15 July 2008

There is NOTHING that I find more disturbing...

than a patient who does not have time for me. Access-a-ride, be damned.

So, there I was, clipping along my usual Tuesday patient marathon (trust me, 8A to 7P full of patients does not a happy surgeon make), when... "DrB, MsG wants to know when you will be seeing her. Her Access-a-Ride is coming soon, and she wants to know if she should reschedule," my medical assistant came into my office exactly as I pushed away from the EMR to get MsG. This automatically put me on edge. "Wait a minute," I said, "what time is her appointment?" "4:50," my assistant rolled her eyes. (She knows me too well, and could already see my blood starting to bubble.) I snapped my neck around to face the clock, "It's 5:02... twelve minutes past her appointment time. What's the problem?" Well, apparently, MsG had asked her transport service to pick her up at 5:16 (?huh?... why 16? and not, say 19? or 14, for that matter?) Well, I told my assistant to give the patient the choice (a grave error, this): stay and be seen--now--and the appointment would take roughly twenty minutes, or reschedule. "The patient will stay," my assistant soon told me. Three of the medical assistants in our 'area' (little office space in the medical center) knew of her predicament and promised to keep a look-out for her ride. They promised to make sure that the van did not leave without her.

So in she came. She was sitting in my office by 5:04PM. I acknowledged that I was running fourteen minutes behind schedule, and apologized. She, in turn, decided it was important for me to know that she had been waiting since 2PM. I (as nicely as I could muster at this point) explained to her that everybody has an appointment time, and I see patients according to the time of their appointment. It would not be fair for me to see patients out of turn. Frankly, I had been seeing patients nonstop (well, unless we count the seven minutes it took me to wolf down cold rice at 1:22PM) since 8AM, and there was no time at 2 for me to fit her in. I then quickly explained to her that I am happy to see her now, and would like to help her.

This is when the fun started. During my customary history taking, the patient was practically hanging out the window looking to see if her ride had come. I had to focus her attention back to me repeatedly, thereby wasting time (do you see the chasm here?). I called to the front to make sure that the medical assistants had not forgotten about MsG and her van--not only did they not forget, but the news had spread far and wide. More people were involved in making sure that the said van did not escape. It was not enough. That is when she started to look at her watch. But it was not a nonchalant, "Oh, let me just check the time here a second..." type of looking. NO! It was an all-out, "I need to get the f... out of here, and this damned surgeon is holding me up" kind of looking at the watch. Again, that strange dichotomy, that conflict, as I expressly told her that if she did not have time for me, we could easily reschedule her appointment. No, she said, "I'm here now..." as her voice trailed off. She was as far from here, now as possible.

I then started to examine her. She squealed even before I touched her, pushing my hands away. "Ma'am, I have to examine you. Please try to relax, as I cannot help you otherwise..." Once done, well, at least as far as she was concerned, she flew out of my office. She did not know what her treatment plan is, did not make a follow up appointment, and ran down the steps (cane waving in the air at her side) to an empty street to WAIT for the Access-a-Ride to come. (That was at 5:22PM.) I was so irritated (and busy), I did not wait to see when they finally got there to get her.

Her story? I honestly am not sure which is more disturbing--the above, or the below (what I am about to write). This lady, in her early seventies, had apparently been having trouble with her fingers (right ring and middle) for more than three years, "probably going on four," as she tells it. Her PCP attributed it to arthritis. The trouble? Locking of the fingers, so that she has to pull them, with pain, back into position. PEOPLE!! Holy moly, this is NOT arthritis (simply put, break-down of cartilage in a joint so that the bones rub against each other), it has nothing to do with arthritis. These are plain and simple trigger fingers, AKA flexor tenosynovitis or stenosing tenosynovitis.

(I have yet to master photo and drawing inserts here, so bear with me.)

Tendons are connections between the bones in the fingers and the muscles in the forearms (hence the reason that these patients will often have pain into the forearms). The flexor tendons are held in place with a pulley system (they are not like rubber bands, and therefore do not stretch, or give), of which the first annular pulley is the proximal-most in the palm. It also happens to be the tightest of the pulleys (in every person, in every finger--it is just the way we are made). When a patient has gout, or rheumatoid arthritis, or overuses a finger (always carrying heavy groceries, one on each finger), or falls on an outstretched finger, the flexor tendons will get inflamed. Once inflamed, they cannot pass fluidly past that first annular pulley. So, the person tries to bend the finger, the tendons bunch up distal to the pulley, and if the finger is forced to bend further, the tendons will clunk, or pop, under the pulley and get 'stuck,' or locked, now proximal to the pulley. So, the patient has to somehow maneuver the finger open.

If this is allowed to go on long enough, the tendons can actually get foreshortened, as the patient will eventually find it too painful to fully open and close the finger. That is, in effect, what had happened to this lady. She cannot straighten out her right ring finger at all. Not that I got a chance to explain this to her... (She also has a left middle trigger finger that has been ongoing for about 6 months.) So, what she needs is occupational therapy as optimization for surgery for the right hand, and an injection into the left.

Therapy for triggers should always include ultrasound with steroid ointment (NOT Biofreeze) and a home exercise program. This is a pet peeve of mine--for triggers, steroids, properly applied, work, Biofreeze does not.

Surgery consists of simply filleting open the first annular pulley. We have found that it is not necessary for motion of the tendon, or, for that matter, the finger. As long as the neurovascular bundles are protected, it is a fairly simple procedure (which gets hairy in fat hands). As for the injection, it is a steroid. The reason that steroids work (as an injection or an ointment--as in therapy) is that they are anti-inflammatory; they help to reduce edema around the tendon. In this way, the tendon can move in a supple manner past that A1 (first annular) pulley. The caveat is that there is a limit, as repeat injections can cause weakness, or even breakage of the tendons. I tell my patients no more than two injections per finger for your lifetime. Also be aware that in diabetics, the injection may make their sugars rise for a few days--better yet, don't just be aware, make your patients aware!!

You people have only an inkling of how much this lady upset me. I felt somehow abused. Maybe that sounds a little melodramatic, but... I did not even have a chance to go through a treatment plan with her.

14 July 2008

Prove it

One of the hardest things, I think, in medical practice, is attempting to prove to a patient that you (as a specialist) are in the right, when, in fact another surgeon in your specialty has proven some other thing to said patient. (still with me?)

So, last Thursday, I was called, nay, paged, by the medical assistant of Dr X, who frantically told me that I have to do surgery on patient TB. I had to stifle a laugh and ask her to slow down, as I explained to her, "I never do surgery on a patient that I have never seen before. And, by the way, please explain to me, again, why, if Dr X has determined that TB needs surgery, she will not be performing it?" She took a breath, and, rather confused, affirmed that, "Of course, you should see the patient first. You see, the patient does not speak any English, he only speaks Spanish, and I have no idea how he got your name, but he did. And Dr X saw him yesterday and said that he needs surgery ASAP, but she cannot do it, as the hospitals that she goes to don't take his insurance."

For a myriad of reasons, I have a weakness for patients who are not fluent in English... whether it is the time that I spent in my fellowship in the South Bronx, or my own immigration into the States, but there you have it. So, I told the medical assistant to have the patient come to see me on Friday.

That is where the fun started. First off, Friday decided to be hell-day. I did not see that many patients (19 in all), but I felt like I saw about 50, and like each of them whipped me one-by-one. I did a few procedures, which added to the craziness. So I digress, back to TB:

My Spanish is mediocre, at best. It was learned on medical missions in Guatemala and in the aforementioned South Bronx. It has been slightly bettered recently, as I have been dating a Hispanic man, but still, it is not conversational. I was ready. We have several Spanish speaking people in our office, and I had alerted my ~favorite~ one that I would need her help. Alas, I got the man into the office, and he started speaking... perfect English. huh? I asked him where he got my name (as Dr X's medical assistant was in a quandary as to how that had happened), and he evenly stated, "Dr X provided me with your name, as the hospitals she goes to don't take my medical insurance." come again? (now I was wondering what language I spoke to that MA in...)

OK, fast forward to... the man had had a close run-in with his lawn mower. Apparently, he managed to stick not one, but BOTH of his middle fingers (and a tiny bit of his left index) into the blades while the motor was still going. "I didn't hear it," was his defense. No one else involved, just one man and his mower. ehem.

One really lucky man, I might add. Here is what he got: a left distal phalanx fracture (a tuft fracture), and a right mallet deformity. (Look here for dealing with mallets--Dr Bates gives a great tutorial.) The mallet was due to an avulsion fracture of the dorsal distal phalanx, but he also had some tissue loss (with ER repair/ coverage 2 days before I saw him) of the volar surface of the finger tip.

Problem was, that he had a tremendous amount of edema at the right finger. You see, fingertip injuries without bony involvement (which this, in effect, was), can often be treated very conservatively. They heal GORGEOUSLY--often with no scar. But, as soon as you start mucking with trying to tightly re-approximate skin to skin (remember: re-approximate, don't strangulate!!), you can cause enough edema for cell death. Cell death equals ischemia and, well, skin death. So, TB was looking at skin edges that didn't look so healthy, and a surgeon (moi) that did not want to touch him with a twelve foot pole. As far as I was concerned, surgery is not indicated! And he had so much edema, that if I did any sort of grafting, it would certainly fail. (This, by the way, was one of the surgeries for which Dr X had apparently booked TB. That, and something for the other middle finger... in other words, surgery on BOTH hands at the same time. YIKES!!)

Now, I was quite comfortable with my treatment plan (get the edema down, treat the mallet, treat any skin death as it happens--it usually sloughs off like a scab), but I had to convince the patient, his wife (who did not, in fact speak a lick of English), and his brother-in-law (whose grasp of English was somewhere between the two). So, how do you (I), a relatively young surgeon (at least 10 years junior to Dr X) who does not speak their native tongue (Dr X does) convince these people that I am in the right? By standing my ground, repeating myself as many times as necessary, explaining and re-explaining, going over the x-rays, and, above all, showing them that I care.

I still do not understand Dr X's approach. You might ask why I do not just pick up the phone and call. It may sound awful (to me it does), but there have been many affirmations that much of what Dr X does has to do with inflow of cash... and a bullshit excuse might just put me over the edge. I really do not, am not ready to, hear it. I mean, really, both hands... at the same time?! Only in extreme, extreme circumstances.


Oh, I wanted to mention how honored I was to be mentioned in this month's edition of SurgeXperiences. Please make sure to take a look at the nicely written conglomerate as soon as you get a chance!