28 years old, 1970 Vascular Surgery, ER and Trauma

The head of surgery was a vascular surgeon. I’d do a rotation in predominantly vascular surgery under his direct tutelage. An honor really. I was considered a good assistant so it might well have been self serving.  I think all the time helping my father and brother under cars taught me anticipation.

We did lots of aortic aneurysms but the surgery I remember most was the 12 gauge buckshot abdominal shooting. There were other shootings but this was the one I fell asleep pulling back on a liver retractor.

“Gunshot surgery not exciting enough for you, Doctor?’  Hearing my name I startled awake. 

 “No sir. It’s not that.”  We’d been at it for 8 or 9 hours. He’d been carefully removing every lead pellet from the intestinesand then carefully closing up the intestine. We’d already taken out the spleen and stopped what seemed like a hundred bleeders. Now he was delicately moving along the small intestine and integument feeling with his fingers to get all the lead out. It was 5 or 6 in the morning and we’d started the night before.  I had already peed in my scrubs. With all the smell of piss and shit I’m sure no one noticed.   Falling asleep was noticed. I’d been on the retractor for hours.

“I just wouldn’t want you to fall over backwards and hit your head causing the nurse to feel she had to take care of you,  leaving me alone with the patient.” The nurse smiled over the mask at the twinkling eyes of the master surgeon.

A couple of more hours later we closed up.  Sponges were counted carefully. All the tools were counted and doubled checked.  Then he used a staple gun to close the abdomen, a long incision from chest to pelvis, to have the best view in an emergency operation.  

The man lived to go to jail. The other criminal had died.  I came away thinking that anyone who shoots another human being should be required to clean up the mess and assist in the surgical repairs.  Let him hold the retractor. 

I come from a ranching, hunting family so grew up surrounded by guns and had begun competition shooting in early teens. I shot rifles and shot guns. I shot birds and ducks.  In my family we also had a rule if you shoot something you had to eat it. So that was a good reason for me not shooting bad men. Te must taste rancid.

 But really bullets make a mess and the laws against criminals who use guns are so terribly weak in Canada. When I lived in England the criminals were afraid to use guns because the laws against them were terrific but in Canada the law was easy on gun wielding criminals.  I didn’t like it. Any of us who worked trauma had little respect for the bleeding heart judges who’d go easy on gun wielding criminals.  

I never saw any gun  accidents. Even when I worked in the country I didn’t see gun ‘accidents’. I continued to see criminals shooting each other and doctors like me cleaning up the mess and judges going easy on them. Fact is judges should be required to stand in OR’s holding retractors 12 hours so maybe they wake up and stop playing politics and do their jobs.  

I did a month in the Emergency where I”d see knife wounds.  My favourite memory is this poor old guy who came in with a long bread knife stuck his abdomen.  The police had found him on the side of the street and called the ambulance. The ambulance had correctly not touched the knife that looked like Excalibur standing out of the guys abdomen just begging to be pulled out.  The head of emergency told us not to and called the trauma surgeon. All the nurses and staff were so solicitious with this poor guy moaning with this knife sticking out of his abdomen.

Well , next thing the police have found another guy and he’s brought in on a gurney with half a bag of groceries with him.  He was found unconscious and had been bashed about the head with a baseball bat. His face was all swollen.  The police and ambulance had picked him up nearly delirious collapsed but insisting he wasn’t going to let anyone steal his groceries hence the bag of groceries on the gurney.

Now this guy looks up and sees the other guy with the knife and is almost on him pulling out the knife. 

“You bugger that’s my knife’ he’s screaming. 

The guy with the knife in his belly is holding onto it and swinging his free arm to keep the other guy away from it. Thankfully the police hadn’t left.  So they come back in and hand cuff both guys to their gurneys till trauma, called to hurry, comes and takes the first guy away, The second guy goose necking as he sees the other gurney leaving, keeps screaming  “that’s my knife”.

Well, the story unfolds. The first old bloke with the knife in his belly had attacked the second old guy with a baseball bat attempting to steal his bag of groceries. He almost did and would have if the second old guy hadn’t bought a bread knife that day. So when the first guy is winding up to whack him again with his baseball bat the second guy  pulls out the bread knife and plunges it into the  guy abdomen above him. The first guy falls in the road. The second guy picks up his groceries forgetting his knife and staggered off home not making it because he’s now got a head injury that causes his collapse.  Neurology finally arrived to find him and take him from the emergency. They had to bring the bag of groceries or he wasn’t going to go with them despite being still handcuffed to the gurney.

Apparently the two old guys knew each other from the Legion too. The nice first guy was the actual bad guy with  while the second guy really was an  victim who was lucky to be a live .He had a small hematoma and both guys had surgery later that day with the different services. They were in their 80’s and did their recovery on different wards. No further battles were reported, the nurses taking special care to keep the two old raging bulls apart.

Canadian Psychiatric Code of Ethics - II

http://ww1.cpa-apc.org:8080/publications/position_papers/cma.asp

Code of Ethics

I. Consider first the well-being of the patient.

II. Honour your profession and its traditions.

III. Recognize your limitations and the special skills of others in the prevention and treatment of disease.

IV. Protect the patient's secrets.

V. Teach and be taught.

VI. Remember that integrity and professional ability should be your only advertisement.

VII. Be responsible in setting a value on your services.

This is the full list of the Canadian Medical Association Code of Ethics. The CMA has written a short explanation related to each. Dr. Cliver Mellor prepared an 'annotated version" for the Canadian Psychiatric Association showing the relevance to psychiatry with some specific and general examples.
In my blog Canadian Psychiatric Code of Ethics part I I've address I. Consider first the well being of the patient and stated that I believe this should be the starting point for all 'codes of ethics' for all working in the health care field.
II "Honor your profession and it's traditions.  I have tremendous gratitude for the medical and psychiatric profession. I consider my training as a physician one of the greatest priviledges I could have in this life. I have further thoroughly thankful for the time I've spent as a physician and psychiatrists serving with patients in rural and urban communities.  The profession of medicine and psychiatry are to me truly grand and magnificent in their achievements and work.  The traditions of the profession are more complex. I will leave discussion of the 'traditions' of the professions to another time of writing.
III Recognise your limitations. This is to me obvious. I'm thankful that I work in a community of physicians and specialists and when I'm consulted I know that if I don't have an answer there is commonly a subspecialist who has more experience with a particular condition that I do.  I am a subspecialist and when I've been stymied by a case I've had the benefit of consulting colleagues in England, Australia and the United States personally as well as taking advantage of local resources including the College of Physicians and Surgeons excellent library and PuB Med literature search.  When faced with a difficult case I've had personal support from fellow psychiatrists who have helped me through difficult personal and practice issues. I have always felt a part of a greater and helpful collective even alone treating a patient in the wilderness as I've so often been called upon to do.
IV Protect the patient's secrets. I've considered this utterly important and gone to extreme lengths protecting files guarding against the 'loose lips that sink ships.'  Having worked in small towns, reservations and on islands with limitted population I've had to be extremely careful about patient confidentiality and information. Despite all this effort I made the error in hiring a staff person who despite being specifically educated and warned about confidentiality released patient information to a boyfriend and disclosed patient information to government organizations for her own personal profiit.  It didn't matter that I didn't recognise her sociopathic tendencies and did my very best to limit damage control by contacting police and notifying those people she had violated.  The experience did make me appreciate the Medical Office Assistants I had had who were collectively responsible and trustworthy in comparison.  I had personally approached two hospitals about their grossly inferior record keeping services and with the Dean of Medical Schools had both these hospitals security improved to minimum standard levels. In both hospitals I had walked in off the street and asked for senior colleagues personal files without showing credentials or having specific care responsibilities for the patient. I was not wearing a name tag, did not need to present identification, and was not known by the clerical staff.  I did not open the files but took the files to the senior personnel and explained the story and told them that I did not feel that I could ethically take the information that I was required to take from patients and have that information stored in this manner. The Winnipeg General Hospital Administrator wanted to phone the police. I am very thankful to the brilliant Dr. Arnold Naimark who essentially 'saved my ass' from the 'evil hospital administrator'  having been apprised of this situation, shocked by the shoddy service,  demanded that the standards be brought up to minimal levels ie requiring signing out and identification notification. It was an early in my career and despite 25 years of experience I continue to see the secular and non medical administration first response to notification of their inadequacy as 'kill the messenger'.  The clerical staff at a another major hospital required to "ID" everyone who took out files condemned me for making their work more difficult.
As a proto hacker I noted there were no 'firewalls' on early filing systems in provincial and federal government storage systems.  Recent cyber attacks by presumbly Chinese military indicate that no information is 'safe' in public filing systems .  There is a tendency to 'keep up the appearances' but there hasn't been any real attempt ot reasonably address the problem. I have at different times had thousands of dollars of cyber security for my office files but know that "a lock only keeps an honest man out'.
Given the difficulty of security ethically doctors are concerned about their 'notes' however legally and from insurance companies there's a trend to all information being made available to third parties and the 'space' in the traditional 'doctor patient' relationship has become increasingly narrow.
V: Teach and be taught.  That's been my way for decades and I have said that my patients are often my best teachers. An administrative doctor who was most peculiar thought that doctors shouldn't be 'taught' by their patients but their patients teacher. I didn't know what planet she came from but every clincian I know learns from each patient 's presentation and passes this learning on to how they deal with the next patient. The gap between clinical physicians  and beaurocratic physicians has never been wider and I fear that there is grave concern that increasingly a controlling managerial sort who wants to keep their hands clean will try to 'jump the queue' with devastating consequences for the profession. This has already been seen in RCMP a once great organization with tendency to promote from the ranks. Recently there has been increasing political appointments 'parachuted in' with the result that the 'administrators' may well not know how to find their arse with both hands in the service. (to quote one RCMP)
VI Remember integrity and your professional ability should be your only advertisement. This requires further discussion elsewhere as it really has been affected by what has been called the 'americanization" 'f the Canadian public health system. it's further affected by the ability of almost everyone to find out almost everything about anyone with the least effort in the cyber reality world.  What was once only available at high cost from a Private Investigator is available in a program from the local computer store as well as all the 'spy' ware tools from the local 'spy' store.  I'm rarely not being observed by some form of camera in the street or satellite coverage.  When is a 'celebrity doctor' 'advertising' or just hawking his or her wares.
VII Be responsible in setting value on your services. I believe this once had more to do with high prices being asked so that people couldn't afford medical or surgical services. Today 'for profit hospitals' and private 'fee for services' approaches come with 'whatever the market can bear' style capitalism.  In contrast I've been criticized repeatedly for 'giving it away for free' .  When I signed forms for my patients others hearing of it threatened their doctors to do the same.  As a result, not wanting patients threatening colleagues, I began to religiously follow the professions fee guides with regard to a number of things which I'd not really considered that importnat. I know my profession is wiser usually than me in terms of 'valuing service'. Even here "I blog" and give 'information' for free in a society where 'information' is bought and sold.  Many colleagues think that my doing 'pro bono' work is questionalbe and a judge recently criticized me for my belief that when I did 'pro bono' work it mad the work less subjct to negative motives and bias. He was right as those doing pro bono work might well be seeking 'status' rather than 'finances'.  I am continuing to learn about market factors and group process issues in the profession which senior colleagues often seemed to have learned long ago. Some of the senior medical administrators have over the years helped me immensely in understanding issues from a broader base than I'd originally seen them.  I have been very fortunate to have such colleagues.