Painful Surgical Rotations

[Lacheln]

Another thread reminded me of a question I've had - I'm worried about my surgical rotations because I have a reconstructed ankle with lasting issues. Standing in one spot for > 1hr becomes progressively more and more excruciating, as I've learned from observing relatively short orthopedic procedures (up to a max of 2 hrs), and the swelling/pain often lasts through the next day. I am honestly unsure whether I will be physically able to bear the long hours of standing required by the surgical rotation. Walking/running is less of a problem, I think other rotations will be ok.

Does anyone have any experience with such situations, and know how programs handle it? I am probably going to get a refinement to take out some scar tissue and spurs, as well as continue hitting PT, but unfortunately my doc doesn't think my ankle will ever be quite the same. (PSA: Don't be a hero and try to play through ankle injury after ankle injury. It is just not worth it, and you will pay dearly in the long run. Zee ankles, dey are delicate.)

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[QofQuimica]

You would need to tell your surgery clerkship director about your ankle up front, especially if you think that you will need some kind of special accomodations. Ideally, it is better if you can tough it out without asking for accomodations; surgery isn't the most touchy-feely culture. You may be able to do some simple things to help yourself without making a big display of it. I have trouble standing for that long also b/c of back issues, but even scrubbed in for a long surgery, I was able to shift around enough so that it was tolerable. It wasn't always the most comfortable and sometimes I'd hurt later, but I never had to scrub out of a surgery early. There are little stools for observers in the OR, and it helped if I put one foot up on a stool instead of standing with my weight equally distributed on both feet. Maybe try that the next time you're in the OR; see if it helps to take some of the weight off your bum foot. You could also try wrapping the ankle and see if that helps. You probably can't do this as a premed shadowing, but I also figured out early on that it helps if you lean on the table a little....you just have to make sure that you don't contaminate the field or yourself, or even worse, lean on the patient. Committing any of these offenses will get you a guaranteed tongue-lashing. Or so I've heard.

 

[Lacheln]

You would need to tell your surgery clerkship director about your ankle up front, especially if you think that you will need some kind of special accomodations. Ideally, it is better if you can tough it out without asking for accomodations; surgery isn't the most touchy-feely culture. You may be able to do some simple things to help yourself without making a big display of it. I have trouble standing for that long also b/c of back issues, but even scrubbed in for a long surgery, I was able to shift around enough so that it was tolerable. It wasn't always the most comfortable and sometimes I'd hurt later, but I never had to scrub out of a surgery early. There are little stools for observers in the OR, and it helped if I put one foot up on a stool instead of standing with my weight equally distributed on both feet. Maybe try that the next time you're in the OR; see if it helps to take some of the weight off your bum foot. You could also try wrapping the ankle and see if that helps. You probably can't do this as a premed shadowing, but I also figured out early on that it helps if you lean on the table a little....you just have to make sure that you don't contaminate the field or yourself, or even worse, lean on the patient. Committing any of these offenses will get you a guaranteed tongue-lashing. Or so I've heard.

1. Yeah, that's what I figured. I am dreading having to possibly address this. Obviously, it's a little premature to be stressing about, but I'm loathe to wimp out of something, etc.

2. That is an awesome idea, I will definitely try that next time I'm shadowing. Leaning on the table will have to wait...plus I can SO see me getting engrossed and have my hand slip off the table, thus abruptly plopping me down into some body cavity.

3. Would that get me a tongue-lashing? Sorry you've had to deal with your back, it sounds like you whipped it like a trooper though.

 

[Law2Doc]

You would need to tell your surgery clerkship director about your ankle up front, especially if you think that you will need some kind of special accomodations. Ideally, it is better if you can tough it out without asking for accomodations; surgery isn't the most touchy-feely culture.

I agree -- if you cannot stand in place for over 2 hours, you are likely going to need accomodations to make it through a surgery rotation. I also would note that rounds can be many hours long (5+) in medicine, neuro, etc with some attendings, so you may be on your feet for very long hours even in non-surgical rotations. And some attendings insist on using stairs instead of elevators for rounds. So you may want to get a better handle on what you can and cannot do before your clinical years, and notify clerkship directors/student affairs accordingly well ahead of time so they can help you navigate through.

 

[Lacheln]

I also would note that rounds can be many hours long (5+) in medicine, neuro, etc with some attendings, so you may be on your feet for very long hours even in non-surgical rotations. And some attendings insist on using stairs instead of elevators for rounds.

By 'on your feet' do you mean lots of standing, or mostly walking, with some standing? Walking is much better for me - I'm pretty sure that I could go 5+ hours, albeit in some discomfort, which is why I was thinking that surgery would be the main hurdle. Stairs are also fine (preferable, actually) - I run. It's pretty much the standing still that doesn't work.

 

[njbmd]

Another thread reminded me of a question I've had - I'm worried about my surgical rotations because I have a reconstructed ankle with lasting issues. Standing in one spot for > 1hr becomes progressively more and more excruciating, as I've learned from observing relatively short orthopedic procedures (up to a max of 2 hrs), and the swelling/pain often lasts through the next day. I am honestly unsure whether I will be physically able to bear the long hours of standing required by the surgical rotation. Walking/running is less of a problem, I think other rotations will be ok.

Does anyone have any experience with such situations, and know how programs handle it? I am probably going to get a refinement to take out some scar tissue and spurs, as well as continue hitting PT, but unfortunately my doc doesn't think my ankle will ever be quite the same. (PSA: Don't be a hero and try to play through ankle injury after ankle injury. It is just not worth it, and you will pay dearly in the long run. Zee ankles, dey are delicate.)

On a surgery rotation, I don't (and didn't) torture any medical students or residents for that matter. I have had students who were confined to wheelchairs, had multiple sclerosis, cerebral palsy and other conditions that did not allow hours of standing in one place. We simply made accomodations for them which didn't take away from their learning what they needed to get through the rotation. You have to speak up and say that you are and are not to tolerate physically.

As a teaching attending, my interest is in you learning the aspects of surgery that will enable you to be a good physician regardless of specialty. None of those aspects has a strict physical requirement. If you are physically unable to participate in surgical cases, believe me, I don't want you anywhere near those surgical cases. There are simply other ways for you to participate in the rotation where you can learn. In short, medical school is not about physically torturing students. It's an opportunity to learn and you want to be sure that you make the most of it.

If there is something horrible about your surgical rotation, you need to let your clerkship director know of your circumstances. If adaptations can be made, most good clerkship directors are quite willing to make them. If you don't speak up, they can't help you. In short, worry about something else but not about your surgical rotation.

 

[QofQuimica]

By 'on your feet' do you mean lots of standing, or mostly walking, with some standing? Walking is much better for me - I'm pretty sure that I could go 5+ hours, albeit in some discomfort, which is why I was thinking that surgery would be the main hurdle. Stairs are also fine (preferable, actually) - I run. It's pretty much the standing still that doesn't work.

It depends on the attending. One of my attendings had rounds that consisted of all the team sitting around a table in a conference room talking about the patients on the service. Then the attending would go on rounds alone. A second attending did the conference table thing and then just made *me* go on rounds with him while the residents did their scut work (miserable, torturous--would have preferred helping with the scut). Another attending would make us all go from room to room, and we'd spend all morning at it, four straight hours. But all of the rooms had chairs in them, so sometimes I could sit down if I beat the residents to them. Loser had to stand up with their back against the wall for support. Who ever knew I'd be spending half my day in medical school playing musical chairs?

 

[Law2Doc]

By 'on your feet' do you mean lots of standing, or mostly walking, with some standing? Walking is much better for me - I'm pretty sure that I could go 5+ hours, albeit in some discomfort, which is why I was thinking that surgery would be the main hurdle. Stairs are also fine (preferable, actually) - I run. It's pretty much the standing still that doesn't work.

As Q indicated there are a lot of variations. But there will definitely be attendings whose style of rounding consists of walking to the room, presenting the patient for 10 minutes in the hallway, then going into the room and standing there for another 10 minutes, and then off to the next room. So we are talking 90% standing and 10% walking in between standing stints.

 

[J ROD]

This is sort of related.

I have been working as a pharm tech for 2.5yrs and I stand or walk around for 10 - 12 hrs a day straight with only 30 minutes where I actually get to sit and rest my legs and feet. Somedays, I might get a 15min break.

Would you all think this is a good endurance test to see if I can handle rotations and such?


Right now, I am doing this 6 days a week too.

The physical demands worry me some as I approach 30!

My legs and feet hurt but I can manage....

 

[Law2Doc]

This is sort of related.

I have been working as a pharm tech for 2.5yrs and I stand or walk around for 10 - 12 hrs a day straight with only 30 minutes where I actually get to sit and rest my legs and feet. Somedays, I might get a 15min break.

Would you all think this is a good endurance test to see if I can handle rotations and such?


Right now, I am doing this 6 days a week too.

The physical demands worry me some as I approach 30!

My legs and feet hurt but I can manage....

10-12 hour days are not exactly comparable to the 30 you might do on an overnight call, but standing all day is good practice, I guess. The key is more about good shoes than anything else. I wouldn't worry about the physical demands as a 30 year old -- all of the attendings will be older than that and they will all be on their feet too.

 

[Lacheln]

Okee dokee, thanks for all the feedback guys. I feel a bit better about things now - if I am limited, I'm limited, it's not the end of the world.

Q - I can so picture the musical chairs game. I will start practicing now.

 

[J ROD]

10-12 hour days are not exactly comparable to the 30 you might do on an overnight call, but standing all day is good practice, I guess. The key is more about good shoes than anything else. I wouldn't worry about the physical demands as a 30 year old -- all of the attendings will be older than that and they will all be on their feet too.

From what I can tell at my hospital, docs walk around and then sit some and write up patients.

So, basically, they are up several hours and get to sit some and rest up on their feet and legs.

From what I have heard this is the case except maybe on surgery.

I will do whatever it takes though. I just have a bad knee that acts up every now and then. I used to be a catcher, lol!!

 

[Law2Doc]

From what I can tell at my hospital, docs walk around and then sit some and write up patients.

So, basically, they are up several hours and get to sit some and rest up on their feet and legs.

From what I have heard this is the case except maybe on surgery.

I will do whatever it takes though. I just have a bad knee that acts up every now and then. I used to be a catcher, lol!!

Yeah it's not like you never get to sit in the non-surgical rotations, it's more that it doesn't compare to the desk jobs a lot of nontrads once had -- in medicine you may be spending the bulk of your very long day on your feet. get good shoes -- doesn't matter how ugly they are, the key is comfort.

 

[J ROD]

Yeah it's not like you never get to sit in the non-surgical rotations, it's more that it doesn't compare to the desk jobs a lot of nontrads once had -- in medicine you may be spending the bulk of your very long day on your feet. get good shoes -- doesn't matter how ugly they are, the key is comfort.

Thanks. I have some Klogs that I like very much.

I will handle whatever comes because I must...no matter how many hours I have to stand.

Plus, I have noticed after awhile your legs and feet get numb to the pain.

 

[ShyRem]

I can sympathize. I too have a long-lasting ankle injury, and now walk/stand on a chronic grade II/IIb sprain that is as good as it's ever gonna get. I did mine in in 2001. 2002, 2003, 2004 were excrutiating years for me as far as standing and walking went. Running is TOTALLY out of the question. Stairs needed extra PT work. And I have this fabulous neuroma on my ankle now that if anything rubs on it, the lateral part of my foot goes numb for about 2 days. A debridement helped my standing pain a LOT.

What has worked for me: PT. 8 months worth of PT in 2001. Another years worth in 2002 after I had surgery. I shortened my stride by 6" or so. I changed ALL of my shoes. Birkenstock, Haflinger, Dansko are my friends (but I have to concentrate when I walk in Dansko), along with some other Israeli/european brands. Flat. No heels. Ever. I changed how I stand as well (this was KEY). And no running or anything that has me putting a lot of weight or strain on the ball of my foot (yeah, my stride looks a little funky if you really pay attention, but I've learned to hide the odd stride well). And I sleep a lot on my stomach with my foot dangling off the bottom edge of the bed because the weight of the covers is rather painful on my ankle.

So. I'm now a 3rd year, and I did surgery rotation first. It really wasn't so bad. I wore a Bauerfeind Malleotrain brace fairly often, or an EpX stabilizer (mainly because I often wore my Danskos). I continue to do my PT ankle exercises, but since they can be done anywhere I often did them in between surgeries when I had 5 or 10 minutes to sit. Lunch was always PT while eating to keep the ankle moving. I also shifted my weight from one foot to the other, or utilized the step stool for a footrest.

Bottom line: It's possible. Keep up with the PT, and find shoes and braces that work for you. They're worth the extra money - this isn't a place to skimp and buy the supermarket brand of brace or the PayLess or Target shoes. Spend the extra money, put in your PT time and your feet will thank you for years to come.

 

[Law2Doc]

...
I will handle whatever comes because I must...no matter how many hours I have to stand.
...

Yeah, the "just suck it up" attitude carries you a long way on this path. Get good at telling yourself that.

 

[J ROD]

Yeah, the "just suck it up" attitude carries you a long way on this path. Get good at telling yourself that.

Unfortunately, I am well aware of it already....at least I am battle tested.

I have learned not to get up or down just around whatever it is!

 

[Lacheln]

It sounds like we have a lot of similarities, with a couple of exceptions:

I can sympathize. I too have a long-lasting ankle injury, and now walk/stand on a chronic grade II/IIb sprain that is as good as it's ever gonna get.

The surgery you mentioned, was it a reconstruction? I had a severed atl and a torn calcaneofibular, plus the requisite cartilage damage etc. Before surgery I had extreme laxity and constant pain, it even hurt lying down, and I think you mentioned covers...oh yeah, painful. The reconstruction completely tightened things up, it feels really stable now. It was a loooooooooooooooooooooooooong rehab process though. Tons of PT etc.

My ongoing problems are due to impingements and cartilage damage, which is why I might have a refinement. I've worked my way up to being able to tolerate heels for about 10 minutes upright - ie. walk to the car and sit down, walk to the restaurant/show and sit down, walk back to the car and sit down, walk in the house, and disgustedly throw shoes aside as I sit down. I had to have all of my pants rehemmed after my injury because my whole freaking wardrobe was built around heels.

PT helped with everything else, but not this, and not the standing pain. I think I can run (after 2 years) because I do have a stable ankle (your issues with running, stairs, and weight on the ball of your foot all sound related to laxity), but the spurs are more of a problem when I'm standing. My arch also fell during this process, so I rely heavily on orthodics in all of my shoes (and yes, definitely go for the good ones, you'll save money in the long run anyway).

I guess my point is in wondering if there is more they could do stabilize your ankle? I'm sure you have explored the options, I just ask because many of your symptoms sound like ones that surgery was able to correct for me (but it took me well over a year to see the full results).

 

[ShyRem]

Unfortunately not. I have a congenital ligament laxity issue. So I have to live with what I have now. It's better than I had before, and I'm grateful for the ability to walk. I've refined my short stride and now most people can't tell I use one foot oddly.

Heels - yes, I had a whole closet full of them too. Can't wear a single thing over 1" anymore. *sigh*. Beautifeel makes some really pretty and very comfortable shoes (but they're pretty pricey).

Spurs. I am fortunate to not have any of those. Gel inserts? On the other hand, the debridement was much faster to recover from than the original injury. MUCH faster. I would imagine the release and spur removal would be similar recovery. And I would really go to some high-end shoe stores and try on every pair (ugly or not) until I found something outrageously comfortable - no matter what the price. At this point, my cheap shoes are over $100 a pair. The ones I splurged on for over $200 were totally worth it.

 

[Gut Shot]

I have a congenital ligament laxity issue.

You should bring this up in The Lounge.

 

[45408]

By 'on your feet' do you mean lots of standing, or mostly walking, with some standing? Walking is much better for me - I'm pretty sure that I could go 5+ hours, albeit in some discomfort, which is why I was thinking that surgery would be the main hurdle. Stairs are also fine (preferable, actually) - I run. It's pretty much the standing still that doesn't work.

My feet bothered me more on peds in-patient than they did on surgery. Our rounds peaked at 4.5 hours long, almost all of which was spent standing in just a few places. You could sit down if you wanted, but I tried not to. I rarely thought of my feet on surgery, because I was pretty interested in what we were doing. I agree with the suggestion to shift your weight to one foot more than the other.

 

[Lacheln]

Shyrem, that is too bad. . Have you seen/tried insolias? A couple of my friends swear by them, especially now that they have insert versions, which make them vastly more affordable.