So I sent one of my patients to prison today. I mean, I didn’t convict or sentence him or anything, but one of the things military doctors have to do sometimes is certify their own patients as medically-fit for detention. (As opposed to civilian GPs, who don’t have to sign-off when civilian patients go to jail – there’s docs at the jail itself for them.) First one I’ve had so far.
25-year-old, history of alcoholism since at least high school; on counselling and probation for the same since last autumn, conditional on staying dry and sober for six months. Found in violation of probation around Christmastime, and sentenced to three weeks in prison, starting as soon as I sign him off “fit for cells”.
It’s one of those gray areas in medicine and the doctor-patient relationship – obviously some might object and decline a medical assessment that would send them to jail, and some might not be so willing to trust a doctor who’s bound to pass them on to prison, but it’s one of those things where patient consent isn’t necessarily the final word.
Of course you have the usual commandments, “Consider first the well-being of the patient”, “first do no harm” and all that, but being in uniform you also have your responsibility to the military. It’s the third key principle of Canadian military ethics everyone learns inside-out in Basic Training, “support lawful authority”. (The first two being “Respect the dignity of all persons” and “Serve Canada before self”, in that order.)
The other thing they drill into you in Basic Training – at least, the version for medical officers – is that you’re not just a doctor for the patient in front of you, but you’re also looking out for the broader military at large. It’s more than the responsibility to community that goes without saying to all physicians in general – you actually have a duty to consider how your patient’s health might affect mission objectives, required military tasks and the rest of the team.
Not that this is just a military thing. Emerg physicians do this all the time too, giving (usually) inebriated belligerents a once-over before police take them off to cool down in the Drunk Tank. When I was working Emerg I never had anyone refuse a check-up; of course they knew as soon as I signed off they’d have to face the music, I guess they figured they’d already been caught, no sense delaying the inevitable. Most were all “been there, done that”, just going through the motions anyway.
Back in Inuvik and Masset it used to be the most frustrating thing about Emerg, getting called out in the middle of a (usually) Friday or Saturday night. Nurses in the North are really good at sorting out all the real emergencies, and taking care themselves of the worried-well coming in at ungodly hours of the night. But for the “fit for cells” and all the medico-legal baggage that comes with it, a doctor had to actually give the blessing.
At least it got easier the longer you worked there – you’d get to know the regulars and their background stories with each visit, so you’d get quicker and better at picking out what was for real, and what was same-old same-old. You’d also get to know the cops bringing them in – at least, the ones who tended to worry most about patients/prisoners going bad in holding cells; the more veteran ones grow their own spidey sense for “sick” and “not sick” and can make the call without having to stop by Emerg.
You’d also get to know the court schedule – the night before, you could be sure at least one person out on bail would try to pull something to get out of their day with the judge. Suicide attempt, drinking binge, you name it. Of course when they do, they get admitted involuntarily; judging by the number of times they’d later leave against medical advice, it’s probably no better than taking the jail time.
Anyway, I guess the complicating thing with this case today was, he’d been set up with an addictions counsellor and psychiatrist since his first violation, and still had some follow-up appointments to attend; if he goes to jail, he’d miss one.
Bit of a judgment call – what do you think? I figured, if he still was breaking probation despite counselling and Psychiatry, one missed appointment wouldn’t change anything with him; maybe 3 weeks in jail will actually hit home and do the trick. What’s more, interfering with a sentence imposed by “lawful authority” for the sake of counselling that isn’t working anyway (yet?) wouldn’t exactly send the right message about the justice system.
He didn’t seem all that bothered about it, kind of the like the ones I see in Emerg actually. “Been there, done that”; no surprise for him apparently. Likely I’ll be getting used to seeing it too.
Last day in Masset. It was actually the longest rotation so far in all of residency; supposed to be 12 weeks, but got most of the first two whittled off with leave and the licensing exam (I passed, by the way) and a week Christmas holidays in the middle. Still, at 10 weeks less a few hours it was the closest I’ve been to actually “settling down” and living and working in the “real world”, without packing up and moving just as things are starting to get familiar and make sense.
Back when I was figuring out where to go for residency, the UBC programme warned: “As some of the practices are in semi-isolated areas, residents should be medically and socially self-sufficient.” I didn’t really know what that meant exactly, “socially self-sufficient”, but looking back, it was actually a lot of fun, starting out on my own, middle-of-nowhere rural BC.
It was kind of weird at first. It’s only 750 people or so, so everyone knows each other, if not by name then at least by sight, and whose family they’re in. (750! That’s like my high school! I had university classes bigger than that!) When I’m travelling, I’ve always liked the feeling of going somewhere, sneaking around anonymously, blending in and passing for a local. But when you’re in a town this small, you can’t prowl around and pretend you’re from there – everyone knows you’re new. They’re friendly about it, wanting to meet the “new doctor”, but I missed the comfort of anonymity and getting asked directions by obviously-lost tourists.
Last “day” was actually a 9am-9am on-call shift. Follow-up visits with some familiar patients – kind of a weird feeling calling in a patient from the waiting room, without having to introduce yourself anymore. Pretty much every time for the past 5 years I’ve had to start with the disclaimer, I’m the med student/resident working with Dr so-and-so… and apologetically rifle through the chart and ask for past medical histories that are already as much part of their usual GPs story as it is theirs – so well-known in their doctor-patient relationship they’ve already forgotten the dates and details. It’s so contrived starting from scratch sometimes; now it’s nice to have something feeling like familiarity.
A 20-month-old kid with the usual cough and cold – this time, I don’t have to ask about their past seizures with fevers, or what their delivery was like or if they got their shots, etc; I already know. Not getting better since I saw them last week and managed to convince them It’s probably just a regular cold, it’ll likely settle down in a few days without any antibiotics – well, at least I (and they) tried to get away without willy-nilly amoxicillin, but I guess now he’s earned it. Still feverish on-and-off, looking a bit more uncomfortable than last, and still won’t let me look in his throat, but he did let me look in his ears this time – all clear.
A 12-year-old boy who chopped off his right index fingertip, which I reattached – looking scabbed over, not as clean as it was a few days ago, but still not obviously infected or falling off. I don’t have to ask about his background either, so when his 6-year-old sister asks out of the blue, “Can girls be doctors too?” I can actually take time to answer. Of course, most of my classmates are girls. Maybe if you help your mum take care of your brother’s finger you can go to doctor school too. “Cool. Do you want a chip?” She was munching away on a tin of Pringles as I was poking and prodding her brother’s mangled fingertip – tolerates gore, that’s a good sign for a wannabe physician.
A 40-year-old chronic alcoholic stumbling in, vomiting with belly pain, three days after his last fortnight-long binge – don’t need his chart to know he’s got big, burst-prone veins down his throat, globs of fat in his liver and cysts in his pancreas that make his vomiting and belly pain more worrisome than the usual “healthy alcoholic”; already went over all that last time I kept him in, a month ago. I remember, I read him the riot act about his alcohol – If you keep drinking, you will die. It will probably start with you throwing up blood, and a burning in your belly. The blood will keep pouring out, and the burning will keep going right through to your back. It will be a painful death – and he says he managed to stay dry for a week and half after that. He’s earned himself at least an overnight stay this time – lucky me. Maybe if I could add more gore and pictures to the story he could stay dry longer. They really should put pictures of post-mortem bloody throats and diseased livers and pancreases on warning label on alcohol.
A 50-year-old with a really bad, incurable joint disease that goes for your back and basically cements your spine – the rheumatologist managed to get him approved for a new drug that actually works! His brother, with the same disease started it a while ago and has never been better. After 3mo with me, going through the motions trying stretching exercises and older anti-inflammatories (which don’t work – but you have to prove you tried them before Medicare lets you try anything else), I got to give him the new stuff on my way out:
$1 600 a shot, twice a week – but it’ll get him moving and bending and dancing and tying his own shoes again. He’ll also be back to his worktable and traditional stone-carving and and wood-working he’d been much too stiff to sit over the past few years. Wish I could actually stick around and see it happen.
I got this carving from another of my patients. He made my preceptor a whale paperweight – “To swallow up the paper, and anyone trying to take it away” – and I got this bear pendant. (Can’t wear it next to my dogtags, so I just put it on display with some beach rocks I picked up.) It’s made of argilite – a rough, black local stone carvers hack out in big 50kg chunks off a rock face – with an ivory eye. The argilite powders up when you carve it, so you can tell who’s a carver by looking at their hands for the tell-tale black coating. One master carver (he recently sold a carving for $10K) is covered head to toe in it; unfortunately he’s also got the lung problems you’d expect with all that rock dust.
Anyway, it’s something you probably don’t see in on medical shows on TV – I don’t know, I don’t watch them – doctors actually starting to get to know their patients. Dr T made it a learning objective: “By the end of this rotation, I hope you learn to know your patients, and start to enjoy them.”
It’s actually not as farfetched as it sounds – you do look forward to hearing about your patient back on their feet and back to fishing, and rattle on catching a steelhead this big, and the even bigger one that got away; or taking their diabetes seriously, joining the pool, and swimming 4 laps, then 6, then 8, then 12 at a time; or cutting back on smoking, and spending money on their kids instead (“The doctor says you have to buy me toys instead of your cigarettes”); or even being able to sleep and getting their energy back after cutting out their coffee (I know how hard that was). It’s more realistic than, say, gossiping about the latest tryst between a resident and attending, or what goes on in the private room when no one’s looking, etc, etc.
Of course it’s not really on-guard for Soviet bombers anymore, they use it for things like forest fires and tsunami alerts… ie, they’ve held on to what they have, and adapted it to new needs. If they can use it, why drop it? Same thing with the small-town openness and spirit: like my preceptor’s wife unexpectedly (and thankfully!) picking me up from the airport my first day; the clinic secretary calming and entertaining two kids while I faced their brother seizuring and mum freaking out; my preceptor coming in on his off day when a 70-year-old guy was bleeding out; and of course the phenomenal hospital food! I’m not sure if that “speech” actually made a point, but it seemed to make sense, they nodded and smiled politely.
Speaking of the food again – last meals:
Baked salmon, roasted vegetables (surprisingly spicy – some kind of pepper I’d never had before; it wasn’t chili, I have no idea), wild rice, salad, an aliquot of strawberry sundae, and, of course, cranberry juice!
Curry chicken (you know the supply ferries are working again when there’s chicken available), glazed carrots, steamed broccoli, mashed potatoes and gravy, chocolate brownie, and a vegetable juice that wasn’t V8, because it tasted more peppery.
Hung out at the hospital late, expecting things to pick up to make for a slow clinic day. No luck, but missed two of the nurses stopping by my place that night with some wine (“We’ll miss you – you’re a square, but you’re cute”). This morning, a little farewell tour before flying back to Victoria the afternoon. Lucky the weather cooperated – nice to not face the usual gale-force winds and pouring rain when saying ‘bye, and with the calm, sunny weather, nice not having the one every-other-day flight cancelled.
Last look at the library – about as a big as a living room:
and being the only library around, the home of the town’s priceless one-shelf historical collection:
Unfortunately, space is tight, so some things have to make way to keep things fresh – I’d've rescued some myself, if I had space in my luggage:
Last breakfast at the Two Champ’s Cafe (that’s how it’s spelt, “Champ’s”) – I actually managed to finish the entire Everything Omelette this time:
Last read of the local rag, the Observer. Apparently “Holy Ch__st” may offend some Islander’s sensitivities:
Last run by the town’s weathered military presence, the old abandoned barracks – looks like the anti-drugs programme is being taken to heart among the local vandals:
And poking round the “Downtown”:
The “Family Foods” grocery icon with a healthy 2 parents and 5 kids, and the regular folks on their regular street corners, chewing the regular fat.
Then all aboard the little Beechcraft – no problem getting the check-in staff to let my over-weight luggage aboard, but even I had to stoop to get in, it’s that aerodynamic; small, but every seat’s an aisle seat and a window seat, so either way you get what you need; and no cockpit door, so everyone’s got to come together to stop the terrorists if they make a move.
Kind of a microcosm of the town, I guess: “aerodynamic” facing the gusts and squalls coming off the Pacific; small, but you can get what you need; and everyone has to come together to make it work.
The Ceeb’s Sounds Like Canada radio show is running a series on hospital food this week. It’s sort of the “great equaliser” among patients – young or old, surgical or medical floor, private room or ward bed, everyone chows off the same menu. The usual culinary critique – they even managed to get a quip from the Minister of Health: “For every negative experience one patient has, there are ten who have been well looked after and whose biggest complaint seems to be hospital food.” And even Senator Pat Carney joined in, with her own first-hand insight. Great equalizer indeed, one of the negotiators of the North American Free Trade Agreement, of all people, sharing a meal (though not necessarily at the same table) with average Joe Canuck in hospital.
But like a lot of things about the health care system, the vast majority of people actually don’t have first-hand experience with it (fortunately for them), but everyone has an opinion. “Surgery wait times are too long.” (It might be a painful wait, but it doesn’t change the outcome – no one is dying earlier, or becoming permanently disabled, because they had to wait.) “There aren’t enough MRIs.” (There are literally only a dozen or so diagnoses where the MRI is essential – and a lot of those are neurology things we can’t do anything about anyway.) “What the f-, they airlifted me away for surgery and now they won’t fly me back!” (If it’s not medically-necessary, why should Medicare pay for it? You’re lucky you don’t get billed for Emerg and doctor visits that aren’t medically-necessary too.)
And of course, “Hospital food sucks!”
I’ve been asked before – no, doctors don’t prescribe what you get on your meal tray. We do specify, in general terms, what kind of foods you’re provided: “low salt diet” for heart patients, “diabetic diet” (sometimes with calories specified) for people with diabetes, “low protein diet” if your body can’t metabolise protein properly. Usually what you get with each of those isn’t far off from “normal food” – it’s the stuff you actually should already be eating at home, if you have an underlying medical problem.
Sometimes you end up with stuff that’s less familiar, like “clear fluids”, “full fluids” or “soft diet” if your bowels can’t tolerate solids yet. It’s basically what it sounds: things you can see through (like water or juice; Jello too), then things you can’t (like milk, pudding or broth), then soft semi-solid stuff (like oatmeal, mashed potatoes and veggie puree). You’ll also get restricted menus if you can’t chew or swallow totally normally – the traditional ice cream after you get your tonsils out, that sort of thing.
Patients’ meals actually are a good measure of how well they’re doing, and I think patients (and especially their families) can tell from what they get. It’s more accurate than the medical mumbo-jumbo jargon we can’t help but gloss over sometimes. It’s one thing to tell a patient You’re doing fine! and “reassure” the family Everything is going to be ok!; then the nurse comes in with a slurry paste of sugar and oil for “dinner” and then they really know how “fine” and “ok” they are. Conversely, when they finally graduate to, well, anything else (trust me, anything looks good after the sugar and oil “dinners”), that’s how they know all is right in the world (and their bowels) again.
Most hospitals can accommodate preferences like vegetarian, vegan; one nursing home I was at in Toronto had a whole floor of Jewish patients, and another of Chinese, so they always had kosher and Chinese menus for each (and you could switch around if you wanted to). For alcoholics likely to withdraw, we can even order a drink a day – just enough to keep you from getting shaky and seizing, but no more. And usually we want to get you eating (and BMing) normally as soon as you can, so if you wanted to bring in anything specific, just ask, and we’ll say if it’s safe or not.
I actually like to know what my patients are eating, and trying some if there’s an extra tray. Plus sometimes I’m too busy to actually leave the hospital and get something. Yes, some hospital food tastes like it was microwaved and shipped over from a factory kitchen across the province – because it has. If the cost savings of closing down the in-house kitchen to outsource meals means the difference between being able to provide medicines and surgeries, so be it… but it’s sad when things are so bad we can’t even give sick people a decent meal.
“Comfort food” – there’s a reason why good food is uplifting. Because, well, it’s good for you.
Apparently they wanted to axe the Masset Hospital kitchen and outsource it, either to the other hospital on the island, or to a factory kitchen on the mainland. Either way, it would’ve been a fragile setup, subject to the whim of the next windstorm or hurricane or earthquake threatening the island. Or a mechanic putting the wrong oil on the ferry, knocking out all shipping to the island for a week. Like this week.
Luckily they didn’t, because they have an amazing cook (she’s much too down-to-earth to stand being called “chef”) who uses the best local seafood and produce, right from the island. (At low tide, if there’s been a heavy northwest wind for long enough, followed by a southeast, fresh scallops wash up on the beach.) Plus she’s just too nice; like my Mum – asking if I’ve had enough, telling me there’s more soup on the stove and scones in the oven and worrying that I’ve lost weight – except white.
Grilled salmon, baked potato, steamed vegetables, with a brownie, Mandarin orange and a standard 250mL aliquot of 2% milk. This was one of my first hospital meals in Masset – and from then, I knew this rotation was going to be a treat.
Steak! In a hospital! Now that’s comfort food. With mushrooms and caramelised onions, mashed potatoes and steamed broccoli, corn in syrup and chocolate pudding. And a 120mL kids’ cup of apple juice – the first time I’ve had apple juice since elementary school.
Roast beef (slightly peppered and gravied), with mashed potato, carrot, squash (I think it’s squash anyway), fresh salad and blueberry cake, freshly-baked. They ran out of juice that day, so just a glass of water.
Steak – again!? Crazy! And mashed potato, peas, cauliflower, and – this was special – cheesecake from the hospital director’s husband, who is apparently a cheesecake master. That’s the cheesecake to prove it. Maybe that’s their way of saying “please stay and work here.” Small-town hospitals are notorious for tricks like that.
Christmas – steak! With mashed potato (I guess it’s a staple of hospital food everywhere), mixed vegetables, squash (I think – but scooped and strung out from the skin), salad, and lemon pudding with cinnamon and whipped cream. And just for Christmastime, festive cranberry juice instead of apple.
Actually, if I were a hospital Chief of Staff, I would prescribe cranberry juice with every meal – cut down on bladder infections, as generations of girls already know from their mums: drink cranberry juice! With so many inpatients with catheters (which are infection-prone), it would really help. (So would steak… yeah…)
Anyway, from the comments I get, hospital food (good or bad) ranks up there with post-op pain, uncomfortable beds, noisy wards and caring nurses as what people remember most about being a patient. Patients’ families also definitely take a critical eye on what their loved ones get. If I still had time, I would’ve done my residency research project on hospital food – menus, nutritional value, composition, variety, local vs outsourced, and of course, presentation and taste.
Volunteering myself to leave no tray unsampled – in the name of quality control and patient wellness, of course.
