Another piece from a while ago –

A few days ago I had to help transport a critically ill 25 year old across town from University Hospital to Victoria Hospital. The ambulance in which we were transporting this young patient was being driven with lights blazing and sirens blaring, I was shocked at how many drivers failed to yield to the ambulance. We had to slow down considerably several times. Not only were drivers failing to yield, some were actually changing lanes and getting in front of (and behind) the ambulance.

When we first started to use clot busting drugs for heart attacks and now for acute strokes, the mottos “time is muscle” and “time is brain” became popular because we understood that every minute counted. Indeed, by the time we arrived at Victoria Hospital, the patient had become unstable and required immediate life-saving measures.

The MTO code specifies that it is an offence to not yield to emergency vehicles – an offence punishable by a fine of $90 and 3 demerit points. But the issue of yielding to emergency vehicles is much more important than fines and demerit points.

One of the basic principles on which civil society is based is the intrinsic desire for people to follow the rule of law. We commonly understand that no amount of enforcement can make people do things they fundamentally do not want to do. Furthermore, in a civil society it is not merely the rule of law that governs it, but rather an agreement among citizens to live in a certain way – the social contract if you will.  Countries with civil, democratic traditions in which citizen understand the need for respecting the law have things like parking meters and subway systems without ticket turnstiles. Although these are monitored, it is impossible for them to function in an effective manner if people were intent on abusing the system.

The word we commonly use for this type of system is the ‘honour system’. When people decide to not honour their commitments, society as a whole loses. Society assumes a financial loss due to the unpaid underground ticket or parking meter. Society further assumes the cost of increased enforcement and finally, and perhaps most importantly, society endures the loss of trust – the feeling that members of society cannot trust each other to carry out their obligations.

When the issue is monetary – as in the example of the parking meter or public transport, it can be difficult to work up the appropriate indignation to display in reaction.

However, there are instances where our civic obligations carry a much more important consequence than just monetary loss. In the case of yielding to emergency vehicles, people’s lives are at stake. The driver who fails to yield can only gain a few minutes in arriving at their intended destination. But for the ill patient being transported in that ambulance, or the person waiting for the fire truck, those few minutes can separate health from illness and life from death.

Next time you hear an emergency vehicle coming down the road, think about what you would want drivers to do if you were the person riding in the back of that ambulance or waiting for that fire truck and then do the right thing – pull over. And if you can’t hear the emergency vehicle because your radio is on too loudly consider turning the volume down and paying closer attention to what other cars around you are doing – if everyone is pulling over maybe they are seeing something you are not.

In other words, think about others, not just yourself

This piece was originally written in 2006. Although Ariel Sharon’s massive stroke figures in the beginning, this was really just the instigator for a broader piece on consent.

The headlines were suitably dramatic. The Globe’s was ‘With victory in his grasp, fate intervenes.’ The Times of London: ‘First stroke treatment could have triggered the second.’

Only time can tell but it is extremely unlikely that Mr Sharon will return to political life. Mr Sharon’s condition highlights the uncertainties of life. While many of us think of medicine in absolutes, medical therapeutics remains a matter of probabilities. Mr Sharon’s illness is hardly unique. Many Canadians suffer from similar conditions that predispose to strokes. The treatment, particularly if a person has already suffered from a stroke, is precisely the treatment that Mr Sharon received.

Doctor – “Sir, you have an irregular heart rhythm that can cause your blood to clot. If one of those clots, God forbid, travels to your brain, you could have a stroke.”

Patient – “Oh, that can’t be good. Is this treatable?”

Doctor – “Well, we can’t completely prevent strokes, but we can reduce the chance of having one. The choices are an aspirin a day or blood thinners.”

Patient  – “What’s the better choice?”

Doctor – “Well, if we take a 100 people like you, 6 are likely to have a stroke in the course of the year – so the risk is 6%. If you take aspirin, you can reduce that risk from 6% to about 4%. If you take blood thinners, you can reduce the risk to 2% or even less.”

Patient – “What are the risks of taking aspirin compared to blood thinners?”

Doctor – “The risks of taking an aspirin a day are mostly around gastrointestinal bleeding. In most people, we can detect and treat that well, but in a minority of patients, it can be life threatening. The risks of taking blood thinners are also very uncommon but can be quite serious. If you are prone to falling, for example, and you bang your head hard, you can have a bleed in your head. If you are unlucky enough to have a second stroke while on blood thinners, the stroke could become a bleed.”

Patient – “Is that serious?”

Doctor – “It can be. Mind you, it’s exceedingly rare, likely no more than 5 people in a 1000 who are on blood thinners suffer from a major head bleed.”

Patient – “Well, doctor, what would you do?”

Discussions like this take place because of a principle called Informed Consent enshrined in Canadian law and our current ethical framework: Patients must be informed of the risks, benefits and alternatives of a proposed treatment before consenting to it. This principle was enshrined by a decision of nothing less than the Supreme Court of Canada.

This is easy enough when the choices are straightforward. Inevitably, as our treatments become more complex, the risk-benefit evaluations also become more complex. In the example above, the risk of stroke is somewhat high – 6% per year, rising to 12% per year if a person has already had one stroke. The risk of a bleed is less than a tenth of that. It’s not usually a difficult decision, although it occasionally becomes one after high profile cases like Mr Sharon’s.

Other situations are more difficult to explain to patients. Suppose you have a disease that kills half of those who are afflicted with it within 5 years. Surgery can cure the disease but the risk of dying from surgery is 20%. Do you go for the 50% chance of outliving your disease or the 20% risk of dying from the attempt at treatment? If you’re 40 years old, you may feel like taking the surgical risk, but what if you are 75 years old? What if the risk of dying during surgery is low, but there is a high risk of having a disabling stroke or kidney failure that requires dialysis?

When presented with scenarios like this, many patients ask the physician to effectively make a decision. Which begs the question of why we go through this process at all.

How can we expect people to make truly informed decision when the information presented is a matter of probabilities? And if it boils down to the physicians’ recommendation, why go through the anxiety-provoking litany of risks and alternatives?

But maybe that’s the whole point. As physicians, we are not here to spare patients the anxiety of their health care choices. We are here to allow them the anxiety of making uncertain decisions based on their values and their judgement. Just as your banker wouldn’t tell you what to do with your money without explaining the risks and benefits, neither should your physician tell you what to do with your health without an explanation of the same.

Mr Sharon’s condition serves to remind us, in the most dramatic way possible, that there are no guarantees in life.

[Update 1: It turns out your bankers don’t tell you the risks and benefits of what they are recommending you do with your money. This piece was written before the collapse of 2008. Maybe a little more informed consent in the financial markets would have been a good thing.]

[Update 2: Almost six years later, Ariel Sharon remains comatose but has been moved to his ranch starting in late 2010].

Apologies in advance for the death-related themes… In my line of work it’s difficult to avoid or minimize. Roughly one-fifth to one-quarter (20-25%) of all patients admitted to a tertiary care intensive care unit die.

One of the challenges of health care and I strive to convey this to my residents is to appreciate the uniqueness of every individual human being for whom we care. It is easy, in the hustle and bustle of a busy practice, to gloss over the humanity and focus on the technicality. A quick succession of patients means it is often easier to refer to the patients as bed or room numbers or as diagnoses rather than by their name. Bed 36 or room 212A can evoke more in a healthcare provider in terms of detail than Mrs Smith. I try to insist on names and to encourage others to do the same, but, again, in a busy practice, it is easier to do what it is easier.

I try to encourage myself and others to know at least one detail of a person’s life. I feel that this is important as a way of anchoring the patient in our minds, rather than seeing the patient as a case. The less a patient is able to communicate, the more this becomes important. The ICU – and modern hospital practice in general – is a place for procedures. It is a place where things get done – tubes, lines, devices, surgeries ..etc. The more a patient is unable to communicate, the more important this element becomes – ensuring that we remember that their is a unique individual human being with a personal unique life story. Otherwise, we can easily forget that we are doing these things – lines, tubes, procedures ..etc. for the patient rather than just to them.

Ensuring that you have a connection, however, small, with the person who is the patient does have its drawbacks. When the outcome of a hospital or ICU stay is death, having invested even a small part of you in the patient can make it so much more difficult to care for them at the end of life. Imagine having someone known to you (I won’t say “close to you”) die every week. Difficult.

Two incidents stand out in my mind that I think I will remember for some time to come. One occurred two years ago and the other just last week. The two could not be more different and in a way they exemplify this notion that every individual is unique. The first patient was an elderly woman – in her late 70s I think who had just relocated to London from elsewhere to be closer to her family. She had not yet made any friends and her family was out of town on vacation when she developed a sudden chest infection and had to be brought into hospital via ambulance. She was assessed in the emergency room and was too unstable to be admitted to a regular ward bed and so was transferred to the ICU. The illness progressed very quickly and it became apparent she  would not survive. We finally located the family and it was obvious they would not be able to make it back in time. The patient’s daughter could not bring herself to hear about her mom’s condition and I spoke mostly to the son-in-law. The patient’s daughter finally managed to wrest every last bit of courage in her being to come back on the phone. The only thing she could say was, “please don’t let her die alone.” I assured her we wouldn’t. I went back into her room and tried to do my best to talk to her about how much her family wanted to be there for and with her. I don’t know if she could hear. I felt some kind of conversation was important, but it was hard to sustain a monologue and so eventually I think I just held her hand and waited. I don’t remember it being long – I think she passed away over the course of 20 or 30 minutes.

The second story is about a much younger person – a woman in her 30s who died surrounded by family. It is still a little too fresh to write about, but it instigated these reflections. Whenever we go through these experiences in the ICU, and as I mentioned above, we go through them with some regularity, I am reminded of a line from a poem by the Scottish poet Edwin Morgan . I first learned this during my GCE O Levels (Thank you, Mr Dickson): “These were next to him when he fell/and must support him into death.”

We have the privilege of being next to people at the most important events of their lives – births, deaths, illnesses and cures. Some may fear the emotional investment that is necessary to provide that support. There is a certain fellowship that develops among the people who care in this way and that is also one of the privileges of practicing with caring professionals.

Death in Duke Street – Edwin Morgan

A huddle on the greasy street –
cars stop, nose past, withdraw –
dull glint on soles of tackety boots,
frayed rough blue trousers, nondescript coat
stretching back, head supported
in strangers’ arms, a crowd collecting –
‘whit’s wrang?’ ‘Can ye see’m?’
‘an auld fella, he’s had it.’
On one side, a young mother in a headscarf
is kneeling to comfort him, her three-year-old son
stands puzzled, touching her coat, her shopping bag
spills its packages that people look at
as they look at everything. On the other side
a youth, nervous, awkwardly now
at the centre of attention as he shifts his arm
on the old man’s shoulders, wondering
what to say to him, glancing up at the crowd.
These were next to him when he fell,
and must support him into death.
He seems not to be in pain,
he is speaking slowly and quietly
but he does not look at any of them,
his eyes are fixed on the sky,
already he is moving out
beyond everything belonging.
As if he still belonged
they hold him very tight.

Only the hungry ambulance
howls for him through the staring squares.