Medical School 2020, Year 2, Week 25

From our anonymous insider…

Musculoskeletal week features 14 hours of lecture.

Monday morning, A nerdy early 40s orthopedic trauma surgeon discusses osteomyelitis (bone infections) and infectious arthritis (joint infections). An infected bone or joint requires surgical debridement to remove the infected tissue. “Antibiotics cannot penetrate this avascular infection. Ubi pus, ibi evacua. The age-old mantra. One of the most satisfying things is taking pus out. You go in and leave it better than they arrived, period.” Students’ favorite part of his lecture: “A classic case of chronic osteomyelitis is a WWII soldier who was shot. The bullet seeded bacteria that was walled off by his immune system from the healthy tissue. 45 years later in the soldier’s old age with a depressed immune system, the infection activates.”

A lively 50-year-old pediatric orthopedist presents childhood muscle and bone disorders. Her practice involves improving gait and balance in movement disorders such as cerebral palsy. She does this by using braces, botox injection into certain muscle groups, and tendon release/transfer.

Cerebral palsy, present in about 2 per every 1000 live births, is a “non-progressive movement disorder caused by ischemia to the developing brain, typically in utero but also in early childhood. Example ischemic events include a cord wrapped around neck of baby in utero, stroke or a near drowning event. “When parents hear CP, they immediately picture a wheelchair bound, drooling, not functional child. If the anoxic event covers the entire motor cortex, then yes. But, more often CP deals with specific muscle groups. Some just have an issue with a few toes. CP is a spectrum.” She explained how cerebral palsy a common malpractice suit. “If your baby has cerebral palsy, call us to sue your Ob/Gyn. It is not always the obstetrician’s fault. 70 percent of events are thought to be prenatal.” 50 percent of CP cases have a history of prematurity. “Interesting the advances in prenatal care have not improved the incidence of CP.”

[John Edwards, the 2004 Democratic VP nominee, had a pre-Senate career as a plaintiffs’ lawyer suing physicians in cerebral palsy cases, At trial he would channel the words of the unborn child for the jury’s benefit. Expert witnesses hired by insurance companies defending these lawsuits would explain that there was no scientific basis for holding the obstetrician responsible, but the juries would often award millions in damages. Attempts to set up funds to compensate all cerebral palsy victims, not just the ones who sue, have been fought by trial lawyers. Edwards was a candidate for the 2008 Presidential election, but his campaign was impaired when a former campaign worker gave birth to his child and funds needed to be diverted to keep the new mother quiet. (She could have sued for child support in North Carolina, but the revenue obtainable through conventional family law is limited compared to in California or Massachusetts.) Edwards was criminally prosecuted by the U.S. Department of Justice for this diversion of funds to Rielle Hunter, but a month-long trial resulted in a mistrial on most counts.]

Our orthopedist lecturer showed a before-and-after video of her 10-year-old patient with cerebral palsy. The child initially had limited mobility, walking on his toes with a scissors gait. “Everything was tight. I was giving regular Botox injections, but those were having diminishing effects. I performed an adductor tendon release and transfer.” After the surgical intervention and physical therapy, the class could not discern any gait abnormality. “This child will not be able to compete in sports, but he’ll live a relatively normal life. Remember that cerebral palsy does not spread; we call it a static encephalopathy.” Several classmates were astonished about the tendon transfer surgery. Jane: “We can do that?”

She concluded with some career advice: “Do not assume children with physical impairments have mental impairments. Just because their body is failing them does not mean their mind is failing them too. And when you choose a specialty, think whether you are improving the quality of your patient’s life, or just prolonging their suffering.”

Our third lecturer: a surgeon specializing in nerve reconstruction presents on upper extremity nerve injuries. Type-A Anita, an aspiring Ob/Gyn, exclaimed in horror about nerve injuries during delivery: “That happens? We are barbaric!” Erb’s and Klumpke’s palsies occur if the infant’s head is placed in extension or if the infant’s arm is placed into abduction (away from body), respectively. “If the kid regains elbow flexion in three months, there is a good prognosis that he or she will fully recover.” The surgeon explained that it is possible to do nerve transfers. “We can get back elbow flexion and shoulder range of motion. Animation of the hand and wrist are still extremely difficult.”

Gigolo Giorgio ask about the potential role for nerve scaffolds in the future. “It is here! We use it today, keratin scaffolds, pig submucosal, cadaver scaffolds. And some people are starting to use nanotechnology to implant growth factors and such. That’s above me, I’m just the mechanic!”

Two sports medicine physicians held workshops on common musculoskeletal injuries using X-rays, CTs and MRIs. “Knee dislocations used to be caused only by severe trauma such as a football injury or car accident. We now are seeing low-velocity knee dislocations. An obese individual will step off a curb, and the momentum of the body on a fixed tibia will posteriorly dislocate the knee. Really no good surgical repairs for that so far.”

After lecture I attend the weekly “quarterback” meeting where rotating students air concerns and complaints about the curriculum to the block director. Students complain that lecturers get off-topic following questions from unprepared students. Mischievous Mary and Geezer George cited infractions from students who did not know the anatomy of the brachial plexus (nerves innervating the upper extremity). “I do not go to lecture because of it. It is more effective for me to use that time studying in the library.” George: “There is something wrong when some of the best-performing students do not go to lecture.” Several students tried to show their maturity relative to others in the class. A student recommended that two or three lectures be highlighted each week that require preparation. Mischievous Mary and Geezer George lept on it saying “we are not kids, if you did not prepare just shut-up during lecture.”

Wednesday morning, our sixth lecturer: a 50-year-old orthopedic surgeon lectures on bone diseases. Osteoporosis, and its precursor osteopenia, are diseases of disordered bone deposition resulting in decreased bone mass density [BMD]. “Your bone mass density peaks in your late 20s, and continues to decline thereafter. Moderate weight-bearing exercise is the most effective way of to raise your peak BMD, and to decrease the decline of BMD after your glory days. Moderately overweight individuals actually have stronger bones because they load their bones with more weight.” (He may be taking his own advice here; Pinterest Penelope described him as “tubby.”)

Why is osteoporosis bad? “The weak bone from osteoporosis is prone to fracture from normal weight-bearing activities and falls. People with osteoporosis can spontaneously fracture their vertebrae with no injury at all. Someone who falls on their butt or side should not get a fracture. One-year mortality after a hip fracture is 30 percent. This is not something you just put a screw in it and be done with. Yet, our medical system does not think about bone health. I see so many patients who have been on glucocorticoids on and off for asthma. [chronic steroid use causes osteoporosis.] They have terribly weak bones in their 50s. Frankly, there is nothing to do about it now.”

Thursday morning the whole class turned out to hear the last orthopedist lecturer, Hot Shot, a spine surgeon known for being one of the most highly compensated surgeons at the university.

“When the spine is injured, it shuts down. This is called spinal shock. Reflexes will be absent, even if the connections are not broken. You cannot assess the spinal cord injury level until spinal shock is over [2-3 days].”

Hot Shot explained why he choose Ortho: “I never wanted to do a rectal exam again. Boy, was I wrong. As a junior resident — that’s the guy in ER — my attending would tell me every single trauma case gets a rectal. If you do not do it on the patient, I will do a rectal exam on you.” He explained that every trauma patient should have a bulbocavernosus reflex test to assess the spinal cord integrity. This reflex is elicited by applying pressure to the glan penis or clitoris (or tugging on a Foley catheter), and feeling for increased anal sphincter tone.

Gigolo Giorgio asked whether spinal shock could be shortened by steroids. “We do not know what causes spinal shock. Like most things in medicine, our understanding is observational.”

After lunch, two state health department epidemiologists lead a workshop on an example hepatitis C outbreak. The senior epidemiologist begins describing the case: “I got involved after two or three calls from EM physicians diagnosing acute hepatitis from a new hepatitis C infection.” Hepatitis C is reportable disease in most state, meaning every physician must report the case to the health department. She scheduled a private meeting in a McDonald’s parking lot with one patient, a 25-year-old male college student. “Fast food parking lots are a good meet-up location. People want to remain anonymous.” (This is apparently an occupational hazard; the 55-year-old woman weighed at least 180 lbs.) The patient reluctantly explained that he visited a nearby college for an Ultimate Frisbee competition and “raging” party. Alcohol, cocaine, marijuana, IV drugs were all used. The patient explained, “There were a few tattoo artists hooking people up. I got a small one. I do not even remember it, I was so wasted.”

The junior epidemiologist, a 40-year-old with pink and purple hair, interviewed two other patients, including a married graduate student who had sex with several partners at the party. This patient provided contact information for one of the tattoo artists. The tattoo artist was an herbal medicine enthusiast in her 40s who claimed to use a homemade needle-cleaning machine. After interviewing 10 people (providers and patients), the epidemiologists completed their case report, estimating that, between tattoos, sex, and IV drug use, 200 people were exposed to hepatitis C.

[If the Editor were qualified to work in a state health department, the report would read “People spent 85 percent of their time at the party having sex with strangers, getting tattoos while too drunk to remember, and injecting recreational drugs. They wasted the rest of their evening.”]

We go to our small groups. Straight-Shooter Sally: “[The epidemiologists] seem so cynical.” My facilitator, a 45-year-old EM physician who stopped practicing seven years ago after she gave birth to children, but is trying to study for her boards now: “Everyone who works in the ED becomes cynical. Part of it is your job training, you are supposed to see the worst in everyone to not miss anything. Part of it is just who you are dealing with. Some people just think different. No shame in taking advantage of the system. For example, I had a patient with a connective tissue disorder who would keep coming to the ED every few days. He would purposely dislocate his shoulder to get Dilaudid (hydromorphone). In residency we had this homeless couple who would come in once a week, matter of factly state they were contemplating suicide knowing they would have to be admitted. They would get ‘two hots’ [warm bed, warm meal]. The male was a registered sex-offender so he was not allowed to go to homeless shelters. Instead he was surrounded by children in the ED.”

Straight-Shooter Sally gives a 20-minute presentation on tobacco cessation. She presents the findings of a “landmark study” (“A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation”, NEJM, 2009) in which people who could receive $750 over a one-year period were three times more likely to quit. All of us have seen COPD [chronic obstructive pulmonary disease] patients during our shadowing. They can barely walk, but they still smoke. Might they be more likely to quit if Medicare or Medicaid didn’t pick up nearly all of the cost of their care? Type-A Anita shut the question down: “No, people would die.”

I shadowed my family medicine physician mentor that afternoon. Regarding the first patient, a 54-year-old male with chronic hepatitis C infection, my attending says, “Ask him about his alcohol intake.” I ask, “Sir, how much alcohol do you drink per week?” He responds, “A bit.” “What do you mean by a bit?” Patient X: “Well it depends on the day. I have a few beers most days. If there is a football game on, at least a six pack. If there is a NASCAR race, then at least 12 beers.” The attending came in, explaining”We cannot treat your Hep C until you quit drinking.” Patient responds: “Doc, I cannot. NASCAR is coming up. I… I… I just can’t. After NASCAR season we can talk.”

Our patient case: Elizabeth, a 22-year-old female diagnosed with spinal muscle atrophy (SMA) at the age of 2, presents for excruciating hip pain and lower back pain not managed by her pain medications. She has had two spine surgeries for scoliosis and three hip surgeries to prevent hip subluxation (partial dislocation) that are common in SMA due to muscle deterioration.

SMA is a genetic disorder where a defect in the survival motor neuron 1 (SMN1) gene results in progressive loss of the anterior motor horn neurons in the spinal cord that innervate muscles. These muscles begin to atrophy causing joint weakness, joint instability, and pain. Elizabeth’s neurologist explained: “If you ever see these patients, your heart will break. They have full cognition, full sensation. Their minds are trapped in their bodies.” (Don’t go to North Dakota if your heart is easily broken; SMA prevalence there is 3-10X more common than in the rest of the U.S.)

Elizabeth: “I was quickly put in a wheelchair. I have a less severe form of SMA, but I still work hard on PT to maintain my function.” Her 55-year-old mother added: “Elizabeth of course needs help going to the bathroom, putting clothes on. She cannot rotate herself from one shoulder to the other while she sleeps. You cannot imagine how difficult it is to try to help your child in the middle of the night while she screams out of pain from you touching her.”

Elizabeth has minimal strength in her arms and legs. Her atrophied back muscles cause severe spine deformities. These have required three separate spine and hip surgeries within two years. She is unable to walk.

“I enjoy therapeutic horseback riding and training service dogs,” continued Elizabeth, who had brought her enormous shaggy service dog. “Service dogs are not pets. They are medical equipment.” The Bernese Mountain Dog helps pick up and carry items and also prevents depression. “Emotional support dogs are a fraud. I go shopping with my mother and one time a dog wearing a service vest started barking at my dog who was working on a task for me. The owner did not even apologize. It was fake. Emotional support dogs are ruining things for people who really need service dogs.” (Type-A Anita blushed. She has been obtaining emotional support dog documentation to facilitate flying her black Labrador puppy to fly home during upcoming vacations. Nearly all of the couples in our class have been adopting puppies lately and getting together at a local dog park.)

[Editor’s Christmas gift idea for Anita: “Black Labs Matter” poster, with optional yellow Lab holding an “All Labs Matter” sign.]

What did Elizabeth wish people knew about the disability community? “People with disabilities are not stupid. I still have a brain. When I am at the grocery store with my mom, people come up to us and ask: ‘What is her name?’ My mom just turns around and ignores it. I respond, ‘I am right here!'”

Mischievous Mary asked the mother how she learned about the diagnosis. The mother, today in her late 50s explained, “I have two older children. I knew something was wrong with Elizabeth quickly. I kept bringing her to the pediatrician because she was missing her milestones. The pediatrician brushed them aside and said she would be fine. ‘She’ll be sitting up in no time.’ I called a doctor who is a family-friend. He agreed that something was seriously wrong and scheduled an an appointment with a neurologist. The neurologist called with the rest results one evening while my husband was out with the kids. I was all alone as he said, matter of factly, ‘Your daughter has spinal muscle atrophy and will not live for more than five years.’ I do not remember what happened for three days after that. I had a nervous breakdown.” (Straight-Shooter Sally afterward noted that it was possible that the doctor had good intentions, citing an HIV patient’s doctor who called the patient at home so as to avoid a public scene in the medical office.)

“I hated people after that phone call,” the mother continued. “I hated anyone who had a healthy child. ‘Why me?’ I would ask. When I went to my oldest son’s basketball games, it would knock me down seeing these healthy kids and their happy parents in the stands. It sounds terrible to say, but when my sister had a healthy baby girl, I hated her too.” She continued: “I dropped everything and devoted my whole life to my baby. This destroyed my marriage. I regret this, but my marriage was destroyed by my daughter.”

There is some hope for SMA patients. Elizabeth’s muscle movements improved dramatically after starting nusinersen (Spinraza), an orphan drug approved by the FDA in December 2016. “The new drug is amazing. I did not notice anything until my fourth dose. I used to have to use two hands and struggle with all my might to lift an object like a cup. One day I noticed I could pick up a cup with one hand!”

There may be even more hope for Biogen, the marketing partner for Spinraza. The list price is $125,000 per injection ($750,000 in the first year and $375,000 annually after that). The geneticist explained: “No one pays the sticker price. Most people are in a clinical trial, or the insurance company is negotiating behind closed doors to bring the price down. The only challenge I have faced is with the hospital pharmacy carrying these expensive orphan drugs. We have learned to never bill the patient. It just creates mayhem. Before we purchase the drug we get pre-approval from insurance or deal directly with the drug company.”

Elizabeth concluded by saying, “Do not listen to what other people tell you. Everyone told me I would never be able to ride a horse. I can now trot a horse all by myself.” Elizabeth goes on dates with other women and advocates for the local LGBQT community.

Friday concludes with a suture workshop. A plastic surgeon lectures on the types of sutures and various suturing techniques. Each student is gifted a basic suturing kit with forceps (“pickups”), needle drivers, and scissors. We practice on chicken breasts and a suturing model that incorporates synthetic material to mimic the epidermis, dermis, and subcutaneous fat. Mischievous Mary, an aspiring cardiothoracic surgeon, schmoozed with the general surgery clerkship director who helped with the workshop. Pinterest Penelope: “God, she was sucking up so much.” Jane and I steal a few sutures to practice at home.

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane’s father, an internist, rents a three bedroom ski condo for a nearby medical conference. Jane, her sisters, and I join for a weekend getaway. I am falling behind in my studying for the upcoming block exam.

More: http://fifthchance.com/MedicalSchool2020