Rheumination

Happy Holidays

Pine Needles

Apply Ice

In excess, freezing rain is one of nature's most nasty spectacles.  In moderation, it's one of nature's most exceptional beauties.  While east coasters hunker down and await rescue, Montrealers (who know something about ice storms) marvel at nature's work. 

Photos by yours truly

Mentors and Dementors: The Knee Jerk

 

Dementor, Dr. Marion, sucking all that's good about medicine out of a resident

I, like most first year clinical fellows, felt a little awkward.  Just removed from the great unwashed mass of internal medicine residents, I was already  supposed to  exude rheumatology-ness when interacting with colleagues I had shared call with only weeks before.  It takes a bit of knowledge, a bit of show, but everybody generally plays along.  

I saw a floor consult on my own. An older women with a painful, red, tender knee.  It was right over the knee cap and extremely tender.  I thought it was an early pre-patellar bursitis, likely gout.  Unfortunately there was very little swelling and I didn't think I could get fluid.  She was on coumadin so I didn't want to muck about just to produce a crystal or two. I ordered some prednisone with a presumptive diagnosis of gout.

The following day we rounded with the consulting rheumatologist.  There was quite a crowd, which was exceptional for the times.  Two fellows, a resident, a med student and our staff rheumatologist, Dr. Marion.  It was my first time rounding with Dr. Marion and I wanted to impress her.  She was known by housestaff to be an excellent clinician and terrific teacher.  I presented the case with as much enthusiasm as such a mundane diagnosis could muster and we went in to see the patient.  I had not had an opportunity to revisit the patient since I prescribed the prednisone so I was a little concerned that we would find a massive oozing abscess leaking from a negligently  untapped bursa.  I was pleasantly surprised to find that not only was the patient not in septic shock, but had, in fact,  had complete resolution of the bursitis. Damn I'm good.

 Dr. Marion looked at the knee, flexed it a bit and palpated it unenthusiastically, like she was testing for ripeness.  

  "Mrs Johnson, your knee is fine.  There's nothing wrong." she said without discussion.

I thought it was a rather curt way of discussing the diagnosis but hey, I'm only a fellow.

  "We can stop the prednisone" said Marion.

"Do you want to taper it over a week ?" I asked.

 "No, just stop it, it's nothing."

Getting the gist of what she was saying, but not understanding why, I reminded her that just yesterday the knee was red, hot .

"She probably just had her legs crossed"

Beautiful.

Dr. Marion was telling me, with all the gathered housestaff as witness, that I must have mistaken the redness of acute leg crossing for an attack of a gout.  Silly boy.

Our relationship never did recover, although she probably didn't notice.  Fortunately my career was already decided by then and I subsequently discovered that, among rheumatologists, this kind of behaviour is extremely exceptional.  I can't help but wonder though, what might have happened  if I were an R3 at the time, trying to sort out my subspecialty options.  Residents work with but a  few staff in each field  and every personality reflects on their specialty.  Our  path to subspecialty is a crooked one, littered with anecdote; some gruesome, some wonderful.  You have to wonder whether our eventual choice is based more on the positive mentor experiences, or negative dementor types.

Wii Rheum

At the last rheumatology conference we were entertained by the use of audience polling/questioning and instant response via touchpads provided to every participant.  A question was posed and we had ten seconds to answer.  We were then given instant tabulated results which I have to admit was fun and actually quite informative. I guess the reason for these gadgets was simply to increase our attention, knowing that we would be asked a question after the talk.  Those CME guys are always thinking up new tricks. But I think the idea could be used more effectively.   In fact, I think an entire session could simply be dedicated to asking questions about common practice choices and comparing answers. Anonymity could also provide cover for some truly revealing questions like:

If you use anti-inflammatories yourself, which do you use?

If you developed RA today, how would you treat yourself? 

If you had a prostate/breast cancer, would you take an Anti-TNF for your RA.

If you were a bone, what bone would you be?

Of course, the same could be done with a blog, but that would require actual readers and you would have to be wary of pharyngula-like poll crashing by pharmaceutical companies.

Another interesting thing about the touchpad users at the conference was the difference in age and comfort with the technology.  I don't want to generalize too much but several older rheumatologists did not play along, while some fifty-sixty-ish docs were aiming their touch pads at the screen up front like a TV remote with a bad battery.  I'm not sure but I think I saw a rheum fellow waving her touchpad at the screen, coaxing her response numbers up in Wii-like fashion.  I'm sure the CME types noticed as well.  

Rheum fellows at next ACR convention

Backs are a Pain

 I complained not too long ago about the lack of evidence to support an evidence-based clinical practice in rheumatology.  Not more than a week later I had rather dramatic confirmation of this stand.  At our latest rheumatology conference we had a guest speaker from the local physiatry group talk about his approach to the diagnosis and treatment of low back pain.  He started out by enumerating the causes of mechanical back pain and claimed that 15-30% of low back cases are of sacroiliac origin.  It's an odd feeling being told that you have incorrectly diagnosed 30% of your back patients over the last twenty years.  By the look of my colleagues, they had the same funny feeling.  So we all pretty well wrote him off.  Rheumatologists in general don't talk much about the sacroiliac joint unless it's inflamed, then we talk about it a lot. It's a big unmoveable beast that shouldn't cause  mechanical trouble.  Nobody I know would suggest treating low back pain with specific sacroiliac measures.  In a fairly recent review of back pain, a rheumatologist mentioned this joint in her differential of low back disorders and promptly got a letter to the editor rebuking her for it.  This was rebutted by a train of dissenters from around the world and from several specialties. If you check out rheumatology texts, or at least the ancient tomes that I possess, sacroiliac joints are pretty well sequestered in the ankylosing spondylitis chapters. They may be mentioned in the low back section, but nobody  deigns to expand upon the subject.  In the physiatry/chiro/spine type literature though, there is ample reference to investigations using controlled selective injections which prove not just the existence, but the regularity of this condition. 

Note, that the question here is whether a specific joint causes 30% or 0% of mechanical back pain, one of the most common complaints seen in medicine.  If we don't have that figured out, just how successful will our treatment studies be?

The Color of Phlegm

While doing my usual exhaustive research for my post on phlegm, I came upon a site called colourlovers. It is apparently a forum to discuss color, design and all things pretty so I was a little surprised to see it show up in my google search for phlegm.  As it turns out, the color creations often come with rather unique names, and the following was titled PHLEGM:

I think though that this artist has either never had a respiratory infection or he/she has a really bad one.  Much too green for my disliking.

I think Hoakie pokie has more phlegm-like potential

or maybe even "So good to see you"

or perhaps "Snooze Inducing"

I'm not really sure but I refuse to do the field work necessary to find the true colour.