Avast pirates! Aarrr!

The vernal equinox has passed. A winter of 'flu and ague has warmed into a spring of seasonal rhinitis.

[I just plugged "ague" into dictionary.com to check the spelling. The computer said, "Bargain ague! Find, bid, win it on eBay Australia.com."]

Every year, winter causes bed block. That is because the community, via the electoral system and the Q health decision makers, via their parietal lobes do not place value on the care of the sick elderly and therefore do not pay for extra beds and nurses for hospitals and staffing and GPs for nursing homes.

One Thursday not too long ago, the public hospital where I work, "A", was "ramping". That is, ambulances were unable to deposit their patients to trolleys in the Emergency Department because there were no more empty trolleys. In fact, every hospital in the city was "ramping".

One of Captain Bligh's Q health band of bilge rats rang to ask me if I would admit public patients to the co-located private hospital in order to take the pressure off another hospital, "B", located about 20 km South West of "A".

"Well, that would be fine," I said. "How will you pay me?"

Silence at the other end.

"I mean, are you going to pay me for time in attendance and all the associated on call work on an hourly rate or will I bill you with item numbers on a case by case basis?"

"Um, well, we thought, since you are an employee of Q health, that you would just sort of, you know, do it. "

Silence at my end.

But not for long.

I pointed out to my caller, Hook 'n crook, that Q health had given me no understanding or support over the past six years in my efforts to juggle a private practice and a public hospital appointment, so, although of course I'd like to help Q health, he had better go away and think up a better agreement and put it to me in writing.

Surprisingly, Hook 'n crook did that and came back with an offer to pay me Australian Medical Association schedule rates on a case by case basis. This was a surprise because the AMA rates are ludicrously high and have little or no relevance to the market place. Then it hit me: this is how my taxes are being spent.

Anyway, I said "yes" and the game was on. Several hours passed and I heard nothing and then a night and then a whole next day. Where were all these patients I was supposed to be admitting?

It came back to me that twelve patients at hospital "B" had been asked to make the ambulance journey to the private hospital, the one near hospital "A" and twelve of twelve had refused to budge an inch from their trolley in the corridor of their local facility.

Aye, me hearties!!

Wake up.

There was this sheep, you see and I can’t remember its name.

‘Fang’?

No.

Perhaps it didn’t have a name?

I remember it was an older sheep and quite large too. It was for our third year physiology experiment.

Might be just as well it didn’t have a name, then?

We had to anaesthetise it, venesect it, resuscitate it and then when it was dead, haul it into a large garbage bin: a big black plastic one with wheels and a lid.

You mean you had to put it to sleep?

No, we killed it.

What’s wrong with that? You had to do it. It was part of your learning. It’s only a sheep.

Did you know that sheep are hard to keep alive? It takes a lot of effort to ventilate an anaesthetised sheep with a piece of garden hose and a large plastic bag.

How did you do it?

What?

Kill the sheep.

Lethobarb. Sodium pentobarbital. It’s bright fluorescent green so you can’t mistake it for anything else.

Is it painless?

Supposedly so.

Still. Poor old sheep.

Yep.

Since the 1970s, when capital punishment resumed in the US, articles about lethal injection have appeared in the medico-legal literature; about one or two a year. Recently, however, there has been a string of comments turn up in the New England Journal of Medicine and, to a lesser extent, in Lancet.

The editorials discuss the ins and outs of execution methodology, what is or isn’t “cruel and unusual punishment” and the ethics of physician involvement, from research to actually pushing the drugs (thiopental, an anaesthetic drug, pancuronium, a paralysing agent and potassium chloride, to induce cardiac arrest).

Certainly, the authors and the people to whom these articles are directed may be ill-educated or psychologically conditioned by the society in which they live. However, they are not ‘un’-educated, they do live in a democracy (or, so they say) and they are physicians. How can they not see that capital punishment is spiritual delinquency? Medically sanitised or not, execution is an atrocity, reflecting human nature at its most base.

Intellectual posturing on the pros and cons of lethal injection is no moral relief. The physician's absence of protest against capital punishment and therefore complicity is an abhorrence in itself.

More cow bell!

I thiik've gured t ut.

Agh. My keyboard's 'Eveready' batteries suddenly turned into 'Nolongeready' batteries.

That's better.

I think I've figured it out: why a suburban public hospital is the last place any rational person would want to work.

You see, it's because the energy balance is all wrong; Feng shui, Yin/Yang, the rainbow connection, call it what you will: it's all snafu.

On the one hand, disease drains energy away. No one can do anything about that; it is the way of things. On the other, the soulless culture of public hospital governance and its perpetual holding back of common sense and resources causes a cosmic constipation. 'In' does not replace 'out'. Making matters worse is the lack of any inbuilt reserve and flexibility within the hospital itself. There is no capacitor in this system. It exists in a perpetual state of attrition punctuated by frequent crises.

I saw Avril again the other day. She's 70 and she's dying of heart failure. It's all down to inoperable coronary artery disease and hypertension. She knows it and I know it. In the whole scheme of things, there's not a lot of time left for Avril. She comes to hospital quite often with everything from a serious bout of gout to a casual VF arrest. Bit by bit, her heart is going, taking her other vital organs with it.

One might say, with Avril, we're rearranging the deck chairs on the Titanic, or, while you're skating on thin ice, you're not falling through. Either way, it's serious stuff.

Naturally, Avril generates a lot of paper work: progress notes, test results, medication charts, correspondence with her GP and other odds and ends. Every time I see Avril, her hospital file has grown a few centimetres thicker.

"Is that all about me?" she once exclaimed, spying her file.

"It is indeed, Avril," I replied.

"Well I must be either very important or very sick," she said.

"I think it's a bit of both, Av."

The real problem is that the hospital has completely run out of chart covers. "Central", the place where chart covers come from, says we can't have any more until the beginning of March. (We ran out in about November last year).

Normally, Avril's chart would have been split into two manageable volumes long ago. As it is, it is bursting at the seams (or it would be, if it had any seams at which to burst). A flimsy plastic doo-dad tries valiantly to hold all the pieces in place while every so often, the hundreds of pages explode in a fountain of parchment all over the unwary intern. It's as though the file is making its own personal protest at being so unwieldy.

"I'm so fat, I can't take it any more!" it cries.

The reason why I worry about Avril's chart is that it is symbolic of this energy imbalance I'm blogging on about. It represents a world which should be orderly and safe but is slowly crumbling into a quagmire.

I can't do anything about Avril's chart cover. However, there is a need for someone, anyone, to add some positive energy to the system. I think there are ways to do this. For instance, I was reading an article in Lancet this morning where a Melbourne physician had decided to, each day, place in her medical ward a pile of photocopied poems beside a bowl of fruit with a sign saying "please take one of each". How brilliant is that!

In my own small way, I've tried to address the imbalance by bringing some favourite tea bags; lemon zingers, chamomile, Earl Grey and the such like to the outpatient clinic for all to share. If tea in the afternoon can happen, then, perhaps, other good things can follow on.

Scum of the Earth.

Everybody has a heart sink phrase. For firemen, it might be “We’ve run out of water”. If one worked in a department store, it might be, “The manchester sale starts tomorrow” and if you were an actor it might be, “The committee of the Augathella Township and District Ladies Auxiliary would like to see you after the matinee. They’ve brought you some lamingtons and knitted coat hanger covers.”

For me, the heart sink phrase used to be, “Dr Zimble, there’s a drug rep waiting to see you.” It doesn’t bother me anymore though and I’ll tell you why in a moment. But first, let’s be clear: the marketing of pharmaceuticals is an odious business. The only people who benefit are the profit makers and the drug reps they employ.

For the last few years, the college of physicians (RACP) has advised us not to accept gifts from drug companies. The gifts range from a very average biro to an overseas holiday. Over the years, I might have collected enough items to furnish an entire house: the Astra Zenica towel set, the Merck Sharp and Dohme bread knife, the Eli Lilley wall clock, the Evista ice cream scoop, the Norvasc solar powered calculator and the Viagra red silk mens’ boxer shorts to name but a few.

A while (several years) ago, I did something I now regret. I accepted a pharmaceutical company invitation to attend a “scientific meeting” on diabetes management. It was an all expenses paid three day trip. I was given a local flight to Brisbane airport, a transfer to a domestic flight to Sydney, overnight accommodation in Sydney, a transfer to an international flight to Christchurch and a transfer to another local flight to Queenstown. At Queenstown, a coach took me to a luxury golf resort. The accommodation in New Zealand was amazing: a country hotel, with heated floors, nestling by a picturesque brook, ringed by snow capped mountains. Bill Clinton’s cottage was over there on the edge of the course.

About one hundred delegates from across Australia attended the conference. We did listen to some speakers, for a few hours. The rest of the time we were wined and dined at the finest Queenstown restaurants and even had time to take a tourist flight over the glaciers to beautiful Milford Sound.

Two things made the meeting quite odd (over and above the fact it was free). The first was a 4 kg bar of Toblerone for each delegate. If we didn’t have diabetes when we arrived, we would by the time we left. The second was the launch of the “novel anti-diabetic medication” pioglitazone. As chance would have it, the day before the launch, pioglitazone was busted in the world media for inducing fatal liver disease. I guess even multinational drug corporations have bad days.

As nice as it was to have a break from the everyday and a chance to catch up with interstate colleagues, the trip was a pointless exercise. I didn’t hear anything I didn’t already know and the new drug was a dud. The money, let’s say $2000 per person (and that’s conservative), could so easily have been spent on worthwhile causes: mosquito nets for malaria prevention, wells for clean water in the Sudan, seedlings for Indonesian subsistence farmers and so on.

I flew home feeling a little guilty but then I thought, maybe this is all normal in the corporate world. Maybe this is what I deserve. That was stupid.

Far more subtle and, to my mind, more sinister than the gifts, are the drug rep visits. A mid-twenties woman, who could pass for an air hostess any day of the week, arrives at a suburban hospital medical clinic. She is dressed to the nines in Georgio Armani corporate attire with the latest and most expensive laptop computer in one hand and a polished Italian leather satchel in the other.

Here comes the heart sink.

“Doctor, Miss Armani is here from Super-Duper Pharmaceuticals and would like five minutes?”

Damn. It’s one fifteen, I have four more patients to see, three calls to return to GPs, an abdominal paracentesis to do and my own ophthalmology appointment to get to by three.

“Okay then, send her in.”

“Dr Zimble! Charlotte from Super-Duper Pharmaceuticals. Thanks for seeing me. It’s so lovely to see you again! We missed you at the Super-Duper Pharmaceuticals dinner last Friday. I know how busy you get though. I’ve been run off my feet myself!”

The idea is, if I prescribe super-duper drug, I too will have designer suits; I too will have my shiny hair coiffed and my makeup flawless and I too will have beautiful young friends like Miss Armani. Heck, I'll be Miss Armani!

Fortunately, these days, Zimbles come with a built in bullshitometer. Miss Armani has absolutely no idea when I ask her questions like: how many patients do I need to treat with super-duper drug to save one life? Is super-duper drug safe if my patient falls pregnant? Does super-duper drug work if it is crushed or chewed? What is the absolute benefit of super-duper drug versus its relative benefit? What is the cost benefit of super-duper drug over tried ‘n true drug in this condition?

About three years ago I decided enough was enough. I said ‘no’ and stopped seeing the Miss Armani’s of the world. They could leave me printed matter if they desired but no appointments would be made.

Nothing terrible happened. No one from Super-Duper Pharmaceuticals came with a shot gun to blow out my porch light; no one sent me orange overalls and a one way ticket to Cuba; and my colleagues didn’t end up knowing anymore about super-duper drug than I did. I'm certain I can live without the Super-Duper golf umbrella.