Flu Vaccine Fiasco

Complications of Bureaucracy

His abdomen gaped from sternum to pubis. Fat pushed up against the bed rails.

The crater in his gut held a wedding cake’s worth of gauze: a sponge soaking up yellow fluid. Tubes, lines, drains, and leads – with monitors attached to half of them – buried our patient. Aside from gnarled toes and mottled ankles, only a few square inches of skin showed.

“There’s nothing surgery can’t make worse,” someone said, sotto voce. Most of us missed the point.

As a surgical resident, I remember the rush of adrenalin, the anticipation of opening an abdomen. Our goal was always the same: get in before the staff surgeon finished scrubbing.

But staff never rushed into a new case. They would ask questions, walk down for coffee, then ask almost the same questions again. They hunted for any possible reason to not operate. It drove me nuts.

Proof of Exudate

Surgeons fix things on the sickest patients (often at 3 a.m.), which no medicine can cure. They operate when certain nothing else will do. Ideally, surgery is not just the right treatment; it is the only treatment.

I watched my Chief Resident operate on my first case as a resident.

“Wahoo!” he yelled.

A trickle of pus had oozed out behind his knife. The pus proved he chose wisely. The pre-operative uncertainty – Does this patient really need an operation? – was gone. He whooped with relief.

Flu Vaccine Fiasco

Surgeons avoid surgery until certain there is nothing better. They do not cut because they can but because they must. Nothing else will do.

Bureaucrats do the opposite. They build bureaucracy because they can, not because they must. It is what they do.

Apparently, the Ministry of Health (MOH) sends out flu vaccine directly to pharmacies across Ontario. Individual pharmacists have vaccine shortly after the MOH release.

Every year, doctors complain, “Why do all the pharmacies have flu vaccine and we have none?”

Unlike pharmacies, medical clinics are blessed with public health bureaucracies to manage supplies. Public health follows a detailed process to determine how to divvy up the vaccine between all the doctors’ offices based on how much each doctor used last year.

This takes time. Public health dribbles out a wee batch of vaccine. Doctors use it in a few days. Then we wait for the next batch. Vaccine dribbles out until mid-December. Then a flood of vaccine arrives too late, a large part unused.

Surgical Bureaucracy

No doubt, public health employs brilliant, well-intentioned civil servants. Like surgical residents, they share enthusiasm to help patients. Bureaucrats may even feel the rush of adrenalin.

Similarity ends there. Surgical residents see the disasters they cause. Disasters might follow a staff surgeon for decades. Bureaucrats never face failure that way.

Complications temper surgical enthusiasm. Digging out dead tissue from layers of necrotic thigh fascia leaves your gown covered in pus to your armpits. Swooning from the stench, you promise to never let it happen to one of your patients.

Civil servants do not see the people they ruin. Bureaucrats never plunge arms inside necrosis caused by good intentions.

“The excitement fades but the stress remains forever,” an old surgeon said.

The rush of adrenalin forces mature surgeons to guarantee they have not missed a good reason to avoid surgery, before they touch a knife. Having found no better course, they do what they must. We need civil servants to do the same.

Photo credit NYTimes.

27 thoughts on “Flu Vaccine Fiasco”

  1. Our shipments are also dribbled out to us. We may get it before you but there is a complex algorithm that determines how much we get and when we can replenish that has no bearing on what we actually need.

    1. Hey, thanks for this, Kathleen

      Not surprising that you struggle to get vaccines also — in the end the MOH is just as bureaucratic.

      My understanding is that there’s an additional layer of bureaucracy for physicians. I was told that the MOH goes more directly to pharmacies. You don’t have the same massive equivalent of the public health bureaucracy. Did I get this wrong?

      Regardless, it is good (sad) to hear that you struggle with the supply also!

      Great to hear from you

      Cheers

      1. The advantage that we have is a well developed supply chain. We have exactly the same limitations as you. Public health is still the gatekeeper but once we have their blessing we can mobilize distribution a lot faster.
        That said….there is a certain red organization with its own distribution network that we suspect ignores Public Health Directives.

        1. Thanks again, Kathleen!

          I’ve been chatting privately on another channel about this exact issue. It appears that the commercial distribution chains work so much better for pharmacies that you get yours to patients well before we even have it in our fridges.

          Especially when demand for vaccine is so high, it is especially infuriating that government won’t find out how the pharmacy distribution channels work and try to match them for the medical clinics.

  2. Terrific description of surgery Shawn. Reminds me of fondly remembered rants from my late father. One of my favorites involved my mother scolding him for being such a wimp after he himself had an ambulatory procedure which she referred to as “minor surgery”.

    Said my Dad : “There is no minor surgery”.

    Best Regards,

    Gordon Friesen, Montreal
    http://www.euthanasiediscussion.net/

      1. I had a Scots colleague once who delivered another great line in broad Glasgow patois ….. “it may be just a wee crack to you, doctor ….. but to the patient it’s a FRACTURE”!

        So much to learn from dry nuance.

        1. 😀

          Mike,

          My Granny on mum’s side was from Dornoch in the north island. I can hear her saying that!

          I hope you are keeping well. Great to hear from you.

          Cheers

  4. Our experience with the pharmacies suggests that the bureaucrats aren’t doing so well there either!
    The analogy with surgery is very powerful.
    Thx.

  5. Is this the same Public Health that has gone through covid relatively blameless, unaccountable and unscathed – though it might be said a pandemic might be their entire raison d’etre ?

    1. Shhh, Rick. (sarcasm) Let’s not mention that until we have a vaccine will you?

      😀

      Thanks for posting!

    1. By the way, I should have added to the comment above that a trainee physician that we knew at the time got the swine flu vaccine and had a severe reaction that put him out of commission for almost a year.

      1. Wow. Thanks for this, Yvonne. I seem to remember reading somewhere about how poorly that vaccine performed.

        I, too, worry about waiting for a vaccine only to be disappointed.

        Thanks so much for taking time to read and post comments!

  7. Every year I bust my ass to get the flu shots to my old and sick patients as soon as I get my hands on vaccine. Every year we give over 400 shots in our clinics and we still only get 100 reg and 25 high dose shots to start. We have to ration the high dose for the most serious but usually everyone in our first clinic deserves it. It’s a trade off of getting the vaccine in early enough to cover a surprise early season for the supposed benefits of the high dose. They are so paranoid about wasted doses but as you mentioned they creat waste by sending us vaccine in January and February well after the time they would be beneficial. By then there is not enough demand to run a dedicated clinic.

    1. 400 vaccines — impressive, Ernest. Well done!

      It sure helps for people to hear about these numbers from the front lines. The public has no idea about the silliness of it. What good is a raft of vaccine in the middle of winter?

      Thanks so much for posting!

  8. Hi Shawn,
    Here is a perspective from local public health:
    1. Local public health does not have any influence over Ministry of Health allocation of flu vaccine to a particular health unit. In my understanding the number of doses allocated to a region is based on numbers from previous year. The timelines for receiving the product by public health are fixed and set by the ministry.
    2. Local public health receives vaccine in three allocations from the government pharmacy.
    – first would have already been received and distributed to long term care and retirement homes. Any vaccine doses left from the LTC distribution would be given to primary care. This might only up to only a handful of doses of high dose flu vaccine per physician
    – second allocation is received right after Thanksgiving and distributed to primary care. There will be additional doses of TIV for example but possibly not enough to meet the demand for all individual physician practices.
    – third and often final allocation will be based on orders placed by local public health at the end of October and
    distributed to primary care in November. These additional doses are not confirmed until the ministry approves the orders so we can’t say how many more would be available then.

    Let’s compare and contrast this process and trickling of a product to primary care through local public health with the pharmacy distribution system:
    – Government pharmacy distributes product to two main third party distributors supplying all pharmacies in Ontario. These distributors receive approx 50% of their total allocation around the same time as local public health does but they are not supplying LTCH and RH from their pool of product.
    – we can assume these commercial entities would also have good understanding of inventories at the participating pharmacies. Distributors could potentially hold most of the product centrally and deliver based on demand to participating pharmacies. There likely would be more flexibility in terms of when the re-supplying could take place.

    Overall, the efficiency of distribution done by a commercial entity whose sole purpose is to move product to the pharmacies cannot be matched by local public health.
    A bigger question is why primary care does not get the product through a large third party distributor instead. Would a large third party distributor be able to reproduce similar efficiency of distribution to pharmacies in primary care settings? Would it matter that primary care settings may not have a computerized inventory system and rely on faxing orders to public health?

    1. What an absolutely fantastic comment!

      Thank you so much for taking the time to write this all out. It is extremely helpful and raises some excellent questions at the end also.

      I won’t dive into everything you’ve raised, but again, thank you SO much for offering this and for suggesting ways that the whole system might be improved.

      Cheers

  9. Here in my very rural area of Alberta, Public Health and physicians refuse to give the vaccine except to under 5 years old (because I legally cannot). During the initial peak of COVID the medical clinic would not see patients in person and would frequently send them to me (this was before the government recognized pharmacists as front line health professionals and finally sent us PPE as we are very accessible and vulnerable). In past years the physicians did not even get the flu vaccination themselves.

    I’ll have to give probably 500 flu vaccinations this season on top of being the only pharmacist for a 50+ km radius. I have to go into our Senior’s Lodge and run clinics on my days off. I’ve done all I can to prepare but it is going to be difficult to maintain my health.

    It’s going to be even harder to maintain my health as it seems I can’t find a way to get my own arm shot up with vaccine! After sending all of these people to me, exposing them to me and vice versa, Public Health and physicians are refusing to immunize me due to a mysterious “policy” I have yet to see.

    I’ve been told to travel to another rural pharmacy to get my immunization but they are open fewer hours than me. I’m probably going to travel at least 150km if I can find a pharmacy that will give me the vaccination on a Sunday. This is just ridiculous. Maybe they can pay for my time and mileage? Ah, a girl’s gotta have dreams.

    I’m all for physicians, Public Health and anyone else with the training giving vaccines. I don’t mind giving them, and population health should be part of our job, but I don’t like it being my primary function when I have medication management to be responsible for! I’m eagerly awaiting regulations that will allow registered Pharmacy Technicians give injections.

    Side notes about reimbursement…in Alberta we initially got $20 per immunuzation. That was cut to $13 and has not been raised despite added PPE and disinfection. In Ontario the government initially wanted pharmacists to do it for zero reimbursement, expecting pharmacies to “donate” supplies. They settled on a whopping $7.50 and last I heard aren’t increasing it despite PPE and disinfection.

    Now if you’ll excuse me I should probably go look up self-injection techniques…

    1. Wow! Thank you for sharing this, Wende.

      I knew that other provinces did things differently, but this is wild. You need to take care of yourself!

      Again, really appreciate you posting this.

      Our fees for immunizations are as follows. They may have increased by a few pennies since the new contract came in:

      G373 Injection-sole reason for visit = $6.75

      G590 Flu shot with visit = $4.50
      (Note: the ‘visit’ would be to address other concerns. A001 minor assessment = $21.70, A007 Intermediate Assessment = $33.70, or A003 General Assessment (once per year) = $77.20)

      Again, these figures have since changed slightly, but readers could search for the latest values in the Schedule of Benefits online.

    2. Now if you’ll excuse me I should probably go look up self-injection techniques…
      *********

      Without a doubt. There are situations of stupidity which demand a direct approach. Step on the vial afterwards ; pretend you did it before ; label and keep it for reference.

      My sincerest sympathies,

      Gordon Friesen, Montreal
      http://www.euthanasiediscussion.net/

  10. This post really struck with me. Maybe it is because I live in BC, but I have never gone to the doctor for a flu shot or any shot. For all our standard vaccines, we go to the health nurse clinic (aka the baby clinic). Work used to offer the flu shot free, then for a charge, then supplied a space only and we had to arrange nurse and shots. Now, all our pharmacies offer the flu shot, along with all our community centres, and many workplaces/university. We have not been able to see our doctors in person since March 16th. Even my torn hamstring was dealt with over the phone and by photo. I really don’t see when we will be able to get into doctor’s offices again, but not until there is a Covid plateau or vaccine. Now to wait in the long lines to vote and get a flu shot this week (the island has always had shortages).

    1. Hello Karia (great to hear from you!)

      Excellent comments. Each province has its own approach to immunizations. Many provinces have vaccination handled by the public health nurse, as you mentioned. For whatever reason, it is still an MD responsibility, for the most part, in Ontario. Given the convenience of getting a shot at the pharmacy, many patients now choose that option (it’s great for pharmacies too).

      You also highlight the bigger problems around access in general. It was tough pre-COVID, now it has been virtually non-existent for most of the summer. Some places have opened up. Others remain closed — often for good reason (e.g., older physician with chronic illness).

      In the end, people with connections inside the system always find ways to get access for themselves and their families. This is well-known and never seems to warrant much attention that major news outlets.

      I’m rambling…

      Great to hear from you! I trust that you are well. Feel free to shoot me an email sometime.

      Cheers

      PS. Very sorry to hear about your hamstring! I do hope you’ve recovered and are back chasing around whomever it is you need to chase around. 😀

      1. Since my kids are 22, 19, and 14…they chase me! I was rebounding the basketball and slipped on the mossy, wet cement (poor 14 yr old that had to witness my ungraceful fall). It was in April and now getting an MRI at end of October as it caused damage to my knee. Yes, our medical system is in deed need of help. In BC, there are so few doctors and most people I know do not have a doctor. It is such a huge relief that we do have the public health nurses and 811. For the most part, we don’t go to the doctor at all. Plus, my new doctor doesn’t “believe” in menopause…so I guess I have nothing “really” wrong with me…I enjoy reading your blog even though I’ve never commented. Keep it up!

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