27 September 2008


So, I went in to the office an hour early yesterday, thinking that that way, I could get some of the pile of paperwork done. As soon as I walked in, I noticed an X-ray hanging on the view box.

"Um, P, what's this?" I asked my medical assistant as I flipped on the switch and let the buzz of the old machine warm up. "Oh, Dr C dropped that off yesterday, for whenever you had a chance to look at it," she said nonchalantly.

The machine suddenly sprang to life, and I did a... more than a double-take, that's for sure, with my mouth agape, stammering. There, on the X-ray was an innocent little finger with more than 90% dorsal and 75% lateral dislocation at the proximal interphalangeal joint. I started firing questions at my innocent medical assistant. "When did this happen? Was anything done about it? Where's the kid, now?"

She knows me well. She knows that I was not angry, just very concerned about the patient. So, she quickly produced Dr C's extension and got her on the phone, so I could fire the same questions at her.

Dr C's answers were not comforting: "It happened yesterday, and the child came right to the office. Yes, of course I did something. I took an X-ray and wrapped it with an ACE."

"Did you reduce it?!"

"Reduce...? It looked less swollen and better, so I sent him home."

You've GOT to be kidding me. That is what I wanted to scream into the phone, but I kept my composure. I said, instead, "Did you get another film before sending him home to make SURE it was better?"

"No." Of course.

"OK, I'll take it from here. Thank you."

P called the child and mother, and they swiftly got into the office. We got another X-ray, and, as expected, still dislocated. So, I explained to them that since it was now more than 24 hours since the original injury, I was not sure if a reduction would be successful. I would attempt it, however, after a digital block. I told them all of the risks and warnings, including that if this did not work, then this fourteen year old boy was looking at surgery! (In my mind, I was thinking, "Damn, all because your stupid PCP wouldn't pull on your finger!!")

So, I numbed his finger and (with a little difficulty) reduced it (YAY!). I buddy taped him securely, and got another X-ray--still reduced (YAY). And, for good measure (he IS a 14 year old boy who likes to play sports), I put him in an ulnar gutter splint. (phew)

Here's the deal: Finger dislocations are REALLY easy to reduce, if they are gotten to in time. And they do really well, if they are gotten to in time and managed appropriately. Often, especially in kids, all you have to do is anesthetize the digit, give a pull and it pops back into place. (You always hear stories of people doing this on their own without anesthesia, but we are doctors. We have the goods. So, be nice, and numb them up.) Yes, sometimes you have to maneuver a little, but just look at the X-ray, and use common sense (AFTER distracting the joint). And always, always treat dislocations like fractures--meaning immobilization for the appropriate amount of time (buddy tape or splint, NOT just an ACE). Because they WILL dislocate again otherwise.

The problem comes when the dislocation is not treated, or treated and not immobilized. That's when things can result in a chronic dislocation. That can cause volar plate laxity, ligament laxity and disruption, and finally a hyperextension (Swan neck) deformity. That necessitates surgery. NOT pretty for a simple dislocation.

Needless to say, the pile of paperwork still awaits me.

Oh, and the man from the prior post (Lucky) is scheduled for amputation on Monday. Yes, there is osteomyelitis present. And, as expected, his first reaction was, "I need a drink," quickly followed by, "I need a cigaret," when I told him he cannot have a drink. I took my time explaining to him that both alcohol and cigarets slow healing. Since his primary goal is getting back to work ASAP, it is in his best interest that the post-operative healing takes place in the best environment possible. While he was in my office, he understood, but I hope he remembers when at home, too.

20 September 2008


We really are... many of us, at any rate. Here I am, complaining about my difficulties with starting a private practice, and yet... I am lucky. quite lucky, very lucky, I'd even venture. happy, healthy, with a tiny, but solid, family, a man who loves me, my cats (2), and a job... and both of my hands with all ten functional healthy fingers. That's it, really. Hands are so amazing, and so important. As a hand surgeon, you see it all. Most days, hands astound me, in surgery, in the office, on the street... and yet, sometimes, I just run on automatic. I think we all do, sometimes. Until it just hits you from time to time.

Yesterday, I saw a gentleman, mid-forties, completely candid recovering alcoholic, "I don't want to drink, doc, but it hurts so bad sometimes. I know a drink would make it better. But I can't. I gotta do better for my new baby."

"How old is your baby?"

"A month and a half--my first. I guess there was a reason I had to wait this long, and my wife, she's so good to me... So, when can I go back to work, doc? Because my wife, she's on maternity leave, and there's no one else..."

You see, this guy has a terrible, I mean really awful, poorly diagnosed and mistreated open wound of the right index finger (yes, he's right handed). Weeping, purulent, probably osteomyelitic, ongoing for more than a year. Did I mention that he was my last patient yesterday evening? Oh, and he works in dietary... in a hospital... and desperately wants to return to work.

Amongst the malingerers and bad attitudes, I just felt so much grief for this man.

And yes, we are lucky.

10 September 2008


I don't really know where to start. Is anyone still out there? Any of the five of you? I have been silent for so long. I thought that, by now, I would be up and running in my little 'enterprise.' ;) FAAAAAR from it.

Opening a private practice must be one of the most frustrating things in the world. Especially in this economic climate.

In order to get a business loan, you must be in business for at least two years. What if you need money to start that business? What if, like me, you are not independently wealthy? You can try lines of credit or business credit cards. Even those, with most banks, you have to already be in business to get. You can try "angel investors." However, most of these guys are currently interested in web-based, tech-y stuff. (Angel investors, by the way, got their name from the early 1900s, when wealthy businessmen would invest in Broadway shows. Now, most angels are far from multi-millionaires. They just find a company that they believe in and want to help. These people are very business-savvy and more often than not want to be on the board of directors or a partner of the company they support.) There are also physician funding companies on the internet. I will have more to say about these in the next few weeks, as I delve more deeply into them.

The whole setting up a corporation thing is another story entirely. Word to the wise: make sure the person that does this for you knows what they are doing!! The first guy I talked to was a business lawyer, who had never heard of a D.O. And he touted himself as a 'specialist' in professional corporations. "So, we don't have to set you up as a doctor, we could just do a regular corporation." This was after my explanation of, "I am a surgeon, a physician..." Which was then followed by, "OK, doooctooor." (very long, drawn out, not nice.) The next one is a family friend of a very close friend. Not good. This is the one that is actually working on my papers, but extremely slowly (molasses slow), and often with mistakes that I have to clean up. I have already paid him, and he is (finally) about two-thirds done, but it has been painful... and I have no idea when the other third will get finished.

These are major hold-ups. Hence, my silence.

And, I am in the meantime, keeping my "day job." Very busy. That was a joy, by the way, telling Mr. Big-Shot President of the company that I am opening a private practice. There I was, excited, like a little puppy, as what I do in my spare time does not affect Mr. BS Pres in any way, shape, or form. But, to be nice, I thought it only right that I put my plans "out there, in the open," so nothing has to be a secret. (Also, so if--rather when--insurance companies make mistakes and send checks to the wrong place, it won't be as big of an ordeal to retrieve the money.) The meeting ended in the most uncomfortable way: Mr. BS just repeating over and over again that I could not steal the group's patients, and me reassuring him that that was not my intention. He was so bothered, in fact, that he came to my office the next day to interrupt my patient hours and again reitterate that I was not to steal patients. This went on for another fifteen minutes.