Do no harm - it's not as easy as it looks

This week was filled with sleepless nights, tossing and turning, the hamster wheel in my head whirling wondering what I could have possibly missed. One of my seemingly well patients came in asking for a routine treatment. I asked all the right questions, did the appropriate vital signs, and a complete physical exam. The treatment that I provided was reasonable, evidence-based and guideline-supported. And yet, I got a message the next morning that my patient deteriorated overnight and died suddenly the next day. I spoke to a family member asking what had happened and the death seemed unrelated to the care I provided. I poured over their chart reviewing past and current notes, bloodwork, imaging. Nothing. Nothing that I missed, nothing that could have clearly precipitated her death. I had caused no harm, it was simply her time to go.

We are indoctrinated from early on in our training to "do no harm" when caring for patients. However, as I progress through my career the definition of harm has changed. There are clear forms of harm like prescribing a medication that someone is allergic to. And then there are grey zones of harm that are much more challenging to navigate. Chemotherapy is an example that comes to mind. It's one of the mainstays of cancer treatment aimed at targeting rapidly dividing cancer cells to save a person's life. However, chemotherapy comes with many side effects to varying degrees that can deeply affect a person's physical and psychological wellbeing. We accept this harm to prevent a greater harm - death. 

While originally this concept of "do no harm" was developed for direct patient care, I'd like to argue that it can be applied to our healthcare system at large. Lack of access to primary and preventative care means more ER visits and longer patient wait times. Delays in colonoscopies and other investigative tools means progression of disease burden. Significant delays in access to specialists means more visits to the primary care providers, leaving less time to see other patients for minor emergencies and preventative care, which can in turn lead to more ER visits. Redistributing the responsibility of patient care increases the risk of healthcare provider burnout and further fueling this vicious cycle.

In my everyday patient interactions "do no harm" is always on my mind but not in the ways one might expect. Do no harm to the person in front of me. Do no harm by putting in safety nets for patients to prevent unnecessary ER visits. Do no harm by putting the time and detail into my consults to make sure that they are prioritized appropriately by patient needs. Do no harm by delegating tasks to colleagues (while simultaneously not overburdening them), and setting boundaries with myself to prevent burnout. Do no harm -it's not as easy as it looks.

Family Physicians: The Safety Net of our Healthcare System

"I'll take my chances at home; I'm not going back there. Last time when I had a stroke, they sent me home without catching it, and when I had a blood clot in my leg, I waited seventeen hours before being seen. I understand the risks, but I just don't feel safe going back there," she said solemnly. Her face was pale but her expression decisive. I looked down at the typed note in front of me - my clinical assessment strongly suggested a heart attack in progress, but I couldn't be certain without an electrocardiogram (ECG) and blood work. Instead of sending her to the emergency room (ER) as I felt to be medically necessary, I respected her wishes and via shared decision making devised a plan together to manage the situation as an outpatient. This mostly involved me arranging follow up with the pharmacist, urgent blood work, serial ECGs, an urgent cardiology consult, and frequent phone calls with the patient.

 

I never expected the Hippocratic oath I took all those years ago stating, "do no harm" to become "mitigate the harm done by our healthcare system". From the staggering wait times to medical errors/negligence, patients have become increasingly reticent to go to the ER. There was always some hesitancy, but it has only escalated since COVID. The fear of wait times, past negative experiences, and mistrust are all reasons patients have cited when I have advised them to seek emergency care.

 

In medicine we learned about something called "the Swiss cheese model". This model represents the various safety nets put in place to prevent adverse events from happening to patients. Like lining up slices of Swiss cheese, the ideal scenario involves the holes being staggered so that while an individual may pass through one or two holes, they will eventually be caught by another layer. Redundancy in a system is critical for safety. However, if the holes line up perfectly, a person may pass through all of them without being caught and something bad may happen. For example, imagine a medication error where a doctor prescribes an antibiotic that a patient is allergic to. Ideally this should be caught by the doctor re-reading their prescription. Yet if it is missed, the other barriers in place include the pharmacist reviewing the prescription, and the nurse cross-checking the medication before administration. On a more systemic level, slices would include accessible primary care/walk-in clinics, abundance of commonly used medications, and timely access to hospital care. Every time we cut corners, another hole is added to that slice of cheese. Forced overtime for nursing staff means more burnout and a higher number of patients assigned to one nurse. Insufficient PREMs (permits doctors need to practice in a given region in Quebec) in an area with high rates of doctors retiring means decreased access to primary care. Inadequate ward staffing means less beds open and longer wait times in the ER.

 

Not enough recognition is given to the critical role family medicine doctors and other frontline workers play in filling the holes of our Swiss cheese model. From catching a cancer on a scan that was missed while a patient was in hospital to frequent follows ups with the suicidal teen waiting to be seen in psychiatry despite repeated visits to the ER, sometimes we are the only slice preventing an adverse event - an overwhelming burden adding to the many reasons why primary care physicians are leaving the field altogether. 

 

The above scenarios do not reflect negligence or incompetence on the part of any individual, but simply exemplify the outcomes when healthcare professionals are overburdened and forced to care for more patients than they can reasonably handle. Instead of forcing primary care physicians to take on more patients or other band-aid solutions that look good on paper, we need our government to work with us at all levels of the healthcare system. Else the holes in our Swiss cheese will only continue to grow until there is nothing left.

 

A day in the life of a family doctor

I roll out of bed at six am trying not to disturb my dreaming partner. After throwing on a hoodie from the pile of clean clothes I haven`t had time to put away, I fix myself a cup of tea and a bite to eat. As soon as that first drop of caffeine enters my bloodstream, I open my computer to review patient charts in preparation for my upcoming clinic. My inbox has about twenty messages from the day before, including one from a secretary stating that my patient -a single mother of two, recently diagnosed with breast cancer- was in distress as her insurance refused to cover her salary while she is off work undergoing chemotherapy treatments. I request that the patient be booked during yet another lunch break to see what can be done to help her out. Next, I print out a slew of drivers license renewal forms and insurance forms to complete as soon as possible. Each sip of tea is a guilty reminder that I meant to complete these days ago. After a brief good morning exchange with my partner, I drive to work to start my day of seeing patients. 

Bzz..bzzz...bzzz.... I silence my phone apologetically, ignoring the never-ending stream of emails about pandemic precautions, equipment shortage updates, and which personnel are out on sick leave as  a young eighteen year old sobs in my office. She is struggling to return back to school after being raped. Her appointment runs into part of my lunch break as I support her through the decision making process of whether or not she should take legal action against the perpetrator. The remainder of my lunch break is spent calling back patients with urgent lab results and speaking to the nurse from the rehab center I work at twice a week, trying to manage hyperglycemias and headaches at a distance.

While the last patient walks out my door at about five pm, my work day is far from over. I have a new pile of insurance forms, prescription renewals, and specialist referrals to complete. I spend the next two hours trying to finish charting all patient interactions. I spend extra time thoughtfully re-working yet another rejected insurance form so my patient with crippling depression after his son's suicide will continue to be paid while on work leave. I receive a result from a CT scan showing a brain tumor and ask around trying to figure out the fastest way to send the patient to neurosurgery and organize an appointment to discuss the result. After a brief dinner and an hour spent catching up with my partner at home, I skim through all the blood test results that accumulated throughout the day through fluttering sleepy eyelids to make sure there is nothing urgent before I  roll into bed to do the whole thing over the next day. And the next, and the next. By the time the weekend rolls around (and I am not scheduled to work) I stumble into bed and sleep for about 12 hours. 

I wish I could say that this scenario was unique to me, yet this reflects the reality of most family doctors in Quebec. Vacation and time off in our profession is hard to come by as family doctors in Quebec are considered entrepreneurs. This means that we pay rent to work in our family medicine clinics. We don't have paid sick days or paid vacation days, or pension. Any days of respite are unpaid. Inasmuch, we are only paid for patient interactions and next to none of the administrative tasks that take place after seeing patients. So we work and work until we burn out or leave the field all together because we simply can no longer bear the weight of our overburdened health care system. To make matters worse medical students and residents see our struggles and fewer are choosing to enter our specialty. 

Family medicine is an incredible specialty and I feel privileged to do the work that I do. Yet it stings every time I see news headlines stating "family doctors don't work hard enough". There is so much hidden labor that goes unacknowledged and simply asking family physicians to take on more patients won't necessarily improve access to and quality of care. The solution is far more complicated. Thus, the next time you feel frustrated as to why your family doctor has no availability, remember it's because we are working day in day out behind the scenes to fill out your forms, refer you to specialists, follow up your lab results, and manage emergencies when they come up. We are working for you even when we don't see you.

Sixth wave or not a sixth wave: Depends on the testing

 As we are at the cusp of loosening restrictions on masking and other public health mandates, there has already been a jump in cases. Many indicators suggest that this could be the start of the 6th wave, however without adequate testing we have no way of capturing if the rise in cases is beyond expected. 

Despite the theoretical availability of rapid testing kits at pharmacies and other locations, many people have been unable to acquire them. Since you are prohibited from taking public transit when symptomatic, PCR testing is then only accessible via drive-through. This is impractical for people who cannot drive, cannot afford taxis, or do not have access to cars. When trying to order home testing kits online, the average delivery time is 5-7 business days, which is too long of a window to accurately capture positive cases. In addition, several websites are out of stock anyway. Lastly, while private PCR testing is potentially more accessible it is unaffordable for many people.

So where do we go from here? The only way to understand the evolution of cases is to collect the data. Without access to testing, we could easily underestimate the number of cases circulating in the community until it is too late. I would like to advocate for the distribution of rapid testing kits to all households, systematic testing in high risk environments to capture asymptomatic cases, easy reporting of positive at home testing results, and clear public health guidelines on when/how long to isolate. 

A rise in cases with the ease of restrictions does not automatically indicate an impending 6th wave. Yet, we will never know the difference unless we look for it. 

Life on the wards with Omicron

 As I rummage through the N95 mask cabinet I finally find the one in my size...it's the last one. I hope when I have to change it in a few hours I'll be able to find the same one on another floor. That familiar sharp almost chemically grassy odor penetrates my senses as the mask is applied firmly to my face. I adjust it to seal tightly around my nose, trying to avoid applying maximum pressure to the bruised areas underneath. 

I gown up with my mask, googles, and face shield to start rounding on my patients one by one. After seeing them I review their labs - another two are now COVID positive. That explains why Ms. C was so sleepy this morning and her toast sat untouched by her bedside. One patient who was admitted for an upper GI bleed is due to go for a special test today...provided they are COVID negative. When I called the gastroenterologist in charge to organize the test, I was told I was lucky that I only needed it now; they were unable to do it a few weeks ago because all the personnel were out with COVID and there were not enough staff available to complete the test. I hoped my patient's repeat COVID test would be negative so we can understand why they have been bleeding and can be discharged home safely. 

One of my other patients - admitted for a bacteremia (bacterial infection in the blood) - needed a repeat cardiac echo (an ultrasound that looks at the movement of the heart, how the valves are working, etc.) to make sure there was no damage done to the heart. We had tried the procedure from the outside (transthoracic echo) but the image quality was poor. This patient needed something called a transesophageal echo. This is a procedure where an ultrasound probe is inserted down the esophagus to visualize the heart from the inside. However, this patient was on a ward with an active COVID outbreak. After much discussion with the cardiologist we all decided that the safest thing for everyone would be to postpone it till COVID had calmed down. The procedure can be associated with a lot of coughing and would increase the risk of COVID spread to the staff. 

My evening shift in ICU started with a printout of the COVID protocol and signover for the many patients admitted to the ward - over half were there for COVID. A patient's worried daughter called asking for an update; I told her we would call her back. All the staff were in said patient's room, flipping them over for the night. Putting these ICU COVID patients on their stomach seems to help with oxygenation. I was instructed to follow up on bloodwork for this same patient that came back with concerning results. However I didn't get the chance to call my staff as a new transfer arrived with a deteriorating respiratory status from one of the wards. I read the chart "severe COVID pneumonia, patient unvaccinated". I scrambled to assess to be able to call for help early if intubation was required, having to remind myself  to step out soon to call back the blaring alarms of my pager - I was being called from other areas of the hospital. 

This wave feels different than the previous ones. People are less sick generally speaking due to vaccination and the properties of this new variant. However, because it is so contagious the sheer volume of people who are sick is that much more. While most will be mild cases, a small proportion - especially if unvaccinated - will end up in hospital/ICU.  The issue is that when you have a huge portion of the population sick with COVID, in absolute number of severe infections still translates to more hospitalizations than during previous waves. Even more challenging are the staffing shortages created by the healthcare workers who are infected and having to stay home to prevent further spread. This impacts EVERYONE's ability to get medical care of any kind. THIS is why public health measures are necessary to curb infection rates. Our system is overwhelmed, our workers are overwhelmed, we all are overwhelmed. So please I urge you to find that strength inside you to continue to follow public health guidelines. Mask up, stay home, stay safe, stay strong. 

A Thankless Thanksgiving

Thanksgiving feels different this year. The once vibrant autumn leaves seem dulled, the days more cloudy, the pumpkin spice lattes less festive. Oh yeah, that's what burnout feels like. Approaching the two year mark into this pandemic, I'm not the same person I was before. 

I used to tell everyone that I loved people, that I was a people person. I used to easily find the good in everyone and cherish the little moments of humanity shared with my patients. I used to feel a sense of devotion and calling to sacrifice myself to try to fill the cracks of our broken healthcare system. I haven't seen that person in a while.

At the start of this pandemic, we as healthcare workers rolled up our sleeves, hugged our families, and threw ourselves head-first into the frightening unknown of this virus. I personally sacrificed my health and ended up hospitalized with COVID-19 during the first wave while trying to care for complete strangers. The patients who once thanked me for my service now roll their eyes when I ask them to put on their masks so I can examine them. Every nose out of a mask in the metro is like a punch in the face. Every maskless person on the bus is a kick to the gut. Every anti-vax person is a painful reminder of how I could have easily lost my life to this virus.

The conspiracy theories run rampant and we continue to see vaccine hesitancy brought about by false claims and poorly disseminated health information. I feel like science rejecters and myself live on completely different planes of existence, with a framework of reality so different from mine I can't even begin to understand their perspectives. When I examine their newborns in the nursery, I feel a sense of longing and a twinge of jealousy; they are so pure and innocent, not yet hurt by the world. People care about them, want to help them, want to love them. Their cries pierce my soul because instead of the joy of new life I see flashbacks to young mothers on ventilators barely pulling through.

So while I recognize my privilege in life and in this field, I also continue to live and breathe the collective trauma that many have now left behind. While I am thankful for the development of these life-saving vaccines, it is a thankless thanksgiving to have to watch so many die simply because they refuse to take it. 

Vaccination Passports: A triple threat protection of our rights and freedoms

We have all felt that glimmer of hope that this pandemic would soon be behind us. Be it due to vaccine developments or cases declining, some sense of normalcy felt within reach. That was, until the Delta variants began to take hold and cases began to skyrocket, signaling the onset of the 4th wave. Whispers of a vaccine passport have been going around for some time and now that cases have begun to rise again this option is being utilized as an additional safety measure.

 

What exactly is a vaccine passport? As defined by the Quebec government website on Aug 13th 2021 it is: "A free official document showing that the holder is protected against COVID-19... It will not show your personal information or information about your medical or vaccination history." The criteria for where it will be used may vary based on the number of baseline cases and new cases in the community, however, it will not be required for access to essential services like education. While there may be mixed feelings surrounding this passport, I would like to share why this is an important measure in protecting our rights and freedoms. 

 

Firstly, regardless of your personal opinion on what constitutes a violation of your rights and freedoms, this virus doesn't care. As humans who coexist together in society, it is inevitable that we will be in close proximity to each other. Be it at the supermarket, on sidewalks, in schools, etc., we all share communal spaces. We are currently dealing with a virus that is predominantly transmitted from person-to-person through droplets emitted via coughing, sneezing, talking, etc. These droplets can go pretty far but most land within six feet of the source. This is why the established safe social distance is to keep a minimum of six feet apart. Masks are another added barrier to trap some of these droplets at the source and prevent them from travelling to others. Put the masks and social distancing together, and you've significantly reduced the risk of viral transmission. These minor inconveniences of wearing a mask and sitting further apart allow all of us to mitigate some of the risk of infection thus helping to maintain our freedom to come and go as we please. The vaccine is simply another mechanism to mitigate risk while we go about activities of daily living.

 

None of these interventions in isolation are perfect, which is why combining them makes them that much more effective. Irrespective of your vaccination status it is still possible to transmit COVID-19 asymptomatically or pre-symptomatically. We've already seen this in hospital outbreaks among fully and partially vaccinated people. You may not show signs of infection yet or at all but be capable of infecting other people. This is why the "but I feel fine" or "I haven't seen anyone except two friends" are not valid excuses. You have no way of knowing who your contacts have seen, and if they may be asymptomatically transmitting the virus to you. This is supported by the fact that 35% of Canadians infected with COVID-19 came from a source that was unknown. 

 

The vaccine is proven to be safe and efficacious at reducing the transmission and severity of COVID-19 infections. By reducing the viral load, there are less viral particles present in the droplets coming out of peoples' noses and mouths. Here we have what I like to call the triple threat against spreading COVID-19: decrease the viral particles in droplets through vaccination, trap the droplets in the mask, and keep six feet apart so the remaining particles can't make it to others. It's simple yet effective.

 

I know one of the biggest worries by those who are vaccine hesitant is the safety of these vaccines. Let me share some statistics to reassure you on this. As per Health Canada data from December 2020 to July 2021, serious adverse events after vaccine administration occurred in 0.006% of all 49,022,551 doses administered - this represents an extremely small proportion of the vaccinated population. Inasmuch, 84.8% of hospitalizations and 82.1% of deaths were among the unvaccinated, compared to 7.0% and 7.8% of those partially vaccinated, and 0.8% and 1.3% of those fully vaccinated. But what about the long-term safety of these vaccines? Based on the decades of data we have on previous vaccines, the risk of any long-term consequences following vaccine administration is extremely unlikely. Most adverse events occur within six weeks of receiving the vaccine, and there are multiple ongoing monitoring processes in place to catch and quickly act on any alarming side-effects that may arise. We saw this at work when concerns emerged about blood clots with the Astra-Zeneca vaccine. It was quickly pulled from the market to be further studied and re-evaluated. 

 

So, to recap, we've shown that these vaccines are safe and our triple threat approach helps to decrease transmission and ultimately hospitalization/death from COVID-19. So what's next? This is where the vaccine passport comes into play; this is a way to promote the rights and freedoms of those who have embraced this triple threat approach. Since they have significantly reduced their risk of transmission/severe disease, they are now allowed to engage in MORE activities that were previously deemed unsafe. This is not a means of infringing on the rights of anti-vaxers but promoting the rights and freedoms of those who are fully vaccinated to engage in activities as they choose. At present, you have the right to choose to refuse vaccinations. However, like all choices we make in life, you have to accept the consequences. 

 

These public health measures follow the same reasoning as to why smoking is no longer allowed indoors and in many public spaces - to protect those around us. You cannot tell who is immunocompromised just by looking at them. That woman standing next to you on the metro might be pregnant and immunocompromised. The young gentleman passing you in the grocery store might have cancer and be on chemotherapy. Until we don't share the same air (which I don't foresee happening anytime soon) your actions (where you go, who you see) have a DIRECT EFFECT on the people around you. People need to use public transit to get to work because many cannot afford any other alternative. Not everyone can have the luxury of having their groceries delivered. People with multiple medical conditions may have no choice but to have frequent hospital visits for care and have to wait their turn for hours in the waiting room. Our triple threat approach is a means of protecting everyone, but especially the most vulnerable people who need it, which could be any one of us. Things happen, life changes, people get sick. You never know when it might happen to you. This passport is a tool aimed at balancing the safety for us all, while trying to restore a degree of freedom and quality of life that we've all lost since the onset of this pandemic. We owe it to each other to support and protect one another.

 

So be smart, be safe, do your research. Get the vaccine. You never know whose life you will save in the process.

 

 

 

 

References

Canada, Public Health Agency of. “COVID-19 Daily Epidemiology Update.” Canada.ca, 28 May 2021, health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html?stat=num&measure=total&map=pt#a2.

Canada, Public Health Agency of. “COVID-19 Vaccine Safety: Weekly Report on Side Effects Following IMMUNIZATION.” Canada.ca, 10 June 2021, health-infobase.canada.ca/covid-19/vaccine-safety/#safetyIssues.

Canada, Public Health Agency of. “Government of Canada.” Canada.ca, / Gouvernement Du Canada, 29 June 2021, www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/main-modes-transmission.html.

“Covid-19 Vaccination Passport.” Gouvernement Du Québec, www.quebec.ca/en/health/health-issues/a-z/2019-coronavirus/progress-of-the-covid-19-vaccination/covid-19-vaccination-passport.

“Key Things to Know about Covid-19 Vaccines.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html.

“Safety of Covid-19 Vaccines.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/safety-of-vaccines.html.