The word “hip” seems to have lost favor as a descriptive of cool, which I can’t help feeling is just as well. For me, at least, the word has taken on a darker connotation, or at least evokes a darker memory. Hip can also mean pain and near death, surgical incompetence and carelessness. I tell you this not to evoke sympathy (though that would be nice!) but to shed a little light on an aspect of our health care system. Such as it is.
Someone was thumping on my head. Now why would they do that? I couldn’t breathe very well, but they kept on thumping. Bang! Bang! Bang! What’s this about? Someone is yelling, or it sounded like yelling. Couldn’t make out the words at first, what with all the thumping. Whoever it was sounded panicked. “Marq! You’re going to be all right!”
Why wouldn’t I be all right?
The thumping stopped. “There he is!” someone said. Quieter, relieved maybe, I don’t know. Where else would I be?
I had gone in a few hours before, three hours maybe, or maybe more, I didn’t know, to have hip replacement surgery. In my pre-op surgery gown, too short and too skimpy and damn cold in the theatre, they brought me forms to sign. Hip surgery is not complicated, no, knees are far worse, a devilish joint the knee, very complicated. Hips are simpler, just a ball and a socket … but still, this is after all major surgery, yadda yadda ya, risks in all surgery, possible cardio-vascular collapse from the anesthetic, yadda yadda, sign here, nobody’s at fault if it all goes awry, shit happens … Nobody can sue, so that’s all right. Did they say that? I signed anyway. What else could I do?
So under I went, and woke to a thumping on my head.
Of course, I wasn’t there, I was in la-la land, so I didn’t know what had happened. Not then.
My wife did, though. She was sitting in the visitor waiting area, with its grim pastels and copies of Senior Health and ancient copes of Canadian Living with the recipes torn out, but she was savvy enough to have brought a book, so that was all right. The patient liaison nurse was supposed to come by every hour for an update, but three hours went by before she appeared. Her first words were not reassuring: “Do you have any family you want notified?” Huh? This was my wife’s first clue something had gone amiss, that and the fact that she was shown from the main waiting area into a private waiting room. After another hour, the Salvation Army chaplain came in, and asked if she wanted to pray. What the fuck was going on? (Her language, not mine; I wasn’t there). Four hours overdue and they’re offering … prayer? Just that week we had been pouring the concrete foundation for the new house we were building together … but would there be a “we”? Suddenly it wasn’t so certain.
The chaplain was followed by the head of the surgeon’s team, who explained that there had been unexpected and rather copious bleeding, and they were trying to track the cause. “Could it have been drugs?” he wondered. Well, no, not unless you gave them to him, you assholes … Finally the surgeon himself came to say the first positive thing she had heard in all those hours, that I was going to be all right, and would she like to go for a walk, get some fresh air? She declined that too.
What had happened was this. They put me under, cut open the flesh at the hip. Brought out the saws, cut away the ball from the end of the femur, drilled into the remaining bone to insert the prosthesis and cemented it fast. Then they reamed out the pelvic bone socket, and inserted its new plastic liner.
I knew nothing, I wasn’t there.
But it had gotten messy fast. Reaming out the socket, the surgeon made a small slip, and nicked the femoral artery, which started, obviously enough, to bleed. Big sucker, the femoral artery; a physician friend told me later that there were two sure ways to kill a man: shoot him in the heart or sever the femoral artery. But they didn’t notice, the buggers. They stapled me up and wheeled me into the recovery room. There, it was a nurse who saw that something was seriously amiss. My abdomen was ballooning, and my blood pressure, she told me later, was trending towards zero, a lovely phrase but not so lovely when it happens to you.
I don’t know what the surgeon said, or thought, when they hauled him back into the operating theatre, but I can guess. Jesus Roosevelt Christ would come close … or some equivalent. An emergency call reverberated through the hospital – desperately seeking vascular surgeon. Fortunately they found one, or I wouldn’t be here. He cut me open at the groin, cut me open again at the belly, plunged his hands into the gristle and blood, found the damaged artery and stitched a shunt, or a stent, or whatever the hell they call it, around the tear, and sewed me up. And gave me six units of new blood …
I don’t know what his name was, something Scottish I think, Mac somebody, but he came round to the wards afterwards, looking cheerful. “Dr. [X ] owes me a bottle of Scotch,” he said. “I sure saved his ass.”
I didn’t say anything. His ass? Hey, what about mine? But I’m not buying him any bloody Scotch.
In the eleven days I spent in intensive care, several things happened, and some didn’t. I healed slowly, had hallucinations from the oxycontin painkillers (earnest conversations with people who weren’t there), the nurses were wonderful as nurses always seem to be, and the offending surgeon hovered. (Should I tell you his name? I’ve heard since he has had other “bad outcomes”.) The surgical internist also came around again, it having become amply clear that it really wasn’t his notion that I was somehow a druggie that had caused the problem, but straightforward surgical screw-up. This was the same young guy who later told my wife, “we took a perfectly healthy man and made him very sick.” He seemed both astonished and relieved that they hadn’t killed me altogether. Teams of medical students came by to check me out, mostly (or so it seemed to me) to gawk at the piquant fact that my testicles had swollen to grapefruit size – check your dignity at the entrance when you go into those places. Those flap-open-at-the-back hospital johnny-coats are an early warning signal.
A week or so ago we ran into a friend of my wife’s, a man in his forties, a master mariner who works for the Coast Guard. He has bad arthritis in one of his knees, but he had been told he is not eligible for surgery – he’s too young. Which is insane. Here’s a perfectly healthy man, a productive citizen with decades of work ahead of him, but he is being forced onto long-term disability and his family into poverty on the off chance he’d have to undergo a second knee surgery in fifteen years or so, an idiotic “solution” that would cost society much more money than both surgeries would have. This passes for social policy in our benighted system.
So is this just whining? Are these aberrations? Anecdotes that skew the real state of affairs? Or is this the norm?
A former squash partner of mine, in the days when squash was still a possibility for me, came to Canada from France almost thirty years ago. He had been recruited to run a prestigious lab that specialized in endocrinology. “When I came,” he says now, “the Canadian system was regarded as one of the best. Now? It is just a joke. People still think of it as good, but that is just because it is free.” He tells me of surgeons at his Toronto hospital who will do no more than one or two operations a day, insist on going home promptly at five as though they were janitors, and are paid hundreds of thousands of dollars for the privilege. “It is a joke,” he said again.
Of course, it is devilishly difficult to compare national health care systems. The crudest method is to measure expenditures on health as a proportion of GDP, at the same time measuring outcomes such as infant mortality, and life expectancy. But if OECD figures show that South Korea spent 4% of GDP on health and the US 13.5% (real numbers, if rather old – 1997) does that make Korea’s system “better” or only “more efficient”? Or does it essentially tell you nothing?
Similarly, if the UK spends $1,347 per capita on health care and the US $3,925, what does that say? Certainly, as a WHO Bulletin put it, “this type of comparison is often used to support arguments that either too few or too many resources are allocated to health care. For example, some observers of the US health care system argue that the high expenditures, combined with similar or worse population health measures than in many European countries, indicate poor performance. [On the other hand the same numbers can be used to argue] that the National Health Service in the United Kingdom is consistently underfunded.”
Better comparisons would include not only the cost of health care, but also its effectiveness and its fairness – how does it treat the poor? WHO therefore compares systems across multiple goals: the distribution of care, the responsiveness of the system, fairness in financial contributions, and per capita expenditures. In its best-known (if somewhat contested) survey using 2000 figures, Canada was an okay 30th out of 190 countries measured; the American were 37th, the UK 17th, and France was first.
In another survey by the Commonwealth Fund, Canada fared poorly. Wait times were longer than all the other 14 rich-world countries surveyed. It was the second-worst for accessing health care after “regular hours”. Canada had the fewest acute care beds of any country (though it could be argued that this is a good thing – fewer Canadians are being unnecessarily admitted to hospital). “Canada was in the middle of the pack when it comes to the percentage of gross domestic product (GDP) spent on health care. The United States spent by far the most at 17.4%, and Japan spent the least at 8.5%. Canada was similar to countries like Denmark, France, Germany and Switzerland, and spent 11.4% of annual GDP on health care in 2009.” Well, okay: Canada fared poorly – but the US came in dead last. A recent healthcare survey by Bloomberg put Hong Kong, Singapore and Japan at the top of the heap, based mostly on their efficiency.
Is this fair? Well, no. As The Economist put it, “The Commonwealth Fund makes quality, access, value for money and equity the leading criteria for judging which countries perform well. Its emphasis on access and per-capita spending mean that America, struggling to extend its insurance coverage, while committing a large amount to overall health-care spending, regularly comes bottom of the table. But that judgment overlooks what American health care delivers well: it scores highly on preventative health measures, patient-centred care and innovation, for instance. It has led the way in reducing avoidable harm to patients, with Seattle’s Virginia Mason hospital delivering “near zero harm”, something many systems, including England’s, are seeking to emulate.”
The Fraser Institute has found that wait times nationally have doubled since their first survey, in 1993.
After my eleven days in intensive care, the surgeon told my wife to get me out of there: “What this man needs most is some yoghurt,” he said, which seems fair enough. The food was disgusting. I was losing weight. I was getting sicker, not better. There was an infection in one of my three incisions. The VON would take care of that at home, he said. And so they did.
I was working for an American magazine company at the time, and naturally my colleagues all told me I should sue after my near-death experience. My boss, a lovely guy, Greek born, Swiss educated American citizen, said I owed it to the public. He was dismissive of those consent forms. No judge will forgive incompetence, he said. But I didn’t want to sue. I wanted to forget the whole thing. Shit happens, I told him. Too bad it had to happen to me.
Six years later, I was back in the same operating waiting area, for a new knee this time, signing yet another form for yet another surgeon telling me that nothing whatever could possibly be anyone’s fault. (Again, I signed). Just a one year wait, this time.
My surgery was scheduled for two pm. At a quarter to three, the surgeon strode into waiting room, fuming. This was not a good sign. Like pilots, I want surgeons to exude calm and competence, not rage. He wasn’t angry with me, but with the hospital. The janitorial staff would go off shift at four, and if they figured they couldn’t get the theatre in working order before then, they would just leave it and we’d all go home to reconvene tomorrow. That’s what he was fuming about. “Here I am, an exceptionally highly-paid surgeon, sitting on my hands with nothing to do because the hospital hasn’t seen fit to hire another $20 an hour cleaner. This happens all the time. It is insane.” His fit of pique seemed to work, and by three thirty he was cutting into my right knee. The operation went well, and an hour or so later he lent me his cell phone to call my wife in the waiting room – not the same private room into which the well-meaning chaplain had wandered, just the main hallway.
Eight months later, the second knee.
Same result. Shit didn’t happen.
Should I complain? It’s fair to point out that I’d had three major surgeries, and it didn’t cost me a dime. And I’m still alive, alive-o. Though it was a near thing.
Still, the average wait time for elective surgery in Canada is supposed to be four months. Quite obviously, that’s a crock.
Should I have tried elsewhere to dodge the waiting lists? It turns out wait times in other provinces are almost as long, with only Saskatchewan showing marked improvement, and the others only slightly better than Nova Scotia; and in any case I wouldn’t be able to travel for five weeks or so post-op, so would need an apartment (for which no government money would be forthcoming. Fair enough.)
A private clinic in Montreal, it turns out, could take me with only a week or so waiting time. But Nova Scotia wouldn’t pay for that, and I would be $18,000 plus a five-week apartment out of pocket.
The health care system wouldn’t pay for surgery out of country, either. I tried that. A university clinic in Rhode Island would be happy to do the surgery, with no waiting time at all – just an X-ray to ensure all is well then on the table with you … The surgeon quoted me a modest figure of $5,000 to do the work, but that, it turned out, was just his cutting fee. The actual prosthesis would be just as much, and the costs mounted … maybe $44,000 US, all told. The clinic seem astonished that I would even consider paying that myself. All their patients have insurance, even in the US of A.
Next I checked South Africa, where I have family. They too have no wait times, but again it would be expensive, and I’d have to put up with a nineteen-hour flight, not good. India was a little cheaper, also with no wait times. My friend the squash player knew a surgeon in Paris who would be happy to do it. No wait times in the WHO’s top ranking system either, and only modest costs ($17,000 CDN. all in, plus of course five weeks of living in Paris, a tough gig that, but not cheap.)
I checked with the health care paymasters in my home province. They will not pay for any procedures in any other jurisdictions if the procedure is offered in Canada – even if those procedures are only available two years from now. Does this make sense? Why not reimburse the patient just the equivalent of what the op would cost here, thereby accruing no extra out of pocket expenses to the Nova Scotia taxpayer, and helping to shorten the wait time? “We can’t do that”. Of course not. It would be against the rules.
Fast forward to December 2013. The second hip was in trouble, so might as well complete the set, no? X rays showed that the joint’s cartilage had vanished entirely. So yes, the system says I am good to go, minimum mobility, maximum pain. The request went into the surgeon’s office (a new surgeon, it should be obvious) that week.
A full year later, I had heard nothing. Six months after that, in June 2015, I was called into the surgeon’s office. It was obvious to him that I could not any longer walk even a few steps without a cane, and agreed with what my physician had already said, that yes, I was entitled to a new hip. “But not one of the expensive ceramic ones,” he said. “You’re too old for that.” Well, thanks a lot.
When could I get it done? He was cheerful. “It is the first question everyone asks,” said, “when will it be done? With luck, another 6 to 8 months. Probably.” Then he added: “Let’s hope the pelvic bone doesn’t split in the interim. It could, you know. It’s vulnerable. That would leave us with a fine mess on our hands.” Thanks a lot, again.
On the way out, his staff told me it could be two more years before the surgery, but even on his timetable that would make the total wait time a month over two years.
The wait times were getting worse, not better.
January, 2016, then. One more time for the consent form. I had already told the surgeon to take care with the femoral artery; figured he might as well know. Forewarned, and all that. Well, he said, I haven’t cut one of those yet, and I’m not about to start now.
Four days later, been there and done that. All’s well. Femoral artery intact. Eight inch gash down the side of the hip. I was not under full anesthetic, just a spinal, but all I remember is someone bashing away at my hip with a hammer, no doubt to good purpose. Then all closed up with staples, and wheeled to a recovery ward shared with two others, a (formerly) homeless guy who hurled himself off a bridge and broke his leg and arm in multiple places, and a very large woman with a broken hip and pelvis who spent most of the time during the day berating her daughter for breaking into her bank account and stealing small sums for beer. Previous occupant of my bed was a Nova Scotia Supreme Court justice. Gotta say it: the system is nothing if not egalitarian.
Once again, the nurses were people of superhuman patience.
This was the Queen Elizabeth II Health Sciences Centre. Across town at the Victoria General, the other large hospital in the capital, the very same week, patient wards were flooding from broken pipes, surgeries were being cancelled, the water was undrinkable due to Legionnaires disease spores in the holding tanks, there was mold everywhere, bed bugs and rodents were rampant. A woman who was in town to donate a kidney said her toilet wasn’t cleaned the four days she was in hospital She fled home to Alberta.
Health care ministers meet every few months to discuss how to fix all this. There are lots of plans, most of them at odds with the others, all of them apparently costing gargantuan sums of money. Still, Nova Scotia has budgeted $1.5 million for the VG this year, but $56.4 million to subsidize a completely unneeded convention centre in a time of falling office occupancies and a collapsing convention business.
Do yourself a favor. Don’t get old and don’t get ill.
No more surgery for me. I have completed the set. Airport security can just get used to it.