Bone Broke? Me Fix!

I'm coming back...

2010-12-23T17:16:00.000-08:00

I haven't posted for a while, but I think it's time to get back to it. I have a little time off here for the Christmas Holiday, so check back for some stuff in a couple of days...

Good Interns

2010-08-01T12:20:00.000-07:00

We are one month into the new year, that is for medical residents around the country. It's hard to learn how to be a good intern. It's also hard to learn how not to be an intern. Since I have the intern thing down, I thought I would provide some tips for those new interns who are trying to figure it all out.

-The reputation you make for yourself on day 1 will last for the remainder of your residency. Be nice, keep your head and don't blow up at nurses. I'm sure you've heard it before, but nurses can make or break you. You never know who knows who in the hospital, so make sure you mind your p's and q's.
-Write everything down. When someone asks you to do something, put it on your list.
-Make check boxes and cross stuff off the list as you go.
-Do things as they come up, if you can. If you can't, you have to prioritize.
-Check and recheck things throughout the day. Follow-up on lab results and tests and keep people up to date.
-Get patients out of the hospital. You're job is to help move patients out, otherwise, they will just linger forever. Make it your mission. Remember, bad things happen to people in hospitals.
-Don't leave the task at hand, unless someone's about to die. Walk, don't run to codes. You need to make sure you have collected your thoughts before you walk into a chaotic room. You're supposed to be the one who knows what to do. Start with A and go in order. Make sure a senior person knows the situation.
-When you get a call about a patient, go see the patient, especially at the beginning. Towards the end, you'll be able to triage more effectively over the phone.
-Call for help. Your more senior residents have been there before. If you figure stuff out on your own, and no one ever gets hurt, that's great, but if you mess something up and someone dies, and you didn't ask for help, you'll never live that down.
-The most important thing that a surgical intern can do is keep the operating room going. Call the consultants, go to the Echo reading room yourself, do whatever you have to do to get the patient into the operating room safely.
-Stay until your work is done. You might find that you are staying late at the beginning, but you'll become more efficient with time. None the less, your more senior colleagues will appreciate your willingness to be a team player.
-Read as much as you can.
-Do something besides work. Otherwise, you'll go crazy.

Nothing to say...

2010-05-17T18:06:00.000-07:00

I don't really have much to talk about these days. I'm sure I'll come up with something in the near future. If nothing else, I'll just have to wait until PGY-2 year starts and I can start taking talking about some more exciting stuff...

The Empty Operating Room

2010-04-21T18:36:00.000-07:00

Have you ever been in a large basketball arena when it's empty and only some of the lights are on, or sat in an empty church, or maybe stood on stage in an empty auditorium? There's something magical about these places when they are empty. When the TV lights are off and no one else is around, you get some time to anticipate the next performance, to place yourself into the spotlight and dream about making the winning three point shot or hitting the high note to bring the crowd to their feet.

At the end of the day today, I was walking through the OR hallway. Most of the cases had ended for the day, the rooms were empty and had been setup for tomorrow's cases. I couldn't help but walk into a room and sit down for a minute, to dream about my opportunity to perform for the crowd. It's hard to dream about the end of the game before the national anthem has even been played, but it's important to have practiced that game winning free throw before the score is tied with 1 second left and you're at the line to win the game.

OK, I'm done with the ridiculous sports analogies. I was just stuck in the moment on my way through the OR and thought I would share.

Taking the scalpel...

2010-04-11T14:14:00.000-07:00

As I near the end of my intern year, my attendings are much more comfortable allowing me to yield the scalpel. At the beginning of the year, I was lucky to be allowed to cut suture. At this point, it isn't uncommon for the attending to scrub out while I close with a medical student and get the patient to the PACU.

It's pretty scary, taking a piece of sharp steel to a person's skin. Although I feel like I have a good understanding of anatomy, it's never enough to have just looked in Netter's before going to the operating room. I'm not the most spatial person in the world, but boy is it important to learn human anatomy in layers. A couple of days ago, I had a nightmare that I cut a patient's superficial peroneal nerve in an approach to a fibula fracture. I can't imagine having to go and tell a patient's family that I messed up their loved one. Hopefully, I won't ever have to figure out how it's done.

Getting permission to cut through a person's skin and mess around with their insides is a big deal. I think that is not necessarily obvious until you are the one holding the knife...

I Chose the Right Field

2010-03-27T17:28:00.000-07:00

As I rotate on non-orthopaedic rotations, I am constantly confirming my decision to choose orthopaedics. I know that I'm rotating through these services for a reason, and each patient that I take care of provides an important learning opportunity. That said, at the end of a rough month on a general surgery or non-surgical rotation, I'll take ten tough orthopaedics days over these other rotations any day.

There are many people that I have taken care of over the last six months whom I will remember for the rest of my career. Not to mention, many lessons that I will keep with me. In addition to the patients, off service rotations are important because they give you an insight into how other services operate. You get an opportunity to meet the residents and attendings on other services and develop an understanding of what is and what is not an appropriate reason to request consultation. I also enjoy getting into the operating room with other surgeons. There, I have been able to pick up a variety of important surgical techniques that will make me a better surgeon.

Own the Bone: Osteoporosis and the Orthopaedic Surgeron

2010-03-21T18:35:00.000-07:00

As orthopaedic surgeons, we see a lot of patients who have fragility or osteoporosis related fractures. These fractures are defined as those that occur from a standing height and are pathologic fractures. Common fragility fractures include vertebral body compression fractures, femoral neck fractures, and distal radius fractures. It has been estimated that 1.5million osteoporosis related fractures occur annually, to the tune of approximately $10 billion. Hip fractures in osteoporotic individuals increases the risk of death in the next year by 10-30%. Individuals who present with one fragility fracture are at increased risk of suffering from another fracture in the future. In fact, this and age are the two most important non-modifiable risk factors for osteoporosis related fracture.

Osteoporosis is the result of an imbalance in bone metabolism. In the physiologic system, bone is constantly being broken down and repaired by a very tightly controlled interplay between osteoblasts (bone forming cells) and osteoclasts (bone resorbing cells). This interplay is modulated by a variety of hormones including parathyroid hormone, calcitonin, Vitamin D, estrogen and testosterone, just to name the most important.

There are two types of osteoporosis: primary and secondary osteoporosis. Primary osteoporosis is the most common and is related to menopause (or loss of estrogen) or extremes of age (also known as senile osteoporosis). Secondary osteoporosis is the result of a disease process such as multiple myeloma or endocrine imbalance. Secondary osteoporosis can also be caused by exogenous corticosteroid use, even at doses as low as 10mg daily, although some may not argue this is not a necessarily low dose of prednisone.

Because of the morbidity and mortality of osteoporosis related fractures, not to mention the cost of care, appropriate individuals should be screened for the diagnosis of osteoporosis. This includes all women over 60 years of age, men over seventy, and individuals over 50 at increased risk for osteoporosis: those with previous fragility fracture, family history of fractures, frailty, low BMI, and treatment with medications such as corticosteroids, anticonvulsants, long-term heparin use, chemotherapeutic/transplant drugs, hormone/endocrine therapies, lithium and aromatase inhibitors. Of course, all individuals presenting with suspected fragility fractures should also be screened for osteoporosis, either in the acute setting or as an outpatient soon after their discharge from the hospital.

Screening is achieved through a variety of modalities, most common being dual energy x-ray absorptiometry (DXA). This radiographic test is used to asses bone density in the hip and spine. This density is then assigned a t-score and a z-score. The t-score is a comparison to the bone density of healthy young adults. The z-score is a comparison to age and sex matched individuals. Most commonly, the t-score is used to make a diagnosis of osteoporosis. A t-score greater than -2.5 standard deviations (SD) from the mean is considered to be significant enough to make the diagnosis of osteoporosis. T-scores from -2.5 to -1.5 SD are considered to be diagnostic for osteopenia.

Individuals who present with fragility fractures should have a laboratory work-up to rule out secondary causes of osteoporosis. These studies include CBC with differential, complete metabolic profile including alkaline phosphatase, TSH, and Vitamin D levels. Other studies to consider include serum protein electrophoresis (SPEP), 24-hour urinary calcium, parathyroid hormone, testosterone (in males), and many others.

In addition to treatment of the fracture, individuals found to have osteoporosis should be undergo treatment to prevent further bone loss and, in the ideal world, promote a more physiologic bone remodeling to occur. Those who smoke or drink alcohol excessively should be counseled to stop. Post-menopausal women should receive between 1200-1500mg of calcium daily. Adults greater than 50 years of age should receive 800-1000 IU of vitamin D3 daily. Individuals with osteoporosis should be encouraged to exercise and should undergo evaluation for fall risk. This often includes a visit to the home and scrutiny of medication lists for medications which may increase risk of fall. Lastly, medications intended to alter the course of the disease process such as bisphosphanates and estrogen therapy, among other, should be prescribed. This will often entail consultation with a primary care physician or endocrinologist.

As i mentioned in the title of this post, the American Orthopaedic Association has started a campaign that they call Own the Bone. This initiative was designed to increase awareness and encourage orthopaedic surgeons to take a more active role in the prevention, diagnosis and treatment of osteoporosis. Of course, the management of osteoporosis requires a multi-disciplinary approach, but the catalyst, unfortunately, for treatment is often the first diagnosis of a fragility fracture. One observational study published in The Journal of Bone and Joint Surgery (JBJS) by Dell et al. outlined a process by which a group in the Kaiser system was able to decrease their incidence of hip fractures by 38% (970 fractures) using a multi-disciplinary screening approach. If the cost of treating one fracture is estimated at $30,000, that amounts to a total savings of over $29million.

Next time you see a patient with a hip fracture, think beyond three screws versus intrameduallary nail. Start the process to rule out osteoporosis. Consult medicine colleagues to assist in the diagnosis and management of the disease. When seeing patients in the office for non-fracture care, identify and encourage screening in appropriate individuals. This is a way we can have a significant impact on the life expectancy and quality of life of our patients.

Sources

Dell et al. "Osteoporosis Disease Management: What Every Orthopaedic Surgeon Should Know." JBJS.
   2009;91 Suppl 6:79-86.
Jacobs-Kosman et al. "Osteoporosis." Emedicine: Rheumatology.
     http://emedicine.medscape.com/article/330598-overview
Lucas and Einhorn. "Osteoporosis: The Role of the Orthopaedist." JAAOS. 1993;1:48-56.

The End of Intern Year

2010-03-20T10:49:00.000-07:00

The end of intern year is in sight. Three months left, and then a new set of interns will be here to take over the painful task of being the ward secretary. Second year, however, may be more painful than the first. This is the time that you are supposed to become an orthopaedic surgeon. The amount to learn is incredible. I don't mind some pain, however. After all, no pain, no gain!

With that, congrats to all who matched. I'm looking forward to your arrival.

The Value of Communication

2010-03-16T18:08:00.000-07:00

I work at a large academic medical center. To officially consult a service, you have to place an order into our EMR. A lot of times, teams will put the consult order into the computer, but they won't call to discuss their consult. For example, when I was doing ortho, I would get a call from a ward secretary to inform me of a consult that was placed 30 minutes ago: 'rule out nec fasc' or 'rule out compartment syndrome.'

Nec fasc is shorthand for necrotizing fasciitis, more commonly known as flesh eating bacteria. This is not a diagnosis that should be taken lightly, nor should it wait 30 minutes to be seen! If the patient really has necrotizing fasciitis, and you leave them for another 30 minutes, they could lose a limb, or worse, their life. Compartment syndrome is the same sort of situation. These are examples of orthopaedic emergencies, situations when a consultant should drop what they are doing and go see the patient immediately. Granted, the yield for these consults is somewhat low, but if you're concerned enough to worry about something that is considered an emergency, you should call and talk to the person who will be doing the consult directly. Imagine if I placed a computer consult to the cardiologist that said 'rule out ST elevation MI,' and then allowed the patient to lay in their bed for the next 20-30 minutes waiting for the ward secretary to notice the order on the printer and call the consult!

It's not just emergent consults, however. If another service wants me to come and see a patient, I'm always happy to. I'll never refuse a consult. I do, however, appreciate a phone call to hear the story first hand. Not only do I like to hear the story, it's always easier to understand the question when you can ask questions back. If imaging needs to be ordered, I can make sure I have everything I need to take appropriate care of the patient.

Communication, however, is a two way street. Common sense would say that when you are finished with a consult, you should call the consulting service and discuss your recommendations. Sure, the recommendations are scribbled on the chart or dictated and won't be available to read for another 6-8 hours. Calling gives the consultant the ability to explain their plan and the thought process behind that plan. It provides an opportunity for the person who placed the consult to ask questions. Most importantly, it makes sure everyone is on the same page.

Too many times, especially in a large medical center, the plan gets confused. One hand doesn't know what the other is doing. Each individual team is making recommendations that contradict the other. In the end, the patient and their family becomes confused and frustrated, and that is a recipe for disaster.

Ring Enhancing Lesions

2010-03-12T06:23:00.000-08:00

Although I'm supposed to be talking about orthopaedic surgery stuff on this blog, it's kind of hard to gather good material when you aren't actually seeing patients with musculoskeletal problems.

This is a case that I saw during an off service rotation that I think almost everyone would find interesting. It's the true House sort of mystery.

I've been unfortunate enough to see two cases like this during my short medical career. Each time, the patient presented the same way. They were brought to the ED by a family member because of strange behavior. They were both having trouble with memory and were acting strangely. Neither was able to really communicate. They would answer questions with short phrases. One was getting confused and had become incontinent of both stool and urine. One had a CT scan (without contrast) that was read as negative. The other got a head CT with and without IV contrast which showed some ring enhancement. Both ended up getting MRI scans that looked similar to the above picture, which I stole from the interweb.

One patient was found to have metastatic breast cancer. The other, at least to the point I stopped taking care of them, remains a medical mystery. Although, trust me, the neurologists, ID docs, and probably many other specialties by this point are on the case.

For those wondering, the differential diagnosis for ring enhancing brain lesions is not terribly long. I found this case at Medscape as a good example of the presentation. They provide the pnemonic MAGIC DR to help remember the DDx: metastatic disease, abscess, glioma, infarction, contusion, demyelination, and resolving hematoma/radionecrosis.

One of the most interesting categories is probably abscess. Their are three classic infections tested on the boards: toxoplasmosis and CMV in immunocompromised individuals and neurocysticercois. I think that cysticercosis is probably the most interesting, but that's just me.

Cysticercosis is an infection in which an individual (usually from Mexico in the test question) eats undercooked pork and then begins acting strangely. The patients experiences these symptoms when the pork that they ingested is infected with tapeworm (Taenia solium) eggs. The eggs hatch and the larvae burrow their way through the lining of the intestines. They then find their way into the circulation and are then free to migrate throughout the body. Their most common stomping grounds include the musculature, brain parenchyma and the eyes. In the eye, if the larvae are alive, you may actually be able to see them moving around in the eye. Treatment is with either antihelmenthic drugs like albendazole or surgical removal.

What lessons can we learn from this case? 1) Always cook your pork. 2) If a patient presents acting strangely, you should think about ordering your head CT with and without IV contrast.

Syndrome Unrealistic Expectations (SUE)

2010-03-10T12:53:00.000-08:00

I did an exhaustive (Google) search, and didn't find this, so I'd like to proclaim myself the first to describe the Syndrome of Unrealistic Expectations or SUE for short.

This is an incredibly prevalent disease. Not only is it seen among patients in both the inpatient and outpatient setting, but also in their family and friends. Some common symptoms include improper utilization of medical resources, delusions that health care is free and labile mood. There are associations with chronic pain syndromes, tobacco abuse and a never ending request for the drug 'dilauda.' The disease is seen in both men and women and in people of all races. No diagnostic tests are usually necessary or available. It is strictly a clinical diagnosis.

There is no known cure for this disease. It seems to be communicable and maybe even heritable. Groups are working on developing a vaccine and are enrolling interested individuals in studies.

Strength in Numbers

2010-03-01T12:00:00.000-08:00

As I am sure many of you have heard, the Center for Medicare and Medicaid Services (CMS) is once again set to cut reimbursement to physicians. In fact, that cut is supposed to take effect today. This is not the first time physicians have faced this cut, but Congress in the past has passed legislation to delay cuts. This may still occur. In fact, CMS will not process claims for physician reimbursement during the first two weeks of March, as a temporary patch is once again expected.

Whitecoat makes an interesting suggestion on his blog: that physicians should just allow the cuts to take effect, but then stop taking care of Medicare patients. His argument is simply that instead of allowing our healthcare system to continue to teeter on brink of death, why not just allow the natural history of the disease to progress and force the collapse of our healthcare system that will in turn, push us more towards the overhaul that we so desperatly need.

One group of physicians at the Mayo Clinic in Arizona has done just that. That have stopped seeing Medicare patients. There are, of course, two sides to this argument. First, and foremost, how would such an approach in large numbers affect care for those who qualify for Medicare? Second, is it fair for physicians to accept a 21% pay cut in return for taking care of often very complex medical problems? Let's not forget that the current level of reimbursement is hardly adequate.

I have another suggestion, and it's a crazy one. What would happen if all of the physicians in a certain specialty in a certain area decided to form what would in essence be one large practice? What if all of the orthopaedic surgeons in one state decided that they were going to join together and refuse to take care of Medicare patients?

We're going to get to a point where crazy things have to happen. We've seen what Congress has been able to do with health care reform. For the send time in 20 years, they have attempted to make a change, and their attempt failed. The jury is still out on what can be done, as President Obama is pushing hard for meaningful reform to occur. I've said it before, and I'll say it again, we're asking the wrong people to enact the change.

It's time for physicians to take charge of their own destiny. While many of us would rather not get in the mix and just stick to the business of taking care of our patients, this approach is nearly as ineffective as my crazy idea above. We're not doing our patients any favors by allowing this current strategy of using temporary patches to stave off the inevitable.

Look at the Pictures Please

2010-02-28T16:40:00.000-08:00

I'm not a person who will get upset at being consulted. If you want me to come and see a patient, I'll come and see the patient. I might ask some questions to help me figure out what I'm getting myself into. When I ask the person calling what the x-ray looks like, I get two responses. 1) We haven't ordered any. 2) I get read an x-ray report. I prefer #1 to #2. Perhaps you aren't sure what pictures need to be ordered, and you want to make sure to get the right stuff. I'm OK with that. I'll order the pictures for you and then I'll go and see the patient.

Reading the report to me is worthless. Waiting all of that time before calling is a huge waste of time. If you push on a bone and it hurts, go look at the x-ray. Look at the picture where it hurts. If you see a fracture, give me a call and I'll come and take care of the patient. If you push on the bone and it hurts but there isn't a fracture, it is still OK to call. For one, I don't depend on the report to make my diagnosis. I, like most of my colleagues, will read the films myself. The radiologist's read is more of a quality control issue to make sure I'm not missing something. Additionally, maybe the patient needs another study, or in the case of snuff box tenderness in the wrist, perhaps we'll just go ahead and splint them and treat them like they have a fracture.

Here is an example of a scaphoid fracture that did not show up on plain films until follow-up.

Entiltement

2010-02-14T16:21:00.000-08:00

I was called to see a patient who was being discharged from the hospital. This particular patient was brought as a trauma, received an extensive workup including CT scans, plain films, and MRIs. They were admitted to the SICU and ended up requiring surgery. The patient had therapies and was treated to all of the "amenities" our hospital has to offer. The discharge planner asked me to come in the room to talk to the patient and family, because they were upset about one of the prescriptions.

This, in itself, is not an uncommon occurrence. On occasion, I will make a mistake with a prescription, or forget to include a home medication that the patient asked to have refilled. In this instance, however, the patient and family wanted to talk to me because the hospital's prescription assistance program would only agree to fill part of one of the narcotic scripts that I had written.

This complaint, alone, isn't really that big of a deal. I have a lot of conversations with patients about their ability to pay for medications. When I write a prescription for anti-nausea medication, I write for both Zofran and Phenergan because although I prefer to give my patients Zofran, it is expensive and some insurance programs will not pay for it. If I know that the patient is self-pay, I explain the difference in cost, give them both prescriptions and let them decide which they can afford. Oxycontin, as another example, is quite expensive. It can be up to $5 per pill.

The discharge planner explained to me that the hospital had limits on what it would provide for different medications, based on cost. Not only that, the discharge planner explained that although the patient had a job (but no insurance), she didn't feel like she would be able to pay for her stay. Because of this, the hospital had agreed to pay for her stay and all of the care that she had received. When you add it all up, the bill is probably way more than $100,000. When the discharge planner asked the patient how much of their care they would be able to pay for, the answer was NONE! The patient and their family expected that all of the care would be provided by the hospital, and had no intention of paying anything.

When I went to talk to the family about the limitations of the program, they couldn't understand the hospital's position. I was left with explaining that all I could do was write two prescriptions, one for the hospital's program, and the other for the patient to fill at a retail pharmacy, which they would have to pay for. They were still somewhat upset when I left the room.

This is not an isolated incident. I have heard many comments from patients stating that they didn't intend to pay for their care. When cost is brought into a conversation about prescriptions or length of hospital stay, patients will often mention that they have a medicare card or no insurance and they will not be paying their bill.

Imagine, for a second, if I went to the nicest steak house in town to order the most expensive cut of meat and the oldest bottle of wine on the menu. Let's say I asked the waiter the cost of these items, and then after his response, commented that it didn't matter because I didn't intend to pay anyway. Do you think I would get served that steak and wine? I doubt it. In fact, I would probably be asked to leave, or even more unthinkable, to pay for my meal ahead of time. If I told that story to 100 people, not one person would find that response by the restaurant to be unreasonable. If, instead, I substituted the story above about the Oxycontin, I don't think the response would be so predictable.

What do we have to do to get across to our patients that they have a responsibility to participate in (pay for) their care? This includes paying for the services of the hospital and its staff. Is the cost of care in our country over inflated? I believe that it is. Should we charge our patients $20 for a Tylenol? Absolutely not! The answer to this problem, is not providing universal coverage to all at the cost of $0. If we expect to reform healthcare and provide coverage to everyone at a reasonable cost, I believe that we have to start from scratch.

Distal Radius Fracture

2010-02-13T12:23:00.000-08:00

The distal radius fracture is a relatively common fracture seen in the ED. Distal radius fractures are often the result of a fall on an outstretched hand (FOOSH). Pattern of injury is dependent upon the position of the wrist at the time of impact. Of note, distal radius fractures are the third most common fracture seen in patients with osteoporosis. Post-menopausal and elderly patients that present with these injuries should have their bone density evaluated and the findings treated appropriately.

When evaluating injury to the distal radius, a complete physical exam and evaluation of neurovascular status should be completed. PA and lateral radiographs should be obtained. The wrist and elbow should be imaged. In assesing the distal radius, several radiographic parameters are important. The first is the radial height, which should be approximately 11mm. Volar tilt should be approximately 11 degrees. Lastly, radial inclination should measure approximately 22 degrees.

There are a variety of classification systems for distal radius fractures. Most commonly, when called from the ED, the consulting physician will describe the injury or use an eponym.

Colles (top left) - This is the most common fracture pattern, with over 90% of distal radius fractures having a dorsal angulation. These can range from simple non-displaced fractures to intra-articular fractures with disruption of the distal radial-ulnar joint (DRUJ). This is the fracture pattern seen after FOOSH injury.
Smith (top right) - In this pattern of injury, the angulation is volar. This injury occurs when the fall occurs onto a flexed wrist.
Barton (bottom left) - Fracture of the dital radius and dislocation of the radial-carpus articulation.
Chaffeur (bottom right) - Fracture of the radial styloid process. These injuries are sometimes associated with disruptions of the carpal bone articulations.

Displaced fractures should undergo closed reduction in the emergency department. A hematoma block and some IV narcotics can provide adequate anesthesia for the reduction.

Reduction of a Colles Fracture
-Hang the wrist with 5-10 pounds of weight at the elbow for 10-15 minutes. The allows ligamentotaxis to assit in the reduction and to bring the fracture out to length.
-Extend the wrist while providing logitudinal traction.
-Use a thumb on the dorsal fragment to push and then flex the wrist to reverse the dorsal deformity of the fracture.
-The wrist should then be placed in a well-molded sugar-tong splint. The wrist should be splinted at neutral. Avoid over extension or flexion as this may place extra tension on the median nerve.
-Post-reduction radiographs should be obtained to confirm adequate reduction.
-Neurovascular exam should be completed.

Non-displaced, minimally displaced, and stable fracture patterns can be treated non-operatively in a cast. Unstable fractures and those that cannot be adequately reduced require operative fixation. Options include percutaneous pinning, use of an external fixator or open reduction and internal fixation with either a dorsal or volar plate depending on the fracture pattern.

**As usual, information for this post taken from The Handbook of Fractures, 3rd ed. Images have been borrowed from Dr. Google.

Nice Patients/Families Make My Day

2010-02-06T09:53:00.000-08:00

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

2010-02-04T08:49:00.000-08:00

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

2010-01-31T12:00:00.000-08:00

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

2010-01-30T11:11:00.000-08:00

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

2010-01-29T23:22:00.000-08:00

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

2010-01-11T02:30:00.000-08:00

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

2010-01-03T09:45:00.001-08:00

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.

What does it take to be an Attending Orthopaedic Surgeon?

2010-01-02T12:26:00.000-08:00

I have recently been through a relatively benign stretch of rotations. Because of this, I have had some time to sit around and ponder some of life's greater questions, such as how much of my life I will have spent learning to become an Orthopaedic Surgeon. I thought I would share the results.

I cannot really quantify the beginnings of my education, but you first have to think about 13 years of primary and secondary education followed by an undergraduate degree and preparation to take the MCAT before one can ever enter medical school.

Medical school is where I can really begin to quantify the amount of time spent during my education. For the first two years of school, I was in class or studying for at least 12 hours per day, 6 days per week. Each semester was 16 weeks long, for a total of 64 weeks of school. That equals 4,608 hours of class/studying. In my first two years of medical school, I took approxiately 90 exams, not to mention the rite of passage that is the USMLE Step 1.

Years 3 and 4 are somewhat less vigerous from the standpoint of pure hard-nosed studying. Although I don't know exactly how many weeks we worked per year, I estimated 45 working weeks per year and 50 hours per week of studying/working/wasting time following residents around the hospital. That comes out to be a total of 2,250 hours. As a 3rd/4th year student, I took 6 shelf-style exams and 5 "home grown" clerkship exams, not to mention USMLE Step 2 CS and CK.

The totals for medical school include 104 exams and 6,858 hours studying, in class or "working."

Fast forward to residency. We get 3 weeks of vacation per year in my program, which equals 49 working weeks per year. At 80 hours per week, the total is 19,600 hours, which does not include time preparing for cases or studying for exams. I will be taking USMLE Step 3 in a few months, and will take 5 Orthopaedic In-Training Examinations throughout my 5 years as a resident. At the end of my residency training, I plan to do a fellowship and will have to take at least two exams to become board certified in Orthopaedic Surgery. For the purpose of numbers, let's assume that a fellow will work 49 weeks during their year and will work about 80 hours per week (which could be more/less depending on call, team coverage or research depending on the fellowship). The total there is 3,920 hours.

The grand totals come up to 30,378 hours of education/studying/working and 112 exams, not to mention research activity and some other things that I might have forgotten about. Granted, this is not an exact accounting of hours, but I would say it is pretty close and may even be an underestimate.

I'm not sure why it matters, or even what brought the question to mind, but I thought the numbers were interesting. Deciding to become a physician is not a small commitment, and the amount of training necessary to be theoretically able to cut someone open and put them back together again is extensive.

New Year, New Focus

2010-01-01T09:56:00.000-08:00

Happy New Year.

Over the past six months or so, I have blogged mostly about educational topics. Although I want to continue along that vein, this year, I also want to include some patient interaction experience and hopefully throw out some other topics that spur discussion and maybe even some controversy. We'll see how it goes. Thanks for reading.

Will my insurance pay?

2009-12-30T15:48:00.000-08:00

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

2009-12-19T18:43:00.001-08:00

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

2009-12-18T17:23:00.000-08:00

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

2009-12-01T21:55:00.000-08:00

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...

2009-11-22T16:40:00.000-08:00

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...

2009-11-22T16:23:00.001-08:00

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

2009-08-07T18:30:00.001-07:00

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

2009-08-07T15:31:00.000-07:00

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

2009-07-26T18:05:00.000-07:00

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

2009-07-08T20:41:00.000-07:00

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

2009-07-07T19:19:00.001-07:00

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

2009-07-07T19:18:00.001-07:00

-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

2009-07-07T19:16:00.000-07:00

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

2009-07-07T19:03:00.000-07:00

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...

2009-06-25T10:36:00.000-07:00

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

2009-06-10T18:01:00.000-07:00

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

2009-06-04T17:46:00.000-07:00

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...

2009-06-04T09:09:00.000-07:00

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...

2009-04-25T07:59:00.000-07:00

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

2009-03-27T20:37:00.000-07:00

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!

2009-03-22T17:56:00.000-07:00

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.