Red Rabbit’s Life

We live in a world where we are bombarded with information. Anything you hear about, you can instantly access a wide range of opinion, news, evidence….

The TV news runs stories about chemicals in baby bottles, about scary drug side effects, about evil vaccines causing autism. People with various motivations post serious misinformation on the net. My radio wakes me up with adverts about a blinky light that cures your chronic back pain and helps you quit smoking.

It can’t be easy not having the tools to decide what is a valid source of information.

For example: my neighbour announced yesterday that along with being a hypnotherapist, he is one of the few local certified tarot card readers.

Does this certification increase or decrease my faith in this guy’s skills? Hmmm….

But then I am living in the area where recently an educational assistant initiated a sexual abuse investigation based on information from her psychic. Full story here. In the immortal words of ICHC: Education: UR doin’ it wrong.

In Alberta, a woman is suing her chiropractor, the Alberta College and Association of Chiropractors, and the Alberta Ministry of Health and Wellness based on the fact that she became paralysed after neck manipulation damaged both vertebral arteries. I have a mixed reaction to this. In part, I think it’s about time. Chiropractors have no evidence for the things they do, and their claims, outside of the possibility of directly causing harm as in this case, may cause people to delay seeking real medical help until their health problem is out of control. Treating period pain: go for it. Treating asthma: fuck off and tell the patient to go to a real doctor.

Plus, don’t get me started on the whole anti-vaccine lobby they often seem to be aligning themselves with.

On the other hand, I feel that people should be keeping themselves informed and not relying on the government to play nanny for them.

What is wrong with people? Surely it’s obvious that the blogsite of sumdood (this one included) is not a great place to get medical information. Surely it’s obvious that if you can’t get hold of the actual research yourself, you might want to doubt what you’re hearing. Surely it’s obvious that if a person is looking to make money from your problem, you might want to seek a second opinion. Surely it’s obvious that if it sounds too good to be true, it probably is.

The greatest tool people have to protect their own health is skepticism. Question everything. I can defend the decisions I make for my patients rationally, with evidence. I don’t mind the confrontation, it keeps me sharp. I will direct people to my sources so they can judge for themselves.

Question the woo as much as you would question me. Make them do the same.

In reference to a patient with a concussion:

“Have a nice trip, see you next fall.”

Gee, thanks for the recognition. But I’m not currently conducting any interesting projects and you  know, I don’t have any charity ideas at the mo…

Who falls for this crap anyhow?

OXFAM GB - UK
274, Banbury Road,
Oxford
OX2 7DZ

Dr. Thomas Brainsbree
National Secretary Oxfam GB (UK)
TEL: +44(0)704-570 7881
Email: tbrainsbree@jmail.co.za

Claims Requirements:
1. Name in Full:
2. Address:
3. Nationality:
4. Date of Birth:
5. Sex:
6. Occupation:
7. Phone/Fax:
8. Present Country:
9. Qualification Number:
10.Brief Description of Proposal: We want to know how you wish to put this Cash/Grant into either your present business or intending business opportunity or other humanitarian services proposal to better your life, family and community at large:………………………………………………………………..

Yours faithfully,
Sir. Graham Mackay
Programme Manager.
 

Hahahahah…..

All female residents/medical students get this one: “Nurse! Nurse!”

In the beginning, I tried not to get bothered by always being called nurse. Nurses are my fellow professionals, and certainly at this stage in the game, the nurses I work with have buckets more practical knowledge than I do. I don’t think I am “better” than anyone.

But. I. Am. Not. A. Nurse.

And yes, I am offended.

If I had wanted to become a nurse, I would have done so. I did not.

I am heading into year 10 of intensive study (you know, to become “just” a GP). I take the responsibility: I am “Dr. Informed.” I don’t get to say, sorry, I’m on break. I am not unionised, nor do I think I should be. I take call for three days at a go (four on long weekends). I “have the big talk” with people nearing the end of life.

I don’t know what colour the pills are (except for synthroid). I don’t know how to make the IV pump stop beeping. I prefer a manual bp cuff to an automatic one, but then I don’t have to take an entire ward’s blood pressure on morning rounds.

I’m curious as to what male nurses make of all this. You guys must get called doctor as much as we’re called nurse. You’re probably just as offended as I am: you trained to be one type of professional, and just because of the way you look, you’re taken to be something else.

So, a note to patients: close to 70% of new medical (as in MD, as in Dr.) graduates are female these days. Even my school, heavily run by the old boys network, was 62% female. A woman in scrubs with a stethoscope is as likely to be your surgeon as your nurse. Either way, it would pay to not piss her off.

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10 things I would do if I had a penis for a day:

• 10. Go to a job interview and not have the interviewer think, hmmm don’t really want to pay for mat leave.
• 9. Write my name in the snow (dammit, it’s June).
• 8. Get paid more for the same work.
• 7. Speak and have people listen, without getting labeled “strident.”
• 6. Wear shorts without shaving legs.
• 5. Become leader of the free world.
• 4. Not have people be surprised that I understand the offside rule.
• 3. Get called doctor without having to introduce myself.
• 2. Get called doctor without having to introduce myself.
• 1. Get called doctor without having to introduce myself.

What is a Family Medicine Resident doing in the ICU?

Learning stuff. The staff like to teach, and they expect me to take the most interesting (read: most unstable) patient of the day, and make suggestions for additions to management.

This means large amounts of review material re: antibiotics, electrolytes, pressors, fluid management, ventilator settings, blood gases…. you name it.

Non-tertiary centres have a huge variation in the quality of teaching, and when it’s good, you really appreciate it. There is, however, an enormous advantage to being in such a centre: no pimping**. Lots of procedures, no seniors to push you out of the way. The tendency amongst the staff to say things like “There’s not much going on here, why don’t we call you if something happens.“

**pimping, to anyone who might not be aware, is the aggressive asking of questions you would not realistically be able to answer, in order to teach you whilst making you realise that, regardless of where in your class you graduated from your degree programme, you are actually an idiot.

Weird thing #2: ICU rounds are at 9:30 am. I rounded on a ward patient at twenty past five in the evening and beat my attending to her. I have never seen anything like this before. I was expecting 7am rounds, if not earlier. I’m an early-bird around here.

Hypertension. Check.

Shortness of breath. Check.

Chest pain. Check.

Actually, that’s all me. The patients are fine, if you look past the cancer. Oncology freaks me out.

But I looove the enthusiasm for teaching amongst the internal med staff. They like to make everyone know everything they know, which is approximately everything. It’s amazing.

Weird thing #1: I am six months older than my current attending. Stay tuned for more weird things, there are bound to be hundreds.

The above is a direct quote from a direct-to-consumer marketing campaign for a vaccine. The implication being of course if YOUR child should get sick with this rather uncommon but certainly serious illness and YOU didn’t vaccinate them then whatever happens to them is YOUR FAULT.

The close to $100 a dose the company makes from this is…. not relevant.

The same or a similar vaccine is publicly funded in Canada during outbreaks, but routine vaccination is not done. Why are they advertising to everyone in the States?

Direct to consumer advertising bugs me, because the vast majority of people don’t have the resources and understanding to make the judgements necessary to choose one drug over another.

My “favourite” example of this is the statin/ace fixed combination drugs, advertised under a fancy new name. It’s a blatant attempt at patent extension for good drugs going off-patent.

Don’t get me wrong, they are good drugs. But taking one pill with both drugs in, and paying A GOOD DEAL EXTRA for the privilege seems kind of silly. Makes it hard to monkey with dosages, and costs public health a scary amount of money.

My favourite people are the ones who say, it’s okay, my insurance company will cover it. Yes, they will, but it’s going to push up everyone’s premiums, including yours.

Who am I to say anything? My mother uses brand name painkillers and acid reducers and swears up and down that the generics are cheap knockoffs that don’t work as well. And no amount of organic chemistry and pharmacodynamics can convince her otherwise.

In most jurisdictions, physicians are meant to provide information to the ministry of transportation about patients who have “a medical condition which may make it dangerous for the person to operate a motor vehicle.

see more crazy cat pics

They are provided with a list of conditions, which is not exhaustive by any means. One such list:

Diabetes or Hypoglycemia or other metabolic diseases- Uncontrolled
Mental or Emotional Illness-Unstable
Dementia or Alzheimer’s
Sleep Apnea-Uncontrolled
Narcolepsy-Uncontrolled
Motor Function/Ability Impaired
Alcohol Dependence
Drug Dependence
Seizure(s)-Cerebral
Seizure(s)-Alcohol related
Heart disease with Pre-syncope/Syncope/Arrhythmia
Blackout or Loss of consciousness or Awareness
Stroke/TIA or head injury with significant deficits
Both Visual Acuity and Visual Field Impairment
Visual Acuity Impairment
Visual Field Impairment

Docs have to report people with these conditions to the ministry, at which point the ministry undertakes to ensure that the person in question is evaluated for road safety. With some folks post stroke, for example, the testing can result in restoration not only of a driving license but in self-confidence after a solid pass.

I have had a few days in the diabetic clinic here, and one thing that really doesn’t surprise me about a lot of teenagers with diabetes is that, like most other teenagers, they are immortal and invincible. They are totally normal and they shouldn’t have to do any ridiculous blood sugar testing, whatever their parents say. They can invariably “tell” when their sugars are high, and from this feeling, independent of blood sugar testing, they stochastically choose boluses.

Kids are great at repeating back what you want to hear and then going their own way. Kids hate that their glucometers tell on them.

They also know when they have screwed up. They often think the doc and the team want to punish them for poor diabetes control.

It takes a lot of effort to convince a kid that this control is for nobody but herself; that the damage won’t be to the team or to her parents, but to her own feet and kidneys and eyes. We saw a kid who, when warned that she needed to get control of her diabetes and test at minimum four times a day plus before driving by the time we saw her next, rolled her eyes and asked, what if I just don’t show up?

We talk to the ministry, is what.

No, it’s not a punishment, whether it feels that way or not.

In this country, a driver’s license is not a right, but a privilege.

PS. Narcolepsy? Really?

Actually, no.

But I am not going to recommend to my patients that they stop using Singulair. That would be stupid and irresponsible. Asthma kills. It does long-term damage. To lots and lots of people with asthma.

And Singulair, for those patients who need it, works.

Here’s my presentation for tomorrow morning’s rounds:

The USFDA announced Thursday that it was investigating the possibility of a link between mood changes, anxiety, and increased suicide amongst patients taking the asthma medication Singulair (montelukast). The other leukotriene receptor antagonists Zyflo and Accolate are reportedly also under investigation. Health Canada is following suit.

Merck officials state that the investigation is based on three or four reported suicides since October 2007. They point out that no suicides have been noted in any of the previous studies, though it is not clear whether this was an endpoint that was recorded.

Safety profiles for most drugs are not complete until several years into post-marketing research, due to the fact that some effects are vanishingly rare and would require huge numbers of subjects/patients to be analysed before they come to light. This is particularly the case for unanticipated events, like suicidal thoughts from an asthma medication.

Word from the FDA is:

“Singulair is an effective medicine that is indicated for the treatment of asthma … Patients should not stop taking Singulair before talking to their doctor if they have questions about this new information. Until further information is available, healthcare professionals and caregivers should monitor patients taking Singulair for suicidality (suicidal thinking and behavior) and changes in behavior and mood.”

Health Canada has not recommended that Singulair be discontinued.

Baseline age-adjusted suicide rates in the US are 11.1/100 000; slightly higher in Canada. Merck reports sales of $4.3 billion from Singulair.

Leukotriene receptor antagonists are second-line maintenance therapy for use as an add-on when inhaled corticosteroids do not provide adequate control. They are generally well-tolerated and the most-common side effects are headache, URI, abdominal pain, cough, and dyspepsia. All that said, there is still no mention of suicidal thoughts, behaviour, or completed suicide in the safety profle on Merck’s website.

The ambulance chasers have, however, already set up at least one website.

I was happy to see a midwife doing deliveries in the Slightly-Larger-Regional-Hospital where I studied OB. In the past, I have generally appreciated some level of antipathy amongst midwives for birthing in-hospital.

Which blows my mind, I have to say. It’s not as though the vast majority of people giving birth need the services of a hospital, but quite often when trouble occurs it is unpredictable and needs the  immediate attention of an obstetrician and an OR team. I’d like to say I respect the choice of women who recognise the risks and choose to birth at home, but I have to say I just don’t get it.

Your “birthing experience” may be important, but in the end, the point is to have a healthy baby.

Childbirth is a natural event. This is true. Of course, so is death.

Women have done this outside hospitals for millennia. Also true. I’ve seen the aftermath of lots of these births… most go fine, when you start with a healthy mother and an experienced birth assistant. But when they go badly, they can go very badly. Cord prolapse in a hospital is a nightmare, but manageable. Cord prolapse at home is an unmitigated disaster.

Epidurals are unnecessary.  That is I suppose literally true, but really, that depends on your point of view. If it’s you having the baby, I guess you’re the one who gets a say in it. If you’re not giving birth…. mind your own business. That includes you, miss midwife, mister nurse, or granola gramma. This birth might involve you but it’s not about what you want.  Pain does not ennoble: it’s just pain.  I have never been so annoyed with another professional as I have been when I have seen OB nurses trying to talk women out of epidurals or pain control. If you have some biblical belief that women should give birth in pain, stay the hell away from my patient.

I don’t want a caesarean. Be sensible. Nobody wants a caesarean…. well, nobody sane anyhow. The doc doesn’t want to call in the OR staff. A vaginal delivery is so much easier and nicer. You’ll recover faster and take up a bed three fewer days. If they’re saying C-section, they’re saying it for one of three reasons: a. there is some pre-existing reason you can’t do a vaginal delivery, b. the baby isn’t coming even though you’ve been pushing well and the contractions are great, or c. the baby is not doing well and might not have the strength to withstand delivery. So get over yourself already.

No forceps. You know, if the forceps are coming out, it’s because they have to. For some reason, the baby has come down most of the way but you need help getting those last few centimetres, and the baby can’t take much more pushing. They’re interesting, but I don’t want to use them unless I absolutely have to.

No episiotomy. Older docs were taught that an episiotomy reduces tearing, so they did them. Younger docs have read the new studies that show minimal differences in tearing and better healing in tears that occur naturally. So, I won’t cut you. But I will try to prevent the tear, and I will sew you up carefully afterwards if you need it. 

Can I have my boyfriend/sister/mother’s lesbian lover present? You can bring the whole flag-football team if you want, just keep them away from my steriles. And let me know who you want cutting the cord. 

Most hospitals these days try and make sure you have a room with its own bathroom, lights that dim down, and a comfy chair. You can have whatever you want for music, from Brahms’ Lullaby to Killing in the Name Of. You can hang out in the tub. You can make the birthing partner bring you smoothies. You can push at your own pace. You can deliver in any position you like. You can swear at the doc, and they won’t hold it against you.

Medical people don’t want you to have all of the above. They want it available if you or your baby need it. Nothing more.