It's All About the Timing

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Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area

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• The Mystery of Pain
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• An Ethical Tool
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• Before You Pop That Pill
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• Hair of the Dog
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• Patching the Safety Net
A series of clinic visits by one patient made me realize just how broken the current health care system is and what can be done to fix it

• The Mystery of the Double Cardiac Arrest
Even surgical residents used to the heady rush of "codes" occasionally encounter emergencies that throw them for a total loop

• What the Fancy Machines Can - And Can't - Do
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"How long is this going to lay me up, doc?"

In the office for something elective or in the ER for something urgent, this is usually the first question I get after explaining what's wrong and how we're going to fix it.

Break your wrist? Six weeks in a cast then six weeks of exercises. Carpal tunnel? Ten days with the surgical bandage-if you have a desk job, you can be back to work that afternoon but you can't hold a racquet for three more weeks. I try not to sound like a waitress rattling off tonight's specials but after 22 years, sometimes I can't help it.

"But when will I be back to normal-out of pain?" This is a far more difficult question.

Like most orthopedic surgeons, I primarily treat pain. Pain is never "normal" and it's almost never gone on schedule; medical judgments about how long it will take to go away are hard to make—and often wrong.

Victoria is pretty, very thin, 13 and loves to dance. She has been en pointe for a year. Hers is the collected smile, extended neck and slightly out-toeing gait of a serious ballerina. I can guess why she's in my office: her foot hurts. She walks without pain, goes to school, even gets through gym class pretty comfortably—but she can't dance. A big dance recital is coming up—dancers from the famous ballet company in the city will be there to watch her—and she wants to be "back to normal" by then. She and her Mom want to know when this pain will go away.

When I touch her long, skinny foot, it hurts at one particular spot. This is where it hurts when she tries to dance. The X-ray at first glance is normal, but if you look very carefully there's a little disruption of the lace-like pattern of the bone's spongy internal architecture at exactly the spot where it hurts. (This X-ray, by the way, was read as "normal" by the radiologist. Only an MRI or bone scan will reliably show the fracture to someone who has not had the opportunity to examine the patient and focus on the one tiny spot.)

Victoria has a stress fracture of the cuboid-the squarish bone on the outside of the hindfoot. These fractures are not common but I've seen a few in dancers and gymnasts. Stress fractures are tiny cracks in bone that seem to occur simply because the substance of the bone itself can't take the stress that's being applied—pretty much the way a paper clip you keep bending back and forth will weaken and turn whitish at the bend before it breaks in two. That white spot is a stress fracture of the metal. Bend it a few more times and the paper clip breaks in half—a completed fracture.

There's a lot of confusion in the lay world about fractures. "Broken" and "fractured" mean the same thing. And a stress fracture is not something about which most folks have any intuitive feeling. So I have this dialogue whenever someone has one:

"It's starting to break-like the paper clip," I say.

"But its not really broken?"

"A tiny bit-yes it is."

"But it hurts so much"

"Well it's your bone, it's alive and has nerves. Ever get kicked in the shin?"

"But if it's alive why doesn't it get strong enough to deal with the stress and not fracture?"

"We don't know. All we do know is that the stress you gave it was too much, too soon."

"So when's it going to get better? How long is this going to lay me up?"

It would be great if the timing issue were as straightforward as the treatment. Treatment of stress fractures is pretty easy. Immobilization or rest—basically avoiding the stress that caused the fracture— usually gets them to heal within six weeks. In a child it might be faster, in an older person probably a bit longer.

But how long does a foot take to stop hurting? Particularly in a time-stressed little girl from a high-power suburban school, drawn to the difficult world of classical dance? There are many reasons, both physical and mental, for this thing to hurt for a long time.

I put Victoria into a big, bulky but very secure foot and ankle brace. At three weeks she was a little less tender but definitely not better-so back in she goes and I'm now the bad guy-no recital. Her mother is sharp, though; I don't have to threaten with crutches and operations to get her on board with me on this. And Victoria comforts me when I say I'm sorry about keeping her out of dance for another three weeks: "It's ok-It's nice to be home in the afternoon. I read and play games, I have a life." This is a little embarrassing for both adults in the room; my kids are overworked too. Another timing issue.

Broken feet often hurt regular people for months after the bones are healed. Our saying is "Foot pain is low back pain of the extremities," meaning many patients with foot pain, like chronic back patients, never get better, no matter what you do. So we treat it with respect. I have seen a stress fracture of the foot keep a middle-aged woman hobbling in pain for over a year. Every doc in my field has experience with schoolgirls whose mysterious foot and leg pains are relieved only by a doctor's note that gets them out of gym. On the other end of the unrelieved spectrum are the non-compliant adolescent patients who sneak the forbidden activities and never let the fracture heal.

But Victoria seems pretty together, I get the strong impression that she wants to dance and the X-ray, which I have now examined with a magnifying glass, definitely shows the fracture.

"How long will it take?"

I suggest "40 days and 40 nights" —that's the basic six weeks, less two days for her youth-and it has a kind of prophetic ring.

"Are you sure?"

"We'll see".

A good sense of timing is the primary mark of a good doctor. How long can the fever stay this high before we hospitalize? Should we use a few more days of antibiotics? When do you tell the woman in labor to come in to the hospital? Tell the aging man it's time for his knee replacement? The family it's time for a hospice? Scarcely any time is spent on questions like these in a medical education and if I were to say, "ok, I'll fix that" I don't know where I would begin, how I would teach it, especially to young people who just haven't felt as many months trickle though them as I have. I wish I could because there is a deep and enchanting thing, sometimes beautiful, about people as they step skillfully with time. It's some kind of dance, maybe a lot like Victoria's.