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.
27 September 2008
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.
10 September 2008
Silence...
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.
Joyful.
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.
Joyful.
04 August 2008
Just a Few Words
Just explaining my silence here. I am in the midst of (ack!) starting a private practice (while keeping my "day job" with the group--it would be a little wacky to give up a steady income for something that is only a dream at this point). And I am overwhelmed. Hence, it leaves little time for posting anything here. Albeit, I do wish I had the time and energy, because, believe you me, I have the stories... just not the juice in my batteries. Soon, soon, I hope... thank you for being patient and understanding. I am assuming both of those. :)
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!
30 June 2008
Flight lessons, and OFF...
Over the weekend, Sabado learned to fly... today, I regained my balcony. Well, not entirely, but as much as I could, for the moment.
You see, the little family will still come here; they still call this "home." But, enough is enough. Call me mean, self-serving, whatever, but when I saw Mommy nesting again (!?!?), I knew something had to be done. And no, it doesn't make sense that she will lay more eggs this season. For all I know, the nest is simply a comfy place in which to rest her little feathered butt.
You see, I am a New Yorker, after all. My balcony is all that I have. If I had a house, with some other stretch of land to, well, stretch on, then it would be a different story. But, I have gone enough beautiful evenings and days without the benefit of my wonderful balcony. I have sacrificed dutifully. And now that the little winged one can flitter at will, it is time.
So, off I went and purchased my heavy-duty broom, and went out this evening in my mismatched tank top and running shorts (yay--they're again in use!), flip flops and gloves, and swept up what I could of the nest, poop, and feathers. Don't worry, there is still much to do--I still need to Clorox (yes, a verb in this case) the place, but it's a start. In the meantime, if I come down with bird flu, we all will know why, and will one of you then kindly contact R, as he does not read my blog. ;)
By the way, as for Sabado, he is too damn cute for words. He still is very discernible by his little left over yellow feathers on his head and the tips of his wings, and of course, he is still smaller than his parents. He is also LAZY. Whenever he sees his parents, he still runs after them, demanding to be fed. I think the idea is that once they can fly, the little ones start to feed on their own. The parents scamper off away from him every chance they get. Oh, but then this weekend, I was starting to wonder if Sabado is a *girl,* because she is soooo clingy to her Daddy. OK, OK, I know, I am projecting human emotions onto a bird. But it's fun!
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