Catch Ya On the Flip Side

It's a bittersweet entry this week, as this is my last blog as an NUHS student. Sad right? I can't believe it's been a year and half that I have been sharing my "wisdom" with everyone. It's been an incredible three and half years. I know its cliché, but the time really did fly by. It seems like yesterday I was sitting in orientation with Dr. Stiefel, listening to how rigorous the next 3+ years of my life were going to be. He wasn't joking either. Those first 2 years, I was a slave to my textbooks, notes, and presentations. The load thinned out over this past year in clinic, but the practice and studying was still and will always be a huge part of my week to week. 

2012-12-04_grad -dinner
Jeff, Guy, and I at a graduation dinner on Saturday.

I cannot thank our professors enough for the countless hours of help and dedication they've put towards us:

  • I'd like to thank Dr. Jennifer "Vice-Grip" Illes for being patient with me constantly nodding off during her post-lunch E&M courses, and of course for teaching me how to adjust!
  • The incredible Dr. Jaya Prakash helped me understand pathology and microbiology in a way I never thought I could.
  • Dr. Richard Leverone, Dr. Terry Sandman, Dr. Heather "Awesome DACBR" Miley, and Dr. Rudy Heiser made me realize how much I love radiology, and who knows, maybe one day I'll follow in their DACBR footsteps.
  • Then there is the always smooth, Dr. "Wiki-SRI-dia" Sridharan Manavalan, who along with Dr. Leslie Pearlstien, taught us the ins and outs of the human body in anatomy class.
  • Who could forget the dynamic Lombard duo of Dr. Robert Humphreys and Dr. Daniel Richardson? Dr. Richardson always made class a blast, especially when he couldn't find his glasses that were always resting on top of his head. I can't thank Dr. Humphreys enough for allowing me to co-manage his Florida neuro cases, and teaching me a lot of his tricks of the trade along the way; and yes, I still owe you lunch, Doc.
  • How could I have gotten by without the incomparable Dr. David "Coach" Seaman? I can break down the conversion of just about anything you throw in your mouth to the enzymatic level thanks my advisor and pal, Dr. Seaman.
  • I am more than confident in rehabbing just about any condition that will walk into my office, thanks to Dr. Tim "You can always be faster" Stark. Dr. Stark has always been there with either quip or advice whenever I've approached him. Thank you.
  • For the past year, Dr. Rudy "wild-assed-clinician award recipient" Heiser, has molded and refined my clinical skills. Dr. Heiser has let me learn through mistakes, treat in my own way, and all the while made sure I was doing it correctly while offering great advice along the way.
  • None of this would've been possible without the countless time and effort put in by Dr. Joe Stiefel. Dr. Stiefel not only taught, but administrated, and handled all the behind-the-scenes activities that made the Florida Campus what it is today.
  • Finally, I'd like to thank my mentor and friend, Dr. Chad "The Intimidator" Maola. There is no way I would have been the student, or the intern, or the doctor I am without all the extra time Dr. Maola put in with me. I'll never forget the day during my last final exam of third trimester, when he came in halfway through the exam and told me to report to his office as soon as I was done. The conversation Dr. Maola and I had that day in his office is the reason I am as good and confident at what I do. I know Dr. Maola has taken some flack over the years for the extra time he has taken with me, but I want to let him know that it never went unnoticed.

Enough with the goodbyes. My time at NUHS has been great. I can't believe all that I've learned over the years, and all the friends I've made along the way. Congratulations to the graduating class of 2012!

Jeff, Guy, Dan, me, and Margaux

All of us down here have plans on practicing in Florida. Margaux plans on pursuing veterinary chiropractic in the St. Petersburg area, Dan Johns has his eye on a practice in Fort Lauderdale, Guy Reshamwala is taking over one of his older brother's practice in Hudson, Jeff Bourguignon will be independently contracting in Tampa, and of course I will be opening my practice in Tampa as well. My door will always be open, and I will continue to answer any emails that come my way. Thank you to everyone who has read the blogs, and Ms. Marie Olbrysh for allowing me to send in my thoughts each week.

I'll leave everyone with an excerpt from one of my early blogs, a fable I took from Aesop's fables: "Hercules and The Wagoner":

A carter was driving a wagon along a country lane, when the wheels sank down deep into a rut. The rustic driver, stupefied and aghast, stood looking at the wagon, and did nothing but utter loud cries to Hercules to come and help him. Hercules, it is said, appeared and thus addressed him: 'Put your shoulders to the wheels, my man. Goad on your bullocks, and never more pray to me for help, until you have done your best to help yourself, or depend upon it you will henceforth pray in vain.' 

Always take responsibility for what you are doing, and remember that self-help is the best-help. Never stop learning, and never stop practicing.

Catch you guys on the flip-side,

Disappointment and Resignation

Hello everyone, and welcome to my penultimate NUHS blog. Yes, I know it's going to be very sad when I am longer writing about my entertaining weekends and insightful blunders with patients, but I am sure you will be able to press on. 

Click for full photo
FSU vs. UF Game (Click photo to see full version)

Speaking of pressing on, I had to walk into the clinic this morning with my head a little lower than I would've liked. I, as some of you may know, am a huge Florida State Seminole fan. I love my alma mater and have stuck with them through thick and thin, and after this weekend, it will be no different. After a fantastic Thanksgiving Thursday, my old roommate and best pal, Rich, made the drive up to Tallahassee for one of the largest and long standing in-state football rivalry games--FSU vs. UF. It felt great being back in my old stomping grounds and hopes were high that we would best the Gators. Unfortunately, our hopes were deflated, as we lost a disappointing 37-26. To add insult to injury, my Tampa Bucs also lost a close match up against the now 10 and 1 Atlanta Falcons. I was not a happy camper last night, but some left over turkey, ham, and casserole did help a little. 


Being disappointed in sports is one thing, but what happens when you become disappointed when treating a patient with no results? At what point do you have to step back and realize that you may not be able to help a patient? Then once you have made that realization, whom do you send them to?

I have been writing mock narrative reports for the past week and came across one of my old cases in which this happened. I took over this particular patient from a graduating intern, who had been treating her for lower back, right hip and right lower leg pain. We had established that the patient had lumbar spine disc derangement, decreased core stability from two cesarean sections, and peripheral nerve entrapment of the peroneal nerve in the right lateral compartment of the lower limb as well as a pretty substantial gluten allergy. This patient was treated 2-3 times per week depending on her schedule, and would find mild relief after treatments, but after two months at this frequency she was still not experiencing any lasting relief.

At this point I reevaluated the patient and began another course of treatment. Prior, the patient was being treated with Cox Flexion and Distraction. I then switched to McKenzie end-range loading techniques (more extension-type therapy), which seemed to offer longer lasting relief. Still a month went by with very little change. Now, I started to pull my hair out. At that point I had to have "the talk" with my patient about possibly finding another treatment option. She was very apprehensive to any kind of injection or surgery, which is understandable and very common. The challenge then became finding another alternative to her care that would benefit her and she would be comfortable with. Together we decided that seeking out an established McKenzie certified practitioner might help, as I am not totally comfortable with some of the more advanced stages of McKenzie protocol. A month or so went by before the patient called the clinic, but when she did it was with good news and she was extremely happy that we made the switch.

I never looked at the situation as a failure on my part, or that I was losing a patient, because in the end something I did made her better. This should always be the goal as a doctor. Money will come and go, as will patients, and as stressful as it might be to keep your lights on in practice, you have to be able to sleep at night also. This patient ended up continuing to be treated by the other practitioner, but she did refer her husband, who is still an active patient.

I hope everyone has a quick and productive week. Everyone should be studying for finals already. Studying early always helps with the crazy amount of exams stacked in a two-week period. Make the final push of the trimester a good one.

Catch ya later,

Never Stop Learning

Hello everyone.  I know I'm looking forward to only a three-day week this week and the food-coma that will be induced Thursday. I always look forward to Thanksgiving. I'm fortunate to have a huge family, who are local for the most part, equipped with two grandmothers who are incredible cooks, and one uncle who's a chef. Not to toot our own horns or anything, but we do turkey-day right. 

Today I'd like to share with you, probably, one of my last case presentations that walked into the clinic last Friday. This patient presented with strange neck and upper shoulder pain that began 4-5 days prior. The patient could not pinpoint a certain action, or mechanism of injury; he had not lifted anything heavy nor sustained any trauma. As the patient was sitting and telling me his story I could notice he was struggling with some nasal congestion. I then began to ask the patient if he had been feeling sick as of late, to which he answered that he had been fighting off some nasal congestion and a sore throat for about a week. Ding, ding, ding! So now we have a patient with some weird neck and upper shoulder pain: that is worse with laying down for extended periods of time and while on his drive to work; that feels better with massage during a warm shower; who has been fighting off what sounds like an upper respiratory infection. What's the next step? If you guessed a physical exam to rule out any life-threatening conditions, you are correct.

The patient was informed of the risks of a physical exam, he consented, and off we went. Through the physical exam we ruled out a disc issue and facet involvement. In fact, the only instigating exam finding was pinpoint tenderness at a nodule at the right suboccipital area (base of the skull), and the same in the area of the left sternocliedomastoid muscle area (left side of the neck). As soon as I palpated over these nodules, the patient would note that was his pain generator. One should not jump to the conclusion of muscle spasm just because palpating over a muscle is tender. What caused that "knot" to form? This is where listening to the patient is key, but not allowing the patient to give you a diagnosis; that's why you are the doctor and they are the patients. 

Remember, that pesky sore throat? I did. I decided to take a look down the patient's throat, and what did I find? His throat was fiery red on the right side. Can you see where I'm heading from here? Now here is where I only give myself an 80% (very generously, if Dr. Maola has anything to say about it). I honed in on a throat infection that was causing inflammation of lymph nodes beneath the suboccipital and sternocliedomastoid muscles leading to neck and upper shoulder pain. This made sense with the red throat, stuffy nose, and alleviation of pain when the lymphatic chains were manually drained by massage in a hot shower. Seems pretty sealed up, right? Wrong.

Dr. Chad Maola, our dean of academic assessment and mentor of mine, saw a very big flaw in my diagnosis. He asked me to take a look inside the patient's ears. Sure as I'm writing this right now, that poor patient's right ear was red as could be; an ear infection was the root of all the pain! The ear infection was causing the lymph nodes to swell, and the infection was draining down the eustation tube (tube that connects the middle ear to the throat for drainage) to the back of the patient's throat causing a sore throat.

Image from Northwestern University

Now, I could have managed the patient for a throat infection and manually drained the lymphatic chains and offered the patient some relief, but what would have happened if I didn't notice the ear infection. With an ear infection in adults, ear pain is an end-stage symptom, right before tympanic membrane rupture. In real life, if this patient came to me, paid me $80 or so for a diagnosis, then had to turn around and head to an urgent care clinic to spend another $80 for them to tell him that he in fact had an ear infection rather than a primary throat infection, he wouldn't be very happy.

I adjusted the patient's cervical spine which resulted in an instant sensation of ear drainage and sent him on his way with some instructions on dripping in some warm garlic olive oil into his ear, continue to massage out his lymphatic chains in the shower, and to seek a physician for antibiotic therapy to clear up the infection. Sure enough, the patient felt ear pain that night, found relief from the garlic olive oil, and after visiting his general practitioner received an antibiotic prescription to resolve the infection. The patient was happy, and I learned yet another valuable lesson from Dr. Maola and my patient.

I hope today's entry helps someone down the line. Assess every option and always allow the patient to tell you what their signs and symptoms are, and then you diagnose them. I hope everyone has a quick short week and a terrific Thanksgiving!

Gobble Gobble,

Part IV Is Finally Over

Hello everybody. Part IV boards are DONE!! This past weekend, my fellow 9th and 10th trimester interns and I had to hopefully make our last trip to Port Orange, Florida, for board exams. 

The first day was the Diagnostic Imaging exam. We were first given very specific instructions on what to expect once the exam began. Next, we were separated into groups and taken to our exam rooms. In the room were 10 stations, each with a view box containing 2 images. On my exam there was one MRI case and the rest were X-ray images. You then had 4 minutes to review the cases and answer two follow-up questions that either asked the next appropriate step in managing the case, what the diagnosis was, or what would we expect to see clinically with that patient. 

The general consensus after Day 1 was that we were all very prepared for that exam. To reward myself after Day 1, I took the rest of the afternoon off, found a golf course, and played a quick solo 18. This ended up being a great way to relax before Day 2. 

Day 2 of Part IV boards began at registration bright and early at 8 a.m. Again, we were given lengthy instructions and bussed to the test site at Palmer College's main clinic. This part of the exam was designed to assess us as if we were dealing with patients in a real life setting. There were 3 stations where we had to take a history on simulated patients, 5 orthopedic and neurological testing stations, and 1 physical exam station--each station was followed by two questions similar to the diagnostic imaging questions. There were then 5 adjustment stations, in which you set up a specific chiropractic adjustment on a patient and verbalized how the adjustment would be performed to the examiner. All of the stations lasted for 10 minutes before you were ushered to the next station. It felt incredible walking out after that last station. I felt confident and prepared for the exam, and hopefully I'll never have to take another board exam again. 


You know I had to mix in a little fun into the weekend after tests like those. After Saturday's exam, I moseyed on down to Tallahassee, Florida, for my good friend Nic's, wedding. Nic and I were pals all through my college years at Florida State, and I couldn't be happier for him. We danced and partied on Sunday well into Monday morning.


It was a great weekend, and I'm looking forward to much less stressful next 4 weeks before graduating Dec. 13. 

Catch you guys on the flip side,

That New Clinic Smell

It's an exciting day down here at the Florida campus; today the NUHS Whole Health Center - Pinellas Park outpatient clinic is open and ready for business. The other interns and I walked up this morning to a fresh, state-of-the-art facility, which even has that new clinic smell. It's an incredible facility, equipped with 10 treatment rooms, a physical therapy room, separate lab room, an interactive classroom, and super-cool conference room. I am typing this now from our very own intern lounge--pretty fancy.


Yes, we are very excited about all the brand-spanking-new equipment, but we are also enthusiastic to have an outpatient facility. Up until now, the Florida campus has had to get by with a 4-room clinic that only caters to the faculty, staff and dependents of those affiliated with St. Pete College and the University Partnership (which includes NUHS, Barry University, Florida State University, University of Florida and others).


The new facility will now allow us to treat anyone and everyone. The services we provide will still be free to the population we would see at our student clinic, but will be at a very minimal cost to anyone else who would like treatment. We are hoping that this will open up a whole new population of patients, and bring some more real-world cases through the door. The more practice we can take on while in school will just help us feel that much more confident once we graduate and are on our own.


Speaking of being on our own, I've started the process of outfitting my clinic once I'm out of the NUHS nest. As many of my colleagues and professors around here know, I've signed on to be an associate with a great doctor, have signed a lease for my future practice (opening in South Tampa, April 1, 2013...shameless plug), and last week even bought almost all the physiotherapy equipment I'll need. These things were a learning experience in and of themselves. Finding the right location that you believe you can succeed in is very important. I staked out the building I wanted for nearly 2 years before it finally opened up about 2 months ago. Then I was very fortunate to make a relationship with a local MRI rep who clued me in on a practice that was downsizing and needed to get rid of a lot of equipment for a very discounted price. From the experiences I've had, I would recommend starting to make relationships as soon as you can, and maintain them, even its just a text or a phone call once a month to touch base. It goes a long way.


I hope everyone has a productive week, and best of luck to everyone taking Part 4 boards this coming weekend. Please everyone wish us luck. I know we are all prepared, but a little luck never hurts either. If anyone needs any help or advice about the new clinic, or starting his or her own, please shoot me an email, its fresh in my head, so hopefully I can help.

Good Luck this weekend,