Monday, April 21, 2008

Revenge, a Dish Best Served Cold [(or how i learned to stop worrying and love dr. deborah peel (with propofol)]

A tri-malleolar ankle fracture is shown above. This is also a dislocation. The red dots are placed to show the track of the multiple fractures, the white arrow shows the tibia, the large, weight-bearing bone of the leg, translated forward on the talus bone of the foot. This is an orthopedic emergency as with a fracture-dislocation the vascular status of the foot can be compromised, so we have to put this back in place and this is done, usually, with a drug like propofol, and some cranking on the heel to pop it back in. Then it is splinted while traction is maintained, and then the patient gets an orthopedic procedure to fix it definitively. Recovery is usually quite complete in young healthy folks but you've got to get it back in place quickly.

Okay, kinda boring I guess. What is not boring about this particular patient is that he happened to be one of my medical school professors. He still teaches at my medical school and I recognized his name immediately. Turns out he has family in the town in which I currently practice. I saw his name on the board and went right in to see if it could possibly be the same person.

This patient, let's call him "Dr Peel", had insisted when the paramedics got to him, that he be flown immediately to his home institution. I told EMS on the radio 'absolutely not'. Besides the fact that we don't fly ankle fractures, we also can do them just as good as anyone else right here in Podunkville.

He was a little nicer when he realized that I was one of his graduates and I came back to the doctor's area and told everyone that I was living a wet-dream. I mean, here's a guy in great pain who is a PhD and made my life miserable for a year, with a bad injury, and completely at my mercy.

I gave him great treatment and got his ankle fixed up but I couldn't resist the following. This guy had taught anatomy and physiology, a first year medical school course, and knew it cold (as one would expect). This course is one of the many 'hoops' courses in med school. It's not that it will be important for us to know it in such detail, and for some of us it's not important at all, but you've got to jump through the "hoop" or you won't finish medical school. It's hard, it's incredibly detailed, and we had to know it all. So, when I gave Dr. Peel the propofol, instead of having him count backwards from 100 to get an idea of when sedation was adequate for me to pull on the ankle, I asked him to define the branches of the brachial plexus. At this point in my career all I can tell you about the brachial plexus is that it exists, and it's a bunch of nerves that extend from the lower C-spine out to the shoulder.

Dammit if Dr. Peel didn't get it all exactly right, even with high doses of propofol and a sloppy tongue. 100% correct. Damn. I got a nice note from him a few weeks later, he did well. Damned eggheads.

Also, as an interesting aside, google ads continues to plop a whole bunch of JCAHO ads on my site. Probably because it's bot sees the word "JCAHO" a lot here. Also, "CMS". I hate to have these businesses advertise on my site simply because we write "JCAHO" and "CMS" a lot. Of course, if all of you were to click on these ads these companies, parasites on parasites, would have to PAY ME BITCH! So, I do recommend clicking these ads often and seeing what wonderful services these douchebags offer. JCAHO. CMS. Click click. JCAHO, CMS, JCAHO, CMS.


  1. I'll let my hyperactive students click on the Google ads. Don't worry, they can only read the three letter words. Oh, wait...

  2. Pay backs a Bitch.

  3. When my husband was in college, they played some drunken game of football at midnight (some tradition or something) and he shattered his ankle into a million pieces. He had a plate and a bunch of screws to put it back together, and unfortunately his body rejected it (that sounds wrong, maybe it was infected? all I know is that it was the most disgusting thing I have ever seen and his dad told him to put vitamin E on it so he did, which did nothing to fix it, obviously) so after we were married and his gross ankle bled all over the brand new sheets in our bed for months and I finally convinced him that it shouldn't still be bleeding, he had it all taken out.

    Just last night I found the jar full of screws/plates in his medicine cabinet. So it made me laugh that you posted this today since I was just thinking about ankles and such.

  4. A few months ago, I got to take care of my dentist who had epididymitis (infection of a structure connected to the testicle).

    As I palpated the tender areas, I reminded him that he is fortunate because he gave me plenty of Nitrous to perform my root canal!

  5. Randy Travis Drinks Cold Beer, for roots, something-t, divisions, cords, branches. That's all I remember of the plexus, and Erb-Duchenne palsy. Oh, so useful.

    Funny story. I really liked my anatomy prof, he was a little old Norwegian bachelor, soft spoken and always smiling like an elf who had gotten into the mead (or whatever elves drink). As for hoops, I prefer anatomy class to step 1.

  6. I liked anatomy, and the brachial plexus since it was the first thing we dissected. We got asked about it in anesthesia although as long as you could inject 20cc of local anesthetic anywhere near it, your block would work.

  7. As a 3rd year medical student, that's officially my new favorite fantasy...

  8. Frank, are you a gas passer? I mean anasthesiologist? I've heard that's a sweet gig.

    Calling all doctors!!!

    I must know!!!

    Do you believe that there are "special" diets that can cure cancer?

    My personal idea is that anyone promoting special diets to cure cancer is a sheister.

    I know a gal who has a brother that is apparently "curing" himself with a special diet. No medical intervention necessary. I told her that if it is something like prostate cancer, it grows and spreads so slowly that it will be a long time before he realizes that the diet isn't working.

  9. Amy, it totally pisses me off when people try to tell me if I ate/did certain things I would not have gotten cancer (I am not offended by what you said, I am saying the IDEA that I could have prevented my cancer by eating differently/taking different supplements, etc. is offensive to me) It is very difficult to offend me about anything, but that idea that many people hold does it.

    I had a nurse at my cardiologists office hound me and ask me repeatedly how I got cancer. She kept saying "you know, because lung cancer is caused by smoking, so what causes thyroid cancer". I tried really hard to be polite and repeated myself over and over that my doctor said there was no known reason other than radiation exposure which did not apply to me. When she just kept asking "yes, but what did you DO to get it?" I finally asked her if it made her feel more safe from cancer when you try and place the blame on me for something I did/did not do in order to get the cancer. She didn't know how to respond to that, and left the room.

    I have heard that sometimes cancer spontaneously cures itself or seems to get better, so someone doing those at home cures might get lucky and that is what we would hear about. Otherwise they would probably die and we wouldn't hear about their lack of success, right?

    Sheister is one of my favorite words to say. It just sounds so naughty.

  10. Amy: The short answer to your question is "NO!!!". The long answer is "HELL NO!!!".

    The people that tout these dietary cures are no better than the slugs that market colon cleanses (have you seen that infomercial with that goofy looking guy with the pock-marked face?), or those who sell grass clippings marketed as "herbal remedies". It's all BS.

    Mind you I'm not saying that a healthy diet isn't good for you...just that it won't cure anything.

  11. Amen, and thank you erdoc85 and radgirl. I told her that he wasn't going to get cured. She'll probably resent me, but I don't care.

    radgirl- I totally don't believe in the diet/herbal crap. Sure a healthy diet is good for you, but short of living inside a nuclear reactor, or smoking cancer sticks, not much you do is going to prevent cancer if it's in your genetic makeup.

  12. Likewise, I hate the vegevangelists who think meat is the root of all evil. I actually typed "foot of all evil", which is way more interesting.

  13. One sleepless night, I watched on TV this quack named Kevin Something who sells a book of "natural" cures that he claims doctors don't want us to know about.
    Why would doctors not want us to know about cures,I don't know...

    Maybe you can tell us! ;-)

  14. Oh Amy!

    How naive! Since I am semi-retired I will tell you how it really is in medicine.

    Right before one is granted a license to practice medicine in the United States (and most western countries) one is kidnapped at midnight and driven to a secret location where one is given the opportunity to either sign on the dotted line regarding keeping the secret cures secret (or not).

    The consequences of not signing are that you do not get a license to practice. This 'Kevin' character did not sign. He is fighting the good fight but everyone thinks he is a snake-oil salesman.

    We have all known how to cure cancer and HIV and alzheimers etc... for many years but by hiding the true cures from the public we are able to continue the money machine that is the pharmaceutical industry.

    The benefit is that every doctor in the western world has an offshore account in which, monthly, a large sum of money is deposited. We then continue to 'practice' and, in the process, earn a reasonable 'on the books' living.

    Kevin does not know it yet, but he is a marked man. I mean he is threatening the livelihood of physicians everywhere who have grown accustomed to the $50k per month we all get offshore. It does get hard to hold the line when it's your mother that is dying from metastatic breast cancer (which can be cured by drinking a slurry of bee pollen and bat guano mixed with goat's milk), but those are the kind of sacrifices we all make to afford the yachts and the vacation homes in Sun Valley or the dacha on the Black Sea.

    люди будут платить много денег для моментального комфорта

  15. *snort*

    Thanks drx

    I want a dacha on the black sea. (I just saw a show on bizarre foods with Andrew Zimmern and he went to a dacha, but I don't know if it was on the black sea.)

    My friend very kindly said that most doctors aren't trained in alternative medicine. I'm not going to argue with her. But you can be sure that I won't be resorting to herbs to cure anyone in my family unless you can derive beneficial compounds from them like Taxol. My husband's a botanist and we certainly don't buy into that bunk.

  16. ..

    I see, so it is all a conspiracy... I should have known!
    How brave of that guy to put his life on the line to expose the scam.

    Back at you:

    Vous devriez arrêter de commenter en Russe, c'est fatigant d'aller traduire sur le site de Google.(Je plaisante)

  17. Damnit X, you know the punishment for divulging "the secret". Your days are numbered. They're gonna send "Double O Doc" to take care of you if you get sick. I did my residency with him. Like 007, he's licensed to kill.

  18. yeah X,
    get in line man. mum's the word dude!

  19. I have about 3 Path professors that I'd like to send to you with shattered ankles at this point...

    On a different note, we have a Student Physician Awareness Day conference coming up this week that is dedicated entirely to CAM. I think next year is dedicated entirely to Deborah Peel and the marvels of JACHO

  20. I just got back from a lecture on the medical treatment of autism by a pediatric neurologist, and I couldn't believe the questions people asked afterwards, the things they'd subjected their poor kids to. The Dr. said that he's actually seen autistic kids admitted in the ER because the parents had put the kid on a crazy diet they heard about on the internet.
    One of the first things the doc said was that there was no silver bullet or magic cure, especially if it's a two for one offer, available only on the internet. So he's just throwing us off the trail, obviously...

  21. Oh no, the docs at MDOD are now marked for divulging their reach-around status with big pharma and it says so on this website...

    I know the surgeons I work with perform esphagos, lobectomies, CABGs, etc including the recent repair of an ascending aortic rupture (ya, that's right bitch-a 6-cm at the aortic root!) for the fun of it! Or I mean, the conspiracy of it!

  22. Cher Amy,
    Mais non. J'aime la Russe! C'est magnifique! C'est aussie mysterieuse!

  23. Bostonian in NY,
    Make no mistake... there's big money in CAM, just no science. Here's something that will work just as well as CAM. As an adjunct to an open reduction and internal fixation of the fracture shown above a CAM practitioner will be signed on the case to do healing touch and to talk nicely to the patient about how well their body is healing the fracture. Also, a proprietary blend of fermented yak butter will be rubbed on the uninjured leg to 'promote healing'. Six weeks later the patient, while smelling bad, will be seen to have had a fine recovery and will feel very good about themselves because that nice doctor with the yak's butter told them they were 'super'. who was that surgeon again? pay me bitch!

  24. Now now...Jenny McCarthy's son is currently "recovered" from autism due to a special diet and vitamins.

    Who are you to question a former playmate-turned-D-list actress with her University of Google degree in Vaccine Toxicity?
    Plenty of Americans believe her crapola.

  25. Ahh ankle injuries. Early in my military career I had a patient sent back from X-ray because he didn't meet the "Ottawa Rules" criteria. John Adams would role over in his grave if he knew American physicians obeyed commands from a former British Commonwealth. Drackman rule #1, if it hurts X-ray it. The only tri-malleolar fx I've ever treated wasn't that impresive on physical exam, it was only after getting the X-ray that I shat myself.

  26. I'm taking anatomy next semester and I'm scared. It's only an undergrad course and I get to choose between a dissection or observation lab (because I'm pre-nursing, not pre-med) but...aaahhh.

    And physiology this summer is going to be a bitch since the summer session runs half as long as a full semester. It's a two hour class, Monday through Friday, with two three-hour labs during the week.

    /will finish school, dammit
    //and maybe even get into nursing school? who knows

  27. Hannah, do you know your name has horzontal symmetry? The dissection course is the only way to go. The Neuroanatomy course at my school had pre-dissected brains and I never could really get it down till I snuck in at 3am and sliced up a few of the Brains they were saving for the test.

  28. Kula,
    Jenny McCarthy is so full of crap (and silicone). She had an army of people working with her kid, and she says she did it all by eliminating Wonder Bread.
    Last night there was this Mom speaking, as an intro, and she got up and said that she has FIVE autistic kids, all receiving public services. After the first two she knew they'd all be autistic, but she had 5 anyway because she wanted a big family. Well, that's fine, as long as she's taking care of themselves. But each autistic kid will consume $3.5 million of public services during their lifetime. This Mom said that autism isn't a disability, it's just a difference. I beg to differ, as I'm completely wiped out after a day with my autistic student, and oh yeah, all my other students. And this Mom was all about being theSexy Autism Supermom, as she had the implants pushed up to her chin with a wonderbra, and her shirt was barely covering her nipples. Add the long, permed blonde hair and fuck-me red heels, and it was just hard to take her seriously. Her five autistic kids don't just impact her--what about all the specialists, teachers,, respite workers etc...paid for by YOU. I need a nap and a drink.

  29. hannah = palindrome

    as is race car and boob

    I like palindromes.

  30. amy: you must have BIG boobs. I like BIG boobs.

    frank: "The Neuroanatomy course at my school had pre-dissected brains and I never could really get it down till I snuck in at 3am and sliced up a few of the Brains they were saving for the test."
    Did you take an Incomplete? (Did anyone else?)

  31. CAM has its uses. I recommend checking out The Tooth from the Tiger's Mouth by Tom Bisio, re: Chinese sports medicine. See link by my name for his page, which has excerpts from it linked.

    I'm not knocking Western medicine. I just think they can work well, hand in hand (okay, next to each other, anyway).