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Hand Tremor

Discussion in 'Podiatric Residents & Physicians' started by 4ycdje, Mar 29, 2012.

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  1. 4ycdje

    4ycdje

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    I'm a 4th year pod student. I discovered this year I have a significant resting hand tremor especially when I'm under stressful & social situations. It seems to distress me more than it should. My current worst nightmare: Suturing in the OR. Match day is next week, and I anticipate I will match at a well balanced program that includes a fair amount of surgery. Sadly, my biggest fear about starting residency is dealing with this tremor.

    I've read a lot about the issue on other forums, but I guess my question is if there is any advice for my specific situation directly from the podiatry arena. I have considered getting a prescription for a beta-blocker for surgery days, but worry that it's too much of a crutch. Any advice is appreciated.
  2. bobdolerson

    bobdolerson

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    Good news and bad news, it would seem.

    First and foremost, it's a good thing that it gets worse in social or stressful situations.

    At least it's not something physical going on, and it's caused by psychological issues that can be dealt with.

    I had that problem for a while playing guitar whenever I'd play in front of a crowd. The things I did a million times on my own became botched songs that disappointed me because I'd start to shake.

    I won't go into what changed my brain to take much of my stress away, as it's much too long for here and probably not suitable for this forum anyway, but the point I would make and try to relate between us is that it wasn't the tremor causing the stress, the stress caused the tremor.

    Kind of frustrating, really, because it gets into a vicious cycle that makes itself worse. You've got to find some way to alleviate some of your stress, and to make yourself more comfortable in those situations. One thing I like to do is do simple hand tricks, things like flipping pens in a circle, or rolling a quarter on my knuckles.

    It takes dexterity and hand-eye coordination. The trick is, do it in front of people all the time. I do it in class, during guest lectures, pretty much any time i can without getting myself in trouble. I used to solve a rubik's cube the same way, always trying to do it in front of people. My performance anxiety (i'm hesitant to call it that due to obvious negative associations...) extended beyond shredding on a guitar in front of a crowd, and was a deeper issue of feelings of inadequacy or somehow thinking I needed to be more than I was or that I wasn't acceptable.

    Get yourself doing things that make you uncomfortable until you realize with the little stuff that it doesn't matter if you mess up once in a while, and everyone makes mistakes. We're old enough that the majority of people don't mock you for simple mistakes, and especially in residency I would hope that those times would be your best opportunities to learn.

    See a guy do something right, and it makes you think he knows how to do that. See a guy do something wrong, and you'll find out his willingness to learn, his ability to adapt, his openness to criticism and respect for academic authority. You have more opportunity to be impressive after you mess up than after you do something right.

    If these issues are severe, you might look at getting some counseling, or a psychiatrist if you're looking more to get medicated (but I don't know hospital views on that).

    Don't let it get you down. I face a lot of the same awkward social feelings and stress, and it makes me perform poorly if i let it get to me. I find that when I'm the top dog (think the difference in how you feel when you start a job as opposed to when you've been there for years and you're teaching a new guy), I'm not nervous or worried what they think because at that point, I know I'm awesome and humble ;-). The more you feel like you belong to the club, the less stressed you'll feel. At least that's how it is with me.

    Good luck. I would love to see some resident/attending chime in here.
  3. 347932

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    Absolutely not. You don't need the beta blocker and it could be more dangerous than you realize.

    The stress will abate with time and no "drug" can help you actually learn to cope. There are breathing techniques to ease the tension, and once it becomes second nature to be under the watchful eye, your tremors will go away.

    We all have/had that. Learn to cope with it and rather than have a "crutch" you will have overcome.
  4. scarshapedstar

    scarshapedstar MD c/o 2016

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    Dangerous? Ever watch a stand-up comedian? You're watching someone on beta blockers.
  5. 347932

    347932

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    LOL. That's good.

    Are you actually comparing someone who tells jokes on stage for living and takes a drug to calm down with someone cutting someones foot open while on a drug to calm down? Really?
  6. scarshapedstar

    scarshapedstar MD c/o 2016

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    He mentioned stressful and social situations. People who act and sing for a living take them as well. I don't see how I'm so off base.

    In any event, he's got a job to do, and if thinking happy thoughts doesn't work overnight then beta blockers are the next best thing. It sounds like your objection isn't so much based on side effects as a general sense of 'pills bad'.
  7. 347932

    347932

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    I take 5 pills a day so I can watch my kids grow up.

    Pills ARE bad if not used for their intended purpose unless monitored by your physician. It's a slippery slope. If this isn't such a bad thing, then you should tell your patients, "Oh by the way, my hand tremors, so I take a pill to calm my nerves in the OR." Are you going to do that?

    Also, how do you know when you've overcome your nerves? Will you stop taking them and then if tremors persist, you'll start again? You don't see how this is a bad thing? Really?
  8. tenaciousplus

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  9. janV88

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    Beta-blockers are indicated for use in anxiety associated tremors.

    I agree with tenaciousplus, see a professional, these things can be managed.
  10. 347932

    347932

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    I did not know this.

    The question remains that is this something you will tell your patients or not?
  11. Ankle Breaker

    Ankle Breaker Senior Member

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    Why in the world would you consider disclosing your personal life to your patients? Patients have absolutely no right to know anything about you outside the office.
  12. 347932

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    I guess I figured since you are going to perform surgery on them, they should know that you have performance issues with your HANDS.

    Let's say you're doing a case and you're hands are steady and then suddenly something starts going wrong. You aren't terribly prepared for this unfortunate turn of events, you become nervous and anxious and your hands start to tremor uncontrollably. No beta blockers to be found. What do you do next? Everyone in the OR sees how badly you are tremoring, and notice that you can't seem to get it under control. How do you think that will seem to them?

    You make your living with your hands. Just saying...
  13. dtrack22

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    So would you recommend disclosing vision problems to surgical candidates as well?
  14. 347932

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    My patients see that I wear glasses. If my glasses broke and didn't have an extra pair or didn't have my contact lenses, I would CERTAINLY cancel my cases for the day.

    If you can't see correctly, why in the world would you jeopardize your patients' safety by performing a procedure on them while not able to be your best in that regard? Can't see = no surgery, right?

    What type of vision problems are you speaking of if not that?
  15. dtrack22

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    I'm speaking of those problems. It's the exact same scenario as the hand tremor. Something that would compromise your ability to operate if something went wrong during the procedure. Something you may not have any control over.

    I don't see the difference between a Dr. who wears contacts and a Dr. who controls hand tremors with beta blockers. Therefore, I want to know if every Dr. who wears contacts to correct vision problems should disclose this to their surgical patients like you suggested the individual with the tremor should?
  16. PADPM

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    1) Prior to self diagnosing, it is absolutely mandatory that you visit a neurologist to make sure that your tremors are purely emotional.

    2) I understand the points made above, the pros and cons of taking the beta blocker. However, beta blockers are not without their own set of side effects. In my opinion, coping and treating the root cause is always going to take precedent over a pill. Medication absolutely has it's place for physical and emotional issues. However, the pill for an emotional issue isn't REALLY treating the problem.

    3) If the neurologist gives you a clean bill of health and it's decided that stress or emotional issues are causing your tremors, it would be wise to first address those problems with the proper professional help. If that does not resolve the problem, then medication should be considered.

    4) If there is a way to treat something without medication, it's almost always better and safer. Most meds have side effects, beta blockers included.
  17. 347932

    347932

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    I really don't see how you can equate the two. I'm not going to continue for fear of incurring the Wrath of SDN.
  18. dtrack22

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    how do you not understand how having vision problems mid procedure is no different than having hand tremors mid procedure?
  19. 347932

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    What kind of vision problems???? My glasses falling on the floor and breaking?? That is not psychosematic like breaking out into tremors when things get a little hairy.

    I don't wear contact lenses in the OR to avoid having one pop out in the middle of the procedure. I check my glasses before each procedure to make sure they are secure and all the screws are tight so they won't fall off or break mid procedure.

    Start tremoring while doing a midfoot recon with a dorsal incision and you cut the DP artery then start tremoring so badly you can't fix it. That is a HUGE lawsuit waiting to happen. You start tremoring when putting a screw in and crack a bone and start tremoring even worse and can't get another form of fixation secure. What do you do?? You can't see a problem with a surgeon who makes his living with his hands having uncontrollable tremors, even with a med that is supposed to control it??

    Especially in our field where surgery can get rather intricate.

    Let me ask you this. Would you want a neurosurgeon operating on your spine with a h/o tremors????
  20. dtrack22

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    Maybe this is easier to understand. Here is your post, notice I can change a few words and it paints the exact same picture. My edits are in red

    My scenario is just as plausible as yours. So you would suggest a Dr. who wears contacts inform all of his patients that he has poor vision, correct?
  21. dtrack22

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    I could make up equally unprobable, hypothetical scenarios where you drop your glasses and go to catch them (since it startled you as it has never happened before) with a scalpel in hand, cutting the DP artery...You can't make up crazy stories and then disregard similar crazy stories.

    So this isn't the same thing as a physician having "uncontrollable" 20/200 vision, even with a device that is supposed to control it?

    Would you let a neurosurgeon operate on you who has equally significant vision problems? Of course not. I wouldn't want a neurosurgeon who currently has a cold operating on me. Asking questions that we all know the answer to (let alone the fact that it detracts greatly from the original discussion) isn't proving anything, nor is it productive.
  22. 347932

    347932

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    I seriously hope you're kidding.

    There are options, like NOT wearing contact lenses. If you insist on wearing them, you SHOULD have an extra pair with you to switch them out if something like that occurs. Step out of the OR, break scrub and get your backup pair. Better yet, just wear glasses.

    You are talking about a physical manifestation of stress when you talk about tremors. If for whatever reason, your vision got worse under similar stress, you BETTER tell your patients or you will have a very short career.

    There is no excuse in my eyes (see what I did there??) to have such a physical manifestation and either learn to control it without meds, or disclose that the ONLY way to control this is with medication. If you forget your meds one day and your tremors causes a patient to be permanently injured, your career is OVER. If you don't disclose to your malpractice carrier that you need meds to control your tremors and something goes wrong because of it, you are done.

    One of the questions on your malpractice and hospital questionnaires is whether you have any physical issues that can preclude you from doing your job. If you're a surgeon and need to control tremors with meds and say that you DON'T have anything physical that precludes and something like that happens, you are on the hook. The hospital will sue you and it's possible your malpractice insurer will dump you and claim you lied on the application, ergo, no malpractice insurance to cover your butt.

    Glasses/contact lenses v.s physically tremoring when under stress. Are you seriously trying to make the argument that they are the same with respect to the danger you could be putting a person in when doing surgery on them?

    I know you like to play devil's advocate, but seriously?
  23. 347932

    347932

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    My daughter has tremors due to a cerebellar infarct at birth. Maybe she will control it one day with meds or techniques I don't know about. Sorry to say, but it is a physical manifestation of damage to her brain. She will likely not be a surgeon as when she gets stressed or is very tired it gets MUCH worse.

    I would not feel comfortable giving her a scalpel one day.
    Last edited: Mar 30, 2012
  24. 347932

    347932

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    Deleted because I was being stupid.
  25. dtrack22

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    But not when your device fails. That is the scenario that you originally suggested, someone who has controlled tremors has their medication fail...what's the difference?

    "You SHOULD have an extra pill with you or an alternate medication"...I can take almost every statement you have made and apply it to a individual with tremors who controls them with medication.

    Again, you can't keep applying different logic to the opposing viewpoint. You said...
    So, if the Dr. with tremors (who has it controlled with medication btw) forgets his meds why can't he cancel all of his cases for the day like you would? Because we both know if you went in blind and screwed up your career is OVER

    Both are controlled. One with medication, one with an external device. Both "treatments" have the possibility of failing the Dr. mid procedure. Any individual who knows of their "disability" and has it controlled would presumably be prepared for a situation when their corrective device/medication does, in fact, fail. Just like you tighten your screws and have back up pairs, etc. why would the other Dr. not have a similar protocol/backup system in place for his tremors???
  26. dtrack22

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    Unless there is a treatment that could control her tremors much like your glasses control your vision deficiency right?

    Again, I could make up a similar story about my daughter being born legally blind, and her vision gets worse when trying to focus on something "rather intricate" as you said. Maybe one day there will be a procedure to control her vision I don't know about. Since the damage appears to be irreversible, she will likely not be a surgeon. I would not feel comfortable giving her a scalpel one day.

    Your story (along with mine) completely misses the point. We are talking about a controlled deficiency or disability. You can't make up examples that don't follow the original premise of the discussion.
    Last edited: Mar 30, 2012
  27. SuperFeisty

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    Uhhh guys, you do know that wearing glasses doesn't mean bad vision right? All it means is that the shape of your eyeballs requires correction. I have a pretty heavy prescription, but with correction, I see as well as (if not better) than other students. I would equate glasses falling off like you accidentally dropping a scalpel on the floor. A hand tremor that manifests itself in high stress situations would be more like temporary blindness/blocked vision. Two separate things gentlemen.
  28. 347932

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    Like what?

    I lose my glasses or contacts in the OR and have a back up pair in my locker I can go get.

    Dr. Tremor takes his meds, but they're not working for him because mid case he screws something up and gets hyper stressed and starts tremoring so badly he can't hold the knife at all. He takes a deep breath or two but can't stop his hands from shaking. What options does he have at this point?
  29. 347932

    347932

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    I am acutely aware of this. dtrack, however is not.
  30. 347932

    347932

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    Are we?

    I know my glasses will always work when I wear them.

    My BP meds sometimes don't, even when I take them, depending on what I eat or if I do my exercise. See the difference?
  31. SuperFeisty

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    It's cause he's not part of our exclusive 4 eyes club :D
  32. 347932

    347932

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    There is currently not.

    Do Beta Blockers eliminate the tremors? Or just the potential trigger to the tremors?
  33. dtrack22

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    So if your glasses fall off and break, you can still see well enough to operate?

    Again, "I have a pretty bad tremor, but with correction, my hands are as steady (if not better) than other surgeons"

    The point is that both you and the guy with tremors require correction to function in an OR...both can be fixed...both fixes can fail.

    And we are still talking about a hand tremor that is controlled. So it doesn't always manifest in high stress situations like you are claiming above. That was the a part of the original question I asked, that Kidsfeet can't answer without making up a bunch of highly unlikely scenarios in order to make my question sound ridiculous.
  34. 347932

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    You can't answer that question either.

    I am 100% sure that while wearing my glasses I can see and function well in the OR. Are you 100% sure that with meds the tremor is controllable in a very high stress situation? If you answer yes, I want to know why you are so sure and how you know so well.

    Seems like what you're saying is that you don't know whether it can be controlled or not. That's dangerous all the way around. So what I'm saying is that if my glasses are on, I can see and function. What you're saying is that with meds it is controlled MOST of the time. So even in the BEST of situations the tremors can become an issues, whereas in my best case, I will always be able to perform. This variable is unacceptable to me.

    Stress level goes up, glasses stay on, I can see, no problem.

    Stress level goes up, meds don't work for whatever reason ( I think they are since I'm taking them, right?), tremors, disaster.
    Last edited: Mar 30, 2012
  35. dtrack22

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    If they are related to anxiety, which is the premise we are operating on since you called it "psychosomatic" (which I had no problem with), then beta blockers would eliminate both at a lower dose than you would typically prescribe for HTN, CHF, A fib, etc

    If the tremor is essential (neurologic, unrelated to "emotions") then beta blockers could still be prescribed to eliminate the tremors.
  36. Ankle Breaker

    Ankle Breaker Senior Member

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    :thumbup:
  37. SuperFeisty

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    I can understand your point, but can you find the number of lawsuit cases in which the reason for the mistake was a doctor's glasses falling off and breaking? How about hand tremors? I'm not a lawyer, but I bet there are a lot more of the second.
  38. 347932

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    How do you know this? Can you provide some literature?

    My daughter rarely tremors unless under stress. How does the OP know there isn't an underlying problem?
  39. SuperFeisty

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    Also, can we have an argument without the beginning of a flame-fest? No need to insinuate negative character about someone who disagrees with you. After all, isn't the point of our posts to help the OP decide what to do? Ultimately it's his decision; all we can do is present both sides clearly and impartially.
  40. dtrack22

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    I am 100% sure that the meds will control the tremor in a high stress situation. I am not 100% sure that one med would do this in EVERY situation, which is why additional pills and alternative medications would be an appropriate backup to have.

    But you can't be sure that something won't happen to your glasses or contacts, affecting your vision in EVERY situation either.
  41. 347932

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    Oy vey, really?

    You can't know that for sure. I'm on enough meds to know that none work that well, even in combination.

    If my glasses stay on, I can see. Period.
  42. dtrack22

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    The OP doesn't. But that has nothing to do with this discussion. We entered this assuming a purely psychosomatic manifestation. How many times do I have to repeat that? Your question would be like me asking. How does the guy with the eye problems know there isn't an underlying problem like an ischemic optic neuropathy?

    You've wandered outside the parameters of the original question a handful of times now...
  43. dtrack22

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    So you're on multiple medications for anxiety?

    "If my meds work, my hand is steady. Period."

    You keep trying to bring up points outside of the original scope of my question. Why?
  44. 347932

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    Your point is what exactly?

    Please refer me to the literature that suggests that Beta Blockers will relieve stress induced tremors.
  45. Ankle Breaker

    Ankle Breaker Senior Member

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    Why is it that everyone has to cite sources when responding to you but when you post we are suppose to accept it because you have so much experience, know everything and have done everything in podiatry? Why? All those posts you've chalked up and I never see citations.
  46. 347932

    347932

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  47. 347932

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    Ask and ye shall receive as above.

    I rarely state my opinion as fact, that's why. If I tell you that a procedure works FOR ME, what type of literature would you like?

    Dtrack is saying he is SURE that the meds will help in this case. He has ZERO experience with it. Where is his info coming from? He is not saying he is stating his opinion. He is stating these things as FACT. Based on what?
  48. dtrack22

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    Essential = Essential tremor:symptoms and treatment; Wick, Zanni, Consult Pharm. 2008 May;23(5):364-70, 375-7

    Anxiety = "Clinical and electromyographic characteristics of tremor in patients with generalized anxiety disorder"; Milanov, Electromyogr Clin Neurophysiol. 2007 Jan-Feb;47(1):3-9.

    There are a couple to get you started. I have to find the slides with articles presented to us in pharm and neuro to put more, but doing a couple minute search will bring up plenty of research
  49. 347932

    347932

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    Am I supposed to take this at face value because he says so??
  50. Ankle Breaker

    Ankle Breaker Senior Member

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    We learn this crap in school

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