Religion is always a touchy subject.
I was brought up without the routine of church every Sunday. I remember my 5th grade art teacher being appalled when I told her we had too much to do, we simply did not have time to sit in church. Yet, I turned out OK. (Then again, I have never been much of a sitter--more of a doer--I even have a hard time watching TV or a movie. I feel that there is so much more that I could fill that time with... such a waste.)
Let me say, before I lose the small audience that I do have, that I am a very spiritual person. I definitely believe in a higher power, but I am more inclined to believe in nature (Mother Nature) than in an overseeing man. hmmm, so, in effect, is it the sex of the force with which I take issue? I do not think so. Taoism somehow feels right to me, but I really have to study more. I also am very interested in Buddhism. So much to see and learn.
The reason I am bringing up this subject? What do I do, when a patient asks, "Are you Christian, doctor. Will you pray with me?" It has happened on more than one occasion, and in the past, I have prayed with them in my own way... but I always feel somewhat of a phony. This is especially true since prayer is not so much used in Taoism and Buddhism--more of a meditation or conjuring, for lack of a better term. Considering my field, I expect to be asked to pray many times in the future.
So, what do you do? What do you think is appropriate?
Showing posts with label patients. Show all posts
Showing posts with label patients. Show all posts
31 October 2010
02 October 2010
Guatemalan experiments
I came across this in the news today, and was plainly shocked.
In today's society and times, human subjects are very closely guarded. Any time a researcher wants to do as much as reviewing charts, one has to get permission from the institute's IRB (Institutional Review Board), after taking a tutorial and test about human subjects.
The fact that a power such as the United States took advantage of the poor and minorities is incomprehensible to me. Between 1946 and 1948, Dr. John C. Cutler was involved in a study in Guatemala. He infected 696 people with syphilis (+/- gonorrhea) by sending infected prostitutes to call on prisoners and enlisted men alike... anyone resistant was inoculated directly. The records are fuzzy as to whether the men were then treated with penicillin, or what the dose was--never mind the prostitutes. Dr. Cutler was apparently also involved in the Tuskegee Study in Alabama. At the Tuskegee Institute between 1932 and 1972, 600 black men who had syphilis were followed (all in the name of science and medicine, certainly) without being offered treatment. In both of these cases, the people involved did not know that they were being used as human test tubes... experimental subjects.
The Eugenics movement started around the same time--in the early 1940s--with the introduction of Planned Parenthood. Eugenics is the belief that certain people are unfit to breed and pass on their genes--and so they should not. We all joke that there should be a permit to procreate--to have children--these people were not joking. For people like Margaret Sanger, population control was the name of the game. Honestly, I had no idea that this was the impetus behind Planned Parenthood!!
In today's society and times, human subjects are very closely guarded. Any time a researcher wants to do as much as reviewing charts, one has to get permission from the institute's IRB (Institutional Review Board), after taking a tutorial and test about human subjects.
The fact that a power such as the United States took advantage of the poor and minorities is incomprehensible to me. Between 1946 and 1948, Dr. John C. Cutler was involved in a study in Guatemala. He infected 696 people with syphilis (+/- gonorrhea) by sending infected prostitutes to call on prisoners and enlisted men alike... anyone resistant was inoculated directly. The records are fuzzy as to whether the men were then treated with penicillin, or what the dose was--never mind the prostitutes. Dr. Cutler was apparently also involved in the Tuskegee Study in Alabama. At the Tuskegee Institute between 1932 and 1972, 600 black men who had syphilis were followed (all in the name of science and medicine, certainly) without being offered treatment. In both of these cases, the people involved did not know that they were being used as human test tubes... experimental subjects.
The Eugenics movement started around the same time--in the early 1940s--with the introduction of Planned Parenthood. Eugenics is the belief that certain people are unfit to breed and pass on their genes--and so they should not. We all joke that there should be a permit to procreate--to have children--these people were not joking. For people like Margaret Sanger, population control was the name of the game. Honestly, I had no idea that this was the impetus behind Planned Parenthood!!
30 September 2010
calling names
I just ran across a blog written by a family practice resident, pontificating "What's in a name?" I find this to be an interesting topic, as I have struggled with it myself in the past.
This, I feel, is very generational, as well as regional. ie: I am much more comfortable calling my colleagues by their first name when they are close to my age (by which I mean within 20 years). However, my soon to be partner is 73, and although I call him by his first name in private conversation with my guy (always preceded by a pause and followed by a giggle), you can bet I call him Dr when speaking to him. (He, by the way, calls me everything from "gorgeous" to "sweets..." although generally, he calls me by my first name. In case you wonder, I don't mind--his demeanor is such that it completely does not sound crass or degrading.) I also have a neurologist friend who is about 3 years shy of being my parents' age. When he asked me to call him by his first name, it took a while (and several slip ups) to get used to.
As for regional: I did my med school clinicals all over the states, followed by residency/ fellowship in the East. I can tell you that in the midwest, it is much more common for Drs to introduce themselves by their first name to other healthcare professionals. It is understood that they, in turn, will be introduced as "Dr" to patients. As soon as I came to the East Coast, it was Drs all around. This makes me often feel pretentious, so I will frequently introduce myself by my first and last name, followed by my specialty. I let them decide what to call me. And, for the most part, I will eventually correct them to call me by my first name in private.
As for patients, I am not too interested in being buddies, so I introduce myself as Dr. Older patients appreciate the formality, for the most part. Although, I have had elderly patients insisting on knowing my first name--and then calling me by that name--which made me feel a little like I was talking to my grandparents. Also, being young and attractive, I have been hit on by patients (of all ages), and I believe that introducing myself as "Dr" nips that possibility in the bud--sometimes. On the other hand, introducing myself as my first name invites that kind of discussion.
Of course, things will be a little different very soon. I think that at my new position, I may introduce myself to patients as first and last name, and let them choose... or maybe the first name will suffice. Cancer is a place where it's nice to have a buddy.
This, I feel, is very generational, as well as regional. ie: I am much more comfortable calling my colleagues by their first name when they are close to my age (by which I mean within 20 years). However, my soon to be partner is 73, and although I call him by his first name in private conversation with my guy (always preceded by a pause and followed by a giggle), you can bet I call him Dr when speaking to him. (He, by the way, calls me everything from "gorgeous" to "sweets..." although generally, he calls me by my first name. In case you wonder, I don't mind--his demeanor is such that it completely does not sound crass or degrading.) I also have a neurologist friend who is about 3 years shy of being my parents' age. When he asked me to call him by his first name, it took a while (and several slip ups) to get used to.
As for regional: I did my med school clinicals all over the states, followed by residency/ fellowship in the East. I can tell you that in the midwest, it is much more common for Drs to introduce themselves by their first name to other healthcare professionals. It is understood that they, in turn, will be introduced as "Dr" to patients. As soon as I came to the East Coast, it was Drs all around. This makes me often feel pretentious, so I will frequently introduce myself by my first and last name, followed by my specialty. I let them decide what to call me. And, for the most part, I will eventually correct them to call me by my first name in private.
As for patients, I am not too interested in being buddies, so I introduce myself as Dr. Older patients appreciate the formality, for the most part. Although, I have had elderly patients insisting on knowing my first name--and then calling me by that name--which made me feel a little like I was talking to my grandparents. Also, being young and attractive, I have been hit on by patients (of all ages), and I believe that introducing myself as "Dr" nips that possibility in the bud--sometimes. On the other hand, introducing myself as my first name invites that kind of discussion.
Of course, things will be a little different very soon. I think that at my new position, I may introduce myself to patients as first and last name, and let them choose... or maybe the first name will suffice. Cancer is a place where it's nice to have a buddy.
30 July 2010
Boring...
One of my favorite patients, who has become a friend, just reminded me of something terribly important.
When we are medical students, interns, residents... we LOVE the adrenaline rushes. We love the interesting patients.. the "once in a lifetime"s... We want to see and experience all of the 'wows.' We trade stories, often elaborating and honing our emphasis on this or that, to make it sound that much more dramatic, we accentuate, we underline, we really lay it on--suddenly, there is blood everywhere, guts are flying, the nurses are frantic, and then we come in and save the day. Don't get me wrong. Sadly, it really is like that, sometimes. But as attendings, it's just our day-to-day... and not the pleasant part of day-to-day.
As an intern in Michigan, we didn't have the 80 hour work week. We worked often in 36 hour shifts, to go home and sleep (hell, who am I kidding, we didn't, actually, sleep--we partied and danced), to come back and do it all over again. We RAN to codes, to see interesting patients. We stayed much past those 36 hours often, to see a rare, or "cool" case, or even just to hang around, in case one came in.
For my surgical residency, I chose to come to New York, but not some posh little hospital. Nope, I went for the hell-hole, in the middle of a crime-ridden area, which farmed us out to other crime-ridden areas in every borough (save Staten Island) and Jersey. During my 3rd year (I think) the 80 hour work week came into effect. We were threatened by our superiors to lie on the forms, as NONE of us worked fewer than 100 hours/ week... although usually more, we lost track... and most of us (yours truly at the top of the list) didn't mind lying. How else would we see all of those funky, excellent cases?!
Hand fellowship--no different. But by this point, my philosophy changed a little. I did this in the South Bronx at a city hospital. Scary place, scary patients... a lot of unethical people (hospital personnel included)--exactly what I wanted--because I knew I would train here and see the worst of the worst so that I could handle anything... Even though I hoped I would never see it again.
When we come to our own as attendings, we really love boring. We don't want to see those one in a million cases. Don't get me wrong, we can handle it, because we are wired to do so--especially as surgeons, I think we are such adrenaline junkies that we LOVE those cases as much as we HATE them. We still boast to our colleagues, all the while praying to whoever our Gods are that we never have to face that again... and going to the hospital at all hours to check up on that patient. just in case.
My breast fellowship, I approached differently. Of course, this was after a few years "out in the field." I knew exactly what I wanted out of it, and I made sure that I got it. Yes, I did see some interesting cases, and yes, I made some mistakes. In the end, the attitude was "well, now I know how to handle it, and I really hope I never see it again." (By the way, in regards to my earlier post, I met a very successful plastic surgeon, who said that he had no less than 10--TEN!!--such cases in his first year. The candidacy and straighforwardness were almost more alarming than the fact.)
So now, when I hear that my patient... my friend... had an uneventful chemo day--after too many events, too much excitement (and not the pleasant kind) on this road of breast cancer diagnosis and treatment--I am no less than thrilled.
When we are medical students, interns, residents... we LOVE the adrenaline rushes. We love the interesting patients.. the "once in a lifetime"s... We want to see and experience all of the 'wows.' We trade stories, often elaborating and honing our emphasis on this or that, to make it sound that much more dramatic, we accentuate, we underline, we really lay it on--suddenly, there is blood everywhere, guts are flying, the nurses are frantic, and then we come in and save the day. Don't get me wrong. Sadly, it really is like that, sometimes. But as attendings, it's just our day-to-day... and not the pleasant part of day-to-day.
As an intern in Michigan, we didn't have the 80 hour work week. We worked often in 36 hour shifts, to go home and sleep (hell, who am I kidding, we didn't, actually, sleep--we partied and danced), to come back and do it all over again. We RAN to codes, to see interesting patients. We stayed much past those 36 hours often, to see a rare, or "cool" case, or even just to hang around, in case one came in.
For my surgical residency, I chose to come to New York, but not some posh little hospital. Nope, I went for the hell-hole, in the middle of a crime-ridden area, which farmed us out to other crime-ridden areas in every borough (save Staten Island) and Jersey. During my 3rd year (I think) the 80 hour work week came into effect. We were threatened by our superiors to lie on the forms, as NONE of us worked fewer than 100 hours/ week... although usually more, we lost track... and most of us (yours truly at the top of the list) didn't mind lying. How else would we see all of those funky, excellent cases?!
Hand fellowship--no different. But by this point, my philosophy changed a little. I did this in the South Bronx at a city hospital. Scary place, scary patients... a lot of unethical people (hospital personnel included)--exactly what I wanted--because I knew I would train here and see the worst of the worst so that I could handle anything... Even though I hoped I would never see it again.
When we come to our own as attendings, we really love boring. We don't want to see those one in a million cases. Don't get me wrong, we can handle it, because we are wired to do so--especially as surgeons, I think we are such adrenaline junkies that we LOVE those cases as much as we HATE them. We still boast to our colleagues, all the while praying to whoever our Gods are that we never have to face that again... and going to the hospital at all hours to check up on that patient. just in case.
My breast fellowship, I approached differently. Of course, this was after a few years "out in the field." I knew exactly what I wanted out of it, and I made sure that I got it. Yes, I did see some interesting cases, and yes, I made some mistakes. In the end, the attitude was "well, now I know how to handle it, and I really hope I never see it again." (By the way, in regards to my earlier post, I met a very successful plastic surgeon, who said that he had no less than 10--TEN!!--such cases in his first year. The candidacy and straighforwardness were almost more alarming than the fact.)
So now, when I hear that my patient... my friend... had an uneventful chemo day--after too many events, too much excitement (and not the pleasant kind) on this road of breast cancer diagnosis and treatment--I am no less than thrilled.
12 May 2010
Never get complacent
It is not everyday that you look down, and your "routine" breast case has turned into a chest case. THANK goodness that it is not everyday!!
Young woman--35--diagnosed with breast cancer 3 years ago. At that time, she had her (unilateral) mastectomy and tissue expander placement. Then, skin necrosis and excision, followed by failed tissue expander--they were unable to expand...
So, she went through her chemo, never had radiation, and we come to this year and her care with me. Back in February, I exchanged her tissue expander for a new one (in fact, there was a hole identified in the old one--presumably from a needle stick). I expanded her over the next 3 months. She is finally happy with size, so we schedule an implant swap--gel (silicone) in place of saline tissue expander--and to augment the other side to match. Enter yesterday...
Cancer side: trying to release capsule, I made a plane inside the pectoralis. I caught it right away, but still... not the way things are supposed to go. "Prophylactic side:" Tooling along, releasing the pec and suddenly I am looking at lung. It was not my day.
Cancer side: oversewed muscle plane and started over again... finished capsulorrhaphy and placed implant--success.
Prophylactic side: oversewed intercostal muscles over a red rubber catheter, oversewed with pec... got a post-op chest xray: tiny apical PTX
Kept her overnight, got serial chest xrays. She is fine, felt greal this morning, pneumo is resolving, and she went home. She feels like a queen, and couldn't stop thanking me. I feel like crap. I consider myself a safe, conscientious surgeon--not a cowboy or careless. How could this happen?! I have heard from a few people that the only way to become an expert is to make and overcome the mistakes.
So, maybe I don't want to be an expert!!
Young woman--35--diagnosed with breast cancer 3 years ago. At that time, she had her (unilateral) mastectomy and tissue expander placement. Then, skin necrosis and excision, followed by failed tissue expander--they were unable to expand...
So, she went through her chemo, never had radiation, and we come to this year and her care with me. Back in February, I exchanged her tissue expander for a new one (in fact, there was a hole identified in the old one--presumably from a needle stick). I expanded her over the next 3 months. She is finally happy with size, so we schedule an implant swap--gel (silicone) in place of saline tissue expander--and to augment the other side to match. Enter yesterday...
Cancer side: trying to release capsule, I made a plane inside the pectoralis. I caught it right away, but still... not the way things are supposed to go. "Prophylactic side:" Tooling along, releasing the pec and suddenly I am looking at lung. It was not my day.
Cancer side: oversewed muscle plane and started over again... finished capsulorrhaphy and placed implant--success.
Prophylactic side: oversewed intercostal muscles over a red rubber catheter, oversewed with pec... got a post-op chest xray: tiny apical PTX
Kept her overnight, got serial chest xrays. She is fine, felt greal this morning, pneumo is resolving, and she went home. She feels like a queen, and couldn't stop thanking me. I feel like crap. I consider myself a safe, conscientious surgeon--not a cowboy or careless. How could this happen?! I have heard from a few people that the only way to become an expert is to make and overcome the mistakes.
So, maybe I don't want to be an expert!!
08 October 2008
Never, not once. until yesteday
I am not proud. I am, in fact, rather ashamed. But the other emotions I feel are anger, distaste, and, quite frankly, dread.
I took the gentleman from this post to the OR last week... last Monday, to be exact. He was a mess. I have never seen anything like it. A grown man, mid-40s, strong (as far as looks--very muscular, fit), handsome, even... quivering uncontrollably at the sight of an IV needle. No joke. It took 5 of us to hold him down, after a lot of begging and bargaining, that is, to sssslide that little 20 into one of the hoses on his arm.
The surgery itself? I was so happy. I took off the distal phalanx routinely, looked at the middle phalanx--SOLID. No signs of infection. Surrounding skin? Healthy. Beautiful. The closure? I gotta tell you, I was so conscious of this man wanting to get back to work, I did not even allow a little dog ear. The whole surgery (minus starting the IV) went so smoothly, I was thrilled that he was coming for his first post op visit yesterday.
By the way, he called the day after surgery about some papers he needed to get filled out for work, but that was it. Smooth sailing. No calls about pain, nothing.
I explicitly ask all of my patients to leave their surgical dressing on until they see me at the first post-op visit. I tell them, reinforce it with their loved ones and write it in capital letters on the discharge papers. It is really, really rare that these orders are not followed. Seriously, my patients know I mean business.
So, I was almost confused when my friend came in with no dressing. Not even something he threw on at home, which some people try to fool me with. (Trust me, a surgeon ALWAYS knows their own dressing.) When I asked him what happened and when? He answered that the night of the surgery (!!!) the finger was itching him, so he took off the dressing so he could bite it (!). Then, over the past week, he remained with no dressing, going about his business (although he assured me he stayed in the house) changing his baby's diapers and the such, but NEVER ONCE WASHING HIS HAND!!!!
He complained (now, in my office, as he waved the swollen digit around) that the pain was tremendous. I asked him why he never called. I was calm, at first, when I reminded him that he called about his papers, but never mentioned any of this. My eyes were met with a blank stare.
I asked him to wash his hands now, in the office, with soap and water. As soon as he finished, he turned to me, "Why is there pus coming out?"
I looked in disbelief, at the same time realizing that it was the only explanation: he had a wound infection, which explained the tremendous pain and swelling. When he washed his hands, he dislodged some dirt and blood that was covering the wound, and now the pus was pouring out.
I told him that I would need to take out at least a few sutures and open the wound to let the pus drain. It was the only way to get rid of the pus and the pain. He started moaning and crying (crying, with tears streaming down his face). This is when the fiasco started. I called my medical assistant into the room. We are both small women. He is a tall, muscular, fit man. After wrestling with him for about 20 minutes, I asked my MA to call our administrator in. A man, pretty much the peace keeper, but not much larger than us. The amazing thing is that the whole problem was that this patient was truly, magnificently AFRAID. He was not aggressive to me or anyone else; he just would not allow me to do what I needed to. The whole procedure, on a cooperative patient, would take less than 1 minute. Really. Start to finish.
With this man, it took an hour and a half. Every five seconds, he was ready, and then he would freak out again. Taking out 3 sutures took 45 minutes. (I left the rest for another day.) He had on 5 layers of shirts, which he started taking off one by one. (I really kept thinking that he was going to be sitting in front of me nude.) He had on two hats (I am not joking). Once he finally let me do what I needed to do, it really did take exactly 2 seconds (scissors into wound, spread, done).
The thing that I find worst of all is my reaction. After the first 30 minutes of begging and cajoling, trying to mesmerize him into cooperating... I lost it. I really did. I was screaming at him. I have never done that. I feel awful. I was cursing, too. Not pretty, not professional. Really, really awful. I cannot stop thinking about it, replaying it in my brain. I cannot justify it. All I can say is that I really just wanted to do right for this man, and he would not let me. On top of that, I had patients piling up outside, so I felt pressured to get a move on. I even told him (and this I truly meant with all my heart) that if I had known that this was how things would go, I would have come in on my day off so I could spend as much time as necessary with him--even the whole day, if I had to. Unfortunately, that was not the case here.
The only good thing, well 2 good things: 1. When all was said and done and the dust settled, he thanked me. I mean, the man knows I really was trying to do good for him, NOT to hurt him. He understands he brought this on himself. 2. We called him today, and he said he is feeling much better with less pain. He is doing the wound care that I instructed him on.
No matter, I am seeing him again on Friday. He is one of the patients that I would move in with, if I could.
I took the gentleman from this post to the OR last week... last Monday, to be exact. He was a mess. I have never seen anything like it. A grown man, mid-40s, strong (as far as looks--very muscular, fit), handsome, even... quivering uncontrollably at the sight of an IV needle. No joke. It took 5 of us to hold him down, after a lot of begging and bargaining, that is, to sssslide that little 20 into one of the hoses on his arm.
The surgery itself? I was so happy. I took off the distal phalanx routinely, looked at the middle phalanx--SOLID. No signs of infection. Surrounding skin? Healthy. Beautiful. The closure? I gotta tell you, I was so conscious of this man wanting to get back to work, I did not even allow a little dog ear. The whole surgery (minus starting the IV) went so smoothly, I was thrilled that he was coming for his first post op visit yesterday.
By the way, he called the day after surgery about some papers he needed to get filled out for work, but that was it. Smooth sailing. No calls about pain, nothing.
I explicitly ask all of my patients to leave their surgical dressing on until they see me at the first post-op visit. I tell them, reinforce it with their loved ones and write it in capital letters on the discharge papers. It is really, really rare that these orders are not followed. Seriously, my patients know I mean business.
So, I was almost confused when my friend came in with no dressing. Not even something he threw on at home, which some people try to fool me with. (Trust me, a surgeon ALWAYS knows their own dressing.) When I asked him what happened and when? He answered that the night of the surgery (!!!) the finger was itching him, so he took off the dressing so he could bite it (!). Then, over the past week, he remained with no dressing, going about his business (although he assured me he stayed in the house) changing his baby's diapers and the such, but NEVER ONCE WASHING HIS HAND!!!!
He complained (now, in my office, as he waved the swollen digit around) that the pain was tremendous. I asked him why he never called. I was calm, at first, when I reminded him that he called about his papers, but never mentioned any of this. My eyes were met with a blank stare.
I asked him to wash his hands now, in the office, with soap and water. As soon as he finished, he turned to me, "Why is there pus coming out?"
I looked in disbelief, at the same time realizing that it was the only explanation: he had a wound infection, which explained the tremendous pain and swelling. When he washed his hands, he dislodged some dirt and blood that was covering the wound, and now the pus was pouring out.
I told him that I would need to take out at least a few sutures and open the wound to let the pus drain. It was the only way to get rid of the pus and the pain. He started moaning and crying (crying, with tears streaming down his face). This is when the fiasco started. I called my medical assistant into the room. We are both small women. He is a tall, muscular, fit man. After wrestling with him for about 20 minutes, I asked my MA to call our administrator in. A man, pretty much the peace keeper, but not much larger than us. The amazing thing is that the whole problem was that this patient was truly, magnificently AFRAID. He was not aggressive to me or anyone else; he just would not allow me to do what I needed to. The whole procedure, on a cooperative patient, would take less than 1 minute. Really. Start to finish.
With this man, it took an hour and a half. Every five seconds, he was ready, and then he would freak out again. Taking out 3 sutures took 45 minutes. (I left the rest for another day.) He had on 5 layers of shirts, which he started taking off one by one. (I really kept thinking that he was going to be sitting in front of me nude.) He had on two hats (I am not joking). Once he finally let me do what I needed to do, it really did take exactly 2 seconds (scissors into wound, spread, done).
The thing that I find worst of all is my reaction. After the first 30 minutes of begging and cajoling, trying to mesmerize him into cooperating... I lost it. I really did. I was screaming at him. I have never done that. I feel awful. I was cursing, too. Not pretty, not professional. Really, really awful. I cannot stop thinking about it, replaying it in my brain. I cannot justify it. All I can say is that I really just wanted to do right for this man, and he would not let me. On top of that, I had patients piling up outside, so I felt pressured to get a move on. I even told him (and this I truly meant with all my heart) that if I had known that this was how things would go, I would have come in on my day off so I could spend as much time as necessary with him--even the whole day, if I had to. Unfortunately, that was not the case here.
The only good thing, well 2 good things: 1. When all was said and done and the dust settled, he thanked me. I mean, the man knows I really was trying to do good for him, NOT to hurt him. He understands he brought this on himself. 2. We called him today, and he said he is feeling much better with less pain. He is doing the wound care that I instructed him on.
No matter, I am seeing him again on Friday. He is one of the patients that I would move in with, if I could.
27 September 2008
Really?
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.
"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
Lucky
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.
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.
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.
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.
breathe...
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!
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.
breathe...
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!
11 March 2008
how 'bout patients like this?
Crazy day today, and not the worst I've had, by far, but... Seeing patients from 8-7:30 straight through, does not a happy surgeon make. 28 of them, to be exact, no breaks. And then the phone calls. Ugh. So, you finally get a chance to breathe... and reflect. 2 patients stand out. Although, my medical assistant is always amazed that I seem to have a knack for remembering everybody, and I do. There are some that just strike a chord.
Mrs.___, who came with her husband; she has DEBILITATING median and ulnar neuropathy--bilaterally, although it's worse in the right. I know I can get her better with surgery. Wanna know why she's refusing? Not because she's scared of surgery, or because her neighbor or church friend told her a friend of a friend's aunt's sister had a bad outcome... But because she thinks that if she gets better, her kids will start using her for their chores and babysitting again. She's convinced that that's why they want her better. The fact that she is pleasantly confused, 70, and quite forgetful doesn't make things any better. I wanted to put my arms around her and hug her, or maybe just cry. I couldn't decide, so I just looked at her and blinked. Her husband sat next to her and comforted her, "No, baby, that's not it, I'll help you. We want you better because we don't want you in pain..." And ya know, it's hard to say...
And then there are the ones that just, well, surprise you. I did surgery (CTR) on a (retired) physician last week. She called today, frantic, that her hand was swollen and she had a blue thumb. OK, "please come right in." Yup, the thumb was blue, alright, as in BLACK AND BLUE, and the hand WAS swollen, because she immediately affirmed that she had not been elevating it, as per my instructions. I changed the splint, as I would have done, anyway, at her scheduled appointment on Friday. Disposition: please elevate the hand as instructed, and wait for the bruise to resolve, keep your appointment in 2 weeks.
You can eat extra pineapple, if you like...
They just sometimes catch you off guard, is all. And I have to say that working for 'the group' doesn't make things any easier. If I was making my own hours, my own money, well, I think it would just make me happier. All in good time, I suppose.
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