Rash on the right calf.

Me: How long have you had it?

Him: About a month.

Me: Anything change in that time?

Him: Not that I can think of.

Me (bending down to take a peek): Looks itchy. Is it anywhere else?

Him: No. Weird, eh?

Me: Nice tattoo. How long you have it?

Him (admiring his tattoo, an awesome goldfish): Thanks. About a month.

Me: Hm. Looks like you’re allergic to orange tattoo ink. That’s gonna suck.

Recently, our local cardiologist called me up. “So, you know that nice guy that we saw recently with the kind of nonspecific chest pain? Well, his stress was positive as it turns out, so I was going to admit him.”

“You were going to?”

“Yeah, I think he needs an angio. He had that nasty MI last year, and he had the CABG, but you know how these things go – it’s no guarantee.”

“Sure. So, what’s going on?

“Well, his daughter is a clinical nurse. SHE thinks it’s GI, and wants him to go home for the weekend. She won’t let me admit him.”

“Uhhhh….???”

“I gave them my opinion, and I think it’s risky, but I scheduled him for an angio next week, and in the end, if he wants to go home, the risk is theirs to take.”

“Wow. Families, huh?”

—–

A member of my family is currently undergoing something medical and I find myself second – guessing her doctor at every turn.

I am trying desperately to keep my mouth shut (but seriously, any doctor who hasn’t heard that pertussis is on its way back and that adults with infants would do well to get a booster with their tetanus shot seriously needs to do some CME). I really don’t want to be one of those family members.

—–

I still think an experienced physician calling up a family member’s family physician who happens to be a new graduate and trying to intimidate them into showering every neurosurgeon in the country with referrals until they get a response is both unprofessional and uncool. I don’t know what to do about it, but I think the college might be interested to know about it.

One of the great things about being a family doc is the follow-up.

Sometimes, people don’t get better as quickly as you’d expect, so you send out cultures. They aren’t always what you expect:

A lady with a persistent cough despite appropriate therapy did a sputum culture which grew Stenotrophomonas maltophila. Traced back to a humidifier that needed cleaning. She responded well to a course of sulfamethoxasole / trimethoprim.

A teenaged boy came in with what looked like a viral syndrome, with fevers, a spotty rash on the legs, and a nasty pharyngitis. I asked him to wait and see. This turned into a peritonsillar abscess (oh dear, poor kid), and grew Arcanobacterium haemolyticum. Again, the patient did well with drainage and appropriate treatment.

You know it’s an unusual bug when your colleagues all look impressed with the treatment you looked up in your Red Book a few minutes earlier. That’s me, always learning.

You need to stop advertising that shit. Every single fucking day, I get people in my office who NEED a statin…. they have ye olde type II diabetes, a cholesterol of six, are horrendously overweight, and won’t go see my dietician because they know she is also going to tell them no more BBQ…. and they keep stopping their lipitor because the 8 million side effect disclaimers are scaring the living shit out of them.

You’re losing yourself buttloads of money.

Besides the fact that my patients are too afraid to take a drug that will in all likelihood extend the time to their next heart attack. But that’s my lookout, not yours.

I have this exact conversation more often than I would have believed:

Guy in boots: “I hurt my back awhile ago, doc, and it’s just not getting better.”

Me: “Mmmhmm…”

Guy: “So, I was talking to my buddy, and HIS doctor gave him this oxycotton for HIS back, and he gave me a couple and they really helped.”

Me: “Let me take a look at you.”

Guy: “Nah, I just need something for the pain. Can I get a prescription?”

Me: “What, do I have moron tattooed across my forehead? Get out of my office, asshole.”

OK, so I don’t really say that last bit, I just think it.

I prescribe narcotics to four groups of people: people I inherited on narcotics. People with terminal disease pain. People who are post-op, and we have a plan to end the narcotics. People who are waiting for a joint replacement or other surgical intervention for a painful condition.

If you show up without one of these conditions and ask me for oxycontin, percocet, or any other branded pain control medication, I will immediately label you a drug seeker and flag your file.

If you show up and ask me for a weaning programme because you’re buying them on the street, and you “want to get off them,” I will cheerfully refuse and give you the number for withdrawal management services. You can buy your own damn wean.

If you tell me you can’t do a detox “right now” because of all the other important stuff going on in your life, I will smile, and nod, and stop listening, because you’re not here to get off drugs, you’re hoping I can get them paid for by the government.

Fuck. That. Shit.

I want to help you. I can only help you if you want me to. This has been the hardest lesson for me to learn: no matter how hard I try for you, if you’re not on board, I can’t fix this problem.

I remember being a kid, and hearing on the news that someone had been arrested for “Soliciting.” Where I lived, this was apparently code for prostitution, in particular the streetwalking sort. I understood this as a child, and I knew what it meant.

So when I moved to Ontario and saw people’s mailboxes with stickers on them which read “No soliciting,” I thought, gee, Ontario has door-to-door hookers? How about that!

In Canada prostitution is in fact, already legal.

However, in some jurisdictions there were prohibitions on various parts of the trade, and her in Ontario until a few days ago, it was illegal to “communicate for the purposes of prostitition,” to “live off the avails of prostitution,” or to “operate a common bawdy house.”

These laws are obviously exceedingly well enforced. One of the first things that got pointed out to me in Collingwood, ON was the brothel. The classified ads of the newspapers are surely not full of ads for sex services. And living off the avails? No, of course, it’s just spare cash, right? Right?

Hm.

So, three sex workers hired a lawyer and mounted a constitutional challenge to these laws. The judge examined them, and struck them down, stating that the current laws “place prostitutes at greater risk of experiencing violence,” by prohibiting them from operating out of a place wherein they can screen clients and have help close by.

Listening to the CBC’s “Cross country checkup,” one could be forgiven for assuming we are a nation of old bags afraid that our husbands are going to run out and hire prostitutes the second it becomes fully legal. These women who called in seem incoherently terrified that prostitution should become legalised, one describing what is essentially the current situation and asserting without evidence that things like underage prostitution and human trafficking would surely get worse if prostitution were legal and licensed. Does the evidence back this up? Amsterdam? Sure, it’s sleazy, but are the women worse off, or better? One writer for the National Post went so far to describe prostitutes as “people of low character” and “unworthy of respect.”

Bigotry much?

My two cents, worth approximately that: Legalise it. Make it easier for women (and men, but mainly women) who are in this situation, by choice or not, to control their working conditions, to control who they see as clients. Make it easier for them to make a choice about where they work, and for whom, and with whom. Make it easier for them to get off the streets. Make it easier for them to access the specific types of medical care they need.

Getting them out from undercover makes them more visible – not less – to authorities. They no longer need to fear arrest or abuse from the police. The police suddenly become a resource, a source of protection.

If your argument is that legalising it makes it morally sanctioned, that’s total bullshit. Alcohol is legal, alcoholism is not morally sanctioned. Smoking is legal, and is becoming more and more socially unacceptable. Your mother will kick your ass for lots of stuff that is legal, and that’s where morality comes from.

The law is not your mother. The law exists to protect society, and a society is judged by how it treats its most vulnerable. If you’re selling your body to live, that’s pretty vulnerable. I don’t care how you got there. It’s society’s job – the law’s job – to make things as safe as possible for these people, too.

Centagenarian arriving by ambulance.

CC: Can’t pick up my tea.

???

There are lots of great resources out there, like here, and this stuff, and this, and this stuff, too.

Or you could just go cold turkey. It’s rough for a few days. And then it’s done. OK, the psychological bit sticks around, I know.

I know all the excuses: not now, things are too crazy at work. I’m trying to lose weight, and I can’t do both at the same time. I can’t because I’m too worried about whatever. I’ll do it in the fall, this time of year is too hard. Blah blah blah.

I never understand why people make these excuses to me. Their smoking is no harm to me. It’s themselves they need to worry about. But there’s a lot of it’ll never happen to me. A lot of the damage is done. A lot of but I don’t smoke that much, anyhow.

It’s not like I can exaggerate the effects. Heart disease. Delayed wound healing. Erectile dysfunction. Hypertension. Peripheral vascular disease. Lung cancer.

But then, I suppose I do have a vested interest.

To call you in to my office, to ask you to bring a relative. You know what’s coming. There’s nothing harder in my job than to be the one breaking the bad news.

If I could do it one fewer time, that would make me happy.

Disclaimer: Written when I was feeling maudlin and depressed about having had to have that discussion too many times in the past months. It’s not all about smoking, or blame. *sigh* It’s just… some things just suck, OK?

I’m Canadian (eh?). I don’t have freedom of speech.

Well, that’s not enirely true.

My freedom of speech ends when I start to call for hatred of another group, violence against a person or group, or I start uttering threats.

Teachers in the UK routinely deal with threats against themselves and their families. According to the tachers I have spoken to, action is rarely, if ever taken, and it leads to a tense classroom environment. In Canada, a threat of violence is a police matter. Teachers who have taught in both systems tell me they feel more secure here.

Ann Coulter is, IMHO, a right wing windbag with nothing of value to add to society. Boo hoo hoo those poor oppressed rich white men. Why ever she was scheduled to speak at Canadian universities is beyond me, but then, nobody asked for my opinion, and I am neither a student there nor required to listen to her, so meh.

At UWO, she spoke as scheduled and apparently, she predictably made an ass of herself, following up an earlier comment regarding Muslims (something along the lines of they should all be banned from airlines and if they want to travel they should use a magic carpet, IIRC). When a Muslim student objected, saying she had no magic carpet, she was told to ride a camel.

Apparently, all this is par for the course for Ms. Coulter.

In Canada, statements encouraging mistrust and hatred of specific racial and religious groups can come under the definition of “fomenting racial hatred,” which our courts consider to be crime. One can be arrested for such things.

U of Ottawa gave her fair warning about Canada’s hate speech laws so she could protect herself. Poor dear, she took offense to their letter.

Several U of Ottawa students gathered outside where she would speak, some in protest, and others merely hoping to get inside. This apparently counts as violent protest to Coulter? It’s a good thing she isn’t into teabagging (snicker).

My thoughts on her statement at UWO:

Dear Ms. Coulter:
Thanks for volunteering to carry my Muslim colleagues when travelling. I didn’t think your hump was terribly obvious, though I do see the resemblance around the nose. I suspect, however, that most people would prefer to fly.

Don’t let the door hit you on the ass on your way out!

We have enough kooks in Canada. We don’t need to borrow any of yours, America, so take her back already!

What’s my advice worth?

Nothing more than what you decide to do with it.

I can’t make you give up drugs. I can’t force you to take your medications. I can’t control what you eat, who you have sex with, or how you treat your family.

I can make suggestions, provide resources, make things available. I can help control a crisis.

Some patients embody that cliche about horses and water. Sometimes I just have to remind myself of that.

There are some people out there who make it hard to make a therapeutic relationship.