Gratitude Jan.15 , 2020

Thank you God for light.  Thank you God for breath.  Thank you God for warmth. Thank you for morning.  Thank you for the night’s sleep. Thank you for the dreams that touched me with otherworlds and mystery. Thank you for the mind. Thank you for Gilbert in bed beside me. Thank you for indoor plumbing, running water, hot water, flushing toilets.  Thank you for coffee.  Thank you for grinders and electricity and intricate machines that make the morning brew. Thank you for my rugs. Thank you for the heater. Thank you for this clothing. Thank you for my positive memories.  Those things that spark the mind looking forward. I thought of old friends and little children and knew I was blessed. I reviewed my fears and felt that I didn’t want to live in a fortress of walls and moats. I’m so terribly vulnerable and I live in a dystopia but I continue to trust. Each day I go out on the battlefield and bring back the wounded.  I rally the dying.  I’m in this insane world but I’m doing my bit. Each day.  I pay my way. I guess I do thy will.  I’m bitching and complaining and self pitying and moaning and groaning and whining but I get up and help the next person in the line. Two malaria’s and and a cholera.

There are the elite. These men and women so far above the world with guards and limousines and servants and nannies.  I’m wrong to compare myself with them without comparing myself with the cripple.  Acceptance is the answer but I keep slipping. I struggle with my thoughts. I’m beating on your chest God asking for protection and support and guidance. I want to be safe in an unsafe world, rich in a planet of poverty. I want to be joyful in the malaise and depression of existence. Life is suffering unto death.  Desire is the root of all suffering. My back hurts. My shoulder hurts. My knees hurts. I’m always in pain. The plane crash, the car crash. All these attacks on my being. I was doing nothing wrong and paying attention. Shit happens. Ive been living but Ive not been able to evade the arrogant narcissist going through the red light oblivious to others or the troubles he causes. Now years later the trauma greets me.  Ive got to get through the pain. 

The life long desire to be in the south in winter. I want to run from the snow. I’m reminded of the terrrible cold.  Lost in blizzards. Making fires in woods, waiting out the night, blue.  So many negative memories. I can pull them out like a speed dial.  Dial up despair.

Yet here I am with you.  I’ve meditated sitting cross legged on the floor, listening to my breath, distracted by every sound and every undone thing but there I am making a space for you. Listening on the radio pointed to the inside.  God’s within.  I am the bubble make me the sea. I’m talking to the architect not the wall. Be with me today. Guide me.  

I’m supposed to act with dignity today.  Dignity the new standard that has been thrown at us.  The latest demand for perfection by aa group of hookers, thieves and murderers.  They have the guns and the lies and own the courts and rig the election and propagandize to the children.  Fear mongering.

I’m afraid.  Jesus said Do not be afraid.  I’m always afraid. A perpetual coward, faking it till I make it.  I dont’ want to go to Ninevah. I ve been on the icy roads with every poor driver who hit me out of control. The memories of the 360 degree flying through the air , the idiot speeding on black ice losing control in the passing lane and hitting me. I never knew a car could pitch pole and the driver still live. My divorce wasn’t long after. I’d had another near death experience and couldnt believe I was alive.  The car rolling sideways and righting itself. The self centred drunk and stoned in the morning party animals. I couldn’t get to the clinic that day. The police man took me to the emergency and I was so thankful my friend was on. I was desperately falling apart, my back seizing like its done forever. The incompetent young lawyer. The deceitful insurance company.  I was a week in bed.  I bought an encyclopedia britannica and began to read it.  Drinking scotch and popping T3, every move excruciating.

I have never recovered. Flashback pains in cold weather, the icy roads a reminder. The stoned Prime Minister wanting everyone to be stoned along with him so he can make factories and money and have more jets and nannies. I’m trying to stop them drinking. Trying to stop them drugging. Then yesterday I was asked if I wanted to be a euthanasia doctor.  If thinking about suicide isn’t enough. The government wants me to kill. I surrender we say.  Let me be captain of the artillery. I’ve read a book about mortar’s and gain a whole new respect for tubes. Meanwhile low testosterone is at epidemic proportions in Canada and no ones cares. I’m writing viagra prescriptions and talking to women who are blaming themselves for the mans noodle. The men are crying.  I’m sitting with crying me. The transsexuals are no more happy.

I’m talking to friends who stay as far away from sorrow and fear as they can. They live in little gated communities of the mind and heart and think they are Jesus. 

I write gratitude lists. I send people to anger management. I get asked to talk about anger and struggle to forgive. Forgiveness is not for them as much as it is for me. It’s also we’re all connected. I’m angry at my toe for stubbing itself.  I’m so unenlightened. I’m so dark. I’m carrying the light each day, trying to reduce the pain, trying to cut away as little good flesh. Taking out the old and weak.  I miss the easy days of surgery. I miss delivering babies. I miss the days when my skills with my hands were sought out. I did cut downs in hospital, always go the lumbar punctures and inserted needles in to hearts, swan gauzes and chest tubes and pacemakers. It was all glorious. Now I muck in the mediocre.  

The pain is real. It is all in your head.

“You saying its all in my head.” 

‘If I cut off your head you’d feel more pain?”

Why is the brain and mind and soul so little validated but the body is all the rage.  They want money and more money and more money.  Everyone is poor.  Validate the pain. Blame the world for my pain. But accountability brings power. I am my nemesis.  I can change me but not you. The serenity prayer.  

I drove to work 2 hours commuting.  Duty.  Wanting a pay check.  I had such silly expectations of what it would be like to grow old. Retirement. The promise of all those years of sacrifice. Now they circle like mosquitoes outside the screen. The vampires are coming in the chimney.

I’m grateful.  I need only look at a flower and see the wonder.  I have to focus on the positive and let go of the negative. Ive got to walk on the right side of the street and then I won’t be hit by the cars, mostly.

Ive so many blessing. I have these glorious times walking in the forest by the river with my dog who is happy, blind and old and so content not to be alone .Thank you Lord that I’m not alone. Not in solitary. Not locked in quiet room by the instrument of my rape and terror.  Not injected with anti psychotic medications for telling the truth and shouting ‘j’accuse’.  I’m vindicated. The enemy dies.  Arjuna talks with Krishna. The war goes on.

I buy a little statue of St. Michael as I look back my back trail and see the karma of all who hurt me and wonder why I am afraid.  Why must I get wounded for the squad to come up. I’m walking point and always afraid.  But someone else is walking point right now. I’m here in the warmth and have a royally expensive tank of propane to replace this one that got me through the night. It’s so cold outside. I miss Mexico and the beach.  I miss the glory days. I wallow in grief, suck on the tit of despair. I grieve so much but then I look back and today is the glory day.  Today is now. Now is where god is. If I get into the future I get into fear and if I dwell in the past I gather resentments. Expectation is a preformed resentment.  I’m searching for God, playing hide and seek, minute by minute. Here in the mystery in the game. I’m looking for love in all the wrong place and all the right places.  Life is a poem and I’m a poet. Life is a song and I’m the singer. 

Thank you for the laughter. Especially the laughter at myself.  This too will pass. The end is a grave. All else is vanity.  

Thank you God for the coffee.  Thank you for this body.  10 fingers 10 toes.  Help me make the time for seeing friends.  Help me face my fears and go out on the road.  Help me face my fears and get out of bed. Thank you for my waking today. Thank you for the prospect of a hot shower.  Thank you for the coming of the light. Thank you that we know the sun is returning and we dont have to sacrifice any virgins. We dont have many virgins left Lord so thank you for science and the knowledge of astronomy.  

Thank you for all your blessings. Help me to know you more deeply feel you more fully trust you more truly.  Thank you Lord for this life and this day. May I make the best of it, serve you and my fellow man and woman. May I be a better man today than I was yesterday.  Thank you Lord. 

Angry at God

I was fascinated to hear a Christian say, « I don’t know I’m angry at God. ».

I said « Jesus was angry at God » 

« Jesus can’t be angry at God. »

‘What about Eli Eli Lema Sabachtani. ‘My God, My God why hast thou forsaken me?

Jesus taught « Do not be afraid »  Love and fear are opposites but anger is fear in ‘fight versus flight’ mode.  That’s the simplest division. The experience of abandonment is grief.

Jesus was angry at the money lenders. But when Jesus was on the cross, if he was suffering, he was ‘doing God’s will’.  Being obedient to God’s will doesn’t mean I’m ‘happy happy happy’. Jonah was angry.  Grief and suffering go hand in hand.

The ‘stages of grief described by Elizabeth Kuala Ross include ‘anger’.  Anger is a natural state.  Things can cause me to be angry but if I hold onto my anger then I can become resentful. The Bible is clear that we shouldn’t hold onto anger but it doesn’t deny anger is human. Holding onto anger or nurturing anger will turn one bitter.

 Jesus was ‘son of man’.  HE was all human. And all God. If he was just a God then he really wouldn’t have ‘suffered.  To be human is to have the full experience of humanity.  The whole issue of the nature of Jesus resulted in the Athanasian Creed and the Hypostatic Union of Jesus, perfectly divine and perfectly human, not a chimera and not a duality, but one.  One person of the trinity.

So I imagine if I’m a man of human nature on the cross doing the will of God but dying slowly in the most horrid pain, I’d feel ‘anger at God’ knowing that God’s perfect love but at that moment of sever pain feeling abandoned . I may know God will not reject me but I am human. Jesus was human even if there are those who would reduce him to an idol.

Today ‘Why have you forsaken me, “while it might remind us of an earlier psalm, might well be said in the vernacular of today, ‘fuck you God.  Indeed there is a movement by this name and a major controversy. People leave the church and no one question if they are angry. People are afraid of anger in themselves and others. 

In psychiatry, in ‘somatic depression’ or the ‘somatic sympton disorder,’ we think of pain as clothed in grelief and fear and anger. Abraham saw depression as ‘anger turned inward’.  Pain is by extension anger turned inward. Somatization and conversion disorder are pain or other physical symptom like fatigue as well, understood to be a mental disorder, not denying the ‘pain’ any more than one would deny the excruciating pain of ‘phantom limb pain’ but recognizing the materialistic error is in the brain, or the biopsycosocial error is in the ‘mind’.  It’s not simply  a ‘brain’ disease perse but a ‘mind disease’as well.

Anxiety is said to be the measure of one’s distance from God as well as a measure of one’s humanity.

It helps one see ‘suicidal thinking’ as ‘anger turned inward””’  more clearly and understand the ‘seriousiuslness of ‘emotional pain’.  Emotional pain can be deadly.

In ‘communication psychiatry’. Everything is sen as ‘communication’. Cancer is seen as ‘that which can be said in on other way ».

The idea therapeutically in psychosomatic medicine is to look for a new and different approach when conventional therapy fails.  If the door handle turned doesn’t open the door , turn the door handle in the other direction.  

Phillips wrote the sweet little classic, « your God is too small ».  

The God of Love is big enough to take all your anger and all your pain.  God doesn’t reject man.  The devil was said to have turned his back on God because he’d rather watch his shadow than look into God’s light.  

Aliénation and isolation are précurseurs for suicide .  Dehumanization and the feeling of being unloved, alone and rejected.  It’s fundamental to survivalhaving purpose as Man’s Search for Meaning showed.  We die most from ‘neglect’

Jesus was foul  mouthed and ill mannered with friends in low and high places. Inhis day and associated with the improper. Today the contemporary ‘cross’ might well be an ‘electrocution chair’, a ‘guillotine’ or a ‘noose.’ We have a Fondness for the symbolism of the museum Christianity and ‘cobweb Christianity’ as seen in the sentiment some view the ‘cross .’ But it can cause us to overlook the ideas of Jesus today.  Christ’s value is not as a ‘myth’ or ‘teaching story’ alone but as a ‘relationship today’.  If I get angry and my friend leaves me , Do I really have a friend in Jesus.  

All adolescents in their relationships with their parents go through this phase.  Today most Christians are unprepared for this adolescent phase of their spiritual relationship which is no surprise when the church seems unwilling to engage at the point of  ‘anger’, especially anger at God.  Rejection of God.  

Ultimately this is tied to suicide and addiction and pain. 

If it’s not the Cross then what is Glad Gethsemane. And why would Kierkegaard say Life is suffering unto death if was he not referring to pain and the burden of life, expulsion from Eden and loss of innoscence.

Morning Rain

I am sitting at the computer listening to the rain falling on the roof.  It was drizzle early but now the tenor sounds have given way to baritone and bass droplets heavy with spring.  The green in the city is wonderful. But I do like the feel of rain.  Going to and fro work I am dressed for a different element of weather.  I will have to step gingerly through puddles, carrying my umbrella.  The traffic will be slower with more risk of accidents, danger and delays.  There will be darkness and ominous clouds.
I can forget more easily in the sun.  In the light I can soak in health and happiness.  I would that the rain washed away my sorrow and pain but it does not.  I fear the barometric falling contributes to the chronic sadness now so evident in my feet and hands. My friend laughingly called it 'stigmata'.  But my back hurts as well and that is so lacking in Biblical reference.  Graecian Roman as in Atlas perhaps, my grandiosity a burden to bear no doubt.  So many injuries and perhaps so many more years to go before the end is welcomed.  It has long lost the flavour of a race.  I am slouching towards Bethlehem at best.  I am Jonah trying hard to run away from Ninevah at least.  
I have faith.  There have been so many signs and miracles in my Doubting Thomas life.  I've been blessed with knowing God whether his shouting or his wee small voice but still I care not to listen. I have a little dog who teaches me that his routine lack of obedience never affects my love for him.  I call and he may listen if there's no distracting interesting dog or smell to cause him to delay his return to me.  I know I'm his human.  I am God's dog at best.  I do his will with the same enthusiasm my dog does mine.  If God wants to play throw the ball or go on an adventure in the woods then I'm a hundred percent his man.  But if it's daily routine, the getting in to work and wrestling with the chronic infusion of State into the affairs of men and the demands so costly of all the beggars in high and low places, well I'm like my dog. His attitude says he was bred to hunt and run and fetch game home not to walk at heal in city streets waiting for his human to pick up his shit and deposit it in some bin somewhere other than where he'd rather go.
I'm recalcitrant at best.  The pain causes prayer.  Injuries turn my life inward.  I am alone with my mind and see how silly and repetitive it's themes are.  Fears, resentments, worries, desires.  All is suffering.  I'm full of self condemnation, speaking to myself, worse than I'd speak to my dog, judging myself a failure when there is so much success to be considered.  I confess and no confession seems enough to unload the baggage I as quickly reacquire.  I'm lost in paths laid down years ago when this destination I've arrived at seemed so much more than what it is when I am there.
I'm journeying, always moving, like a child.
Sitting still I meditate in the morning, begging God, petitioning God, talking with God, listening for God, forgetting myself, silently, wanderingly distracted, losing focus in the persistence of this life when death to self is all that is sought.  I am in God's hands but numb.
I know that the pain measures my distance from God.  I once thought pain was a word trick that reminded me that I must 'pay in' and that 'pa' was 'in'.  Schizophrenics taught me the power of words.  My father was as the father in the biblical story,  Abraham and Isaac, told best in song by Leonard Cohen.  I find solace in water.  Hot tubs and swimming pools are where I feel the greatest relief, returning to the sea in search of an umbilical cord.
I eat, defecate, see, hear, smell, touch, and share with others, even having sex though it's been long since I wrestled or butted heads and shoulders in hockey rinks and playgrounds.  Now only my dog and I rumble.  Even now he sleeps and I envy his capacity for napping and lack of demands on his time.
It is time now to move along.  I've a onerous chore to do and must get to the office to respond to attack .  I am sure God gave me these fingers for poetry and I've wasted the gift on rhetoric and logic. Already I'm preparing the anti venom writing to the venomous and thankful that God loves 'peace makers'.  War is so profitable and the State is ever in an orgy saber rattling and  phoney fighting with constant fabricated emergencies making a mockery of their own indulgences.
My pain comes from believing we really all should be dancing though today even my feet hurt and my back hurts and somedays my head hurts especially as the week progresses and the tiredness comes from facing threat after threat by blue collar and white collar antagonists who know no better.  And Jesus said, "Forgive them for they know not what they do"  
And my pain is constant restraint, holding back and holding in, the desire to join in the hostilities.  I have turned my cheek 70 times 70 times and more and bourne the lashes countless times in good faith waiting and working.
I hang my head in sorrow praying for patience and peace and hoping for the day I return, a prodigal son, at best, but a son nonetheless.  I know there is a home for me in Heaven and as my friend John likes to say Heaven is all the way to Heaven.

Vicozen

Most 'health food products' are just that, food. They are marketed as 'healing agents' but more commonly depend solely on 'placebo effect' for benefit. Often they are touted with 'pseudoscience' taken from the real science associated with the mainstream pharmaceutical industry. That said there are increasingly agents which are effective and beneficial. I have a couple of herbal medicine and alternative medicine texts in my office. I try to keep up to some extent on advances and know there are amazing products coming out of research of traditional medicine. Aspirin was just such a find.

I had a sore throat last year and was developing laryngitis. Normally when that occurs I close my practice. A colleague offered me some Vicozen, a new herbal liquid drink which is not yet widely available in Canada though is available in the US and overseas. It was amazing. Instantly the sore throat was better and in contrast to other occasions I didn't have to take time off work.
 Interested in this product I looked at the ingredients. One was from the leaves of Mitragyna, a tree indigenous to Thailand. This mitragynine in lab research has worked on opioid receptors, noradrenergic and serotonergic systems. I didn't notice any mood altering effect like I might with codeine or such medication but felt better and locally the pain relief was immediate. Others I know who tried it found it was especially good for joint pain  and headaches. They did not notice any negative side effects. That's of course anecdotal and subjective. I was impressed it was effective. Here was this Thailand herbal remedy that really did work.
When I was in India many of the medications that here require a prescriptions there didn't. I was just discussing this with a pharmacist on a recent trip to Mexico who told me that a whole range of medications were over the counter and didn't require a prescription. In Germany however medications that we consider over the counter are there considered to require a prescription. Given the increasing wait lists, there really is a place for over the counter medications.  Clearly it would be best if these actually worked. I don't imagine Vicozen will one day need a prescription but it will certainly provide an alternative approach for pain relief especially for those who are looking for something different. Often chronic pain is best treated with a variety of agents as often one agent alone is limitted by a particular side effect. Time and more research will be needed to find where Vicozen will line up with other effective pain relief medications but my belief is that it will indeed be in that line up.

Personal Injury, Chronic Pain and Comorbidities

Dr. Daniel Gouws completed his medical degree at University of Stellenbosch before emigrating to work in Southland, New Zealand, and Saskatchewan before coming to British Columbia. He passed his Master of Sciences at McGill University in Occupational Health Sciences before becoming a board member of the Occupational and Environmental Medical Association of Canada. He is an extremely intelligent, lucid presenter whose clinical experience is obvious from his revealing insights into the care of patients.  His talk, "Comorbidities and Timelines - What to watch when for when your injured patient or client isn't getting better" was a most informative.
The objective was to identify the factors that could contribute to a poor outcome in patients with soft tissue injuries.
The Trial Lawyers Association of British Columbia, Essential Soft Tissue Injury Conference provided a CD with the notes of speakers and other relevant information. I made some notes during the presentation relevant to my own personal interest. It doesn't do true justice to the wealth and breadth of information that Dr. Gouws presented or give you the slides both medical and humorous that accompanied his presentation.  It does give a glimpse and for that reason alone I think it's worth including them here.

Soft Tissue Injury Conference, TSABC, Vancouver Convention Centre

March3012

Comorbidities and Timelines, What to watch for when your injured patient or client isn’t getting better

Dr. Daniel Gouws,

South Africa

Occupational Health McGill

Mechanism of Injury

• whiplash injuries occur when head accelerates relative to the body, excessive torgue and shear...damage through compression and distraction

Forces involved are considerable, at an imact speed of 20mph (32 km/hr) the human head reachs a peak acceleration of 12 g during extension

If the individual head is in slight rotation, a rear end impact will force the head further into rotation before extension occurs.

In addition to neck pain

-headache

visual disturbances

dizzines

weakness

parasthesiae

cognitive deficits

TMJ

They can often be presenting also with symptons of concussion

Clinical course

Majority of patients improve spontaneously over the first three months

don’t know which go sour

Medical Model

Diagnois

• History (subjective)
• Exam (objective)
• Ass
• Plan

Differences

Acute pain versus chronic pain

• chronic pain doesn’t get better

Role of patient with pain is different for acute versus chronic

Acute - follow treatment advice

Chronic pain - ‘partner’ relationship in care , patient responsible for daily management, very different from treatment of appendicitis

Chronic Pain

-lasts more than 3-6 months

varies in intensity from mild to excruciating

one area or multiple areas

emegence of complications

• increased sensitivity to pain
• emotional and cognitive distress
• non restorative sleep
• fatigue

What is happening in backgrown

• dogs in background of slides

Chronic Pain

• chronic co morbidities

Patients get frustrated with us

We get frustrated with them

Blame game

-There is no exact relationship among - degree of pain, extent of pathological change and extent of impairment

-We do not prove or disprove pain with special investigations.  Special investigatiosn are only considered to be appropriate if they will change the management of the patient

-It is inappropriate to request special investigaton in the abscenede of clinical findings such as nerve root entrapment or potentially surgically correctable lesions.

Comorbidities

• psychosocial
• what is the effect of the injury and comorbidities
• deconditioning
• post traumatic stress
• substance abuse
• Depression and anxiety
• Chronic pain patients who are depressed are 9x more likely to be disabled
• Untreated psychopathology is greatest likelihood for poor outcome

Loss of Control

• Regression
• Isolation

All my friends are dead

Diagnostic Dilemna

• extensive assessment by multiple physicians
• numerous investigations (included repeated diagnostic studies) without any real improvement or resolution of symptons

Drugs

• chronic pain is not an emergency, should get appropriate appointments at appropriate times
• beware of opiates
• Canada has distinction of being one of the top prescribers of opiates in the world

Cognitive Distortions

• unconscious complications of chronic pain
• non uncommon - we are all prone to cognitive distortions - ex ‘the little engine that couldn’t because he was a worthless bum like your father’
• emotional reasonling
• mind reading
• entitlement
• ‘la belle indifference’  - patient smiling while saying her pain is 9/10
• hopelessness

Kinesiophobia

limits activity

limits treatment compliance

becomes self perpetuating - less action - less activity - more pain

Catastrophizing

• research shows relationship between catastrophising and heightened pain intensity -

Relationship problems

-less interest in sex

Procrastination

-once pain is under control I’ll do more

-I have to wait for my MRI because I can do anything (like take out garbage)

Loss of control

• fundamental to ability to cope
• learned helplessness
• the ability to gain a sesnse of control is fundamental to the ability to cope - self control likened to an energy source and fatigue
• once you become disabled a lot of that which was taken for granted becomes a bid decision

Workplace Factors

• adverse outcomes in pain study
• 1)do you enjoy your job
• 2) do you get along with your supervisor

Workplace autonomy

• a factor - disability of chronic pain - less work autonomy - more pain disability

After 6 months chance of return to work drop

Discuss return to work considerations

What can be done?

-individual cognitive behavioural psychotherapy

-exercise

-work conditioning/work hardening

-ergonomic modifications

-modalities used in conjunction with active exercise

• pain self-management programs
• PDP, PGAP programs

Elements

-set personal goals

• improve sleep
• -increase physical activity
• manage stress
• etc

Loss of control

Goal therapy can be effective in helping patients regain control

Chronic Pain Self Management Program

www.selfmanagementbc.ca

The Essential Soft Tissue Injury Conference 2012

This Trial Lawyers Association of British Columbia Conference was put on with the Family Practioners of British Columbia.  Credits for attendance at the March 30, Friday and March 31, Saturday conference was provided to both doctors and lawyers. Personal injury lawyers came from all over Western Canada with maybe a quarter health treatment professionals.
Co Chairs were Robert Marcoux, Sean T. Pihl, Dr. Mark K. Frobb and Dr. Daniel R. Gouws.  I'm here at the end of the first day having coffee at the last break having enjoyed a full day. The conference began with lawyer Dick Byl presenting on Clement versus Clement, regarding as yet to be released Supreme Court statement on 'causation' and 'but for ' ideas regarding 'negligence'.  A fascinating detailed presentation of a wealth of information condensed down to truly pertinent information for doctors and lawyers.
Lawyer Manjot Hallen next presented a truly informative presentation on How to Write a Good Medical Report discussing, expertise, timeliness, billing and what to say and what not to say.  Excellent.  I think I knew most of it from experience but given as '10 commandments' made it truly memorable. I learned a couple of key pieces of information and the source of that requirement in the actual 11.6 laws governing expert witnesses.
Comorbities and Timelines, what to watch for when an injured client or patients isn't getting better was given by Dr. Daniel Gows.  I really enjoyed this South African gentleman, physician, and scholars expertise regarding 'chronic pain' and the sharing succintly of the central ideas that I as a physician deal with routinely.  He made obtuse clinical information clear to a general audience and I admired his communication skills in this regard.
The medical legal panel discussion included Dr. Lisa Caillier, MD FRCPC Physical Medicine, Vancouver, Dr. Raman Manchandra MD CCFP, family physician with special interest in pain management, Surrey BC, and lawyer Sean T. Pihl, Kelowna BC and Kara Naish, Richmond BC.  I love to hear Dr. Lisa Caillier who works with G F Stromm anytime. I've had the priviledge of reading her reports on overlapping patients and thoroughly admire her knowledge and empathy.  The panel was fascinating with great responses to practical questions from gps and lawyers in the audience. Most people were asking questions about ongoing pertinent cases and the insights were most helpful indeed. Very different medical and legal considerations in some regards, similiar in others. What was a delight was hearing how much the lawyers care for their patients and how much we all are working to a common cause, helping the patient get the accident behind them so they can get on with their lives
The afternoon was focussed on Thoracic Outlet Syndrome with truly scintillating overlapping presentations by powerfully impressive physicians, Vascular Surgeon, Dr. Anthony Salvian and Physiatrist Dr. Duncan Laidlow.
I've attended these conferences before and these presentations by Dr. Laidlow and Dr. Salvian were a couple of the very best medical rounds presentations I've heard.What was fun was the nature of the questions from lawyers and doctors that followed.
Now the talk on Myofascial Pain is beginning so I best get back to the conference.