Wow it has really been a long time since I have had a second to post anything. When I was a college student I used to get really annoyed at reading the blogs of residents because they never seemed to update it enough. I just couldn’t understand why they would be so unreliable with their posts; of course now that I’ve become one of those residents I have a new found respect for folks that can keep up a steady blog, ready their material for their cases, take care of their family, do research, sleep, etc.
The last time I blogged, I was about to start my Pediatric Ortho rotation and I was pretty excited; well the rotation came and went and I really had a good time. Peds Ortho was the specialty I was automatically placed on when I was a Sub-I, so it was interesting returning again as a PGY-2 with new found responsibilities. Our Peds rotation is extremely well organized but also very busy. My day usually consisted of me getting to the hospital by 5 am and getting our patient list together. Some programs are lax with the list, but not Hopkins. The patient list is the holy grail of tediousness, and if there is a period missing then you have officially failed in your chief’s mind. After the list is done, then you go to lectures, where one of the attendings goes through a pertinent topic like slipped capital femoral epiphyses (SCFE) or idiopathic scoliosis or skeletal dysplasias. After about an hour of lecture, then you run to the OR, and the variety of cases is what always amazed me. In one day I might do 2 posterior spinal fusions on kids with adolescent idiopathic scoliosis (AIS) or neuromuscular scoliosis, etc. Or in that same day I could do a posterior spinal fusion, a surgical hip dislocation, a pediatric physeal sparing ACL reconstruction, and a polydactyly removal. And the best part is that the kids usually do really well; even if they are pretty sick they usually leave the hospital in their parents car, not via the morgue. I also really enjoyed clinic days also as you always saw such a variety of cases. Sometimes it would be just a kid with a fracture that was treated with a cast that you are checking up on, or a kid who is post-op from pelvic and femoral osteotomies to fix hip dysplasia, or a 15 yo girl who noticed that her back is slightly curved and wants to know if she needs surgery, or a kid with cerebral palsy and multiple extremity contractures who either needs a Botox injection or tendon lengthenings, etc. I really enjoyed also how much you are in the OR on this rotation. We have 4 attendings in peds ortho, and usually there are 3-4 OR rooms going with cases, so usually you are in the room with just you and the attending or you and the fellow, or sometimes just you with the attending talking you through the case. And the spines they do are sometimes ridiculous and are cases that most other peds ortho docs would turn away because of the complexity of the curve and their multiple comorbidities.
Now of course everything wasn’t pleasant during my peds rotation, as nothing in residency can be. This rotation particularly required you to read a lot, and finding time to do that while your wife is a resident and you have a 3 month old boy and a 1.5 year old girl at home just isn’t easy. Then of course you are taking in house call (6 am to about 12 noon the next day..aka 30 hours) so on those days you are either slammed down in the ER with consults, or you are being yelled at by your attendings because you are scrubbed in to a case and they don’t want you even thinking about the call pager which is ringing every 30 minutes while you are in the case. Then there is of course the self confidence issue; I realized this the most on this rotation how low my self confidence was when it came to being a resident. Through out most of my academic career, I have been positively affirmed that I was doing a good job; but that RARELY happens in residency. Usually, especially when you are a junior resident, you are only spoken to when you mess up, and it is usually in a tone to sear the message into your psyche so that you don’t do it again. Then of course that starts me down the road (inside my head) of me beating myself up for making a mistake or for not remembering something to the point where I am thinking of it days after the incident. You just cant do that to yourself in a surgical residency, or else you will drive yourself crazy. While I am still learning; I have started to realize that my self confidence can not depend on what I am told by others…I have to have my own internal barometer. While I don’t like the cocky surgeon attitude I need to have some semblence of that in order survive, especially at a place like Hopkins.
So to get back to my original topic, pediatric orthopaedics is now really high on my list of fellowships to pursue. I love doing spine surgery, especially on kids since they usually aren’t chronic pain seekers like many adult spine patients; I love the variety of cases; I like how much the cases and problems make me think and want to go back and read, and while it may sound corny, I really enjoy the kids, even when their parents get a little crazy.
Bayview (Joints and Trauma)
After spending 2.5 months on my peds ortho rotation I went over to the Johns Hopkins Bayview Hospital where we primarily get our joint replacement experience. Bayview is a great hospital to be at, because even though it is still Johns Hopkins, the atmosphere is 100% more laid back than the main Hopkins hospital, and you get to have a lot more autonomy. While at Bayview I learned how to do my first total knee arthroplasty and my first total hip arthroplasty which is kind of the bread and butter of orthopaedics. Joints is an interesting beast because while peds ortho is all about variety, you get really good at replacing joints being doing the exact same procedure, the exact same way, every single time, 2-3 times a day. One of our senior joints faculty handed me a 100 step paper on how to do a total knee and told me to know it in a week. It almost seems impossible, but after you do a couple you realize how you become a well oiled machine once you learn the steps and can bang out like 5 joints in a day when you get good. And the best part is that the patients usually love their knee or hip afterwards because they have been suffering from their arthritic pain for so long. I really started to get interested in ortho after my father had a unicompartmental knee replacement, and when I saw how much it changed his quality of life, I knew I wanted to be part of a specialty like that. Bayview is also where I cut my teeth on doing some of my first ER procedures for trauma patients like reducing a distal radius fracture or placing a tibial traction pin. Even though it is a pretty straight forward procedure for most ortho residents, its hard not to look like a bad ass when you walk into a patient’s room in the ER, take a drill with a humongous Steinman pin attached to it, and drill it directly through their bone while they are awake. Every time I do it, the ER docs and nurses either stare in amazement or cringe in pain while watching. For those who haven’t seen one, below is an example of one that I did for a segmental femur fracture:
Overall, while I enjoyed Bayview I did not fall in love with doing joints. Even though each case was unique in its own way, you are still pretty much doing the same procedure, the same way, in a different patient, 3-5 times a day. I really like more variety than that, which is why I don’t think it is very high on my list. Also, when joints get infected…that really sucks. And you are stuck with multiple revisions and washouts and the patient really is never the same.
Interestingly it was at Bayview that I was rebuked the most about a spiritual issue. When you get to your surgical residency you will understand that you are always running the around the hospital, whether it is seeing consults, running to the OR to do a case, running back to the floor to take care of a crashing patient, running to the cafe to grab something unhealthy to eat before running back to the OR, etc. Especially as a junior resident when you haven’t exactly become entirely efficient with your time, you are running around even more. I had one particular attending at Bayview who seemed to really like to tear into me for this or for that to the point where I was confident that I never wanted to emulate any aspect of what he/she was like as an attending. But one day, as I was rushing back from the ER just seeing a consult and was taking out the sponge to scrub for the case, that same attending was scrubbing also. We were both silent while we scrubbed and the only thing running through my mind was what the steps for the upcoming case were going to be, what neurovascular structures I needed to be concerned about, what questions the attending might pimp me with, etc. But my attending broke the silence and out of the blue (and most likely because he knew I was a Seventh-day Adventist Christian) asked me what I think about when I scrub. I told him the truth; that I was thinking about the case, trying to run through the steps in my head. I thought he would be pleased with this answer and cut me a break throughout the case. But he instead responded by saying that when he is scrubbing, he is praying to God to guide his hands. He is praying that the patient does well, that he as a surgeon makes the right decisions throughout the case to help the patient; that the he helps and does not hurt the patient, etc. Needless to say, I was thoroughly rebuked. First I was a extremely surprised that my attending prayed at all, seeing as how he usually ripped me a new hole every day for one reason or the other. But the fact that he was telling me; who was supposed to be an example of relying on God for everything about praying before a case was humbling. I realized that in all the haste to get ready for cases, I rarely if ever prayed to God. That this rebuke came through this attending made it even more clear that God was telling me that I was slipping and that I needed to come back to Him. It is so easy to get caught up in the “doing” of medicine and surgery that you forget WHY you are doing…you forget what the driving force behind your compassion is. But thank God that when He rebukes it is to build you up, and not tear your down. Since then I have made it a point to pray when I am scrubbing and I truly feel that I have noticed a difference in how I operate and the peace I feel as I do various portions of the procedure.
Currently I am on ortho trauma which besides being on the peds service is one of the busiest rotations. Ortho trauma entails everything that you would think; we take care of all of the crazy adult “bone” trauma that comes into the ER like shattered pelvises, femur fractures, tibia fractures, patellar tendon or quadriceps tendon ruptures, etc. This rotation really teaches you the bread and butter of orthopedics because when you are out in the community, you may not only be taking care of routine sports injuries, but you will likely be taking call somewhere and will need to know how to handle any trauma that comes in. The operations that we do on this service are very cool, but similar to adult spine, the patients often don’t leave you with the satisfaction that you would expect. In big cities like Baltimore, its not the unassuming, pleasant 30 yo teacher who gets into a car accident and breaks her femur. Instead it is the 40 yo chronic heroin user, with hepatitis C, who was walking across the street while drunk, got hit by a car and presents to the ER with multiple fractures. These people are not inherently bad by any means, but they tend to not understand the herculean effort that went into keeping them alive and fixing them, and instead treat you and the nurses poorly while you try to take care of them. On top of that because of their pre-injury social status, they often don’t have the transportion or the desire to make it to their follow-up appointments, and will instead be lost to followup for months, only returning when their wound is draining or when they have a non-union.
But again that is quite a generalization and you do have a nice subset of patients (of all socioeconomic levels) that you enjoy waking up to take care of. I don’t necessarily think my time on this rotation so far has convinced me if I want to pursue ortho trauma for fellowship, but who knows what the future will entail.