Will my insurance pay?

I have a Sirius radio in my car. The other day, I was listening to the plastic surgery show on Doctor Radio as I was driving on a road trip. Throughout the course of the show, people kept calling to ask about different procedures. The most common question was, "Will my insurance pay for this?"

Although I don't advocate that insurance cover cosmetic surgery, the question gave me an idea.

I have been working on my fitness levels, and I have started working out. When I decided to do this, I thought that I would just buy a workout video (I bought the Power 90 workout by Beach Body) and would go to town. Unfortunately, it's not that easy. This is an intense workout series and there is more expense than just the videos. At any rate, as part of my preventative health care, I think that I should be able to use my insurance premium to pay for a gym membership or hire a trainer to get me going. I don't go to the doctor very often, if ever at all, outside of perhaps a yearly exam and annual vision screening. This would be an excellent way to utilize all of the money that I poor into the insurance company's bottom line.

Obesity is becoming an epidemic in our country. A quick Google search showed this CDC website on obesity. The graph animation on the website is an interesting visual to show how quickly obesity in our country is spreading. Perhaps this would be a way to help lower the cost of health care overall...

Pelvic Fractures, Pt. 2

Here is the finish to the post on pelvic fractures. In my previous post, I discussed some basics to pelvic anatomy and the anterior-posterior patterns (D - F in the figure below) of fracture in the pelvis. In this post, I will briefly describe the lateral compression patterns (A - C) of pelvic fractures and then also discuss the vertical sheer pattern (G).

Also, worth review in this post is the importance of identifying pelvic fractures early in the trauma evaluation. This is one injury that orthopaedic surgeons that treat which is truly life threatening. Early identification of these injuries can save lives in the trauma bay. It is always rewarding to get called to a trauma, look at an AP pelvis and note a pelvic fracture, and then go into the trauma bay to see that the patient is hypotensive and tachycardic, put a binder on the pelvis and watch the heart rate decrease and the patient become more normotensive. Closing that pelvic space is something that must be done ASAP because it can make a huge difference in the hemodynamic status of the patient.


There are three types of lateral compression (LC) fractures in the Young-Burgess Classification. These injuries occur due to a compressive force on the lateral side of the body. The type of injury seen depends on where the force is applied. In this type of injury, the ligaments responsible for pelvic stability become shortened. Pubic ramus fractures often accompany LC fractures and can be on the ipsilateral or contralateral side.

LC I - This injury pattern results in compression of the sacrum. This injury pattern is often associated with transverse pubic ramus fractures.
LC II - In this injury pattern, a posterior iliac wing fracture is noted. Depending on the amount of disruption to the posterior ligamentous structures, varying amounts of instability will be noted. This injury pattern, however, is a stable pattern of injury in the vertical plane.
LC III - This is the so-called windswept pelvis. In this pattern, either an LC I or LC II injury pattern is noted, but the force transmitted by the lateral compression results in an APC injury on the contralateral side. Of note, this injury pattern is especially vulnerable to circulatory damage and hemorrhagic shock.

Treatment of LC pelvic injuries is similar to those of APC type injuries. Treatment is selected based on the stability of the injury In general, non-operative treatment can be selected for patients with <1.5cm of displacement of the posterior ring or ramus fractures with no posterior displacement. Gross displacement of hemodynamic instability can necessitate more aggressive treatment ranging from angiography and coiling of arterial lesions to operative fixation.

Vertical Sheer (VS) injuries are the result of a vertically applied force due to a fall on an outstretched extremity. This injury results in disruption of the symphysis and the posterior ligaments. This is a very unstable injury pattern and often results in cephaloposterior displacement of the pelvis. VS injuries are often associated with vascular compromise and hemodynamic instability. Operative fixation will likely be required to close down the sympyseal diastasis and the posterior ring in addition to aggressive resuscitation to maintain perfusion of vital organs.

These injury patterns do not often occur as a single entity. Combination type injuries are possible.

As I mentioned in the previous post, it is important to be cognizant of DVT prophylaxis in the setting of a pelvic injury. Other injury associations include bladder and urethral injuries in men. Because of this , it is important to send urine to look for red blood cells which might indicate damage to the urinary system. If a urethral injury is present, the patient will need intervention ranging from a Foley catheter and observation to operative repair.

In the next post, we'll take a look at acetabular fractures, their classification, and discuss a little bit on their treatment.

Wrong Mindset

I was doing my daily read through the web, and I found this story on MSNBC. The story is questioning the use of helicopters to transport patients. The author of the story points out that this service is very expensive and that insurance companies will only usually cover part, if any, of the 8 - 25 thousand dollar cost of the flight.

In explaining the high cost of a helicopter transport, Craig Yale, the head of a company that specializes in helicopter transport tries to explain the soaring costs of this questionably overused service. For one, Mr. Yale states that the service requires an enhanced state of readiness, which is expensive. In addition, the cost of equipment drives up the bill, not to mention the highly specialized staff who work in very challenging environments.

I'm okay with those reasons, but one additional statement that he makes in defense of the high cost I found to be ridiculous. "If a given flight costs $7,000, an ambulance operator has to charge $14,000 to make up for people who don’t pay, discounts for Medicare and Medicaid and reluctant insurers, Yale said."

I have to say this excuse to charge more money in the health care industry makes my blood boil. How is it that we've gotten to the point where we just accept the fact that we can overcharge the crap out of people to make a profit and blame the problem on people who cannot afford to pay their bills.

Another quote by an EM physician in California who runs a billing company for air transport professionals exemplifies this. “We’ve got to collect enough money for the service, or the service goes out of business.” The article goes on to quote that this physicians company managed 500 million dollars in revenue in 2008 and 20 million in net income. I'm no expert in finance, but it doesn't sound like this company is struggling to keep the lights on.

Let's look at another example. I went on the web to find the annual report for a mega conglomerate of hospitals, Ascension Health. This corporation had revenues of $407 million. They had a net loss of $710 million in 2009, but this was due to losses that came from a poor market. In 2008, $512 million in revenue led to $356 million dollars in income. In FY 2009, the company lists over $800 million in uncompensated care. Imagine what the profit would be if everyone was paying their over-inflated bills.

I tell this story to say this - the health care industry is NOT hurting for money! Hospitals continue to build, even in this poor economy, and they aren't building double rooms with standard definition televisions. They are building private rooms with flat screen televisions, staffing the cafeteria with chefs and treating putting in applications for Michelin stars.

I'm not saying that making money is inappropriate, but I do think that it would be worthwhile to change the mindset of our industry. Maybe it's time to find a way to focus on providing quality care at reasonable prices to as many people as possible.

Pelvic Fractures

As I promised in a previous post, here is a post on pelvic fractures. It will probably take two or three posts to do the topic some justice.

The pelvic bone is made up of two innominate bones, each made of three separate bones that ossify to become one - the ilium, ischium, and pubis. These bones form a ring and connect posteriorly at the sacrum to form the sacroiliac (SI) joint. Anteriorly is the pubic symphysis. It is important to understand this pelvis as a ring concept, because when fractures occur in the pelvis, the often occur in pairs, as it is impossible to break a solid ring in only one place. The classic comparison is to think about a pretzel. Next time your eating lunch, give it a try.

Pelvic fractures are difficult to diagnose because there is not always an obvious sign of an injury, and can be life threatening if not diagnosed quickly. It is important to have a high index of suspicion if the mechanism of injury is blunt trauma. This is the main reason that the AP pelvis is included in the trauma evaluation with the AP chest. For more on reading an AP pelvis, see one of my previous posts.

There are two common injury patters in high energy pelvic fractures: the anterior-posterior compression injury and the lateral compression type injuries. There can also be vertical sheer injuries and combination type injuries.

In this post, I will discuss the APC type injury (D-F in the image below), and will cover the lateral compression and vertical sheer injuries (A-C, G in the image below) in the next post. The image below is a depiction of the Young-Burgess classification system, the most common classification of pelvic ring injuries. Other classification systems (which I will not discuss) include the Tile and OTA classification systems.


On initial AP pelvis evaluation, APC injuries are suggested with widening or diastasis of the symphysis pubis or in the setting of vertical fractures through the rami. On an adequate AP pelvis, there should be no more than 4-5mm (may be up to 9mm in the setting of pregnancy) between the right and left innominate bones at the symphysis pubis. This injury should always be considered in the case of hemodynamic instability with no other obvious etiology. In order to completely understand the pathology of pelvic fractures, we need to first discuss pelvic ligaments.


In considering pelvic stability, there are five main stabilizing ligaments to consider: the symphysis, the sacrospinus ligament, the sacrotuberous ligament and the anterior and posterior sacroiliac ligaments. This ligament complex is quite strong, hence the high energy trauma required to disrupt them. Rotational stability is provided to the pelvis by the short posterior sacroiliac, the anterior sacroiliac, iliolumbar and sacrospinous ligaments. Vertical stability is provided to the pelvis by the long posterior sacroiliac, sacrotuberous and lateral lumbosacral ligaments.

APC I - In this injury pattern, the symphsis pubis is less than 2.5cm and vertical fractures of the rami may be noted on the APC pelvis. The posterior ligaments are intact.
APC II - In this injury pattern, there is greater than 2.5cm of diastasis of the pubic symphysis. This results from disruption of the ligaments that stabilize the symphysis. One may also note widening of the SI joint due to disruption of the sacrotuberous and sacrospinous ligaments. This is the classic open-book injury. While rotational instability is noted in this injury pattern, there is no vertical instability in this injury pattern.
APC III - In this injury pattern, there is complete disruption of the stabilizing ligaments, including the symphysis, sacrotuberous, sacrospinous and sacroiliac ligaments. This is a very unstable injury pattern and is the pattern most often associated with neurovascular injury.

As stated earlier, in the appropriate setting, it is important to have a high index of suspicion for this injury. Given that this is an injury that should never be missed with potential serious morbidity and even mortality, I have been taught by my seniors to make a habit of looking at the AP pelvis before entering the trauma bay. When these injuries are identified, they should be taken seriously and addressed promptly. Fluid resuscitation should be started, especially in the setting of hemodynamic instability, and blood products should be readily available. One of the easiest ways to stabilize APC type injuries (and often have a noticeable impact on vital signs) is to use a standard sheet folded and then wrapped around the pelvis at the level of the trochanters. The sheet can be fixed anteriorly with some Kocher clamps. There are commercially available products as well.

Treatment of these injuries depends on the pattern of injury and the hemodynamic status of the patient. In the setting of hemodynamic instability, a combination of external fixation and intravascular intervention can be used to correct vital signs emergently. Bleeding can be venous or arterial. Depending on the injury pattern, up to 15 units of blood may be needed to replace losses. There is a good recent article in the JAAOS detailing treatment of pelvic fractures in the setting of hemodynamic instability.

Once the patient has been stabilized and other life threatening injuries have been addressed, these injuries can be stabilized internally with plates and screws. Anterior injury patterns can be treated with external fixation alone but posterior injuries require internal fixation.

A note about coagulopathy. In the setting of pelvic fractures, venous thrombus formation is common. Because of this, anticoagulation is essential to prevent embolism and potentially life-threatening complications. At our center, we anticoagulate patients for 6 weeks after their fixation. When anticoagulation is not possible, prompt placement of an IVC filter is essential.

Sources for this article include Handbook of Fractures by Koval and the AAOS Comprehensive Orthopaedic Review. Images were taken from the AAOS Comprehensive Review.

Not much posting lately...

So, I haven't done much posting recently, but I've finished my orthopaedics experience for the year and am working on off-service rotations until July. I've got some things in the works that I will post in the near future...

Interviews...

Interviews are coming soon. I thought I would take a couple of minutes to post some tips for a great match day down the road.

1) Go to as many interviews as you can make. The process is expensive, but this really is a numbers game. If you go on more interviews, you will have more programs to put on your rank list, and you will greatly increase your chances of matching.
2) Go to the night before social events. This is where you really get a chance to get to know the current residents at a program, and I believe that this is the most important place to learn about a program. Things are a little more scripted on the actual interview day. The social event gives you an opportunity to see who these people are in real life, and it gives you a chance to see how the current residents at a program interact with one another.
3) Go on the tour. Not only is it a great way to see where you will be working for the next five years, it gives you an opportunity to ask some questions along the way and get to know other residents in a more informal setting.
4) I'm sure you already thought of these, but make sure that you: a) show up on time, b) are polite and say please and thank you to those helping you get through the day, and c) stay as long as you can.
5) I'm not really sure how beneficial thank you letters/emails are, but I think sending letters to the programs that interest you the most will not necessarily hurt you. Pay attention to the information that programs hand out, though, because some programs ask you to not send letters.
6) Don't be afraid to tell programs that you are interested. Don't over do it, but, when you decide where you want to go, send an email or letter to the program director to let them know. Ask your mentor to make phone calls for you. If there is a place where you really want to go, you should make that known.
7) Have fun, take a deep breath, and be yourself. People say this all the time, but it's true. You're looking for a place where you fit. You will go to places and discover very quickly that you don't fit in. This place might be a "top five" program. Don't get sucked in just because of the place's reputation. It doesn't matter how good the reputation if you aren't having a good time. Half a decade is a long time!
8) Decide what attributes you are looking for early on. Do you want a more academic program with rigorous education or do you want a community program with a huge clinical component? Do you want to operate as an intern, or are you OK with a more delayed operative experience?
9) Look for the hidden clues. Every program has something in their closet that they don't necessarily want to share. How do the residents talk about the staff and vice versa?
10)Take notes. You'll forget the little details as you go. My approach was to make a running list. I moved programs up and down rank list as I went from interview to interview. In the end, I didn't really make many changes to the list before my final submission.

Good Luck!

How to Read an AP Pelvis

I saw the Quick Guide to reading a Chest X-ray over at ScrubNotes, and decided to publish the ortho version: How to read an AP Radiograph of the Pelvis. As with the CXR, it is important to evaluate the AP radiograph of the pelvis using a systematic approach. Here is that approach that I have been taught.

There are six lines that one should evaluate when looking at an AP radiograph of the Pelvis.

1. The iliopectional line to evaluate the anterior column.

2. The ilioischial line to evaluate the posterior column.

3. The dome of the acetabulums.

4. The 'tear drop' to evaluate the anteroinferior portion of the acetabular fossa.

5. The anterior rim of the acetabulum.

6. The posterior rim of the acetabulum.

It is also, of course, important to evaluate the rest of the bony structures visible on the radiograph, including the pubic rami, the SI joints, the neck of each femur, the visualized lumbar spine and sacrum, and the pubic symphysis.

Fractures in the pelvis can be difficult to visualize and if there is doubt, one can order additional views, including inlet and outlet views to further evaluate for rami fractures. The inlet view will allow for evaluation of the superior rami for fractures and the pelvis for anterior-posterior displacement of the pelvis. Outlet views will allow for evaluation of the inferior rami for fractures and for determination of superior-inferior displacement of the pelvis. Judet views are one additional study that can be ordered to evaluate the acetabulum. These views are shot at a 45 degree angle to the pelvis. The obturator oblique radiograph will allow for evaluation of the anterior column and the posterior wall of the acetabulum. The iliac oblique, conversely, will allow for evaluation of the posterior column and the anterior wall of the acetabulum.

If there continues to be doubt, it is appropriate to order a CT scan of the pelvis with 2.5mm (MSK) cuts. A normal CT of the pelvis will take 5mm cuts, which may lead one to miss subtle fractures. The MSK pelvis will allow for full and detailed evaluation of all of the osseous structures of the pelvis and assist in the determination of what pathology is present, if any. It is important to remember, however, that all classification systems for pelvis fractures are based on plain radiographs, and as such, are necessary for operative planning.

I want to start posting about different fracture classification systems soon - sort of like the "For my own Edification" posts at Trauma Bay. The first will be a post about pelvic fractures, and I hope to get it up in the next few days. I'm an action sort of learner. I learn by doing - and so, as I go over these things, I'm going to start keeping my notes here.

Image Source: KUMC Radiographic Anatomy

The Good Medical Student

The first few months of the year are prime time for 4th year medical students who are interested in matching in orthopaedic surgery. A couple of groups of medical students have rotated with our service by this point, and overall, there is an interesting dichotomy of students. Some of the students are too aggressive, and they end up coming across as a real jerk. Others are quieter than a church mouse. They stand in the corner and you'd never even know that they were there. Not too many, frankly, have been in between.

I thought I would write this post, because I remember doing my first ortho rotation and not really know what to do, especially in the OR. Here are some tips on how to be a stand-up student (especially if you are going to do an away rotation) and increase your chances of matching.

1. In the OR, always help move the patient to and from the bed. If the nurse is standing by the patient, ready to help move the patient, ask him/her if they would like you to take their place. The circulator has a lot of stuff to do, and if you do this job, they will greatly appreciate you.

2. When you walk into the room, introduce yourself to the circulator and the scrub. Put on gloves and get ready to help move and position the patient. Stand by the patient and assist the anesthesia folks if they need anything.

3. Learn where things are kept in the room. If someone needs something, offer to go and get it. You have no idea how helpful this can be!

4. If the patient needs a foley to get the case started, volunteer to put the foley in. If you need help, ask one of your residents to watch you. I know you are on an orthopaedic surgery rotation, but nothing says you can't to do this simple/quick procedure to help move the room along. I do foleys all the time as an intern, and I will continue to do them if they need to be done. The goal is to minimize delay and keep the day in the OR moving. The faster the OR is over, the faster you (and your resident/attending) get to go home!

5. Make sure the scrub has gloves and a gown for you.

6. Ask the circulator if they need help prepping the patient and do so before you scrub for the case.

7. If the attending/resident has a piece of suture, you should have a suture scissor in your hand. The worst thing that can happen is the attending/resident takes the scissors from you because you are not in a good position to cut suture.

8. Pay attention to what is going on in the case. If an attending/resident is drilling a hole in bone, ask the circulator for the depth gauge. If you show that you are paying attention during the case, you'll get more opportunity to do things.

9. Look at the approach for the case and LEARN YOUR ANATOMY. If you answer one question correctly, you'll likely not be asked many more questions - and you'll get rewarded with more opportunities to participate in the case.

10. Watch the closure. When you get an opportunity to suture, give it a go, work to do it correctly. You can practice at home with pig's feet, oranges, bananas, and pretty much anything else that has an outer skin. Ask the scrub to give you any extra, unused suture that might be left over at the end of the case.

11. Offer to write notes. I know that this seems like busy work, but it is VERY helpful, and it actually does have some educational value. When I write a neurovascular exam of the lower extremity, I have been asked what the nerve/muscle abbreviations are - many times. It's OK to ask if you don't know. It's amazing how little orthopaedic surgery is taught in medical school - and because of this, there's a ton to learn.

12. Don't be afraid to ask questions, but know the appropriate time to do so.

13. Be the first person in the door and the last one to go home.

14. Be part of the team and don't ever complain!!!!

15. Nothing listed above is scut! These are all jobs someone on the team needs to do and if you volunteer to do some of the less fun jobs, somewhere along the way, you'll get an opportunity to do some of the more fun stuff!

I am very careful to attempt to get students to participate, but not all residents are that way, not even with me as the intern. Unless you put yourself in a position to be helpful, you're not going to get invited to the party. This is your education we're talking about - and you're paying for it. Not to sound to schizophrenic, but you also have to be patient. You'll get opportunities, but there are dues to be paid first. We all have to do it.

The Trauma Bay

At my program, the intern takes all of the floor/ED/trauma consults during the day. Regular consults on the floor or in the ED are really not that big of a deal. I go to see the patient, look at the films, read about what I've seen and heard and then report to my chief. The trauma bay is another animal, especially if I have been called for something that requires immediate attention like a disvascular limb, dislocated joint, or open fracture. This call usually occurs after the initial primary survey has been completed but before the patient leaves the trauma bay to go to the CT scanner and get additional plain films. The patient has a portable chest x-ray, an AP pelvis and maybe a couple of other portable films of obvious deformities.

Keep in mind, I am the intern, and the trauma/EM staff, not to mention many upper level residents stop what they are doing and stare at me while I complete my evaluation, ask for things that I need and prepare whatever intervention is necessary. Meanwhile, the trauma chief is asking to take the patient to the CT scanner and the nurses are griping about keeping the patient in the trauma bay for longer than is necessary.

So, I have to balance the excitement of taking care of some blown up limb or reducing a dislocated extremity with not overstepping my bounds as an intern - and get things done in a timely manner so that the trauma team can finish their evaluation. Oh yeah, and there is a person laying on that bed with a life/limb threatening injury. We've had some interesting trauma so far, a couple of really bad open fractures, a blown off foot and a couple of dislocated hips, and I've learned a ton in that setting. Number one, I've learned how to walk into a room where anything can happen and things are changing by the second and keep my cool. When I come into the trauma bay, "I'm just the intern," is not really a great excuse. I'm the "expert" in the room and it's my job to take care of the patient. I had to tell a lady the other day that there is a chance we will have to amputate her leg. Luckily, she still has her leg - but we'll see how things go over the course of the next year, not only for the patient - but also for my education...

Approaches - Anterior Lateral Approach to the Distal Humerus

Uses

-ORIF

-Exploration of Radial Nerve

Positioning

-Supine, arm abducted 60 deg, exsanguinate limb and use tourniquet

Landmark - biceps brachii and flexion crease of elbow

Incision - curved longitudinal on lat border of biceps, start 10cm prox to flexion crease and end at flexion crease

Internervous plane - Brachialis and brachioradialis are both innervated by radial nerve - although their innervation plays a minor role in motor function

Superficial Dissection

-Subq tissues

-ID lateral border biceps and retract medially

-ID interval between brachioradialis/brachialis

Deep Dissection

-ID and stay on medial side of radial nerve

-Retract brachialis medially

Dangers

-radial nerve

-musculocutaneous nerve

Approaches - Anterior Approach to the Proximal Tibia

Uses

-IMN tibial shaft fractures

Positioning

-Fracture table: Supine, Hip flexed 60deg, knee flexed 100-120deg+traction (boot or traction pin) No tourniquet!

-Free Leg Position: Supine, remove end table, injured leg flex over side, contralateral leg in support - flexed and abducted. No tourniquet!

Landmark - inf pole of patella, medial border of patellar tendon

Incision - 5cm incision from inf pole patella to tibial tubercle - in line with medial border patellar tendon

Internervous plane - None

Superficial Dissection

-Subq tissues

-Numerous small vessels to coagulate

-Incise fascia superior to patellar tendon

Deep Dissection

-Retract patellar tendon laterally

-Expose deep infrapatellar bursa

-Determine entry point at prox end tibia at junction of ant/sup aspects of the bone

-Entry is extrasynovial

Dangers

-infrapatellar branch saphenous nerve

-popliteal vein - if supports are in popliteal fossa

-ACL insertion/ant. horn MM if nail too post

-medial=valgus

-lateral=varus

-beware cortical bone

-patellofemoral joint if knee is not flexed enough

Approaches - Posterior Approach to the Elbow

-Usually requires osteotomy

Uses

-ORIF fx’s distal humerus

-Removal loose bodies

-Non-unions

Positioning

-Diving Board

-Prone

-Tourniquet

-Arm abducted 90 degrees

-Elbow flexed over side of table

Landmark - palpate olecranon process

Incision - 5cm incision over the olecranon process that is curvilinear. Start lateral and curve it medially at olecranon

Intervervous plane - None

Superficial Dissection

-ulnar nerve as it curves post to medial epicondyle (protect)

-osteotomy 2cm from tip (v-shaped)

Deep Dissection

-Elevate tricep from back humerus

-Beware of radial nerve as is passes from post to ant through the lat intermuscular septum

Dangers

-ulnar nerve - beware traction

-median nerve - ant to distal humerus

-radial nerve - if prox extension of approach

-brachial artery - with median nerve

Approaches - Posterior Approach to the Hip

Uses

-Hemiarthroplasty

-THA, including revision

-ORIF post acetabulum

-Dependant drainage hip sepsis

-Removal loose bodies hip joint

-Pedicle bone grafting

-ORIF post. hip dislocations

Positioning

-Diving Board

-Peg Board

-True lateral

-Good padding

-Be certain you have room to move the hip

Landmark - greater troch

Incision - 10-15cm incision, curved, centered post aspect greater troch

Internervous plane - None

Superficial Dissection

-Incise fascia lata to uncover vast lateralis

-split glut max (may have some bleeding from branches sup./inf. gluteal art)

Deep Dissection

-Retract short external rotators (sup gamell, obt internus, inf gamell)

-Beware sciatic nerve, runs over SER

-Stay sutures in piriformis/obt internus tendons

-Beware quad femoris contains supply blood to hip

-Open capsule - hip exposed

-Dislocate with flexion, ext rotation and abduction

Dangers

-sciatic nerve - beware self retractors - may have two branches - beware of “small sciatic nerve”

-inf. gluteal artery - underneath piriformis = if lots bleeding, put pt. supine and tie off int. iliac artery

Approaches

One of the most important things an intern, or a senior medical student for that matter, must understand if they are going to participate in the operating room is anatomy. I was standing in the operating room today staring into a surgical wound and I begin to think 1-2 years into the future when I will be the one doing a significant portion of cases. It's amazing the background knowledge that goes into being a surgeon. That said, I have decided that, as I begin preparing for cases and studying approaches I was going to make study guides. They are fairly simple, but they point out most of the important anatomical points that an intern/medical student might get pimped on. My source is Hoppenfeld's Surgical Exposures in Orthopaedics, 3rd Ed. There is a newer edition. I should also mention that there are many other ortho exposure books available. This one just happens to be the one that I prefer.

I'll post each approach separately. I'll take feedback if you would like to give it, and I'll continue to post these as I make them. These would make good quick study guides that one could print and stick in their pocket before cases.

Time to Get to Work...

Orientation is in full swing. Patient care begins early next week. I'm starting my intern year with three months of ortho, so I hope to have some interesting stories to tell. Stay tuned...

Blank Check Medicine

I read this New Yorker Article by Atul Gawande today. It talks about the outlandish amount of money spent on healthcare in a small bordertown in the Southwest. In the end, Gawande's conclusion is that the reason this ridiculious amount of money is spent in this town is that the doctors there like to practice what I'm going to call blank check medicine. Instead of using some discretion in ordering tests and procedures in this community, the physicians have decided that doing is better than not doing. The down side is that the outcomes are not any better in this community. In fact, better outcomes seem to be found in places where less many is spent on healthcare. Just goes to prove, more is not always better.

Healthcare is a topic of furious debate right now, as President Obama continues to push for reform now or never. One of the major tenants of this impending healthcare plain will be cutting costs. No question we need to slow the amount of money our nation is spending on healthcare, but is all of this a "Buck stops here" situation? I'm sure that physicians can have a significant impact on how monies are spent, but it's hard for me to believe that writing a few less orders and doing less surgery is going to make the impact that we need.

I believe the major impact will come from spreading out the cost of healthcare. Right now, a major problem is the fact that only a few pay for everyone. Imagine if a person could go to the grocery store and get some food for free. Imagine grocery stores were required to have this food on hand at all times. On top of that, let's say that the grocery store owners were required to pay for this on their own. How would they do it? They would raise the prices of the rest of their food in the grocery store, effectively charging the people who came to the store to pay for their food for the free food. Now, superimpose that situation on American healthcare, and you'll see part of the problem. Health insurance premiums are astronomical. A large portion of small business owners in the country cannot afford to pay their employees, help to provide them insurance and still make a profit. The health insurers insist on making a profit. Don't get me wrong, if you run a business, you deserve to make a profit - but I believe every penny of our healthcare dollars should be going to healthcare. Imagine what we could do with this 42.5 million dollars.

I guess the point I am trying to make is that there isn't an easy answer here. Perhaps, we need to stop worrying about the money - and how much we are going to get paid - and look for a system that will allow us to take care of our patients. This isn't a situation where we can just remodel the kitchen and move into a new house and live happily-ever-after. This is a situation where we need to tear the house down, rip out the foundation and start from the ground up.

Misuse of Medical Services

The concept of misuse of medical services is being debated quite vigorously on a couple of the medical blogs that I like to read regularly. Look here and here. The question is simple: What constitutes proper use of the emergency department? The answer is unclear and the debate is hot. I thought I would weigh in. The post is somewhat lengthy...

I spent my last two years of medical school working in an urban ED in my "spare time." I have definitely seen my fair share of low acuity patients, and even spent some time trying to figure out why a nineteen-year-old mother of three would call 911 and bring herself and her children into the ED to be evaluated for a non-productive cough for less than 24 hours at 3AM. Of course, every patient who comes to the ED for tooth pain has talked to a dentist, but couldn't get in to be seen and every patient who ran out of their narcotic pain medications cannot get an appointment to see their "regular doctor" until 3 weeks from now.

Of course, there is that perception of what is and is not an emergency. Patients do not have the 1-5 triage system memorized and most of them lack advanced degrees in health care. EMTALA doesn't help. Although only a screening exam is "required," it's important to point out that most people that I have encountered believe that the mandate has become much greater than that. I believe that after their "screening medical exam," we should be able to point a patient towards a different venue of care, say back to their PCP or to a neighborhood clinic. I understand that, at times, real emergencies can present with non-threatening symptoms, and I would be interested to see how the number needed to treat comes out.

There is another issue here. Access to care is becoming much more complicated. Today, I read an article which said that the average wait to see a physician (in both primary care and sub-specialties) has increased by almost one week since 2004. This is especially true for patients who cannot afford private insurance. I'm not sure that I would be willing to wait 24 days to be evaluated for my fever and sore throat. If I had strep pharyngitis, I may already have rheumatic fever by the time I can be seen. Then, I'd have to sue my PCP for not being able to see me - and why not do my part to increase the cost of medical care in our country.

I'll tie it all back to education. We need to be explaining to our patients - in a respectful way - what is appropriate use of the ED and the cost associated. We need to make our patients aware of the fact that they are required to pay for our services. The orthopaedic surgeons in my area catch a lot of flack for requiring patients to pay before they are seen. I see both sides of this coin. I have been in school for 21 years and have 5 years of residency and one or two possible year(s) of fellowship ahead of me. It seems reasonable that I should be able to collect a fee for my services. I'm not sure I need to collect it right as the patient walks in the door, but I should be getting paid, and I'm not talking Medicaid rates either. No self-respectable lawyer (aka lawmaker) in this country would accecpt such an insult. Last I checked, members of congress were still giving themselves raises and doctors haven't gotten a raise for almost as long as I've been alive. I know, I know, we make enough money all ready, but the double standard seems a little insulting some times.

Maybe we could establish a system where, let's say level 1 and 2 patients are brought straight to a room without a discussion of costs. Every other patient will at least be advised of the necessity that they pay for their care and be given an option to instead follow with their primary doctor or perhaps go to the ED a the hospital where thre care is assigned (and medicaid - or its equivalent - will actually pay something for their visit). When a patient comes to the ED to request a UPT, the admitting clerk should be able to hand the patient a cup and show them the restroom. The patient should also be informed that they will be allowed to wait in the waiting area for their results, which will be provided after they remit a $50 fee.

I don't think that, in the end, I have a problem with patients using the ED for non-urgent care, but they need to be willing to pay for it. Similarly, I don't care if rich people fly on private air plans - but I don't expect to have to foot the bill...

The Away Rotation...

OK, so I have to promise to start posting regularly. Right now, as I am in between graduating, closing on a place to live and finally starting, there isn't a whole lot that is exciting to talk about. I thought, however, that in honor of the beginning of June, I might talk about the away rotation. This is going to be a stream of thought kind of post, so I apoligize in advance if it rambles on a bit.

I matched at the place where I did my away rotation, so I believe that this can be an important experience. The important thing is to work hard, but not to over do it. In many ways, the 1.5 day interview that you will have for most residency spots is too short. In many more ways, the 30 day interview that you might have during an away rotation can be WAY too long.

The most important advice would be to just be yourself. No reason to concoct some fake personality to try and impress the people you are working with. If it turns out that your personality matches with the attendings and residents at your visiting program, that's the person people will expect you to be when you show up for your interview, and if you match there, for day one on the job.

Once you've gotten in touch with your inner self, if you are given the choice of who to work with, do a little homework before you submit your preferences. Is it possible to work with the program director? Do you know what sub-specialty(ies) you have an interest in? Do you know anyone who goes to that school? Just like doing a rotation at your home institution, it is important to look for someone who will be enjoyable and productive to work with. Spending a month in a temporary place is an expensive investment. I spent about $7,000 on my away rotation, but it got me a job, so I guess it was worth it. Make sure you make a good investment.

If there is a resident at the program who graduated from your home institution, try to contact that person ahead of time. Ask them questions about who to work with, where you can stay, etc. They can provide you with lots of good information, and in the end, can be an excellent advocate for you when it comes time to make the rank list. In my opinion, it is a good sign if there are multiple people from your home institution in the program. This means that the program trusts graduates from your school, and that will be a positive when it comes time to make the rank list.

The rest of the advice is pretty self-explainatory, or at least I think it should be. Be the first person there and the last person to leave. Help out whenever possible in the OR, take call and find a way to be an asset to the residents that you are working with instead of a ball and chain. Be prepared for the operating room. Know what cases you will be participating in. If you don't already own these books, I would recommend you gets your hands on them: Hoppenfield's Guide to Physical Examination and Hoppenfield's Approaches Book (or some other approaches book) to help you with surgical anatomy. You might want some text to read about orthopaedics as well. There are several out there - and I don't think I can recommend one over another.

One last thing to think about is timing. I did my away rotation after I had already turned in ERAS, and too late to ask for a letter of recommendation. The upside to making that decision was that I had already done a couple of ortho rotations and was much more familiar with things. The downside, if you are looking for letters, is that it's too late to make that happen. I only did one rotation, and at the cost that I mentioned above, I'm not sure that I could have done many more. I know, that in some situations, residents will offer to let you stay in an extra room. I have to say, that seems like an extra risk, and extra pressure that I didn't want to deal with, but it would be one way to save some money. Of course, if you know someone in the area where you are going to do a rotation, you might be able to save money by crashing with them.

Well, I think that's all of the advice that I can think about for now. Have fun and happy hunting!

Finishing School...

So, I promise to post more here soon - last few days of medical school, and then I'll have lots of time to write....

My Road to Orthopaedic Surgery

I want to spend some time discussing my approach to pursuing orthopaedic surgery. I will discuss my strategies in terms of planning a fourth year schedule, doing an away rotation, filling out the ERAS application and getting letters of recommendation, accepting/going on interviews, and finally completing a rank list. I know that, many times along the way, I had a lot of questions. Luckily, I had people who I thought were able to give me reliable advice and accurate information. If I've learned one thing throughout my last four years in medical school, everyone has an opinion - and most times opinions are just that. So, over the next few days, I'll spend some time discussing each of these issues. If anyone out there reads this and would like to ask questions, please feel free to do so.

Hello World!

Hello.

I am a fourth year medical student at a school somewhere out there in the world. In less than two months, I will earn my medical degree from one of our nation's public medical schools and then go on to be an intern in orthopaedic surgery somewhere else out there in the world.

I decided to start this blog to chronicle my journey from medical school to residency training. Over the last four years, I have been lucky to have lots of people who were willing to give me advice and to assist me in making my dreams become a reality. I have heard many of those mentors say that it is important to give back. This will be an attempt to do that, to describe the journey that I have taken over the last few years and the strategies that I have used to match into orthopaedic surgery. In addition, I will chronicle my experiences over the next five years. Hopefully, as I learn the field of orthopaedic surgery, develop a knowledge base and a set of surgical skills, I will be able to pass some of that information on to someone else who is interested in becoming an orthopod or to propose some ideas that will help my colleagues in training. In addition, I hope that some other people from out there in the world will participate in the discussion. I learn something new every day and I hope that continues for the rest of my career and beyond.

I like to read med blogs. You will notice some links to some of my favorite blogs on this page in the near future. One thing that I have noticed is that there are not many (if any) blogs that are devoted to the subject of orthopaedic surgery. I hope to not only talk about my experiences, but to touch on the issues from time to time and to contribute something new and interesting to the discussion.