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. In addition to the many cases I saw with Dr. Armstrong, another doctor who works in the office, Dr. Shaw, invited me to watch as he injected collagen and Botox into a patient’s face. 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.