Sad News

Last week I received an email and a phone calll from Tom Shives, my former professor at Mayo who is still a friend and mentor.  "Danny," whose real name is Jared W., had a recurrence of his osteosarcoma a few months ago.  He had to have the leg amputated above the knee.  He underwent more chemotherapy but this time, the cancer did not respond.

Jared  died on July 31, 2007, two weeks after his seventeenth birthday.  He had developed uncontrollable metastatic disease.  This news saddens me more than I can express.

I have spoken with Jared's family and they have indicated that any correspondence or donations to the family can be sent to the attention of Ms. Adeline Smoker, P.O. Box 322, Frazer MT 59225. 

Floyd Landis, Tour de France winner 2006.

About 30,000 Orthopedic Surgeons from around the world descended on San Diego last week for the American Association of Orthopedic Surgeons annual meeting.  San Diego proved to be a superb venue for this meeting.  The weather was glorious.  The waterside convention center and its surroundings are lovely and boast affordable parking.  Attendees need not be limited to the food offerings inside the center, either.  There are plenty of great restaurants within blocks of the meeting.

There are terrific academic lectures, instructional courses and symposia (which are my favorites).  Physicians from across the globe present their research and discuss new ideas in our field.  It's an enlightening, if not overwhelming week.

What most impressed me, however, is my meeting Floyd Landis, winner of the 2006 Tour de France.   Mr. Landis underwent right hip resurfacing in September, 2006.  He had osteonecrosis of the hip after a serious crash injury years ago.  Floyd underwent two operations before the resurfacing procedure.  He told me that after his initial recuperation and rehabilitation, he is impressed at his level of function.  He's back in full training and will take part (not ride) in the Tour of California this Winter.  He's written a book about his innocence in the TdF and will promote it and his defense case during the tour.   

And, talk about coincidence!  My good friend, Doug, also met Floyd during a recent visit to NYC.  Floyd was kind enough to autograph a copy of High Impact Quotations, edited by none other than Richard "Dick" Pound.

Aside from the meeting, I was able to enjoy the fabulous San Diego weather.  I rented a Cervelo road bike from the nice folks at Nytro in Encinitias, CA.  Each day before the conference, I had a few hours to ride on a stretch of Route 101.  It's a gorgeous  road with breathtaking ocean views. 

These are taken at the base of the North Torrey Pines Road hill.  The surfers are out in force on this breezy, sunny day.

Claudette with serious helmet hair. A nice passerby snapped this for me.  Where does a girl find a mirror when she needs one?

Overall, a wonderful experience.  Even though my travel time practically equalled my time in San Diego because of the awful weather situation in New York and some serious flight delays and cancellations.  I made some great airport friends through that ordeal.  And I must send some kudos to the incredible gate agent who helped us on flight 265 out of JFK on Thursday.  You managed to handle a horrible 9 hour delay with grace and professionalism.  You are a credit to your organization!

The New York City Marathon took place on Sunday, November 5, 2006.  More than 35,000 runners from all corners of the Earth participated.  Thousands of spectators cheered them on.  Even Lance Armstrong ran the race this year.

What this means for me as a cyclist is that, after having retired my running shoes after last year's race, I joined some of my cycling mates to marshal the race for wheelchair and handicapped athletes.  Marathon Day is possibly the best day of the year in New York City.  The positive energy is overwhelming

What this means for me as an orthopedist is that many runners in the marathon come to the office for myraid aches, sprains, pains, twists, cracks and clicks.   Most of these issues are benign;  they can be treated with rest, cross-training and over the counter medicines.

Some of them are not.

Our bones are made to withstand the forces of our activity.  They are remarkable in this quality. They do this through their material properties of strength and elasticity.  That is, they either resist the forces or bend to accommodate them.  Until they don't.

Fractures occur when the force on a structure exceeds its material properties.  Sometimes this happens because the force is too great; a car accident or a fall from a height.  In other cases, the material properties of the bone are changed;  there is a metabolic disease or age-related change to the bones so that they aren't able to stand up to everyday stresses.  Something so simple as stepping from a curb might cause a break. 

Finally, there are "overuse injuries."  The stresses themselves aren't enough to overwhelm the properties of the bone.  But, cumulatively, relentless sub-threshold stresses can cause failure of the bone structure.  When we place great, but not failure-level forces across our bones repeatedly, a "stress fracture" can occur. 

A person with a stress fracture may have normal xrays.  She may only have pain when she does high-impact activity.  She may have enough pain to cause her to go to see a doctor.  Sometimes the fracture is never detected and the person self-limits because of pain, the fracture heals and life goes on.  If symptoms cause concern, an MRI test or a bone scan can detect the injury and treatment can be rendered. However, if the offending activites continue, the bone could snap and require surgery or some other "drastic" measure.

Now our bones are governed by our physiology.  Unless there is something wrong with our healing process, bones will mend when treated appropriately.

But what happens when we overwhelm other systems?  How do we deal with the relentless sub-threshold stresses on our emotional skeleton?  There's nothing so definitive as an MRI test to tell us when we've reached the limits of our patience.  The pains related to stress fractures of this nature are vague and difficult to localize.

I've treated four patients in the past 6 weeks with real stress fractures of their bones.  One woman had fractures in both hips.  Another, in her foot.  A young boy had a break in his tibia.  Another young lady was unlucky enough to have had a stress fracture which cracked completely and required surgery.  All of these folks were under 33 years old.

In contrast, I cannot count the number of patients, mostly young women with small children, who come in for treatment of low back pain, neck pain, hand pain, knee pain, shoulder pain... the list goes on.  These women seldom have a concrete medical problem.  I believe the issues here are with the taxing of other systems.  Many of my such patients sleep only three or four hours per night because of work, house and child care duties.  Some have not had a day to themselves for years.  They are exhausted, stressed and overwhelmed and this shows up in the form of physical pains.

But how do I treat this?  My tool kit includes medicines, therapy and surgery.  Is there a way to fortify people so that they are more resilient?  Or do we just wait for them to break?

Namaste. 

click to enlargeMaya was married this weekend.  her folks live in Golden, Colorado, near the grave of Buffalo Bill.  Elevation at their home is almost eight thousand feet.  This means there's 20% less oxygen in the air.  So sea level people like me need to breathe in 20% more to feel normal.  I found my heart racing after I ran up a flight of stairs!

Maya is my best friend from my residency program.  She was the first person I met when I went to Rochester, MN for my interview.  Two years ahead of me in training, she left for fellowship in San Diego after my third year.  Now, she's a well-known Pediatric Orthopedic surgeon who works at Children's Hospital of San Diego.  

She met her husband, Dan, at a Christmas party a few years ago.  It was practically "love at first sight."  He's a terrific man and has an extraordinary 11-year old daughter, Haley.  Here are some photos from the weekend and the wedding. Maya wore the same dress (remade of course) worn by her great grandmother, grandmother and mother.  The dress is more than 100 years old!  Each time it has been remade slightly since each woman had a different shape.  The material had aged to a beautiful gold color.

Maya's parents, Kitty and Rock, have a home in the woods which overlooks beautiful, snow-capped mountains.  Numerous bird feeders set around the perimeter of the house attract all sorts of birds.  It is mating season for the hummingbirds, so we saw scores of them, dive bombing all over the place.  Also, the neighboring herd of Bison had just delivered some babies.  All things bode well for this marriage.

Congratulations, Maya and Dan!  I am honored to have been a part of your wedding and I wish you the very best.

Namaste.

The tangerines are heavenly.  Sweet, juicy.  He gives me four.  "For you, doctor." How did he know I would not have the time for lunch today?  A thoughtful man.  I can see the intelligence in his eyes.

My patient and tangerine fairy is a Korean man.  He tore his Anterior Cruciate Ligament  (ACL) one year ago.  Soccer.  He works as a courier for a fruit distributor.  Very good fruit.  But little English.

I know about ten phrases in Korean.  Learned them during medical school, when on duty overnight in the Obstetrics ward in Flushing.  Women in trouble.  Women who speak not a word of English.  

"Are you bleeding?"  " Where?"

"Do you have pain?"

"Where is your pain?"  "Does this hurt?"

"Follow me."  "Wait one moment."  "PUSH!"   "Good job!"   "What a cute baby!"  "You are doing great!"  "Thank you." "You are welcome."

Great for the Emergency Room.  Not so good for the office.  Can't explain the risks and benefits of surgery.  Can't tell this man about arthritis and the likelihood that his knee cartilage is already damaged after a year without an ACL.  After living for a year with an unstable knee.  We struggle through our conversation in English and pantomime.  I hold up a model of the knee.

"Here.  Here broken.  We can fix, but not perfect."  My hands gesture wildly around the model.

Frustrated, I look online for a translating service.  Perhaps there is a website in Korean which explains this situation? Problem is, I can't read it so I don't know if it says what I want to say.  

I sigh.  He looks at me.

"Doctora,  ?Hablas Espanol?"

Spanish!?  Yes, I speak Spanish!  Why does he  speak Spanish?

We change languages.  He lived for many years in Ecuador.  He is fluent and literate in Spanish.

We discuss his injury.  Surgery.  Alternatives to surgery.  He asks about risks.  He asks about damage already done.  And I can explain these things to him without the internet.  Without a translator. 

We plan to reconstruct his ACL at the start of the New Year.  We've agreed to use a cadaver graft for the surgery.  We complete some paperwork.  Choose a date.  

"Adios, doctora.  Feliz Navidad."

"Y a usted tambien.  너를 감사하십시요."

Only in New York.