A Doctor’s Sick Day

So last night was rough. Most people have had food poisoning at some point in their lives and know exactly what I’m talking about. Nausea, fever, chills, vomiting, diarrhea. None of these things are on my list of favorite pastimes.   I woke up this morning trying to decide what to do. I mean, it really wasn’t much of a decision. I couldn’t possibly go to work when I could barely drag myself off the bathroom floor, but cancelling a day’s worth of patients is not a decision one can take lightly.

I have been blessed to work with good people who I know will take care of urgent matters in my absence, but my patients are important to me. Many of them had also taken time off work and altered their schedule so that they could stop in for advice and treatment, and I could picture the frustration as they were getting their calls this morning because they would have to reschedule. Consider this my apology to you as it has been weighing on me all day.

Even more frustrating is the fact that I am writing this at 3 in the afternoon and I still feel terrible. Shouldn’t this be over by now? I pushed through the early symptoms yesterday, but can I do it again tomorrow? Ugh. The self diagnosis dilemma. I am a doctor so I should know exactly what is going on. I am pretty sure I am right about what I have, but what if I’m not? Could this keep me out all week?

So here is the plan. Enough whining and worrying.  The challenge for the remainder of my sick day (or days), is to remember that this too will pass. This is but a small hurdle in a life full of hurdles that will surely be much greater than this one. And I will make it through those as well. We all need time for ourselves once in a while.

My message to my patients is the same. I know of many of you who are facing some of the big hurdles. There needs to be time to be sad and frustrated, but the challenge is to let go of your concerns, know that God has a plan, and get over the hurdle. Or through it, under it, or around it if you are not the athletic type.  And don’t forget that as soon as I can get back, I will be along with you for the ride.

Why Feet?

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One of the perks of my job is having the opportunity to meet new people every day.  With a new patient, there is generally a few minutes where we make small talk to get to know each other a little bit.  Almost without fail, I get the question, “So why did you choose feet?”  I usually joke about it being much cleaner than working with snot, vomit, coughs, poop, or genitalia.  Or I may answer with something general such as having a chance to treat a wide range of problems from severe trauma down to ingrown nails.  I love the variety and I love that there are always new skills to learn.  However, while these are some of the reasons I chose podiatry initially, over the years I have developed some new ideas on the subject that I would like to share.

Let me paint a picture for you.  When someone asks me, “Why did you choose feet?” it is helpful if you can envision their face.  Their eyes are squinty, their nose is usually crinkled up, and you can often see their top row of teeth sneering at you.  You can quickly surmise that the question they really want to ask is “Why would anyone want to deal with stinky feet all day?  Do you have a foot fetish or something?”  So let me go ahead and end the suspense in case you were wondering.  No.  I do not have a foot fetish.  And this may surprise you, but most people don’t have gross feet.  In fact, most people make sure their feet don’t stink before they come to the foot doctor.  Kind of like brushing your teeth before going to the dentist.  In fact, it is not out of the ordinary for people to get pedicures done right before coming in because they are embarrassed of their feet.  A little overboard if you ask me, but whatever makes you comfortable.  Of course, there are the exceptions.  Some people have severe infections that no amount of soap is going to fix.  There are also plenty of teenagers who just have a general “funk” about them, but you get so used to these things that you don’t notice after a while.

So enough rambling about how feet smell.  Why do I really look forward to my job dealing with feet?  I would like to direct you to a text in the Bible that will help me clarify:

 

John 13:1-17

New International Version (NIV)

Jesus Washes His Disciples’ Feet

13 It was just before the Passover Festival. Jesus knew that the hour had come for him to leave this world and go to the Father. Having loved his own who were in the world, he loved them to the end.

The evening meal was in progress, and the devil had already prompted Judas, the son of Simon Iscariot, to betray Jesus. Jesus knew that the Father had put all things under his power, and that he had come from God and was returning to God; so he got up from the meal, took off his outer clothing, and wrapped a towel around his waist.After that, he poured water into a basin and began to wash his disciples’ feet, drying them with the towel that was wrapped around him.

He came to Simon Peter, who said to him, “Lord, are you going to wash my feet?”

Jesus replied, “You do not realize now what I am doing, but later you will understand.”

“No,” said Peter, “you shall never wash my feet.”

Jesus answered, “Unless I wash you, you have no part with me.”

“Then, Lord,” Simon Peter replied, “not just my feet but my hands and my head as well!”

10 Jesus answered, “Those who have had a bath need only to wash their feet; their whole body is clean. And you are clean, though not every one of you.” 11 For he knew who was going to betray him, and that was why he said not every one was clean.

12 When he had finished washing their feet, he put on his clothes and returned to his place. “Do you understand what I have done for you?” he asked them. 13 “You call me ‘Teacher’ and ‘Lord,’ and rightly so, for that is what I am. 14 Now that I, your Lord and Teacher, have washed your feet, you also should wash one another’s feet. 15 I have set you an example that you should do as I have done for you. 16 Very truly I tell you, no servant is greater than his master, nor is a messenger greater than the one who sent him. 17 Now that you know these things, you will be blessed if you do them.

 

In ancient Israel, people wore sandals.  Everywhere.  Talk about dusty, dirty, stinky feet.  Washing someone’s feet was the job of the lowliest servant because who would want to do that?  So when someone would take the time to wash your feet for you, it was a really big deal.  Especially if that person was your superior (notice Peter’s resistance in the previous passage).  A great example of someone humbling themselves before you, if you will.  John 13:16 says “no servant is greater than his master, nor is a messenger greater than the one who sent him.”  Many of you have not had the privilege of working in a surgical specialty, but to say that there are many doctors with a “God complex” is not an understatement.  Surgeons tend to be competitive by nature.  Top that off with the way they are often catered to by staff, reps, and patients, and you can see how one can easily get a big head.  A really big head.  I love that I have an opportunity to operate at the bottom of the operating table where the feet are.  I don’t work on the head like the neurosurgeons or the heart like the cardiothoracic guys.  Every day I have the opportunity to greet people at their feet.  To humble myself before patients who come from all walks of life.  I have started to embrace the question “Why would you choose feet?”  It reminds me that I am not a hot shot doctor.  I am a servant.  Exactly what my Savior called me to be.

What’s a Lisfranc?

So for all you Tennessee Titans fans out there, I thought you might be curious about what the prognosis is for your quarterback.  Jake Locker suffered a Lisfranc injury to his right foot Sunday against the Jacksonville Jaguars in the second quarter, and the news is reporting that he is out for the season.  So you are probably asking yourself, “What the heck is a Lisfranc injury?”  Or you may be a fan of another team and are thinking, “I hope this is pretty serious.”  If that is you, then maybe you should take a break from football for a while.

The term “Lisfranc injury” pops up in the news now and again, and we usually don’t get much information other than it is bad.  Football players who have suffered Lisfranc injuries in recent seasons include Santonio Holmes, Maurice Jones-Drew, and Cedric Benson.  All of these players went on to have season-ending surgeries.

Now that we have established that a Lisfranc injury is not a good thing, let us take some time to discuss what it actually is.  Lisfranc was a surgeon in Napoleon’s army, and he developed an amputation through the midfoot in an area now known as Lisfranc’s joint.  Many of the injuries that required this amputation were from soldiers falling off their horses and getting their feet stuck in the stirrup, causing a dislocation to Lisfranc’s joint.  Here is a picture of said joint:

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As you can see, this is actually a complex set of joints that make up the midfoot.  There is also a complex network of joint capsules and ligaments around these joints.  Generally, a Lisfranc injury involves damage to the Lisfranc ligament connecting the medial cuneiform to the 2nd metatarsal.  Loss of stability of this ligament causes loss of stability of the midfoot.  The causes of such injuries are multiple.  In football players, the injury is most commonly caused by an axial load on a plantarflexed foot:

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Unfortunately for us, we don’t have access to the x-rays, MRI, or CT scans of our favorite athletes unless you happen to be the treating physician.  And when you are, you can’t tell anyone about it or you won’t be treating athletes for long.

Diagnosis of these injuries is challenging for an untrained eye, and it is not uncommon for a patient to have been told that they have a “foot sprain” only to find that the pain never resolved.  The x-ray findings can be subtle, but the most obvious feature is widening between the 1st and 2nd metatarsals as seen below in the left foot versus the normal right foot.

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Wukich D, Dial D: Rigid Stabilization of Partial Incongruous Lisfranc Dislocations: A Cannulated Solid Screw Technique. The Foot and Ankle Online Journal 2(6):4.

So what do we know based on the limited information we have on our buddy Jake Locker?  Lucky for us there is a classification system for Lisfranc sprains.  This was proposed by Nunley and Vertullo and consists of 3 stages.  Stage 1 has no diastasis and no loss of arch height on x-ray; stage 2 has 1st to 2nd metatarsal diastasis of 1-5 mm, but no arch height loss; stage 3 has 1st to 2nd metatarsal diastasis with loss of arch height.  Stage 1 injuries are usually treated conservatively with non-weight bearing in a cast or boot for 4 weeks, followed by appropriate physical therapy and transition to weight bearing.  Stage 2 and 3 are generally treated surgically, so we can assume that Locker’s injury is in one of these categories.  The fact that there is a separation between the 1st and 2nd metatarsals confirms that the Lisfranc ligament is disrupted resulting in some degree of dislocation of the Lisfranc joint complex with fractures likely involved as well.  A typical repair looks something like this with some variation in the hardware based on the injury:

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Panchbhavi V: Current Operative Techniques in Lisfranc Injury. Operative Techniques in Orthopaedics 18(4): 239-46.

Typical recovery would be about 4-6 weeks of non-weight bearing followed by 4-6 weeks of partial weight bearing with crutches and a boot.  Then you could start some light athletic activity and see how things pan out, if you will.  The screws can be removed at 16 weeks, but often are left in place.

In the long term, some degree of arthritis is expected, so it will be interesting to see how he plays next season.  For mobile quarterbacks, this can be somewhat of a problem.  Pushing off can also be problematic during the throwing motion, but usually is fairly well tolerated.  Stiff insoles for the athletic shoe can also help decrease motion in the midfoot and diminish some of the symptoms.  So for our buddy Jake Locker, stay tuned next season.  Watch closely when he throws and scrambles to get an idea about how he and his doctor did.  In the meantime, best of luck to Jake and everyone involved.  And in the meantime, Tim Tebow is still out there…