Attendings and Residents: What did you do today?

[Josh1]

Hi all,

I'm an undecided 3rd year with some leanings toward anesthesiology but my friend told me about PM&R and I liked the rehabilitation aspects, it sounds like fun. I've read the faq about what PM&R does but I don't really know yet what exactly happens day to day. I'm going to schedule a 4th year elective early in PM&R but I just wanted to get a snapshot from any residents or attendings:

What did you do today? What type of patients did you see? What procedures/technology did you utilize? Do you actually do rehabilitation with people like the physical therapy people do?
A detailed snapshot would be helpful.

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[SportsMed09]

While this has been delineated in previous threads, I sill give an updated perspective from a PGY-3 standpoint.

The answer is, it depends on what rotation you're doing. If it's spine/pain, you will be evaluating patients neck and back pain in the clinic and doing injections under flouro such as medial branch blocks and transformalijal epidural stroud injections. If it's sports, seeing athletes/musculoskeletal complaints, doing peripheral joint injections, covering events. If it's stroke or SCI or TBI, doing bread and butter IM (consulting when needed) and learning about the sorfici stroke manifestations depending on the area of infarction, or about TBI, or about SCI medicine(quick; what should you do when an SCI above T6 starts having HA, blocked sinuses, goosebumps, and a 20mm Hg increase in systolic BP?) Or, at every residency, you can learn to do EMGs and diagnose simply peripheral neuropathies to brachial plexopathies, or see weird findings based on different clinical entities (look up myokymia on EMG, and shat that sounds like). We don't do the therapies for te patients, but are involve with other atypical aspects of care compared to other specialities, such as prosthetics and orthotics for BKA patients or those with functional deficits s/p SCI or stroke.

You will have a good lifestyle even in residency, and can make good money coming out. Any othe questions are welcome.

 

[scifiMD]

Note: I'm an attending for a University department so this is NOT what an average doc does--probably way more outpatient/procedures. This is also not MY average day as everyday is somewhat different with different responsibilities

8am--accidently woke up late....not a good start to the day, texted the residents to let them know I'm running late
9am--after getting ready, then reading a Thomas the Tank Engine book to my toddler and peeling her off my leg, got to leave the house
9:15am--stuck in gridlock traffic
9:30am--finally made it to resident clinic and started staffing

Patients in resident clinic ranged from 63yo go-getter with hip pain who is compliant with PT and home stretching just in for f/u and refills on NSAIDs (best one of the morning) to 25yo whiny butt with multiple piercings and tats but in the "worst pain ever" and crying with minimal palpation to anything (worst one of the morning but did talk her into a trigger point injection). Overall lots of MSK patients--couple of bursa injections, couple of trigger points, few referrals to interventional.

Noon--head to lunch at Chipotle with the resident on consult service
12:45pm--back to hospital to staff 2 new consults and update 1 old one (new TBI--patient jumped out of girlfriend's car; chronic SCI with new pneumonia and just weaned off vent; f/u girl with TBI and no disposition)
3:30pm--drive across town to the rehab hospital; answer phone calls from assessment nurses for admissions; check Facebook for no good reason; then get on SDN
4pm--no resident on my service this month so I have a physician assistant to see people on the inpatient side--meet with the PA to round

hopefully I get out of here by 6pm, but could be a little later

The best part of this field (to me) is that I get to do a little bit of everything. Helps me from developing burn out. Some inpatient, some outpatient, some procedures (MSK injections, Botox, baclofen pump refills and management), some consults, some EMGs. You can tailor the field to fit what makes you happy.

Anyway, only 5 more minutes before I'm back to the grind...

 

[PMR 4 MSK]

I came to my office and worked on telephone notes and documents that came in after I snuck out of the office early yesterday.

My first pt no-showed, likely because she is now weaned off of the narcotic she likes too much.

I then saw a pt with new-onset ankle pain. I saw her last month for the opposite leg pain, which is better after use of an NSAID. I diagnosed peroneal tendinitis and wrote an RX for PT. We don't do the therapy, we prescribe it.

My next one was a new pt with leg pain thought to be either osteoarthritis or radiculopathy, but appears to me to be neither, possibly myopathy or amyotrophy. I ordered labs and an MRI.

Next a new guy with back pain that resolved itself b/w when he scheduled the pt and today, but he kept the appointment to get advice on what to do the next time it recurs and how he might be able to prevent a recurrence.

Then I had an MRI follow-up. She has a herniated disk pressing on a nerve root, consistent with her symptoms. We plan to do an epidural steroid injection for that.

The next recheck was last seen 2 years ago, had neck and arm pain and had an epidural. She had been pain-free until a week ago, when it recurred spontaneously. I recommended an NSAID, gabapentin and a recheck in a week.

Then a pt sent for a Synvisc injection to the knee under ultrasound.

Next a f/u on a pt with a severe brachial plexopathy after he fell down some stairs while intoxicated. He also had a c-spine fx without spinal cord damage. He is continuing with PT and weaning off the hard cervical collar.

Then a recheck on a pt with hand contracture due to CVA. It is not getting better enough with baclofen, botox injections and even joint injection for OA of the hand joints. I'm sending her to a hand surgeon to consider surgical release of the tendons/joints.

Then a new pt - middle age female rehabbing a cocaine habit with acute exacerbation recently of chronic back pain. I sent her to PT.

Then lunch where I ran some errands, then over to the ASC for a couple epidurals under fluoro, one transforaminal, one interlaminar. The latter one was tough - a stenotic 93 y/o. I shoulda gone transforaminal on that one too, but last time we did it interlaminar and it worked well for him.

Then a cancellation gave me time to do notes.
Then a RUE EMG r/o Guyon's canal syndrome vs Cubital tunnel syndrome. It was normal.
Then a recheck on a pt with recurrent shoulder pain with rotator cuff tendinitis. I injected it with steroid.
Then my last pt could not be seen because she neglected to tell the schedulers that she wanted this put under Work Comp, for a disputed claim that WC will not authorize. We won't do that. She left in a huff.
Now I am SDN'ing.
Then I'll go pick up my daughter from school, have dinner and enjoy the evening.

 

[slammer922]

I came to my office and worked on telephone notes and documents that came in after I snuck out of the office early yesterday.

My first pt no-showed, likely because she is now weaned off of the narcotic she likes too much.

I then saw a pt with new-onset ankle pain. I saw her last month for the opposite leg pain, which is better after use of an NSAID. I diagnosed peroneal tendinitis and wrote an RX for PT. We don't do the therapy, we prescribe it.

My next one was a new pt with leg pain thought to be either osteoarthritis or radiculopathy, but appears to me to be neither, possibly myopathy or amyotrophy. I ordered labs and an MRI.

Next a new guy with back pain that resolved itself b/w when he scheduled the pt and today, but he kept the appointment to get advice on what to do the next time it recurs and how he might be able to prevent a recurrence.

Then I had an MRI follow-up. She has a herniated disk pressing on a nerve root, consistent with her symptoms. We plan to do an epidural steroid injection for that.

The next recheck was last seen 2 years ago, had neck and arm pain and had an epidural. She had been pain-free until a week ago, when it recurred spontaneously. I recommended an NSAID, gabapentin and a recheck in a week.

Then a pt sent for a Synvisc injection to the knee under ultrasound.

Next a f/u on a pt with a severe brachial plexopathy after he fell down some stairs while intoxicated. He also had a c-spine fx without spinal cord damage. He is continuing with PT and weaning off the hard cervical collar.

Then a recheck on a pt with hand contracture due to CVA. It is not getting better enough with baclofen, botox injections and even joint injection for OA of the hand joints. I'm sending her to a hand surgeon to consider surgical release of the tendons/joints.

Then a new pt - middle age female rehabbing a cocaine habit with acute exacerbation recently of chronic back pain. I sent her to PT.

Then lunch where I ran some errands, then over to the ASC for a couple epidurals under fluoro, one transforaminal, one interlaminar. The latter one was tough - a stenotic 93 y/o. I shoulda gone transforaminal on that one too, but last time we did it interlaminar and it worked well for him.

Then a cancellation gave me time to do notes.
Then a RUE EMG r/o Guyon's canal syndrome vs Cubital tunnel syndrome. It was normal.
Then a recheck on a pt with recurrent shoulder pain with rotator cuff tendinitis. I injected it with steroid.
Then my last pt could not be seen because she neglected to tell the schedulers that she wanted this put under Work Comp, for a disputed claim that WC will not authorize. We won't do that. She left in a huff.
Now I am SDN'ing.
Then I'll go pick up my daughter from school, have dinner and enjoy the evening.

So much msk. That's awesoeme. What setting are u in? Do u have sportsmed spine fellowship? Just seems like there's no nuero today, is that typical?

 

[Jitter Bug]

It depends on your setting. When I worked in a large urban hospital I did alot of neuro: TBI, post polio, CVA, MS, SCI. Both inpatient consulting, inpatient wards and in my outpatient clinic.

Because the big 3 of neurorehabilitation all start with trauma/acute onset emergencies (SCI,TBI,CVA) you will need to have a level 1 or 2 trauma hospital with neurosurgeons/neurologists around, or those cases just won't be coming to you.

If you want a large outpatient neurorehab practice you should be on staff with a large trauma hospital, do consults for them to get the business.

Most MSK/Spine comes from their clinic PCP's or direct self referral so you can build that base through marketing and don't necessarily need to be involved with hospitals if that's not your thing.

We all market the polulations we enjoy treating and purposely don't go looking for work we can do but don't like. II have a former colleague who got really into lymphedema and head and neck cancer rehab and now has given herself a national reputation. She just followed her interests.

 

[RUOkie]

Since I have a break, I'll respond to what my day will be like today.
Woke up at 4:30, 3mile run, shower, eat breakfast.
Round at hospital, 2 new consults, 5inpt rehab patients, team staffing.
Go to office at 9:30 Botox pt for spasticity with US guidance (better visualization than EMG in this situation)
Then follow ups for low back pain/fibromyalgia/shoulder pain
2 EMGs
3 Independant Medical Exams for US DOL
2 new patients. One is a new work comp injury (injured shoulder yesterday) the other is a 73y/o with insidious onset of L shoulder pain.
Then back to the hospital to finish up what I could not do this morning.
Spend time with my family.

I don't have office hrs tomorrow so I will do my IME dictations then, after my bike ride.

 

[PMR 4 MSK]

So much msk. That's awesoeme. What setting are u in? Do u have sportsmed spine fellowship? Just seems like there's no nuero today, is that typical?

Private pratice in multi-specialty ortho clinic. No sportsmed/spine fwllowship. I don't get much neuro, since we are an ortho clinic, but I get 8 - 10 EMGs per week.

I see some spasticity. An occasional TBI or CVA, but most are sent to me for another problem, usually pain.

 

[ogp]

Since I don't see a resident reply yet I'll give mine.

Had a difficult night with the kids up sick so I slept in until 715am . Got to the hospital by 8am (on time) where I am on an inpatient stroke rotation. Prerounded on my 10 stroke patients and dictated 2 transfers to subacute facilities by 10am when our team meeting started. Led team meeting (meeting with PT, OT, SLP, nursing, neuropsych, case management and social work) in discussion about 6 of our 18 stroke patients and how much longer they need in rehab and what the discharge plan is. Rounded with attending from 11-12. Attended Rheumatology Rounds (case about ankylosing spondylitis) at noon and ate a catered "indian" food lunch. Dictated a 3rd transfer to subacute and finished my notes on my 10 patients. Discharged a SCI patient home s/p baclofen pump placement and titration (our Stroke attending is the baclofen pump guru). Admitted a patient with SDH and midline shift that stabilized on neuro floor and needed rehab for global aphasia and left sided weakness. Had a few free minutes before my "call" night started so I helped the spinal cord injury (SCI) resident admit a SCI patient (57 yo F with L1 ASIA C SCI after epidural hematoma s/p T6-S2 posterior spinal fusion, PSF). Then performed botox injections on a consult patient on the neuro floor who has severe spasticity s/p old stroke headed to subacute. Botoxed biceps and finger flexors, toe flexors and gastrocs bilaterally. Started call with a SDH patient with BP 220s/100 only mildly responsive to nitro and hydralazine . STAT repeat CT of head showed progression of SDH with a little midline shift (transferred that to ICU STAT). Admitted two late transferrs from outside hospitals to the SCI team (one Gullian Barre Syndrome patient that was extubated 3 days ago and still has no movement in bilateral lower extremities and one T6-T12 PSF for unstable compression fractures with continued bilateral lower extremity weakness).

Now I'm going to try to get some sleep (usually get 6 -7 hours of sleep on call in house covering approx 35-45 stroke/SCI/general debility/ortho patients, much different than my surgical intern year last year with an average of 1-3 hours of fragmented sleep) before I meet the Saturday "on call" resident at 8am for signout. Then I will enjoy my Saturday and Sunday off with my family.

That's pretty typical for a Friday day and night call for us. At least as a PGY-2.

 

[lobelsteve]

4 new patients, 14 follow ups, 11 procedures.

New: lumbar DDD, lumbar radicx2, cervical radic +/-CRPS
Procedures: MBBs, RF's, TFESI, CESI, SIJ, intercostal

Monday gets more exotic with gasserian, SCS trial, GRC block, and reg stuff.

M-F 730-430, no weekends, no call.

Had an unfortunate nice lady who I saw 2 days ago. 10/10 pain, worse than 2 weeks prior when I got an MRI that showed moderate canal stenosis. Now she cannot get out of bed without help. Got Xrays. Her daughters demanded I admit her to the hospital for pain control. I said I did not and called 2 surgeons to see if they could hep her out. Called her the following AM to review and L5 Fx noted. Had MRI scheduled that afternoon and could have vplasty that right up. She went to the surgeons and demanded to be admitted. He got the MRI, did the plasty, and will decompress her L4-5 stenosis in 2 more days.

Wish I could have fixed her fracture in the office, but I am not admitting for pain control.

 

[Tapspatellas]

Just getting ready to turn in on a night of call, so I'll run you through my day. I'm in a stand alone rehab hospital.

Showed up at 8am and got signout from the post-call resident. Finished my coffee while I made a loop to sign restraint orders. Called to evaluate a couple of pts and ended up sending one back to the acute hospital. Did an admission H&P while returning the occasional page. Had lunch and watched some football while chart reviewing for my next incoming admission. Admitted that patient while returning the occasional page. Ate dinner and did some reading in the call room until I got bored and looked at sdn.