Can you give Digital block as a means of pain management

[cool_vkb]

Just wondering if someone gets a toe fracture. Instead of giving tylenol 3 or other narcotics can we give them a digital block. In that way the we kill the pain locally and the patient doesnt have to take oral medications.

I know local anesthesia goes away easily. but i read somewhere that if you mix Lidocaine + Marcaine + Steroir (the steroid prevents the rapid breakdown) then it can last for few days.

What do you guys think? and what are some of the long acting local anesthetics?

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[PADPM]

Yes, in theory you can give a local anesthetic for pain management, and now there are even post operative pain management systems that infuse local anesthetic to surgical sites to prevent the use of narcotics or morphine pumps, etc.

However, there is a down side to injecting local anesthesia for a fracture patient or trauma patient. You may end up with a patient that now has no pain feedback, and can potentially aggravate the injury. Additionally, sometimes pain is an important barometer to let you know if something is seriously wrong. In some trauma cases, it can let you know if excessive swelling may be causing compartment syndrome, if numbness is occurring due to nerve injury/compression/vascular compromise, etc.

However, in the case of a simple digital fracture, a digital block would probably cause little harm. Please remember that a fractured digit can often be quite edematous/swollen, and injecting a few cc's of local anesthetic can cause even more temporary swelling.

Marcaine is probably the most common used long acting local anesthetic utilized in podiatric practice. The use of epinephrine increases the length of duration, but I personally do not use epi in the digits. The literature warns against this practice, though some practitioners still use it in the digits. In theory, epinephrine is contra-indicated in "end" organs, which means areas where the circulation ends such as the toes, fingers, ears, eyelids and yes, the good 'ol penis.

I don't know where you heard that a steroid prevents the rapid breakdown of local anesthetics, but that's one I've never heard. I'm wondering if you are thinking about epinephrine. The use of steroids is usually limited to reducing local inflammation, which in turn reduces pain since inflammation causes pain.

However, an injection of cortisone/steroid at an area of an acute fracture is NOT indicated since cortisone/steroids actually inhibit healing.

 

[whiskers]

Your local anesthetic will be broken down by tissue esterases which are enzymes.

Steroids do not act on these enzymes.

pH, temperature and binding affinity affect how quickly enzymes act.

As far as injecting anything painful.... Pretty much, if it hurts, you can inject it and make a few extra dollars for doing it.

Just remember that it doesn't necessarily make the patient happy esp when the results could be temporary even with steroid use and the fact that it hurts like hell and the patient knows that you can give them a pill.

 

[Feli]

The local is usually just for the reduction, stress views of lat ankle ligs, etc... keep in mind creating/worsening any possible compartment syndrome as PADPM alluded to, though.

For pain control post-op or post fx, Ropivicaine is generally the best via either pain pumps or guided blocks. Anesth will usually do that if you're at a decent sized hosp/surg center. The point is just to reduce the need for the oral opoids and NSAIDs, not to replace them. Give the rx also... unless you really like getting paged/called.

Injectibles, IV, oral, and phys therapy type (icing, immobilization, positioning, elevation, etc) modalities are all part of the equation. You can't separate them and try to make one of them the end all be all IMO. That'd be like trying to focus on conservative treatments, pre-op eval, surg technique, or rehab. You need the whole spectrum for optimal results. For the pain control, maybe run searches for "multimodal analgesia" and you'll get some good info and articles. I've heard Guido LaPorta or some orthos lecture on the subject, but those were also basically just thily veiled Celebrex-sponsored pitches (still some good scientific info and food for thought, though).

 

[PADPM]

Your local anesthetic will be broken down by tissue esterases which are enzymes.

Steroids do not act on these enzymes.

pH, temperature and binding affinity affect how quickly enzymes act.

As far as injecting anything painful.... Pretty much, if it hurts, you can inject it and make a few extra dollars for doing it.

Just remember that it doesn't necessarily make the patient happy esp when the results could be temporary even with steroid use and the fact that it hurts like hell and the patient knows that you can give them a pill.

Where do you come up with this inaccurate information?? The line "As far as injecting anything painful....Pretty much, if it hurts, you can inject it and make a few extra dollars doing it."

That is one of the most inaccurate AND irresponsible comments I've ever read on this site. Please let me know when and where you practice so I can assure that no one I know ever goes near your office.

First of all, with proper care and technique, an injection does not have to be "painful". Secondly, if for some reason you did decide to anesthetize a patient that came into your office with a digital fracture, it would be part of the fracture care and you would NOT "make a few extra dollars doing it".

The use of local anesthesia during any procedure is NOT billed separately and therefore you can NOT "make a couple of extra bucks doing it".

The only time I know of that you can obtain reimbursement for the use of local anesthesia is when you are billing for a DIAGNOSTIC nerve block when treating a nerve related disorder.

If all your injections "hurt like hell", you'd better brush up on your technique. There are many, many times during your daily practice when you will have to give injections to children and adults that "fear" needles, and with proper technique and a caring attitude, there is ABSOLUTELY no need for any injection to "hurt like hell", no matter what you are injecting.

If you gain a reputation for giving needles/injections that "hurt like hell", you won't have much of a practice. Word spreads pretty quickly when patients aren't happy. And if YOU believe that the injection will be that painful, it won't be hard for the patient to figure out that the worst is about to come.

If YOU believe the injection can be given with minimal discomfort and you assure the patient that's the case, you can eliminate unnecessary fear and stress in your patient.

And it's not always about the "money" and what you can do to "make a few extra dollars". It's about doing the best thing for your patient.

If you simply strive to constantly do the best thing for your patient without constantly thinking about the money, you'll be practicing better medicine and ultimately you'll build a better practice and the money will follow.

Treat the patient, not their wallets or insurance company.

 

[NatCh]

Just wondering if someone gets a toe fracture. Instead of giving tylenol 3 or other narcotics can we give them a digital block. In that way the we kill the pain locally and the patient doesnt have to take oral medications.

I know local anesthesia goes away easily. but i read somewhere that if you mix Lidocaine + Marcaine + Steroir (the steroid prevents the rapid breakdown) then it can last for few days.

What do you guys think? and what are some of the long acting local anesthetics?

Yes, you can administer a digital block to control pain. I don't know about lasting for days, but contrary to Whiskers' findings if you've ever had anything really hurt, you would appreciate even a few hours of relief. Sometimes just getting the pain under control lets the patient settle down, then pain pills can manage from that point. With good technique, a 30g needle, bicarb, slow administration, and cold spray you can give an injection with only a modicum of pain. Emphasis on good technique. For those who are really sketched out about needles I give an Rx for an anxiolytic (e.g., Valium or Xanax) and a Lidoderm patch and have them come back for a later appointment with someone to drive them (because of the anxiolytic).

Toe fractures typically hurt around the time of the initial injury, but after awhile the pain subdues and it becomes mostly just tender or sore. Splintage and protection are usually enough, plus elevation, ice, and maybe an OTC medication.

I would like to point out that physicians fear opioid medications perhaps too much, and we are notoriously stingy with the Rx pad. In the case of a toe fracture, opioid use is justified. There's nothing wrong with writing for a pain med when indicated. The state of Oregon now even has mandatory Pain Management training seminars for all MD/DO/DPM/DDS/DMD doctors plus all ancillary clinicians since as a whole we under treat pain.

I know you were just using it as an example, but Tylenol 3 is barely effective, and it causes nausea in a lot of people. I don't even bother writing for it.

Vicodin is more potent but the Tylenol component is easy to reach max dose or overdose (plus it also causes nausea).

Norco is hydrocodone, like Vicodin, but has a lower Tylenol dosage so there is more head room before max dose.

Oxycodone (similar to Percocet but without the Tylenol component) is nice because without the Tylenol you remove it as the limiting factor. A patient can take a 5mg tablet and cut it in half if they only need a little pain control, and dose up if they need more. Oxycodone is also more easily tolerated than hydrocodone, but if the patient does have nausea you can write for phenergan or have them take an OTC Benadryl.

Dilaudid is good for severe pain.

You can use NSAIDS (if not contraindicated) concurrently with opioids, so for example one regimen would be: 800mg ibuprofen q8h for baseline pain plus addition to oxycodone 5mg-15mg q4h for breakthrough pain. In the case of fracture management though, some people avoid NSAIDS. You can also have the patient take OTC extra-strength Tylenol concurrently with oxycodone and ibuprofen, but since we're now talking about numerous pills you need to have a patient who can handle the task of managing multiple meds all at once.

 

[PADPM]

NatCH makes some very good points regarding the unjustified fear of many doctors regarding writing for opioids. In reality, the real concerns should be for acetaminophen toxicity.

Recently, news reports and medical reports have related patients that have taken compounds such as Tylenol with codeine, Percocet, Vicodin, etc., and between doses they have also taken "non aspirin pain reliever", not always realizing they were taking acetaminophen in ALL these medications.

The toxic dose of acetaminophen is not that high prior to causing some liver concerns, therefore the recommendations have been to lower the dose of acetaminophen in the opiods. Instead of writing for Vicodin with a higher dose of acetaminophen, it is now more prudent to use a dose of 325 mg, etc.

I agree with NatCH that I have rarely seen Tylenol with codeine to be very effective when it came to eliminating pain. Similarly, a lot of older docs in my area (MD/DO) use Darvocet which I have found to be basically useless. Pain is very real and should always be addressed. Unless a patient has a history of abuse, you should give your patients the benefit of the doubt.

Patients that are actually "seeking" strong drugs are usually pretty easy to identify. As a general rule, they come in and tell YOU what drug works for them and actually request a drug by name, and these patients are almost always "co-incidentally" allergic to NSAID's and less potent medications.

Taking multiple medications can be confusing, and adding a narcotic can also add fuel to the fire since the patient may become a little "goofy" on that medication. I always make it a practice to dispense explicit written instructions and have the patient sign the instructions and keep a copy for our office chart. Although most pharmacies now provide computer print outs, I'm not confident that most patients actually ever read that material.

 

[whiskers]

Where do you come up with this inaccurate information?? The line "As far as injecting anything painful....Pretty much, if it hurts, you can inject it and make a few extra dollars doing it."

That is one of the most inaccurate AND irresponsible comments I've ever read on this site. Please let me know when and where you practice so I can assure that no one I know ever goes near your office.

First of all, with proper care and technique, an injection does not have to be "painful". Secondly, if for some reason you did decide to anesthetize a patient that came into your office with a digital fracture, it would be part of the fracture care and you would NOT "make a few extra dollars doing it".

The use of local anesthesia during any procedure is NOT billed separately and therefore you can NOT "make a couple of extra bucks doing it".

The only time I know of that you can obtain reimbursement for the use of local anesthesia is when you are billing for a DIAGNOSTIC nerve block when treating a nerve related disorder.

If all your injections "hurt like hell", you'd better brush up on your technique. There are many, many times during your daily practice when you will have to give injections to children and adults that "fear" needles, and with proper technique and a caring attitude, there is ABSOLUTELY no need for any injection to "hurt like hell", no matter what you are injecting.

If you gain a reputation for giving needles/injections that "hurt like hell", you won't have much of a practice. Word spreads pretty quickly when patients aren't happy. And if YOU believe that the injection will be that painful, it won't be hard for the patient to figure out that the worst is about to come.

If YOU believe the injection can be given with minimal discomfort and you assure the patient that's the case, you can eliminate unnecessary fear and stress in your patient.

And it's not always about the "money" and what you can do to "make a few extra dollars". It's about doing the best thing for your patient.

If you simply strive to constantly do the best thing for your patient without constantly thinking about the money, you'll be practicing better medicine and ultimately you'll build a better practice and the money will follow.

Treat the patient, not their wallets or insurance company.

Oh no you misunderstood me, my injections could never be painful. I use a secret technique only known to jedis such as myself. Don't hate on me for that. I simply can't help it.

 

[dtrack22]

I could be way off but this is how I read whiskers post...

As far as injecting anything painful.... Pretty much, if it hurts, you can inject it and make a few extra dollars for doing it.

As far as giving an injection to a patient complaining of pain...pretty much, if their foot hurts, you can give them an injection to help with the pain and make a few extra dollars doing it.

If I'm right then PA's post didn't really get at the real problem with whiskers post...if there was one.

 

[whiskers]

When someone comes to you and pays you the top dollar they kind of expect results and injections are one way to get quick pain relief while they go fill their scripts.

But then again, some see it as evil.

OMG.

 

[PADPM]

No one said or even "inferred" it was "evil". However YOU are the one that stated "you can even make a few extra dollars for doing it".

I simply gave some legitimate medical reasons why SOMETIMES injecting local anesthesia into an area of trauma may not be prudent, but also stated injected local anesthesia at the area of a digital fracture shouldn't usually cause a problem.

Read carefully.

I also made it VERY clear that despite another one of your famous inaccurate statements, you can NOT get reimbursed from insurance companies for utilizing local anesthetic as part of your patient care, unless that is being utilized for a diagnostic nerve block for a nerve related disorder.

If a patient is "self-pay" and you are charging extra for that service, in my opinion you are taking advantage of your patient.

Now go hang another diploma on your wall for best reading comprehension. You know, right next to the awards for giving the "best injections" and being the "most respected".

 

[whiskers]

No one said or even "inferred" it was "evil". However YOU are the one that stated "you can even make a few extra dollars for doing it".

I simply gave some legitimate medical reasons why SOMETIMES injecting local anesthesia into an area of trauma may not be prudent, but also stated injected local anesthesia at the area of a digital fracture shouldn't usually cause a problem.

Read carefully.

I also made it VERY clear that despite another one of your famous inaccurate statements, you can NOT get reimbursed from insurance companies for utilizing local anesthetic as part of your patient care, unless that is being utilized for a diagnostic nerve block for a nerve related disorder.

If a patient is "self-pay" and you are charging extra for that service, in my opinion you are taking advantage of your patient.

Now go hang another diploma on your wall for best reading comprehension. You know, right next to the awards for giving the "best injections" and being the "most respected".

As a matter of fact, my reading comprehension has been the source of many awards. I have the award already on my wall next to my best injectiion and most respected ones.

take xraysfor a few extra bucks.

Next you will criticize the use and billing of a soft cast like unnas boot for this situation as well. LOL.

Then sell them a surgical shoe. lol

Give them a tetanus injection if they need it for a few bucks lol


Then on their next visit they can get a whirlpool or a ultrasound for a couple more bucks. LOL (again)

Then sell them some lotion for their feet and shoes etc and make some more money.lol

Then I can eventually get them into some orthotics. lol

Injecting and soft casts and whirlpools and ultrasound and office lotions etc can and boost revenue esp if you have the office staff to help facilitate it.

lol. But then again, we should work for free and let medicare abuse us and not pay us crap for the honor of helping people.

you can double your money if you are smart: gasp.

Medicine is part business. A service nothing more nothing less. A fractured toe does not kill anyone and if a person wants a better quality of life they will pay for it out of pocket. Otherwise they should be content with the pain and debility of it.

BTW, I'd rather have a cash patient than a mediscary patient any day of the week. mediscary patients are bummers due to the fact that their insurance really truely sucks.

 

[PADPM]

I'm not going to continue to fall into your trap and continue with your childish game.

How can anyone take a "doctor" or future doctor seriously when every sentence ends with "lol". I know you're really proud of yourself, and it warms my heart to know that you keep yourself amused.

I see that same behavior in the institutionalized patients I treat.......lots of these patients are also in restraints.

You also have a knack for making up scenarios that simply don't exist, or making statements that have no vaild basis.

Once again, I never alluded to any comments even REMOTELY stating that the use of an Unna's boot (that's the correct term), or the use of physical therapy, or the dispensing of a surgical shoe is inappropriate.

I DID discuss some POTENTIAL complications when considering the use of injections following trauma, but ONCE AGAIN stated it shouldn't be a problem following a simple digital fracture.

And for the THIRD time, I simply corrected you (which often needs to be done) and set the record straight to let it be known that insurance companies will NOT pay for the use of local anesthetic as part of a treatment, unless it is being used diagnostically. Therefore, you're not going to "make a couple of extra dollars".

Believe me, I don't need you to tell me how to create revenue for our practice. We wouldn't be looking to add another doctor to our present staff of well over a dozen DPM's and a staff of over 50 if our practice wasn't doing well.......without selling foot lotion.

None of our doctors work for "free" and our offices all accept Medicare, because we all believe that this patient population needs and deserves care. At the present time, our offices are reimbursed fairly for Medicare services, and we are providing a much needed service.

When your grandmother needs care, just send her to one of our offices. We have plenty of doctors and offices to accomodate her.

I really hope you're not a DPM or training to be a DPM, because I would hate to have someone with your sarcasm and attitude as a colleague.

You never mention anything about patient care in your posts, all you ever mention is $$$$$. Maybe someday you'll figure out that if you treat your patients well and provide quality care and practice ethically, you will make an excellent living. The $$$ will come as a result of the above without having to be so angry and cynical.

Stop blaming Medicare, the ABPS, the APMA, the ACFAS and everything else around you. If you are honest, ethical and have the skills AND care about your patients, you'll do well. If your only motive is $$$$, it will become obvious and your career will be short.

 

[whiskers]

I'm not going to continue to fall into your trap and continue with your childish game.

How can anyone take a "doctor" or future doctor seriously when every sentence ends with "lol". I know you're really proud of yourself, and it warms my heart to know that you keep yourself amused.

I see that same behavior in the institutionalized patients I treat.......lots of these patients are also in restraints.

You also have a knack for making up scenarios that simply don't exist, or making statements that have no vaild basis.

Once again, I never alluded to any comments even REMOTELY stating that the use of an Unna's boot (that's the correct term), or the use of physical therapy, or the dispensing of a surgical shoe is inappropriate.

I DID discuss some POTENTIAL complications when considering the use of injections following trauma, but ONCE AGAIN stated it shouldn't be a problem following a simple digital fracture.

And for the THIRD time, I simply corrected you (which often needs to be done) and set the record straight to let it be known that insurance companies will NOT pay for the use of local anesthetic as part of a treatment, unless it is being used diagnostically. Therefore, you're not going to "make a couple of extra dollars".

Believe me, I don't need you to tell me how to create revenue for our practice. We wouldn't be looking to add another doctor to our present staff of well over a dozen DPM's and a staff of over 50 if our practice wasn't doing well.......without selling foot lotion.

None of our doctors work for "free" and our offices all accept Medicare, because we all believe that this patient population needs and deserves care. At the present time, our offices are reimbursed fairly for Medicare services, and we are providing a much needed service.

When your grandmother needs care, just send her to one of our offices. We have plenty of doctors and offices to accomodate her.

I really hope you're not a DPM or training to be a DPM, because I would hate to have someone with your sarcasm and attitude as a colleague.

You never mention anything about patient care in your posts, all you ever mention is $$$$$. Maybe someday you'll figure out that if you treat your patients well and provide quality care and practice ethically, you will make an excellent living. The $$$ will come as a result of the above without having to be so angry and cynical.

Stop blaming Medicare, the ABPS, the APMA, the ACFAS and everything else around you. If you are honest, ethical and have the skills AND care about your patients, you'll do well. If your only motive is $$$$, it will become obvious and your career will be short.

Welcome to my whiskers web of humor and laughter.

Your definition of professional just is not the same as mine. You could probably benefit from diversity training. You probably practice in a very white suburban area where "my kind" ain't welcome. But you do make some good points and seemingly a good guy regardless of how you bash me and trample my feelings. Maybe it's just your controlling personality which probably comes from your how you treat your residents... I can't make myself disrespect you and call you names and be childish like that.

Fortunately today's residents are being trained just as much by MDs and DOs as they are by old grumpy controlling DPMs on geritol. That way they can realise that a profession does not have to be dysfunctional and controlling where kissing the behind of some old crusty DPM gets you somewhere (which it never has and never will, you just end up abused and no one respects you).

I am not sure why you take my posts so personally but I wish we could be friends and be nice to each other. I am trying so hard to be nice and courteous and professional.

Sure I may post some wrong things but that doesn't make me a snake in the grass like you portray. I have feelings too and I am hurt by this all.

I've always respected your posts and looked at you as a mentor and a brilliant poster but now it seems we have had a bit of a divide with this.

It's nothing personal with me. Regardless of how you treat me I will continue respecting you and reading your posts and liking you.

LOL

 

[PADPM]

Sorry to disappoint you "Whiskers", but you're wrong on most points here.

Although our practice has many offices, none of them are even remotely "rural", and the residency I directed was in a major city.

Sorry, but I'm a city slicker, not a country bumpkin.

Your second "assumption" is also wrong. I've had the greatest rapport with my residents, and I'm still in touch with residents I've trained over 15 years ago. I take pride in the fact that my graduating residents have always bought me plaques for my office in appreciation, thanking me for my dedication and friendship. I get calls weekly from my "old" residents just to say hello, sometimes to ask advice, sometimes to ask for "pearls" on how to pass the ABPS exam or sometimes to fill me in on great news such as an engagement, birth of a child, the opening of an office, etc.

I've always treated residents with complete respect and never ONCE demeaned or yelled at a resident in all the years I've been involved with training. I've had residents put sutures through my finger, and screw up royally, and I never ONCE raised my voice or treated a resident poorly or unfairly.

When residents visit my office(s), they are there to learn and not to be "slave" labor. I don't have them do my "scut" work. I have them there to learn about practice management, private office issues and to follow post operative patients. They aren't asked to perform menial tasks, so I believe you have me tagged wrong. I respect the residents and often discuss unique cases to see if they have any ideas that I may have "missed". They are smart and well trained, and those are facts that I don't dismiss.

I've never wanted or asked any resident to "kiss my butt". On the contrary, I've had residents and their spouses to my home for holidays, dinners, etc.

And I treat my office staff the same way. Although I've had office assistants leave due to pregnancy, retirement, career changes, etc., I have never had an employee quit and have only fired ONE employee in all these years (she stole money from patients).

I'll disappoint you again, because I'm certainly not old or "grumpy" and I don't like the taste of Geritol. I still compete is several sports on a pretty high level, so there's not too much "crust" build up.

Let's walk away from this trash-talk and understand something.

I'm not patting myself on the back. But the fact remains that I've been in this profession for a while now, and I've been active with the APMA, the ABPS, the ACFAS and as a residency director. I'm part of an extremely well respected, very successful large practice. And as per my prior posts, I've volunteered with community organizations, coached sports teams, etc.

If I was nasty, grumpy, old fashioned, abrasive, treated people poorly, controlling, etc., I can guarantee you that I would not have succeeded in ANY of the endeavors above.

However, when I answer questions on this site, I try to be "professional" since I'm attempting to help those who I believe will benefit from my experience and mistakes I may have made along the way.

And when you answer with sarcasm, cynicism and lol's, I have a hard time figuring out your motivation.

I don't come on this site to get into pissing matches, my goal is to provide some assistance based on my past experience. If that can help anyone, including you, than I'm happy.

Hopefully, some day you may understand that I'm not the enemy.

 

[whiskers]

Sorry to disappoint you "Whiskers", but you're wrong on most points here.

Although our practice has many offices, none of them are even remotely "rural", and the residency I directed was in a major city.

Sorry, but I'm a city slicker, not a country bumpkin.

Your second "assumption" is also wrong. I've had the greatest rapport with my residents, and I'm still in touch with residents I've trained over 15 years ago. I take pride in the fact that my graduating residents have always bought me plaques for my office in appreciation, thanking me for my dedication and friendship. I get calls weekly from my "old" residents just to say hello, sometimes to ask advice, sometimes to ask for "pearls" on how to pass the ABPS exam or sometimes to fill me in on great news such as an engagement, birth of a child, the opening of an office, etc.

I've always treated residents with complete respect and never ONCE demeaned or yelled at a resident in all the years I've been involved with training. I've had residents put sutures through my finger, and screw up royally, and I never ONCE raised my voice or treated a resident poorly or unfairly.

When residents visit my office(s), they are there to learn and not to be "slave" labor. I don't have them do my "scut" work. I have them there to learn about practice management, private office issues and to follow post operative patients. They aren't asked to perform menial tasks, so I believe you have me tagged wrong. I respect the residents and often discuss unique cases to see if they have any ideas that I may have "missed". They are smart and well trained, and those are facts that I don't dismiss.

I've never wanted or asked any resident to "kiss my butt". On the contrary, I've had residents and their spouses to my home for holidays, dinners, etc.

And I treat my office staff the same way. Although I've had office assistants leave due to pregnancy, retirement, career changes, etc., I have never had an employee quit and have only fired ONE employee in all these years (she stole money from patients).

I'll disappoint you again, because I'm certainly not old or "grumpy" and I don't like the taste of Geritol. I still compete is several sports on a pretty high level, so there's not too much "crust" build up.

Let's walk away from this trash-talk and understand something.

I'm not patting myself on the back. But the fact remains that I've been in this profession for a while now, and I've been active with the APMA, the ABPS, the ACFAS and as a residency director. I'm part of an extremely well respected, very successful large practice. And as per my prior posts, I've volunteered with community organizations, coached sports teams, etc.

If I was nasty, grumpy, old fashioned, abrasive, treated people poorly, controlling, etc., I can guarantee you that I would not have succeeded in ANY of the endeavors above.

However, when I answer questions on this site, I try to be "professional" since I'm attempting to help those who I believe will benefit from my experience and mistakes I may have made along the way.

And when you answer with sarcasm, cynicism and lol's, I have a hard time figuring out your motivation.

I don't come on this site to get into pissing matches, my goal is to provide some assistance based on my past experience. If that can help anyone, including you, than I'm happy.

Hopefully, some day you may understand that I'm not the enemy.

No padpm. I think you are a good guy. You are a professional and I can sense that. I hope you don't my posts personally.

I sincerely like and enjoy reading your posts. They are encouraging and informative.

I hope my posts don't discourage your posting here since you are one of the good guys.

 

[PADPM]

I do appreciate reading your "serious" side and the peace treaty. However, you did throw a "curve" at me when you changed/ "edited" one of your posts AFTER I responded to that post!!!!!! In your post PRIOR to the "edit" you said I probably practiced in a "rural" area, prior to changing it to a "white suburban" area???
(You can see it was edited at the bottom of the post. My response was written at 9:39 and your edit was at 9:40)

My response may have been a little different, if you ORIGINAL post was worded like your EDITED post.

Regardless, it's nice to see that you have more sincere side, and that's the Whiskers that should post more often....in my opinion.

 

[whiskers]

I do appreciate reading your "serious" side and the peace treaty. However, you did throw a "curve" at me when you changed/ "edited" one of your posts AFTER I responded to that post!!!!!!
(You can see it was edited at the bottom of the post. My response was written at 9:39 and your edit was at 9:40)

My response may have been a little different, if you ORIGINAL post was worded like your EDITED post.

Regardless, it's nice to see that you have more sincere side, and that's the Whiskers that should post more often....in my opinion.

Completely agree.

 

[PADPM]

Whiskers,

Just for a quick clarification prior to running off to the office.

When you "edited" your post, you changed it and wrote that I probably practice in a "white suburban area where "my kind" ain't welcome".

Just to set the record straight, I personally have no racial, religious or ethnic biases, nor would I tolerate that from my staff, residents or colleagues.

Over the years, I've chosen residents based on their academics, moral character, attitude and skills and not by any racial, religious, ethnic or sexual orientation.