The soldier said to me, “Bill, you’ve got one foot in the past and one foot in the future. You’re pissing and shitting on your day. Get your head in the same room as your ass is.” So that’s what I do. As I taught my schizophrenic and autistic patients I coordinated my internal world with my external world. After brain injuries we ask people to maintain a running commentary of what they are doing outside, describing it inside. When I’m in a crisis at sea alone, facing life and death I actually speak outloud what I’m doing. On my motorcycle at high speed on the highway when it gets somewhat complicated I slow right down by saying inside, ‘I am riding my motorcycle.”.
So this memory trip, remembering the highlights that come to mind, revisiting the past seems like opening flood gates. There are just so many people I really liked and really enjoyed working with and finding solutions with. I saw my job as a ‘problem solver’. I did’t have a preconceived idea. I didn’t think the solution to every problem is a prescription but rather how can I ‘fix this’. That’s called a ‘manly approach’ and in Canada everything manly is criticized these days. But back then people wanted solutions and I was totally ‘solution’ focussed. I’d actually ask.
“What would you like to see happen?”
“If this was fixed what would you see yourself doing?
Then these patients would describe to me what their lives would be like without their illness. This would have us both visualizing about where we wanted to get to and having a clear idea about what we wanted to achieve together. Working today in the fentanyl epidemic I learn that so many people simply have no idea of what they really want but they are solely focused on what they don’t want. That’s part of the problem but it’s not the solution. I try desperately a lot to get my patients today to stop thinking of drugs and alcohol and think instead of life.
I learned this in Morris.
I acquired all these patients with chronic diseases. My predecessor at the time had done his best and I was now given the opportunity to do my best with continuing his good work. I expect he did the same as I did when he took over from the fellow he followed. In medicine we stand on the shoulders of those who go before us. I never forget this but I sure meet a lot of people who don’t seem to know it or don’t want to admit this.
One of several problems in the Morris community was chronic stasis ulcers in the legs of old people. The arteries carry blood AWAY from the heart. A for arteries and away. That’s how we were taught to remember it. The arteries are thicker and prone to plague. They’re muscular and can expand and contract. When there’s an obstruction other arteries can take the flow. It’s no different than a road system for the red blood cells to carry the oygen to the muscles and skin. Veins return the blood to the heart pump and take back the waste as well.
The calf is a secondary pump. When people don’t move enough among other reasons the main artery in the middle of the calf gets clogged. The blood then gets carried to the peripheral or ‘secondary’ arteries. Because the skin isn’t getting enough flow because of blockage of the main arteries, there’s fluid accumulation, called edema, which comes from the backlog because the veins are not carrying enough blood back. The arteries literally dump the ‘fluid’ carrying all the immunological components and nutrients into the space between cells where it washes about before returning to the veins. This is beyond the capillary system which is the smallest structural component of the transportation network. The cells are floating in this bath which just gets bigger and bigger when there’s a blockage to the blood flow, new blood going in and old blood going out.
This ‘edema’ creates a pressure outward. Now the skin isn’t getting sufficient nutrient to stay alive and begins to die. The chronic ulcers or craters that follow are called ‘stasis ulcers’. The skin always has bacteria on it. There’s good bacteria and bad bacteria. It’s mostly a balance of ‘tribes’ rather than one tribe of bacteria being that much better than another. Staphylococcus bacteria is often considered negatively when there’s too much of this to other bacteria. Bacteria are eating dead skin. Aerobic bacteria like air. Anaerobic bacteria don’t need air. When there’s a shortage of blood flow to the outer skin because the pressure builds up because of the traffic jam in the interior, the antibodies that are carried in the blood don’t get to the surface and these ulcers occur and ‘suppurate’. Suppurate means get infected and ooze and bleed.
Varicose veins are one of the first signs of obstruction and often lack of exercise of the secondary pump of the system. Exercise is good. We all descend from runners.
At the time the time the prevailing treatment was to use the latest antibiotic creams and change bandages weekly. The specialist would arrange for the nurses to see the patients in the wound clinic at the hospital or for a few do home visits.
My job, the limited role I could play, was to exam the wound and rewrite the prescription for the antibiotic cream, ensuring that it was perhaps getting better more importantly not getting worse.
That was the first thing I did to shock the town of Morris. I began drawing circles on the old people’s legs to outline the size and extension of the ulcer. I also began to take measurements of the size of the calf ,record that and ask the patient to record how many minutes of the day that he or she was walking. I regret my curiosity because the wealth lies with doing the same old thing and not rocking the boat. Change costs a fortune and is resisted by powerful forces. People love their platitudes.
The fact is,as Dr. Johnson the great English philosopher said, “the reformer is the enemy of anyone who benefits from the status quo.”
Today working in the fentanyl epidemic I see the wealthy spreading and also noted the transplants surgeons working over time. Thousands of new kidneyes, hearts and livers mostly for the wealthy. But I’ve been jaded by experience. I’ve had my life threatened and almost died in a murder attempt by a person whose income depended on the ‘status quo’. Even a wounded dog will bite if you try to get it out of it’s corner where it will surely die in the coming flood. Back then I was just curious and innocent and it really was a joy. I love when the good people rally and miracles occur before the government or some other ‘big player’ swaggers in and puts a stop to things or demands all the profit or creates new laws that steal the joy.
Back then I had an ally in the Morris pharmacist. I had an ally in the families and patients. I also had an ally in the older nurses. Only the younger nurses insisted things be done the way they weren’t working but the way the books said.
I asked my patient what woud change if his legs were healed.
“I’d be able to visit my grand children in Alberta. I can’t travel because I have to go to the wound clinic every week. It doesn’t get better but if I don’t go it gets quickly worse.”
I thought it would be good if this man got to visit his grand children in another province. Each of the patients told me what they wanted to do and none of it was a ‘big deal’. Happiness wasn’t a Ferrari.
When I was in Winnipeg I’d go to the library. There was no internet in these days but the librarians were genius. I’d explain my ‘problem’ to them and ask for their ‘solution’. They’d come back with books and papers and I’d take these home and spend weekend researching. I’d spend years of doing this. Every ‘problem’ I encountered for decades of my work till the government thugs and their useful idiots sucked the blood out of the air I did this. In the end I couldn’t ‘fight the system’ but back then I didn’t even know about ‘systems’ or ‘city hall’. I was so naive and innocent and enthusiastic.
I couldn’t find anything different in all the recent literature and nothing in the North American literature. I’ve been reading translations of other medical journals for years because I couldn’t find a local solution and thought maybe someone else had a different idea. I found lots of good solutions in the Hong Kong enlist medical journals at one time. Didn’t know why others weren’t doing it but of course there was no money in it.
Doctors were paid like everyone else in society for what they had ‘learned’. I was a ‘professional’ before the government bastardized even this. Professionals were not about what they looked like or acted like or any of the politically correct nonsense the silly stupid people make masses of money off of. Professionals were ‘learning machines’. I’m a continuous learning machine. In a sane world I’d be rewarded for ‘solutions’ which would come from my ‘learning’ , ‘not text book learning’ or the ‘appearances of learning’ but ‘learning that resulted in solutions’. I’d be paid for ‘outcomes’ not the bureaurcratic government shit that passes as the same, not the ‘knock off’ which is the ‘filling a chair.’ Bureaucrats are necessary not for their day to day work as much as being there. A lot of medicine is indeed routine and perhaps 90% of what I learned in school or on the fly could be applied in the workplace with success.
I used to look up everything and check my books which were always on my desk.
One old codger said, obviously with a sales, business or bureaucratic background, said.
“You know people would trust you if you knew something and weren’t always looking things up,. My other doctor in Winnipeg never looks anything up.”
“That’s why your problem persists. I’d be glad not to double check things if you want but I’d rather do it my way and solve your problem. I don’t really care that much what you think of me. My only concern is curing the disease you have.”
He shut up and I went back to work curing another ‘chronic disease’. I cured hundreds of “chronic” diseases in the next couple of years.
The “UNNA’s Boot’ was the first of these. I eventually found it described in an old English text book describing medical diseases and treatment in the 50’s. There was a description of UNNA’s boot. It’s a zinc solution soaked cast which is made by soaking bandages in the zinc solution and tightly wrapping the calf and ankles.
This is where the pharmacist came on board. There weren’t any ‘UNNA’s BOOT’s’ back then in Manitoba. He’d never heard of them or seen them but he knew of the zinc solution. He was older than me and remembered one doctor using something similiar. I had the mixture description in this old English country medicine book and he proceeded to get out his solutions and make it up from scratch there in his pharmacy. We’d do a lot of that over the years. He was a terrific ally, so enthusiastic and not just a ‘pill pusher and counter’ , a real pharmacist. I’d meet another years later at the Riverview Hospital, another in the Saipan Hospital and another in the specialists medical building on the Broadway corridor by Willow street. These amazing people who kne their chemistry and could discuss real pharmacy and physiology.
So there in my office with this bottle of “UNNA’s Solution” and gauze bandages I’d soaked the bandages in a painters tray and wrapped my old patients legs tightly. Dred worked like a pressure stocking on steroids.It took about a half hour. I mention this because everyone always complains I’m late and I am but it’s only because an office visit is set for 10 minutes and that’s all I got paid for but this whole ‘UNNA’s boot’ procedure took a half hour in addition to the hours of reseach. So with an angry waiting room and loss of income I got that first UNNA’s boot on.
Anyway the UNNA’s boot worked brilliantly. The pharmacist and I were making these up and dozens of old men and women were getting them. I’d started with a day or two of wearing them and got up to a week of them being worn without a change being made. Eventually there were no more chronic stasis ulcers in the t own and surrounding area. New ones responded to the standard wound healing now.
Breakthroughs local or further out are timely. Bacteria are learning machines. A few years back when I began to work in the downtown Eastside, the ghetto of Vancouver, the women, especially those working, were having recurrent urinatry tract infections and kidney infections that were resistant to sulfa and ciprolex the cutting edge treatments of the day. When I’d begun practice there was this old antibiotic called ‘nitrofurantoin’. I just started using it again figuring all the young smart doctors wouldn’t even know what it was. Sure enough all these women’s UTI’s were cured at the time and I was heralded as a genius. Everyone loves a winner. The irony was that a year later nitrofurantoin caught on and everyone was using it again with great success until the smart bugs caught on. I’m hoping the guys whose job it is to solve that problem get some support rather than finding themselves constantly fighting bureaucracy to do their jobs.
Dozens of men and women responded to the UNNA’s boot. The old guy visitted his grand children. The pharmacist and I had fun. The ‘stasis ulcers’ cleared up in the community. Bob and Mike began doing them too with their patients. We could have had a calf beauty contest for the elderly that year and beat every other jurisdiction. We encouraged increase in exercise and the standard wound care worked just fine ‘early’. The UNNA’s boot was needed for the healing of the more deeply damaged tissue.
I noted a decade or so later that a company was actually making a packaged UNNA’s boot with the solution on the bandage. I couldn’t believe it would be as good as the Morris Pharmacists UNNA’s Solution prepared from scratch individually with love but it’s now out there.
I always figure when I’m figuring out something there’s a thousand other smart folk doing the same thing. It’s not a race because it’s not about business and copywrite and money but rather about solutions. Is spiritual.I had a New Zealand sailor come to Canada and his mast had stairs on it. I asked if he’d put them on mine. It increased the weight on the mast and affected the speed of the boat but I was a ‘cruiser’ not a racer. As a solo sailor I didn’t have the same time and luxury that makes the standard ‘bosum chair lift’ to get you up the mast, work. Instead I could hook on and hook off and run up the mast like a monkey. It’s what they did for hundreds of years in the old wooden sailing boats. Ours were the only two boats with stairs on the mast at the time. They’re around but I had to order in the stairs. Now I see there’s dozens of other cruisers with stairs on their mast. I expect when I see such a boat that it’s an off shore sailor whose either single handed or sails with little crew. It’s a good idea and good ideas spread like epidemics. It’s not ‘my idea’. I come across too many people into that ‘my idea’ shit. I just want a ‘solution’ .
The other thing that happened in Morris like the UNNA’s Boot was the corneal abrasions. A couple of times a week I’d see an eye injury in the emergency. Everyone of them was a corneal abrasion. It was a minor injury. I rather enjoyed freezing the eye and using a needle to pick the sliver of metal out of the cornea. Then I’d put some antibiotic cream on the eye and put a patch on it. The patient would be walking around like a pirate and off work for 3 or 4 days. Guaranteed we had a pirate or two walking around Morris any week of the year. There was a bus factory in the town. They and others did a lot of welding.
After a few weeks of fixing corneal abrasions I became curious as to why I was seeing so many. Mike and Bob were seeing them too. I phoned the plant and asked for a tour of the bus factory. Sure enough all the welders were wearing safety glasses and doing everything right. Someone suggested that workers were getting the metal in their eye on purpose so they could get time off work. That was simply idiotic. No one tries to get a piece of metal in their eye to get off work.
I looked over the cases and discussed it with the plant owner who was a great guy who when I brought the matter to his attention was very concerned, not just because of loss of time from work but he honestly liked his workers and was part of the town.
I’d seen one abrasion where the sliver of metal was actually like a tiny spear and almost went through the cornea into the fluid. This would not have been good and beyond what we could treat in the country. There was real potential for serious eye damage and I didn’t know how these recurrent abrasions would affect vision in old age.
Yet all the safety procedures were being followed.
Well, seeing where the welding was being done, welders working side by side and others coming over to talk to them I saw the problem. When the welders were welding they had their goggles on. They were getting the abrasions when they took their goggles off and the guy beside them was continuing to weld. Also guys were getting abrasion when they came up behind the welders to ask a questions or make a comment.
With the great bus manager I had them put in a large plexiglass divider that separated the welders and another barrier so that people couldn’t go into the welding zone.
Corneal abrasions all but stopped the next day.
“I used to like doing the corneal abrasions,” Mike said. “IT was a nice break from the office routine. “. Over the years I’d hear that sort of comment again and again and know that my colleagues weren’t complaining but rather offering a back hand compliment.
Years later my ‘solutions’ interefered with some bad folk making millions and I began to come against the evil corruption in the health care system and all their allies. But that was years ahead. The owner and manager of the bus factor thanked me. The workers were always glad to see me. Everyone always offered to buy me drinks. Now I had the old men and old ladies loving me for the solution to the ‘stasis ulcers’ and the young guys and their wives happy with the bus plant solutions.
My next task was dealing with the “99” emergencies that came in the night to the hospital. No one was on top of these. In the city hospital heart attacks and respiratory failures happen daily so the nurses and the doctors are right up to snuff. Minutes and seconds make all the difference at these times. No body can keep up to date with everything especially in rural areas.
As it was I’d just done 2 months of ICU and after saveing a few lives in the ER getting the patients intubated and bagged and getting the right medications into the veins I noted I was having trouble remembering the medication dosages in the heat of the moment. The nurses were really slow too. So I ran a workshop for the nurses reviewing and doing all the ICU procedures again and running the whole staff through this with a view to doing a review course every 3 to 6 months. I had the Sally Ann doll brought in and there were at least 2 or 3 nurses who were way ahead of the game. The problem became apparent that it wasn’t the nurses but rather the head nurse and the administrator. I’d checked and the doctors were very keen. Bob was always first to do and want the best for his hospital and town.
We had some resistance from the nurses who saw this as a ‘job’ but that was only a few. I’d have 30 nurses and find that I had only a couple of nurses that were a problem ,one because she was so dizzy and the other because she was such an asshole and bully. This would become apparent in time.
Today I say even Jesus had a bad apple and he only had to deal with 12 disciples and he was god. How to deal with the bad apple is societies is a main thing. I saw it first in this microcosm. The stupid one wouldn’t learn and the the administrator wouldn’t adjust to her obvious limitation. I would eventually demand that this sweet but air head nutbar not be allowed to be on alone, but the obnoxious young head nurse and the administrator would over ride that .I’d then have tosave a half dozen lives in miraculous dramatic rabbit out of a hat ways because the idiot had caused a wholly unnecessary crisis.
The thug was the wife of a prominent citizen and had come back to nursing without having kept up her skills. She had all this social authority but none of the merit. She wasn’t keen on the learning because it showed up her obvious deficiencies. She actually improved over time motivated to be good. Regardless being young and naive I bull dozed through all the objections and got the nurses functioning really well. Admittedly the two keen nurses who the head nurse was jealous of so didn’t give them the authority they deserved ,did the main work after I taught the courses in the morning each week. No one had done this in years and it’s was great to see everyone on the ball.
The next thing I did which was really a breakthrough in the day was recognize if I was beginning to forget the crash cart medication dosages and protocols others would be too. I didn’t want to wait till I forgot in an emergency months down the road.
I’d also been to a talk where I was able to ask staff in general what other country hospitals did about their car accidents and emergencies.
“People don’t live. The doctor doesn’t arrive until well after the people have died.”
‘We just tell the ambulance to keep on going. We dont’ know how to deal with major trauma. We don’t see enough of it.”
So another weekend I was at home with the books and these great high school MARKERS and huge sheets of cardboard. By the end of the weekend I had the principal protocols with standard medications in order given with dosage and flow charts for the major emergencies, MI, CVA, blood loss, etc.
I glued them too the previously white blank emergency walls. I don’t hunk much of white walls in emergency spaces. I had my first showdown with the administrator.
“You can’t do that ,” he said “It doesn’t look professional’.
I may or may not have told him to ‘go fuck yourself’ that time. Eventually I’d say that because he was a royal ass and obviously needed to be told.
Thanks as always to Bob and Mike that hurdle was bypassed. Bob was forever smoothing the ruffled feathers of the pompous adminstrator. The Mayor of the town, one of the old families actually came in and asked me about it. He thought it marvellous. He was this very bright eccentric old guy who loved his town and loved his scotch. So the posters stayed.
Bob and Mike both thanked me.
A few weeks later, Bob confided in me.,
“I have to admit Bill I was afraid to come to emergencies at night because I couldn’t remember all the medications. I just didnt use them enough. I didn’t want to look like an idiot and was always terrified to go to the emergency. I know it slowed me down. Knowing that’s not going to be a problem I’m glad to run to the emergency. It’s really made a change.”
Word got out. Pictures were taken of my posters. Dozens of emergencies in the country started to have these posters. The doctors made them themselves and later some commercial ones became available.
That’s how I first came to know the head of northern medicine . He asked me for a copy , made some changes and put them in all the nursing stations through the province.
I saved dozens or more lives in the years to come thanks to those charts. Everywhere I went. I put them up on the wall and noticed no one took them down. In one place I just wrote the medication and some formulas on the wall with a black ink marker and saw they’d stayed there years later.
It seemed like every day there was some exciting challenge and most everyone was on board with the solution. It was way before we had to work to the lowest common denominator in the committtee. The speed of electricity is dependent on the slowest conductor. As I got older I saw more and more elevation of the cousin of the boss, all the politics that makes government so slow and painful began to invade medicine. The lights went out one after another. Somewhere they continued to shine. I love the light and am always still looking for it and seeing it on somewhere . Doctors are collectively keen on saving lives, reducing suffering and solving problems. There’s the art and science of medicine and they collectively love the pragmatism.
I was doing complete histories and physicals on all my patients by booking one or two aday and getting the charts up to snuff. I’d also changed the chart to my favourite charting system which used the front and back folders rather than leaving them as just holders. I’d seen this in my work in one of the hospitals and saw the genius of the designs so introduced it in Morris. I also stapled a ‘problem list’ to the front of the chart so it didn’t get lost in the ‘notes’. Bob and Mike and I then discussed these changes with each other and the head nurse. She was really smart but had all this hierarchal stuff going on and was in a weird alliance with the administrator. On this occasion she saw immediately the merit in the problem list and the redesign of the hospital chart now that S.O.A.P. Was coming in. The only problem was she said.
“We’ll have run it by the administrator to see if he approves.”
I suspect I said ‘WTF!” I’ve been remiss in language school having not spent decades in Political Correctness training but instead studied surgery and a whole bunch of other useless stuff.
“This is purely clinical matter and doesn’t require ‘administrative approval’ Isn’t that right Bob.”
“Sure is.”
Mike had this wry smile and had done his time in hospital politics so admitted it was always entertaining to him to watch me open up these balls of trouble.
The charts were upgraded. The administrator wrote memos saying that he thought he was supposed to be involved in critical hospital decision making. Bob rewrote my return memo ‘go fuck yourself’ and my career of life with need for and loving kind ‘EDITORS” began.
At the time no one knew he was embezzling or some such thing but it would unfold that I’d meet the administers previous boss who fired him for lying cheating and stealing and was thoroughly astonished to hear he had a job. Apparently he was a favourite of the other provincial political party. This would explain why we had some ‘hack’ in a bureaurocratic power position. Years later I’d ask some guy , not for the first time, ‘how the fuck did you ever get this job.” Really I’m astonished at the idea of a plumber flying the supersonic jet and yet this is more and more common in government. I loved this man who with wonderful candor said, “I’m a friend of the premier and it’s easy money.’ He didn’t know his ass from a hole in the ground but of all the idiots I’ve had to work with he was my favourite. He went onto say, “I guess it’s obvious that I ‘m an idiot and don’t know my ass from a hole in the ground whereas you obviously know this shit so why don’t you tell me and I’ll say it was my idea and we’ll both win.” That’s how things worked so well at that hospital for a year until he was promoted for his genius and winked at me when he left. I didn’t want to go through training another idiot so I left too. I loved that good old boy and forever after voted for that premier and his party.
You can work with honesty. Our administrator was a liar. As a doctor I need ‘facts’ and ‘true information’. I’d lose a patient that would change the course of my life because the patient and his family lied to me.
That death caused me to become interested in ‘non compliance with medical regimen’ and aware why as much as 40% of medicine didnt work. Id’ eventually end up in psychiatry because psychiatry and immunology were the only fields at the time directly addressing this issue of ‘resistance’ and ‘secondary gain’ and the ‘push back’ to change. I’d love studying Ericksonian Psychiatry and their work specifically on ‘Change.’ Dr. Watsylwalick and the Palo Alto school would be as interested as I in this issue. When I got on the scent in those days I became a hound dog.
It eventually took me to St.Paul. “I do that which I don’t want to do and I don’t do what I know I want to do.”
That’s the elephant in the room and there’s literally millions to be made by ignoring it and coming up with all kinds of ‘lies’ to the contrary. There’s more money in the ‘blame game ‘ in Canada than in science and solutions and change. But that’s another story. That one death never left me and changed my whole approach to all aspects of my medical care. Mostly I learned to ask, ‘what’s the benefit of this disease?’ ‘What did this disease initially solve.?’ “Why did this terrible thing come into being as the only alternative viable to death?” Those were the questions I’d learn. I’m considered a freak today because that’s the way I think. I met a group of wise men and holy men who taught me this but they’re just as much freaks. I like them though.
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