Dad + Doctor

You might think that medical training would be a great asset to any parent.  Docs are trained in all kinds of cool things like Heimlich maneuvers and laceration suturing.

Heck, if the wife got pregnant again (Nope…don’t even ask) and went into early labor, I bet I could spread out a shower curtain on our living room floor and just take care of everything right there.  Noo problem.  Doctor DAD!

But when does all that stuff actually happen (and do doctors anywhere really suture up their kids by lamplight in the kitchen anymore)?

What does happen to the kids much of the time is some thing or another that COULD BE TERRIBLE.  Everybody, even the cat, knows the incident, or symptom, etc, might be the end of famSW101 as we know it.  What the untrained blissfully don’t know…is JUST HOW TERRIBLE it might be.

So, in essence, the only difference between a doctor-dad and every other non-medical dad, is a stupefying knowledge of all the evil possibilities that could be behind a kid’s latest symptoms.

Headache for a few hours, some fever, woke up disoriented?  What do you think, honey?

Um.  Well.  Probably meningitis.  Have you ever seen a child die of meningitis?  We’ll be lucky if she keeps her limbs.  Could be coupled with flesh-eating bacteria, too.  Hopefully at least some of her face doesn’t rot off.  We may not even recognize her…if she miraculously survives the ordeal.  It’s ok, though.  We’ll still love her.  Help her set up a profile on Matchmaker.com even though she’ll be totally deformed.  Some saint of a man will learn to love her, unconditionally, like we do.

OR, saaay, it could be an absence seizure.  Maybe the first of many.  Maybe she’ll slowly have progressively worsening seizures until some galactically-renouned neurosurgeon implantes a permanent zaptrode into her medulla oblongata and calms the seizures but unfortunatley makes her arms twitch at 0.5 second intervals, often causing her to smack her own face.

“Probably just a cold, dear.  Check her every once in awhile, and keep me posted,” like, every 8-10 minutes would be nice, at least until I get home from work so I can sit at the foot of her bed chewing my nails down to the carpel tunnels until the last moment before I’m due back at work tomorrow.

Since the day I simultaneously got fired and quit my job (aka graduated, but that’s such a boring designation), I have been much more “Daddy” than “Doctor”.  Of course, this mostly has been great.  Lots of “back-ee-ball” with one particular boy.  Trips downtown to fairs and toy stores.  Swimming pools, squirt guns, stories.  You know…Dad-kid stuff.  Some good catch-up after 3 years.

Today, I got to take everyone to gymnastics.  Excellentcool.  I’m always working at this day and hour when not subsisting on the dole.

All 4 kids have their own class.  Each is good at particular things and they ALL have a blast.  10 minutes into it today, however, I see from the Parent Stadium, my 7 year old crying and sitting on the mat.  The instructor picks her up and carries her over to the parent area.

No problem.  She’s one of the more melodramatic.  We’re good.  All good.  Everything’s good.  I’m fine.  I’m FINE!

I saunter up to my crying daughter – James Dean vibe gushing in all directions – and find that she somehow hurt her knee.  Not sure how.  Didn’t bang it…probably.  But it’s so bad, she can’t bend it, walk on it or use her foot.  Instructor gets me some ice and goes back to her class.

Really?  You can’t walk, or bend it at all?  Like, at all?

Turns out she can, in fact, bend her knee…but every time she does, she screams in pain.  The noise she makes should be built into father-specific alarm clocks.  Set that thing to belt out a child’s scream of pain…and you could show up to a tax-code seminar at 4:30 am with a slight twitch and the retention capacity of a SETI cloud-processing computer.

Daughter is crying both because of the pain, and because she doesn’t get to climb the rope – her favorite exercise (because she’s the only one in the family that can do it).  Daddy knows Daughter would never miss rope-climbing.  You could nail-gun her leotard to the balance beam, and that kid would wriggle out of it and happily climb the rope freak-naked if she needed to.  For her, gymnastics is the rope.

And she’s the one who notifies me that she won’t be climbing the rope today.

*Sirens*

*Red Flags*

*Cow Bells*

*60′s ‘Nam Choppers overhead*

So the poor crying girl is immediately subjected to a bunch of physical exam tests that really should be reserved for the likes of LaDanian Tomlinson or Landon Donovan.

I try to get her to walk (she bawls).  I check her gait (more bawling).  Tippee-toes.  Squatting.  I look for knee effusions (more crying, sorry sweetie), patellar tracking, joint-line tenderness, patellar grind test (she loved this), Valgus/Varus stress tests, McMurray, Lachman, A/P drawer, pivot shift, Nobel’s, Ober’s, Wilson.

None of this, alas, helped with the tears.

Did she blow out her knee?  ACL maybe?  At 7?  She’ll need a walker by 35! Maybe the PCL.  You can usually walk on those and she’s moving around a bit.  Maybe bursitis, or one of the collaterals.  Compartment syndrome?  Nah.  What about a fracture?  Maybe.  Could be.  Jeez, she’s gonna need pins!  Oh!  Didn’t even think of gastrocnemius tear…poor kid! Or meniscal tear.  What about Plica syndrome…I don’t even remember what the heck that is, but maybe she’s got THAT!

I held her in my lap through the whole lesson.  Then I carried her out to the car afterward.  Once home, wife and I set her up with ice and Motrin (anti-inflammatories).

A few minutes after she settled into her at-home field clinic, she starts crying again.  OH NO!  It’s really starting to hurt.  Something terrible really did happen.  Oh, my beautiful child will never run again, maybe never walk.

“Where does it hurt, sweetheart?  What’s wrong?  Why are you crying?”

“I’m so BORED!”

“You’re bored.”  My eyes droop a bit.  I cross my arms.

“Can I puh-leeze get up now?  I had to sit all through gymnastics too.”

10 minutes later, the kid is throwing her brother’s basketball and chasing moths.  Her knee still hurts, to be sure.  But only a little.  She fully plans on climbing the rope next week.

Residency was tough, yes.

But this is why I’m losing my hair.

Twisted Knee – What I Did

Here’s a follow-up to the case about the twisted knee (read about it here, if you want the background):

Options for treating and working up the guy’s knee included simple stuff like rest, ice and a knee immobilizer. Additionally, my fantabulous American health care system gave me the options of providing the pt with a CT or MRI, Xray and/or referral to a orthopedic specialist. I also could have mentioned that skiing and any other sport involving coordination + velocity should be bypassed from that moment forward.

I picked R-I-C-E, first and foremost. R-est, I-ce, C-ompression and E-levation tend to cover a multitude of musculoskeletal injuries. I put a knee-immobilizer on his leg, which really does little for the joint other than force it to stay still, which leads to much less pain, which leads to less involuntary muscle flexion, which might help healing but helps the pain for sure. Finally, I prescribed clinical-strength anti-inflammatories. I did not get imaging or send him to a surgeon.

It has been about a week now, and he is doing reasonably well. It will be a long time until he forgets to think about his knee when he is doing any sport. He may never have perfect use of his knee, although I still expect a full recovery at this time.

MRI is considered the gold-standard for knee (and joint) injury. But a good physical exam by a real smart doc (jury’s out on me) is statistically just as likely to identify joint pathology. When I started med school, this ohooollldd doc gave us a lecture on the physical exam. I can see why they picked this guy for the lecture because he stood up there growling for an hour about how he could diagnose pathology just as well as these “young docs who don’t know nuthin’ except for how to order more technology.”

“You can learn all you need to know just from the physical exam.” He said often, before falling asleep and asynclitically engaging his coffee cup.

His dictum is less true when it comes to detecting early cancers, etc., but he is right to some extent. We use more imaging than we need to, and it contributes in a small way to the higher cost of medical care in America. This patient is recovering as fast as can be expected (that is to say, sloooww) under the circumstances. He probably wouldn’t heal any faster with surgical intervention, either. He just needs to wait it out.

And I hope he keeps skiing.

You Be The Doc – Twisted Knee

Below is a case I saw recently that challenged me. You be the doc and tell me what you would do. In a few days I’ll describe the plan I settled on with my patient:

The Story: Young man, approximately 30 years old. Exercises regularly, in very good shape. Recently was skiing and tried to swerve. His left ski continued in the same line but his body and the other ski turned more than 90 degrees to the right. Before he could right himself, he heard an audible “pop” in his left knee, and then he crashed (I asked if the wipe out was at least cool…he said no, it was slow and goofy. He was barely moving). When he tried to get up, he felt excruciating pain in his knee and throughout his whole leg. He was barely able to get down the hill and could hardly walk to the car. Conveniently, someone else was driving home.

He came to see me on crutches, nearly incapable of putting weight on the knee. The accident happened approximately 24 hours prior to seeing me. He said the knee did not swell dramatically and that some motions hurt intensely and others weren’t so bad.

The Exam: The knee looked almost totally normal compared to the right one. I couldn’t see any swelling and couldn’t make fluid waves by bunching up the skin and tapping on it. The lateral (outside) and medial (inside) edges of the joint were not painful to pushing. The patella (kneecap) and the ligament that holds it in place were aligned well and not tender. There was no laxity in the tendons and I couldn’t push the lower leg in and out (called the drawer sign).

However, determined to cause him massive pain in some way, I succeeded by holding his foot at the sole with his leg extended and twisting like I was turning a faucet. The pain was so bad he broke into a sweat, got out of breath, and gave me a seriously murderous look. The pain was equally bad rotating the other direction. Most other motions of the joint did not cause pain but there was some stiffness.

The Choices: Here are some of the things I considered for a plan:

A.) MRI
B.) R-I-C-E. This is the acronym for Rest, Ice, Compression, Elevation
C.) Knee immobilizer
D.) Xray
E.) Referral to orthopedics for eval and probable surgery
F.) Narcotic pain meds + B
G.) Non-narcotic pain meds + B
H.) All of the above
I.) Tell him to learn to ski better and not be such a clutz (KIDDING, kidding, didn’t really think this about the guy…I’ve bailed like an idiot more times that I can count on my surfboard)