Family Practice

I started family practice three weeks ago and sadly haven't grown any fonder of it than I was on day 1. I enjoy the pediatric patients that come in but sadly they make up only about 15% of the practice. Most of the patients who come in throughout the day are there for "well visits". The term well visit is one huge oxymoron. When I did peds I enjoyed seeing the words "well visit" at the top of the encounter sheet because it meant there was nothing wrong, everyone was happy and I basically just got to play with kids for 30 minutes. In the adult world a well visit is anything but a good time (well mostly). The check-ups wouldn't be so bad if patients actually made an effort to make themselves well. They come in with new labs and want you to tell them that all of their numbers are picture perfect regardless of any efforts made to improve them on their part. Half of the time their results aren't improved and we have to increase their current medication dose or add new ones. Most of our patients have high blood pressure, diabetes, and high cholesterol. Those 3 diagnoses are guaranteed. There is sometimes another disorder like thyroid issues, cancer, or congestive heart failure. Those are the fun ones. I will say one thing, all of these disorders have really forced me to learn medications and how to interrpret lab results and why they are so important.

So as not to sound like a Debbie Downer, there are a few things I enjoy about family practice. I like that you have the luxury of taking time when with a patient. Most medical specialties schedule so tightly that you are only able to give 5 or 10 minutes per patient. It's normal for me to be with a patient for 30 minutes during a well visit. This leads me to my second like; talking to patients about things other than their problems. It's a nice change to be able to just talk to a patient. Some of the older patients have some really amazing stories! These stories sometimes give you an unexpected lift in the middle of a frustrating afternoon. This can back fire though. If I'm in a hurry to get out of the office that evening the last thing I want is to chit chat and look at pictures of someone's grandchildren or hear the latest neighborhood gossip. Nonetheless I am polite and give them the time because sadly I may be the only person they get to talk to that day. The last thing I will put on my list of likes is drug rep breakfasts and midday snacks. These are always a surprise. You never know when someone is going to drop by with a large box of assorted pastries from the local bakery. This too helps with those mid afternoon blues :)

It's no wonder there are fewer and fewer general medicine doctors anymore. It's a lot of medication juggling, helping those who won't help themselves, and fighting with insurance companies to get paid. Maybe I'm making one giant sweeping generalization here and it's not that way at every practice but that has been mine thus far and my friends' experiences have been similar. I sound like a heartless whiner. At least I know without a doubt that this is not the area of medicine that I want to practice in.

Another One Down

I apologize for the hiatus over the past 6 weeks. I was in Pittsburgh doing a clinical and the router in the house I was living in wasn't compatible with my computer so all extraneous internet usage went out the window.

While in Pittsburgh I did orthopedic surgery again only this time I was with a sports medicine specialist. I have always thought that sports medicine was what I wanted to do. I've had that idea in my head since I was a high school student. In college I did athletic training and exercise science, after college I worked in physical therapy doing a lot of sports rehab. Imagine my surprise when I get to sports medicine in the clinic and operating room and discover that it is not for me. I found myself bored most of the time. In the clinic it's the same things over and over again. In the O.R. it's either arthroscopic or there is a resident running the case which means I can't scrub in so you just stand around and watch. Observing is all well and good in the beginning but after 4 months of orthopedics I'm ready to get in there up to my elbows in everything!

The rotation wasn't bad at all, it just wasn't super duper exciting. The PA I was with was great. She was my age, easy going, and very knowledgeable in all areas of medicine not just ortho. The doctor was a great guy as well. He was easy to get along with and eager to teach and gave me as many opportunities to do things as he could. He was one of the team docs for the Pirates and even hooked me up with 4behind homeplate seats for a game. I enjoyed being with them but the topic didn't quite do it for me.

I took quite a few things away from this rotation. One I now know that sports medicine isn't for me. I learned that I need to be challenged on a daily basis in order to be content. I've learned that I don't particularly want to work in a teaching institution because I don't like sharing my OR time with other people. I liked living in a big city but I know that I don't want to live in a big city for an extended period of time.

My next rotation starts tomorrow and is family practice/internal medicine. I know NOTHING about either of these and am mentally preparing to have my butt handed to me on a daily basis. I guess I'll get that challenge that I've been missing for the past few weeks.

Accidents happen to everyone

I should have taken a clue about how my day was going to go from the very first patient of the morning. We were consulted for a tibia fracture in the ER. We went down to check it out before our first surgery of the day, at 7:30. Waiting for us was a middle aged train wreck of a woman. She was on 3 very strong psych meds and had a fifth of jack for breakfast. We learned some other "fun" facts about her while we took her history. She was an alcoholic, had liver failure, kidney failure, Hep C, and was an IV drug user. Perfect...This is just the patient part. The ER was slacking too. This lady had a displaced tibia fracture that clearly needed to be surgically corrected. They hadn't done their side of things and prepared for us to get there. This delayed us and was not in the patients best interest. My attending let the head ER doc have it and the guy never yells at anyone!

The 4 shoulder surgeries we had during the rest of the day had a few problems. One guy had really soft bone and every time we put an anchor in his humeral head it would pull out and leave a giant hole in his bone. Another case was missing pieces of equipment and another the scrub tech dropped like 5 things so we kept having to wait for more tools. It just was not going well. We still had one more case though, the tibia fracture from the ER early that morning.

This was a bigger case requiring lots of hands so there were four of us scrubbed in on this one. Everything was going smoothly and we were making good time. We were at the part when you put one of the supporting cross pins in the tibia. The doctor was drilling a hole through the tibia to place the screw through. He had one hand on the drill and the other on the other side of the leg supporting it as he drilled. Somehow he ended up drilling straight through her leg and directly into the end of his finger!! Let me put this into perspective for you, he drilled a hole straight through her hepatitis C infected bone marrow/blood and straight into his finger! His face went immediately white when he realized what he had done. I watched him do it and even saw both layers of his rubber glove get ripped right off. Anytime you accidentally stick or cut yourself in surgery it's a big deal. You have to go to employee health and go through a battery of tests and sometimes prophylactic medications. If you remember from earlier in this post I said that this woman was an IV drug user, hepatitis C positive, and unknown HIV status. This is the WRONG patient to accidentally cut yourself with. I felt so bad for this guy! He handled it pretty well considering. We paused the surgery and properly cleaned out his finger, then he gloved up again and finished the surgery. The only difference was he was now asking us all of the statistics on blood-borne pathogens. Guess everyone copes with thing differently.

I have been in on a lot of surgeries with high risks like hep C or HIV. The first few times you do them it's a little unnerving but you learn to be a little extra careful and wear a few extra layers and it's not big deal. I had almost lost my fear of these types of cases until today. This accident put that healthy respect back into me. I will remember that case every time I go into a high risk surgery for the rest of my life.

Snap, Crackle, Pop!

Today I was seeing a patient who fell out of her wheelchair and hurt her wrist. The xrays showed a displaced distal radial fracture (a fracture in the thumb side of the wrist that wasn't lined up.) Like usual the doctor came in the room to see the patient after I had seen her. He decided that since she was old (81 years) that she didn't need to have it surgically plated. This meant that we were going to have to manually reduced the fracture in the office. I was standing back watching and he looked at me and said that this was my patient so I needed to fix her. I was kind of shocked and questioned him but quickly jumped at the chance to do this. I have seen closed reductions before but nobody has ever let me do it. I'm going to explain how this is done so be prepared for a little bit of brutalness.

The first thing you have to do is to determine exactly where the fracture is using both the xray and touch. Once you figure that out you have to numb the area with zylocaine using a technique called a hematoma block. That is exactly what it sounds like, you put the needle directly into the hematoma inside the broken bone. It amazes me how little the patient's react to this because it looks excruciating! You then let them sit for a little bit to let the numbing agent set in. Once it is numb you grasp the wrist below the fracture with one hand and grasp above the fracture with your other hand. You then pull the fracture apart and pull the bottom of the wrist in the direction of the fracture. While doing that you push the hand down as hard as you can and it should slide into place. I was surprised at how much force this took. The sound and feeling of her bone moving was disgusting! Generally I love gruesome surgery/injury stuff but this actually turned my stomach and made me a little nauseous. In fact just thinking about it makes me nauseous.

I still cannot believe he let me do that!! While I am grateful for the opportunity to have been allowed to reduce the fracture part of me hopes I don't have to do it very often. Gross...

Last week we were consulted on a 75 year old male with possible multiple myeloma. Before going over to the hospital to see him we pulled up his films to get an idea of what we were dealing with. The man had boney lesions in his humerus, spine, and femur. We were being consulted on the lesion in his femur. The femur is a large weight bearing bone so it's important that it's integrity not be compromised. A lesion will compromise that integrity which can and will most likely lead to a fracture. A femur fracture in a cancer patient would be devastating to their chances of recovery. The oncologist wanted to know if this patient was a candidate for surgery to prevent the bone from breaking. After reviewing his chart and speaking with him and his family it was determined that he would be a good candidate.

We did his surgery 2 days later. This surgery was probably the most manly/barbaric orthopedic surgery that I'd seen thus far. It was also one of the simplest. We placed a rod called a gamma nail down through the femur. Surprisingly it only took 3 incisions, 1 larger and 2 small. The gamma nail itself was as long as the man's femur. That's huge!! The patient is lying flat on their back on the table and the table is up in the air at eye level. During the procedure you basically take this gigantic rod and hammer the crap out of it until it is shoved inside the entire length of the femur. I probably shouldn't have used the word hammer to describe how we get the nail down there. It's actually a metal mallet, more like a mini sledge hammer. It's very heavy which helps with getting the rod down. The doctor was hammering with all he had for 2 straight minutes to get that thing in place. Once it is determined that the nail is at the correct length you take and place another smaller rod and put it through the hip perpendicular to the gamma nail. This holds it in place and provides extra support to the femoral neck hopefully preventing a future fracture there as well. Then you put 2 small screws across the very bottom of the rod to keep it from sliding up. It is the messiest ortho surgery that I've done. I hope I get to do that one again before I'm done!

Sorry there's no pictures. The only pictures I could find were actually surgery pictures and some of you would not appreciate those :)

I started my new orthopedic rotation a week and a half ago. On this rotation we spend 2 days a week at one office in the city, 2 days in the OR in the city, and half a day in the office in the country and half the day in the OR at a country hospital. I have found that I really enjoy the mornings that we spend at the country office. While the office itself is very nice, I think it is the patients at this location that I am drawn to. I blame it on my upbringing. These people are similar to those that I have grown up around.

Before I go any further let me first say that just because you are from "the country" that doesn't mean that you are stupid. A lot of the patients up there may be less educated but they still want to understand their injury or disability just as well as someone with a graduate degree. These people tend to put more trust in you than those in highly populated areas do. Whenever I am in a room with these patients I have instant compassion and a strong desire to help them. I genuinely want to help them, it's almost a feeling of needing to help them. Helping them comes in many forms for me. It may be casting a broken arm, taking sutures out, or answering their many questions. It makes them feel important. Growing up in the sticks I can appreciate how valuable a specialists' opinion can be. I also know what it's like to see a doctor who clearly would rather be at his usual location with his usual clientele. It is very important to me that my patients never feel as if I would rather be treating another type of person.

I'm not really sure what all this means in the grand scheme of things. I do not think I would be content in a very small town right out of school. However, I cannot deny the compassion I carry for the rural underserved patients. Perhaps someday I will find myself back in the country. It's kind of ironic that I have spent my entire post high school life avoiding the country and now I find that that is what I am most drawn to.

Yesterday was an OR day, and as you all know I really like ortho OR days! I was with the shoulder surgeon and his PA. We had three different kinds of shoulder replacements on the menu for the day. I had never seen any shoulder surgery at all so it was once again a baptism by fire. It turned out that shoulder surgery is one of my all time favorite kinds of ortho surgery. The shoulder anatomy can be difficult to really understand because everything is so packed in and tight. These surgeries really helped me to understand the anatomy and how it all works together. You can't put a tourniquet on for this so its a really bloody surgery and bloody surgeries are my favorite kind. The first replacement we did was called a reverse shoulder replacement. This is a pretty cool operation. They basically put a prosthetic "ball" on the glenoid (the socket part of the shoulder) and then put a "socket" where the humeral head is(the ball part of the shoulder). Hence the term reverse. It's a good procedure for the older person who doesn't need a lot of function but wants pain relief. You can only lift like 10 lbs with it and can only raise your arm to about shoulder height but it gets rid of pain from an arthritic shoulder.

The second operation we did was a hemi shoulder replacement. In this procedure they leave the socket side of the shoulder alone but replace the humeral head with a prosthetic ball. This one gives more function than a reverse but isn't as good at relieving pain symptoms. The guy we did this on was an angus beef farmer so he needed his shoulder!

The third and final operation of the day was a total shoulder replacement. In this one they remove the ball and socket components and replace them with prosthetic parts in the normal anatomic position. Normally this takes about 2 hours to do. It took 3 1/2 yesterday! Our patient was a thick muscular middle aged male with massive deltoid muscles. We were working down in a 5 inch hole. In order to get down in the hole you must retract all of the surrounding tissues and bones. This is absolutely exhausting. It was more tiring and physically demanding than any other joint replacement surgery I have done but I loved every minute of it! I even woke up with sore legs and pecs this morning. I wish I had more time with that doctor.

My time at this rotation site was overall a good experience. I wasn't quite sure how it would go rotating with so many doctors but I ended up liking it. All the doctors were welcoming and liked to teach. It's too bad that the practice is in NEPA or I would be interested in working there. I start my next ortho rotation on Monday and am looking forward to new people, new experiences, and new challenges.

This week I was with the senior back surgeon in the practice. As far as ortho goes backs and hands are the areas that I know the least about so I was looking forward to this week. The first day with back guy was about what I expected. We did office visits all day which was boring but I did learn a good bit from him. I learned that back pain basically has 3 origins: disc, vertebra, or muscle. (I guess you can throw tumors in there too.) Disc problems generally cause the numbness, burning pain, and tingling with bending in certain positions. Vertebra can cause similar symptoms but can be from degeneration, fractures, or spondylothesis. Muscle pain usually hurts in one general area and doesn't have nerve type pain. That is in no way an exhaustive list of causes of back pain but the average person's diagnosis would be one of those.

My last day with the back guy was in the OR and boy was it a long one. On first glance the schedule looked pretty nice, only 2 cases! I should have known better. Nobody who has OR time for the day only schedules 2 cases unless they think they will use all their time. We had 2 lumbar fusions on for the day. I have done a whole lot of joint replacement surgeries but this was my first back surgery so I wasn't exactly sure what to expect. The first case was a 4 level lumbosacral fusion on a 50 y/o female who had a previous lumbar decompression done years ago and also had a bone stimulator implanted years ago. Oh, and she was around 250lbs. I later learned that that was a significant thing to note. When I feel my own spine I can feel it pretty well, it's right there just under the surface. This wasn't the case on this lady. It took us 3 hours just to dissect down to the spine and find all the landmarks we needed to do the actual fusion itself. We were looking down into a 7 inch deep 12 inch long hole. That only exposed the spinous processes, not the entire vertebra. After 2 hours of meticulous placement of screws and rods and digging around under her butt fat for 30 minutes to find and remove the bone stimulator we were finally ready to close...6 hours later! I don't know if you've ever stood in one place looking down into a hole for 6 hours but it gets tiresome. And this was only the first case. The second case was an even larger lady but fortunately she was younger and had not had any previous back surgery nor did she have a bone stimulator that needed to be removed. This procedure went much like the first except it included a discectomy and was only a 2 level fusion. During this operation the doctor told me to take the probe and "poke this". So being the good student that I am I did as he said and her left leg jumped right up off the table. He told me to do it again, so I did. He asked what I thought I was doing to cause that and I answered that I was poking the L5 nerve root. SCOOORE 5 points for LeAnne. That was the most fun I had all day. Makes you want to run right out and sign up for a lumber fusion doesn't it? :)

I might have to do more back stuff at my other ortho rotations but for now my back days are over. Thank goodness. I do not see a future in back surgery for me.

I'm half way through the first orthopedic surgery rotation. I have finally figured out that I really like this specialty, which is a big relief considering I chose to do a specialty in it. Ortho surgery is tough stuff, meaning physically demanding. It's not so mentally exhausting because it's all geometry and physics. I have seen a variety of different ortho surgeries now but knee replacements are still one of my favorites. I think I like them because they are so physical and gory. For the most part they are pretty straight forward. It's next to impossible to mess up a knee replacement. They use pre cut metal pieces to cut the bone to the perfect shape. Essentially it's a stencil that's used to cut out puzzle pieces. Then you just glue all the pieces in to the permanent position. They use the same tools that a carpenter would use in his woodshop; power drills, mallets, chisels, power saws, nails, and screws. I can see why it's predominately a man field. It's pretty cool when you use a power saw to cut through bone and instead of sawdust and wood chips flying it's bone dust and bone chips. We have to wear these suits to prevent infection. They look a lot like nuclear suits that you would wear if you were going into a reactor. It's surprisingly a relatively non-bloody procedure especially considering you are essentially amputating a leg and putting it back together. They use a tourniquet so the blood flow is cut off to the limb. After all the parts are glued into place they let the tourniquet down and then it gets messy. But up until that point it's fairly blood free. The only complaints I have about knee replacement operations is that they take 2 hours for one knee and a lot of the time we do 2 knees during the same operation. 4 hours of holding legs gets really tiring. A typical OR day is between 12 ands 14 hours. My body feels like it has been through a massive workout at the end of the day. This exhaustion is strangely a rewarding feeling. If I decide to work in orthopedics when I'm all done I'm going to have to workout frequently just to be able to do my job. My next OR day will be spent doing back surgery. I have yet to see that so I'm pretty excited!

*Obviously the girl in the picture is not me but that is exactly what we wear for joint replacements.

Orthopedics #2

Today was day 2 of orthopedics. I'm doing my first ortho rotation at a huge practice. I will rotate through 14 different physicians and PAs over the next 6 weeks. I had a warning from some other classmates that this was going to happen so it's not a total shock. I realize it's only been 2 days but I'm not really a fan of being with this many clinicians. It's impossible to gain someone's trust in 2 days. So far I've done only observation and I have a feeling that's pretty much what the next 5 1/2 weeks are going to be like. We see a lot of patients during the day. Today we saw 55 patients in 10 hours!! And I thought my old physical therapy job was always overscheduled at 40 patients a day. This is pretty much the norm throughout the entire practice. We hand out cortisone injections like candy and schedule knee scopes like they are party invitations. Tomorrow is an OR day, I haven't been there yet so I'm looking forward to it. We have three cases: one patellar bursa removal, bilateral total knees, and an achilles tendon rupture repair. I've only ever seen the TKRs so I should learn something and be entertained. I don't know the doctor very well so I probably won't get to do anything cool like run a saw or hammer something but just watching in the OR is better than just watching in the office. Orthopedics and sports medicine is what originially got me interested in medicine and it is where I am the most comfortable. I decided to do a specialty track in it so for the next 18 weeks I will be doing three different ortho rotations. It's a little disheartening to have it start off like this. I hope things become a little more interesting or this is going to be a very very long 4 months.