PRESENT Residency Insight

Contact us today to learn more about how PRESENT can transform the way you deliver residency education!

Residency Insight

Residency Rumble
Round 4
FOLLOW UP

The Residency Challenge / Rumble is continuing as a huge success. We have received overwhelming response and interest from around the country and are excited to create this forum for podiatric residents.

Last night was the Week 4 competition with 10 programs competing to make their way into the first of the prize rounds. The 6 (yes 6, read on) remaining teams will all receive the Primal Pictures Interactive CDROM Podiatric Medicine and Surgery, and compete next Tuesday to be one of two programs to receive Apple iPods, and then of course onto the final round, where the Champion will receive a 27" Flat Screen.

While the overall purpose of the Rumble is to promote learning through a bit of healthy competition, we have also found that it has created a sense of community and interest. Toward that end, we present discuss below for you on 2 questions appearing in Rumble rounds. This is an important part of the learning experience and we encourage you to add your 2 cents in whenever you have an opinion regarding anything in PRESENT lectures, the Rumble or anything that we do.

Here is the feedback that we received from participants regarding QUESTION #4 for the Rumble this week (and the reason that we threw it out):

4 Which of the following is NOT a component of Felty’s Syndrome?

    A Rheumatoid Arthritis
    B Splenomegaly
    C Leukopenia
    D Thrombocytopenia

The CLASSIC definition of Felty's Syndrome is universally referred to in the literature as: RA, Splenomegaly, and Leukopenia. For example the National Library of Medicine and NIH define Felty's Syndrome in their encyclopedia as "a disorder characterized by rheumatoid arthritis, an enlarged spleen, a decreased white blood cell count". This can be found at the following link:

http://www.nlm.nih.gov/medlineplus/ency/article/000445.htm

However, since the question was not phrased with the best clarity ( it should have asked "Which of the following is NOT one of the 3 CLASSIC components of Felty's Syndrome ?") and multiple sources (Primer on the Rheumatic Diseases. Edition 11 page 167 Publication from the Arthritis Foundation. Editor: John Kippel, MD) do cite thrombocytopenia as a possible component of Felty's Syndrome, I agree that this question should be excluded from the scoring. Therefore the posted results for the Rumble this week DO NOT INCLUDE the responses for this question. We THREW OUT question #4, and only counted the remaining 4 questions.

We appreciate the feedback such as the inquiries sent about this Rumble question. Please keep up the good work and let's make PRESENT a community voice for podiatric residents...

FEEDBACK from Members

The following question appeared in Round 1 of the Rumble:

1 A patient with a PMH significant for atrial fibrillation, on coumadin sustains a Hawkins Type 2 open fracture of the left talus. What is most suitable management for this patient?
    A Immediate ORIF; control hemorrhage intra-operatively with thigh tourniquet
    B Administer cryoprecipitate intra-operatively, and attempt ORIF
    C Immediate ORIF; control hemorrhage with administration of 2 donor units of platelets
    D Administer 2 units of FFP and attempt ORIF

FFP (Fresh Frozen Plasma) is indicated for the emergency reversal of coumadin. Administering FFP will allow for attempted ORIF of the open fracture site while minimizing the intra-operative and post operative bleeding complications.

We received this message questioning the validity of answer D from one of the Residency Directors (we didn't obtain his permission to publish his comments in time for this issue, so we'll keep him anonymous):

To: Editor, PRESENT

Sorry, but open fracture of Talus should not require FFP. The Coumadin should not present a problem for this injury and should not require Prophylactic FFP

         Anonymous

NOTE from Editor:

Thanks for sending in your comments on this Rumble question. The issue dealt with FFP peri operatively in a patient with an open fracture. While I think there is lots of room for discussion, I would have to agree with the question writer from Scholl who designated that the BEST possible choice was D, to administer the FFP and proceed to ORIF.

I sent the question to one of our Georgetown Vascular Surgeons for comment and got the following reply:

Answer depends on a couple of things (as usual), urgency of ORIF / PT-INR level / history of embolic events due to a fib..........

But, putting all that aside - D is the best answer!”

I think that when you look at the other choices, D was the best possible answer. But of course the question you raise is more along the practical / clinical lines and that certainly could be debated at length…

Thanks again for your feedback!

John S. Steinberg, DPM
Editor, PRESENT

Send in YOUR most interesting clinical case for others to learn from.
SUBMIT CLINICAL CASE
Please send any suggestions, thoughts, questions to me at: editor@podiatry.com

John S. Steinberg, DPM
Editor, PRESENT