
            During one of those visits, when I was following up on what was going on and keeping Tom informed, he smiled and said,
            "Hey, doc, I have something for you!"
            "What, you are giving me one of your horses,?"
             "No," He said, rummaging around his pocket, "this, I want it to have a good home!"  He smiled, cheerfully, and pulled out the PFM.
                " I can't take this," I said.
                " I want you to have it," he said.
                 "Thanks," I said and took it.
                  Tom, died soon after that of metastatic kidney disease.  
                  His wife, who was also a patient of mine, with whom I had always thought I had a good relationship,came to see me, told me I had not diagnosed him quickly enough and she was going to find another doctor!
                  Every time I  pull out that damn pen I think of Tom - and I think he would like that!

Wednesday 28 January 2015

The Pediatric Dilemma.

          Recently a little girl of native ancestry with a serious but treatable disease died because her parents prevented her from receiving the appropriate treatment.  This was on the basis of cultural values and despite the supplication of members of a noted pediatric hospital, the judicial system saw fit to take a position that parental authority was not to be over-ruled and that ultimately led to her death.   Although it may be a bit of a stretch, if parents are legally entitled to make decisions, based on cultural values that may lead to the death of their children, honour killings could be argued to fit into the category.   Parents may be well-intentioned but the judicial system dictates:

        Ignorantia juris non excusat or ignorantia legis neminem excusat (Latin for "ignorance of the law does not excuse" or "ignorance of the law excuses no one") is a legal principle holding that a person who is unaware of a law may not escape liability for violating that law merely because he or she was unaware of its content.
        Ignorantia medicina neminem excusat  (ignorance of medicine excuses no one) for a person  or group recommending  withholding life saving treatment or recommending a treatment for which there is no supportive evidence..  The onus must be on them to prove beyond a reasonable doubt that they are not harming their children.
         Thus liability for the outcome of such actions is clearly  the responsibility of any group who embarks on such a course. It is their responsibility to prove that their recommendation does no harm.  If cultural  values determines the acceptability of actions, then we are giving our imprimatur to the perpetrators of honour killings and numerous other practices long abhorred in our society.
         I believe these parents are guilty of manslaughter. The medical opinions of all are not equal. 
         It is time that we of the West clearly state our values and our commitment to enforcing many of  them before political correctness destroys us!!

Sunday 25 January 2015

Stroke-standing on one foot.

     When I read "Ability to  balance on one leg may reflect brain health and stroke risk, I smiled.  "Struggling to balance on  one leg for twenty seconds or longer was linked to an increased risk for small blood vessel damage in  the brain and reduced cognitive function in otherwise healthy people with no clinical symptoms"  read an  article from AHA Journal    "Stroke".
      It went on to state that their study found that the ability to balance on one leg is an important test for brain health.   Researchers found that the inability to balance on  one leg for longer than twenty seconds was associated with cerebral small vessel disease, namely small infarctions without symptoms such as lacunar infarcts and micro-bleeds.  
       Pretty heavy duty stuff, thought I, knowing full well that I  could easily stand on one foot for a minute or more.  So, I decided to try it out.
        I did fourteen seconds.  So much for objectivity!!
        Try it yourself, you may get a surprise. 
        Let me know how you did, if you dare!!  And I  don't think you will!

Tuesday 20 January 2015

Administridiots at Work!.

Bill 20 came under fire from the federation that represents the province’s family physicians. (Montreal Gazette).

           At a general council meeting in Montreal, the Fédération des médecins omnipraticiens du Québec (FMOQ) took an official position against the proposed legislation, which would require family doctors to take on a minimum of 1,000 patients or risk losing up to 30 per cent of their pay.
“There is only one message: It’s no to Bill 20,” said Louis Godin, president of the FMOQ.
They’re convinced that in no way will the minister’s goals of improving access to family doctors be achieved by Bill 20, Godin said, flanked by several doctors from groups that also represent family doctors working in different fields as well as future physicians.
         “On the contrary, we’re expecting a drop in access. We’re expecting a drop in the quality of family medicine that will be done in Quebec. And even more, in the long term it’s the future itself of family medicine that is in play,” Godin told reporters, adding there isn’t a medical student today who will choose to practice family medicine under the conditions proposed in Bill 20.
          "Family medicine takes time," said Godin.
            I don't want to go into the varying figures quoted by each side.  I want to go into the changes that have occurred as a result of the metamorphosis of a caring profession into the Health Care Industry and the excessive influence of the administidiots who have effected these changes.  The old fee-for service system, so detested by the administrators, many of whom had a primarily financial background, had built into it a balance that equated work done with remuneration received.  Physicians on that system would decide how much they wanted to work, some very long hours and  some not so hard and they were paid accordingly.  When the capitation system and various similar systems became prevalent things changed radically.   Human nature being as it is, it does not take long to realize that with an annual  fee per patient, where the payment is much  the same whether one sees the patient once or fifty-two times a year, one doesn't want to load up one's practice with too many complicated, multi-problem patients. Cherry-picking has become a major problem.  Nor is a physician likely to do time- consuming procedures that he is capable of doing but for which there is no reimbursement.   Because of this unnecessary referrals are made and inappropriate expenses are incurred and specialist waiting lists become unwieldy. 
              This is not a rant against a national health service.  Every civilized country needs that.  It is a criticism of the lack of  understanding of the administidiots in charge.   Sad to think that a once noble profession has been forced to become civil servants in all but benefits.

Monday 19 January 2015

Doctor in Training. Pt 2.

      So, there I  stood at the bottom of bed number thirty-six.   Lying  on  the bed was a young  man, about my age writhing in spastic, athethoid movement, neck extended, contractures of the arms  and legs and a more shocking example of the  physical misfortunes than I had ever seen.  He seemed to totally lack any sort of control over  his body, until my shocked eyes fell on his left lower extremity.   Between  his big toe and his second toe he was holding a pen, and despite the spastic movements of the rest of his body, he was writing in a small , precise cursive hand  (foot!) on a stabilized notebook.
       After I got over the shock of seeing a human being who seemed to be dealing in some way with the unimaginable devastation, I managed to pull myself together and said apprehensively, " I'm Stanley Smith, a medical  student, and they sent me down to take a history and do a physical examination.  Is that alright?"
        The patient, later internationally known as the author of the book  and subject of the movie "My Left Foot," and "Down all the Days", was  kind to an apprehensive new medical student.
        His speech was dysarthric and difficult to understand, his manner kindly.  He was  obviously used to this teaching  hospital routine.  I won't attempt to replicate his speech - that would just make him - and me sound stupid!!
        "Yes, I know you students have to learn on someone," he replied in a dysarthric drawn out drawl.
        I was grateful I could understand him and he me.
        I took a history  of  sorts, more social than medical.  After he told me he nearly died during delivery and that he had suffered serious brain damage, we got on to his life, which was much more in line with  what I  could comprehend than the medical stuff.   That sort of human interest stuff gets knocked out of young doctors if they are not careful.  The line between left wing loony stuff and human kindness becomes indistinguishable to many.
        "So what do  you do most of  the time?" I asked him.
        " I write," he said.  "I've started doing a bit  of painting too," he said.
         He had a certain leprachaun- ish  look about him that precluded an  overly sympathetic attitude and made me feel that somehow he was managing to get some fun out of life, as indeed he was.  If you want to know how, read "Down all the Days".
          The only other famous 'medical case'  I met in my student days, was Douglas Bader, the legless RAF Air ace,  who was a double lower limb amputee and talked his way back into combat missions sans legs.  He came to the Meath Hospital to encourage and reassure pediatric amputees regarding their their future life, though I don't think he was recommending that they become fighter-pilots!

Tuesday 13 January 2015

My First Patient.

        I well recall my very first day of clinical medicine.  After pre-med and two years of anatomy, physiology, pharmacology, pathology and various other medical sciences, I was about to see a real live patient.  My brand new stethoscope placed around my neck (we wore them differently in those days, less stylishly but ready to pop into our ears at a moments notice), my white coat pockets bulging with second hand equipment, a reflex hammer, an ophthalmoscope/otoscope, a safety pin and elastic band (for testing sharpness sensation and light touch), ready to spring into action at a moments notice.  Most important of all, was our clinical notepad to record the history we were about to practice taking from the poor  patients who  were often fatigued from repeating histories to successive groups of medical students.  Most of them were tolerant and many of them actively sympathetic, the more seasoned patients often instructing the students on how to properly take a history.

Friday 9 January 2015

Dental Student Impropriety.

    Thirteen dentistry students at Dalhousie university in Nova Scotia were suspended over extremely offensive Facebook posts about female colleagues.  When  I  tried to  look this up on the Dalhousie Facebook page, there was no mention of it..  It would appear  that despite the "outrageous and offensive" nature of  the posts, disciplinary announcements were delayed by fears that the male students were in danger of self-harm over the scandal. The Royal College of Dental Surgeons demanded to know the names of the students involved.  Some of them would be applying for licenses to practice in the province of Ontario.  The Royal College, who's responsibilities include the protection of patients, are entitled to know exactly who they are dealing with when an applicant applies for a license to practice in  the province.  The University's excuse for failure to pass the relevant information to the College of Dentistry:
    "We had credible reports from our front-line staff of potential self-harm."
Stop, for a moment!
      Had they no concern for potential harm by their future licensees to patients?
      This is what happens when administridiots take control of health care.
      I would unequivocally state that these students are totally unfit to practice dentistry or any other health care profession.   Further, I think their names should be published.  We talk a lot about transparency these days but much of it is just that -talk!
     I certainly wouldn't want them to look  after any member of my family.
     Would you?
       Comment if  you have any opinions on this

Tuesday 6 January 2015

Death by Cancer.

             Dr. Richard Smith was an editor of the prestigious British  Medical Journal until 2004.  Writing in a blog for the BMJ and philosophizing on the  the best way to die, he comes to some bizarre conclusions.  There are four ways to die, he postulates, sudden death as from a heart attack, the long, slow death of dementia, the ups and downs death of organ failure  and death from cancer, where you may hang on for a long time but go down usually in weeks; he mentions, but does not elaborate  on  suicide, assisted or otherwise, as a fifth.  He describes 'watching in horror' as a senior student while his colleagues tried in  vain to save hopeless patients with multi-system failure.  He does not seem to recognize that today many of the patients he considered hopeless are curable or at least very beneficially treatable with modern management .  After reflecting on dementia and mentioning that most people who he has polled in various presentations chose the 'sudden death' option he opines as follows:
               "So death from cancer is the best, the closest to the death that Buñuel wanted and had. You can say goodbye, reflect on your life, leave last messages, perhaps visit special places for a last time, listen to favourite pieces of music, read loved poems, and prepare, according to your beliefs, to meet your maker or enjoy eternal oblivion."   He does recommend that the situation can be somewhat ameliorated with love, morphine and whiskey.
                The presumption of  the man amazes me.   He does not seem to understand the nature of the human being.  :"Dum spiro spero."  No wonder he ended up editorializing for the BMJ instead of practicing medicine.  It was a good choice for one of his presumptuousness and egocentricity.
He certainly wouldn't have made it as a family doc!              

Friday 2 January 2015

The Rotunda Papers. Pt.2.

                 "I remember hanging out with you at the Rotunda and watching you play poker with your fellow medical students while you waited for a call. I think that's where I learned how to play Acey-Deucy. They were interesting times!"
A comment made by my younger brother on reading  part 1 of the Rotunda papers.
                       Yes, that was how we we filled in our time while we were waiting for those adrenaline stimulating calls that could occur at any time around the clock!  When we weren't in-house waiting for calls we were often across the  road from the Rotunda in Mooney's Pub, having a beer, if we could afford one and a coffee (6d) if  we couldn't.  They actually had a phone line in Mooney's dedicated to the on-call staff of the Rotunda,  But much of the waiting time, we spent playing poker in our cell- like rooms.  There was a group of American students and a Canadian who were studying medicine in  Basle, Switzerland who frequently spent their time playing poker including the above variant that I hadn't heard of before.  I joined in when I could afford to.
                 And indeed they were interesting times.      During the morning clinics that the pregnant patients ( Nobody thought of calling patients 'clients' in those days ! ) attended for monthly follow-up until the last few weeks when the visits were weekly, we students were each assigned a patient to do an initial history and physical examination..  Most of the women regarded us kindly and frequently pointed out things we had omitted from our history taking.    Our consultant would come around, instruct us in examination techniques, during which the student was usually a good deal more embarrassed than the patient.    A series of  questions would frequently be fired at us to determine whether our history and physical examination skills were up to snuff.
            Had you determined the position  the  baby was lying in?  Had you heard the fetal heart?   Are you sure that's the baby's head down there and not its rump?  And so on.
            There was no ultra sound in those days and some of  the consultants were still using an old-fashioned fundoscope, which  was like an  inverted funnel, instead of a stethoscope, claiming they could hear more acutely with it.   Indeed, some of the really old  consultants laid a  silk  handkerchief which they carried in their jacket pocket (they didn't have to  wear white coats) on the patient's abdomen and listened by placing their ear on the abdomen.  They also claimed that they could hear more acutely using this technique.  Today, they would probably be charged with assault!
           At any time during the twenty-four hours when the excessively loud alarm, which had an extension  in  each of our tiny  rooms went off  we were expected to drop everything and head for the delivery suite.  The  bell meant that a complicated delivery was taking place in the delivery theatre.  The  specialist and  his immediate team were gathered around the patient ready to perform their miracles, while we medical students  and student nurses would sit in something like  the 'bleachers' at a ball game and watch the action and  try to learn something.   The 'Master of the Rotunda' was the archaic title by which the head doctor of the entire institution was known and was akin to Merlin, the magician of Arthurian  legend in his magical skills - mainly in pulling babies out of  the womb in impossible obstetrical situations that no mere mortal could cope with.  Caesarian section was a risky procedure only availed of as a last resort!