There are the Victims of Bullies....and there are the Nightmares of Bullies......

Well, I lamented earlier on Bullying, which was heartfelt because my eldest daughter spent a big portion of this past year being victimized by it. Things have gotten a lot better with my daughter's self esteem finally being nurtured by her Mother and I to a robust and decreasingly delicate pillar in her life......

.....And then I have my littlest daughter....my delicate little flower.......who MAY or MAY not have been involved as the victim of a bad bullying incident during recess recently (in case the Principal is reading this).

Allegedly, a much larger boy than her wanted her recess snack - so he grabbed her leg and wrenched it up painfully, causing her to allegedly fall violently and painfully onto her back on the pavement of the playground.

She had the breath knocked out of her and laid there in shock for a second before getting up to challenge the offender. When she reached for her snack, he pushed her back again.

Then, she may or may not have wound up and socked him hard in the mouth - possibly splitting his lip (or it could have happened when he walked into a door) and shocking him into running away, crying out of shock and embarrassment.

My "delicate little flower" then noticed that she might or might not have split her knuckle open on what could have been his teeth - or possibly a "graze from the swing set on the playground"....and she marched into the school and inquired as to where she could obtain a rabies shot.

I only discovered the above that might or might not have happened upon my inquiries that I made of her when I came home from work and noticed her carefully washing her knuckles in the sink and then applying antibiotic ointment (she is quite familiar with wound care after having been patched up no few times from various accidents on mountain hikes, etc.)

So I suppose that there are some people that can be the natural victims of bullies....and there are those that can be the natural nightmares of bullies.......

I'm still laughing.....

Bullying in Teenage Girls is aweful

I have had patients in my office over the years - teenaged girls and their parents - complaining of their horrific experiences with bullying by other teenaged girls. The problem appears to be getting worse over the years. I suspect that the worsening of bullying in teenaged girls might be a result of the fact of several things:

1) The ubiquity of access to texting, facebook and twitter.

2) No direct consequences for bullying through texting, facebook or twitter.

3) An increased divorce rate, resulting in single parent families that leave teenaged girls relatively unsupervised.

4) The decline of the "stay at home Mom (or Dad)", with both parents' attention engaged at work and not in their daughters.

5) The fact that girls are physically, but not mentally, maturing younger and looking much older than they are between their ears. This is a virtual recipe for poor self esteem.

6) The decline of the community: people no longer know their neighbours. Community support with "friends" in the community is increasingly a thing of the past. People are, now more than ever, living like islands unto themselves. Group support and self policing of kids.

7) Teachers that have been increasingly marginalized by a growing culture of entitlement that does not let teachers discipline kids when it is necessary.

8) A second generation of people that have no idea about how to impart a culture of discipline, honour and respect to their kids - because their parents never taught them these lessons either.

9) An increasingly common belief by uninformed parents that their teenagers are entitled to privacy in their lives and correspondences via twitter, facebook and texting.

10) Parents find it difficult to view their teenage daughters objectively.

It is easy for these teenage girl bullies to do their damage through texting, facebook and twitter.

Bullying from afar through a digital medium is easy, because consequences are rare.

When I grew up, if you said something rude to a person - or within earshot of a person - you risked being rightfully punched in the nose. This doesn't happen any more. There are no consequences for an evil Facebook post, twitter post or text. Broken noses are getting more rare as bullying is getting more common!

It is now safer than ever to be a bully. Consequences are rare, and you can do it safely at home from the couch.

An unbelievable number of teenaged girls are living with one parent after their parents divorce. Inevitably, one or more of these parents ends up in a new relationship - and tends to focus on that relationship rather than their teenager, in the false belief (or hope) that "the kids are older now, and don't need my attention so much any more".

Even when their parents are "still married", an amazing number of teenaged girls are completely unsupervised. Their parents are both working in demanding jobs, and one of them may have returned to work after years of being home for the kids. The parents believe - erroneously - that their teenaged girls no longer need so much time and attention.

Nothing could be further from the truth. Teenaged girls are more insecure than ever in history. Their parents may not know that their teenaged girl is a bully.....or being bullied.

The fact is that - the cause of being a bully is insecurity. And the cause of being bullied is insecurity.

So where does this insecurity come from?

In short - insecurity comes from everywhere. It is inevitable - and each girl will respond to it differently. Their only hope is their parents and guardians (because friends at this age tend to come and go) - who they NEED to provide guidance. When girls don't have parents or guardians that can defend them from insecurity.....these girls need more resources. A friend, a friend's parent(s), a teacher, a counsellor, a clergy person, etc.

If your teenaged girls are getting bullied, try these books & sources:

How to Win Friends and Influence People for Teenage Girls by Donna Carnegie

Odd girl out: The hidden culture of aggression in girls by Rachel Simmons

A post on Bullying in Girls

A review on Bullying in Teenaged Girls

An E-Book Titles "Why Me" on Bullying in Teenaged Girls.

Alberta Health Care at an all time low

Well, I take care of my fair share of Health Care workers - ranging from cleaners to executives....and they all report the same thing. They are all highly demoralized. They perceive no leadership, vision, responsibility, support or competence from their leaders.

There appears to be no hope that things are getting better - at all. The state of Health Care appears to continue to decline, despite various occasional puff pieces handed to the popular media by one politician, adminsitrator or another. These politicians are not bad people - I actually admire them. Who on Earth would paint such tempting targets on their backs for paltry sums of money and the collective derision of society? They HAVE to be doing this because they believe that they are good people that are trying to do a good thing.

They just aren't doing a good thing.....

At the very least, these people are brave souls that are being tasked with a delicate operation with no training, tools or support. Albertans generally seem to want Health Care - but they don't want to pay for it (ie. they don't want to pay 50% taxes). Health Care is a bottomless pit of costs that will never end. The culture of "free health care" is admirable - but wrought with a risk of development of a sense of collective entitlement.

Ever been to Detroit? How about Greece this past summer? This is what a culture of entitlement gets you. Our politicians - at the very least - should be brave enough to acknowledge this and to make policies that provide care while fighting a culture of entitlement. It can be done - just ask the folks at the Mayo clinic in Rochester. This is a non-profit medical wonder that still makes billions in revenue every year. I'm proud to have met and worked with these Mayo folks. They really do "get it".

We can fix Health Care in Alberta by looking at successes like the Mayo model and building upon them.

This past week, I sent a patient of mine to the hospital with horrible abdominal pain. The initial hospital that I sent him to via EMR, said "no more people!". So he was diverted to another Hospital. He then spent more than a day in the E.R. waiting for a bed in a hallway. He made it into an E.R. bed after more than a day....then he made it on day 3 into a hospital bed in a shared room after a 24 hour hallway wait. During all this time, he was unable to eat due to his pancreatitis. He had to pee in a bottle under a sheet in the hallway whenever he sensed that nobody was really looking.....then he made it to his room once his spot was made available.

He stayed in that room for 5 days until they could take out his gallbladder. He did fine in surgery and his surgeons and nurses were excellent. But his room was filthy. His bathroom was filthy. The tap in the bathroom ran full time from a severe leak. Nursing staff stated that the leak probably leaked over 100 gallons per day and that this had been happening for at least the past 6 months....along with over a dozen other taps in the same hospital ward. This was just the tip of the iceberg on a list of maintenance items that were very necessary in this very busy hospital.

This lack of upkeep has drastically affected staff morale as well as patient well being - and I hate to think of how many hospital infections are caused by the increasingly filthy and improperly cleaned and maintained hospital wards.

Mr. S. went home early with the promise that he would follow up with me asap. I visited him several times in the hospital....and no, I don't think that my payment from Alberta Health for the hospital visits, will even cover the costs I paid for my parking.

So what do we do?

This is, in my opinion, the cure to the Health Care System in Alberta:

1) Attach all health care funding to individual patients and make hospitals and clinic compete for this funding.

2) Allow patients to top up this funding to be able to attend private medical services and clinics if they choose to.

3) Make sure that public hospitals and clinics meet and even exceed the capabilities and service options of the private clinics.....by funding these public hospitals and clinics appropriately.

4) Legislate long term health care plans for the people of the province - and keep this long term plan protected from political meddling. Keep this long term plan administered mostly by Physicians and Nurses. And a few "smart" members of the public.

5) Put the Physicians and Nurses back in charge. Of EVERYTHING IN HEALTH CARE. They are all amazing efficiency experts as part of their work and training, and they know VASTLY more about health care delivery than any politician or administrator. Put a few smart citizens on these boards to work with them.

Hope that helps.

Rural Roots:

Rural Roots:

Nice composition. Bleakness with lack of contrast and cool dryness of the prairie - with the little, insignificant splash of colour on the flowers remind us of the inevitability and cold finality of often unpredictable death - and our futile attempts to defeat it through beautification.

The status of Health Care in Canada - Obama take note

Today, I was too busy to see a patient who came to the office in desperation and pain.

That was because I was seeing other patients in more desperation with more pain. In fact, I was doing a little operation on a 17 year old blind boy who had been hobbling around with a piece of glass embedded in his right foot for the past 2 years.

He had seen at least 4 Physicians for his probem and had undergone at least two exploratory procedures. His Physicians had no luck sending him to a plastic surgeon because of an over 2 year wait in Calgary to be assessed - and the difficulty in accessing a Specialist that "does feet".

So - the poor fellow hobbled in pain through most of his highschool years. He was sent to me by his Physician after his Physician learned that I do "things like this" (I don't really - but I suppose that I do now because it seems that I get a lot of referrals like this).

I had just removed a large tennis-ball sized benign vascular tumor from the left buttock of another fellow who had been unable to sit for the past two years. His tumor had recently become necrotic and intensely painful, and he had been advised by the E.R. that they would arrange for him to be seen by a surgeon - the arrangement never happened....twice.

The poor lady in the waiting room went home.....scared at having lost 20lb in the past 3 months and at the intense pain with any bowel movement or passing of gas.....and even more scared that she could feel a mass protruding through her rectal area.

My next two weeks were booked solid with increasingly desperate people. Some of them were returning to ask why their colonoscopy screening tests were taking over 18 months to get booked.....others wanted to know why they had to wait 12-18 months to see a neurosurgeon for their incredible back pain that required surgery.

After a dizzying day of little, but significant surgical procedures; I recalled that I forgot to eat again.....it had been 20 hours since my last meal. When I woke up this morning, I got up from the bed to walk to the bathroom - and distantly heard a loud thump that scared my wife to death and had the kids running into the room......I stared up at them in confusion - not remembering losing consciousness.

I seemed fine (except for a sore left wrist), but for the first time in my life - felt the cumulative effects of rountinely 3 hours a night of sleep, chronic dehydration, stress and probably malnutrition ganging up on me.

The strain of a College Complaint from a patient being charged for surgical supplies that I had to pay for, but Alberta Health wouldn't pay for - and to which the patient felt entitled, combined with the mounds of paperwork for everything from Blue Cross drug authorizations to Handicap parking forms and demanding letters from various insurance companies, employers and various patients that wanted notes for "time off from work".......had finally started to affect me in a way that I have never felt before.

I thought that I was handling this all pretty well; with a generally good mood and an increasingly strained cheerful outlook......however, I'd never fainted before.

The rest of the day had me quite thoughtful about my predicament. I need to see my 40 patients per day - they are desperate to get in for their appointments with my current 3 week wait....but I am also handling about 10-12 emergencies per day that keep me at the office at least 2-3 more hours than I am scheduled for....this adds at least another 2 hours of paperwork to my day and keeps me up later and later at night.

And I am working harder than I ever have in my life while making less than I ever have. Alberta Health, for example, has refused to pay for various surgical procedures that I have done since last May. They grudgingly agreed to pay about 30% of my actual costs of doing the procedure (never mind my income) - and didn't care a rat's ass that I was going to be personally in the hole about it. They simply disagreed that the procedures had been performed. The surgical pathology reports, the patient testimony and my surgical notes complete with digital photos did not appear to matter to them in the least. They simply refused to pay. It's not a battle that I will win with them - and is reminiscent of the deservedly and ubiquitously despised HMO's in the USA.

One of the best, brightest and smartest Physicians I have ever known told me last week that he has had enough of the same sort of strain. The constant pressure to attend to impossible demands from an ever increasingly desperate patient population and decreasing payments from the Government, were just too much to handle for him any longer. He's pulling the plug on his 5000 patients. This is, in part, because Alberta Health fixes our rates to something below our operational costs - and they state that they will charge us as criminals if we charge any rates in addition to what they are willing to pay - even if we just want to make our costs and earn nothing. It is an untenable situation that our increasingly disconnected Government is unwilling to address.

So, for this reason; out of about 36 Docs that have worked in my Medical building about three years ago - there will be only about 4 left starting this July.

Many of them have left to go to private medicine or the USA - shunning Alberta Health....and they're all ecstatic with their decisions. But I am not prepared to abandon my patient population yet.......yet......

And so, after a day of doing these surgical procedures....I got home and listened in awe as my wife skillfully helped my eldest teenaged daughter successfully manage an episode of serious "Facebook bullying" by another grade 8 girl. I may have done some pretty neato surgeries today (the blind boy is walking fine now....I found the damned glass) - but what my wife did today to help our daughter REALLY blew me away. After 20 years, she is still teaching me a hell of a lot. I am soooo lucky to be married to this hottie!

And so, as I FINALLY sat down at the table to FINALLY eat something....my thoughts drifted to that poor elderly lady that I was too busy to see today. I put down my fork, looked up her number in my compter (at the table) and called her. And listened. And sympathized. And became embarrassed at how dreadfully our Health Care System has failed her.

So I watched my meal get cold as I called the Gastroenterologist on call at the hospital.

He listened for a few minutes in sympathy. I had referred this lady "urgently" about 4 months ago, but my referral - like every other referral I have made to G.I. in the past year - went essentially ignored, even after I called twice.

He then told me that he could not really see her soon, as that he was busy scrambling with more urgent cases and that she really had no hope to be seen as an outpatient. He told me that I should just send her to the E.R. as "an emergency" and to tell her to expect to wait at least 15-25 hours to be seen.

I have taken this approach before - and they often just tell these patients to see their Family Physicians because the issue "is not really an emergency" (very true). So I opened my laptop again and wrote an "urgent consult note" to the E.R. Doc and then called the E.R. triage nurse to inform her that the patient was going to arrive soon in the E.R. and that I wanted a call from the E.R. Doc to explain the situation.

As my meal went from cold to arctic - I called the patient back at home to advise her to go to the E.R. She told me that she could not afford a taxi, couldn't drive and didn't know if the bus was operating this time of night. She lived only a few blocks away from my house and I briefly entertained thoughts of driving her to the hospital.....but by this point, I didn't know if I could make it upstairs safely to bed - never mind driving anybody to the hospital. We talked some more, and she agreed to phone a friend for a ride.

Pushed my plate away.....It's time to get some sleep. I hope that she gets to the hospital and gets seen......

Hope the pager doesn't wake me up.....last night I got a call from the ICU about another patient (85 years old) of mine that was frustrated with his cough - so he took a whole bottle of tylenol and ativan in the hope of dying. ICU wanted him sent to Psych after "forming" the patient (taking his rights away). He is very clear about his intention to go home and kill himself. He isn't crazy - he just doesn't want to live anymore with his COPD and mild cognitive impairment.

So - do I let him go home to kill himself, or do I continue to take away his human rights at a cost of $3000 per day to the tax payer because "I know what's better for him".

They didn't teach the wrangling of this stuff in Med School.........

Thank God for my family!

It's the long weekend.........time to recharge (it's going to snow).....

Ok - I'm up to date: the H1N1 flu shot is worth it!

A little more research (between my daughter’s volleyball tournament games) has revealed some reassuring referenced statements about Thimerosal.

The official CDC statement is here:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a4.htm

And the official Canadian Statement is here:
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07pdf/acs33-06.pdf

WHO’s official statement on Squalene is here:
http://www.who.int/vaccine_safety/topics/adjuvants/squalene/Jun_2006/en/index.html

A REALLY good and well referenced review of Squalene appears to be this one:
http://www.mdpi.com/1420-3049/14/9/3286/pdf


Bottom line is that it was a good exercise to go through: being asked by a patient to do a mini-lit review on this subject – with additional online discussion through a Physician's newsgroup list. Accepting the popular opinion just isn’t enough....going through the exercise of finding/evaluating/reading well referenced material has been invaluable.

The components of the H1N1 vaccine that are causing concern are the Thimerosal (Mercury) and the Squalene (the stuff blamed on "Gulf War Syndrome". The articles detailed above are very well written, researched and referenced. The bottom line is that - while it is probably preferable to not have these things in the vaccine, having them present in the H1N1 vaccine is not sufficient to exclude the vaccine from your "to do" list.

This is really a question about "RELATIVE RISK". After everything is said - your risk of morbidity or death is higher WITHOUT the H1N1 vaccine than it is WITH it!

I am now a lot more confident in recommending the H1N1 flu shot. At least now, I’ll be able to have a lot more familiarity with the increasing onslaught of questions I’ve been getting about the safety of these components of this vaccine.

This has been a great exercise!

JF

Ps. The Tom Baines Boas got Silver!

The safety of the H1N1 Swine Flu Vaccine - We can always trust the Government, right?

Patients have been emailing me about the safety of the H1N1 vaccine. The concern is that it is the first vaccine made for the civilian population to contain an adjuvant called "Squaline".

There is not a lot of information on the effect of Squaline on OVID - but the "independent" research appears to be quite chilling.

As a result - I am not comfortable recommending the H1N1 vaccine until this issue is more fully answered.

Does anybody out there have any additional wisdom to add? Read on:

Because there is no listing on the safety or efficacy of squaline on OVID, I have conducted an online literature review on the subject - which is surprisingly interesting. The bottom line is that the Swine Flu vaccine is the first to have Squaline included as an ingredient. Only three other vaccines for civilian use have been developed that contain this molecule - and two of them did not earn FDA approval in the U.S.

If you need to get immunized against the Swine Flu, it is possible that a better alternative will be the vaccination with the AstraZeneca nasal vaccine "MedImmune" - which more closely mimics a natural "real life" inoculation that does not use squaline.

Bottom line is that this is, I believe, the first time a vaccine has been allowed to escape proper FDA approval processes. It is interesting to note that "official published studies in prestigious medical journals have revealed that Squaline is safe in humans". The "studies", however, were published by the "makers" of the vaccine - a new conglomerate of Novartis and Chiron. This is in DIRECT contrast to "profound and lasting autoimmune effects" of Squaline found by independent researchers.

Experience has revealed in abundance that Drug Companies do not necessarily provide unbiased data to the public and to Doctors (remember Viox, Baycol, Naprosyn, Tequin, etc., etc.).

That being the case - I don't believe that I can recommend the H1N1 vaccine to anybody until a repository of reliable information has become available. The Cochrane review people are great resource that does exactly that - and they haven't entirely caught up to the safety of H1N1 vaccine yet. Their official statement about H1N1 flu vaccination is in the following:

Some public-health officials have described flu vaccines as “highly effective,” but the internationally recognized Cochrane Collaboration (which accepts no money from the pharmaceutical industry) did a systematic review of all high-quality randomized trials (25 in all) studying influenza vaccination. They concluded that “the evidence does not support universal immunization of healthy adults.” Period.

An interesting and reasonably referenced article without special interest ties is listed here:

http://www.foodconsumer.org/newsite/Opinion/Comments/180720090846_squalene_the_swine_flu_vaccine_s_dirty_little_secre.html

and here:

http://www.newsmax.com/health/vaccine_swine_flu/2009/07/07/232717.html

Hope this helps somebody.....

I'm between a rock and a hard place. If I recommend the H1N1 vaccine - I could be sentencing patients to significant morbidity as a result of potential dangers from Squaline. If I don't recommend the vaccine, I could be sentencing people to morbidity or mortality from H1N1 infection. This is a tough position to be in - and the old Hippocratic oath of "Doing no Harm" is a seemingly impossible challenge in the absence of good and reliable information.

Do I believe, so called, "Officials"? I know that my Professional knowledge of the issues with this vaccine vastly surpasses that of most "Officials". Also - as a Professional, I've learned to trust my caution when it comes to advice from "Officials". I still remember Tequin, Vioxx and Baycol being bandied about in my office by a small army of Drug Reps that assured me (with less than half of my education and knowledge on the subjects) that all of these drugs were effective, safe and "properly studied".

None of that turned out to be the case.....but then if we had applied the same amount of rigorous concern to ASA - it never would have won FDA approval! The wisdom of the ages has taught us how to handle and recommend the use of ASA. It certainly has its risks and benefits.....but the information gleaned from dozens of years of experience with the H1N1 vaccine is simply not available to us.

So - we are left with inadequate and suspect data.....and patients literally entrust their lives and well beings to my advice!

So - for now, I'm saying "no" to H1N1 vaccinations until I can get better and better referenced, unbiased and properly questioned information.

ps: another good synopsis is at: http://www.digitaljournal.com/article/280927

Bottom line: Wait for unadjuvinated H1N1 vaccine that is devoid of Thioresal (Mercury).