I'm coming back...

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

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...

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

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...

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

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

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.