Written by Kenmont Group

Guest Post: Niv Milbar ’13, Richmond ENT

I have to start out this blog by say­ing that my Princetern­ship at Rich­mond ENT was unbe­liev­ably inter­est­ing and extremely reward­ing. This being my first time in Rich­mond, I did not know what to expect in terms of the peo­ple I would meet and the expe­ri­ences I would have. Dr. Mike Arm­strong ’85 and his fam­ily are some of the nicest peo­ple I have ever met. Dr. Arm­strong loves to teach peo­ple who are inter­ested, which made my expe­ri­ence absolutely awe­some. The first thing that I learned was about the struc­ture of a pri­vate prac­tice. The first morn­ing, Dr. Arm­strong brought me with him to his office where he prac­tices along with three Nurse Prac­ti­tion­ers named Shel­ley, Tamara, and Becky, and sev­eral LPNs. Dur­ing office days, each sched­uled patient would arrive and be signed in by one of the LPNs, who would take the patient back to one of the rooms. Then, one of the nurse prac­ti­tion­ers would go speak with the patient and do an ini­tial exam­i­na­tion, writ­ing down all symp­toms and con­duct­ing a thor­ough exam­i­na­tion of the patient. Once they were fin­ished, Dr. Arm­strong would come in and exam­ine the patient again and dis­cuss the best treat­ment strate­gies with the Nurse Prac­ti­tioner and the patient. The unique thing about Dr. Armstrong’s prac­tice is that rather than each patient receiv­ing a 10-minute check by the doc­tor, the patient receives at least 30 min­utes of exam time with the Nurse Prac­ti­tioner and Dr. Arm­strong together, which truly affords the patient the best care.

Through­out the first day, Dr. Arm­strong must have seen 30–40 patients and I was able to observe almost all of these inter­ac­tions. Sev­eral patients required that Dr. Arm­strong exam­ine them with a nasal endoscopy, which meant putting a scope into the nasal canal and show­ing video of it on a TV screen in order to visu­al­ize the inter­nal nasal anatomy. As he did this for dif­fer­ent patients, Dr. Arm­strong explained to me not only the anatomy of the nose, but also showed me how each patient’s prob­lem was unique. With cer­tain patients, the endoscopy would show struc­tural dam­age that was pre­vent­ing cor­rect breath­ing, and with one patient with chronic sinusi­tis I was able to visu­al­ize the true extent of dam­age that occurs in the nasal pas­sage­ways from such a dis­ease. With cer­tain patients who were expe­ri­enc­ing issues with their sinuses, Dr. Arm­strong used CAT scans to look at pic­tures show­ing what sinuses were filled with fluid and explained to me how he could tell when a sinus is dis­eased based on the pic­ture that appeared on the com­puter screen. This was reward­ing because after see­ing so many of both the endo­scopies and the CAT scans, I started being able to rec­og­nize when some­thing looked unusual.

Niv and Dr. Armstrong

One of the most inter­est­ing cases I saw was a patient with Meniere’s dis­ease. Being a mol­e­c­u­lar biol­ogy stu­dent, I found Dr. Armstrong’s expla­na­tion of the mis-regulation of sodium/potassium pumps lead­ing to fluid imbal­ance and ver­tigo very inter­est­ing. It was even more amaz­ing that we saw nearly the exact same case with the next patient when the dis­ease itself is genetic and rare. Dur­ing that first day, I learned many new things and was exposed to so many unique issues involved in ENT.

On the sec­ond day, Dr. Arm­strong had an entire day of surgery dur­ing which I was able to observe and ask ques­tions. We started out the morn­ing with sev­eral Myringo­tomies, which involved mak­ing a small inci­sion in the ear drum of patients who expe­ri­ence con­stant mid­dle ear infec­tions, and plac­ing a tube in the ear so that fluid can drain and hear­ing can improve. Dr. Arm­strong had a packed sched­ule that involved sev­eral of these in a row, but for nearly each one Dr. Arm­strong would pause and allow me to view the place­ment of the tube in the ear and would explain to me how each ear looked rel­a­tive to what it should look like. In addi­tion, Dr. Arm­strong also con­ducted sev­eral ade­noidec­tomies and one ton­sil­lec­tomy. Dr. Arm­strong used a unique tech­nique which used decreased tem­per­a­tures that reduced bleed­ing to dis­in­te­grate the ade­noids and to remove the ton­sils, which I was able to see as they were removed from the patient. I was also able to observe as Dr. Arm­strong used a scope to explore all the way from the esoph­a­gus down to the duo­de­num which was espe­cially amaz­ing because the view of the inter­nal anatomy was so clear. Dur­ing some of the more repet­i­tive pro­ce­dures, I was able to observe the work of a pedi­atric urol­o­gist, which involved a surgery to repair a cir­cum­ci­sion. I had never really con­sid­ered the impor­tance of a pedi­atric urol­o­gist so this was an extremely enlight­en­ing expe­ri­ence and the doc­tor was also an excel­lent teacher. Dr. Arm­strong fin­ished his day with a closed nasal recon­struc­tion. He explained to me and showed me each step of what he was doing, from remov­ing the deformed car­ti­lage and bone all the way to crush­ing the bones to recon­struct the sep­tum. Surgery day was amaz­ingly inter­est­ing and as busy as Dr. Armstrong’s day was, he always went out of his way to show me and explain to me what he was doing.

This Princetern­ship was one of the best expe­ri­ences I have had to date with med­i­cine and only fur­ther con­firmed my inter­est in it. I learned so much and I was wel­comed into the home of a won­der­ful fam­ily. I can­not express my grat­i­tude enough to Dr. Arm­strong and the Arm­strong fam­ily. I hope that other stu­dents in the future will get to expe­ri­ence the Rich­mond ENT Princetern­ship because it is truly a reward­ing experience.

Source: http://blogs.princeton.edu/princeternships2011-2012/2012/05/24/niv-milbar-13-richmond-ent