physasst Posted July 17, 2014 Share Posted July 17, 2014 Sigh. Rant ahead....enter with caution. SO, I am seeing a disturbing new referral pattern recently from some of our younger orthopods. Not the senior guys, they're on top of things.... I'm getting a lot of postop total joint patients who have ongoing pain. Now, roughly 15% of TKA patients and 6% of THA patients will have chronic severe pain. If we add in any pain, it's like 44% of TKA and 27% of THA patients. There is some more recent evidence that it is closer to 30% of all TKA/THA patients will have chronic moderate to severe ongoing postop pain. The younger orthopods will see a patient, evaluate them, and tell them, "Well, it can't be your joint, because the xrays look good"......."it must be your spine"...... So yesterday, I had a patient with hip area pain that started.....wait for it......when they had a THA revision. Start up pain in the groin, anterior thigh, and lateral hip area over the incision. What's your worst activity? OH, you mean it hurts a lot when you lift your leg? The patient also complained of some mild distal toe numbness. The orthopod noted some femoral stress remodeling, but told them that the xrays looked good and that he didn't think any surgery would be of benefit. He thought that the spine could be involved and got an MRI pelvis and LS Spine. The MR, showed a broad based central disc protrusion at L5-S1 that the radiologist didn't even comment on, that slightly displaced the bilateral S1 roots in the lateral recess, but didn't compress them. The pelvis showed some T2 enhancement in the sciatic nerve that could be mechanical. Hip provocative maneuvers are wildly positive. I tell the patient, the numbness in your toes? That could be secondary to this S1 root irritation. Wouldn't do anything but some therapy for treatment (Injections don't work for numbness..) I tell them that the hip pain is absolutely, unequivocably coming from the hip. They ask me to call the orthopod which I do. His response? Well....."it's not her hip". I say, "no, it really is"..them "it's not related"....me "what are you talking about?, it started at the same time as their surgery"...them..."well, yeah, they're temporally related".....me...."yep"(thinking- that means they're related).....him...."what about that sciatic nerve root enhancement"......me.."It's not related to her current pain distribution"(thinking-learn your friggin neuroanatomy).....him.."well, I don't have any surgery to offer them".....me..."well, that's your area of expertise, I have nothing to offer her for her spine, as it is not causing this current pain, I've already had them schedule a subsequent visit with you...".....him.."(sarcastic)..thanks".....me "no problem..have a great day".... I swear...I wanted to scream.... The thing is....the older orthopods don't do this. When they have a patient with postop pain that is intra-articular in nature, they don't go fishing. They tell them that they are one of those patients that will likely have ongoing pain, and they send them to pain management...... We already have virtually every other specialty sending us any pain that they can't explain (my favorite are the GI pain patients)...as, well, "it has to be the spine" (A couple of times it actually has been with thoracic radiculopathies)......coupled with the myriad of fibromyalgia patients that are sent because of back pain.....many of them have had extensive workups, injections, multiple MRI's, colonoscopies, etc. NONE of it needed. Then they are pissed at me, when I tell them, "this is Fibro, this is not your spine...you do not need any more imaging, and I would definitely NOT recommend any more injections. You need cognitive behavioral therapy, physical therapy, and a consult for medication management with non narcotics." The point is, I don't need ortho piling on..... Anyway...needed to rant as this is becoming a little bit of a nuisance for me. Not only that, but I feel really bad for the patient, as they are basically a ping pong ball in the system, and I feel like they are being charged for a visit with me, that wasn't really needed. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2014 Moderator Share Posted July 17, 2014 yup, ortho has issues. next rant: hospitalists with no souls or common sense... Link to comment Share on other sites More sharing options...
patachok Posted July 18, 2014 Share Posted July 18, 2014 yup, ortho has issues. next rant: hospitalists with no souls or common sense... Speaking of...had a patient today with bilateral sacral decubitus ulcer, eschar present. ER folks did not say anything, while hospitalist PA managed to stage it! How in the world do you stage an ulcer, when it is covered in necrotic tissue!? My attending general surgeon was fuming mad! Even us, students, thought is was unstageable.Hope he never treats me... Link to comment Share on other sites More sharing options...
nebero Posted July 18, 2014 Share Posted July 18, 2014 Speaking of ortho, let me ask you guys a question. What is a double blind study? Sent from my SCH-I535 using Tapatalk Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted July 18, 2014 Moderator Share Posted July 18, 2014 Speaking of ortho, let me ask you guys a question. What is a double blind study? Sent from my SCH-I535 using Tapatalk 2 ortho guys looking at an EKG Link to comment Share on other sites More sharing options...
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