Tuesday November 10, 2009




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The tribal elder's slippers

[Oct 20 2008]

by Hal Newman


David Newman should be writing this follow-up to his column titled 'Vignettes' of July 10, 2008. Sadly, his computer keyboard is dormant and his tribal elder's slippers are tucked neatly beneath his bed.


David is in the hospital battling cancer and all of the systemic failures derived from the insidious disease that has crawled out of his colon to pollute the rest of his body. His wife, my stepmom Anne, has been his constant bedside companion throughout the ordeal.


He had significant discomfort in his gut and was getting dehydrated when he took the step over the stoic threshold and into the ER of the hospital that dominates the neighbourhood skyline in his adopted hometown of Hamilton, Ontario. Too many hours spent in painful agony in a gurney led to admission to a ward on a floor.


It was all the tubes that took my breath away when I visited David in his room. My sister and I had roadtripped seven hours to get there and just when you think you're really prepared for anything, there's our father with tubes running this way and that. Multiple IV lines, oxygen cath, NG tube, catheter tubes - lots of tubes and corresponding electronic alarms and beeping sounds.


David was in there amongst the tubes. He was conscious and he was fairly coherent between blasts of self-administered Morphine to try and quell the pain drummers beating out a tragic tam-tam beat somewhere deep in his guts.


After spending some time with my dad, I believe the cancer has begun to migrate throughout his system as he had several quite bizarre disconnected stream-of-consciousness episodes wherein he described conversations he seemed to be having in his head – nothing bad or sad so I figure that’s okay – if he feels like playing an imaginary trumpet in response to my sister describing some of the flowers in the garden, well more power to him.


He'd definitely want me to tell you about one of his nurses, a certified gem by the name of Simon. Simon sees David as a person, not just a patient. Simon's the person who has bent protocol to see to it that David is to be assessed by the palliative team. And the lady from the volunteers who stops in to spend time with Anne. And the gentle physiotherapists who try to coax David's failing body out of bed and up into a wheelchair for a spin around the floor.


Not the docs though. Not more than a sentence to be wasted on people who seem to have forgotten why they chose this path in the first place. 

No one knows for sure how much or how little time he has left however he seems to have made spiritual peace with himself, Anne and the rest of those he holds close. He’s still pretty pissed off about having cancer so he directs that anger at his surgeon and physicians and nurses. The updates from the hospital have been rife with setbacks so I don’t know how many times we’ll hear that ‘his condition has worsened’ before he finally reaches terminus Eldorado.

David is intellectually curious and researching pandemics, the Black Death, and the ethics related to surge are important forays into a world less familiar and comfortable. Gradually that world has become a significant part of his world and at 70something he became immersed in the inner-working of Hamilton's first community emergency response team. He proudly showed off the emergency kit and helmet he kept in the trunk of his car on the last roadtrip he and Anne made to Montreal before he was diagnosed with cancer.     

I believe the chapters in Big Med written by David A.H. Newman are drawing to a close. If he makes it back for another write or two or three or ten, he can print out this column, crumple it up and throw it in the garbage can beside his desk. That would be sweet.

Either way, I think he'd want his readers to know that he enjoys exploring your world and learning more about emergency management, public health, and disaster preparedness along the way. He especially likes the interactions with readers who redirect his pathways or take him to task for not getting more indepth or validate his thought processes and the words he puts to 'paper' in Big Medicine.

Likely he would close a column with the simple words: 'Be well.'

Instead, I'm going to close this column with a passage my father wrote about what it means to be a First Responder:

"You may not receive heartfelt thanks for what you do. Sometimes you will be blamed, because people suffering pain and loss need to blame someone. It goes with the territory and only time can redress the injustice. Learn to accept the hurt with the good things, and don't be too hard on yourself. 

"If you can give support and show compassion beyond the minimum the situation seems to call for, you and your colleagues will long be remembered with gratitude, and you will build reservoirs of credibility and affection for you and others to draw upon; and you will know that what you are doing is worthy and significant."

Be well. Practice big medicine.








[Jul 10 08]

I have incomplete recollections around my most recent stay in hospital. My wife, Anne, who has suffered through this time perhaps even more than I have, helped me fill in some of the blanks – one possible side-effect of chemotherapy is memory loss, and since I experienced just about every other side-effect, why not forgetfulness too?

The Colon Surgery Experience

I had my first experience of a colonoscopy, January 29th 2008 when I learned I had cancer. Before agreeing to the surgery, I was warned that 20 percent of patients experienced a blockage which could require further surgery; this could occur soon after, or years later. At the time I commented; “So what if I say no?” and we (the surgeon and I) both laughed, because it was so obviously a “no-choice” situation.  

February 27th 2008 I was operated on, and emerged with half my colon gone along with my appendix and snippets of my small intestine. I had been in good shape going into the surgery, and recuperation went according to schedule.

The important event in recuperation is having one's bowels functioning. The whole ward seems to be focused around that first time, and once that happens, solid food appears, and if that goes well, its up and out in a very few days.

To Chemo or Not

Recuperating at home went well and by the end of March I felt ready to tackle the issue of chemotherapy. It wasn't a clear-cut decision given my age, 77, and that I am diabetic (one pill a day keeps it in check). My life expectancy is short-term – the odds of a diabetic living past 80 are not good. Being a cancer survivor doesn't improve the odds. Given that background, chemotherapy might, at best, improve the situation marginally.

However, life expectancy numbers are actuarial conclusions assembled from the history of the lives of very many individuals.  The statistical meaning is that of the population of all people of my age and with my history and conditions,  most will not live past 80. Statistically, some will die earlier, and some will live well past 80.

Actuarial tables only apply to large groups. As the size of the reference population gets smaller, the data becomes less meaningful (there are too few people living to say 110 to be able to predict life expectancy beyond that point) and at the limit, where the population is just one person, actuarial data is meaningless. Each person is unique.

Then it becomes a game of “What If.” “What If” I don't fit into the mainstream of the actuarial prediction? What If I'm a 'dot' on the chart out on the favorable extreme of those who survive well beyond their 80th birthday? Then the benefits of chemotherapy might well justify the discomforts and hazards of the procedure. At least that's how I argued, and convinced myself to go ahead.

An additional factor was the results from biopsy samples taken from my lymph system during surgery: four of sixteen samples showed cancer cells at a microscopic level; which meant such cells were floating around my system and potentially could proliferate; chemotherapy, statistically, would wipe most of them out along with any incipient cancers. 

On the other hand, without chemo, if additional cancers did develop, it or they would begin to affect me in two years or so.  If one believes the actuarial models, whereby I'm dead within 3 years, it's not something to worry about. But if I should live beyond that, it reinforces the argument for chemotherapy.

Eventually, I signed the cancer clinic's “Informed Consent” Form because it was the only way to get to the treatment. “Informed Consent” was a cruel joke: I was not informed beyond a sketchy outline of what was ahead; the whole situation amounted to coercion – a polite extortion which made it clear where the power lay: the clinic was of the specialists, by the specialists, for the specialists.

I was offered a choice of three chemo approaches: once a day for five days and then the rest of the month to recuperate (for six months on the same pattern), or having a portable pump installed running continuously for four months, or taking pills. That was the total of the information I was given. I chose the first option. At no time was I told about any alternatives to chemo.

We did attend a lecture on chemo side-effects given by a nurse. It went on and on, rapid-fire, listing the main problems we might encounter, and what we might do about them. There was no time to absorb it all; there were too many things that might occur. There was nothing about the actual treatment process.

The Cancer Clinic Relationship

During the weeks prior to starting chemo, I had met with an oncologist a few times for assessment. In common with many specialists, he was not a great communicator or listener. My diminished hearing, and his rapid delivery – mostly using abstruse medical jargon – didn't help. I can't judge his professional capacities, because I don't know anything about oncology or chemotherapy. 

While the cancer clinic claims to believe in informed consent, any and all information, beyond the most sketchy introduction, had to be searched for relentlessly: it was very much like a scavenger hunt. If asked a direct question, the doctor or his nurse might give an answer of sorts, but it usually needed interpretation beyond our capacities to understand. Part of the problem is we seldom were able to ask the right questions on the spur of the moment: it takes time to work out the implications.

Once, as if conferring a great favor, the nurse, as an afterthought, handed us a booklet on colon cancer and its treatment (prepared by a commercial sponsor). It was loaded with valuable information and should have been included in an information package to be given to sufferers up front, but which no one thought to assemble or provide. This was true of the cancer clinic over-all. There were many volunteers available and they were universally helpful and cheerful, and doing what they could to make us feel comfortable, but they couldn't begin to answer our questions because they weren't professionals. And the professionals were nowhere to be seen. It was a place with a culture of non-communication, which I have to assume comes from the top.

The Chemo Procedure

May 5th 2008, I turned up for my inaugural chemo experience. First came some blood work, and a bit later the actual session which lasted all of three minutes! First came an injection of Leucovorin to make the main drug more effective (though the Leucovorin has its own hazards), and then a much larger dose of 5-Fluorouracil. Finally, a smaller shot of saline solution to wash the hazardous stuff away from the injection site. That was it. I don't know if the amounts I received were typical or not -- it was 85 mg of the Leucovorin, and 825 mg of the main one.         

On the last of the five days (Friday), I got a glimpse of patients equipped with a pump. The pump and IV etc. have to be changed every week; which meant checking in at the cancer clinic for several hours. This was just one of those details deemed not worth telling a prospective patient about.    


The actual chemo seemed to go well, though food tasted peculiar. Having completed my five days of treatment on the Friday, I felt fine on the Saturday. But Sunday the side-effects started in earnest. I first noticed a wicked sunburn: a side-effect of the Leucovin (listed among the dozens of possibilities), but I had no idea how sensitive to sunlight I had become. Then, progressively, loss of appetite – I had to force myself to eat anything; variously the runs, and constipation; queasiness; vertigo; and so I descended into the nightmare that just over a week later put me in 'emergency'.

I don't know if the severity of my reactions could have been predicted; though it might have been prudent to start me on lower levels of the same drugs to see how I reacted. 

Another unhelpful factor, was a prescription for “Iron.” My red cell count was slightly low, and the  oncologist I was assigned to wanted to build me up so I'd be better able to withstand the chemo --  starting me on Ferrous Fumarate (300mg daily) several weeks before the chemo was scheduleds to start. The oncologist didn't mention it, or prescribe anything for it, but my pharmacist pointed out that the stuff was severely constipating and recommended a stool softener to go along with it. I took the  “Iron” for three weeks, and it was severely constipating. I struggled with it, and decided to stop taking it before starting chemo; on the premise that I should allow the chemo room to do its own damage unimpeded by the havoc the iron pills were doing. In hindsight, constipating someone recently recuperated from major colon surgery seems something less than brilliant.

It probably was toward the end of the week after chemo that a complication – a blockage – occurred,    though I didn't know it at the time.

A Low Point

It was Thursday May 15th or Friday May 16th: a week after  completing my first round of chemotherapy. I don't recall if it was night or day, if I was on my own – whether Anne was home or not. (Anne tells me she was sleeping upstairs, but after my fall she moved downstairs too). I had been using the downstairs bedroom because I could no longer handle the stairs.

It had been a vicious week of spiraling downwards. It seemed as if I was encountering every one of the “side-effects” outlined in the forty-four page handout thoughtfully provided by the cancer clinic.

I remember making my way to the bathroom (adjacent to the bedroom I was using). Quite suddenly I collapsed – finding myself on the floor, having smashed into the sink cabinet on the way and destroying one of the cabinet doors. I was personally undamaged though. I lay there on the floor for a while. I tried to call to Anne, but couldn't. I then tried to get back to the bedroom only a few feet away. I couldn't even crawl, but wriggled and pulled my way along and reached the foot of the bed where I lay for another while, contemplating the impossible effort needed to get up on the bed. By superhuman exertion I managed to get my arms up and then pulled and pushed my way, bit by bit, on to the bed, where I lay exhausted. I think that's when I understood that if I weakened much further, I was going to die.

I don't remember much about what else was happening to me. Anne tells me I was hiccupping constantly, and that I threw up a few times. On Sunday, May 18th, she phoned the cancer clinic and spoke to whoever was handling calls on the weekend. She was told to get me to emergency right away.


Anne phoned our neighbors, and with their substantial help was able to get me standing, and into the car. We live just as few minutes from McMaster Medical so that's where we headed. With help, I was able to transfer into a wheelchair, in which I sat for the next while.

Emergency was busy, but we were seen almost immediately by a Triage Nurse. There were many infants and youngsters who had higher priority, so we waited an hour and a half, which I didn't mind. Then I was moved into a room within emergency. They ran assorted tests, and I think I was taken to have X-rays of my gut area. The usual IV was connected. After a couple of hours, a doctor appeared. He went through the lab and X-ray results, asked some questions, and decided to admit me.

Fortuitously, a room was available in Ward 4-Y (close by Ward 4-X where I had recuperated after the original colon surgery).  The room, 4-Y 14, was bright. I was the only patient in it. There was a nice view of trees. For the moment, I was content to simply relax and let events happen as they might. Maybe I slept. I don't recall.

Later, after suitable tests had been run, the surgeon told me that there was a blockage, and he and his team had decided on a three-fold strategy: to help me survive until the poisons from the chemo had been cleared: to build me up so if surgery was needed I'd have a fighting chance of surviving it; and to try to get the blockage to clear itself so the surgery wouldn't be necessary. And that's what they did.


At first I was content to lie there and give myself up to the circumstances. I couldn't do anything to help myself, and was drowsily happy to surrender the burdens of life and leaving the decisions to others. I mostly listened to my 'Walkman' and slept. But Anne tells me I was still hiccupping a lot, and I seemed angry and unsettled to the point I even threatened to check myself out.  

Also, the IV had been very poorly placed: it kept crimping and shutting off, and every time I moved, it kept getting caught in sheets or blankets, or bumping into something, which was painful. After a few days, it was removed and reinstalled properly. 

The problem with the anger was: I had no one I could legitimately focus my anger on, so for a while I worked myself up in bitterness focusing on those targets that were available: the oncologist and the cancer clinic being high on the list. 

I found that the only one I was hurting was myself, so I decided to cool it. I also worked out that I was in fact angry at the Universe and Circumstance -- “Why Me?” “Why should I be inflicted with this cancer, and all the complications, and it wasn't fair, etc. etc.” “Why didn't 'they' catch 'it' sooner?”  

But there's no answer, the Universe has its own concerns, and makes a remote and unlikely target. So I decided to accept that what is, is, that recriminations are pointless and fruitless, that eating myself up serves no useful purpose, and that even specialists are human and as such are far from perfect.  

I can understand the need for rage, for lashing out at something, or someone, when fate closes in, but that urge has to be  put down, and without delay. Anger is a dangerous luxury; because it always comes with horrendous side-effects which guarantee destruction of all one holds dear – including life itself. 

I have no doubt that it was my reactions to the chemotherapy that sent me to hospital more dead than alive. But I doubt that anyone could have predicted that in advance: each person reacts differently.  given what did happen, there's no way I'm going back for more. I may, however, want to explore other treatment possibilities – if I can find someone competent who is a good listener and can communicate simply and throughly, who is up-to-date on what's going on in oncology, and who is willing to take the time to spell out the details. 


After two weeks or so in hospital, with daily visits from my surgeon and his faithful pack of juniors, I began to ask if surgery wasn't inevitable. But he was still hopeful that the strategy had a good chance of working, and he remained, as always, confidently patient – and that inspired confidence in others, including me.  

By this time I had a second IV feeding me what looked like a milkshake; it was an enriched formula intended, for the time being, to replace solid food. I also had a tube up my nose and down my throat which was connected to an intermittent pump which was intended to help draw up and dispose of whatever was in my stomach. It was nasty in taste and seriously irritating to my throat: I developed a vicious cough which made it near impossible to sleep. So all was not wine and roses.  

In that hospital's culture, the universal answer to pain and discomfort, is to treat the symptoms with morphine. I was limited to three injections a night, at a minimum two and a half hour intervals. I wasn't in pain as such, but the discomfort from the throat irritation was real, and the morphine – while it's effect lasted -- allowed me to sleep.   

My vital signs were closely monitored. Four times a day, night or day, asleep or awake, there were the standard barrage of tests: blood pressure (always low), blood sugar (all over the place), temperature (always normal), blood oxygen (good), etc. And then insulin to 'control' the blood sugar), and heparin to prevent blood clots forming. (Since I was still not taking in solids, they couldn't give me my usual medications in pill form: everything came in by IV or direct injection). And every day or so, blood work.  

Early on, they checked for C difficile and other nasties; a useful precaution in light of what has and is happening at too many hospitals in Ontario. 

With Anne's help unplugging the power cord to the IV stand and maneuvering it to the other side of the bed, I could, holding on to something, stand up, and walk. I recalled from my recuperation from the original surgery that walking was very helpful. So I walked most days, though not as fast or as far as I wanted.    

Then, early in week three, late one night, the blockage cleared. It happened suddenly: it was as if the levees had crumbled, and the city was inundated. Except this was not water. 

It took a while to clean the bed, the room, and me. The same thing happened a few hours later, though the quantity wasn't quite as overwhelming. After that, I tried to get myself out of bed, and with the help of my cane, walked over to the bathroom on my own; which was much appreciated by everyone, including me.  

I asked if the tube couldn't come out of my throat; they agreed, and that was one less encumbrance. The milkshake IV was disconnected, and actual meals, on the order of soups, cream of wheat and juices  appeared. The cough was still there, but that didn't concern the medical team, and on the Saturday we agreed that I might as well go home.  

The care I received in hospital mirrored my earlier experience recuperating from colon surgery. Almost without exception, it was professional, compassionate, highly skilled, timely, and successful; thanks to many dedicated individuals. The health care system, as I experienced it, worked as it should.  

Home, Expectations, and Insecure Reality 

When I got home I weighed 174.5 pounds. I looked like a long-distance runner, though I couldn't have run 10 feet without collapsing. Prior to the colon surgery (Feb 27 2008) I weighed 208, down from my usual 215. After colon surgery I weighed around 200, so I lost 25 pounds during the chemo experience.    

The cough picked up in hospital was still very much with me, so I made an appointment with our Family Practice doctor. Lacking indoctrination in the specialist culture, he took the time to listen to the tale of my adventures, and being a person with common-sense, as well as having a belief in evidence-based practice, he sent me immediately for a chest x-ray. Not surprisingly, it showed fluid and a partially collapsed lung, so he put me on an anti-biotic. He also prescribed a cough medicine of undoubted power, but with its own hazards as it contained an opiate, and was potentially constipating. But it allowed me to sleep nights, and as soon as I could I cut back on its use.  

Given that the prime focus of the last six months had been a preoccupation with not getting constipated,   

I found myself monitoring and timing every fart and visit to the toilet. I admit to a not entirely rational, though not entirely irrational, fear of having to return to hospital (though that would not be the end of the world). The anti-biotic complicated matters because it effectively killed off useful bugs in my digestive system, leaving me variously constipated, or going often. So I intermittently resorted to 'fiber'  and then worried about how much or how little to take. Eventually, the lingering effects of the anti-biotic wore off, and thankfully, for now at least, my guts seem to be functioning to a reasonable schedule.  

Unreasonably, I had expectations that the surgery, and the end of the blockage, would restore me to perfect health with all systems working normally. I now realize that there is no such thing as 'normal' so I do the best I can given age and life-style, medical history, and on-going conditions – like everyone else.    

I have been eating lots of protein and gradually extending the range and variety of what I eat and drink. My weight, after a fast initial gain, was stuck at 180.5 until the effects of the anti-biotic wore off. Then I started to rapidly gain weight and energy, and am up to 190 as of July 7th. I handle stairs easily, and regularly walk a mile or more: at first that wiped me out for the rest of the day, but now its becoming routine. I've come a long way in a short time, though there's still a ways to go. 

Be well.


A re-awakening


Part two of a three-part series


[Mar 30 08]

I got the word on the Monday that my surgery was scheduled for the Wednesday at 11.30 a.m. That meant a last meal – my last for the next seven days -- and then another session with the cleaning fluid all day Tuesday; preparatory to checking in and walking the last mile.

On the Wednesday, we went to the hospital and checked in: I packed my clothes away and instead was supplied with a “one-size-doesn't fit anybody” gown, said goodbye, a quiet prayer, and trudged along a length of corridor into the operating theater.

It was much larger than I expected, very brightly lit, with equipment all around the periphery, three massive light fixtures reminiscent of flying-saucers, a half-dozen or so people, and a 'bed' of sorts center-stage. I said hello, got some hellos in return, and was invited to lie down on the bed/platform.  

It was 11.45 a.m. Someone came over and gently placed a mask over my nose and mouth. “I'm going to put you to sleep now,” he said. “All right,” I said. And then it was late afternoon and I was somewhere else, and Anne was there with me.  

I didn't feel much at that point. Whatever they had hit me with was still active in my system; I felt good, drowsy, and content, for the moment, to just lie there. I gradually discovered IV taps in both wrists, and a catheter – all installed while I was under. When I shut my eyes I hallucinated – so I kept my eyes open. 

From time to time, people came in and monitored my condition: blood pressure, temperature, blood oxygen, and electrolytes. Blood sugar was measured using a device left over from before the flood – it was huge: closely resembling the turret on a main line-of-battle tank, and about as cumbersome. The latest versions are tiny, only require a droplet of blood which can be drawn from anywhere comfortable such as an arm, and give a result in five seconds. Whereas this thing from the remote past was vampire-ish in its demand for blood – obtained by slashing at a fingertip. Definitely cruel and unusual punishment.

Then there was a delay while the meter made up its 'mind'. Long enough to read “War and Peace,”  watch the entire StarWars series, or take a leisurely stroll to Chicago and back. Finally, a reading emerged, and the nurse then disappeared while she consulted with the resident oracle.  

I never did discover the whereabouts or identity of this mysterious being. I came to understand that there was some kind of mysterious shamanic presence, who, being brought the patient's vital signs, consulted zodiacal charts and the entrails of chickens, and issued instructions. In my case, if the blood sugar level was above ten, the nurse reappeared with a needle full of insulin which went into my shoulder. At the same time, another needle of heparin went into my thigh to prevent blood clots. 

They were delighted with my blood pressure, which was, to me, way too low – in the 50's and gradually ascending day-by-day into the 60's and low 70's. Everything else held remarkably steady throughout. It seemed I was healthy – for the circumstances. 

I discovered I was in a ward dedicated to Gastro-Intestinal cases; mostly recovering from surgery. There seemed to be two beds per room with one toilet shared by two rooms. This may seem a trivial aspect of my brief stay in the ward, but it wasn't. The pivotal events, which determine the timing of everything else, including getting out of there and going home, are farting, and having a bowel movement. This is understandable if you recognize the extent of the surgery.  

In my case, as I discovered later, the entire right branch of my colon was gone, along with my appendix and a portion of my small intestine. This took some ingenious re-connecting and re-working of blood supply to what's left of my guts. I have a main incision running vertically four inches or so, and a subsidiary cut of an inch or so to the left plus a small hole below; the subsidiary stuff used perhaps to assist the re-assembly.

There seems to be a rule: don't tell the patient anything unless asked. I might have gone on for years, attributing this or that ache to my appendix; not knowing it had gone to a better place. But I asked, and must now find something else to be a hypochondriac about. The surgical team did an incredible job; for them its routine, but to me its mind-boggling. The cancer must have been large, to necessitate such a long incision. 

The GI Team on the ward was superb; deeply experienced, caring, thoroughly professional. They made a difference -- for many patients. I only encountered one exception, and she was a monster; more about that later.

As to caring, and acts of kindness; most everyone on the ward was caring and kind. A couple of examples; I found the 'bed' totally unusable. I tried, but with all its infinite adjustments of angles, whenever I lay there for more than a few minutes, I got totally painful bunched muscles in my neck. Mostly, I sat up in a chair – dozed some, worked Sudoku puzzles, read, listened to music, and took the occasional walk – pushing my IV stand ahead of me. One night, sitting in the quasi-dark, dozing, with my neck in a knot, my night nurse came quietly in and placed a hot blanket around my neck. She had gone to the trouble because she thought it might ease my pain. It did, but the main benefit came from realizing someone cared.  

Another time, another nurse came in pushing an IV stand which she switched my assorted devices to. She had recognized that the stand I had been using, and pushing along the corridors on my walks, was as recalcitrant as a shopping cart with a sticky wheel. The new stand was silent and smooth, and much easier to roll along. Another act of gratuitous kindness.  

These were sweet and helpful gestures. They say a great deal about the prevailing culture. 

Now back to the toilet issue. The one for my room (and the adjacent room) was located on an outside wall. This meant it was as cold as an outdoor privy, though not quite as attractive. Also, with four people fully preoccupied with peeing and otherwise attempting to produce something – for example, my immediate neighbor must have shuffled into the can every half-hour all night and all day (which wearied him and the rest of us), and the good folks in the next room must have had ostomies, because they were duly represented by an orderly, who spent most of his time in said bathroom carefully inspecting beakers of output. As he said of the toilet -- , “This is my office.” So the notion of quietly relaxing on the can, and producing, was not entirely realistic. Yet, eventually, it happened. 

In the meanwhile – I felt, and appeared, as though the surgeons, in a perverse moment, had sewn a fully inflated rugby football into my gut. I was distended. It felt as hard as concrete, and it hurt. It hurt non-stop and it hurt considerably.

Enter the pain 'management' specialist. For peculiar and arcane reasons, the powers in the ward are divided. The surgical and recovery team must defer to the pain management specialist, and do so with a grimace reflecting deep irony. So the patient falls between two jurisdictions, with ineptitude holding sway. 

One first encounters the pain people soon after one opens one's eyes. Not feeling anything in particular and slowly getting used to the strange concept of still being alive. “On a scale of 1 to 10, how much pain are you feeling?” This became a frequent refrain. “Compared with what?” I asked. “Well, this is how we assess your pain.” I gave up trying to explain that there are different kinds and qualities of pain: continuous pain, intermittent pain, hot pain (such as with Shingles), special pain (as with kidney stones), and so forth. They weren't interested. They didn't listen. They had their scale and that was that. 

They extolled the merits of the pain pump which was part of my IV rig. This device dispensed morphine as and when the patient wanted – except the dosage was preset, and the timing between doses was also beyond the patient's control. However, it meant the nurses were no longer responsible for helping patients through pain and that was felt to be a good thing.  

As to the usefulness of morphine to control the pain resulting from the surgery and the bloating – I got the pain specialist to admit there was no positive impact. There were however, “side-effects”: the morphine actually increased the bloating and hence increased the pain, while retarding healing. Further, the morphine caused involuntary 'twitches' – if you define 'twitching' as lashing out with arms and legs with enough force to cause serious injury to a patient or an attendant. 

Having come to that admission, the pain specialist then recommended Tylenol 3 as a substitute. Tylenol 3 contains codeine and, while it does control pain effectively, it is also highly constipating. If you recall that the big event, the happening, is having a bowel movement to prove one's reconnected bits and pieces of digestive system are working again, you will understand that Tylenol 3 is as counter-productive a recommendation as one could come up with – short of hara-kiri. But that's inevitable when the patient isn't seen as a person.  

The next big idea was something called Percocet – another narcotic. But no one could tell me anything about it, and I found that strange. In this modern era, even the smallest pharmacy has as computer system which scans for interactions, and spits out reams of paper describing a drug, what its used for, cautions, side-effects, etc. etc. There is a pharmacy in the lobby of the hospital. Yet here we have drugs brought forth with a total lack of information to go with them; and the patient is expected to make an informed decision. Lacking information, I decided to forgo all further pain medication, and tough it through. (I've been through worse).And this is supposedly the era of evidence-based medicine! Pain Management, as I experienced it, is a cruel farce. 

I was told to walk: it helps the healing, and gets the guts churning again. A physio 'specialist' showed up to get me on my feet and walking, but with Anne's help, mostly moral support, I was able to function on my own. The swollen gut hurt seriously, but when I walk, I walk. I'm not used to a slow shuffle, so I strode along at a fair clip, leaning as if into a wind as I pushed my IV stand along. Each time, I went further – another lap, or a longer corridor. Surprisingly, despite many days without solid food, aside from the pain, I felt strong, and without vertigo. So I walked. 

The surgical team appeared early every morning on their rounds: they inspected the incision, pressed and probed, asked after progress, and checked vital signs. They were always cheerful, and relentlessly optimistic – a useful and reassuring attitude in the circumstances. I was always glad to see them; fitted out as I was with a fully inflated football and hurting, it made it easier to bear knowing what I was going through was par for the course. 

And after my bowels began to churn around and I produced gas and other good stuff, events happened rapidly. I was allowed my diabetes medication (Actos) and my trio of blood-pressure pills, and since I kept those down and the readings continued to look good, my meals changed from diet jello, apple juice, and ersatz soup, to muffin, crackers, cream soups (hot and delicious) – even a hamburger of sorts. I couldn't eat it all. And then my week had gone by and I was ready to be released; but with blizzards raging every second day – it was a bad week for storms – they allowed me to stay an extra day until the weather allowed access. And then I was out of there walking under my own steam, and went home.  

About the monster I encountered: you can't tell a monster by how they look – they appear normal and harmless enough. A monster is a monster because it does monstrous things – notably taking advantage of a privileged position in the health care system to deliberately inflict pain and suffering on patients and even colleagues. Sometimes they do much worse. They do these things because they like to. Their colleagues know who they are and what they are doing, but are powerless to intervene; because the monsters enjoy the full protection of their respective unions – professional and otherwise. And the monsters are vicious and vindictive and without conscience. 

The incident began when it was time to change an IV tap. It was in a comfortable position on my right arm well above the wrist, but there's a protocol that no IV tap should be left in place more than a few days. My nurse of the day tried to find a place on my left arm. I had asked her to  be careful about interfering with my left wrist – I'm naturally left-handed and I needed the strength in my left hand and arm to get myself up and around. She tried to find a suitable vein but wasn't having success. The system dictates that in such circumstances she call in a backup – an 'expert'. Enter the monster. 

She was young, seemingly angry at being interrupted from whatever she as doing. I repeated my request to keep my left wrist free so I could lever myself around. Thereupon she placed the IV tap into my wrist, with expertise, in the perfect place to paralyze me with pain if I attempted to move my left wrist in any way whatsoever. Having done her handiwork, she flounced out.  

I looked at my nurse, made eye contact, and, speaking in  an even voice, gently but firmly, told her this was no good and had to be removed right away. She looked at me for perhaps five seconds, and, recognizing something in my voice and eye, said she would be right back. What she had recognized was that I was not going to back down, come hell or high water I was prepared to make my stand. She was back in a few moments with another nurse – definitely not a monster. She was gentle and skilled. The IV tap came out and then she installed one in a different place on my right arm. She dated it, taped and secured it, and life went on. I thanked her, and my nurse. 

I could, at the time, have demanded to see a patients' ombudsman. I could have demanded to see a doctor in charge. I decided to save it, and get on with getting out of there. In the grand weighing of things, the ward and the people running it, were accomplishing daily miracles. New patients were emerging regularly from surgery, each representing a miracle of modern surgery at its best,and each, in a week or thereabouts, as an outcome of the care and compassion of a dedicated team of outstanding individuals, would be on their way home in a state to face their new realities.  

Its a shame that one monster diminishes the accomplishment of the team – but that's the reality, and that's all it takes to cheapen and taint what is to me a miracle of healing.

I've been a member of teams in many kinds of settings – industrial, high-tech, low-tech, and institutional, small, large, and world-scale. I've researched them, and been a mentor and consultant to many. I've taught many thousands of would-be managers. I've had the privilege of working directly for and consulting with several remarkably able chief executives – knowing just one of them would have been a great experience.  

I know how teams can form themselves and how effective they can be at self-managing – and self-selecting and proving their members. Gaining acceptance by such a team is a high honor. I know what motivates – and what gets in the way. The GI Ward Team, in most respects, is ideally motivated. The team effectiveness is tested by each new patient, and the turnaround is just a few days. Yet each person is unique in some respects, and so the challenge each represents for the team is both similar to every other person they have seen through the recovery phase, but never identical. These are ideal conditions for what is, in every sense, a customizing team. The patient is the goal and that is as it should be.  

And then the team on the ward works closely and I believe comfortably with the surgical team. In reality it is all one team and there is powerful respect all round.       

I won't label the pain management fiasco as monstrous, though I could. But I'm reminded of Carl Jung's observation – that organizations tend to monstrous behavior, and the larger the bureaucracy, the more monstrous the outcomes can be.  

The team, left to itself, would soon enough dispose of any monstrous tendencies. And you can bet that pain would be managed effectively and realistically. What gets in the way is bureaucracy with its artificial divisions into often meaningless jurisdictions. Organization charts seldom reflect reality.

And patients should not be artificially divided to suit organizational boundaries. 

Given the way things are, every patient needs a visible champion. Anne was, and is, my champion – and I have others on call in the wings. That helps enormously – no one should have to face 'The System' alone.

A problem with personal grammar


Part one of a three-part series


[Mar 19 08]

For many months I was troubled by gas in my gut. It was worse when I was stressed; there's an instantaneous connection between mind and body. I discussed it with my family practice doctor. He suggested something to cut down stomach acid, and that helped -- I had fewer bad days and more good ones.  

I also asked him about trying something to reduce anxiety. He gave me two prescriptions for the same thing but in two strengths. I started with the mild dose. After four days I was as alive as a zombie, and had the shakes; not to mention vertigo. I decided the stuff was not for me, so I stopped; it took a few days to wear off – it eventually did, which was a relief; because the effects were so bad that I feared permanent damage. And that was supposed to be the low, innocuous dosage. I should know by now that if side-effects are on offer, I'm usually first in line. 

That aside, my doctor suggested checking my plumbing out – top and bottom. If he hadn't. I would have insisted: enough of wondering what was going on – it was time to get the facts! This was back in December. My doctor estimated I'd probably hear from the hospital in March or thereabouts, but lo and behold, I got a call Jan 29th (the day after my birthday). They had a cancellation, so I took it. Quick trip to the pharmacy to get the powder to mix four liters of not-bad tasting stuff and a couple of pills; all to clean out the plumbing so the view from below would be unobstructed. The problem with the four liters is having to drink it in two hours or thereabouts. And not eating for twenty-four hours and more.

My system was cleaned out quite thoroughly, and on the Thursday (January 31st) at 2 p.m. I checked in for my appointment. This involved getting naked, donning a hospital gown (open at the back) and then a hospital gown (open at the front), getting an IV tap attached to the back of my left hand, and then sitting around in a cramped waiting area with a dozen others similarly attired – all of us clutching large garbage bags containing our clothing. As its winter here, and a wicked one, clothing includes heavy boots, jeans, and layer upon layer of parka, sweaters, etc.  

After waiting two hours beyond my appointment time, I got to chatting with the man sitting on my right. His appointment was for 1.30 p.m. That's when I figured I might be there a while. At 5.15 p.m. I was called, placed on a bed on wheels, and trundled into an ominous-looking but very clean room replete with bright lights and TV monitors.  

First on the menu was the endoscopy. This involves shoving a tube with a TV camera in it down your throat and into your stomach. Beforehand, they spray your throat with an anesthetic so the gagging reflex will be subdued. This doesn't quite work. Then you are turned so you are lying on your left side, and before you can think about it you are attacked. Once the scope was well and truly in, it wasn't too bad, but the first intrusion was not fun at all. The nurse, who was highly efficient – I guess she had to be because the throughput demand for these inspections was high – kept telling me I was doing fine, but at the time that lacked credibility. However, it took just a few moments and then the thing was withdrawn (that goes easily) and it was on to the next stage.  

By then any concept of personal dignity had vanished, and it was good to simply be able to take an unobstructed breath. I remember saying: “I hope you'll drug me before anything else.” And as I said it, the nurse injected the contents of two syringes into the IV tap. From then on, while I was quite aware of what was going on, and occasionally it was uncomfortable – even painful – I was content to let it happen.  

The colonoscopy experience is unparalleled – modern technology allows you to watch the evolving perspective on TV from the vantage point of your own rear end – an experience usually available only to contortionists and yoga experts.     

Having nothing better to do at the time, I decided to watch the big screen. It was like the view from an open train car traveling at speed through a very long ribbed tunnel which curved in the distance. And yes, the four-liters of cleaning fluid had done their work and the tunnel was spotlessly clean.  

It all moved along routinely, except at a couple of points the person directing activities at the rear pumped some gas in to keep the tunnel expanded. And at the same time, to keep the stomach muscles from expanding, the nurse pressed firmly on said gut area. That hurt, but being suitably drugged I couldn't get too outraged at that, or at anything. Then, when the camera was well along, someone to my rear took the analogy of a plumbing snake seriously, and to keep the train moving, as I experienced it, hammered away at the back end of the train. That was a bit unexpected. 

Then, close to the end of the trip, the view ahead became colorful. The doctor, who might be an expat brit by his accent, said: “Hullo. Now that looks interesting!” So they took some close looks,  and I couldn't be sure what I was seeing except I assumed (correctly) that it wasn't something that should have been there. As I recollect, it was fleshy and had liver-red blotches here and there. And it seemed to be the target of the biopsy probing. The nurse came over with a long thin red cable-like thing, and almost immediately I could see it on the TV. They were taking some samples of whatever it was, which the nurse placed neatly on slides on a table below the TV screen I was watching. After four or so samples she asked “Is that enough?” And the doctor said: “Get one more,” and so she did. Then the train backed rapidly out. 

Then the doctor came around, face to face as it were, which must be unusual for someone in his line of work, and I said: “You found something.” And he said “Yes. Its a cancer. Fortunately its a slow-growing type.” I said” Okay.” Whatever they had drugged me with, if he had told me a meteorite was about to destroy the world I would have blandly said: “Okay.” I asked him: “How long has it been growing there?” He laughed, and said: “Likely, for years.” And he added, “At your age things tend to grow slowly.”  

He said, “I want to see you again next Thursday, and I hope to have a surgeon with us. By then we should have the biopsy results. And, I want to set up a CT scan as soon as possible so we'll have that too by Thursday. That will help us locate this nasty precisely.” I thanked him and the nurse and the resident (with the beard). The doctor smiled and said: “You know, tomorrow you won't remember much if anything of what I just told you.” “You are kidding,” I said.  “No,” he said. “One of the drugs you were given has that effect.”  

I did however remember considerable detail, so this might have been one instance in which I wasn't side-effected. But to give him his due, while I know what I do remember, of course I don't, by definition, know what I've forgotten.  

They started to wheel me out, and then I said: “My glasses?” The resident handed them to me, and I rolled from the room to the recovery area where Anne joined me and after twenty minutes or so I got dressed. I asked the orderly about the doctor's amnesia comment. He said: “Yes, one of the drugs does have that effect on short-term memory.” 

We got to the bitterly cold underground parking, eventually retrieved the car, and drove home – all of six blocks. It would have been much easier to walk. I had to wait a couple of hours before eating anything, and kept it to something light. I couldn't drink anything alcoholic for another twenty-four hours but have made up for that since. 

We met with the GI doctor the following Thursday. He told us that we had caught my cancer in time and the prognosis was excellent. Since then, others have told me this is one of the the easiest and most favorable kind of cancer to deal with -- if caught soon enough. I have no reason to doubt their opinion.   

Even so -- Samuel Johnson remarked that the knowledge that one is, in just a few days, going to be hanged, sharpens the mind wonderfully. This kind of event does re-shape priorities.  

Oh yes, the title of this screed -- “A Problem with Personal Grammar” -- my colon needs to be altered to a semi-colon; presumably by a grammatical surgeon.  

I've had my tonsils out at age 3, a replacement lens put in my right eye 72 years later, and I still have my appendix. I have lost a few teeth here and there. Not bad -- So far.

A week later I went through another colonoscopy: by now I am a veteran. This time the surgeon ran the show, getting a first-hand look. He also snipped out a polyp, which proved benign. The surgeon couldn't confirm a date and time for the main event. In our system of rationed access to health care, there's a problem finding money in the local budget to “buy” operating theater time. The surgeon and his team are available and the operating theaters sit empty much of the time, and I have nothing better to do; so its a matter of allocation of cash from someone's budget.   

Over the next weekend, we were in Ottawa where I delivered a very well received presentation to the annual conference of the National Council on Ethics in Human Research. We met many remarkably gifted people from a variety of career backgrounds, and attended some fascinating sessions. The issues are far more relevant and complicated than I had initially thought: material enough for many articles, some science-fiction plots, and perhaps a new career stage. It was nice to be invited, and, for a while, it diverted our thoughts away from the surgery -- and that was useful and welcome.      

The day after we returned home from the conference (bitter cold and icy) we met with the surgeon, and then I went through pre-op sessions in which I was probed, inspected, and quizzed at length: blood-pressure, blood-work, ecg, interview at length with an internist, ditto with an anesthetist, and chest X-rayed from various angles. It seems I'm a prime low-risk candidate to survive the surgery.  

The intent is to use laparascopic surgery. (I don't know how the word is spelled). Practically, it means a very small incision and recent technology, making it much easier to heal. Even so, it does involve considerable cutting, fitting, and stapling. As well, though everything indicates the cancer hasn't spread, they will snip samples here and there for subsequent microscopic inspection – to see if any individual cancer cells lurk. Nominally, three hours are requested for the actual surgery with an hour or two to come out of it. Then perhaps a week in hospital and then home. 

We awaited the phone-call telling me to get packed and prepared. Meanwhile I tried to get my files in order. The surgery might happen in a few days or a few weeks: there was no way of knowing – the “System” has its own insular logic. Then the situation clarified with a phone-call on the Monday: “You're booked for Wednesday Feb 27th at 1.30 a.m.”


To be a First Responder


[Jan 8 2008]


This is an exploration into the forces and values which guide First Responders of all kinds everywhere.  

If I had gone at it the usual way, I might have surveyed the populaces First Responders serve. Or I might have analyzed articles on First Response to produce lists of descriptive words and their frequencies. But instead of  being scientific and rational and following an approved research methodology, I decided to follow my intuition.     

Of course, intuitive ventures leave you with an assortment of cryptic phrases and imagery, which then have to be dressed up in words and arranged according to headings – and that is a subjective process,  so my own background has something to do with the result.

Finding a title was challenging, because it raises the question: “What's this going to be used for?” It might be a  useful article for would-be first responders to read, and ask questions around. Then someone could fill in some of the blanks with stories from her personal experience.

It might also serve as a starting point for those sufficiently interested to take issue with and add to – helping to gradually accumulate a “First Responder Manual or Book of Front-Line Wisdom” – “Aphorisms from the Field.” You will encounter quite a few aphorisms in what follows: an aphorism is a powerful one-liner which rings true across time, distance, and circumstance.

The Nature of the Work

First Responders never know exactly what they will have to deal with next, or when, or where. They have to become expert at dealing with the unexpected. They are always led by the situation, however, they can and do learn to be prepared – to be ready to take on whatever comes. It needs a “Job Shop” mentality, and an assortment of general-purpose skills and tools.

Provide for what is needed to meet the Future -- Accumulate Strength through Foresight. That is your best insurance.

Most calls are routine, in the sense that experience and commonsense help to minimize the risks. But exceptions happen, and then precipitate rushing into danger -- Heroics without consideration -- can endanger and sometimes kill; you and others. Heroism should be a last resort. So Patience becomes a strength.

Whatever situation you are called to is sure to involve danger for someone. So don't give in to confusion: be firm in finding out  what the situation really is, to the extent you can, and don't jump in blindly. Seek verification, and document the evidence. Trying to enforce your will on the situation means ignoring the emerging reality – and reality does and will emerge. 


Hippocrates said, in his most famous Aphorism -- “Judgment is difficult.” Judgment has to be informed by experience and by the facts. Informed judgment equates with Situationally-Relevant Wisdom – and that amounts to Know-how. Judgment can't be taught, though it can be exercised.

If every situation was clearcut and only needed a yes-no answer, there wouldn't be any need for judgment. But nearly all real-life situations involve trade-offs, and sometimes there are no good answers – only combinations of more or less good and more or less bad. However you decide, someone will inevitably suffer – and you, if you have any feelings, will also suffer, inevitably. You too are mortal and stress is real. Your colleagues and advisors can help you deal with it: don't try to stand alone: you are a member of a team and the team is there for you, as you are for the others.    

Deal with multiple demands and competing claims resolutely and intelligently. Use your informed judgment to assign resources and energies -- as in Triage situations. Follow the rules, and your values, and don't be afraid to talk it out with colleagues – but remember that coming to judgment is not the same as taking a poll. Advice and consensus are simply more elements to consider. Facts alone will not give you an absolute answer where there are no absolute answers.

It isn't enough to rely on your enthusiasm to carry you through. Enthusiasm creates opportunities for both Greatness and Illusion. Judge carefully. 

Don't judge anyone unless you understand the special circumstances surrounding the individuals and the action. There are always special circumstances. Treat each and every person as someone special – as a unique being caught up in a possibly unique situation.

Confront whatever is causing Suffering

Some may regard suffering as noble – even pious; perhaps its in the human makeup to seek virtue in  the most grim experiences – when we are the ones afflicted. But it is not noble, pious, or virtuous, to ignore and pass by the suffering of others. Suffering is evil and there must be no compromise when facing it.

It is the first responsibility of a First Responder to look out for and attend to sufferers. Service is about easing the path.

'The way to exorcise suffering is to make energetic progress in the good'. The 'good' isn't always easy to define. But a sure sign, and a useful measurement, is the observation of re-awakened life.  

There is a great mystery underlying the struggle, which, for humankind, is without limit and end. The struggle has its dangers, not least becoming entangled in our own hatreds and passions -- passion and reason cannot exist side by side. Know thyself, and be on guard: we are each our own worst enemy. Self-Knowledge (Inner Perception) allows inner concentration on outward events: essential when you have to confront and subdue Outer Danger.

You may not receive heartfelt thanks for what you do. Sometimes you will be blamed, because people suffering pain and loss need to blame someone. It goes with the territory and only time can redress the injustice. Learn to accept the hurt with the good things, and don't be too hard on yourself. 

If you can give support and show compassion beyond the minimum the situation seems to call for, you and your colleagues will long be remembered with gratitude, and you will build reservoirs of credibility and affection for you and others to draw upon; and you will know that what you are doing is worthy and significant

Desire for Independence and the need for Role

We all want our independence, our freedom to do our thing unhampered by the restrictions of authority and the rules, regulations, and protocols imposed on us, and that we impose on ourselves by our choice of profession, training, and service. At the same time, we need others.

Most important, and most irritating, we have no choice but to fit in with the formal structure of society; otherwise we have no place to fulfill our calling. We are forced by our calling to train, to meet standards, to accept credentials, to follow the rules.

We must fit into the on-going structure of assignments, of peers and supervisors, of mentors and teachers – and of how they choose to judge us. Peer acceptance, in particular, is the biggest hurdle, and, the greatest reward. There is nothing quite like winning acceptance as a member of a team.

While structure, status, and rules do get in the way, they sometimes are a blessing --- if you have the courage to think for yourself, and have earned enough authority to follow your hunches.

Hippocrates states that 'Experiment is Perilous' – its usually safer for the provider as well as the patient to go with what 'we' know works because we've seen it work often enough. Be wary of applying untested 'remedies': because life and well-being are precious and must not be put at risk unduly. The modern expression is “Evidence-based.” Note that 'Evidence-based' is not the same as “Conventional Wisdom,” which is seldom wise and lacks factual support.

But what has worked time and again, and for many, may not work for a particular individual – or the situation has already deteriorated too far. Sometimes you may have to judge whether or not to push the limits. Hippocrates said: “Desperate situations may demand desperate answers.”

It takes rare courage to decide, and if you go ahead with a last resort attempt, it may not work; and then the patient is dead, or worse, and you are in deep trouble because you departed from the accepted norms. This is why many breakthroughs happen on the battlefield and during pandemics and other disasters – because the usual standards do not apply.     

We learn and we try. Life goes on and lives go by, and there's always more to learn and to try. As Hippocrates said: “Life is short, and the Art long.”

Have the courage of conscience to say “No” to orders which are poorly thought through, unnecessarily hazardous, or cruel and humiliating to the sufferer or to their families, or to your colleagues. Challenge the tradition and the 'received wisdom' when it clearly flies in the face of the evidence. Shun the monsters in the system. Report such events and individuals, and errors and omissions, without fear or favor. You owe it to your colleagues and to the people you serve, and ultimately you have to answer to and live with yourself.

Being true to yourself and to your calling has its challenges.

Emotional Growth

First Responders are never alone, though it may sometimes seem to be a lonely existence. However, relationships are the central fact; as exemplified in the team interplays, the provider-patient relationship, and the learning, mentoring, and  teaching.

Relationships depend on a capacity to allow feelings into the open, and then fulfillment, joy, and love – in the best sense – happen. Everything alive has feelings, including feelings for others; though humans can develop blocks against showing it -- Blocking is one defense against emotional overload, but it comes at a high cost. Personal Growth, like Caring,  is impossible without Understanding and Compassion.

The best defense is to recognize that the emotional burden can at times become overwhelming: when it seems everything in our life is coming apart. This means accepting that each of us has finite limits, and needs help. We seem to be getting better at doing that: it is no longer shameful to admit to being      human and mortal. Problems sometimes are not of the outer world, and only loom large in your mind. Talking it through can help you regain perspective.

Don't take it out on yourself, or on your significant others who only want to help you, and for all  the right reasons. And music has its own soothing power.


Your work can bring you a sense of self-worth which is a wonderful asset when derived from knowing you are on your own special personal path, and that your path is worthy.

Find your on-going process of being as you go through life: your life is your very own significant enterprise. Seek to learn, discover, and understand whatever you think will help make you what you believe you are meant to be -- to the extent one can in one lifetime.

Don't become impatient: learn as you go, and don't be afraid to change your situation when you think  you should. Everything comes in its own time (Ecclesiastes).

Making It So -- Act with Purposeful Consistency

Join in the Stream of Life with a worthy goal or purpose. Then you can act with dedication and devotion, without doubt or fear,  in continuous support of your mission.

Your words should be supportive, positive, consistent, and truthful. It only takes one person of inferior character to frustrate and put down many others. Build teams carefully, and trust peer selection. 

Bring your earned credentials and authority to each situation, tempered always by understanding and compassion. 

Be a center of stability for yourself and others as things happen; be supple, yet solid in what counts.


Time is alive, dynamic, and has many aspects: we live according to Cyclical Time -- The Seasons and the Life-Cycle; we all seek The 'Right' Time; we try to live in accordance with 'The Times'; we sometimes desperately want our 'Set-aside' Time for contemplation and inner discovery. And on some level, we 'know' we are part of 'All-Encompassing Time' -- the on-going Process of The Cosmos.

We also speak of 'Moments out of Time', markers with potential for greatness or doom -- when all creation stops for an instant -- the birth of a new life, the collapse of a hope -- a time to live and a time to die. There are even those rare, sacred, instants when time itself is transcended, allowing us an intimation of Creator. 

All of these aspects and qualities enter into the lives and works of everyone, and of First Responders in particular. First Responders know from first-hand experience that the Cosmos has dimensions beyond what we can measure and understand – they have been 'touched' by it, though they may prefer to not talk about it -- because its impossible to communicate the experience to someone who hasn't 'been there': other than to acknowledge that 'It' does happen.


As you Grow, the Values you live will influence the world around you. Recognize and accept you are an exemplar – let your light shine, illuminating your path, and serving as a beacon for others.

You have the potential to impact many lives – for good or for ill. Live appropriately.

NOTE: Substantially the same article appeared in First Response, the print journal of the Volunteer Ambulance Officers Association of Tasmania Vol 12 #2 November 2007.



Covert and overt bias in the Ontario referendum process

[Sep 30 07]



On October 10th, Ontario will hold an election. Voters will also be asked to decide, by Referendum, whether to continue with the current system of voting by riding (electoral district) with the candidate getting the most votes declared the winner, or according to “Mixed Member Proportional.”

We arrived at this point through a devious process. It was initiated by the majority Liberal Government through the Ontario Legislature. Then, in March 2006, individuals were chosen by random selection from the voters lists – one from each of the 107 ridings – to form “The Citizens' Assembly on Electoral Reform.” The members of the “assembly” (plus alternates) were then put through a lengthy process of education and indoctrination by a team of academic experts hired as consultants.

Attempts were made to portray the process as impartial, legitimate, and representative, but the outcome was preordained, illegitimate, and non-representative. This wasn't the fault of the individuals who made up the 'Assembly' – they were worked over by experts.

This was an exercise in 'Smoke and Mirrors' and it was deliberately planned and neatly executed.


The name “Assembly” was chosen to conjure up an equivalence with such honored bodies as “The Constitutional Congress,” and “The Fathers [and Mothers!] of Confederation” but it has no such legitimacy. It is, accurately, a randomly selected aggregation of individuals, citizens of Canada and resident in Ontario. They were not selected for their skills, insights, or super-powers. This in no way diminishes them; they are citizens and voters, and they did their job well: given what they had to work with, their terms of reference, and what they were subjected to.

Even Ontario's Chief Electoral Officer was sucked into the sleight-of-hand. A pamphlet in his name went to every household in Ontario. It states: “In March 2006, the Citizens' Assembly on Electoral Reform, an independent body representing electors in Ontario, was created.” Representative of electors how? In truth, the Citizens' Assembly is a lot less representative of the electors of Ontario than the eclectic and spontaneous 'meetings' which take place every Sunday morning at our corner Tim Horton's.

The Title “The Citizens' Assembly on Electoral Reform” implies the way we elect voters is fatally flawed, and the members of 'The Assembly' have a sacred duty to recommend a 'better' way. A more impartial title would have been: “An Inquiry into the Merits and Flaws of various Electoral Systems,” but that wouldn't have had the same sense of urgency and importance.


To educate and suitably guide the members of the “Assembly,” the Liberal Government of Ontario enlisted a team of Academics to prepare background material, make presentations, run question-and-answer sessions, and lead the whole process. (The background material is freely available on the 'Web', and there is a lot of it).

The academics came with strong credentials and did an awesome job in both presenting information and in making it seem as if the whole process was impartial.

The 'educating' began with a learned paper on “Ontario Values and the Electoral System,” setting forth a set of values to guide the “assembly's” deliberations, together with a one-sided argument against the present system. This key document unequivocally tels the “Assembly” that 'Mixed Member Proportional' (on the lines used in Germany) is the only possible answer. Accordingly, the Ontario Electoral Reform Referendum, which flows directly from this paper, offers voters only two choices: the present system, and MMP.

Under MMP, Ontario would have a larger Legislature (129 members) but fewer ridings (reduced to 90 from the present 107). Each voter would have two votes: one for a candidate in a riding, and one for a party. Riding candidates would be elected by 'the most votes wins'. Another 39 members of the Legislature would be 'elected' according to a party's proportion of the total of votes received province-wide. Each party would prepare its candidate's list in advance, and obviously those at the top of a party's list would be the most likely to succeed.

The author claims the present system, in which we vote by ridings with the candidate with the most votes declared the winner, is neither fair nor democratic: because we now have more than two parties and the proportion of seats gained no longer matches the proportion of votes.

This argument is short-term and narrow. Third, fourth, etc. parties arise because the established parties are not meeting the aspirations of significant numbers of people (usually concentrated in a region) on one or a 'basket' of special issues. When this happens, it is as if an earthquake has struck the body politic. There is a time of radical utterances, and sometimes minority governments follow.

The traditional parties then work diligently to co-opt the upstart movements; by luring members to defect, and by adopting some of the more popular planks. This usually works, but it takes time: usually a matter of years.
Sometimes an upstart matures from a protest movement to become a more permanent main party in its own right. And, as we have witnessed in very recent times, the upstart may go so far as to co-opt and replace a traditional party!

The point is this: a free and democratic system, parliamentary or otherwise, undergoes peaceable change only in this way, and it takes time for the changes to work their way through the system; as voters and politicians alike negotiate, debate, co-opt, and horse-trade. This may not be academically neat, and is not swift, but it is the essence of politics in a civil and pluralist nation in which checks-and-balances are accepted as necessary by all parties. The alternative is dialectical change, which is tantamount to revolution; which is how academic fields change their governing paradigms. But that is not in line with how the rest of us see the world.


All votes are not equal. Urban ridings contain 3 to 4 times the voters of rural ridings. This imbalance was deliberately built into our democratic tradition to offset the overwhelming economic clout of the big cities c.f. of Toronto in the case of Ontario. Proportional Representation would invert this imbalance to overwhelmingly favor Toronto over those living in small communities and rural areas. This is precisely why the Liberal Party of Ontario wants the referendum and desperately needs a vote in favor of MMP – then even if the Liberals win a minority of seats riding by riding, they could still end up with the majority in the legislature by virtue of the larger numbers of voters in Toronto.


MMP is the only way that fringe groups can gain a measure of legitimate power, though, of course, they always have the option of using non-legitimate and criminal methods , such as extortion, intimidation, vandalism, violence, arson, and murder.

Hitler first got a toe-hold of legitimate power through proportional representation, and then sent his brown shirt and black shirt private gangs into the streets to create chaos. Then he represented himself as the only one who could bring the violence under control, forced an election, and won handily. Then there were no more elections, and no more freedoms.

Because proportional representation is not in any way tied to ridings, a few malcontent votes in each riding can total up across the province to gain representation in the legislature (2.5% = 1 seat).


We do not live in a civil society, but for the most part most people abide by the law. If the new electoral system comes in (2011 or sooner in the likely event of civil unrest), you can expect radical polarizations across our society. Thanks to 'multiculturalism' and politically correct ‘diversity’, the fracture lines are already in place.

With MMP, new political parties will emerge from each nest of aggrieved feelings. Already existing, they only need the catalyst of the Referendum to appear. Each will axiomatically give rise to it’s polar opposite. Long-standing antagonisms will find dangerous forms of expression. There will be no room for moderation: the would-be moderates will be howled down -- or silenced by more violent means.

The ‘Iron Law of Oligarchy’(first stated by Roberto Michels in the 1920’s) will overtake tolerance and civility -- organizations, even those with the most noble and altruistic of ideals, will find their values surrendering so the privileges and power of their leaders can be perpetuated.

In the nature of things, and especially in organizations lacking any effective external checks and balances such as competition (the public service unions faced only by spineless governments are the prime example) confrontational politics and extremism will inevitably take over.


I am listing some of the main forces which will emerge as political parties, but note that the names they ultimately choose may not have much relationship to what they really stand for:

Power/Supremacy: variously of Whites, Blacks, and any other Color or Creed or Race, or Ethicity, Belief, or Culture (including the long memory of Historical Reality and Myth): each proudly dedicated to killing all the rest.

“God is Great but We are Greater.” Even within each mainstream faith, there is plenteous opportunity for factionalism and sectarian strife brought to the political (and street) battle-grounds. Remember the Wars of the 'Reformation', Ireland, and the Balkans?
[Will Irish Catholics merge with the Green’s?] [Will Boyne Battle be resumed?]

“Working Families” -- “We can continue to Have It All!” [Sure, and who pays?]

First Nations - “We Own it All! And We can get ‘it’ (guns, booze, tobacco, illegals) for you Wholesale and Duty Free.” [Business as Usual]

New Grange - “Green Acres is the Life for Us, Toronto is for all those Wuss.”

The Battle of the Area Codes:
“416 - Toronto Uber Alles”;
“905 - Not in Our Backyard!”
The Rest of the Area Codes - We All Hate Toronto!”

Pro-Choice [but only on Abortion] vs. Pro-Life [Human that is]

Green - “If all the people were dead, this planet would be a great place to live!”

Evolution is Great and Darwin is It’s Prophet - “Freedom, except for the Right to Believe in God.”

Public Everything - “Government is the Way and the Truth.”
Private Property and Right to Life and Liberty - “Please Sir, may we have some more?”

Women’s Rights - “Anything you can do I can do Better.”
Men’s Rights - “Yes. So where do we go from there?”
Children’s Crusade – [Ask any Advertiser]

Non-Governmental Organizations - All Government Handouts accepted, so we can turn around and bite the hand that feeds us.”

Groups and Clubs, all easily convertible into political parties: Service Clubs, the Legion,
Sports Associations, Pro- and Anti- c.f. Fishing and Hunting, Guns, and many more.

Imagine, post-referendum, if MMP prevails, and if we are still allowed to vote, facing a Ballot listing Parties representing a hundred and more warring sects and factions.

Its coming soon to a theater much too near to you.




Healthcare facilities and indigenous infections


[Sep 10 07]


Today's hospitals have taken precautions to prevent the entry and the spread of infections. One hospital has announced it will screen all patients for resistant bacteria and viruses as part of its admissions process. Any carriers will be suitably quarantined.

Hand sanitizer dispensers in lobbies and on the wards outside every room are a key aspect of modern health care. You might think that the doctors, nurses, and support staff -- the ones most frequently in contact with patients – would make the most frequent use of hand sanitizing between ministrations. If this is what you think, you are wrong. Hand sanitizing is almost exclusively used by visitors in their own interest.

When you next visit someone in a health care facility, quietly watch as the staff goes about its appointed rounds; spreading bacilli here, viruses there.

On a recent visit to a friend convalescing after a knee replacement – she was in a cheerful room with seven other patients – we learned that she had been given pneumonia as an added touch. Most of the others in the room had the same infection. This is sharing at its best, in accordance with the highest principles of egalitarian health care.

We were privileged to watch the doctors and nurses at their work, diligently and unselfishly carrying infections from bed to bed. Not for them the interruptions of sanitizing hands between patients.

And where the more lethal infections are to be found, there too the bravest and best will be found: accumulating germs and viruses so these too can be more broadly distributed.

This is not unique to one hospital or city, province or state, or nation. It happens everywhere, be it in a public or a private facility. Drop in sometime and quietly watch what goes on. Visit a ward. Have a coffee, and relax. Give it the time it deserves.

At a minimum you will be surprised. You might even be appalled.

A related report from Johns Hopkins Hospital (Aug 29 2007) deals with a 2004 outbreak of Norwalk virus at 24 hospitals in Maryland. It states:

“Outbreaks need to be identified quickly and dealt with immediately”
“Relying on standard infection control procedures is not adequate”
“It may be necessary to close the infected units, isolate the infection source, get strict on hand hygiene, conduct a thorough washing down of units, and keep repeating these steps until the outbreak is stopped.”

The punch-line is: “Health care workers especially need to be vigilant about these steps because they are the group primarily affected by outbreaks.” How odd; I would have thought the patients might be somewhat affected too.

However, this was a wide-spread emergency situation, and health care workers were definitively impacted; so emergency action was called for.

This was different from the common-or-garden hospital infections -- which have little impact on health care workers. They merely prolong patient recoveries, add to the strain on scarce resources, and occasionally lead to slow and permanently crippling deterioration until eventual death in a long-term care facility.

Best to wash your hands of the whole thing.



Wait Times and Danger Pay


[Aug 27 07]


No More Waiting?

A sign of the times (and of an election in Ontario in October): a forceful ad campaign and a new web site
www.nomorewaiting.info sponsored by CARP (The Canadian Association for Retired People).

CARP has three simple “demands” --
*No more waiting in the Health Care System
*Provincial government funding for all medications approved by Health Canada
*Major federal Government funding support for home care-givers.

CARP seems to be ready and willing to take on all the provincial governments: Ontario is in the cross-hairs right now because it will be the first to go before the electorate. (Strike while the politicians are hot).

Like the other provinces, Ontario has committed to 'reducing' wait times in five critical areas. Anyone unfortunate enough to need attention in an area not presently covered is out of luck. The obvious remedy is for the sufferer to aim for one of the five areas in the government's focus -- regardless of what the actual problem is. So you need a new shoulder: sorry that's not covered, so go for a new hip. At least you get some attention, and who knows, given the prevalence of error and incompetence, you might actually end up with a new shoulder instead. Though it might well be on the wrong side.

Ontario defines wait times as the time from seeing a specialist and getting a booking for an operation until the operation actually takes place. This is a neat definition. It leaves out all that nuisance stuff: like finding and getting an appointment with a Family Practice Doctor who will recommend a Specialist, then trying to get an appointment with said Specialist (which might take a year), and then after seeing said Specialist, your Wait Time begins. Going after a second opinion sets the whole cycle back to square one; so take what you can get, and pray a lot.

Ontario (and the other provinces) established what are claimed to be reasoned Wait Times, by consulting with a slew of experts. CARP established its own estimates by consulting with a slew of experts. The CARP estimates are a matter of days and weeks; the Ontario estimates are a matter of many months. The key difference seems to be that Ontario asked what was reasonable for the Health Care System to accommodate, while CARP asked what was reasonable for the Patients.

The Supreme Court of Canada (June 5th 2005) made it clear that “Access to a Wait List is not the same as Access to Health Care.” It also stressed that a provincial government (of Quebec in that instance) does not axiomatically have the right to arbitrarily torture and murder its residents by denying them the means to access health care for services covered by the provincial health care plan which are in fact not being delivered. Similar findings are expected in regard to the other provinces. But don't hold your breath, because the Millennium is still off beyond the horizon.

Here are some quotes (March 16 2006) from Dr. Alan Hudson, Lead of Ontario's Wait Time Strategy:

“For many people, wait times are the tool they use to take the pulse of the health system – to measure the quality of the care they are receiving. The reason for this is clear: the best medical procedure in the world isn't good enough if it isn't delivered in time. The problem is the access patients have to health care.

“Incredibly, there has never been a system for managing wait times in this province. For too many years, Ontario residents and health care providers had to rely on rumors and anecdotes about wait times because nobody was collecting and assessing the data that would have painted an accurate picture of wait times across the province.”


Yes, it is incredible and it's not just in Ontario: it's the same for all the provinces. No one has a clue because no one has ever audited the healthcare system and no one has ever brought together the numbers to allow a determination of such trivialities as efficiency, effectiveness, quality of services, consistency, and reliability.


What is known: healthcare in Canada costs $80 billion a year. That's a trillion dollars since 1992 and in real terms that adds up to a whole lot of cash. What isn't known: is that money usefully spent? Could the job be done for less, and could it be done better? Is there value for money? The healthcare administrators don't know. The unions - professional and otherwise - don't care. The patients are happy just to survive.


Danger Pay


Back when SARS threatened Toronto, the Ontario government of the day introduced strict quarantine measures reminiscent of the often drastic quarantine laws applied in times of plague [as in London 1664-65].


Quarantines are difficult to enforce, but the quarantine worked for Toronto and SARS was contained. But, as can happen when something new attacks in epidemic proportions, people died and some of them were healthcare workers.


They died in part because we didn't know enough -- we never do -- and in part because people wore the wrong masks, or they weren't properly fitted, and because the hospital culture took a while to get over an under-estimation of the dangers. We will be ready for SARS next time, but next time it won't be SARS, and there will be casualties.


One outcome of the re-hash of the SARS experience is a call for danger pay -- looking ahead to an anticipated pandemic. Undoubtedly healthcare workers will face risks and uncertainties; some will be casualties and some will die. It's not enough to say that it goes with the territory and the Hippocratic Oath -- I'm not sure it does when it comes to the crunch.


In the exceptionally virulent plague outbreak in London [1664-65], many of the best doctors and nurses died in the first weeks, as they worked valiantly and desperately to help the sufferers. This was not the dark ages; London was a capitol of enlightenment, home to many men and women of science and medicine. But when the plague came, in a particularly horrific form, they didn't know enough. Regardless of how advanced we think we are today, the same truth holds -- we never know enough, and too often, the best among us die trying to stem the tide.


Danger pay or compensation or insurance may well be justified. But think about it: pandemic is just one form of disaster affecting the many, and the response to disaster involves the many. There are many unsung heroes. There are many who suffer, and too many who die. Pandemics, like disasters in general, do not differentiate between the professionals and the rest of us. Doctors and nurses, and orderlies, and many other healthcare workers, are on the firing line. But so too are the paramedics, firefighter first responders and a host of others including volunteers. And then there are the collectors of the dead, and the ones who dig the pits and dispose of the corpses. How about the folks trying to maintain law and order while the world around panics and goes ballistic? And finally, there is the largest category of them all: you, me, and everyone else; the patients and the potential victims. We are all in it together, so where does danger 'pay' begin and end, and with whom?


A few callous souls have argued that if 'we' don't get danger pay 'we' will simply down tools and refuse to show up at work; the 'we' variously referring to doctors and other healthcare workers. It's an interesting argument. Fortunately, there is a precedent --


A few years ago, emergency room doctors in Winnipeg walked out. They claimed, likely justifiably, that they were overloaded, the system was breaking down, and no one cared. So they downed tools and the entire emergency system shut down. I think the walkout lasted for two weeks or thereabouts. The mortality rate in Winnipeg dropped alarmingly; of the order of 30 percent. In due course, the emergency people returned to work.


But one seems to have absorbed the underlying issue: if there were no healthcare system, would we be worse off or better off? What would happen if all the patients downed tools and walked out? How would the politicians cope with a pandemic of angry voters? Let them try to quarantine that!


Remember Bob: "You have the power." So vote as you like, but vote often.


Of social engineering and partisan politics


[Posted Jul 15 07]


Last Friday evening, well past sundown, we heard a pounding at our back door. It got louder. I went to investigate; a young man was busily trying to wrench the screen door open so he could attack the main door. He succeeded in damaging the locking mechanism and twisting the door out of shape. Then he hammered at the back door proper, trying to break in. I was not amused. I unlocked the door and asked him in non-genteel terms, what he thought he was doing. He stepped back with an idiot smile on his face and waved a handful of light bulbs at me. At my added suggestion that he take off rapidly, he did.

He was evidently a would-be savior of our planet who had picked up on the messages from the Government of Ontario that it is not only okay but laudable and legal behavior to trespass, steal private property, break in to people’s homes, rummage through their most personal belongings, and admonish them for their life-style choices.

This may seem weird and cynical to you, and it is, but this is an election year in Ontario and anything goes in the interest of getting re-elected.

To further this end (which not everyone sees as desirable) the Government of Ontario commissioned and sponsored a series of TV ads. David Suzuki, who has the virtue of speaking without apparent anger or malice, and does his admonishing softly and intelligently, is the central player in this slick and expensive ad campaign which is cloaked in the image of energy-saving and what the Ontario Government deems a politically correct life-style.

In the first ad, it is dusk and we are looking on a street of classy (very expensive) single-family homes. Various individuals appear: they are all young, trim, attractive, and smiling. They come from different racial groups – a living panorama of the delights of Ontario-style diversity. There are no older folks: presumably they have no place in the latest version of the Ontario vision, and have been relegated to the backyard or the basement (but not for long, since Mr. Suzuki will show up there in the next commercial and they will have to be trundled off to the attic or garage).

A young man walks out on to his porch – all the houses on this street have attractive porches: nostalgia-modern in design and totally absent any of that old decadent stuff like rockers and hammocks. Every house has its porch light beside the door at a convenient height so Mr. Suzuki can flit from home to home snatching the old style light-bulbs and replacing them with the new fluorescents. We are not shown what Mr. Suzuki does with the old bulbs: perhaps he tosses them into the shrubbery for the squirrels?

The man who has just emerged from his home is called Bob and Mr. Suzuki knows his name! (Maybe Mr. Suzuki calls everyone, male or female, Bob?) Bob is evidently of even temper, because he is not in the least perturbed by the sight of someone changing his light-bulb, and those of folks up and down the street, without asking permission. Perhaps Bob is on valium? Perhaps everyone in this commercial is? Anyhow, everyone on the street is as happy as if they were in the closing scene of a Disney family entertainment, and so is Bob: more so, when Mr. Suzuki tells him: “Bob, you have the power!” And Bob does have the power: to smile and agree with Mr. Suzuki.

In the second commercial, Mr. Suzuki materializes in the basement of a man’s home. We never do learn this man’s name: just as well because he is a beer drinker! How Mr. Suzuki gets there is not disclosed: the man is surprised by his presence there, so perhaps Mr. Suzuki broke in – or worked a ‘beam me in’ deal with Mr. Scottie of Star Trek. Regardless, Mr. Suzuki takes it on himself to prowl around. He even inspects the guy’s beer fridge. Lo and behold, it contains four small bottles of beer! (“Four green bottles, standing on the wall …. Etc. ad nauseum”) The brand of the beer is not revealed. Mr. Suzuki gently admonishes the guy for having that big fridge with only four bottles in it. This is a clear and evident waste of energy! The guy is overcome with shame and goes on his knees promising to do better. Mr. Suzuki tells him, gently, that he too has the power. The guy goes on a rampage turning off every appliance in the house and scaring the wits out of his family.

Though the second commercial doesn’t show it, after Mr. Suzuki is beamed elsewhere by a beneficent Ontario Government, the guy takes action to redeem his self-esteem. No more will he be caught with a big fridge holding only four paltry bottles. He gets on the phone and orders a complete and vastly expensive security system – no more strangers in his basement! Then he rushes out to his enormous pick-up truck, warms up the 407 horses under the hood while revving the engine every few seconds to the delight of his long-suffering neighbors who wish he would materialize on some other planet. After generating a sufficient tonnage of smog, not to mention the noise which approximates a 747 coming through your window, he takes off to a second-hand store and buys another beer fridge which he picks up with one hand and tosses into the pick-up. Then he heads for the beer store. He is a believer in diversity, so he buys 24 cases of 24’s - -each different: – he is a big guy and four measly bottles aren’t going to even wet his whistle. Thanks to Mr. Suzuki, now he knows better.

Finally, he stops by a discount supermarket and buys a two-yard high stack of frozen pizzas. He heads home where he plugs in the second beer fridge, guzzles the four bottles in the first fridge, crams in as much beer as the two fridges will take, gets the oven hot and slides in three pizzas, turns on the TV to the ball game, turns the air-conditioning up as strong as it will go, and settles in for a happy green afternoon.

Oh yes, he now has a huge and extremely vicious dog trained to kill strangers, and fetch his beer. Unfortunately, he hasn’t yet been able to train it to fetch pizza – the dog loves the stuff, and no one is going to argue the point. But alas, none of that appears in the commercial: you have to take my word for it.

I note that the Ontario Government, and Mr. Suzuki, are come-lately to the light-bulb replacement game. I replaced all the bulbs in our home two years ago. I liked the idea that the fluorescents burn much cooler, and I assumed safer; and of course use much less energy and seem to last longer. I have had one fluorescent burn out quietly; which is reasonable after two years. However, another one loudly exploded, fuming up the house and destroying the light fixture: it took three days to get the smell out.

As to the Ontario Government and its peculiar ethics, I will vote suitably come September. Have a cool one, David.



Ethics and Triage: A Nasty Scenario [Posted 17:40 Dec 12 06]--If only the rich could pay the poor to die instead of them, Then the poor would make a very good living. (Ancient Yiddish Joke)

A Flu Pandemic has begun. The hospitals are crowded. Staff is overworked: many have come down with the flu – one sort or another. The ‘normal’ flu doesn’t vanish just because of a pandemic. Even before the flu's came, the usual ailments and conditions have just about taxed the limits of the system’s capacities; and the pandemic is a long way from peaking.

It’s bitter cold outside. People, old and young, are dragging themselves, or loved ones, or neighbors, to Family Practice offices, and to hospital Emergencies. Taxis refuse to take them – this stuff is dangerous! – public transit is barely operating: drivers are sick, or calling in sick and maintenance is non-existent. Who would want to ride the bus and breathe in undiluted virus? So people drive, or walk, or stumble, or are wheeled to their local version of purgatory.

The paramedics and first-response people, like many doctors, nurses, and orderlies, have, in some cases, literally worked themselves to death. Others are genuinely seriously ill at home. In any case, hospitals won’t allow ambulances to unload: the situation has become too serious for ambulances: they are irrelevant against the scale of the emergency. This puts the First Responders in a Catch-22 bind: what are they supposed to do with the living, the dying, and the corpses? The fire-paramedic and police stations have become hospital wards, and mortuaries.

Family Practice offices are crowded; there weren’t enough to begin with, and now more and more are closed – the doctors and nurse practitioners have strived valiantly for weeks, working round the clock; but many have succumbed to the illness and are too sick to carry on. Some have already died. The sufferers keep arriving – and are told to go to “Emergency.”

The Emergency is so crowded it’s impossible to move: too few staff, too few Triage Officers’, too many forms and too few to fill them in. More tests needed? – long waits; supplies dwindling.

It’s not just in “Emergency” – the corridors are lined with sick and dying. The ‘lucky’ ones have beds; others are wrapped in blankets on the floor. The sound of coughing, hacking, groans rasps and rattles adds to the background. The place doesn’t smell- it reeks.

The only ones around to help are family and volunteers; but they too are a dying breed.
The kitchens have shut down. The Tim Hortons a few blocks away is the main source of hot soup and beverages.

The chaos extends outside the hospital. Every few minutes a car pulls up to the curb and someone terribly sick is pushed out or loaded into a wheelchair; and then abandoned. People are desperate. People don’t want to watch loved ones die. They want to get them to where help is available, but there is no more room at the inn.

There’s no room and the authorities have instituted a quarantine. There are fierce barriers to admission - -even to approaching the hospital. Police and Military, guns evident, are supposed to enforce the ban, but they didn’t sign up to turn away the sick and dying to perish of exposure on the street; at the very gates of supposed aid and comfort. They try to keep a semblance of order: lining up the wheelchairs – many with their frozen dead occupants -- in neat rows. Some are in tears; none will ever be free again in their minds. This is not a job: this is hell.

Worse yet are the ones who have lost it, watching their loved ones going downhill with no access and no hope. Some arrive in a rage, screaming threats, demanding access -- armed and very dangerous. Are they to be gunned down on the spot? Is there time, patience, and skills to talk them into calm? Can it be done?

Pharmacists (legitimately part of the Front Line) are also besieged as people line up to request, demand, and plead for something – anything – to help their loved ones. They are worked off their feet doing what they can, but they are hampered by government irresolution in deciding what powers pharmacists should have. It would have been an enormous assist to everyone if government had given them emergency powers to prescribe and dispense on the spot; and if government had also picked up the tab for all pandemic-related drugs. Some go ahead and prescribe anyhow; but supplies are dwindling.

As in all pandemics, even in our supposedly enlightened age, the miracle-workers with trumped up testimonials from the crowned heads of Europe, quacks with nostrums, and ‘end is nigh’ callers to repentance all have their moments of glory -- and riches: its remarkable how expensive the goods and services are which these selfless folks ‘freely’ offer. Human nature is eternal in its often excellent ways -- and in its folly.

At the other end of the chain, the mortality rate among those admitted to hospital is much higher than predicted: in part because the virus is especially virulent; in part because the system has broken down; and in part because all attempts to establish interior quarantines (cohorting) have been defeated by increasingly over-worked staff, and a shared air-circulation system. The usual crop of hospital-specific infections is proliferating.

There are no more resources left and little chance of getting any anytime soon: suppliers and distributors are at their limits and manufacturers are forced to ration dwindling output.

The hospital mortuaries are full. Autopsies will have to come later -- much later; if at all. Meanwhile, bodies, neatly toe-tagged, are stacked like firewood in a more-or-less exterior courtyard. The weather is cold enough: they will wait there quietly. Anyhow, morticians have closed up shop for the duration. Those with the courage and strength retrieve their dead and go to join the long lines at the crematoria.

The death rate is also high among the thousands cleared out from the hospitals to make room for the pandemic flu sufferers: sent home, or to long-term care facilities, or otherwise moved out of sight and out of mind. They live, or die, or will be debilitated for the rest of their lives.

Scalpers are thriving: they don’t mind the cold as they wait patiently on the streets around the hospitals for new arrivals. The going rate for an admission for one is $25,000 (up front in cash). There are enough takers to make the middle-men wealthy, and to handsomely reward the good folks inside who are ready to pocket the bribes. Being a triage officer, or a key person in the paperwork chain, is a license to print money.

Anyhow, a disproportionate number of highly placed bureaucrats and politicians, and their friends, family, and lovers, seem to get rooms and beds and ventilators, and the world’s gone mad around you, so why not get some benefit? After all, you’re one of the few still on the job, taking the big risk with your life, so why not?

There are still some who are trying hard to stay ethical – to do the right thing because it’s in their nature. But it is hard; because so much has gone wrong and it’s not a matter of pointing blame. It doesn’t mean the Plan was flawed. It doesn’t mean that society, and the system, were at fault. There may have been flaws and errors, but that’s only because we are human and frail and mortal and come with the full set of emotions. This emergency is overwhelming – like a millennium storm it has surged through our cities and buried our best plans and hopes in an abyss of tragedy. (It happens).


Worst Case scenarios seldom happen: by definition, they are unlikely. But when they do happen, they tend to be much worse than anyone could imagine.

I wrote this scenario to try to answer a lurking question: are Ethics and Triage at all compatible? Worst Case scenarios test the limits and when I think about what could happen at the limit, I don’t at this point see any room for Ethics (or Morality) in a Triage situation --- unless, and this may be key – the Ethics are built in to the Triage Design.

However, stating a set of lofty humanitarian principles up front is not the same as ensuring they are followed in the field. With the best will in the world, Triage has to be based on other principles – such as making the most effective use of limited resources, and the greatest good for the most.

Fairness is a worthy test of a system – in the sense that Triage and what follows must not be arbitrary, and should be equitable (without fear or favor). In the main, that is feasible – though there will always be queue-jumpers. But Fairness has little to do with Compassion.

Hard choices -- sometimes the trade-offs are wrenching, at best.

I’ll try to work some more with these issues. Your views, in the light of your own experiences, would help.

Be well.



Pandemic Flu Planning: "A Flow is a Quantification of Assumptions" [Dec 6 06]--References. I have made use of three references: 1] Government of Ontario Flu Pandemic Plan, Chapter 17 Acute Care Services & 17a: Tools; 2] Shoppers Drug Mart Healthwatch Pamphlet: Flu; and 3] Government of Ontario Pamphlet, “What you should know about a flu pandemic.”  April 2006.

My own comments are enclosed in brackets [like so].

Flu and Pandemic Flu Facts


Flu is caused by influenza A and B viruses.

It is spread mainly by virus in the air.

It finds a comfortable home in your airways.


It starts to be contagious 1 day before you first experience symptoms and remains contagious for at least 5 days after symptoms start.

Flu can lead to serious complications: pneumonia, bronchitis, sinus infections, ear infections, dehydration, and in very serious situations, death.

Ordinary flu happens every year: usually from November to April – and then stops.

Pandemic flu usually comes in two or three waves several months apart. Each wave lasts 2 -3 months.

5%-20% of the population may get the flu in any given year.

A yearly flu shot reduces risk of catching flu by 70-90%.


A pandemic is distinguished by its scope: it is a worldwide epidemic.

A pandemic flu strain often develops when an animal or bird virus mixes with a human virus to form a new virus. Because people have little or no immunity, the disease can spread faster than with an ordinary flu.

The symptoms are the same as with an ordinary flu but can be much more severe.

There were three flu pandemics in the 20th century: the most deadly, the “Spanish Flu” in 1918-19 killed 20,000,000.The death rate was highest among healthy adults in their 20’s and 30’s. [The Median Age of Ontarians is 37].

A flu pandemic could happen any time.

We can’t predict just how society will be affected until we learn how strong the virus is.

There is no existing vaccine for pandemic flu. It will take 4-5 months after the start of the pandemic to develop a vaccine.

Drugs used to treat ordinary flu may also help people with pandemic flu but we may not have a large enough supply, and we won’t know how effective they are until the virus is identified.



Based on CDC’s U.S. FluSurge Forecasting model and an assumed 35% Influenza Attack Rate --

Over an eight week pandemic:  [there might be 3 such waves in a pandemic year]


Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
3675 6125 9188 11638 11638 9188 6125 3675

Peak admissions/day: 1814


Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
726 1209 1814 2298 2298 1814 1209 726


If you live in Ontario: during the first wave --

You have 1 chance in 3 of catching the pandemic flu

If you catch it, you have 1 chance in 2 of needing to visit your family doctor

and 1 chance in 70 of needing to be hospitalized 

If you need to be hospitalized, you have 1 chance in 5 of dying there.

An unknown proportion of the population will develop health complications.

These levels are at least six times greater than typical hospitalizations for influenza and pneumonia during inter-pandemic periods.

[If you don’t get the pandemic flu in the first wave, your odds improve greatly:

*improved natural immunity from the 1st wave experience

*probable availability of a pandemic flu vaccine

*much better understanding of how to deal with the virus]

Resources needed by Hospitalized Influenza Patients:

100% using an acute bed for 5 days

15% using ICU beds for 10 days

7.5% using ventilator support for 10 days

If the Assumptions hold:

At the peak of the pandemic, influenza patients will use:

52% of all Acute Care Beds

170% of ICU Beds

117% of Ventilator-supported Beds

Current Demand for hospital services is already high: ICU Beds are utilized 90% daily.

The FluSurge model does not take into account Health Care Worker absenteeism but the Plan assumes that staff will contract influenza at the same rate as the general population in their communities. [History suggests staff will come down with pandemic flu at a much higher rate, and fatalities will be disproportionately high -- especially in the first weeks. If so, the net effect will be to seriously reduce availability of trained staff as the pandemic goes on: the impact will be particularly grave should a second wave and then a third wave hit]

[The Model does not consider how patients will be moved to and from hospitals: Ontario is a big province with a population of 12 million (5 million households). However, Ontario is 80% urban, and most live in the so-called “Golden Horseshoe – from Oshawa to Niagara, including the Greater Toronto Region]. 


There has to be a Phased Approach:

*Deferring non-influenza care

*Dynamic use of influenza Triage

*Dynamic Use of Admission/Discharge Criteria

These will vary according to available and needed local hospital resources.

Specifically --

*Defer Services for Non-Life-Threatening patients.

*Discharge ALC (Alternative Level of Care) patients to Long-Term Care.

*Discharge acute patients and inpatients to home care.

*Create “flex-beds” from reserved or recently closed beds.

*Deploy freed-up beds for influenza patients.

*Use Ventilator Capacity anywhere sufficient oxygen is available:

  ER, post-anesthetic care units.

*Cohort infectious and non-infectious patients.

Re-deploy staff.

*Defer holidays and leaves of absence.

*Establish 12 hour shifts.

*Train non-clinical staff to handle support services: meals, personal care, patient movement, cleaning, etc. and support for health care workers and families (child care, pet care, etc)

*Coordinate with other hospitals.

*Encourage participation of public in Home Health Care courses before the pandemic.

*Cross-train clinical staff.

[Wait until the Pandemic strikes. Then count backward 1 year, and initiate training].



With the assumed 35% Attack Rate the phased development of Surge Capacity will not be enough to meet the Peak Demand. Accordingly, a Mass Emergency Care condition will have to be declared: this will have “substantial legal, regulatory, and logistical implications.”

The type of Triage contemplated is only justifiable in an Overwhelming Crisis i.e. when all resources are in danger of being exhausted.


*All patients will be cared for – one way or another. [True, but not very comforting.]

*Triage is a practical application of Ethics [Everything is.]

*Fairness and Justice will prevail. [How about Compassion?]

*Based on Clear and Transparent Criteria.

Timely Accurate Information is vital

Health Care providers will need real-time data about patient outcomes during a disaster; in order to modify criteria and prevent over- or under-triage. The Protocol will evolve with time and use.

Triage Models

No Triage systems have been developed yet for use in critical care or medical illnesses but there are models available to draw on:

Illness Severity Scoring Systems: “cumbersome and impractical during a disaster when human resources are scarce.”

Military Triage Systems: “devised specifically for Trauma and not for medical conditions or biological events.”

SEIRV Triage System: “developed for use in Bio-Terrorism attacks.”

Categorizes patients but does not address Resource Allocation.

Uses ‘Inclusion’, ‘Exclusion’, and ‘Minimum Qualifications for Survival (MQS)’, to guide triage decisions – “which should be part of all Critical Care Triage Systems.”

Sequential Organ Failure Assessment Score (SOFA): “may be useful as a component of a Triage System.” It uses general physiologic parameters applicable in a wide variety of conditions.

Inclusion Criteria

Identifies patients who may benefit from admission to critical care: focusing primarily on respiratory failure.

Exclusion Criteria

Identifies those needing a level of resources which cannot be met in a pandemic, and even if ICU resources were found they would have a very poor chance of survival (SOFA Score of > 11 i.e. mortality rate of > 90% even with full critical care). For example --

*Severe burns

*Cardiac Arrest not responding to prompt defibrillation or cardiac pacing .

*Needing large blood transfusions

*Underlying “significant and advanced” illnesses with poor prognosis and high short-term mortality (as in advanced cancer and end-stage organ failure)

MQS -- Minimum Qualifications for Survival


*Place a ceiling on the amount of resources that will be allocated to any one individual.

*Early identification of patients who are not improving and are likely to have a poor outcome.

In other words -- find a ‘balance’ between those who are sick enough to need the resource and will do poorly if they don’t get it, but are not so sick that they are unlikely to recover even if they do receive intensive care. In other words, every patient who is admitted to critical care should survive. [And those not admitted will surely die? Self-fulfilling prophecy.]


“Effective Triage depends on an established, skilled, and practiced infrastructure.”


This is a Multi-disciplinary Team:

*Making clear and transparent decisions with support from ethical and legal experts.

*Using consistent Criteria flexible enough to allow local responses.

*Primarily responsible for:

  -- Modifying the Protocol as the pandemic evolves – based on analysis of

      [as it happens] data

  -- Command and Control over the critical care resources in the field.

  -- The key decision – when to activate the Protocol.

“These issues are too important to be decided by the individual Triage Officers in the field.”


“The best triage decisions are made by senior physicians with training in triage and significant clinical experience.”

They must be given proper training beforehand, as well as on-going support during a pandemic.


The quality of decisions by the Committee and by Triage Officers depends on the availability of accurate [up-to-date and sufficient] information. There has to be a reliable two-way Communications Network between the Field and the Committee.

[Given the current lack of effective communications and a near-total absence of reporting of system-critical information in all aspects of health care, it’s hard to believe that the Plan – which results from considerable research, intellect, and experience – will work as stated: but it is a very good start.]


On Tuesday, November 21, 2006, The Hamilton Spectator headline read:

“No pandemic care for elderly” as the page 1 lead-in to an article by Joanna Frketich.

On page 8 of the same issue, an article by Peter Van Harten was headed”

“Pandemic rules hard to swallow?” with the sub-head “MD predicts major ethical debate.”

I’m amazed there weren’t more such headlines, but it takes a certain amount of effort to locate and then read such things as pandemic plans, and supreme court decisions.

Does one have to be able to read as a criterion for attending journalism school? Evidently the Spectator people can, and do. I wonder about some of the others.

The debate over ethics will surely take place – if not before the pandemic, then after. As with all disasters -- natural and non-natural – the political propensity to re-hash will once again raise its very ugly head.

One element (among many) in the Draft Triage Protocol Exclusion from Admission criteria set is Age > 85. So Seniors might be well advised to hide their birth certificates and lie about their age.

Triage is never easy. If a pandemic comes upon us the hard choices could become very hard. “Tennis anyone?”

Be well.



Shingles [Jul 1 06]--I have shingles: an evidence-based statement. By inference, many years ago I had chicken-pox.

Most of us, as children, had chicken-pox. It comes, it goes, and is forgotten. But the virus does not forget – it hibernates in a safe place where the immune system can’t get at it. There are many safe places for it to hide, and it arbitrarily picks one. There it patiently waits for the immune system to weaken so it can emerge and do its nasty work.

Its hiding place is alongside a particular type of nerve with connections to the skin. The nerve could be in an arm or leg, torso, or face, but always confined to right or left side.

Mine happened to hit my left leg, mainly on the flank of my calf.

There is pain, and a rash appears. The rash may or may not itch – mine didn’t. The pain focuses at or near the rash but can also wham you up and down the nerve; in my case up to and including the hip joint. The pain has the same quality and warmth as a bee sting; except it is worse and unrelenting. It is extremely uncomfortable.

If you are fortunate enough to be in your doctor’s office in the first 72 hours after you first notice the pain or the rash, there is an injection available which will roll up the virus quickly. If you are like me and have no clue what the pain and or the rash is about, and find it difficult to get an instant appointment, you get to endure the whole show.

After the first 72 hours, your choice of remedy is quite simple: there is nothing whatsoever to do because there are no cures. It runs its course and you hope for the best. If you are smarter than me, you immediately get a prescription for a pain-killer – as I eventually did (two weeks in). In the interim, I conducted some serious research: Tylenol on its own has no impact. Hard liquor has a short-term impact but is not cost-effective: I can’t handle that many shots (maybe you can, but Tylenol with Codeine etc. is a better bet).

How long does it last? I don’t know yet. So far it’s been three weeks. It shows signs of weakening but only a little. I think the ultimate edge has been slightly eroded but the main punch remains. The rash has faded to a shadow of what it was, but it’s like watching paint dry in a humid climate: change happens very slowly.

I did a web search on Shingles. The number of useful websites I found was approximately zero. Most of the official medical sites don’t recognize ‘Shingles.’ Despite the rest of the universe and common humanity, the official name is ‘Herpes Zoster,’ and if you don’t know that to begin with, you are in double jeopardy. Some sites offer sure thing instant cures (magical ointments, natural organic compounds, nostrums, potions, and spells). You might as well burn your folding money while chanting an incantation over it – it would be cheaper, and just as effective. The official sites offer technical data (all useful if you get to your doctor in the first 72 hours but not beyond). They also offer horror stories of the gruesome manifestations and complications shingles can bring; but almost nothing useful in the way of hard facts. They introduce you to the stuff of nightmares to enjoy while you endure those 96 hour nights of pain, and allow you to build your own fears and doubts without any interruption by useful facts, such as:

How long will this last?
I’ve had it for a few days now. Will it spread to other parts?
Does the pain last as long as the rash?
Does the rash have to vanish completely before the pain quits?
Is it contagious?

I had never heard of shingles before I got it. Then, almost immediately, I heard from many others – “Yes, I had it.” Going to the pharmacist for the pain-killer, I told him what it was for. He reacted like a person startled: “That’s amazing! I’ve had all kinds of people in the last week or two all wanting something for shingles!” So there it is. It seems as common as the common cold, and talking with others about it is reassuring. They went through it, in its various manifestations, and they survived. It was very painful, it lasted two or three weeks, they were not all seniors, and it went away.

I go to a remarkably fine, mature, experienced, competent, compassionate, up-to-date, evidence-based family practice doctor. He took one look at the rash and something came over his expression. He couldn’t face me. He outlined the situation. I asked what I can do about it. “Nothing,” he said, “and rushed out of the room. Later I concluded that he personally had gone through a bad time with shingles, or he knew people close to him who had.

The next time I saw him I quietly challenged him. It turned out when he saw I had the shingles rash, he had something like a post-traumatic stress event. His thoughts were caught up by the situation of another patient with shingles suffering extreme pain months afterward. It’s driving the patient nuts and not doing the doctor much good at all. They are trying frantically to find a good way to kill the pain without reducing the patient to the status of a drugged up zombie, and so far the virus is winning.

Sometimes, rarely, the “common” moves into an altered state and then all bets are off.

There is talk of vaccinating against shingles: if it becomes available, do it.

Be well.


Wait Times - The Made-In-Ontario Solution [May 13 06]--We Start from Where and What we Are

Dr. Alan Hudson, “Lead of Ontario's Wait Time Strategy,” in a March 16, 2006 release, summed up the situation, and the intent:

"It’s an access problem –" "…The best medical procedure in the world isn't good enough if it isn't delivered in time."  

“There's no quick and easy solution. We're fighting a backlog that grew steadily through the 1990s as healthcare cutbacks took their toll on hospital operating rooms. An ageing population that requires more and more health services is increasing that pressure.”

“Incredibly, there has never been a system for managing wait times in this province.  ….. because nobody was collecting and assessing the data that would have painted an accurate picture of wait times across the province.” “We are having to build a system from scratch.”

What’s being Done

Ontario has allocated funding to hospitals specifically to increase the number of surgeries and procedures in five areas (agreed to by all the provinces): cancer surgery, cardiac procedures, cataract surgery, hip and knee replacement, and MRI and CT exams.

To qualify for this extra funding, hospitals have agreed to collect and send the province data on wait times and ‘quality’ for all their cases in the five key areas.

Ontario has established a web site which will present the most recent data on wait times broken out by individual hospitals across Ontario. The database should be operational by December 2006, covering 50 hospitals representing 80% of the volume in the five key areas.  Eventually, this registry will cover all surgical procedures in Ontario.

“The data, supplied and verified by individual hospitals, is submitted electronically directly to the Wait Times Information Office, or Cancer Care Ontario or the Cardiac Care Network and is compiled by the Wait Times Information Office.”

“There are significant challenges in compiling and ensuring the precision of this data.”

No identifying information is provided to the Wait Times Information Office, about the patient or the physician. Each record does include a unique encoded identifier that the hospital can refer to if there is a data quality problem or transcription error, but the Wait Times Information Office does not have access to this information.

Other challenges remain: setting wait time ‘targets’; prioritizing patients on the basis of ‘need’; and identifying ‘best practices’ for increasing system throughput.

Eventually, integration of care will be extended across a region under a “Local Health Integration Network” umbrella. [“Integration” presumably means matching patients to services on the basis of access to delivery – within a “region” and even beyond according to urgency.]  

Wait List Defined 

“A wait list allows doctors to prioritize their patients by the urgency of the treatment they need.” [An operational definition and a peculiar one: rather than “allows,” think in terms of “arises from.”] 

“For surgical procedures, Ontario measures the wait time from when a patient and surgeon decide to proceed with surgery, until when the actual procedure is completed.”  

“For diagnostic scans (MRI and CT), Ontario measures the wait time from when a diagnostic scan is ordered until when the actual exam is completed.”

“We measure the time you wait from when the procedure is formally booked in the hospital, until it is actually carried out.” [A workable approach, but it ignores the sometimes inordinate delays a sufferer must endure trying to get to another specialist for a second opinion – let alone the waiting to see the initial specialist. Still, one has to start somewhere and work to the art of the feasible.] You may experience several separate wait times from when you first notice a health problem until your treatment is completed.” 

“Anyone needing surgery or treatment that is not an emergency will be placed on a wait list. A patient needing emergency surgery is treated as quickly as possible and does not go on a wait list.” However: “Currently, there is not a consistent method for doctors or hospitals to prioritize their patients, nor is there much coordination to make sure that patients who need care the most get the fastest treatment.” 

Various Ontario reports outline the complexities of the challenge – “The length of time a patient waits can be influenced by a number of factors” and these factors may vary with changing circumstances and conditions – unique to each hospital, each specialist, and each patient. Standard definitions and measurements which apply to all and which permit comparisons between hospitals, regions, and provinces are at best elusive. For example, each of the five key areas (Cancer Surgery, Cardiac, Hip and Knee Joint Replacement, Cataract Surgery, and Diagnostic Scans) has its own characteristic difficulties.

“What’s being measured is the interval from "decision to treat" to "treatment." But it may not be easy to fix an exact point in time as when the “Decision to Treat” occurred. The process of negotiation and fact-finding involving patient, specialist(s), family, friends, etc. is complicated and to an extent indeterminate. It likely comes down to a matter of judgment.     


The wait time information system uses methods of data collection and analysis which differs from those used in the “ICES Access to Care” report and in the “CCO Cancer System Quality Index.” Different hospitals are included, different procedures (e.g., for cancer) are included or excluded, and different numbers of procedures are included.

“There is work underway to develop standard definitions for wait times across the country, but caution should be exercised when comparing data between provinces.”


Ontario has developed, with the help of “clinical experts.” wait time targets for the “optimal” length of time within which a patient should be treated. They include urgency classifications and will eventually be incorporated in Ontario’s “Wait Times Information System.” [“Optimality” is very much in the eye of the beholder. Shouldn’t “patients” have a say in what is for them, after all, a life-defining pivotal event? To coin a phrase:

Your Optimal is my Pessimal.” (If there isn’t such a word, there should be).]

Have a great week. Be well.


They are not served who only stand and wait [Apr 28 06]--Foreword. The Supreme Court of Canada decision of June 09 2005 rocked the foundations of health care in Canada. The decision offers a remarkable window on the roles of courts and legislatures, the charters of rights and freedoms, the evidence and the facts and the differing points of view brought to them, the health acts, fundamental justice and the burden of proof, and much more.

The following article looks at the court’s decision in terms of wait times. The court’s own words are approximated in “quotes” -- I have done some editing and arranging. The context and the headings are mine. Anything in [ ] is my editorializing. Much of the rest is my summary and paraphrase and addition.

I don’t know why the June 09 2005 decision hasn’t provoked a more intense public reaction. While the full text of the decision (84 pages of closely reasoned argument and fact pro and con) is, at first glance, overwhelming, the key messages are presented clearly and decisively. I found it very difficult to summarize until I broke out the contents according to a few main headings: wait times, deference, the charters, the health acts, the facts, etc. etc. This “re-packaging” made it much simpler to track, but at the cost of losing or obscuring some of the intricate linkages.

I must express my admiration for the members of the court who produced such a landmark document and reasoned so finely (both pro and con). I hope I haven’t, with my own short-comings), cast a shadow on their efforts.

Background to the Supreme Court of Canada Decision of June 09 2005

The Government of Quebec had in place a prohibition on buying private health insurance for services already covered under Quebec’s public health plan.

Two Quebec residents took the government to court asking for a ruling setting aside the prohibition; on grounds that their rights under the Canada and the Quebec Charters (of Rights and Freedoms) were being violated -- the wait times inherent in the public system were causing undue physical and mental suffering, risk of irreversible damage and for some, death.

The case was heard in a Quebec lower court: while the court agreed that the waiting times were excessive, and caused pain, suffering, and even death for some, it rejected the appellants’ request: on grounds that lifting the prohibition would seriously threaten the public health system and the greater good had to be served even if some individuals suffered unduly.

The court’s finding was then appealed in the highest Quebec court which upheld the first court’s ruling. This set the stage for an appeal to the Supreme Court of Canada, where, five-to-four, the court found for the appellants, and in so doing, made history:

“It is the high duty of this court to insure that the Legislatures do not transgress the limits of their constitutional mandate and engage in the illegal exercise of power.”

“…The prohibition on obtaining private health insurance, while it might be constitutional in the circumstance where health services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services. Life, liberty, and security of the person must prevail…”

The Basis of the Appeal according to The Court

“The appellants submit that the delays resulting from waiting lists violate their rights under the Quebec and Canada Charters. They seek a ruling that because delays in the public system place their health and security at risk, they should be allowed to take out insurance to permit them to access private services.”

“The primary objective of the Canada Health Act is “to protect, promote and restore the physical and mental well being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

“Where the government puts in place a scheme to provide health care, that scheme must comply with the Charter.” “By imposing exclusivity and then failing to provide public health care of a reasonable standard within a reasonable time, the Quebec Government creates circumstances that trigger the application of section 7 of the Charter.”

“….security of the person encompasses “a notion of personal autonomy involving, at the very least, control over one’s bodily integrity free from state interference and freedom from state-imposed psychological and emotional stress.”

“Given the ban on insurance, most Quebeckers have no choice but to accept delays in the medical system and their adverse physical and psychological consequences. The prohibition against private health insurance and its consequence of denying people vital health care result in physical and psychological suffering that meets a threshold test of seriousness.”

“The relief sought by the appellants does not necessarily provide a complete response to the complex problem of waiting lists. However, it was not up to the appellants to find a way to remedy a problem that has persisted for a number of years and for which the solution must come from the state itself. Their only burden was to prove that their right to life and to personal inviolability had been infringed. They have succeeded in proving this.”

Promises Unkept

“Access to a waiting list is not access to health care.”

“Governments have promised on numerous occasions to find a solution to the problem of waiting lists. Given the tendency to focus the debate on socio-political philosophy, it seems that governments have lost sight of the urgency of taking concrete action. For many years, the government has failed to act; the situation continues to deteriorate.”

“While the government has the power to decide what measures to adopt, it cannot choose to do nothing in the face of the violation of Quebeckers’ right to security.” “Under the Quebec plan, the government can control its human resources in various ways: whether by using the time of professionals who have already reached the maximum for payment by the state, by applying the provision that authorizes it to compel even non participating physicians to provide services, or by implementing less restrictive measures (like those adopted in the four Canadian provinces that do not prohibit private insurance or in the other OECD countries).”

The ‘Expert’ Testimony

The government called experts in health administration and policy. These experts did not know much about wait times. Nor did they present economic studies or rely on the experience of other countries. They simply assumed, as a matter of apparent logic and ‘commonsense’, that insurance would make private health services more accessible and that this in turn would undermine the quality of services provided by the public health care system.

The appellants, relied on other health experts who offered their own conflicting ‘logic’ and ‘commonsense’, arguing that prohibiting private health insurance is neither necessary nor related to maintaining high quality in the public health care system. Allowing people to buy private insurance would make alternative medical care more accessible and reduce the burden on the public system: resulting in better care for all. Otherwise, only the wealthy could afford to travel abroad or pay for private care in Canada.

“We are confronted with competing but unproven “common sense” arguments, amounting to little more than assertions of belief.”

The Facts

“Canada is the only OECD country to prohibit insurance for health care provided by non participating physicians (within Canada this is true of only six provinces). There is no indication that the public plans of the provinces which are open to the private sector suffer from deficiencies that are not present in the plans of the other provinces, and the variety of measures implemented by different provinces shows that prohibiting insurance contracts is by no means the only measure a state can adopt to protect the system’s integrity.

“The experience of other developed countries suggests that there is no real connection in fact between prohibition of health insurance and the goal of a quality public health system. Many western democracies that do not impose a monopoly on the delivery of health care successfully deliver medical services superior to and more affordable than the services presently available in Canada: a monopoly is not necessary or even related to the provision of quality public health care. Nor does it appear that private participation leads to the eventual demise of public health care.”

It was suggested that the government’s continued commitment to a monopoly on the provision of health insurance is supported by “a series of authoritative reports; (Romanow and Kirby). “The import of these reports, which differ in many of their conclusions, is a matter of some debate.” [Their conclusions, for example, seem to be tied to ideology rather than reasoned consideration of the voluminous evidence they contain.]

The Politics of Fear

The court concluded that the arguments that abolishing the prohibition would threaten the integrity of the public system amounted to fear-mongering:

Fear-Mongering re Quality

The emergence of the private sector would lead to a reduction in popular support in the long term because the people who had private insurance would no longer see any utility for the public plan.

The quality of care in the public plan would decline because the most influential people would no longer have any incentive to bring pressure for improvements to the plan.

There would be a reduction in human resources in the public plan because many physicians and other health care professionals would be tempted by the profit motive to leave the plan.

An increase in the use of private health care would contribute to an increase in the supply of care for profit and lead to a decline in the professionalism and ethics of physicians working in hospitals.

Fear-Mongering re Cost and Access

Overall health expenditures would increase due to the additional expenditures incurred by individuals who decide to take out private insurance, plus the cost of management of the private system by the state.

Insurers would reject the most acute patients leaving the most serious cases to be covered by the public plan.

In a private system, physicians would tend to lengthen waiting times in the public sector in order to direct patients to the private sector from which they would derive a profit.

The Supreme Court’s Conclusion

These outcomes are highly unlikely in the Quebec context:

If the increase in overall costs is primarily attributable to the individual cost of insurance, it would be difficult for the state to prevent individuals who wished to pay such costs from choosing how to manage their own finances.

The public plan already handles all the serious cases, so the situation couldn’t be exacerbated if that plan were relieved of the clientele with less serious health problems.

Non participating physicians may not practice as participants; therefore they will not be faced with the conflict of interest. As for physicians who have withdrawn, the state controls their conditions of practice through the agreements they are required to sign.

“For each such threat mentioned, no study was produced or discussed. While it is true that scientific or empirical evidence is not always necessary, witnesses in a case in which the arguments are supposedly based on logic or common sense should be able to cite specific facts in support of their conclusions.”

A Final Thought -- What’s at Stake

According to ‘Finance Canada, 2004-2005, federal/provincial/territorial spending on health care was $88 billion: Ontario alone allocates 35 billion a year. For all of Canada, that’s $1 Trillion dollars expended over the past 15 years with almost no accountability. Where did $1 Trillion go? Who benefited? What was delivered as a result? No one can say whether the money and the resources it paid for, was used effectively or not: no one knows because no one has been looking. Why?



Progress is a two-edged sword [Apr 10 06]--Introduction

The future will be astounding. Miracles of technology are already with us. For example, in the major cities of Great Britain, surveillance cameras, on guard against crime and terrorism, are commonplace. In America, there are at least 20 million closed-circuit TV systems in operation. Cell phones are ubiquitous.

Technology, however, is not the key ingredient. We, meaning humankind, are the future. This is our blessing, and our curse.


Interoperability is a recurring issue. After every disaster, each rehash, criticism, and inquiry has stressed the need for interoperability: that the people on the ground doing the hard work and facing the real dangers must be able to talk with each other.

Communications networks and equipment have to be compatible. This has not happened, despite assorted task forces, commissions of inquiry, and study groups analyzing the problem to death. It takes money and smarts: and both seem to be in short supply. The problem is resolvable, technically, but non-interoperability has many dimensions.

Catastrophes, natural and human-caused, are part of our history and will inevitably be part of our future: that's life, and recent disasters have reinforced the message that we are creatures of tradition -- so much so that we seem unable to learn in time to make essential adaptations in the interests of our individual and collective survivals.

Plug and Won’t Play

This is a sad story. My wife was writing a book. Her publisher wanted changes in the final manuscript, and imposed a deadline. Then Murphy's Law, or if you prefer, the sometimes perverse nature of the universe intervened.

She tripped on a sidewalk and fractured a small bone in her left wrist. A very effective touch typist, she had to revert to one-handed “hunt and peck.” Then her computer packed in suddenly. She had saved most of what she needed on floppies, so that was not lost, though other material was. We went to our neighborhood corner store and bought a new computer. I load the programs she needed and the stuff she had archived.

While she worked on her revisions I bought her a shiny new external, plug-and-play, modem at one of our handy neighborhood computer and electronic superstores -- a highly regarded attractively packaged device made by one of the leading manufacturers.

I brought it home and in high spirits unpacked the modem and its installation CD. The instructions were easy to follow: I attached the USB connector, got the computer to look for new hardware, “told” it that I had a suitable installation disc, and the installation “wizard” went to work. The installation finished, I made the connection to the phone line, called up the dialer, and voilà! An error message. After playing around for a few hours, and getting nowhere, I contacted the manufacturer’s technical support.

The following day I got an e-mail back telling me that the installation CD that came with the modem was obsolete. I had to download an up-to-date driver. So I went to my computer (which is connected), found the driver, downloaded it, transferred it to a floppy, went back to my wife's machine, and installed the new driver. I cracked up the dialer, and voila! -- an error message.

I e-mailed technical support, making sure to include previous correspondence, telling them the sad story, and in anticipation of their next suggestion, included a printout of a log showing the modem in action millisecond by millisecond. A day or so later, I got an e-mail answer telling me that the modem was working fine, but that I had to delete a particular .dll file.

I searched for the .dll file, eventually found it, highlighted it, and hit the delete command. Nothing happened. I tried a few times, in various ways, using various incantations, signs, and wonders, but it would not delete. I had a strong drink or two, subdued my desire to say rude things, went back to my computer, and sent off an e-mail relating the latest developments: being sure to include all previous correspondence: each e-mail back and forth now represented a considerable accretion.

I received another suggestion by e-mail: that in order to delete the file, I should somehow revert to DOS, convert the file in some mysterious way, and then it might delete. I did the only sensible thing at that point, and deleted the e-mail. Then I unplugged the modem, neatly placed it in its packaging together with the installation CD, took my sales slip, and went back to the store, turned it in, and got a refund credit.

I sent a nice note to the manufacturer's technical support people thanking them for their good will, effort, and remarkable patience. I then got my wife's original, obsolete, modem up and running, and she and it and I got back to work.

There is a moral to this true story: the wonders of technology; don't count on them.

The Non-interoperability of People in High Places.

By “High Places” I do not mean mountains -- people engaged in mountaineering learn very quickly to be interoperable, or else. High places in this context means people occupying positions of authority in agencies which purport to coordinate and direct the efforts of first responders in the face of dire emergency.

The lessons of history, including the very recent past, are clear: humanity is very good at creating hugely complex networks and hierarchies of agencies which are supposed to work together effectively, but humanity is not good at getting the people appointed or elected to high positions in these networks and hierarchies to share. There are many reasons, notably unenlightened self-interest, individual ineptitude, and sheer terror of having to make a decision and be held accountable for it.

Electing and appointing “better” individuals to high places would be a start; though there will always be arguments about what and who is “better,” and why. It would also help if people have a chance to learn about working together by working together on less-than-overwhelming emergencies. A team of sorts eventually emerges, and then if the big one ever hits the response may prove to be adequate.

Don't expect too much from bureaucrats and politicians, its better, in the first instance, to be prepared and self-reliant. Then you can be grateful for whatever useful comes your way from on high, but your survival will not depend on it.

Customer Assistance at CA Feb 2006

On the other hand – I bought anti-virus software from “Computer Associates.” I wanted to find out if I was duly ‘registered’ so I phoned their Customer Service. I don’t know where their customer service person was located. He spoke excellent English with a touch of an accent reminiscent of the Indian sub-continent.

Something strange happened when I phoned:

*I was answered right away.
*The person who answered was intelligent
*He found my file in a few seconds
*My questions were answered completely and with clarity
*He was courteous above and beyond the call of duty.

If something isn’t done to stop this kind of behavior it may prove to be catching!

Off-Shoring Services

The March 2006 issue of “The NBER Digest” (NBER = National Bureau of Economic Research) contains a summary of “Service Offshoring and Productivity …” [NBER Working Paper 11926 by Mary Amiti and Shang-Jin Wei]:

“Service outsourcing is doing more than fueling an economic boom in the tech-savvy provinces of India. It is also playing a major role in …. the surging productivity of American manufacturing firms. …. (which) are getting bigger boosts in productivity from outsourcing services to overseas providers than from the more familiar practice of turning to foreign concerns for manufacturing … of parts and packaging.”

“… Offshoring makes it possible for firms to restructure in a way that pushes out the technology frontier. This is more likely to arise from offshoring service inputs, such as computing and information, rather than offshoring material inputs. …. “service offshoring is likely to be more skill intensive.”

Know-how and productivity are closely connected. But an organization (private or public) need not have every kind of know-how on its payroll. It should concentrate on those know-how’s essential to its “Core,” and sub-contract (outsource) the rest whenever it’s advantageous. This is precisely how Polaroid succeeded for many years. Its “Core” is its proprietary know-how – bound up in processes, patents, key people, teams, contacts, and credibility.

As the level of skills and know-how’s grows in the “developing” countries – notably in India and China – off-shoring as out-sourcing makes good sense. Customer Service, for some, is alive and well; and it is profitable.

And though Mr. Chirac may not be overjoyed about it, English as it is spoken and the Global Economy go together.

Note: portions of this column appeared in the November 2005 issue of “First Response” published by the Volunteer Ambulance Officers Association of Tasmania Inc.













I write about the state of the world: the Kyoto discord; terrorism; bio-attack; corporate betrayals; health care; political incapacity (seems to be a permanent condition); anticipating and handling natural and unnatural disasters; the human condition and spiritual issues; social and technological change; history; myth (including various forms of political ‘correctness’); and futures. I explore the inner and outer realities and the illusions which together shape the human experience.

The “Holland Self-Directed Career Search Guide” defines me as Artistic, Realistic, and Investigative.

The “Realism” comes from many years of hands-on experience: as a systems engineer, a member of top management, and a consultant to some very capable chief executives.

The “Artistry” expresses itself through seeing “reality” in new ways, communicating those different perspectives dramatically; and leading team-building processes on behalf of leaders who want to influence their own destiny.

Being a teaching professor helped: you can’t teach effectively except through concepts; you can’t conceptualize what you don’t know; and you can’t manage an adaptive class process unless you can draw on deep relevant experience: you have to have lived and breathed the course content (and much more).

My “Investigative” skills and capacities were polished by going through a Ph.D. program, but I have always been driven by curiosity, wide interests, and the compulsion to bring order out of chaos.

I am the once-and-future teacher, mentor, consultant, researcher, explorer, writer, and tribal elder at your service.


Previously on David Newman:


Covert and overt bias in the Ontario referendum process [Sep 30 07]


Healthcare facilities and indigenous infections [Sep 10 07]


Wait Times and Danger Pay [Aug 27 07]


Of social engineering and partisan politics [Jul 15 07]


Ethics and Triage: A Nasty Scenario [Posted 17:40 Dec 12 06]


Pandemic Flu Planning: "A Flow is a Quantification of Assumptions" [Dec 6 06]


Shingles [Jul 1 06]


Wait Times - The Made-In-Ontario Solution [May 13 06]

They are not served who only stand and wait [Apr 28 06]



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