Orthopedic Pimp Questions

Here is a list of questions that I'll add to from time to time of ortho pimp questions I have been asked/heard people asked.

What is the innervation of the three muscles that insert as the pes anseurinus?

What are all the muscles that insert on the scapula?

What is the muscle belly of the iliotibial band?

What is worse regarding ROM lost, a subtalar or talonavicular fusion? (TN)

What composes the nucleus pulposis and annulus fibrosis--in detail?

In the OR:

What nerve is in danger with this incision?

What is the innervation of this muscle? As mentioned before, much more rarely are questions re: origin and insertion asked-- don't waste your time knowing the 3 main arteries to the knee if you don't know the innervation of the tensor fascia lata.

What muscle is this?

Why can't I use the cautery on the Mayo stand? (Only patient is grounded)

What are the layers that I will be cutting through? More commonly asked in gen surg than ortho

As always, feel free to add other questions you have been asked in the comments.

Secrets to Orthopedic Away Rotations

Here is a quick rundown of what I've learned and been told about how to thrive while on an orthopedic away rotation.

First and foremost, as I'm sure you already know this is a tryout. It's a chance for you to try a program on for size, but moreso it is a chance for them to see what kind of resident you might be in their program. It's easy to slip into the mindset that just because you graced them with your presence for a month that they are going to think better of you. Not so. In fact that is why on average it is a lot easier to hurt your chances of getting into a program by doing an away than it is to help your chances. The all encompassing first rule of away rotations is: always work hard.

What are some of the ways you can shine? You can prepare the notes before the resident's arrive in the morning. Perhaps it is just where I am at, but unlike general surgery, it seems that the residents do not care (and may even prefer otherwise) if you see a patient in the morning before they get there. They seem more concerned that the actual rounding process is streamlined. Regarding the OR and pimping, the most important thing to know is anatomy. Most commonly you'll be asked questions such as "What nerve is in danger with this incision," "What muscle is this," etc. Expect more nerve-muscle questions than insertion, origin and action questions.

When in the operating room, assume that once you are given a role once, they expect you to fill it from that time onward. For instance, some common tasks are adjusting the lights, sponging up blood in the field, and using the suction. Additionally, one should be familiar with deep tissue, subcutaneous, and skin closure so that when the attending asks if you are comfortable doing so you don't respond by saying something like "we'll I only saw it once..." Another thing to mention: when the resident or attending moves towards where you are standing, you should move to the other side of the table, they won't always take time to say "Hey can you switch positions with me."

Another OR tip: when retracting don't worry about them repositioning the retractor frequently. It is likely nothing but them wanting it in a specific place and not a commentary on how you are doing. You'll likely notice them doing the same thing with the residents.

The biggest thing that programs are looking for is hardworking, teachable medical students that appear to be engaged in the case or lecture, with whom they can get along with on a day-to-day basis. Most of the time they would rather have the above student as a resident than one that is just the best at answering all of their pimping questions.

Hiking Mt. Olympus

After hiking Mt. Olympus (Utah) today and nearly requiring LifeFlight to get me off of the mountain, I thought I might share a few thoughts that you will not easily find on SummitPost or other similar sites that dramatically oversimplify some of the challenges that you will face. But before I get ahead of myself, here is the rundown of what happened and the mistakes I made.

Starting out around noon (aka the "Hottest Time of the Day"), I parked just down the street from the trailhead, along Wasatch Blvd. I had read on a few pieces on climbing Olympus that there were more cars broken into in the parking lot that there were windows shattered along the street--a rumor that was denied by several people that I met on the trail. But going back to the start time, if you are from a humid state such as the southeast or midwest you will be unpleasantly surprised at how hot it is. The temperatures were in the mid-90s, but because it is so dry here it felt like high-70s and I thought nothing of it.

After starting out at a decent grade out of the parking lot, you enter a series of open switchbacks with low vegetation and great views of the valley. There are a few spots with minimal exposure, but for the most part the trail is extremely safe. In my mind the trail has four segments: the first segment contains mostly scrub brush and grasses.

In the second segment, you enter an area of low trees mixed with increasing amounts of rock that you have to navigate as you climb. In the middle of the summer, this segment also contains your only source of water on the hike in the form of a small stream. Many other sites talk about how it is a steep hike that is only 3ish miles each way, but you would be surprised how fast you go through water, especially if you have not fully acclimated to the altitude.

The third segment of the trail has higher trees, steep grades and significant amounts of rocks in the trail that will slow you down. Many times you are walking in a tunnel of foliage with increased humidity.

The final segment is what I found to be the most grossly underdescribed in other websites. This is the segment of the hike above "the Saddle," a flat segment of ridge that gives great views to the east.

First of all, if this is grade 3 climbing then it's 3.9. The last 45mins or so of the climb is a lot closer to grade 4 climbing than it is grade 3. When I think of grade three climbing, I think of the kind of climbing that is necessary near the summit of many Colorado peaks where you are going up and over some low boulders but would not fall/roll more than 20ft in a worst case scenario. The last bit of climbing on Olympus has significant exposure in several spots and requires at least minimal vertical climbing skill, more than your average mountain hiker may be comfortable with, especially considering many hikers on Olympus are lugging decent sized packs up, which significantly alters one's center of gravity. Never mind my biggest pet peeve about this segment.

Utah. I get it. You are all about the "go for it, and if something goes wrong, maybe we'll be able to help you before it is too late." I also understand the massive amount of wilderness in Utah. But this is probably the second most popular hike in the SLC area! This is a trail that has 12 year olds and 70 year olds on it. And yet there are zero markings as to the trail above the saddle! Not only is this incredibly dangerous, but it also means that you waste large amounts of energy coming back down as nearly everyone takes different paths and has to double back when they hit a 10 foot drop off. In other words it's manageable on the way up but can be disastrous on the way down.

I got in a situation where I was so low on energy that I had to continue down despite the fact that it was much much more dangerous and exposed than the path that I went up on. There were times where a slip backwards would have almost certainly meant broken bones and likely worse. Not only is the trail marked at all, but there is a grand total of two cairns to help one navigate down, and one of them is next to the mailbox at the summit! It's no surprise that in the past few years a number of people have died.

To wrap up my meandering story, although I brought plenty of water I quickly dried up the available calories in my body and became so nauseated that I could not get a dry granola bar to go down--so I called for help. Luckily as the trail is mostly on the valley side, you should be able to get help if needed. I had become so weak that I was afraid of falling down the trail, even though I was back in the 3rd and slightly less steep stage. I had to just sit and wait until my friends could help me by bringing some zofran (anti-nausea) and some liquid energy.

Was much of this my fault for leaving on a hot day at the hottest time of day? Yes. Should I have brought more calories with me? Yes. Are there dangers inherent to climbing Mt. Olympus that are not described on other sites? Yes. I hope that if you are like me and searching out info about the climb that you be sure to start early, budget extra time, and take extreme caution above the Saddle area if you plan on summiting. Multiple people die here every year, if you are like me you may underestimate how difficult the grade is, especially if you are used to the typical Colorado 14er which rises a mile in 7 or more miles walked. Feel free to share your Olympus stories in the comments section.

PS these images are my own, please do not copy them onto other websites without permission as they are protected.