Memories of Family Practice IV - The Law

Physicians, like most people, do not fancy being called before a court of law. Unlike the average citizen, the chances of that happening are greater though. Because of one’s education and experience, a physician is considered an expert, no matter how average a practitioner he or she might be. He or she is there for libel to be called as a witness in a case, particularly if it involves one of his or her patients

I am happy to say that I was able to complete my Family Practice career without ever being called to testify in court. This is not to say that I did not have my "brushes with the law." On one occasion when we had in our emergency department a male patient who was evidently intoxicated and had been involved in a motor vehicle accident that caused some harm, we evidently overstepped our bounds by collecting a blood alcohol sample without his permission. He might not have been competent enough to give permission in any case, but that might not matter to the law. As a result, I had to drive a number of miles across country in the winter to the municipal hall nearest this gentleman’s residence, where there was a hearing, or maybe even a convening of a court, about the accident. I was fortunate in that nothing more happened to me because of this error other than "getting my knuckles wrapped."

On another occasion, I was not in trouble. A senior citizen, relatively newly admitted to our local personal care home, had been assaulted by visitors who were after his money. He did suffer significant brain injury, although I do not recall that it left any lasting sequel. I do remember that there were signs of serious brain injury including having blood from his ear, which often indicates trauma that has affected even the interior of the skull. In that case, I was called to testify and give my findings at a hearing, or, again, was it a court? that was held in the Gladstone Town Hall. I was glad to do this on the behalf of our care home resident.

I remember one other incident when I was already practising in Brandon. I had done some minor surgery, as I recall, to a lesion in a patient’s anterior abdominal wall. The wound became infected and he ended up in emergency and got more definitive treatment there at that time. This had apparently necessitated opening up the wound and doing some debridement and cleansing. He threatened to sue me but the attending physician in emergency wrote a report that suggested the gentleman had not done a good job of following up on aftercare either. The case went no further.

In this case, and in other cases where, as a physician, I suspected I could get into trouble, I was fortunate to have the strong support of the physician mutual insurance body, the Canadian medical protective association. If one reported a situation to them with concerns that there might be legal ramifications ,or they were already at play, they had physicians and lawyers experienced in these matters to look into it and come to our defence if we were deemed defensible. Even if not, they would come to our aid to mitigate the consequences as much as possible. We were fortunate to have this organization in Canada. I know that in the United States, where such bodies are private and for profit, their insurance premiums were sometimes 10 times what our hours were as Family Physicians, let alone what some higher risk specialties such as obstetrics and neurosurgery paid.

Another instance where physicians can come down on the wrong side of the law or medical standards is when it comes to prescribing drugs. There were two classes of drugs where I knew my prescribing habits were not exactly on par with many of my colleagues. The one area was in the treatment of pain. This is an area of controversy still and there was a lot of education about it even then. There was a large concern on the part of the public and even a number of physicians that prescribing narcotics or opiates would lead to addiction. There was also a concern that physicians might collude with patients and issue prescriptions where they were not warranted, or in excessive amounts. Being a rural area, there was sometimes concern that individuals coming from the city might try to take advantage of us in that way. Indeed, I remember one woman who stopped in, I believe on her way to Riding Mountain National Park, giving a story that she hoped would result in a prescription for an opiate. I am not sure exactly what happened but she did get a prescription and then was discovered possibly trying to turn it into a powder and inject it in the washroom. This came to light after she had left so I quickly alerted the pharmacist to cancel the prescription and I believe the police caught up with her later as well.

Chronic pain was always a dilemma. There is so often such an overlay of psychology and trauma history. One really had to make appropriate assessments and be judicious about the use of medication in these circumstances. I had paid more attention to this area of treatment than probably some of my colleagues had and learned that if there was a need for some medication along these lines, it was better to mete it out in a controlled manner. If one gave episodic prescriptions, the withdrawal from these drugs was what would lead to the desire for them and sometimes cycle into abuse and drug seeking behavior. In my time in Family Practice I really never encountered anyone who exhibited undue behaviour around getting prescriptions or renewals.

The other area where some of my colleagues again were not, in my opinion, as versed as I was, was the relatively new area of diagnosing and treating attention deficit hyperactivity disorder in adults. I had a very few adults in my practice who seemed to fit that profile, and again, I tried to be judicious and spread out my prescriptions but also keep them regular without significant dosage changes which could've been a problem.

In any case, one of my colleagues thought that this was all going to fae and reported me to the College of Physicians and Surgeons, our provincial licensing body. As a result, I lost my ability to prescribe these medication's for a six month period and was obliged to take a six week course of remedial training. I was fortunate in being able to turn this into a positive experience in more ways than one. In the first case, somewhat surprisingly, I obtained a College of Family Practice bursary to cover some of the expenses of not practicing for six-weeks, ergo no income. It also meant leaving home and going to Winnipeg to spend some time in different programs there to supposedly make me more informed about working in this area. I was fortunate in that I was able to stay with my younger brother during this time. Having a number of relatives and friends in Winnipeg also gave me an opportunity to spend time with him. Some of this re-education time was spent in the drug and alcohol foundation treatment centre, an independent facility on Portage Avenue. Some of it was spent with the department of psychiatry at Saint Boniface Hospital and their methadone treatment program.

The other way in which I made something positive out of it was that I took the opportunity to address a group of students on this subject. I had been a member of the Christian medical and dental Society of Canada since I was a student and was still keeping up connections with colleagues in this organization. It was thus that I was able to arrange a meeting with a group of students to talk about the issue of drug abuse and dependence.

In the end, it was kind of ironic, and some would call it poetic justice when the colleague who had reported me had to take a medical leave of absence on my return. I was left to follow some of his patients and discovered that he was, in my opinion, guilty of excessive prescriptions of tranquilizers, such as benzodiazepines, which was also always a danger.

Other than this experience, I do not think that in my family practice years, the College ever received any complaints about me and so I would thankfully consider that my record as a family physician was quite good overall.

Memories of Family Practice III - My First Patient(s)?

I was on my way to this content after the first paragraph of the previous episode, but mentioning the ambulance entrance next to our clinic, and some exchange with the person most connected with that service, lead me to the side track that you saw there.

Continuing on then where I was headed. You probably wonder why the question. I am going to comment about the first patient I remember seeing in that clinic in Gladstone. However, the question mark with the bracketed ’s' is present because I had seen dozens if not hundreds of patients already by that time.

As medical students, we were introduced to patients in the third year if not already the second. After my second year of medicine, with some quick training by a doctor, Michael Scott, who was in charge of outreach of The Northern Medical Unit in Winnipeg, I spent the summer learning the practice of outpatient medicine in my former hometown (ages 2-10) of Grand Rapids. This is a community some 300 miles north of Winnipeg. I worked with nurse Betty Calyn, nee Hildebrand, from the town of Morden, only 7 miles from where I was born, and also of Mennonite background like myself. This was all under the eye of Dr. Steenson from Ashern, who would come up mostly on a weekly basis.

In addition to the usual situations that present themselves in outpatient clinics, having been given a crash course in suturing, there was some of that minor surgery to be done. We had also been taught the correct way of removing fishhooks, as this is a community where people from outside come to fish with rod and reel - around the village or at a lodge(s) nearby. The locals do net fishing on Lake Winnipeg and had formed their own fish co-op already. Besides helping patients from the mixed – blood and Caucasian community on the west side of the Saskatchewan River, we also served the indigenous community on the east side of the river, in what is now known as the Misipawistik Reserve. Once a week, we also traveled to Easterville/Chemawawin Reserve for a clinic there. This was sad community about 30 miles south of Winnipeg, built more or less on the limestone rocks of the ridge that traverses Manitoba from Long Point to t e east on Lake Winnipeg, westwards towards Saskatchewan. They were the members of the Cedar Lake band that had been displaced from their lovely community on the shores of Cedar Lake when Manitoba Hydro decided to use the Saskatchewan River to build a hydroelectric dam at Grand Rapids and flooded out this upstream community. Needless to say, that whole story has not yet been resolved.

Besides seeing local patients with complaints referable to every body system, be they acute or part of a chronic condition, we also did immunizations, prenatal and postnatal care. We never did have to deliver a baby. Either there were a local midwives that took care of that or they had gone out to a hospital, perhaps in The Pas or Ashern or elsewhere.

After my third year of medicine, under the auspices of the same program, I spent the summer at another nursing station under Dr. Scott's supervision, at South Indian Lake Manitoba. There was a similarity here to what was happening in the environment to what had happened at Easterville/Grand Rapids. Again, Manitoba Hydro was undergoing a major effort in diverting the Churchill River to provide more water flow for more hydroelectric dam development downstream, towards Hudson Bay. The result of this was that a year or so after I left this community, a good deal of it was also flooded out. It had been a scattered community on both sides of the river/lake, but if my memory serves me correctly, all were removed to the east side.

This community was more remote than Grand Rapids, which had highway connections to the rest of the province. South Indian Lake then was only served by regular Calm Air service to Thompson on the way south and Leaf Rapids and Lynn Lake on the way west. Thus, when we had patients that needed services beyond what we could provide locally, we either sent them out on these planes in whichever direction was most convenient, or dictated by the gravity of the illness. Thompson was a bigger center, already on the way to Winnipeg, so more severe conditions were always sent that way. Sometimes, the situation was acute enough that a charter plane was used to make an evacuation.

One aspect of medical evacuations was that they needed to be accompanied by someone with some healthcare or medical training. This was where I, as a medical student, often came in. I don't recall trips to Thompson as much as to Liynn Lake. One I remember there was a young indigenous woman who needed medical attention subsequent to a miscarriage. The physician who took care of there there was the same one who turned out to be a community colleague when I started in Gladstone, Dr. Ruth Cottrill. Once Dr. Cottrill had taken care of the patient, we still had an evening and morning before the return flight to South Indian Lake. All our expenses were paid, so the patient and I went out for dinner together, watched some TV in my room together, no doubt had breakfast the next morning together, and then flew back to South Indian Lake. I did this as a human being with another human out of their environment, although some might chastise me for crossing boundaries. I met this woman again at a residential alcohol treatment centre in Winnipeg was when I was taking a brief alcohol and drug addictions residency. That prompted me to write a song, “Marita", about her. If you are curious, you can find it under my name on Soundcloud. It might even be on my Youtube channel.

This hydroelectric intrusion into the South Indian Lake community came some 15 years later than it had come to Cedar Lake and Grand Rapids. At that time, I was not even a teenager, whereas here I was a young adult. Between that and my position, I became much more aware of local feelings about the whole situation. One young girl returned from British Columbia to see her hometown before it all changed. Her sadness reflected that of an elder in the community, Annie Moose, whose words led me to write a poem called Little Birches (on my Facebook page). She was wondering what would happen to the new growth along the lakeshore. The young woman’s reflections led me to write another song, which is also on my Soundcloud and Youtube accounts, "Anna's Song." With the capabilities of the Internet, and the help of Facebook connections in South Indian Lake, within the last decade I had made contact with Anna again, this time living on Vancouver Island.

There was a large camp of Hydro workers in the community already at this time. They had their own kitchen and cooking staff and for a price, local inhabitants could eat there as well. The downside of that was when it appeared that the cook did not perform the best hygiene and introduced Shigella into the community. That led to an outbreak which, to my recollection, no one died from. However, there were some severe cases of this gastroenteritis. I got the nickname of "shit collector" because one of my tasks was to go around the community collecting stool samples for a control and a public health project we then undertook. Needless to say, I was not always a welcome visitor. Who would be if that's what you came for, but also because my being seen visiting you might identify you as a carrier which might not be pleasant in the community.

Just the same, I enjoyed my experience here enough that when the call went out for someone to go back to this community for the Christmas and New Year break, I went. Part of the reason for this was the nurse was going on a holiday, which ended up with me having to look for a nurse to work under, as that was the stipulation in those circumstances. A friend at the time, Rosalie Loeppke, obliged me and we had a good time. It was quiet in the community as the Hydro workers had all left for the season. One of the major difficulties we had to contend with was keeping things from freezing, as we did have running water and sewer. We used snowmobile for getting around and sometimes that was difficult to start but we had a good maintenance man, Lamont Linklater.

There were two medical experiences that stand out in my mind from this short stay. One was a woman coming in labour when we were unable to arrange an evacuation. All went well though, and a healthy little boy came into the world. The other was when a woman somehow got an ugly slash down her leg from a snowmobile on which she was a passenger. We cleaned it up and I tried to suture it but realized it was more than could be handled by simply closing the gap. We covered our efforts with sterile dressing and arrange for an evacuation.

The other non-medical experience that I remember was the one time in my life, so far, although there is little chance of that happening really where I live now, of falling through the ice. Rosalie and I were out for a nice evening walk on the lake when we chanced too close to some reef rocks where the current was greater and down I went. I managed to step my way out and made a quick run for the nursing station to change into dry clothes! 

We enjoyed socializing with some of the locals and the next door Hudson Bay Company staff over Christmas (the manager’s wife was a former schoolmate from Grand Rapids) and I also enjoyed being able to attend the community New Year's dance, where we were entertained via a decent rock band from Nelson House. I even got to dance with our attractive nursing station administration assistant. It was the beginning of 1975 when we left the community.

In both these summer circumstances, I enjoyed my time being back up north, where I had been raised till the age of 16. They were like homecomings. Family even came to visit me in Grand Rapids and in South Indian Lake my youngest brother spent some time with me.

Then, there was one more extended situation where I saw a patient before I was actually in my own practice seeing patients, which we will come to yet. This third situation was where, as a second year Family Practice Resident, with a license to practice, I was part of the St. Boniface Family Practice Unit Outreach Program to Northern communities. This led me to take small planes this time, to fly into Bloodvein River and Little Grand Rapids, which included extension trips into Paungassi. These communities were known to me, even though I had never been in them before, as the same mission that my parents were working under when we spent five years in the community of Loon Straits on Lake Winnipeg, had mission stations, as they were then called, at both Bloodvein and Paungassi, so I knew these “missionaries”. This work also at times included Little Grand Rapids and there were resident workers there at times too. My own parents spent a summer there in the mid ‘70s.

This situation again basically allowed for seeing outpatients on consultation with the nurses who ran the nursing station. Sometimes this also then included decision about evacuations. Again, immunizations would've been part of the program as well as prenatal care and post surgical care. All these situations, including continuing care of individuals with hypertension, diabetes, arthritis, respiratory and bowel conditions would have been part of the every day experience. Even though in the first two instances, I was a student, under the circumstances, and the supervision of the nurse and then doctor, we dispensed basic medication such as lower level antibiotics, anti-hypertensive, diabetic medication and medication for arthritis. Now, with three more years of medical education, I could make better assessments and make more advanced decisions about intervention.

Not having kept a log of these experiences, I must say I really cannot recall individual patient experiences from most of my time in these communities. Again, I enjoyed all of this, as it gave me a chance to interact with people of the north, particularly indigenous people, such as I had grown up with. There were also opportunities to do fishing, canoeing and boating; there was time for some pleasure.

So, that first real patient of mine in practice - even here I might have to declare a caveat. I was not in private practice, so patients really ‘belonged’ to the health centre.

I ushered a woman whom I judged to be in or nearing middle-age into the examining room. I offered her the chair for patients and she sat down - or should I say tried to. Without wanting to be disrespectful, the truth was her girth prevented her from sitting down comfortably between the rms of the chair, let along then easily extricate herself. We did get acquainted and I got her blood pressure checked, which is what she had come for. I don’t recall whether she had been a previous patient of the clinic or whether she was just coming to check out the new doctor. She had driven a few miles, as she was from one of the ‘seven regions’, namely the neighbouring village of Plumas. I do remember that I did not see her again. I guess she went back to whomever she had been ‘doctoring with’ before.

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Memories of Family Practice II - The Clinic and Ambulance Emergencies

Memories of family practice II - The Clinic and 

Ambulance Emergencies

The Clinic

It was my first day in what I have indicated I am calling family practice. I had access to two examining rooms at the north end of the main floor of the health center on the east side. This mostly faced an open field with a grove of trees beyond. The centre portion of the building being the inpatient units and the far end being the emergency/minor surgery room. Across the hall was the administration office of the practice where all the records were kept and a receptionist and stenographer sat. At the end of the hall was a staircase to the outside and the basement. Below us was the laboratory and x-ray facility and below the hospital was essentially the dining room room, kitchen and laundry facilities. When I began my time here, because the elevator was also at this end, this end of the building served as the ambulance entrance as the entrance to the basement was ground level. The main entrance at the emergency room/inpatient area at the other end of the building was up a flight of steps.

Ambulance Emergencies

Indeed, our centre was fortunate to have an ambulance and even more so to have a dedicated and trained team of volunteers to use it. Much of the credit for this efficient program went to the centre’s Educator, Joy Pritchett Sheridan. She began the year I arrived to teach the volunteers First Aid, CPR and then what was then called First Responders, later Emergency Medical Responders. Besides making forays into the countryside in response to emergency calls, the ambulance was frequently used to take medical, obstetric and surgical emergency transfers to Portage la Prairie where there was a General Surgeon, or all the way to Winnipeg.

There were times, because of the nature of the call, that a physician was required to monitor and help the patient and team on these trips. One that I remember well was on the day the ash cloud from Mt. St. Helen’s descended on the prairies. Visibility was poor and it was hot. We had a pediatric emergency to deal with, epiglottis. This can result in sudden closure of the airway, in which case a breathing tube would have needed to be inserted. We made it though. Of my memory serves me correctly, the child was actually Joy’s little son. Another time was when our office receptionist was in labour. Progress was not optimal and then it became more of a risk situation when stool or meconium was detected in the birth canal, indicating feel stress. We might have had to deliver and suction en route but we made it to the Women’s centre In Winnipeg on time.

Of course, all these transfers and to be made as rapidly as possible. Just as important was the communication groundwork necessary with the team to whom we wished to bring the patient so they were ready for us. With obstetrics for example, if it looked like a Caesarean Section was necessary, the time it took us to get to Portage was pretty much the time it took them to get a team and the Operating Room ready, so that worked well. Generally, the receiving end was co-operative, but sometimes one had to use some pressure. It was occasionally somewhat annoying when I, a graduate certified Family Physician, had to try to persuade a trainee resident on the phone at the other end that the trip was necessary. Sometimes one had the sense that they, in the big city centre, thought they knew best, even when these folks often had less experience and were still in training!

Overall, our ambulance team did a great job. Rarely, we would get a call from the other end saying that the patient had not made it, which was not necessarily the fault of the drew. Sometimes we just could not stabilize a patient well enough before having to send them off if there was any chance for them. One really troubling such incident was when a young man had smashed his motorcycle into an obstruction at high speed in the wee hours of the morning. Initially, we did some assessment including some X-rays showing obvious fractures, but it was evident more help was needed. The young man was intoxicated and restlessly uncooperative too. It was disturbing then too receive a call from a Brandon orthopedist this time to say the young man had not made it. His behaviour had been a sign of blood loss and decreasing oxygen.  There had been too much internal blood loss.

At that time, emergency trauma training was only beginning and I often was aware of my lack of adequate training in this area. We never had blood to transfuse and even putting in so-called big bore ‘lines’, intravenouses, to pour in fluids, was not something I was trained to do or felt comfortable with.

Farming accidents were the cause of other emergencies. Rural medicine practitioners were well aware of some of the dangers and the pressures farmers were under, particularly during seeding but especially harvest times.  Climate and weather often made for small windows of opportunity to get these things done and farmers tended to take dangerous shortcuts at times. On one occasion, an older farmer came in with the ambulance. Heavy grain had been clogging his machine and in an effort to get the combine pickup working ha had gotten too close to the pickup without turning it off. It had pulled half his body in before a co-worker stopped it. The pickup prong marks were patterned across his abdomen, a sure sign of pending infection.  We dispatched him to Winnipeg as quickly as we could but we sensed his fate was already sealed.

One particularly obnoxious bit of machinery was the Power Take Off (PTO) at the back of farm tractors. This was a device that rotated at high speed from the tractor transmission to engage implements being pulled, such as hay balers and combines, that required the propelled motion the PTO would provide. There was provision to cover them from the top and sides but this was sometimes deemed to be in the way and removed and again, there was often that hurry. I think it was on my first ‘on call’ after starting ‘work’ in Gladstone, a sunny summer evening still, when a farmer rushed in with his young son’s leg all wrapped up. Power Take-Offs function like an augur or screw sometimes and his lower leg had been pretty much stripped to the bone. All we could do was clean it and rewrap it more sterilely before sending him onwards. His leg was never the same, but it was saved.

I remember one sad incident where the ambulance team had responded to a motor vehicle accident. One victim that arrived at our facility was an infant that had been in the arms of its mother in the front seat. Not long after that changes led to all of that being unacceptable - infant car seats appeared, and if you wanted to seat-belt strap it into the front, it had to face backward. Needless to say, the infant’s skull was crushed - I will never forget the sensation of handing that head; it was a tragic case of DOA.

 

On the return trips where I had gone along, we were often tired but happy with the success of our trip. It was always great to stop for breakfast - why are emergencies always at night? - and the pancake breakfast at the Husky on the Trans-Canada/Number 1 Highway near Headingley hit the spot. Sometimes the crew would let me sleep on the stretcher in back as, like as not, a full clinic day was waiting on arrival back at “Seven Regions”. It did feel a bit weird to sleep on an emergency stretcher in an ambulance though.