True Stories From Podiatric Residency

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Originally Posted by NatCh

At the VA? Say "hi" to Nixon for me.

Nat

Nixon is no longer at the program. Dr. Dancho has taken over as program director. I never had the opportunity to meet Dr. Nixon but Dr. Dancho is great.

Originally Posted by krabmas

one of the students now, all the sudden looks at me and goes " I know who you are, your on SDN"

Wow Krab, you're an official SDN celebrity!

Originally Posted by IlizaRob

Nixon is no longer at the program. Dr. Dancho has taken over as program director. I never had the opportunity to meet Dr. Nixon but Dr. Dancho is great.

Jim Dancho runs the program now??? I never would've foreseen that. Any idea where Nixon went? Did he finally retire?

You know what I liked about Dancho's surgical technique? He didn't waste any movements. Every step had meaning. He did not overcomplicate anything just for the sake of complexity. For instance, when transecting the EHB tendon some surgeons will isolate then elevate the tendon with a hemostat, then use the blade to cut it. It ends up being five distinct moves with two instruments and at least two hands (and hopefully you're ambidextrous):

1. Incise parallel to EHB on one side
2. Incise parallel to EHB on other side
3. Insert hemostat deep to EHB
4. Elevate EHB and spread hemostat
5. Incise EHB

When I first saw Jim transect the EHB, he took the #15 blade and went *poke*...and the tendon was cut. In my head I thought, "Well that was easy." Why does everyone else make a such a production of it? Distillation such as that is probably why Jim did the fastest Austin I've ever seen -- 13 minutes skin-to-skin.

Nat

Got called to the ER today to evaluate an infected foot ulcer. X-ray showed osteo and gas and her white count was 19. We took her tonight and I ended up doing an I&D with 4-5 digit amps and resections of 4-5 met heads. I packed it and we'll take it back in a few days for revisional stuff. Good case

I saw a 17 yr old patient today who had her foot mangled by a boat prop and another patient with the bone from a catfish fin in his heel that had been there for 10 months. Only in Minnesota.

I saw a man from El Salvador that had consolidated Charcot of the Calcaneus at the STJ. In his country they thought it was osteo and did many surgeries. We admitted him and his chest x-ray has an infilltrate in the mid lungs. I think the foot is a secondary concern at this point.


Then yesterday I daw a 33 week gestational period baby (kid would not be born yet) was born at about 26 weeks with severe calcaneovalgus. The feet rest on the anterior aspect of the legs. This is an oppisite more common form of clubfoot.

Originally Posted by gustydoc

I saw a 17 yr old patient today who had her foot mangled by a boat prop and another patient with the bone from a catfish fin in his heel that had been there for 10 months. Only in Minnesota.

Hey gusty,

Are you doing externships up in MN or just working for a DPM clinic this summer? What area are you seeing patients?

Right now I am doing a one month externship at Mercy and Unity in Coon Rapids, MN. In september I will be at Regions in St Paul for a month.

I was called to the emergency room at 4 this morning because a lady got in a fight with her boyfriend and kicked a wooden door. The door shattered and she got a huge wooden splinter through the medial aspect of her ankle. It entered just superficial to the medial malleolus, proceeded proxmial just under the tissue, and exited about 4 cm proximal to the medial malleolus.

I numbed her up, excised it and flushed the crud out of it before closing it up. I then made her promise to never kick a wooden door again

I got called in this morning (5AM) for a gunshot wound to the right foot. It was accompanied by a nice calc fracture. And of course, he was minding his own business.

Originally Posted by jonwill

I got called in this morning (5AM) for a gunshot wound to the right foot. It was accompanied by a nice calc fracture. And of course, he was minding his own business.

Sounds like you are getting some pretty good trauma. Do you DMC guys ever do any bunions up there or do the patients have to shatter something for you to operate?

Originally Posted by gustydoc

Sounds like you are getting some pretty good trauma. Do you DMC guys ever do any bunions up there or do the patients have to shatter something for you to operate?

Yea, we do a TON of elective. Last Wed, we had 25 cases.

When it rains, it poors. I was called to the ED at 12:30am this morning. A 14 year old boy was caught in a drive by and had a gun shot wound to the foot. It had lodged right in the tarsal sinus. Surprisingly, there were no broken bones. We took him to surgery at 4:30am and I pulled out a .38 slug.

Originally Posted by jonwill

When it rains, it poors. I was called to the ED at 12:30am this morning. A 14 year old boy was caught in a drive by and had a gun shot wound to the foot. It had lodged right in the tarsal sinus. Surprisingly, there were no broken bones. We took him to surgery at 4:30am and I pulled out a .38 slug.

What is a 14 y/o doing out at midnight?

Originally Posted by Dr_Feelgood

What is a 14 y/o doing out at midnight?

The same thing that they are always doing: "Minding their own business"!!!

Originally Posted by jonwill

When it rains, it poors. I was called to the ED at 12:30am this morning. A 14 year old boy was caught in a drive by and had a gun shot wound to the foot. It had lodged right in the tarsal sinus. Surprisingly, there were no broken bones. We took him to surgery at 4:30am and I pulled out a .38 slug.

Shoulda left in there and billed for an MBA implant.

Originally Posted by NatCh

Shoulda left in there and billed for an MBA implant.

nice! arthroeresis detroit style

Originally Posted by NatCh

Shoulda left in there and billed for an MBA implant.

No, but I did bill for a tarsal sinus evac!

Originally Posted by jonwill

No, but I did bill for a tarsal sinus evac!

so, you removed Hoke's Bullet?

Grand Rounds

jonwill: "Here we see a positive bullet hole sign..no really..."

Stop it, Stop it! The pod-squad is cracking me up.

I'm on anesthesia and did pian rounds today.

13 yo m on PCA w/ 0.3mg dilaudid every 10 or 12minutes, not to excede 1mg/hour.

The pain nurse asks the patient if he's had any nausea or vomit from the meds. The patient denies N,V but says, "you know, I noticed that everytime I press the button my throat closes a little bit." he then continues, waving his hands as if it is not serious, " it's OK, it is just a little, I'm fine".

We discontinued the dilaudid, told the patient that he had what was most likely the beginning of an allergy to dilaudid and to not take it again.

Then the floor nurse was called to let her know and she said that the patient told her this throat closing info yesterday. The pain nurse nicely taught her that it was a big deal and to not ignore that kind of info.

Originally Posted by krabmas

I'm on anesthesia and did pian rounds today.

13 yo m on PCA w/ 0.3mg dilaudid every 10 or 12minutes, not to excede 1mg/hour...

Isn't that a pretty hefty dosage... even for an adult?

What kind of pain did the patient have?

Nat,

Nixon has gone to Atlanta, Village Podiatry Group, he's the head of research there.

SportPod

Originally Posted by SportPOD

Nat,

Nixon has gone to Atlanta, Village Podiatry Group, he's the head of research there.

SportPod

Interesting, thanks.

Nat

Originally Posted by Feli

Isn't that a pretty hefty dosage... even for an adult?

What kind of pain did the patient have?

I guess if you get up to 1mg per hour, yes, it can be. The kid was a post-op patient so post-surgical pain in his abdomen. And he was the about 50-60kg which they treat as adult dosages, he may have been older than 13 maybe 14 or 15. The point is the closing of the throat though not the dose.

The normal adult dosage of Dilaudid for PCA is 0.3mg every 12 minutes (ish).

If we start dilaudid as a prn med we are told to prescribe 0.5-1mg and see how the patient does.

Originally Posted by gustydoc

Right now I am doing a one month externship at Mercy and Unity in Coon Rapids, MN. In september I will be at Regions in St Paul for a month.

Were you still in the Twin Cities yesterday, or were you travelling to your next clerkship?

$10 says almost anyone about to leave any area hospital at 7pm last night was told, "hey, I think we might need you to work a double,"

Originally Posted by Feli

Were you still in the Twin Cities yesterday, or were you travelling to your next clerkship?

$10 says almost anyone about to leave any area hospital at 7pm last night was told, "hey, I think we might need you to work a double,"

I left MN the day before the 35W bridge collapse. I am sure the residents are putting in some overtime.

best nail avulsion case ever.

Kid crashed on the way to pods office and sustained acetabular fracture. He was going to pod office for nail avulsion.

I got called to the OR to do a partial nail avulsion while the ortho trauma doc, resident and med student worked on the hip.

Saving lives one nail avulsion at a time.

Originally Posted by krabmas

best nail avulsion case ever.

Kid crashed on the way to pods office and sustained acetabular fracture. He was going to pod office for nail avulsion.

I got called to the OR to do a partial nail avulsion while the ortho trauma doc, resident and med student worked on the hip.

Saving lives one nail avulsion at a time.

Weird (that they even paid attention to the nail). Since he was under anesthesia, did you just yank it out with a hemostat then walk out of the room, total time 15 seconds?

Originally Posted by krabmas

best nail avulsion case ever.

Kid crashed on the way to pods office and sustained acetabular fracture. He was going to pod office for nail avulsion.

I got called to the OR to do a partial nail avulsion while the ortho trauma doc, resident and med student worked on the hip.

Saving lives one nail avulsion at a time.

That is HILARIOUS!!! Did you scrub in and have a surgical tech assist???

I got called to the ED this morning for multiple gunshot wounds to the foot.

Originally Posted by jonwill

That is HILARIOUS!!! Did you scrub in and have a surgical tech assist???

I got called to the ED this morning for multiple gunshot wounds to the foot.

Multiple foot GSW's? Shotgun wounds, or did someone get forced to dance like in the cowboy movies?

Originally Posted by NatCh

Multiple foot GSW's? Shotgun wounds, or did someone get forced to dance like in the cowboy movies?

I prefer Back to the Future III ...sort of a cowboy movie.

Originally Posted by PODonny

I prefer Back to the Future III ...sort of a cowboy movie.

I wonder if the patient was driving 88 mph?

Originally Posted by NatCh

Multiple foot GSW's? Shotgun wounds, or did someone get forced to dance like in the cowboy movies?

His story was he was trying to break up a fight in the street. He was then assaulted and shot twice in the foot, one went straight through and the other lodged in the medial cuneiform - 1st Meta joint. True story? Not sure but what I do know is that his blood alcohol level was 0.178!!!

Originally Posted by jonwill

His story was he was trying to break up a fight in the street. He was then assaulted and shot twice in the foot, one went straight through and the other lodged in the medial cuneiform - 1st Meta joint. True story? Not sure but what I do know is that his blood alcohol level was 0.178!!!

It is funny he told you what he was doing. Most people say they were minding their business on their way to church.

So it was a traumatic lapidus? First the traumatic athroeriesis and now this?

Originally Posted by jonwill

That is HILARIOUS!!! Did you scrub in and have a surgical tech assist???

I got called to the ED this morning for multiple gunshot wounds to the foot.

SO here are the details of the nail avulsion...

The orthopedics asked about infections - colds and the such. The parents remembered the toe was maybe infected.

The ortho paged the chief of podiatry (we do ortho trauma for 3 months in our 2nd year) and asked him to come down and take care of the nail. I was sent instead.

I had my own table, no scrub tech, and only avulsed the lateral border of the nail where pus was expressed. I told the ortho, who was up at the hip, that I saw some pus so he asked anesthesia if the patient was given ancef yet. Then he asked me if I wanted to cover for anything else. I replaied no. He said what about gram negatives. I replied no that the most common infecting organism is staph aureus. He then turned to anesthesia and asked for something to cover grma negatives. So much for confidence in the 1st year.

That is the story for the most part.

Originally Posted by krabmas

SO here are the details of the nail avulsion...

The orthopedics asked about infections - colds and the such. The parents remembered the toe was maybe infected.

The ortho paged the chief of podiatry (we do ortho trauma for 3 months in our 2nd year) and asked him to come down and take care of the nail. I was sent instead.

I had my own table, no scrub tech, and only avulsed the lateral border of the nail where pus was expressed. I told the ortho, who was up at the hip, that I saw some pus so he asked anesthesia if the patient was given ancef yet. Then he asked me if I wanted to cover for anything else. I replaied no. He said what about gram negatives. I replied no that the most common infecting organism is staph aureus. He then turned to anesthesia and asked for something to cover grma negatives. So much for confidence in the 1st year.

That is the story for the most part.

What med did Anesthesia end up giving?

Originally Posted by krabmas

SO here are the details of the nail avulsion...

The orthopedics asked about infections - colds and the such. The parents remembered the toe was maybe infected.

The ortho paged the chief of podiatry (we do ortho trauma for 3 months in our 2nd year) and asked him to come down and take care of the nail. I was sent instead.

I had my own table, no scrub tech, and only avulsed the lateral border of the nail where pus was expressed. I told the ortho, who was up at the hip, that I saw some pus so he asked anesthesia if the patient was given ancef yet. Then he asked me if I wanted to cover for anything else. I replaied no. He said what about gram negatives. I replied no that the most common infecting organism is staph aureus. He then turned to anesthesia and asked for something to cover grma negatives. So much for confidence in the 1st year.

That is the story for the most part.

Maybe he likes drug resistant bugs? I guess you learn a lesson next time you work with that turd write for Gentamycin and fry everyone's kidneys. Heck its his malpractice insurance.

Originally Posted by NatCh

What med did Anesthesia end up giving?

I do not know. I did not ask. I suck at antibiotics so I did not want to ask and then get asked back "well what would you use" and look like a dumb sh_t for not knowing what to cover with.

Originally Posted by krabmas

I do not know. I did not ask. I suck at antibiotics so I did not want to ask and then get asked back "well what would you use" and look like a dumb sh_t for not knowing what to cover with.

Anesthesiologist: "Well what would you use?"

krabmas: "Nothing other than Ancef, because the most common infecting organism is staph aureus, BUT if the Attending prefers more broad spectrum coverage then how does he feel about Unasyn?"

hey krabmas,

Just confused what "they get the calls, but we cover the cases" means.

Good day.

Originally Posted by krabmas

3yo F vs. automobile - her foot got run over by the car. She had some abrasions and on x-ray no fractures but a foreign body at the same location as on of the abrasions. No laceration.

We cleaned her up bandaged her - she said thank you after screeming like a lunatic. Sent her on her way.

That is the exciting trauma so far at the Level one INOVA.

There is an orthopedic trauma team that gets most calls - we cover the cases though. I'd rather cover the cases than get called to the ER.

Man, Jon the trauma in Louisville might rival DMC. I have seen some extreme cases and I've only been on podiatry call for a week. A guy that was run over by a boat and is in critical condition from the mulitple lacterations (shoulder, abdomen, and heel), a guy in the ICU because a tree fell on him and he had an open skull fracture but the degloved his foot and ankle, motorcycle accident, car accidents, and the list goes on and on. It has been a very tiring week, thank goodness I'm off after Saturday. That means just two more nights for the drunks to get injured.

Originally Posted by Dr_Feelgood

Man, Jon the trauma in Louisville might rival DMC. I have seen some extreme cases and I've only been on podiatry call for a week. A guy that was run over by a boat and is in critical condition from the mulitple lacterations (shoulder, abdomen, and heel), a guy in the ICU because a tree fell on him and he had an open skull fracture but the degloved his foot and ankle, motorcycle accident, car accidents, and the list goes on and on. It has been a very tiring week, thank goodness I'm off after Saturday. That means just two more nights for the drunks to get injured.

Sounds like you're having a good experience down there. I don't know a whole lot about the Louisville program but I've heard good things about it. My week has actually been pretty good. I've done a ton of elective stuff. I did have another GSW on Tuesday morning.

Originally Posted by jonwill

Sounds like you're having a good experience down there. I don't know a whole lot about the Louisville program but I've heard good things about it. My week has actually been pretty good. I've done a ton of elective stuff. I did have another GSW on Tuesday morning.

A lot of the cases are seen at the Uni of Louisville (Level 1 trauma). They've got a clinic there two and I saw my first and second gunshot wounds.

The weeks been fun but I'll be happy to sleep.

Originally Posted by dallasite

hey krabmas,

Just confused what "they get the calls, but we cover the cases" means.

Good day.

People show up to the ED. The ED calls the trauma team. There is a pod on ortho service that gets called if they are on call that night. Other wise when the cases eventually go to the OR the pods help ortho cover them. There is only one ortho resident.

got called to the nursery this morning for a 2 day-old girl with B/L clubfoot. Did the first ponseti cast with a nurse, the little one barely cried. Not as exciting as the multiple gunshot wound case, but it made my day.

The last 3 days: 4 calcaneal fractures, 2 lis franc fracture/dislocation, 2 ankle fractures. What a weekend!

I did my 1st pilon fracture today. I put an ex-fix on it. Sweet! The guy jumped off a 3 story building and sustained a tri-malleolar right and a pilon left. My co-resident did the ORIF and I did the ex-fix.

Originally Posted by jonwill

I did my 1st pilon fracture today. I put an ex-fix on it. Sweet! The guy jumped off a 3 story building and sustained a tri-malleolar right and a pilon left. My co-resident did the ORIF and I did the ex-fix.

show off.