Nice Patients/Families Make My Day

I had the pleasure of taking care of a very nice older lady the other day.  She fell while walking to her car and fractured a few bones.  Despite her injuries, she was always in a very good mood.  When her family arrived, the nurse called and asked  if I could come and talk to them and explain her injuries.  I printed out some pictures and went to the room.

I started with showing the pictures and explaining each injury and our treatment plan for that injury.  I answered all of their questions and then we spent a few minutes talking about the surrounding area.  I made some suggestions about where the family could have some dinner and then went back to my work.

Everyone in the room was nice; smiling and laughing during our conversation.  No one complained about the hospital or griped that their family member wasn't in a private room.  When I told them to have the nurse page me if they had any other questions, or needed anything that I could help with, everyone said thanks.

Although most of the interactions that I have with patients are not unpleasant, not many are as pleasant as this particular encounter.  Maybe I'm not good enough at lightening the mood?  I don't know.  I do know, however, that something as simple as a good (or bad) conversation with a patient can have a significant effect on the day.

Lost in the Job

I've been thinking a lot recently about my transition from medical student to intern.  Seven months into the year, I have been looking back at how my attitude towards patient care has shifted.  As a student, we were all taught to know everything about our patients.  We were encouraged to spend time talking to our patients and their families.  I really enjoyed that part of my "job" as the medical student.  I'm not the world's greatest people person, but I do enjoy meeting new people, talking to them, listening to and learning from their stories.

As an intern on a busy surgical service, spending a lot of time with our patients is impossible.  On the busiest of days, seeing patients at all can be a struggle.  Patients look forward to the time when their doctor(s) visit.  They have questions and concerns that they want to address, and they are looking for someone to take some time to explain recent findings and update them on the plan.  On top of that, they are "locked up" in an unfamiliar place where bells, whistles and announcements are played all day and night long, people come into their rooms at weird hours to wake them up and ask a million questions and their privacy and dignity are sometimes taken for granted.

Although I don't have an hour to spend with each of the 20 patients on my service every day, I do have a couple of minutes to make some social rounds in the afternoons, to say hello to my patients and make sure their questions are answered and their needs are being addressed.  It's not like I don't want to talk to my patients, but more as if I get lost in the workload of being the intern, answering pages and checking and double checking to make sure that everything is being done.

Arranging Your Fourth Year Schedule

It's approaching the time of year where third year medical students are starting to think about how to arrange their rotations for the fourth year.

This is probably the most control you will have over your schedule throughout your medical school career. Where I went to medical school, we had three months of required rotations and seven months of electives. That leaves two months for vacation. We also had one month of vacation available during the third year, and if you did an elective during that month, you had three vacation months available and were only required to do 6 months of electives.

Let's start with the important part. How might you consider spending your vacation month(s)? First, and foremost, is interview season. Most, if not all interviews take place during December and January. You should plan to be able to travel during both of these months. I did fifteen interviews, six in December and nine in January. You don't necessarily have to use your vacation months as many schools have electives available in their catalogs that do not require an extensive time commitment. There is time for trips if you would like to travel the country/world. Many of my friends have gotten married during their vacation months, so please, do not make it all about business. This is the last year in life that you will get to enjoy, so build in some time for enjoyment.

There is one other matter to consider as you are thinking about scheduling a vacation - board exams. If you are not already aware, you must take two parts of Step 2: the clinical knowledge (CK) examination and the clinical skills (CS) examination. First, you must think about your Step 1 score. Are you happy with that score? Does it make you competetive for Orthopaedics. I would venture to say, if you have a score of 240 or greater, you do not need to worry about taking Step 2 right away. If your score is lower than that, you might want to consider taking the exam earlier in the year. Otherwise, put off the exam for as long as you can. I have been told by many people whom I trust that Step 2 scores are not heavily considered by program directors as long as the Step 1 score meets the cutoff.  Which brings us one other important point.  Many programs have a cutoff that is programmed into ERAS.  If you don't meet that cutoff, they don't ever look at your application.  If you think your score might be on the borderline, I would talk to the program director at your school, or the program director of places that pique your interest.

Now, to scheduling.

June - August - Start the year with some orthopaedics, preferably at your home institution.  This will allow you to get familiar with what is expected of an ortho sub-i in a relatively safe environment.  I've written a post about it in the past, but I'll hit the highlights.  Expect to work your tail off.  Be helpful but not annoying.  Read and prepare yourself for cases.  As an alternative, you might want to take one month during this time frame to get involved in a research project.  It's not required, but having some research on your CV will prevent you from getting thrown out of a program's interview pile for no good reason.  Speaking of CV's, don't forget about ERAS.  Make sure you have time to complete your application and run down letters of recommendation.  You might be getting these letters during the early part of the year, which is OK - but you should expect to have all of your letters by the end of October, middle of November.

August - October - This is the prime time for away rotations.  Pick one or two places that interest you and go visit.  If the program allows you to pick which attending(s) you can work with, do some research first and find the program director or chair.  Make a point to work with people who can go to bat for you when it's time for the program to make their rank list.  Remember, this is a month long job interview, so be on your best behavior at all times.  I've seen the match process from the other side now, and I can tell you, it's somewhat difficult to get yourself to the top of the rank list.  It is NOT HARD AT ALL to find yourself at the bottom, or off the list completely if you piss someone (even an intern) off.  That said, this is probably the best way, if you play your cards right, to get to the top of the list.  Programs will rank you higher if you spent time there and did a good job, mostly because all applicants look very similar, and having taken the time to spend a lot of money to work at a place means a lot.

November - Interview offers will start rolling in November 2nd or 3rd.  Use this month to do something fun or something required and get organized for your upcoming interviews.

December - January - Keep it light, if you do any rotations at all.  You'll be traveling all over during these two months trying to get a job.

February - June - Finish up your required rotations.  Spend time with your family and friends.  Travel the world.  Drink a lot.  Do whatever you want because come July, you are a career (wo)man, and you just won't have as much time for that kind of stuff any longer. 

July - Time to start learning your trade.  Hopefully, you've matched at your #1 program and you are ready to rock and roll.

I hate Lauge-Hansen

For whatever reason, I have a difficult time wrapping my head around the Lauge-Hansen (LH) ankle fracture classification.  The Weber classification is a little more straightforward, but doesn't impart as much information about the injury as the LH classification.  I'm going to go through ankle fractures like I did with pelvic fractures and hopefully, in attempting to understand the LH classification, impart some knowledge on everyone else.  As usual, I'm stealing my images from the AAOS Comprehensive Orthopaedic Review.  Information is borrowed from this text and the Handbook of Fractures.

To begin, let's take a quick look at the anatomy of the ankle joint (picture below).  The ankle is made up of articulations between the tibia, fibula and talus.  The joint is maintained by a variety of ligaments.  On the lateral side, the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament and the inferior transverse ligament help to prevent eversion of the ankle.  The lateral collateral ligaments of the ankle (anterior/posterior tibilfibular ligaments, calcaneofibular ligaments) help to prevent inversion and anterior translation of the fibula.  Medially, the strong deltoid ligament, which has a short and thick deep layer covered by a more superficial layer help to resist inversion of the foot.

When a patient has an complaint of pain/trauma about the ankle, in addition to a complete physical exam, radiographs should be obtained.  A standard series includes AP, lateral and mortise views of the ankle.  The mortise view is shot with the ankle rotated approximately 15 degrees to be perfectly perpendicular with the transmalleolar axis.  When reading ankle films, the medial clear space (distance between the medial articular surface of the medial malleolus and talar dome) should be less than 4mm on the mortise view.  In addition, the tibiofibular clear space (distance between the medial wall of the fibula and the tibial incisural surface) on a mortise view should be less than 6mm.

 

In terms of classification, there are two classification systems.  The first is the AO or Weber classification system, which is dependent upon the fibula fracture pattern.  

-Type A is a fracture below the level of the syndesmosis.  These are usually stable fractures caused by an inversion of the foot. 

-Type B is a fracture at the level of the syndesmosis.  This is the most common type of ankle fracture.  If the medial side of the ankle is not injured, these are often stable injuries.  In a patient with a Weber B fracture without an obvious medial malleolar fracture, stress radiographs should be obtained to evaluate the syndesmosis.  Stress views are obtained with manual dorsiflexion and external rotation of the ankle.

-Type C is a fracture above the level of the syndesmosis.  These fractures usually occur as the result of an external rotation of the ankle.  These fractures are often unstable because of associated medial sided injury.

While the Weber classification system is quite simple and easy to understand, the Lauge-Hansen (LH) classification system (images below) is much more commonly used to better understand the mechanism of injury.  The classification system is based on the pattern of injury to the ankle.  First, the position of the foot is described as either pronated or supinated and then the deforming force of the foot (adduction, abduction, or external rotation) is described as well.  Each fracture pattern has additional stages described for a more complete understanding of how additional force leads to progressive deformation and injury to the ankle.  As in the Weber system, the LH classification is described primarily based on the fibula fracture pattern.

Treatment of ankle fractures is based on the stability of the fracture pattern.  In general, fibula fractures without associated disruption of the medial deltoid ligament are considered to be stable injuries that can be treated non-operatively in a boot or short leg cast.  If the medial structures are compromised, surgical treatment provides much more desirable outcomes.  While the fibula is often fixed with a plate and screws, cannulated screws are often all that is necessary to provide the necessary fixation for medial malleolus fractures.   In addition to fixation of the fractures, the syndesmosis must be evaluated and stabilized if it is disrupted.  This is often achieved by insertion of a screw from the fibula into the tibia.  Post-operatively, patients should maintain non-weightbearing status until the fracture has healed.  They are often started in a short leg splint which is converted to a walking boot once the patient can begin weight bearing.

Breaking Bad News - Real World Style

 

Over the last few months, I have taken care of many patients with injuries like the intraparenchymal hemorrhage above.  I have found having conversations with the family and friends of these patients to be difficult to get through.  Part of me believes this is because I don't really have the experience or expertise to answer their questions.  The rest of me has decided that experience doesn't really change the fact that this sort of conversation is never easy.

In medical school, we practice breaking bad news to patients and families.  I remember a particularly comical "practice session" in which my charge was to tell a high school soccer player that he would never play sports again because he tore his ACL.   First off, pretty much everyone knows that an ACL injury is no longer a career ending injury.  Second, sitting across from your friend, who's task is to play said injured soccer player doesn't really make for an accurate representation of what the experience of breaking bad news is supposed to be like.

Now, let's talk about the real life scenario, when you are the "neurosurgery resident" on call and the poor patient with an injury similar to the one above rolls into your ED.  Literally, you are the only "neurosurgeon" in the hospital, and Grandpa's family has a million and ten questions.  Grandpa is intubated and requiring medications to control his blood pressure.  His neuro exam is nada, even with sedation off, and the ED doc says that the family would like to talk to the "neurosurgeon" before they make a decision on code status.

Nothing can prepare you for this experience when you are the person breaking the bad news, not even watching other physicians.  To me, the most difficult part is the emotion involved.  Getting past the obvious elephant in the room can be very hard.  I'm not great at keeping my emotions out of the mix yet, and I'm not really even sure how much emotion is appropriate.

Oh, and then there's that little fact that facts aren't always the most important part of the discussion.  Painting the big picture for this devastated family is not easy to do.  I've noticed that the family doesn't always want to focus on the big picture, because I think it's too much to take in.  It's easier to focus on the little things like vital signs and CT scans and getting the family past that can be a difficult task.  At least getting the WHOLE family past that can be a difficult task.

I believe that the most important thing a physician can do in these circumstances is put the facts on the table.  Explain what we know to the family and explain the uncertainty that comes along with these devastating injuries.  Once everything is explained, we have to put the ball in the family's court and continue to do our jobs.  It is important to revisit the family as the situation changes and they develop a better understanding of their loved one's condition and expected outcome.  I also find bringing other specialists (like palliative medicine) to the table can help give the family a complete understanding of the situation at hand.

Some people might ask why I care.  In five months, I'll be off to the happy land of Orthopaedic 

Surgery.  Although we don't necessarily deal with life and death every day in Orthopaedics, sitting a person down to explain that the best treatment for their injury would be an amputation is a difficult thing for patients to hear.

Although I said at the beginning of the post that experience isn't the primary determinant of how well a physician can handle these conversations, I do believe that it helps.  The rest is people skills and being able to relate to our patients in a way that allows them to hear what we are saying and understand their options.  Easier said than done...

The 4AM Page

I've heard about it, but I didn't know that it existed, until the other day.

4AM - working on my couple hours of sleep before rounds - pager goes off...

"Doctor, Mr. So and So's Labs are back"

Na=140
K=4.0
Cr=1.1
BUN=22

Me (To myself) = What the hell is going on?  Is this a dream?  Is this nurse reading lab values or a textbook?  What did I do to piss this person off?
(To Nurse)=Well, those lab values sound excellent.  I don't think we'll need to do anything at this point.  Thanks for calling...

We even have a replacement protocol to keep that from happening.  Not sure if this person was having a bad night or what...I've heard the old adage piss off a nurse and they'll call you for ridiculous stuff. 

H1N1 and Young People

A couple of months ago, I took care of a patient who was admitted to the hospital after elective surgery. He went to the SICU after his surgery (because of the surgery that he underwent, not because he wasn't doing well), was quickly extubated and did great for the first four days.

On post-op day 5, the patient developed a high fever (105 degrees F) and cough. He quickly developed progressive respiratory failure and had to be intubated. Testing confirmed that he had H1N1 influenza.

His chest x-ray looked like the one above. The patient further developed a secondary pneumonia that eventually grew several bacteria, fungi and even another virus.

Eventually, the patient had to be placed on ECMO (extracorporeal membrane oxygenation) in an attempt to maintain his oxygenation because his lungs were just too sick to provide adequate gas exchange. This patient, unfortunately, did not survive.

In an related story, one of my colleagues took care of a young pregnant lady in the ED who came in with progressive respiratory failure, had to be intubated and went into premature labor. She delivered a still-born fetus and was admitted to the MICU. Imagine seeing an OB, MICU, Pulmonary, Cardiology, Vascular Surgery and ED attending with their respective entourages trying to figure out what to do with this patient.

Above is a graph published by the CDC. The full report can be found here. This report details the number of cases, hospitalizations and deaths attributed to H1N1 between April and mid-November 2009. By far, people younger than 65 are much more affected by this particular virus.

It looks like, at least at this point, we have surpassed the second peak of the virus. Some experts, however, expect another peak to occur as we approach what is typically the worst of flu season.

The moral of the story is this: if you have young children, get them vaccinated. If you are <65, you should get yourself vaccinated. That's my PSA for the day.