Grand Challenges Canada: Drowning Prevention
Drowning is the number one cause of death in children in countries like China, Bangladesh, and Vietnam. It is preventable.
Consider supporting this effort, submitted by Dr Steve Beerman, former president of the International Lifesaving Federation (ILS), to reduce childhood drowning mortality through local programming in rural Bangladesh.
This project is one of 450 proof of concept projects seeking 70+ significant phase 1 investments from the Canadian Government. The ability of the project to engage public interest and support is part of the selection process.
If you have 2 minutes, view the video link. If you like this project idea, hit the “Like” link to register your support.
(Learn more about Bold Ideas for Humanity at http://www.grandchallenges.ca/)
Both the CMA and CFPC have taken strong and clear stances regarding the role of physicians in prescribing medical marijuana in Canada, largely in response to the changes that Health Canada is planning to enact in 2014. Despite a consultation process that included the CMA, Health Canada and Minister Aglukkaq propose that to help protect the system from abuse,
“Health care practitioners will be able to sign a medical document similar to a prescription, and then patients can purchase the appropriate amount from an authorized vendor. The new system would cut red tape for individuals and ensure that they have access to marihuana for medical purposes produced under quality controls while streamlining the process for applicants and health care practitioners.” (from Health Canada)
What that statement doesn’t explicitly say is that it is shifting the responsibility from the government onto physicians; this in in direct opposition to the recommendations the CMA provided during the consultation. It also comes after a survey of physicians indicated that we are as a group uncomfortable about the lack of evidence and safety in prescribing such a substance. More than half of those surveyed reported “they have insufficient information about the appropriate use of marijuana for medicinal purposes” which, if I was doing the survey I would have selected, reflecting my feelings that “I can’t justify it, medically.”
CMA President Anna Reid summarized this problem well, from the CMA news archives:
Reid argues that the federal government is simply “dumping the responsibility” for medical marijuana use into doctors’ laps after initially establishing the program that gave patients access to the drug for medical purposes.
“Not only does prescribing drugs that haven’t been clinically tested fly in the face of medical training and ethics, but marijuana’s potential benefits and adverse effects have not been rigorously tested.”
If people want to smoke marijuana, they can choose to do that. However, as a physician I am not prepared to be prescribing an untested, not quality-controlled, non evidence-based, potentially harmful substance. Making physicians responsible for providing access to Medical Marijuana is especially unjustified given that there exist synthetic versions that were tested through normal clinical drug trials; these medications offer the same potential benefits in the treatment of, for example, chemotherapy related nausea and anorexia.
The CFPC’s full statement can found here, but I’d like to re-post it here since I could not have said it better myself:
On American comedy TV shows and in movies, MJ using characters often try to pass their (illegal) weed off as prescription for glaucoma. Call me a grumpy narc but can’t they just use eyedrops? Even the Glaucoma Research Foundation says that’s bogus… you’d have to smoke up q3h to reach therapeutic levels!
NSFW Vid:. Why does everyone suddenly have glaucoma?
What do you think?
The Cleveland Clinic made this simple video that helps patients and health care providers remember that we are all human. We are all going through our own “stuff;” how we act and how we interact with others going through their own “stuff” is a big part of delivering care.
Sometimes my “stuff” shows. If I’m worried about my boyfriends’ new job, didn’t have lunch, am excited that I’m a new auntie, didn’t sleep because my neighbour blasted music at 0300, look forward to dinner with my parents, am sad that a patient I got to know died – it might be on my face or in the way I act. Everyone tries to be as professional as possible and that doesn’t necessarily mean isolating your work and personal life. I know that I get overwhelmed by time pressures sometimes, when I feel I have to see too many patients and cannot be as thorough or as kind as I want to be, because I simply do not have the time. My frustration is that I know I’m not doing the best job possible, and that makes me pretty upset. It shows on me as grumpy or busy busy busy. I try really hard to be accessible and courteous but more than a couple of times I’ve been rude to a nurse when I’m in my “holy crap, how can I possibly care for all these very sick patients all at the same time”-pressure zone. And I feel terrible about it. And I sheepishly apologize.
I’ve had patients act incredibly rude to me, and had to leave the room to let them cool down. When I see them again, they apologize, and usually their emotions come from something we can’t see; they are worried about their elderly mom at home, they miss their dog, their friend died of the same thing they just got diagnosed with and they are scared. For clinicians, empathy is a part of our everyday toolbox but it’s not uncommon for patients to acknowledge that they see the context of people around them too. “That nurse has been so busy! I hope she had lunch!” and “I’m feeling well, how are you today doctor?” are little things that go a long way to helping us (healthcare providers) feel like we are human and have problems and joys too.
Empathy can be as simple as acknowledging that the person you are talking to has “stuff.”
http://health.clevelandclinic.org/2013/03/empathy-exploring-human-connection-video/
I…. I guess there is a book!
Lately I’ve had a number of requests from nurses regarding hospital patients that I think fall under the same category. Maybe my perspective is off? I really have a hard time when I’m asked to medicate someone because they are having what appear to be normal emotions in response to hospitalization/new illness diagnosis. I understand where the nurse is coming from, but I also know a pill will not solve the issue.
I have been lucky to be working with some really skilled nurses. They are observant, they are strong advocates for their patients, and they also come to me with the situation, ideas for improving it, and are open-minded to hearing my thoughts. I try to be but I’m not always open-minded to theirs – in one category particularly.
There has been a cluster lately of requests for medication to help calm patients down. We do this all the time for people who struggle with chronic anxiety or panic disorder or are in acute psychosis. We use behavioural techniques and medications to help them feel more in control and give their brains a chance to tackle the difficult things they face. We also use environmental modification, re-orientation, chemical, and physical restraints (if absolutely necessary) for patients who are delirious.
In cases of delirium, behavioural methods and chemicals (anti-psychotics) are used to help prevent someone from hurting themselves (i.e. climbing over the bedrails, falling and breaking a hip) or hurting someone else with violent/aggressive behaviour. It’s not ideal, but managing the behaviour gives the body time to recover from the underlying cause (infection, metabolic derangement, medication effect, new structural changes to the brain, etc.). Often it is a sweet, pleasantly demented old lady who gets a bladder infection and suddenly becomes not herself, confused, scared, disoriented, and striking out physically at those providing care.
It’s a terrible thing for the patient, for the family, and for the health providers. We are learning to become experts at preventing and managing delirium but it’s still a factor in many geriatric hospitalizations.
Now, I’m talking about something different. When a person is not delirious, their brain is working, they know who they are, where they are, why they are in hospital, and they want to leave or are “anxious.” They are afraid to leave their wife or kids or parent or dog alone at home, even if someone else is helping look after things at home. They are afraid to acquire a new illness in hospital. They miss their food. They hate the hospital bed. These people are often stubborn, frustrated, and have big hearts that are stretched because they can’t physically be available to those that need them, or they simply miss things at home. They can leave hospital against medical advice if we think they are of ‘sound’ (competent) mind. They might get worked up, find themselves at the nursing station, asking “when is the doctor coming?” “when is my test?” etc.
Lately, I’ve seen quite an increase in requests to give these patients “a little ativan” or “a little something to calm them down.” What am I being asked to medicate? Some people hate being in hospital. Everyone is at least a little bit stressed about being there, unless they are too sick to even notice or care, in which case they don’t have the energy to contemplate going home anyway. It would be ABNORMAL to want to be in hospital. People get better in hospital, but also bad things happen there. It’s loud and crowded and the food sucks and there’s no where for family to stay and you have to wear embarrassing gowns and get needled and so on. It’s NORMAL to not want to be in hospital. Right?
Yeah it’s not Canada. But that’s a lot of drugs!
So what shall I medicate? Chances are if I give “just a little ativan” I’ll make this persons fears come true: more complications in hospital, side effects of medication, etc. Moreover I’ll be suppressing their normal, appropriate reaction to, yes, a really stressful and uncomfortable situation. Plus the effect is temporary and doesn’t solve the underlying problem. And if they really don’t think they should be there, they can leave.
We can always use our words to reassure but when I have 26 inpatients in a day and 8 hrs to see them all (and we’re meant to spend 30min/patient), it’s hard to keep going back to hold the hand of someone who is scared. Fortunately, the same nurses who wonder if we could try a little medication are the most empathetic of the lot and their words are kind and reassuring to patients. But it’s hard for them to find the time too! They are even busier than the doctors. They have too many patients and too little time to bring them medications, start IVs, put in catheters, rub backs, bathe, teach, assess, measure vitals, help in-and-out of bed, answer calls from the family, etc. In the middle of the night when a patient is just plain upset, it would be nice to have a magic pill to help them feel better.
Sadly, there is no magic pill. The nurses are not wrong in their request, these patients definitely need something to help them, it’s just nothing that is contained in a medication. Part of health is developing a healthy coping style and some patients have this already; laughter is a pretty good place to go. I’m not afraid to be colloquial with patients, saying things like “It sucks!” or “I know you are frustrated! And you sure are stubborn!” and usually there is a laugh, a response at being understood, acknowledged but also in acceptance of the fact that we can’t solve everything at once. I try to help them with the coping as best I can and often ask patience of patients. “It’s the weekend and uh, unfortunately, nothing really happens around here on the weekend! Even the food is worse on the weekends!”
There’s probably more for me to learn about teaching someone the skills they need to cope, but I thought about what I naturally do to help people managed and it seems my mainstays are:
- explaining things so they understand what is happening, what to expect
- acknowledging how they feel, and sharing my empathy which I usually have because it’s easy to see that people are (rightfully) ‘stressed out,’ and I know I would be too in their shoes
- asking what we can do differently or what would help them feel more comfortable – sometimes it’s simple things like removing an IV, getting a bath, or having their family bring in warm socks
- having a laugh because yes, being in hospital is a kind of shitty thing to have happen for most people (sometimes swearing helps too… yep. select patients only!)
and if all else fails and I can’t convince them: - letting them know that I would like them to stay but they are free to sign themselves our “against medical advice” (AMA) if they feel strongly against the idea of remaining in hospital. This helps them know that they have options, and even if they don’t choose to leave AMA, perhaps bringing it up as an option gives them back some of the control they feel they have lost by being hospitalized.
After that, gee, I don’t know. I guess at that point, I would like a magic pill for making me feel better when I have failed to help someone. Or tips. Tips at how to help people cope, those will probably work better anyway 
REVIEW: The Spirit of the Place
Don’t even look at the cover. Read the book.
Samuel Shem (Stephen Bergman), best known for the iconic House of God, is back. A few novels later, he’s got a gem: The Spirit of the Place (Amazon.com, Amazon.ca kindle version).
In The Spirit of the Place, Shem keeps some of the blunt honesty and humour of his former work but provides a more intimate look at the life of a physician. And, it’s not really about medicine at all, it just happens that a physician is the perfect specimen for the kind of intensity and vulnerability that the protagonist needs to have. Instead of ‘buffing and turfing’ patients, Dr. Orville Rose (Orvy) is focused on, well, he doesn’t really know what. He struggles to accept the caustic embrace of family and is forced to confront it head-on.
With the news of his mother’s death, Dr. Rose returns to Columbia, the inexplicably whale-themed town where everything breaks and his past – and mother – haunt him. She has willed him the house, car, and half her savings on the condition that he stay in Columbia for 1 year and 13 days. He knows immediately what to do: flee back to Italy and his esoteric girlfriend, Celestina. Surprisingly, she suggests that Orvy obey the spirits and, since she’s already left him for a Swiss banker, he has little else to do. He joins his old mentor’s practice and is soon stuck piecing together fragmented Columbians at all hours of the night. His misery continues thanks to scathing posthumous letters from his mother delivered at regular intervals. It doesn’t help that his childhood-bully, now an American Hero, is living across the street and much to his chagrin, Henry Schooner seems desperate to befriend Orville.
The work gets harder when the good Dr Rose finds himself abandoned by his colleague, cleaning up the mess that the Columbians made of themselves. I think every health care provider, at some point in their career, has felt this way:
‘I’m the guy at the bad end of it all!’ he cried out, standing there on the icy street. “I am the one they call to sew them up, cast their bones, pronounce them dead. I’m the one called in for a dose of reality and I am sick of it! Do you know how much effort it takes just to sew up a wound, let alone try to repair a blown-off leg? How many years – hard, disciplined years – it takes to learn it? I put out enormous effort, superhuman effort on a daily basis, and they put out none! The Colombians eat crap and lie around like pigs and smoke so the nicotine makes them feel a little jazzed up while the carcinogenic tars mix with the PCBs from the river and the cement dust to destroy their lungs or livers, and they say to themselves, “gosh, I think I’ll go to the doctor!” – page 115
Just as that sounds familiar, most physicians can identify an old codger who mentored them and whose practice late in life was charming if sketchy. In this book, Bill Starbuck is that old doc. He prescribes his own remedy, Starbusol, for every ailment possible.
Another strike against Bill was his increasing reliance on his own special medicine, Starbusol. For decades, he had made the stuff himself. It came in bottles, smelled of pine, and tasted like a cross between cherry cough medicine Coca-Cola. In extreme cases, it could could be injected. No one, not even Orville, knew what was in it. – page 56
His wisdom is more convincing than his cure-all is effective:
‘Well, that makes sense.’ He smiled. ‘One thing I learned is, is that whenever you think you are choosin’ things based on the facts, ten years later you look back and see you didn’t know shit from Shinola about what was really going on in the world and in your life to push you to think you were choosing things one way or another.’ – Bill Starbuck, page 47
Through Bill, Shem provides relaxed wisdom, and through Orville he gives reassurance that we are all a little weird and fractured. I admire any writing that humanizes physicians, and the foolishness and cowardice that result in a faltering journey for Orville make him real and relatable.
From that first afternoon as a child in the field looking up at the clouds passing across when he had discovered the ‘something else’ and when, on bringing it back to his mother he’d been told he was crazy because ‘there’s nothing else but this,’ Orville had lived in the deep, secret, abiding sense that he was abnormal . . . Alternative to the culture, always. Even, years ago in college at Syracuse and medical school in Dublin, alternative to the alternative 60s – talking the talk but not walking the walk. – page 270
Women in The Spirit of the Place are less subjects of fantasy and more complicated challenges, compared to those in The House of God. Orville finds himself captivated by Miranda and her son Cray, whose slow-to-warm-up temperament provides great and endearing reward. Shem has traded in juvenile sexuality for a more mature and intimate strain; lust becomes love and though broken, like everything in Columbia, Orvy recognizes it.
While there is no list of rules to live by, The Spirit of the Place offers a more aged humour; wisdom in place of wit. House of God fans who rely on quick jokes might be disappointed but those who have also grown up themselves will appreciate Shem’s evolution. It’s still cynical, it’s just a little more honest and bare, forcing us to confront the fact that we are all – or have once been – as lost as Orvy.
Laws of the House of Our Land
I’m reading Samuel Shem’s newest work, The Spirit of the Place in order to review it. Stay tuned for my thoughts on this newest work from the famed House of God author. I will say that maybe I’m in the mood for some silly but accurate medical rules; since the new book doesn’t contain any, I think I’ll make up a few of my own.
Laws of the House of Our Land (ᓄᓇᕗᑦ = Nunavut)
1. Have a shower while on-call, and the phone will definitely ring. Then you’ll be outside in -40C with wet hair.
2. It’s not TB until it’s TB. And even then, it might not be TB.
3. You have to die of something.
4. A B-hCG is positive until proven otherwise. Even if the patient has had a Tubal Ligation.
5. There is no placement.
6. It’s not a MedEvac until the plane has landed.
7. Don’t draw the d-dimer.
8. Informed refusal is just as good as informed consent. Just be sure to write it down.
9. Never go out without your snowpants on.
10. Show me a nurse who doesn’t suggest an x-ray and I will bow and kiss her feet.
Pourquoi apprendre le français?
Une amie francphone m’a demander: “Pourquoi apprendre le français?”
As a kid, a strange green puppet named Dimontou was my first exposure to this foreign language. When I was a teenager, I got to go on a 2 week exchange to Joliette, QC. I’ve been to Montreal for 4 or 5 times now but am dying to check out Quebec City in winter and to experience Carnaval de Québèc. I’ve always loved winter, and it is utterly charming to combine a snowman mascot, tire d’érable, and an ice hotel into one vacation. No?
Tire d’érable; maple syrup taffy made by pouring hot maple syrup onto fresh snow. Yum!
I have been trying to keep up my French skills by writing or talking with french-speaking friends, and have for a while realized I’d need to do much more than that to approach bilingualism. I would like to join an adult french conversation class, or take a medical french course, but being as transient as I am right now, it would impossible to even figure out in which city I should take a class.
One downside to travelling so much (usually to work in Nunavut, to Ontario to visit family and friends, and sometimes for holiday) is that I can’t commit to anything. I was frustrated by this for a while and could see it inhibiting my ability to sign up for interesting activities, like a French class. I was desperate to do something as I am not often around my French-speaking friends these days and feared that I would lose what French ability I was privileged to have.
I have no idea who this French teacher is, but this photo depicts what learning French in grade 1 was like, almost exactly as I remember it. You can see Dimoitou looks a little sad here. But he’s always happy to help kids from the 1980s learn Français!
I’ve tried Rosetta Stone, but the basic levels were too grindingly boring for an intermediate like me, and the emphasis seemed to be on learning vocabulary like “cat” and “dog” rather than on speaking and getting the flow of the language. I finally settled on Rocket French. I bought the first 2 of 3 levels, and am very slowly ticking away at the exercises. There’s a big emphasis on speaking and pronunciation, with dabblings of cultural enlightenment and a slow enough introduction of new words that I haven’t yet been overwhelmed. (No this isn’t an ad! This program works well for me because I already have a foundation in French, but I think it would probably be really frustrating for someone new to the language!)
But the question is ‘why do you want to learn French?’ For me, it’s not a simple answer. I don’t need it for a job, although it might look good on a resume. I don’t live in a French-speaking community and rarely do I see Francophone patients, although when I do it is fun to try and talk and gesture to learn about and help manage their medical issue in an awkward medley of Franglais.
I have no idea what this French energy tonic from 1915 is all about. I don’t think I would even if the ad were in English.
I have used it clinically with mixed results. I’ve assessed and arranged treatment for a patient with an esophageal blockage [with a lot of help from a bilingual nurse] and did the discharge education for a patient who had a GI bleed and TIAs [using some combination of his wife's bits of English and my French]. More recently I clarified a medication list for a French Catholic priest and we concluded the appointment after sharing some jokes about patient autonomy.
Unfortunately, my broken French isn’t always adequate. I remember struggling to tell a woman about an unwanted pregnancy. Not knowing the word for pregnant (enceinte) I had to tell her “you are with baby” (“vous-etes avec bébé“). In another case, a woman told me she came to the ER because of “champignons.” I knew that word, it means ‘mushrooms.’ I struggled to realize that she meant ‘fungus.’ I thought of Athlete’s foot, or some fungus on her skin involving some other part of her body. It was only when she pointed that I realized what she meant: yeast infection. Oh.
It is a big place. About 23% of Canadians speak French as a first language. (www.canadafaq.ca)
While it would certainly feel a lot less horrible to stop having a quizzical look on my face when a French patient is trying to tell me their story, it’s not the only motivation for improving my language skills. Here’s what I wrote to my friend, polished up a little. Please pardon the sporadic accents, I’m still trying to figure them out on my keyboard – and pardon the terrible French, because as you know, I am still learning.
“Je voudrais apprendre français parce que je pense que je peux! Le raisonnement est une combinaison de l’utilité (pour le voyage ou le travail ou pour parlant avec des amis comme toi), la beauté de la langue, un defi (I had to look that up!), et une croyance que tous les Canadiens devraient essayer un peu de leur langue seconde. J’ai eu la chance d’avoir des bons professeurs de français et d’etre exposés a français à une age jeune; j’avais l’impression que c’était dommage si je ne l’utilise pas, et plus mauvais si j’ai le perdu”
I forgot to tell her how much I like cheese. That alone is probably a good enough reason to learn French.
Use it or lose it, just like so many other skills in Medicine and life in general. This language is too worthwhile for me to let it go.
