Team Broken Earth Mission to Haiti Day VII

 May 2nd, 2017
Today, we’re leaving Haiti. Yesterday was by far the busiest and most traumatic day of the entire deployment; it was also the last day.
A truck rolled in with three trauma patients. One had an obvious head injury with a large scalp laceration, was combative, lying on the ground, and getting everyone’s attention. George and the Haitian E.R. doc, Dr. Charles, were taking care of him, and he managed to roll off the narrow stretcher in his anguished agitation. While that was going on, our paramedic, Lorna told me that there was someone lying in the back of the truck. I went to look, and saw an elderly women lying on her left side facing way from us on the floor of the empty trailer.
I got some help to move her into the ER, and tried to assess her. It was difficult, because everyone was looking after the young man with the head injury. Fortunately, I had Kim and Lorna to help. The patient was very quiet, which worried me, but she was still a GCS 13-14 and she was protecting her airway. She had some facial lacerations and left facial swelling, but seemed neurologically intact. She denied any shortness of breath, chest pain, belly pain, or back pain, but complained of hip pain, and I was worried about a hip fracture. I put her in a c-spine collar, because I was worried about a c-spine injury as well as a possible closed head injury with her facial swelling and her altered level of consciousness. I was reasonably hopeful that she didn’t have an unstable pelvic fracture, because she was hemodynamically stable, and seemed reasonably comfortable, especially after we put a Foley catheter in, but it was still a consideration and I was anxious for her to get imaging done.
Meanwhile, the other docs had decided to intubate the other patient, which they did with impressive skill, considering how big he was, and how he needed in-line neck stabilization. I tried to assist by providing BURP. George did a FAST, and the patient had a slip of free fluid in the RUQ. I also ultrasounded his belly and chest. He had no pneumothorax, and it appeared that there was no interval change in the free fluid around the liver.
The patient I was looking after remained stable, but she had a couple of facial lacerations, including one on her lip, and one on her left eyelid that required closure. Her left eye was also full of gravel, which we flushed out with normal saline. The hours dragged on, without the requested CT head, c-spine, and pelvis X-Ray getting done.
The other patient was going to be given blood, and needed it urgently, but Dr. Charles explained that an HIV test needed to be done on the patient first. If the test was positive, then the family wouldn’t be able to say later that the patient had received tainted blood, and sue the hospital. Apparently, this has happened before. What about drawing the blood for HIV testing, and then doing the transfusion while awaiting the results? This would help minimize delay. No, explained Dr. Charles. The results of the test must be reported to the family before the transfusion is given. There must be no way that family can later say that their loved one received blood in hospital and is now HIV positive as a result. I can understand this, but it causes a delay that can be life-threatening in a trauma patient with blood in his belly, and a deep scalp laceration. 

 
Eventually, the patient went to CT and X-ray, four hours after arrival in the ER. There was much commotion and tight spaces, and heavy lifting, getting this patient who was intubated, and must have weighed over 100kg, on and off the stretcher for his CT. The scan showed what looked like poor differentiation between the brain’s grey and white matter, suggesting swelling and injury, as well as some trace subarachnoid blood. Afterward, his chest X-ray confirmed the placement of his endotracheal tube, showed what looked like a big heart, and likely some right-sided pulmonary contusions. 
He went from X-ray to the ICU, where we were getting him settled when he suddenly went bradycardic as I was trying to scan his heart and look for a pericardial effusion as Ana had requested. His heart rate came up a bit, and then he developed PVC’s and went into Ventricular tachycardia (VT), and finally ventricular fibrillation. CPR was started, and an attempt at defibrillation was attempted, without success. CPR and pulse checks continued. He was given several 1 mg ampules of epinephrine. His lab results were available, and showed that he was very acidotic, so bicarbonate was given. Calcium chloride was requested too, but too slow to arrive, needing to be retrieved from the pharmacy. As an EMT went to get it, I believe he was initially refused, and in retrospect, if a doctor had gone, it might have been more quickly procured. Eventually, we got a pulse and we were about to start him on norepinephrine. We weren’t sure why he arrested. Did he have a pericardial effusion, thus explaining why his heart looked so big on X-ray? Did he have a cardiac contusion? His heart looked very hypokinetic on ultrasound, but I didn’t see a pericardial effusion.
Despite the return of circulation (ROSC), the patient arrested again, and after more rounds of CPR and epinephrine for his PEA (Pulseless Electrical Activity) he couldn’t be resuscitated. The code was called, after lasting almost an hour. On hearing of the patient’s death, I could hear family members in the compound outside of the ICU wailing and screaming with grief. 
The final CT report available after, showed that the patient had massive brain swelling with a traumatic subarachnoid hemorrhage and uncal herniation, his brain pressing on the brainstem and disrupting the primitive regulation of his basic bodily functions, such as respiration and cardiac activity. There is no coming back from that. 
I know Dr. Charles was upset with the outcome and we wondered, if things could have happened faster, maybe the brain swelling could have been identified on a CT done earlier, but there wasn’t much that we could do. We couldn’t give him mannitol to decrease the brain swelling, because his blood pressure was so low. These are difficult conditions to work in, with limited resources, and a slow pace of execution.
We can only try our best, and not become angry or frustrated at the way things are done. We’re not there to show people how to do things the right way. If anything, we’re there to learn how to make do with less. In an era of increased scarcity of medical resources, we may be forced to learn these lessons anyway.
My lady with the hip fracture had by now been in the ER six hours. I accompanied her to the CT scanner, and saw that her head was fine, and c-spine intact. Her facial bones were not broken. She only had a lot of soft tissue swelling and the lacerations that I sewed up.i was expecting her to go to the X-ray after her CT, and found much to my surprise that it had already been done while I was away with the other patient. So it is that my expectations had been lowered. A critically important X-ray that I would expect being done within minutes of her arrival had not been done for several hours. Still, it had already been done, and I had already resigned myself to it not having been done, so I didn’t even bother to check. The X-ray showed an unstable pelvic fracture, the worst I’ve ever seen. I can’t believe she wasn’t in more pain. She seemed comfortable with morphine. It’s lucky that she didn’t bleed out into her pelvis. We tied a sheet around her to act as a binder. I left her with a plan to admit to ortho, as our orthopedist suggested, so that she could have an external fixation of her fracture. I’ll have to find out what happened with her.
George saw a third patient in the accident who had a broken thumb, and needed only stitches and a splint. The spectrum of disease from a single accident ranged from the life ending brain injury, to the life-threatening pelvic fracture, to the most minor injury.

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Team Broken Earth Mission to Haiti Day V & VI

Apr. 29th

Today was a busier day. This morning, there was an elderly man on a vent who had had a stroke overnight. He also had a cardiac arrest, lying there in a coma, not on any anxiolytics, analgesics, or sedation. He was hooked up to the defibrillator that serves as a cardiac monitor and it made this incessant and loud beeping that just raised the tension in the already crowded room.

The second patient was a young man who had a head injury two weeks ago. He presented with an ALOC and was taken to the O.R., and he had a subdural hematoma evacuated through burr holes and a Jackson-Pratt drain remained to remove any further accumulation of blood and fluid. He breathed on his own, a mask applied to his face.

I find I spend a lot of the time just standing a round. I try to be helpful, but not intrusive. The local ER doctor will occasionally ask for advice, and I will oblige. There was a patient who had hemoptysis, lymphadenopathy, and infiltrate on chest x-ray. He was awaiting a CT. I suspect that he has TB.

George and I saw another child, a 15 year old boy, with head trauma. He presented with ALOC after falling off the back of a truck. He had blood issuing from his left auditory meatus, and his CT showed what looked to be a small area of pneumocephaly. We didn’t see any other evidence of a severe injury, such as a skull or c-spine fracture. I wonder if he had a basilar skull fracture. Those can be very hard to detect on a CT scan. The final report was pending, and I must be sure to find out the results.

The elderly man on the ventilator was finally extubated by the ER doc at the consent of his wife. I was very glad, because there were otherwise no ventilators left in the hospital. This patient had had a terminal event, and with a stroke, then a cardiac arrest, and ongoing coma, any likelihood of meaningful recovery was slim to none. Despite this, the patient remained on the monitor that continued its merciless beeping. I questioned this. Because the patient had been extubated and was palliative, why would he need to be monitored? The ER physician said that she wanted to know when he expired. This kind of makes sense. I don’t think patients get the kind of monitoring that they get in ICU, so its hard to appreciate a change in condition, such as when someone’s in pain or not breathing. If the monitor registers asystole, it will be a cue to pronounce the patient and move him from the ED. It seems possible otherwise, that he might expire, and not be noted for some time afterwards, especially if he is lying quietly dead.

As the afternoon wore on, I was getting bored. Fortunately, Ana from ICU invited me to help with some ultrasounds; really, a high point. I diagnosed a likely pneumothorax in the quadriplegic gunshot wounded patient, who had a persistent air leak. I’m not sure why. A tracheobronchial fistula could cause a persistent air leak, and would be very likely given the trajectory of that bullet entering the patient’s neck.

I discovered a likely emphysema or pneumonia in a young man with a chest tube from trauma. He had pronounced subcutaneous emphysema.

I also scanned the heart of an elderly man, and saw very clearly how poor his ejection fraction was. The leaflets of the mitral valve barely moved at all, and the heart looked grossly hypokinetic. On the coveted four-chamber view, the bowing of the IV septum into the left ventricle suggested that he had right-sided CHF, and his plethoric IVC further confirmed this. These were exciting findings in that I think they helped with patient management, illustrating a need to give lasix, a diuretic, to relieve the fluid overload and pulmonary edema.

 

Apr. 30th

Today was the day that I pronounced someone dead in the back of a truck for the first time. A young man on a motorcycle was brought in to the hospital in the back of a pick-up truck. Kencey, the EMT, asked me to assess him after he’d gone out to meet the truck and found that the patient was dead.

When I saw him, he looked pale, with blood on his face. He was limp, with no response to pain, and no deep tendon reflexes. He had no breath sounds or heart sounds on auscultation, but it was hard to hear anything anyway with all the people crowding around, and the noise, and the hot sun beating down. It was the eyes that were the dead give away to the patient’s condition. The pupils were fixed and dilated, and the eyes looked pale, cloudy, and soulless. The eyes themselves were dead. He was cradled in the arms of his friend, who was quietly weeping.

With my pronouncement of death, the friend began wailing piteously. His grief filled the compound. The truck backed up, the body’s legs sticking out off the back of the tailgate.

I pronounced dead someone in the back of a truck with a crowd of people around me.

It was overwhelming, declaring someone dead “in the field”. Usually, the body’s brought in on a stretcher and wheeled into a quiet cubicle or trauma bay.

The ultrasound continues to be a source of great pleasure and satisfaction. I used it to diagnose a kidney stone in a young man with abdominal pain. He had right-sided hydronephrosis, and his urine later showed blood and leukocytes. He went home with Clavulin and Tramadol as he was feeling much better after the morphine. I wonder how common nephrolithiasis is in Haiti.

I also saw a ten-year-old boy with radial and ulnar forearm fractures causing severe deformity. He was sedated with ketamine and a nice closed reduction was done by the two orthopedists, John and Marco.

Team Broken Earth Mission to Haiti Day III & IV

Apr 27th

Today, I saw a young 33 year old man brought in having been hit in the back by a gate. His left hip was sore, and we were trying to get him to X-Ray, but the X-Ray machine wasn’t working properly so he didn’t get the film done for several hours. The X-Ray showed a superior and inferior pubic rami fracture on the left side. No real surgical management is needed. He’ll use crutches and be protected weight bearing for six weeks with crutches. I sent him with a prescription for crutches, diclofenac 75mg BID, and tramadol 50 mg q4h.

The most interesting patient was a 3year old girl, who’d been hit in the head by a rock, and had a GCS of 7-8, a large, boggy scalp hematoma and what looked to be an overlying small abrasion. George took the ultrasound probe and was able to see that she had a depressed skull fracture, as the line of the bone was discontinuous. The patient had a CT scan confirming a depressed skull fracture, a cerebral contusion, and pneumocephaly.

The neurosurgeon was a very nice man, and he had a fellow with him. The patient was admitted and will likely go to the O.R. Tomorrow. In the meantime, she was loaded with Dilantin

I.V. It appears that by history, she had a seizure shortly after the injury. In any case, she was at high risk of having a seizure, so seizure prophylaxis was appropriate.

I do feel that I’m able to make some difference here, but everything takes so long. Just getting someone registered literally takes hours. I don’t find myself too bothered by it though, the way I was last year. I find that having another E.R. doc in George around helps.

April 28th

Today, we had our day off, and had a chance to do some sightseeing. We had the choice of going on a city tour (which I did last year) or to a restaurant at the top of a mountain overlooking the city, the Observatory. It was a spectacular view. You could see the way the peninsula branches off to the west, and how the main landmass draws off to the north into a shroud of fog and clouds, prescient of the rain that eventually fell later in the day. I could see the runway of the UN base, and I looked to see what appeared to be a sprawling block full of gravel. On closer inspection with field glasses, one could easily make out the existence of shacks, probably low to the ground: a mass of uniform concrete. I tried to see where the hospital was, and looked for the Citie Soliel, a slum reputed to be the most dangerous in the Western Hemisphere.

As we sat in the restaurant, we were able to enjoy a drink. I had just about the best coffee that I’ve ever had. It had a fine crema on top and was rich, black, and strong.

We then made our way back down the mountain to meet the rest of the team who went on the museum tour that I had been on the year before.

After, I went with ten other members of the team to the hotel with a swimming pool and a buffet; it was an unsettling oasis of opulence in a city characterized by extreme poverty.

Everyone else on the team went to the orphanage, where I had been last year. I was glad to have the option of not going again. It was too emotionally draining. I would’ve sooner spent the day in the volunteer quarters than have gone to the orphanage again. It was that upsetting. It might be the sense of desperation in the children that manifests as a rehearsed performance, a cloying play on your heartstrings. It would seem a horribly manipulative performance, if children weren’t performing it. At that age, they can’t be faulted for behaviors borne out of a need for survival, unlike similar behavior in an adult, which is borne more out of a fear of abandonment.

Team Broken Earth Mission to Haiti Day II

Today was a very active first day. There was a 38 year old woman, apparently a nurse working for the Red Cross, who was taking money out of an ATM, and she got shot in the back.

In the E.R., she was found to have a left sided pneumothorax, and the Haitian E.R. Physician put in a chest tube. Her vital signs were initially stable, but her blood pressure began dropping and she became bradycardic. She had warm extremities and no sensation or movement below the neck, suggesting a spinal cord injury. With insertion of the chest tube, she had no blood returning from the chest, and with the bedside ultrasound of the abdomen, she didn’t have any free fluid that we could see. It seemed most likely that she was in neurogenic shock, secondary to a spinal cord injury. She was taken to the CT scanner, and found to have a fracture at the C6 level, with fragmentation of the vertebra and the bullet still lodged in the soft tissues of the neck. Fortunately, there was no evidence of neck hematoma or soft tissue swelling or any clinical evidence of airway compromise. She was admitted to the ICU, with the local neurosurgeon considering surgery. At the time, he elected to wait a bit. She is a quadriplegic now, with very little functional recovery expected.

This is one of those sadder cases. There was little history from the patient, which makes one wonder if there is more to the story than she is telling us. Did she know the assailant? Was she involved in any illegal gang activity that she is unwilling to disclose? There is no evidence for this. However, it may be that this woman is simply an innocent bystander, who was at the wrong place at the wrong time. This is somehow much worse to contemplate.

A young boy in the paediatric ER had been observed overnight after being hit by a motorcycle. He had been drifting in and out of consciousness, drowsy but rousable to painful stimuli. He also was having abdominal pain. The day before, he had had a hemoglobin of 91, which isn’t unusual in Haiti. He had become more obtunded throughout the day, and there was concern that he might have had a serious intracranial injury, or bleeding into his abdomen. Scanning his belly showed a large fluid collection. It was difficult to determine if it was blood, or a very distended bladder. We inserted a Foley catheter, and drained the bladder for almost a litre. With that, the fluid collection on US disappeared, confirming that he merely had a full bladder. There was some delay getting the needed CT scan of the head, due to concern that the family would have to pay for it, and would be unable to. Fortunately, the hospital generously did the CT without charging the patient’s family. There were problems with the scanner, which had to be rebooted. It would seem though, that there was no brain injury requiring neurosurgery. A few hours later, that patient was much more awake, and it is hoped that he just had a bad concussion, and will be able to go home soon.

Team Broken Earth Mission to Haiti Day I

Apr 25th, 2017
Today, at 330 in the morning, we left for Port Au Prince (PAP). The journey so far has gone smoothly, and there was the deceptively charming sight of a rainbow in a light morning drizzle, and blood pink sunrise seen from the airplane window on the tarmac at Pearson Airport. 
Why should such a sight be deceptively charming? It’s beauty might belie some of the traumatic and frightening things that we will see in PAP. To be truthful though, it’s a time to celebrate as well. It is great to have a chance to go with a great and supportive team and work in an austere environment with the dedicated and resilient professionals that live and work there year round. The Haitian people are very nice to work with professionally, and to help them in the care of their patients. 
I look forward to the social aspect of the trip, getting to share meals with my colleagues and be a little more outgoing than I would ordinarily be at home. It does leave me questioning myself at times, however. I’ve felt like I’m having so much fun that I must seem like some loud mouthed, bellicose medical tourist. I feel like I imagine Donald Trump would feel if he went on a medical mission to Haiti. I spend my working hours surrounded by hardship, austerity, and scarcity and yet in the evenings I’m free to go off with my team to a nice restaurant and drink the addictive “Mexican Coke”, laced with sugarcane instead of corn syrup or whatever the hell else the North American bottling plants put in their coke. 
We do not hold court in Mar-A-Lago, and dictate world policy in front of patrons whose only security clearance is their possession of incredible fame and wealth. We do, however, enjoy the trappings of a privileged existence that many of the locals can’t enjoy. There is a part of me that, despite volunteering of my time and skills to help people in need, I feel very concerned with my own comforts. I want to help as much as I can, and yet I don’t want to burn myself out with long irregular shifts, knowing next week I go home and back to work again at full tilt. 
I don’t think these feelings are a cause for guilt, or unique to my experience, but it is important for me to be aware of them. Coming to Haiti gives me a better perspective on what it’s like to practice medicine in an austere environment, thereby making me a more appreciative doctor when I go back home. In the end though, it’s the self-awareness that comes from broadening one’s own horizons through an experience such as this, that is more important to me.
I’m not here to fix the system or take over. I’m here to help in any way I can, maybe do some teaching, and some learning at the same time.

Zombies from the Mountains

In a couple of days, I’ll be heading back to Haiti for another week long mission. This time, there are twenty-nine people on our team, twice the number that went last year.

Much has happened since we were last there. A hurricane hit the country last fall, leading to renewed devastation. I want to help, but I know that the experience of working there is as much a benefit to me as it might be of benefit to those I’m fortunate enough to care for.

We must look to Haiti for guidance in our own journey towards actualization of ourselves as a democratic society, and learn from its deep cultural traditions. This will help us understand ourselves and our patients better, and maybe improve how we provide care in our home countries.
The magnitude of injury and burden of disease is enormous in developing countries. With limited access to medical care, illness and injury often go untreated, and people are left maimed, bearing these wounds for the rest of their lives.

The zombie has become an integral part of Western culture. There is the element of body horror reckoning what age, illness, and trauma can do to our bodies. 

In the zombie apocalypse, we have to reconcile ourselves with how badly we can deteriorate, and yet still cling to life experiencing the full effects of that horrible deterioration. That is the horror of illness, and one that many health professionals can relate to. 

The origins of the zombie myth in Haitian culture can help us to understand the dehumanizing aspects of illness,. Dehumanizations has consumed the health care of modern “First World” countries with all the excessive bureaucracy, waste, and rationing. All this has resulted in many unrealistic promises and expectations.

The zombie has its roots in the mythology of slaves who worked the sugarcane plantations of Sainte Domingue, as Haiti was known when it was a French colony.
Today, we understand the zombie as a being consumed by need to eat the flesh of the living to sustain itself. 

To those of us in the First World, zombies serve as a metaphor for rampant consumerism and the depersonalization that results from a need to continually acquire more things: new cars, new phones, new houses, and the like. The dehumanization and depersonalization of modern life with its boring jobs, mundane responsibilities, traffic jams, and mortgages become wiped away in the zombie apocalypse; one is forced to take the full measure of oneself, and see what he or she is capable of. In a sense, the zombie narrative becomes escapist fantasy as the heroes live on the edge, foraging in a desolate landscape that becomes almost idyllic because it is devoid of people. The roads are freely travelled with no traffic jams to impede one’s progress.

This narrative of zombies does not serve us well, however, and forgets that the original zombie of Haitian folklore was not consumed by a need for the living flesh of others, but consumed by the needs of his own flesh. In Haiti, before the slave revolt of 1804, the French imported slaves and worked them to death on sugarcane plantations in brutal conditions. The emotional and physical toll of slavery led many to contemplate or commit suicide, but in taking one’s own life, a slave would be denied a peaceful afterlife and forced to walk the plantations of Hispaniola as a reanimated corpse. In death, they would have no control over their bodies, but still be trapped inside them for eternity. In this way, the zombie of Haitian folklore becomes a metaphor for the effects of disease and injury. Those so afflicted must often see themselves as trapped in their own bodies, having lost their freedom, autonomy, and sense of themselves.

The Haitian zombie represents the horrors of dehumanization. The zombie of today’s industrialized nations represents the horrors of depersonalization of living in an impersonal world. 

Caring for the most vulnerable people in our modern society has become very difficult in an age of increasing bureaucracy, decreased funding, and resource scarcity. There are thus two types of zombies who walk among us: the zombie of the past, and the zombie of the present. 

We become vulnerable through the dehumanizing effects of illness and injury, but it is through depersonalization that we end up losing our humanity. In the health care systems of Canada, particularly Ontario, the overwhelming bureaucracy and rationing of care has caused patients and providers alike to become cynical as they try to cope with learned helplessness and isolation. Despite all of Haiti’s own problems with austerity and resource scarcity beyond anything we can imagine in Canada, the Haitian people seem to have retained their faith and humanity. 

I found in Haiti a much more philosophical understanding of life and death. It’s not to say that life, being more dangerous, leads to some fatalistic expectation of death, and that no one fears it for that reason. From my experience, I sensed a much stronger spiritual connectedness between people, their environment, and those around them. 

In Haiti, with its limited resources, the resilience of its people has strengthened a sense of community and caring. Patients gained a level of attentiveness, care, and support from their families that I’m unused to seeing back home. Despite the privations that the people of Haiti have endured, they haven’t lost dignity or humanity.

Looking to Haiti’s religious and cultural traditions, and its turbulent past, the people of Haiti have a greater understanding of what it is like to be dehumanized. Despite that, they haven’t let it define them. I didn’t see the cynicism of a depersonalized medical industrial complex there. The lesson for us in Canada is that despite the dehumanizing effects of illness and injury, we can do much better to prevent the depersonalization that occurs through seeking and providing care in our country. The dehumanizing effects of illness and injury make us vulnerable, but it is the depersonalization occuring through seeking care that is making us victims. 

As a society, we must recognize that we are all stakeholders, including patients and providers. Let that empower us to take responsibility and fight for the change that is sorely needed in our healthcare system. Let us refuse to be victims anymore.

                          *******

The following article was the inspiration behind this post, and I’ve included a link to it in the previous post:

From Haitian Slavery to ‘The Walking Dead’: The Forgotten History of the Zombie – The Atlantic

Bill 87 and the Voice of Dissent

Power always thinks… that it is doing God’s service when it is violating all his laws.
-John Adams
Bill 87, the “Protecting Patients Act” is the latest initiative by the Ontario Ministry of Health to amend the Regulated Health Professionals Act. This will allow the Ministry of Health to have more oversight in the discipline and regulation of “self-regulated” professionals such as physicians, thereby protecting patients from horrific abuses such as sexual assault.

This is an important goal. The sexual abuse of patients is a terrible crime for which appropriate disciplinary measures must be taken. Sexual assault is a criminal offense and must be treated as such. There are some physicians who have disgraced our profession by taking advantage of the doctor-patient relationship to sexually abuse the patients who have placed their trust in them. The legacy of trauma and grief that these people suffer cannot be underestimated or undermined. They deserve our support as a profession as they try to come to terms with the lifelong effects of abuse. These patients deserve to be recognized for the courage that they show in trying to get on with their lives, and they deserve justice.

I can understand a need for greater oversight of professionals involved in the care of patients. However, it seems that there is an unstated intent of Bill 87, and that is to muzzle the voice of dissent among regulated front line health care professionals. Doctors and other health care workers have become more vocal in their criticism of how the ministry is abrogating its responsibilities to provide care to the patients of Ontario.

In the last few years, the Ontario government, and a sympathetic media, have publicly vilified physicians. This has helped to legitimize the government’s unilateral action against the medical profession, especially when physicians cannot strike, and have no binding arbitration.

This time, things are different. With social media and its ability to organize physicians in a united front against government action, real challenges to government are being made through coordinated efforts, and they have met with results. There have been some courageous physicians speaking and fighting and organizing on behalf of our profession and we have been galvanized towards public criticism of the government through blogs, petitions, and political activism. In recent by-elections, the Liberal government has lost staunchly supportive ridings due in part to physicians making healthcare an election issue, and calling the government to account for its failings.

The increasing level of organization among physicians is no doubt of concern to the Minister of Health. The “Protecting Patients Act” has a proposed amendment that would require a health professional’s college to include in its reports to the minister any personal health information about that member, including mental illness. I fear that anyone of us practicing in the front lines of healthcare will potentially have charges of “professional misconduct” brought against us for speaking out against government, and be threatened with the release of our personal health information. Free speech is a right, and we should not fear censorship or persecution by politicians for criticizing them.

The stage is being set for implementation of Bill 87 by a certain media outlet that acts as a staunch Liberal government supporter and apologist. All this past week, there have been countless articles about physicians bullying each other, particularly online. Several examples have been cited in the news of physicians using foul language to denigrate their colleagues, particularly those who opposed the faulty, and failed, TPSA last summer put forward by the Ontario Medical Association to the physicians of Ontario that it represents. While there is ample evidence that many of those supporting the TPSA, including the OMA, have engaged in bullying tactics of their own kind, this is conveniently ignored by the media. This is probably due to the fact that evidence of bullying in the name of the Ontario government would discredit its position. It serves any anti-doctor, government-sanctioned media well to focus on the actions of grassroots physician groups, and their leaders, who are critical of the government’s management of healthcare.

Bullying in any form is never okay, but it is not that bullying among physicians is a professional issue; it is that it has been made into a political one, suggesting that physicians need tighter regulation of their behavior at a government level. It’s a bit rich, really, to suggest that physicians bullying each other is something new, as the media tone would suggest. Anyone who has trained as a physician, or watched medical dramas on television for that matter, can attest to bullying and intimidation towards medical trainees and junior staff that has been going on for generations. The issue of physician bullying is given so much press now, because it serves a specific political agenda. The government wants greater control of increasingly dissident doctors; the OMA’s entrenched leadership wants to dissipate the unwelcome growing challenge to its power.

More than ever, a voice of dissent is needed from physicians and other regulated professionals, who work on the front lines of health care, and can offer critical insight as to how real change and reform can occur. Government legislation that has the effect of muzzling those professionals ultimately hurts the public and patients of Ontario most of all. As physicians, we have a duty to protect our patients, and part of that protection is advocating on their behalf to government and bureaucracy. The Protecting Patients Act may ultimately leave patients more vulnerable, if there is no longer anyone who can safely speak for them.

The False Dichotomy between Physician Income and Acceptable Healthcare Funding

The following is a letter that I wrote to the Toronto Star in response to a passionate indictment of Ontario’s healthcare system by Dr. Nadia Alam.

I am writing in response to the several opinion pieces that have been published in the Toronto Star in response to Dr. Nadia Alam’s recent post, where she voices concerns about Ontario’s healthcare system.


As an emergency physician, I see evidence of this “broken system” every day in my practice. The Toronto Star’s published responses to Dr. Alam’s indictment of healthcare focus on a perceived grievance by physicians about their incomes. This is unfortunate. By making the narrative about physician incomes, it further excuses the government from being held accountable for their mismanagement and underfunding of the healthcare needs of Ontarians. It also minimizes the challenge to the public, to see themselves as stakeholders in the issue of healthcare funding.


Addressing the social determinants of health will not be accomplished by enshrining continued cuts to the physician services budget, and to suggest that decreased funding to physicians makes available funds that translate into patient-centered care is disingenuous. Since ongoing cuts to the physician services budget, beginning in 2012, do patients wait less time for a hip replacement? Do they have improved access to their family doctors? Do they have improved access to home care and elder care? I have my own opinions, but I want to hear from the patients and public of Ontario, to see if they feel like they have better access to the care they need for themselves and their families, then they did before.

More Mountains IV

Friday 13/5/16

I arrived at 7 am for my last shift before leaving to go back to Canada the next day. Overnight, a 64yo man had come in hypotensive. I can’t remember all his medical problems, but they were quite extensive, including diabetes and heart disease. He had lived much of the last few years in the USA. He had come in lethargic with a low systolic BP of 63. His urine was positive for leukocytes, and overnight, he had received about 2L of crystalloid and some ciprofloxacin IV. These were good interventions for a possibly septic patient, likely secondary to a urinary tract infection.

I was told that the patient’s BP is normally this low, and that he was awaiting transfer to a private room. I was resistant to this course of action, as I don’t know anyone with a SBP in the 60’s who isn’t a newborn, and suspected that his usual BP was, if anything, hypertensive. I was concerned that he was in septic shock, so I ordered another 1L fluid bolus.

In the meantime, I wanted to start a norepinephrine drip. Back home, I would write the order of say, “Levophed 8mcg/minute” and the RN would start an infusion through a pump. Unfortunately, we had no IV pumps available in the ER, so I had to calculate a “drip rate”. Essentially, I would have to add the norepinephrine to a bag of saline, calculate the concentration, and calculate a drip rate. I was fortunate to have a calculator on my phone specifically for this purpose, which was very helpful, lest anyone be too impressed with my apparent mathematical skill.

What I did, was take two 4mg vials of norepinephrine, one of which had to be ordered from the pharmacy, and injected them into a 1 L bag of NS, this gave a concentration of about 8mcg/mL. From this, I could start an infusion of 8mcg/min, by running a drip rate of 1mL per minute. The drip was helpful in improving the patient’s BP, but I could tell that his requirements were going to increase. I spoke with Brian, the ICU physician volunteering from New York, who had a bed available for him, and the patient was transferred there.

Later that day, Brian asked if I could do a bedside US of the patient. It seems that as the day went on, he had developed increasing abdominal distension and pain.

I wondered if maybe he had some occult intra-abdominal infection that had progressed in the time since leaving the ER. I also thought about an intra-abdominal compartment syndrome, which seemed likely, given how much fluid he’d received.

The US didn’t show any free fluid, or dilated loops of bowel, to suggest an obstruction. However, the surgeon noted that there was significant bowel wall edema on the US, and ordered a CT scan. We wondered if the patient was going to need an operation. The CT was very helpful, as it showed an ileus secondary to dysentery, and therefore, no surgery was needed.

The patient didn’t do very well, requiring increasing doses of vasopressors. I believe the ICU doctor started epinephrine, to add to the norepinephrine. His nurse in the ICU told me that he made several gestures with his hand pointing upward, indicating that he was expecting for his spirit to soon ascend Heavenward.