Well, for those who want the full picture, so to speak, here it is, a fracture of the right clavicle. My right clavicle, that is, the injury I described in the last blog post. Now this particular image accentuates the appearance of the break in the bone because my arm has been externally rotated, that is, my elbow is touching my torso and my right hand has its palm facing forward with the forearm at a ninety degree angle to the rest of the body. Not too surprisingly, that was the position where it hurt the most.

Now compare this image on the left, with my right arm across my chest, palm facing my body. One can just appreciate the break in the upper border of the bone. Looks better, doesn’t it? Looks like it might even heal decently, if I can just keep it in that position. And that’s the problem, since a right-handed person such as myself can’t do much productive work with his dominant hand continuously folded across his chest. Even the simplest of tasks can be a challenge. Have you ever tried to put on a sock with one hand? Even typing this short post causes my shoulder to ache a little. It’s also hard to write notes, sign prescriptions, or mark worksheets without the hand coming off the chest at least a little. Implanting a pacemaker is well beyond the possible.

But at least my fracture is non-displaced. It can heal if I can keep it immobilized (relatively). Uh, I think that means I can’t ride a bicycle for a while. So I’m going to do a lot of hiking in Vermont, it seems . . .

For those who want more details of collarbone fractures, see this article.

Tags: injuries, fractures

Well, it finally happened. Here I am at age 49 and I’ve never broken a bone in my body-until today. I still don’t know how it happened. My wife and I decided to go out for a bike ride together. We were pedaling along at an easy pace when I suddenly found myself pitched sideways in an instant, on the ground, my left foot still clipped in to the pedal. I remember hitting my right shoulder on the pavement. A woman in a car stopped next to us on the shoulder as I sat upright and assessed my injury. I was briefly nauseated but it passed quickly. I had some ugly “road rash” on my arm and leg. I could move my arm but the shoulder didn’t feel too good. The good samaritan in the car (thank you, Julie S.) piled our bikes and us into her vehicle and took us home. Vikki found me a large bag of cold ice and I drank a beer and went to bed. There was a pretty good lump at the top of my right shoulder but I thought it might just be a hematoma. Nonetheless I went for an Xray and sure enough I had fractured my collarbone distally just before the joint at the shoulder. Luckily I got ahold of one of the local orthopedic surgeons who was on his way home but graciously agreed to come review the film, then went back to his office and rummaged around for a shoulder sling.

Fortunately I don’t need any surgery. Unfortunately, Vikki and I are scheduled for a husband-and-wife getaway trip to Vermont in a couple of weeks in order to-you guessed it-go biking. Oh, well, I may have to pull a “Tyler” a la’ Tyler Hamilton who in 2003 won a stage of the Tour de France about two weeks after breaking his clavicle in a bike crash. It’s too late to get a refund of the payment for the trip and I didn’t take out travel insurance so it’s grin and bear it or lose the money.

Tags: injuries

On a typical work day, I head out the door between 7:30 and 8 am. After arriving at the hospital I usually start my inpatient rounds in the ICU. The physician’s assistant or nurse practitioner who helps us in the hospital will see some of the patients first, but I’ll just pick up a chart of someone on the list and dive in. I’m pretty fast making rounds now because I’ve learned the routine at each hospital: where to find the charts, and where to find the information in the charts. I’ll start to fill in some of the relevant information for my chart note. Every patient gets a “progress note” (even if there’s not much progress) which contains certain information meant to enhance inter-provider communication, supply advice between consultants and attendings, and provide a medical-legal record. A progress note on an established patient consists of a heading with the date and the identity of the particular note-writer e.g. “Cardiology”, and then several categories of content: Subjective (the patient’s symptoms), Objective (blood pressure, pulse, examination findings, lab results, test results), and then Impression and Plan-or for consultants “Recommendations.”

So I’ll fill in some of the note with data from reports on the chart, and then go see the patient. Sometimes the visit is brief (patient comatose, or demented, or feeling well) and sometimes it takes a while (new patients, family present with lots of questions, etc.). Then I’ll fill in the exam findings and formulate a plan. [I’ll try to attach a typical note below for illustration.] Somewhat archaically these notes are hand written. That’s a subject for a separate post, but for now let’s just say that some doctors really do have the proverbial terrible handwriting that makes their notes in the chart next to useless.

At some point, usually before rounds are completed, the office calls saying that I have patients waiting. I’ll go and see anywhere from three to 12 patients in a row before taking a break, usually to go back to the hospital to see more patients or interpret some “studies”. These are diagnostic cardiac tests. While I’m in the office, I will interpret studies such as echocardiograms, nuclear stress tests, EKGs, 24 hour rhythm monitors, carotid artery ultrasounds, or computed tomographic angiograms (CTAs) in between seeing patients. There are often phone calls, too, from ER physicians wanting to admit or transfer a patient or from other physicians with questions or concerns.

At lunchtime I usually go back to the hospital to see more patients on rounds or interpret similar diagnostic studies which have been generated at the hospital. Often there will be more involved diagnostic procedures to be performed at the hospital such as coronary angiograms. Sometimes there will be a pacemaker to insert. Each of these activities is accompanied by its own arcane set of paperwork to be completed and placed in the chart. I probably sign my name and attach the date about 50 to 100 times a day between office and hospital.

Finally, by the end of the day the last patient has been seen in the office and hospital, the last chart signed, the last EKG read, and it’s time to go home. Usually I try to leave by 6:15 pm or so. By staying efficient and keeping up during the day, this goal is usually accomplished.

I typically will see 15 to 25 office patients and 8 to 15 hospital patients a day. I will probably read 5 to 10 CTAs, 10 to 15 echocardiograms, 50 EKGs, 5 to 10 rhythm monitors, and perform 2 or three arteriograms.

This is my typical day’s work. Some days are busier, some a little slower. Some are downright crazy usually due to emergencies or a sudden deluge of new consultation requests, often in the context of one of my colleagues being away on vacation. I’ve managed to adjust my work style to get it all done, but at some cost to patient relationships. All in all, my days are usually full and rarely boring. There are some routine elements to the work with infinite variations. More on those in a later post.

Which is the greater good: to serve more people or to serve fewer ones better? To be more specific, in my current medical practice, I see a far greater number of patients than I did previously. Consequently, in a given day, I spend less time with each patient. I now can pretty much classify any new patient and their symptoms into one of a relatively small number of categories within the few couple of minutes of the encounter. Rapidly I can begin to triage their workup and select what diagnostic or therapeutic options I will employ. There is a limited number of clarifying questions I will ask. I try to do a little patient education regarding new drugs or unfamiliar diagnostic tests. If the patient has any questions I try to answer them. Then I speak some “transitioning” language so as to prepare the patient to be checked out by my staff. And I move on . . .

Many of our patients are poor or indigent. Many don’t have a lot of formal education. There’s a high incidence of smoking, obesity, diabetes, and sedentary lifestyles. It’s difficult to explain complex concepts of cardiac anatomy and disease pathophysiology to them. Usually if I try to engage them in the decision making process they just shrug and say “whatever you think, doc”. The most worrisome disorder - coronary artery disease - is highly prevalent and dangerous when undiagnosed. Yet the symptoms are often misleading or non-specific. The physical exam is nearly useless. But with a ten second CT scan that I might order, I can instantly see a “snapshot” of their cardiac risk that creates immediate direction for their therapy-or major reassurance when negative.

So what’s better? Should I spend more time establishing a relationship with these patients (most of whom, if new patients to the practice,are referred anyway by the primary providers for a consultation) or should I attempt to see a larger number so as to provide more of them with useful even potentially life-saving information and advice? I wonder . . .

Tags: obesity, technology, smoking

There are a lot of complications that result from obesity. Here are some that I observe on almost a daily basis:

• Obese people can’t exercise easily, which only compounds the difficulty in losing weight, since most studies have shown that exercise is a requisite for permanent successful weight control.
• It may prevent needed diagnostic studies--there are weight limits for the tables used in medical imaging, for example. Even if one is under the weight limit, the bigger the patient the worse the quality of the study--fat scatters X-rays and exacerbates artifacts.
• High blood pressure is difficult or impossible to control
• Diabetes is difficult or impossible to control
• Cholesterol levels are difficult or impossible to control
• Obese patients wind up taking lots of medicines, sometimes ten or fifteen or even twenty different agents-expensive!
• It promotes blood clots in the legs and lungs--potentially fatal
• Obesity increases the risk of heart disease independently of other risk factors
• It increases the risk of arthritis and early joint replacement
• Chronic low back pain and accelerated arthritis can lead to painkiller addiction

We live in a food toxic environment with many people never doing more than going from car to house and back to car--a recipe for ever-expanding waistlines and more of the above.

Tags: obesity