I’ve been having a thing with my high school English teacher. She was quite the babe back in the late 60s at Vicksburg High and I was maybe her pet, but nothing ever progressed then like you read about now. I went looking for her to find a discerning reader for my new blog.
Also, I had come across a stack of my high school essays with her red ink all over them, even though there was usually an “A” on the front. Who better to judge whether I’d made any progress in 50 years? My snoop program found but one person with that name, right there in California where her pharmacologist-research scientist husband had whisked her midway through my senior year. Emails bounced back, but one of those real actual letters did the trick. She emailed me back, and we’ve been swapping ever longer messages ever since. This is bragging material to my high school buddies, who all liked (and feared) her too. But having an email relationship with your old English teacher gets you a whole bunch of new essay assignments. She swears she’s given up red ink grading, but you know the expectations are there, if only from a glance at her coffee cup.
She seems not to mind my verbose offerings, unlike some of my email friends. In our last exchange, she mentioned that her high school boyfriend and roommate of 22 years has been talking about having his sore, swollen knee ‘drained.’ She wondered what I thought of this. She learned early on in our correspondence that I’m a rheumatologist, and was smart enough to know what that meant. I’d sent her a picture of me and my mentor Bill from 1987 presenting a poster on some more radical knee interventions (pasted in in about a paragraph), so she was curious about this knee drainage thing and also about my opinions of rice in arthritis, stemming from a bizarre invitation I had forwarded her asking for my contribution to a scientific journal on rice science. I’d offered that the main role of rice in arthritis treatment is to heat it up in the microwave and place it on the aching joints. She asked if she owed me for the consultation.
What happened went from there. She’d touched a nerve.
I let my California license lapse last year when I decided I couldn’t justify the $820/2 yr renewal fee. So this recent consultation is gratis, but mind you is coming from a source no longer certified by your state.
As Andy Breckman sings “Here comes my career” https://www.youtube.com/watch?v=FOiqDqfFvjM, so stand back
Draining joints was my thing. After appropriate cleansing and local anesthesia, you take a 21-18 gauge needle (3-5 mm), poke it into the swollen joint, drain any fluid there (saving it for analysis if a diagnosis is uncertain), then usually pushing back in some corticosteroid or rooster comb extract. Knees usually have some fluid, smaller joints less likely. I easily did 10,000 over the course of my career, probably more. I was the go-to guy for teaching others how to do this, and the guy they called in when no one else could get it. I conducted courses at national meetings, and was asked to write chapters about it in several textbooks (1-5). But I did more unique things than that. That handsome dude with me in the picture I sent you was my Chief of Medicine Bill Kelley’s first trainee at Duke and had set himself in Chicago after bailing on academic medicine at U of I. Might as well show him right here, he and I standing by our poster at the 1987 American Rheumatism Association regional meeting in Chicago.
We eventually published results of the trial (6). He got orthopedist at Northwestern Dave Stulberg to teach him how to do arthroscopy, then set out to see how it could be used in arthritis patients. Kelley, also a rheumatologist, thought that was a good idea, and picked me to go spend some time with Bill Arnold and learn it. I thought he picked me for my smarts, which everyone was saying were considerable. Years later, I had Kelley’s son Mark as an intern on my service. Mark said his dad had picked me for my height, “because orthopedists respect size”. Kelley later confirmed that to me face to face. So that meant right after buying a house and sticking my fiancée Kathy in it, I had to go live in Lincoln Park for a year and drive home on weekends.
We endured, and got married in October after I came back for good. Once I got going (it took about 6 months for the orthopods to stand down), I became hot shit for a while. Nobody in academics was doing this at the time so I got to show the way. I thought I figured a few things out, published (7-11), taught courses around the country, lectured abroad, and got job offers from Mayo Clinic and University of Alabama (which I turned down, of course). I helped show the way in use of smaller “needle scopes” which could be done in procedure units, avoiding the O.R. Towards the end of the 90s, obstacles began to pile up. Some well done controlled trials showed arthroscopy really wasn’t doing anything in osteoarthritis of the knee (OAK), the drugs for rheumatoid arthritis got so much better that the knee situations an arthroscope might help grew uncommon, and we really couldn’t figure out much from the biopsies of the joint lining (synovium) we were doing under arthroscopic guidance. It didn’t help when I cut through an important nerve in back of a patient’s knee while cleaning it out, an easy lawsuit to win and she did. The department decided not to renovate my equipment when it started breaking down and for the last two years, ending in 2002, I had to rely on the O.R. and just didn’t generate enough business to justify continuing, and I was shut down. Needless to say, I panicked for a while. I’d achieved tenure 10 years earlier, so I wasn’t really worried about my job. But I had lost that great thing that made me unique
Oh, that joint lavage thing was supposed to duplicate what some thought was the main effect of arthroscopy, in which saline is flushed through the joint to clear out debris and provide a clear view. We’d just stick a 14 gauge (8mm) needle into a knee, fill it with saline and then rinse-wash-repeat until a liter had passed though. Prospective trials, done more rigorously than the one Bill and I had communicated, showed the intervention conferred no benefit beyond sham and that was that. Bill still thinks there’s something to it. Some docs overseas still do it for certain situations. I wrote a commentary in Nature (Rheumatology) in 2007 regarding its use in inflammatory arthropathies like rheumatoid arthritis, where it actually may be effective (12). But I sadly tossed out all my special needles when I cleaned out my office last year.
I kept doing some odd invasive procedures no one else did: needle muscle biopsy (13) and minor salivary gland biopsy (lip biopsy), mainly done to support a Sjögren’s Syndrome diagnosis. I taught a lot of fellows how to do the latter, and one of them, Sara McCoy in Wisconsin, had me join her to teach a workshop at our national meeting last year. They asked us to do it again this year.
There’s one more thing: ultrasound. Radiologists have been doing this to sort out joint problems for years, and some of the pioneering work was done by U of M people. All through the 90s, I was itching to get involved, but our radiologists showed me no love. In 2001, our Division hosted Marina Backhaus from Berlin, who was showing rheumatologists all over the world how they could do their own ultrasound and coming up with stuff the radiologists had missed. I befriended her big time, not because I was sucking up to advance my career, but because I genuinely liked her. Kathy too. We took her to the Ohio State football game and had her over for family Thanksgiving. I was unable to find a picture of her at any of those proceedings. We we’re probably having too much fun to take pictures. But here she is in Leeds, UK, mid June 1999 for an arthroscopy course I was helping to teach. That’s my great scopy buddy, friend and hero Staffan Lindblad of Stockholm with a forgotten but nevertheless attractive French rheumatologist in the foreground.
She continued her rise into the academic stratosphere, but she’s still good for a hug whenever I bump into her at a meeting. She convinced my Chief that rheumatologists getting into ultrasound is a good idea, and they found $100K to buy a machine. I scored a big 3 year award (my only one like that ever) that carved out some time in which I could seriously teach myself and in about 3-4 years the chief of musculoskeletal radiology said I was good to go. His deal was I could do all the ultrasound I wanted, but could bill for it only when guiding procedures. That was pretty much what I wanted it for anyway, so o.k. by me. And it was neat how ultrasound could turn a difficult tap in to a piece of cake. Easier on the patients, too, as there’s less struggling. In 2007 the American College of Rheumatology convened a Task Force on the use of ultrasound in rheumatology. A lot of rheumatologists had started picking up the procedure as the machines got better, smaller, and cheaper, but a few were using it for some iffy indications. The group elected me chair, a shock to me at the time, and we set out all divide-and-conquer eventually producing a white paper I mainly wrote and finally in 2010 pushed Arthritis Care and Research to publish (14). The ultrasound club is way bigger than the arthroscopy club ever was, and I hardly occupy the same position of prominence. I’ve had the satisfaction of training several fellows in the procedure and managed one cute publication about a maneuver during ultrasound that is now taught as standard practice (15).
Maybe one of the best consequences of ultrasound is that it’s gained me one of my best friends. In 2014, shortly after my accident, the NIH decided it would be a good idea if we could assemble a cadre of people at all the centers studying the synovium who could biopsy that synovium under ultrasound guidance. The folks doing this best were at two institutions in London. The NIH didn’t know when they invited me that my right hand was useless from my December bike accident. My Chief encouraged me to go anyway and even secured NIH approval for business class fare because of my “disability”. Off we all went. My hand was good enough to take a stab at some of the things they were teaching us.
There was a tall, blonde (two of my weaknesses) good looking lady there from St. Louis. Barnes. That’s her just to my right.
She became an intern the year after I left but she’d heard some stories. We knew so many of the same people, and often had the same opinions about them. We had 2 dinner “dates”, one at the famous Ronnie Scott’s Jazz club in Soho we needed to take a rickshaw to find there to see the blind and spectacular Diane Schuur. Deb and I have been fast friends since, her Jeff liking my Kathy and all of us becoming best of friends and compatible traveling companions. We’ll be meeting up in Chicago next weekend (done as of this post: 3/6-8/20), taking separate trains, for a weekend of jazz, eating, and drinking. And, oh, the NIH sponsored group did produce (16).
It’s all been procedures so far. I talked my way into getting one of the major rheumatology texts to have me do a chapter on just procedures, which made it into another edition and is probably my prettiest work (16). They have someone else write it now, but it’s the same pictures. But I’ve spent most of my time over the past 36 years being with patients, not invading them. But every doctor does that, right? My patients have been my sustaining force. It is a great privilege to be in a profession that provides the opportunity for so much giving and for so many distractions from your own innate selfishness. If I ever came home irritated and pissed off, it was because something in the system kept from getting done something I’d wanted for my patients. You’re supposed to remain professional, maintain barriers, and not become friends with your patients. I found that so hard to do, and never really succeeded. Even towards the end, I insisted keeping the computer off to the side so I could sit face-to-face with my patients. I hear that’s no longer possible. If so, I’m really glad I’m out. But I’ll always cherish the time I spent with them. It was a pretty good 40 years (36 at UofM).
References
- Arnold WJ, Ike RW. Specialized procedures in the management of patients with rheumatic diseases, in Cecil Textbook of Medicine, JB Wyngaarden, LH Smith and JC Bennett, Editors. Nineteenth edition. 1991, WB Saunders: Philadelphia. p. 1503-1508.
2. Ike RW. Therapeutic injection of joints and soft tissues, in Primer on the Rheumatic Diseases, JH Klippel, Editor. Eleventh edition. 1997, Arthritis Foundation: Atlanta. p. 419-421.
3. Ike RW, Arnold WJ. Specialized procedures in the management of patients with rheumatic diseases, in Cecil Textbook of Medicine, L Goldman and JC Bennett, Editors. Twenty-first edition. 1999, WB Saunders: Philadelphia. p. 1487-1491.
4. Ike RW. Therapeutic injection of joints and soft tissues, in Primer on the Rheumatic Diseases, JH Klippel, Editor. Twelfth edition. 2001, Arthritis Foundation: Atlanta. p. 579-582
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5. O’Rourke KS and Ike R. Minimally invasive procedures. inPractice Rheumatology 2015. Available at: http://www.inpractice.com
6. Ike RW, Arnold WJ, Rothschild EW, Shaw HL and the Tidal Irrigation Cooperating Group. Tidal irrigation versus conservative medical management in patients with osteoarthritis of the knee: A prospective randomized study. J Rheumatol 1992;19:772‑779.
7. Ike RW, Fox DA. Arthroscopy in rheumatology training programs associated with NIH-multipurpose arthritis centers: Results from a survey of program directors. Arthritis Rheum 1993;35:1329-1331.
8. Ike RW, O’Rourke KS. Detection of intra-articular abnormalities in osteoarthritis of the knee: A pilot study comparing needle arthroscopy with standard arthroscopy. Arthritis Rheum 1993;36:1353-1363.
9 Ike RW. Arthroscopy in rheumatology: a tool in search of a job. J Rheumatol 1994;21:1987-1989. Editorial.
10. Laing TJ, Ike RW, Griffiths CE, Richardson BC, Grober JS, Keroack BK, Toth MB, Railan D, Cooper KD. A pilot study of the effect of oral 8-methoxypsoralen and intraarticular ultraviolet light on rheumatoid synovitis. J Rheumatol 1995;22:29-33
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11. Ike RW, O’Rourke KS. Compartment directed physical exam of the knee can predict articular cartilage abnormalities disclosed by needle arthroscopy. Arthritis Rheum 1995;38:917-925.
12. Ike RW. Arthroscopic lavage of the knee with or without corticosteroids versus joint aspiration—which is best? Nature Clin Pract Rheumatol 2007; 3(6):320-1.
13. O’Rourke KS, Blaivas M, Ike RW. Utility of needle muscle biopsy in a University rheumatology practice. J Rheumatol 1994;21:413-424.
14. Ike R, Arnold E, Arnold W, Craig-Muller J, Kaeley G, McAlindon T, Nazarian L, Reginato A. Ultrasound in American rheumatology practice. Arthritis Care & Research 2010; 63(9):1206-19
15. Ike RW, Somers EC, Arnold EL, Arnold WJ. Ultrasound of the knee during voluntary quadriceps contraction: a technique for detecting otherwise occult voluntary quadriceps contraction: a technique for detecting otherwise occult effusions. Arthritis Care & Research 2010;62(5):725-9.
16. Mandelin A, Homan P, Shaffer A, Cuda C, Dominguez S, Bacalao E, Bridges SL, Bathon J, Atkinson J, Fox D, Matteson E, Buckley C, Pitzalis C, Parks D, Hughes L, Geraldino L, Ike R, Phillips K, Wright K, Filer A, Kelly S, Ruderman E, Morgan V, Abdala-Valencia H, Misharin A, Budinger GRS, Bartom E, Shilatifard A, Peabody T, Pope R, Perlman H, Winter D. Transcriptional Profiling of Synovial Macrophages using Minimally Invasive Ultrasound-Guided Synovial Biopsies in Rheumatoid Arthritis. Arthritis Rheum 2018;70(6):841-54
17. Ike RW. Minimally invasive procedures, in Rheumatology, MC Hochberg, J Silman, JS Smolen, ME Weinblatt, and MH Weisman, Editors. Third edition. 2003, Harcourt Health Sciences: London. p. 245-252.
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