Okay, so today was really day 2 in the burn unit, but I was tired yesterday, and fell asleep before I had time to post.  But day 1 was certainly more post-worthy that day 2... so we're just going to pretend.

I chose to do a rotation in the burn unit this year, because I did a rotation last year during surgery, and really loved it.  I chose to do one last year because I thought I was going to hate it.  Burns are one of those things that I was always afraid of, that seemed kind of mysterious, and seemed almost "beyond medicine", beyond help.  But during my month last year, I came to enjoy the surgeries, the medicine of taking care of burn patients, and the progress you can make with a burn patient, albeit slow, that gives them back a normal life. 

So yesterday, I headed up to the BICU (burn ICU) at the time I was told to be there, ready to jump right back in where I'd left off almost a year ago.  I was met with a situation I hadn't experienced last year.  Not only was I alone on the unit (there was a 3rd year med student, but neither the PA's nor physicians had arrived yet, but we had a patient who had come in overnight that they needed some direction on.  Normally this wouldn't be a problem, except this was a situation that I could do NOTHING about.

Overnight (around midnight), a patient came in after being pulled from a mobile home fire in which his home was burned to the ground, and he was pulled out by fire fighters after being found right inside the front door.  He made it from the ED up to the burn unit, but he had a "nonsurvivable injury".  Over 93% of his body had full thickness (3rd degree) burns.  He required a surgical airway in the field to ventilate him, his face was completely burned, part of his feet had been burned off.  The only part of his skin that remained intact was a portion of one arm and flank.  There is a score that we calculate that determines, based on age and percent burn, what the likelihood of death is in a burn patient.  His score was 149%, meaning there is a 149% chance of him dying from these injuries.  Given modern burn care, we actually can save people up to 120%.  But he was well beyond even that.  He we kept alive with comfort care while they tried to locate family, but after hours and hours of trying, we were not able to contact them.  Eventually, it was decided that it was inhumane to continue to keep him alive, and support was withdrawn.  He passed away less than an hour later. 

It's something to see, a person with injuries like that who is still alive.  The truth is, he would have lived a bit longer if we'd continued care.  But he was in excruciating pain.  And the body simply can not heal such huge wounds.  Infection, organ failure, fluid loss, huge metabolic needs; any number of things would have eventually taken his life. 

When I was in the BICU last year, we didn't have a major burn come in during the whole month (meaning >60%).  I hope we don't have another one for the rest of the month.  Today, we saw many more manageable cases.  People with smaller burns that we can treat, heal, and give back normal lives.  It's extremely satisfying to take a patient that, without care would most certainly die, and take them to the point that the only way to tell they were burned is to see the scars. 

I'm sure there will be many more stories over the next month, hopefully of success.

In the mean time, I'll leave you with some lessons learned on burns.  Please, heed this advice.  It's based on 2nd hand experience.

Don't, ever ever ever, smoke while wearing oxygen.
Don't burn the fringe off cut off jeans... while they are still on your legs.

Stay safe!
Kari

I have quite a busy day planned!  It started with a trip to Lowe's, and the farmers market, and now I'm getting ready to go to a rugby game, then heading out for a run, then going to the football game (or maybe dinner with a friend... not sure yet!)!  And it's a BEAUTIFUL (although a bit warm) fall day!

So, after going to Lowe's, I decided I needed to stock up on produce for the week.  I love going to the farmers market because there are lots of interesting people, I can get basically anything I want or need, it's all local, fresh produce, and it's cheap!  Today there was a crafts festival also, and the place was crammed!  I don't think I've ever seen it so busy.  But it was definitely to my advantage, as there were all sorts of new stands I hadn't seen before (breads, cupcakes, goat cheese, chicken, tree nuts).  I'm going to try to make it a weekly outing, at least until winter :)

Today, I got squash, zucchini, three sweet potatoes, red potatoes, a couple bunches of broccoli, a dozen eggs, a loaf of fresh bread, and a huge apple muffin for under $20! 

And then, I came home and proceeded to promptly drop my brand new light bulb from Lowe's onto the floor, where it shattered into 4500 pieces.  Whoops. 

And THEN, I made a delicious egg sandwich with my fresh loaf of bread, farm fresh eggs, and a slice of cheese I already had in my fridge.  And it was delicious. 

As people who race bicycles go, I am NOT the most coordinated of the lot.  You'll never see me cross a finish line with both hands in the air, my left had rarely leaves the handlebars, and while I can ride around all day with my right hand in the air, if I hit a bump, it'd better be ready to save the day from a wobble and crash.

Taking all of this into account, I have had one (maybe two...) not so awesome experiences with refueling during rides.  These include chugging down a big glob of undissolved electrolyte "beverage", and disasterously finmbing a stramberry Gu, resulting in strawberry Gu all over my hands, shifters, cables, stem, and tire, which, PS, is not easy to get off.  Gross.  So, with these various catastrophes NOT making my rides more enjoyable, I went on a quest for something that would provide adequate fuel, taste good, and not make a mess if fumbled.  Enter: electrolyte "gels".  There are many many brands, and I tried lots of them.  Two of my favorites, in texture, flavor, effectiveness, and ease of eating/access are Gu Chomps and CarbBOOM energy chews.  I've had more experience with the CarbBOOM chews, so I thought I'd throw them up in the Gear section, and give them the props they deserve.

I'm coming to the end of my orthopedics (foot/ankle/trauma) rotation.  In the past 4 (almost) weeks, many people have asked or assumed that I'm going into orthopedics.  Some are surprised, some not so surprised, when I tell them I'm actually going into Family Medicine and want to do Sports Medicine.

For those of you who have not known me since I was a youngin' (or, in high school I guess), orthopedic surgery was kind of the plan since I decided I wanted to go into medicine.  That was also the plan as I started medical school.  I was never really interested in the spine/joint replacement side of orthopedics, but really liked musculoskeletal medicine, trauma, and sports medicine.  I think a lot of it comes from orthopedics being very mechanical, and very logical.  But as I went through the first two years, and into third year when we started doing rotations, I realized that I also really liked patient continuity (not that that really surprised me), taking care of everyday problems, and getting to know patients and being able to at least address all of their problems and concerns.  I also discovered the world of primary care sports medicine.

Prior to coming to medical school, I thought the only way you got to take care of athletes was to be an orthopedic surgeon.  I'd never though about all the other stuff that athletes need that doesn't fall into the realm of things that orthopedists take care of.  But as I rotated through family medicine, got to know some of our primary care sports medicine docs, and spent time doing event coverage with them, I realized that I was incredibly comfortable and happy in that setting.  It gave me all the musculoskeletal medicine I liked, the acute sports injuries, but also the ability to take care of concussions, heat illness, normal illness in an athlete, nutrition, conditioning, and also leaves the flexibility to take care of normal family medicine patients.

Now, don't get me wrong, I still definitely enjoy the actual surgery part of orthopedic surgery.  And on some level I know I will miss not being able to take care of patients from injury through complete recovery (if their injuries require surgery).  I also think that I would probably be a pretty good surgeon.  But I've figured out over the last couple years of trying to make this "career" decision, that no matter what I choose to do, I will have to give up something I know I would enjoy doing.  But, unfortunately, I can't do EVERYTHING.  Fact.  Sad, but true.  So the question became, what will I miss less?  Will I miss surgery less, or will I miss family medicine/patient continuity less.  And I decided that I would rather give up the surgery than give up the ability to continue to take care of every day medical problems. 

I don't want to be the doctor on the sidelines who gets called to the stands for a spectator whose passed out or had a seizure, or is having a heart attack, and have no idea what to do.  It's important to me to have the skills to take care of people, not just injuries.  I know that if I did orthopedic surgery, I would miss being able to take care of everything else, being able to be the one person who takes care of a whole patient.  I know that as a sports medicine doctor, I want to be able to take care of athletes of all ages and abilities, through many injuries and illnesses, and during different times in their life.  And I'm confident that this is the decision that is right for me. 

Sometimes, I get twinges of sadness that I won't be in the OR once I finish my training...

And then I spend a day in clinic, an evening on the sidelines, and I get over it.

This weekend, I put my new CamelBak M.U.L.E to work.  I also just spent about 27 minutes googling "M.U.L.E" because I figured it had to stand for SOMETHING (seeing as there are periods after each letter...), but I came up with nothing.  Disappointing. 

Apparently, in the world of trauma orthopedics, it was a slow weekend.  Which, for me, means that we finished both our cases by 9:30, I got coffee with my attending, and have time to write a blog post I have been avoiding for a long time.  So, here it comes!  We are about to delve into the world of chronic pain...

Chronic pain, and the narcotic use and abuse that comes along with it, is one of the most difficult things to manage in medicine (according to me).  Patients with chronic pain don't fit into one box, although I think a lot of times we try to put them all into the same one.  These patients are as varied as patients without chronic pain in all of the things that we tend to label patients for: noncompliance, motivation, obesity, comorbidities, disability, job status, tobacco and alcohol use.  When someone comes in complaining of chronic pain who works a white color job, has never smoked, exercises regularly, has followed all the recommendations doctors have given them, and has never lost a prescription for vicodin, we tend to trust them.  When someone comes in complaining of chronic pain who is on disability for back pain, smokes a pack and a half a day, eats cheeseburgers, and calls in the middle of every month for a refill of oxycodone, we tend not to trust them.  Right or wrong, good or bad, that's how it tends to be.

Taking care of a patient with chronic pain means you are trying to accomplish a number of things in an undoubtedly frustrated person.  You're trying to treat their pain, prevent addiction to narcotic medications, give them as much of a functional lift as possible, treat their other medical problems, set out clear expectations and boundaries, and identify treatable sources of pain (ie treatable by means other than pain meds). 

The problem with treating pain is that there is no way to monitor how well the treatment is working, or how much pain a person is "really" in.  The end goal, one would hope, would be to control pain enough that a person could function normally, without being too zonked by pain meds, and without being in too much pain to do the things they need to.  This is a difficult balance that is dictated by the amount of pain, a person's pain tollerance, their motivation to do normal function, the kinds of pain medications they are on, their dependance to the medication, and any secondary gain that is always a concern with narcotic medications.

As I see it, these are the major complicating issues in pain treatment:

People have different pain tollerances.
People have different motivations.
Some pain medications are controlled.
We can't measure effectiveness by anything other than patient report.

These are the questions I ask myself when considering treating someone with chronic pain:

Who am I to judge how much pain they are in?
What kind of meds are they on, and what have they tried?
What is the source of their pain?
Is what we're doing helping?
Is there an end in sight?

And these are the tough questions that make me think I will be very conservative with pain medicine when I actually can prescribe it.

If narcotics aren't working, why keep prescribing more?
Is it my responsibility to refill their meds if they keep "losing" them?
If their functional status doesn't change with pain control, what's the point (ie why are they on disability)??

I realize that some of this makes me sound jaded, or mean, or whatever.  That's part of learning the balance, I think.  Patients have real pain, and need real treatment.  But it's important to give them realistic expectations of how much you can help them.  For the most part, patients with chronic pain will never be pain free.  There are lots of people in the world who live in pain every day and live normal, productive lives.  I think that is my major hang up with the whole pain thing.  If you're going to be in pain doing stuff, or not doing stuff, why can't you do stuff?

That's what it boils down to for me.  But that is coming from a person who likes to do stuff.

So, will I treat chronic pain, prescribe narcotics to patients when I'm actually a doctor?  Sure.  But I imagine I will lean on the more conservative side than some people.  This very well may change as my time in medicine moves on.  But I think setting boundaries and sticking to them from the start is important for both the physician and the patient.  That way, if/when a situation progresses to the point that the physician is concerned that there may be dependance, abuse, ineffectiveness, or secondary gain, there are established rules to fall back on. 

How do the medical and the non-medical people of the world feel about this issue?  Should doctors give pain medications freely without question to patients who request them, or should they be restricted?

Weigh in!

... Sort of.

So this was the general plan for the weekend:  Wake up Saturday, drive to Whitetop, VA with my cycling friend, Chris, and his wife Erin.  Set up camp, unpack, then drive to the start of the VA Creeper trail.  Ride.  Ride some more.  Maybe stop for lunch.  Finish riding.  Go back to camp, eat some tasty dinner, shower, do camping-like stuff.  Wake up Sunday, eat breakfast, pack up camp, do a little hiking, drive home.  And that's pretty much how it went... except I spent a LOT of time distracted, and not taking pictures.  Sorry.  Here are the ones I did take!