True Stories From Podiatric Residency

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Yea, it's a long and busy year...

THAT I'M FINISHING!!! :laugh:

When are you coming up?

I get back from Hawaii on the 27th so I will probably head up to look for a place the first or second week of May. I am planning on actually moving the week after graduation in June.

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I was in the OR until midnight with a talar body fracture. Driving at 70MPH while drunk is a bad idea. Then, I got called to the ER at 4AM for an open ankle fracture. I'll never rollerskate again:laugh:

Yea, it's been one of those nights...not bad for an "orthotics salesman." :D
 
I was in the OR until midnight with a talar body fracture. Driving at 70MPH while drunk is a bad idea. Then, I got called to the ER at 4AM for an open ankle fracture. I'll never rollerskate again:laugh:

Yea, it's been one of those nights...not bad for an "orthotics salesman." :D

What is the call schedule up there like for interns? Q3 or 4? Are you required to stay in the hospital for that? Not exactly sure how call works at this point, and obviously as a first year student I wont be finding out for a while, but was just curious.
 
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What is the call schedule up there like for interns? Q3 or 4? Are you required to stay in the hospital for that? Not exactly sure how call works at this point, and obviously as a first year student I wont be finding out for a while, but was just curious.

It's actually not bad. You have 1st call (covers DMC Downtown) and you have 2nd call (covers Sinai-Grace). 1st is Mon-Sun and 2nd is Mon-Fri (1st call covers both places on the weekend so 2nd gets the weekend off). These people cover the ER, floor patients, and any consults. This is day call only (7am-5pm). Night call is split between all 1st and 2nd year residents on service which usually numbers between 4-6 residents at a time. But night call is taken from home so sometimes, you get called out while other times, you sleep through the night.

Granted 1st year residents take more call than 2nd years. 3rd years take no call. This year, I am taking 13 first call and 7 second call. I think I'm taking 55 night calls or so. As a second year, I'm taking 3 first calls and 7 second calls (less working weekends) and 35 night calls.

It is a really good system and works well. You have some very busy days and weeks but you also have plenty of time to breath.
 
I was in the OR until midnight with a talar body fracture. Driving at 70MPH while drunk is a bad idea. Then, I got called to the ER at 4AM for an open ankle fracture. I'll never rollerskate again:laugh:

Yea, it's been one of those nights...not bad for an "orthotics salesman." :D

I got called sat for ankle fx and 5th met fx - one on each foot. She was gardening.

Sun - pt fell down the stairs and fx dislocated her ankle. the talus was behind the tibia.

there was also an MRSA infection/abscess in a foot that oozed pus upon I&D.

And a foot laceration

oh and the best was the partial nail avulsion!
 
I got called sat for ankle fx and 5th met fx - one on each foot. She was gardening.

Sun - pt fell down the stairs and fx dislocated her ankle. the talus was behind the tibia.

there was also an MRSA infection/abscess in a foot that oozed pus upon I&D.

And a foot laceration

oh and the best was the partial nail avulsion!

Did you cast them for orthotics??? :laugh::laugh::laugh:
 
Did you cast them for orthotics??? :laugh::laugh::laugh:

My co-resident put an ex-fix on the fx dislocation today.

I was busy doing a hammertoe, wart removal, osteochondroma excision and nail avulsion, and a peroneal tendon repair (that was the best case of the day).
 
So how much time do you guys spend rotating on other services? I know that in most residency programs the residents spend time on med, gen surg, vascular, ER, etc. How much of this experience do you believe is going to help you in the future? My belief is that with the profession heading in the right direction (as it seems to be) it will only be a plus learning more about other services and enlightening them on what we are capable of doing and building good relations for consults/referrals. Nothing beats team work, especially in health care!

:thumbup:
 
So how much time do you guys spend rotating on other services? I know that in most residency programs the residents spend time on med, gen surg, vascular, ER, etc. How much of this experience do you believe is going to help you in the future? My belief is that with the profession heading in the right direction (as it seems to be) it will only be a plus learning more about other services and enlightening them on what we are capable of doing and building good relations for consults/referrals. Nothing beats team work, especially in health care!

:thumbup:

You are exactly right, we not only do these rotations for our own learning but also to educate other specialties.

At my program we spend 1 month on medicine, 1 month of gen surg, 1 month of vascular (so 2 months of gen surg call). the equivalent of 2 months ER - 20 hours a weekend for 13 weeks thrughout the first year.... those are our big ones in the 1st year.

Every rotation I have been on I have learned something that will stick with me and help me as a podiatric physician.

On my psych rotation we had a patient with steroid induced psychosis. I may have briefly learned about this in pharm in school but did not really remember it. So now I will never forget it and its symptoms which take a long time to resolve.
 
So how much time do you guys spend rotating on other services? I know that in most residency programs the residents spend time on med, gen surg, vascular, ER, etc. How much of this experience do you believe is going to help you in the future? My belief is that with the profession heading in the right direction (as it seems to be) it will only be a plus learning more about other services and enlightening them on what we are capable of doing and building good relations for consults/referrals. Nothing beats team work, especially in health care!

:thumbup:

I was skeptical going into it but am very pleased with the knowledge base that I have built. We do 2 months IM, 1 month ID, 1 month general surgery, 1 month vascular surgery, 1 month ED, 1 month plastics, 3 months ortho trauma, and 3 months ortho peds during residency. After IM, ID, gen surg, and vasc, I feel very comfortable admitting and medically managing most patients. Down the road, I see this being very useful as pods have admitting privileges at many hospitals across the country.
 
corticotomy for brachymet of the 4th today. Percutaneous mini rail then small incision for the osteotomy.

Removal of spur from ankle for anterior impingment, yellow/brown/red syovial tissue appeared - sent to path for possible PVNS.

removal of plantar fibroma...
it was recurrant and huge with lots of dissection of the plantar space. Good view of anatomy that you often do not get to see.
I tried to post a picture but I cannot figure out how to do it. It seems that only images w/ URLs can be inserted.

Help?... Anyone?
 
corticotomy for brachymet of the 4th today. Percutaneous mini rail then small incision for the osteotomy.

Removal of spur from ankle for anterior impingment, yellow/brown/red syovial tissue appeared - sent to path for possible PVNS.

removal of plantar fibroma...
it was recurrant and huge with lots of dissection of the plantar space. Good view of anatomy that you often do not get to see.
I tried to post a picture but I cannot figure out how to do it. It seems that only images w/ URLs can be inserted.

Help?... Anyone?


you need to upload your pic to a site like tinypic.com. when you upload it on there (no registration required), it will give you a url for the picture, then just come back here and post it :thumbup:
 
2427w5c.jpg


the fibroma is falling out of the foot.

the freer is pointing to the FHL.

The other linear structures going toward the fibroma are nerves.
 
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2427w5c.jpg


the fibroma is falling out of the foot.

the freer is pointing to the FHL.

The other linear structures going toward the fibroma are nerves.

Wow! tats awesome. I read somewhere that sometimes they take out Plantar fascia itself (if fibroma is recurrent but it has long recovery time). since you said that this was recurring. Did you considered removal of the plantar fascia also or just removed the fibroma only?

now that iam done with Lower extremity and fundamentals in pod course. iam able to appreciate & understand the articles in Pod today or Podiatryonline or JAPMA magazines.

Could you please list some common Soft tissue surgeries performed by Podiatrists on rearfoot and leg region.
 
Wow! tats awesome. I read somewhere that sometimes they take out Plantar fascia itself (if fibroma is recurrent but it has long recovery time). since you said that this was recurring. Did you considered removal of the plantar fascia also or just removed the fibroma only?

now that iam done with Lower extremity and fundamentals in pod course. iam able to appreciate & understand the articles in Pod today or Podiatryonline or JAPMA magazines.

Could you please list some common Soft tissue surgeries performed by Podiatrists on rearfoot and leg region.

This was not my case. I was merely the photographer. But the patient barely had anything left in his foot that resembled plantar fascia, it was all fibroma and scar tissue.

You are right though, that it is recommened to remove the plantar fascia if the fibromas are recurring and bothersome to the patient.

Some soft tissue masses...

The most common is the ganglion cyst.
PVNS - pigmented villanodular synovitis (needs wide excision)
lipomas
neuromas
schwannomas
synovial sarcoma (often referred to ortho oncologyst)
angioleiomyoma
glomus tumor
hemangiomas

there are more...


There are also other soft tissue surgeries performed in the foot and ankle but do not involve the removal of soft tissue masses, like repair of ligaments and tendons.
 
I ran into a pulm/crit care doc yesterday. I told him I was going to post this about him so no HIPPAA problems.

He is always looking for ways to make more money in medicine. He does not do many procedures because that is the nature of pulm/crit care - order writing and medicine prescribing. Many of his patients do not have insurance and the ones that do will pay the plastic surgeon $5,000 for breast implants but argue about paying a $10 co-pay to the pulm/crit care doc.

So he asked me I could teach him how to cut nails so he could do this in the hospital and get re-imbursed for it. He hears that it pays well. The podiatry residents do not cut nails in the hospital except for nail avulsions and very special circumstances.

I could not believe he was asking me this. And he is very serious about it. Everytime he sees me he says how smart I was to go into podiatry. That I will be rich and own a boat.

Well I already own a boat. I bought an inflatable kayak - Ha!
 
Just out of sheer curiosity, how much does/can nail cutting "pay?"
 
about $35-50 per patient depending on the insurance and state and medical necessity.

Thanks; do those numbers represent suggested payment for "standard" nail-cutting procedures (i.e., just routinely clipping old folks' nails, etc.), or do more serious procedures like in-grown toenail removal pay more?
 
Thanks; do those numbers represent suggested payment for "standard" nail-cutting procedures (i.e., just routinely clipping old folks' nails, etc.), or do more serious procedures like in-grown toenail removal pay more?

Nail avulsions (total or partial) atleast in chicagoland cost arnd $200-300:) and the whole procedure doesnt takes more than 15-20 min :cool:
 
Nail avulsions (total or partial) atleast in chicagoland cost arnd $200-300:) and the whole procedure doesnt takes more than 15-20 min :cool:

Sweet! How common are nail avulsion cases for the typical private-practice podiatrist? How many could/should you expect to see per day? Also, are these cases scheduled ahead of time, or are they walk-in "emergency" patients?
 
Sweet! How common are nail avulsion cases for the typical private-practice podiatrist? How many could/should you expect to see per day? Also, are these cases scheduled ahead of time, or are they walk-in "emergency" patients?

Do a google search. There are plenty of threads and pages.
 
while rotating in the ER, saw a lady with a sigmoid colon perforation from anal sex!
 
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while rotating in the ER, saw a lady with a sigmoid colon perforation from anal sex!

:eek: r u sure its sigmoid colon.

I guess we can now derieve a moral of the story from here. "Confuscious says ....." (lol dnt wanna put additional words)
 
I've seen some real good stuff on clerkships so far... adult cavovarus, pilon, complex flatfeet, lapidi (is that the plural?), etc in Atlanta. Neat stuff during my first few days Detroit also... retrograde IM nail tomorrow.


while rotating in the ER, saw a lady with a sigmoid colon perforation from anal sex!
Hey^... at least it was a lady...
...if you were still in Miami, it might've been a guy :barf:
 
Saw a Ehlers-Danlos pt with a non-union Lapidus at the DMU clinic. That was pretty sweet and only on my 3rd day!
 
Not too "sweet" if you're the patient, though. Yikes.

Was it originally plated or just screws?

It was a failed staple. When I say sweet, I mean educationally sweet, not sweet for the patient. Just to make sure everyone doesn't think I'm sadistic and such.
 
Sweet! How common are nail avulsion cases for the typical private-practice podiatrist? How many could/should you expect to see per day? Also, are these cases scheduled ahead of time, or are they walk-in "emergency" patients?

At the office this week one attending had 3 in less than 2 hours. They were scheduled cases.
 
Called to the ER for a MVA. The patient on a motorcycle was hit by a car. He sustained multiple injuries and we were consulted on an open foot fracture. On CT, the navicular WAS GONE and the cuboid was crushed. I washed it out and threw an ex-fix on the foot. Now it's 4AM and I can go sleep!
 
On CT, the navicular WAS GONE and the cuboid was crushed. I washed it out and threw an ex-fix on the foot. Now it's 4AM and I can go sleep!

what do you mean by "navicular was GONE". like gone as a gone in it came out of the body and was lost at accident site or was it crushed. How is the healing time in midfoot area. i mean do the wounds,stuff heal quickly or they need months?

Midfoot injuries and fractures really fascinate me. the midfoot bones always look so compact and flawless i used to think Midfoot joint fractures are pretty rare. but the more iam reading literature iam getting suprised. I was following a local DPM, we saw a Lisfranc's fracture (the lady missed a step when walking down the staircase, woah i just coudnt believe the damage. now i always take elevator:))
 
what do you mean by "navicular was GONE". like gone as a gone in it came out of the body and was lost at accident site or was it crushed. How is the healing time in midfoot area. i mean do the wounds,stuff heal quickly or they need months?

No, we had the navicular. The paramedics brought it in a specimen jar!!!:laugh:

It was pretty neat though. I shot a pin through the calcaneus, one into the 1st metatarsal base, and one into the 5th metatarsal base. I put a rail medially and laterally and distracted it out. After I was done, the cuboid was actually pretty close back to shape (comminuted of course). And there was a void medially where the open fracture/navicular avulsion was that is packed open with a few retention sutures. He will go back soon for some sort of medial column fusion with a graft but he'll never be the same again.
 
No, we had the navicular. The paramedics brought it in a specimen jar!!!:laugh:

It was pretty neat though. I shot a pin through the calcaneus, one into the 1st metatarsal base, and one into the 5th metatarsal base. I put a rail medially and laterally and distracted it out. After I was done, the cuboid was actually pretty close back to shape (comminuted of course). And there was a void medially where the open fracture/navicular avulsion was that is packed open with a few retention sutures. He will go back soon for some sort of medial column fusion with a graft but he'll never be the same again.

Why didnt you just throw the navicular in the autoclave and pop it back into place? Instead you had to come out with all this fancy smancy ex-fix stuff. :laugh:
 
Why didnt you just throw the navicular in the autoclave and pop it back into place? Instead you had to come out with all this fancy smancy ex-fix stuff. :laugh:

I know you are just joking, but have you ever seen an autoclaved bone? I have. it turns black. do not do this. If the bone falls on the floor - put it in saline w/ baci and/or betadine, soak and irregate it if it is necessary to put back in.

Anyone else seen anything different done to salvage bone from the floor?
 
I know you are just joking, but have you ever seen an autoclaved bone? I have. it turns black. do not do this. If the bone falls on the floor - put it in saline w/ baci and/or betadine, soak and irregate it if it is necessary to put back in.

Anyone else seen anything different done to salvage bone from the floor?

Here in mo-town, we just give it an old spit shine!
 
No, we had the navicular. The paramedics brought it in a specimen jar!!!:laugh:

It was pretty neat though. I shot a pin through the calcaneus, one into the 1st metatarsal base, and one into the 5th metatarsal base. I put a rail medially and laterally and distracted it out. After I was done, the cuboid was actually pretty close back to shape (comminuted of course). And there was a void medially where the open fracture/navicular avulsion was that is packed open with a few retention sutures. He will go back soon for some sort of medial column fusion with a graft but he'll never be the same again.

Will he ever be able to walk or run (like for exercise) ever again, or are those days over (if he even did do a lot of jogging up to that point) for good?
 
Will he ever be able to walk or run (like for exercise) ever again, or are those days over (if he even did do a lot of jogging up to that point) for good?

Yea, he'll most likely end up fine. We'll do a mid-column fusion at some point.
 
I know you are just joking, but have you ever seen an autoclaved bone? I have. it turns black. do not do this. If the bone falls on the floor - put it in saline w/ baci and/or betadine, soak and irregate it if it is necessary to put back in.

Anyone else seen anything different done to salvage bone from the floor?

I didnt see it but rumor has it that one of the docs at a local hospital in Iowa dropped a bone graft on the floor. Threw in the autoclave and it turned out great. I think the patient actually ended up with a supernatural foot. Jonwill knows what Im talking about.
 
earlier this week a guy had a fight between his foot and the lawn mower. The lawn mower won.

He had a skin defect of 4x8cm from the navicular cuneiform joint to the distal tibia. Lacerated all anterior tendons, and all other structures that traverse the navicular cuneiform joint. The bone was exposed and you could see little divits in the bone where the blade hit it. He had a good perf fib pulse, but the DP/AT artery was never found - it must have coagulated by it self.

We reattached all the tendons after irrigating and fishing for them. then put integra on the defect and a VAC w/ a posterior and anterior splint.
 
earlier this week a guy had a fight between his foot and the lawn mower. The lawn mower won.

He had a skin defect of 4x8cm from the navicular cuneiform joint to the distal tibia. Lacerated all anterior tendons, and all other structures that traverse the navicular cuneiform joint. The bone was exposed and you could see little divits in the bone where the blade hit it. He had a good perf fib pulse, but the DP/AT artery was never found - it must have coagulated by it self.

We reattached all the tendons after irrigating and fishing for them. then put integra on the defect and a VAC w/ a posterior and anterior splint.

wow! that sounds so interesting.

quick question, The DP/AT artery : is that dorsalis pedis/anterior tibial artery you are referring to? just wanna make sure i am understanding hospital terminology :)

From our LE course i remembered that if AT artery gets damaged then the perf fib artery starts supplying the dorsalis pedis artery and thereby supplying the entire dorsal foot. Is this what is happening here with this patient? Just wondering how cool it wud be to see how things we read in books come to life in clincials :). plzz lemme know if this is the same scenario with this patient.
 
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earlier this week a guy had a fight between his foot and the lawn mower. The lawn mower won.

He had a skin defect of 4x8cm from the navicular cuneiform joint to the distal tibia. Lacerated all anterior tendons, and all other structures that traverse the navicular cuneiform joint. The bone was exposed and you could see little divits in the bone where the blade hit it. He had a good perf fib pulse, but the DP/AT artery was never found - it must have coagulated by it self.

We reattached all the tendons after irrigating and fishing for them. then put integra on the defect and a VAC w/ a posterior and anterior splint.

Nice! I had a guy drop a saw on his foot a few months ago. Feet and power tools just don't mix!
 
wow! that sounds so interesting.

quick question, The DP/AT artery : is that dorsalis pedis/anterior tibial artery you are referring to? just wanna make sure i am understanding hospital terminology :)

From our LE course i remembered that if AT artery gets damaged then the perf fib artery starts supplying the dorsalis pedis artery and thereby supplying the entire dorsal foot. Is this what is happening here with this patient? Just wondering how cool it wud be to see how things we read in books come to life in clincials :). plzz lemme know if this is the same scenario with this patient.

since the patient's foot is clinically well perfused an arteriogram was not performed. The perf fibular and also the plantar blood flow are most likely both supplying the foot.
 
wow! that sounds so interesting.

quick question, The DP/AT artery : is that dorsalis pedis/anterior tibial artery you are referring to? just wanna make sure i am understanding hospital terminology :)

From our LE course i remembered that if AT artery gets damaged then the perf fib artery starts supplying the dorsalis pedis artery and thereby supplying the entire dorsal foot. Is this what is happening here with this patient? Just wondering how cool it wud be to see how things we read in books come to life in clincials :). plzz lemme know if this is the same scenario with this patient.
Yes, DP/AT stands for dorsalis/ant tibial as you suggested.

If you review your notes, not all people even have both a DP and perf fib (and if they have both, one or the other usually predominates). If the patient's main dorsal artery/arteries get damaged, then the PT artery will pick up most of the slack. Remember those anastamoses between the dorsal and plantar arteries that are located in sinus tarsi and the met interspaces? Those are your "backups" if you will.

If the PT artery gets bagged, however, then you are in serious situation. It supplies a whole lot more of the foot than the dorsal artery/arteries do... you were probably taught a ratio of about 80/20 supply (PT/AT).
 
earlier this week a guy had a fight between his foot and the lawn mower. The lawn mower won.

He had a skin defect of 4x8cm from the navicular cuneiform joint to the distal tibia. Lacerated all anterior tendons, and all other structures that traverse the navicular cuneiform joint. The bone was exposed and you could see little divits in the bone where the blade hit it. He had a good perf fib pulse, but the DP/AT artery was never found - it must have coagulated by it self.

We reattached all the tendons after irrigating and fishing for them. then put integra on the defect and a VAC w/ a posterior and anterior splint.
Great case... did you get the C, or was it mostly done by vascular?
 
We had another patient recently w/ alzheimers and DM w/ plantar ulcer submet 3 w/ previous 2nd toe amp. The 3rd toe was erythematous and edematous and the ulcer probed to the 3rd met head as well as tracked up the flexor tendons. It was decided to amputate the 3rd toe and resect the 3rd met head.

Previous to the sx the patient had trouble keeping a bandage on his foot. He showered w/ the bandage and removed it at will.

Post-op the patient was instructed to NWB, and keep the dressing CDI.

POD #1 the patient had no bandage on his foot and said that he urinated on it then was in the hall trying to get the attention of the nurses who he says told him to go back to his room. So he was WB.

We changed the dressing and reinforced it like fort knox. The patient is like Houdini. He thought the dressing and his foot were dirty so he cleaned the foot w/ the dressing in the sink. Then took the dressing off.

POD#2 the on-call resident walks into the room and sees the patient w/ no dressing on his foot. After getting the sign-out from me about all the tape we put on the dressing.

Today a jones type splint was applied to disuade the patient from removing the dressing again.

We will see in the AM what happens.
 
Yes, DP/AT stands for dorsalis/ant tibial as you suggested.

If you review your notes, not all people even have both a DP and perf fib (and if they have both, one or the other usually predominates). If the patient's main dorsal artery/arteries get damaged, then the PT artery will pick up most of the slack. Remember those anastamoses between the dorsal and plantar arteries that are located in sinus tarsi and the met interspaces? Those are your "backups" if you will.

If the PT artery gets bagged, however, then you are in serious situation. It supplies a whole lot more of the foot than the dorsal artery/arteries do... you were probably taught a ratio of about 80/20 supply (PT/AT).

thanks for the info.
 
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