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.

Sayonara kiddos

I am all finished with my pediatric rotation and all finished with my last winter semester ever! Overall peds went very well. I had a lot of uncertainties going into this rotation. I wasn't sure I was going to like it at first because of the drastic change from trauma to that but the kiddos grew on me a little more each week. Doing the rotation in my home town was also something I was unsure of. It was odd running into people that I went to high school with and played on sports teams with. I would like to know what some of them were thinking when I walked into the room to examine their child. Then again, judging by the looks on some of thier faces maybe it's best if I don't know. I was unsure of how working with my uncle was going to go too. Working with my uncle turned out to be a good decision. I learned a lot from him but we also had fun. It was nice to not be intimidated for once. He is a fantastic pediatrician and I can see why everyone wants him to treat their children.

There is one thing that keeps sticking in my mind about this rotation. While here I have seen that there is a real need for more medical practioners. As students we have all had the "underserved" lecture and most of us listen but then don't really think about it again. Nurses and patients kept asking me if I was going to be coming back to the area to practice. They all really wanted me to come back because I am familiar with the people and they need more practioners. I do not plan to come back to the area to practice, at least not right away. I really feel like scum for that. There is a true need and I am knowingly walking away. I do not see myself being content doing family practice in a small town though. Perhaps someday when I have a family and am looking for something more layed back I'll consider it.

So to sum up the last six weeks I'd say that I have learned a great deal of pediatric medicine, I have learned that I absolutely adore newborns, and I have gained a new found respect for the people of this area and for rural medicine in general.

In case you are wondering why there is a scenic lake picture on here that's Raystown Lake, the lake in my hometown.

I have learned something on this rotation that I doubt I will be seeing or doing on any other rotation, circumcision. Circumcising or as we affectionately call it in the office "whacking wienies" is actually a pretty cool procedure to see. I can say this because I am a female. I highly doubt there is a man alive that could watch this without wincing. The instruments used for the procedure even have cool names like the Gomco, "helmet" (bet you can't guess where that goes), kellys, probe, and the circumstraint. I think the "helmet" might actually be called a bell but we refer to it as the helmet because it's more fun. The whole procedure takes around 20 minutes and is pretty much blood free which is kind of amazing considering you are amputating skin. Most of the babies tolerate it pretty well too. They are given a few drops of a sugar based liquid then a pacifier is stuck in their mouth. The doctor I am with uses a local anesthetic as well. That sugar must be some good stuff because the babies don't seem to notice you sticking a needle into the bottom of their little peenies. A funny side note: I noticed that when we inject the lidocane it of course causes the base to swell making it look a lot like a tiny little elephant trunk.

The success of the procedure is dependent on correctly fitting tools and the doctor's ability to achieve hemostasis. This is done with hemostats and the Gomco clamp. Patience and precision are also key. I was watching the doctor do one the other day and I realized just how important it is that he get this perfect. He can't leave even a millimeter of skin because that millimeter of skin will grow with the rest of him. This little guy has to carry that penis around with him for the rest of his life! You can't have one that looks like the result of a drunken lovefest between a turtle, an elephant, and a grub. Some girl will take one look at that and run the other way! The doctor I'm with is very good at them so rest assured Huntingdon county you will remain well populated in the future.

The after care is pretty easy as well. You just put Vaseline on it for a few days until it heals. End of story. The procedure seems to be well tolerated by the little ones and makes taking care of them a little easier on the parents. Even after watching this I would still want my future sons to have it done.

"Babies are such a nice way to start people" -Don Herrold

So far my favorite part of peds is the babies. I'm talking the really young little babies, 4 weeks and under. In the practice that I am in we see them within 24 hours of birth and then again at 1-2 weeks and again at 4 weeks. So I've been getting to see a lot of little ones. When we see them in the hospital within 24 hours they are brand spankin' new. It makes getting up an hour and a half early worth it. I love almost everything about them at this age. I love how they are still always warm when you hold them. I love the fresh clean baby smell. I love their onsies and tiny socks. I love the way they get raging mad and scream at you when you undress them and examine them with your freezing cold hands. I love playing with their reflexes. I love how their eyes look so fresh and shiny when they open them. I love their soft baby hair. I love the little grunting noises they make. I love to watch them as they discover new things, like their hand. This list could keep going and going but I'm sure I've already lost over half of your interest already so I'll stop. I haven't seen any super sick newborns yet. I saw one with Tetralogy of Fallot but she was stable and doing well for now. If I were in a different setting like a NICU I might change my mind. I can't imagine how difficult that would be.

Like OB, this specialty is making me excited at the prospect of having little babies in the house. I'm not in any position to be having children right now so someone in my family needs to have a baby soon so I can get this out of my system!!!! Sorry for the lack of medical things in this post. Next time I'll try to find an interesting case instead of just rambling on and on about my love for newborns. I promise!

Kids kids kids

First let me apologize for not updating this for a week and a half. A lot has happened since I last posted, I moved back home and started my next rotation. I am now doing pediatrics in my hometown with my uncle at his office. It has been an interesting transition. I haven't lived at home for this long in 9 years. I'm still getting used to the daily phone calls asking what time I'm coming home and the occasional visit from our golden retriever in the middle of the night but overall it's going well. I especially like coming home to home cooked meals everyday and parking in a garage!

Going from a level one trauma center to outpatient pediatrics is quite the adjustment as well. In fact I don't think you can compare them in any way. It's a welcome change of pace though. Working with my uncle is very different too. For once I'm not intimidated out of my mind. That may sound bad but I mean it in a positive kind of way. I am still learning something everyday and being challenged. Examining children is completely different from examining an adult. We take things for granted with adults. Adults aren't terrified of a simple thing like a stethescope, well the "normal" ones aren't anyways. With an adult you just jump right in and do the exam, end of story. With little kids you have to explain everything you're going to do and let them touch everything first to prove to them it doesn't hurt. You have to earn their trust. You also have to earn the parents trust. All this has to be done in under 25 minutes! Talk about a challenge. I've only been doing peds for two weeks but I have found that these 5 things are necessary to successfully exam a kid:

5. A friendly face
4. A knowledge of current cartoons
3. A plethora of different noises and voices
2. A love for children
1. PATIENCE PATIENCE PATIENCE

I'm sure this list will grow weekly and I am looking forward to figuring out all of the secret little tricks of pediatrics.