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Welcome to the upper hand, where Chuck and Chris talk hand surgery.
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We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Thank you for subscribing wherever you get your podcasts.
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And be sure to leave a review that helps us get the word out.
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Oh, hey, Chris.
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Hey, Chuck, how are you?
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I'm doing great. How are you?
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I'm good. It's always nice to do our little shtick in front of a guest.
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I know and we're lucky to have a guest, but we're gonna keep the audience, if they haven't read that read the title of the podcast, we're gonna keep them in suspense for a couple of minutes.
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How was your Thanksgiving?
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My Thanksgiving was good. It was a probably a certifiably appropriate Thanksgiving, it was my immediate five. My wife and myself and my three kids, and they were all eager to go elsewhere and be with people.
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And we didn't do it. So it was it was great. It was really good food and good time.
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Excellent. I cooked for 16. And I think just my wife and I ate most of it. My kids didn't really like most of what I prepared. But it was really for me. So I enjoyed it.
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Excellent.
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Excellent. All right. So let's jump into the routine things that we do here. Do you have a review to share with the audience at all?
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Yeah, we're always really thankful for our, for the reviews that our audience, community leaves. So this one is on iTunes, and it's from bikes and beer was left about 12 days ago. So thank you, for the five star review. We always love the five star reviews, we'll take anything we can get. But this one says I'm a Midwest shoulder and elbow surgeon who dabbles in some basic hand surgery, the podcast has been great for me to brush up on some basic hand topics and confirm my treatment algorithm. Thank you so much for your time and teaching. You're very welcome bikes and beer. And we like bikes and beer as well.
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And thank you for the review.
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Again, we appreciate when anybody goes on either iTunes or wherever you get your podcasts and, you know, rates us reviews us it is helpful keeps us going.
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So thank you again.
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Yeah, absolutely that's a that's a great review. And thanks for all the others have given us a review. But it's a nice segue.
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Because Chris and I are trying to figure out who our listeners are. It may seem like a silly question, but and we want to talk about what we want to talk about. But I think understanding who's listening helps us provide a better podcasts for everyone.
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Which leads us to our To our listener survey! So Wow, what a wonderful transition Chuck. So if you wouldn't mind going on. And filling out the listener survey, you can find it on social channels, as well as theupperhandpodcast.wustl.edu, there's a link to that, you will be entered for a chance to win the coveted upper hand coffee mug and I believe we're going to be doing a, do a drawing for the next episode. So we have to remember to do that.
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Yeah, we're keeping our guest in the dark here for just a little longer, but our guests should know that they will receive as a thank you an upper hand coffee mug. So you know, there's no monetary appreciation for you joining our podcasts. But there is a highly coveted mug. So that's coming your way soon.
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Any fun cases recently, Chuck?
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You know, I did an interesting one. And I would like to share briefly with you. I think I'm gonna keep it really simple. But, you know, I feel like I've been doing this for a long time. And hope that my my, some people call it their spidey sense if you're a spider man fan, but you know, when you when you look at an X ray or look at a patient and something just doesn't seem right. I think you have to listen to your intuition. And obviously, that's challenging when you're just out of fellowship, or even if you're in residency or fellowship. But what I tell my trainees is, I want them to talk to me when I'm doing a surgery. And if something seems like the wrong direction, or they're confused about why we're doing a surgery on a patient or inter operatively, the whole thing I want people conversing about what we're doing and why we're doing it. And I'll say that I'd had an unusual case where the X rays just didn't look right, it was a scaphoid fracture. And I'll just say that I did a scope. And I don't usually do that. And that was helpful to clear up a confusing picture for me, but I think my main point is without going into the details of the cases, you know, conversation is good. And I know, in the in the olden days, as we sometimes refer to them, you know, having a resident or fellow speak up or speak out was foreboden. And now there's so much talk about safety and stop the line and communication. I think that for me, it's incredibly important in who I am as a surgeon, that people feel comfortable with their thoughts, and that's why we have an indications conference, and we just want everything out front.
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And so Chris I don't know your thoughts on that in general, and I'd love to ask our guest opinion once we do a formal introduction.
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Yeah, I agree with you. I mean actually, as part of my orientation. I have in the bullet points that I go through with trainees like I will tell you when we are deviating from the board or the book answer and the reasons why if I remember, you know, when I walk out of room, there are just some patients you know what you're saying your spidey sense, your gumption, your intuition that you know, you're gonna have to do something differently, either based on the radiographic characteristics, or a lot of times it's patient personality.
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And you're going to do something a little bit different than how they would answer on the in training or on the on the CAQ.
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Perfect. All right, well, let's get into the meat of this podcast. So it is my great pleasure to welcome Asif Ilyas who is at the Rothman orthopaedic Institute in Philadelphia. He is a professor of Orthopedic Surgery at Jefferson. He is the fellowship director. He is also the president of Rothman opioid Foundation, which is really probably the key reason we're so grateful that he's joining us today. He's the past president of the Pennsylvania orthopedic society. And he's an outstanding hand surgeon, near and dear to my heart is also his sport, his love of sports, and the fact that he is a consultant for both the Philadelphia Eagles and the Philadelphia 76ers who have by the way, done a nice pivot this offseason, I'm interested to see what they can pull off. So they've they've done some interesting things. All right, so first of all, welcome. And thank you for joining us.
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Thank you guys.
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Chris, Chuck, thanks for that introduction. Thanks for having me. Happy to be here.
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Absolutely. So So how does what is what is your strategy in the OR to minimize risk of adverse events? and complications? Are you do you have an operating room that's easy going and flowing and trainees feel empowered to talk?
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Are you more kind of old school?
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What's your strategy?
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You know I'm not sure entirely where you are, where I definitely encourage open communication. I think it's really important, discussing the case beforehand. And then when things go a little bit off in terms of what we would normally do or what have you, we talked about it. And you use the term spidey sense. I use the term the force. So I find residency and fellowship is essentially Jedi training. And I tell all my trainees that really residency and fellowship training is about learning to see what you can't see, and to feel what you're doing. Because anyone can do what's directly in front of them. But it's knowing what's lurking in the soft tissue planes or in in the in the X ray that you can't obviously see that inference, that gumption that you also mentioned, I think that's the key. And when you're and when you're when you feel that disturbance in the force, you need to speak out and say, Listen, this doesn't seem right.
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And kind of act on that.
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I love that. That's, the force. I think the spidey sense is taking a backseat to the force, we are now going to start referring to it as the force.
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Well, I will just say one thing, though. So I, you know, I've been saying this since I was, you know, starting out in practice, and I really do feel that it's Jedi training.
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But it's funny, you know, I'm starting to I don't really feel old. But more and more residents are like I hadn't seen Star Wars before. And it really, it's like, it's a kick in the gut.
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And like, really, you've never seen it. I've actually made fellows watch Star Wars so they can understand my inferences.
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Otherwise, they just stand there staring at me. And that's no good. That's just makes for a really awkward one year if they don't know what I'm referring to.
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Well, we are in fellowship application season.
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So for anybody that's gonna be applying to fellowships, you have to laugh and understand your attending's references and really prepare for that rotation when you're with old guys like Chuck and Asif, I mean, you really got to be ready.
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Yeah, you know, it's funny, because we do joke about that all the time. I mean, I referenced Seinfeld, for example, which is, it's inconceivable that this generation would not know exactly what I mean with every Seinfeld reference. But it's not just the music anymore. Old school, TV, movies, everything.
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I still watch Seinfeld almost every day, because I have it on record. And it's like a warm blanket. I just put it on in the background. I could I could recite those episodes by heart, but they don't know. So there was, I had a medical student in the room the other day, and Nirvana was playing. And I asked him who sings this and they didn't know so I said it's Nirvana. And they said, Oh, that's classic rock.
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And it was just it was too much for me. I was like, Are you kidding me? But I guess from their perspective, it is 30 some years old. So they're not wrong.
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It is a classic.
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And it is a classic. That's true. So Asif we just had a, what Chris and I thought at least, we're biased, was a good three part series on distal radius fractures. And we would love if you shared a single pearl. We could probably talk all day about distal radius fractures, but share a single Pearl, about your how you think about distal radiuses or how you treat distal radiuses something that that we can latch on to and maybe talk about briefly.
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Sure, I mean, if you want to keep hand surgeons busy, have them talk about distal radius fractures and thumb basal during arthroplasty, they'll talk all day about that. And because we see a lot of it, we find it interesting. We're fairly good at it. There's a lot of nuances, a lot of little, you know, aspects to it that drive what we do. And you know, first to be kind of cynical, we probably over treat them surgically. I think nowadays, I think we've been very aggressive in managing them surgically. I think because, you know, they do well, we can mobilize people quickly. It's very consistent, the complication profile is pretty low. But it's also, I think, a fun case to do, and we can really help people with it.
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I think from from my practice, you know, being out now almost 15 years, it's I think the big advance for me was, I kind of grew up with the volar plate. I remember as a Junior resident, we started using volar plate.
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And we're still dorsal plating a lot. And then went to the volar plate, but I kind of trained through that period. So I'm very comfortable with that. And we've seen a big embrace broadly. But I think some of the alternative treatments and sometimes when a volar plate doesn't work is not the right choice. And I think I know you guys had talked about that, where it's a mistake to use a volar plate. And we always I had a mentor, who always said, you can't be a one trick pony you have to be able to, you know, manage different fractures in different ways. For me, I think one of the really interesting techniques that have come around and it's not new, but I think it's just been more normalized is bridge plating, where you span the wrist, and the fracture with the plate, either an anatomically designed plate specifically for that purpose, or just a DCP that you use. And what's the concept I like is this concept of an internal x fix, where you can really stabilize the wrist, you can really hold a fracture in the wrist out to length, you don't have to worry about pin track issues, there's not a rush to remove it, but you will need to remove it. And for me, I think where it helps in is, is in a polytrauma situation, I'm in a center where there's a lot of older folks who will often fix their hip or ankle along with the wrist fracture. So for me, I've come to use bridge plating a little bit more frequently by no means a high volume relative to volar plating, but more substantial to say 5-10 years ago where if I have someone who's has a lower extremity injury that needs to weight bear with that, where we would normally use a platform Walker, if you put a bridge plate and they can, they can weight bear normally on a regular Walker. It's well tolerated, it's comfortable. And the other issues I find where it's helpful are for you know, radial carpal instability patterns where there's a fractured distal radius and the wrist has been unstable, you can neutralize, or in cases of severe articular comminution where you don't think you're going to get a perfect reduction or stable reduction. I think a bridge plate is also a nice bailout, if you will, either by itself or as an adjunct to a volar plate. So it's a nice little technique, relatively easy to do with a good profile in terms of problems.
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Yeah, it's interesting. That's a great summary for sure. Maybe we can talk briefly about it. So I like bridge plating, and I certainly will do it, I probably do 60 distal radius fractures a year give or take mixed population of, you know, sick patients or older patients in the hospital and elective outpatient, I probably only do two or three bridge plates, I don't know what your ratio looks like. The other thing we should touch on and Chris and I are planning do a distal radius therapy session.
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To me, the most remarkable thing about bridge plating is you're locking up a joint completely for three or four months, then you take the bridge plate off, and patients are like, Okay, well, you know, go move my wrist, it's not that big a deal.
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It's, it's stunning to me. So is your ratio similar?
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It's exactly the same. We've studied our series here, and I'm about 5%, you know, we'll get we'll get a bridge plate, I'm probably doing about 75 distal radius a year, you know, I might do four to five, you know, and it's usually those type of scenarios enough that you notice enough that you're taking care of them, but not nowhere near, you know, take them all. But and I totally agree with you the motion, there's no motion loss, which is really remarkable. We have a series coming out where we looked at our outcomes and their motion is normal, it's like a like a volar plate motion once you're out far enough. The main if we're talking about it, I'll say there's two complications that I've noticed with them. One is a index MP joint and or middle MP joint tightness, where I think with the extensor mechanism has to run over top of the bridge plate, I think it tightens up those joints, they can usually get that back. And I'll often just do a manipulation under anesthesia when I take the plate out and just have to have a contraction just to you know, make, you know, manipulation just to loosen up that joint. But I think those joints get tight and I'll often go to the index or the middle depending on what, where it lines up better. And then the other issue I've had that I've corrected with changing my plate is I had I had a few fractured plates. So a lot of plates have holes in the middle segment. So if we're if you're applying it for someone who's weight bearing through so I use an analogy of someone, one of, my trauma partner Jim Creek uses this term called a functional quadraped someone who has used all four limbs to ambulate. So if you have a lower extremity injury, like a hip fracture using a walker, you're bearing weight through it so if you've got those holes in the middle of your plate, they're a huge stress risers and I've had two cases where they've they the plate broke, which is in and of itself, not a big deal. It's almost like dynamizing, if you will, but one of my cases resulted in a EPL rupture from that broken plate. So I've gone to a plate now that doesn't have holes in the middle to avoid that.
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So quick question, technical thing, I know that there are some surgeons that believe in going to the index versus the middle finger metacarpal for various reasons.
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Sometimes it's the fracture displacement. Sometimes it's the prominence with regards to the extensor mechanism. Where do you
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You know, honestly, Chris, I think I'll put a word go?
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where it sits the best. The logic of going to the index metacarpal. The best logic I've heard, I've heard different arguments for it. And it's probably 50/50, for me, to be fair is that the index metacarpal puts the wrist and slight ulnar deviation, which is mechanically advantageous, so if you grab a plate and grab a glass, use your walker, you're in a little bit of ulnar deviation. When you go in the middle, sometimes you're neutral to slightly radially deviated.
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And so I find that's a little bit better. But again, I'm happy to go middle. And I think to slide the plate in, it slides better through the third compartment, third, and fourth, and then the second, it's just a tighter compartment to get it through. But I think it wherever it fits the best and it gives the best alignment to hold the wrist for several weeks. I'll just add one thing. So what I do one thing I do from a technical perspective, I placed the incision in over the second webspace, I put it between the index and middle metacarpal. So I'm not I don't I don't commit to one or the other. So when I put the plate in, say the index metacarpal doesn't seem right, I can go to the middle metacarpal through the same incision, not burning bridges.
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Yeah, that's nice. And do you make multiple small incisions or you make one big incision?
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I make two small, so like, small and like three centimeters distal three centimeters proximal and I fixed distal first, then use your ligamentotaxis bring it out to length, I'm exposed proximately at this point. And then once I bring it out to length, then my second screw goes proximally in the shaft and I use a non locking in the beginning to kind of be able to crank down on it and compress the plate to the bone. And then I neutralized it with a locking screws above and below. I may or may not take out that that cortical screw based on how much stability I think it needs. I probably three locking screws above and below and one cortical shouldn't make a difference. So for the most part, I leave it be, but you can convert them all to lock or if you want to maximize rigid rigidity with the construct.
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maximize rigidity and maximize the reps monetary take home. Yeah, absolutely.
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Well, those, those heated seats aren't going to pay for themselves.
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All right. So let's I have an interesting segue into our topic. So my son had shoulder surgery on Wednesday. And we've there's been some surgeries in our house, but not a lot. And he had a slap lesion and instability, and it's been long standing. And this has been long term plan.
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And he's doing great, thankfully. And he was given 30 narcotic pills to take home. And it's been interesting, I haven't, you know, like most things my house, I'm an observer of most things in our house, not an active participant. But my wife is doling out she's doling out the narcotics to my 21 year old, which is good. And there has probably and he's doing great. Like he does not have much pain. And he's doing the Motrin, and you know, as well, but I think he's probably taken six pills since Wednesday, and I think he might be done. Which to me is somewhat remarkable. And I don't give him kudos for being the toughest kid, although clearly he's you know, at least reasonably tough. But it's just a really super interesting thing, my wife's fear of narcotics, which I think is appropriate. We've never had an issue in anyone in our extended family or friends that I'm aware of, but it's such a unbelievable crisis in our country that, you know, your expertise is going to be a really interesting discussion. And so I guess, Chris, any any opening comments, before we turn to our expert?
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Well, I mean, I'd like to know how, you know, clearly Asif you've made this a big part of your, you know, academic enterprise, you clearly have dedicated a lot of efforts and done an incredible amount of research and you know, you put in your effort where you're you're, you're walking the walk.
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So tell us about how you even started working in this space, because there's not a common area for hand surgeons to be working in.
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Yeah. So first of all, Chuck I'm happy your son's doing well, I'm going to be judging and say 30 pills were too many. And I think it's a great example of a concept of diversion, which we'll talk about is you know, we always had to be careful why the numbers we prescribe because, you know, opioids have value but street value plus abuse value. So you know, when you give someone too many Tylenols or too many Cephalexins it doesn't matter, right? But when you give too many and now you've got 24 in your medicine cabinet, your son may not do anything with it, but your son's friend comes over to play, you know, Xbox with them can grab them. So we got to be really careful about dissemination of opioids into the community because it's diversion potential. And if you look at studies that Have and I know I'm going off topic right away. But where people get their opioids from to abuse for those who do abuse 70% have come from friends and family, and typically not from their own doc. So it's not always that person is going to be the one necessarily it's that it's disseminated. But I digress. I'm sorry. So, um, so to answer your question, Chris, um, you know, it started kind of slowly, um, you know, I've been involved in research for a long time I enjoy doing research, I find that I know, you guys agree with this because I know you're, you're academic docs too, is that research just really adds that kind of, you know, that special seasoning to what we do, at the end of that, at the end of the day, you know, we're all in practice, we're doing our work, and we get pretty good at it and at the end of the day, we're just making the donuts, right, I mean, we can do 95% of our surgery without thinking about it at this point, just like any other. Any other you know, labouring specialist, guy who changes your tires versus builds your transmission versus fix your, fixes your distal radius, you get into rhythm, you know, how to problem solve, you know how to do it. To me research is where you kind of add that extra layer of challenging dogma. You know, seeing if we can do things better, trying to trying to get past like, I do this because of fill in the blank and actually seeing if it makes a difference.
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But, you know, in orthopedics, as you guys likely know, most of the research that we do doesn't make a huge lot of difference.
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It's incremental, you know, findings. Oh this is 10% better, this is 3% better, there's no difference, which I find frustrating. And then I had a few experiences early on in the pain management sphere, where I saw several patients who had some real complications from opioids, several of my own and several of my of my partners.
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And I realized that this is kind of a big deal. You know, we take this oath to do no harm and and I think we all believe that. But then we're inadvertently doing harm with the way that we're being nonchalant in terms of managing our patients pain. And then Chris, you mentioned as hand surgeons that's uncommon, but I would push back in that majority of hand surgeons today, are orthopedic surgeon, so we're used to, you know, the orthopedic world and management of musculoskeletal pain in an aggressive manner, we've all trained in residencies that had aggressive pain management strategies for the most part, and, and secondly, we're high volume surgeons. So, you know, we'll typically I'm sure you guys do 400, 500, 800, 1000 cases a year so imagine, if you're that shoulder surgeon who gave your son 30 pills and no offense to that person that's not an unreasonable number, it's a common number to give you multiply that by 500 800 cases per year by one person in one town in one area, that's you just start extrapolating that out, the inf- the impact we can have negatively is enormous. But at the flip side of that is the impact we can have positively if we look at this critically and improve on our practice habits is also enormous. And that's where I find that there's real value in this.
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So what was your normal standard prescribing pattern before you started paying attention?
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30 pills. 30 pills, just like Chuck said, I mean, you know, first water them but you guys in residency we used to write the the pain medications for our attendings. And it was not uncommon after a joint or spine case to write 50 or 100 pills at a time and to discharge them home. And my first couple years in practice, I gave everybody 30 pills, it didn't matter if I was doing a shoulder replacement, I was doing a distal humerus or after a carpal tunnel, they were getting 30 pills. And it was I don't think I was an anomaly. I think that was we didn't really pay attention to it. And we just gave those medications. And I think it was only a matter of time and the data kind of, you know, cropped up and snuck up on us and show that, you know, the medical field collectively might be doing some harm. And and I'm going to just drop a quick preface here because, you know, I often have this discussion.
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And sometimes I sound like someone who's beating on the medical profession and beating on doctors. That's not the point and also that I'm beating on opioids. That's not the point either. I think, firstly, let me just preface we can't do the work that we do without opioids.
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So this is not opiate bashing by any means. I mean, it is amazing what it allows us to do in helping people. That's the first thing. And the second thing I will say is that the opioid epidemic in America is multifactorial, we are not the problem singularly. We are one of the many, you know, contributors to the problem. And I would say first that we inadvertently have been contributing to this problem by by being, you know, not being aware of what we had been doing.
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But now we're embracing that now. But there's many other variables as well, including patients, by the way, the patients are a huge problem in this in terms of their own issues, psychiatrically, emotionally, substance abuse, expectations. pharma is a big problem in this and then the government's been a big problem with this in terms of their, you know, and societal bodies who have driven aggressive pain management. So it's very complicated. So I always want to put that out there that this is not doctor bashing, and what have you. But as doctors, and as scientists, we have a lot of authority here and credibility to impart positive change. And when we say things, and I can tell you being in the advocacy sphere, people listen to us, especially when you have strong evidence behind it. People absolutely, listen.
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It's a really interesting thing. Two additions, number one, it I have been really pleased to see that my patients understand the problem. And so when we talk about narcotics for post operative use, they get it. And most of them don't want anything special. And it's just a very different conversation that I had 15 years ago. So my mentality 15-20 years ago was two things. One, I don't want my patient to have to go back to the pharmacy pay another copay to get another prescription. So I want to give them enough that they're, you know, the, I don't want them ever to have to go back for for a refill. And second of all, I don't want them to call the office, right. And we want to minimize the burden on the patient and on our staff.
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And so we don't having to call back to ask for more narcotics, and so we gave them too many pills. But it is the work that you have done amongst others that have that have really shown us and, and I will share my son's experience with his shoulder surgeon that you know, even 30 pills may be way too many for a shoulder procedure.
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And again, I'm sure it runs the gamut from patient to patient, but it's really impactful stuff.
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And it's it is very different than an incremental improvement in a carpal tunnel, you know, surgery.
00:26:28.339 --> 00:26:45.859
So Chuck, what were you giving, say 10 years ago for carpal tunnel, or were you doing anything differently for a carpal tunnel versus a cubital tunnel versus a distal radius fracture? And what what is for both of you what's changed in terms of you know, what your standard prescribing is?
00:26:46.619 --> 00:27:08.579
Yeah, so my I'll go first, and then I'd love to hear Asif's thoughts. So my standard back in the day was essentially 30 pills across the board, any procedure you got, whether it be maybe maybe even a trigger finger, but definitely a carpal tunnel, and anything more significant was 30, Norcos, so hydrocodone with with Tylenol.
00:27:03.509 --> 00:27:18.150
And nowadays, I generally have three levels, the lowest level is carpals, and triggers. And I may get judged here and you should judge me, Asif if you think this is inappropriate, I have three levels,
00:27:18.210 --> 00:27:20.730
Chuck, this is a friendly place, we can, this is, it's okay,
00:27:21.539 --> 00:27:24.269
I can take it.
00:27:21.539 --> 00:27:45.029
But the first level is like a carpal or a trigger. And I still still I still do give almost every patient narcotics, so six or eight pills. The next level, I don't know would be a straightforward distal radius or something like that, which is typically 12 to 14 pills. And then I have another level which I rarely go to which is like 20 pills for something really big.
00:27:41.549 --> 00:27:50.190
So that's how I think about it, which again, I may be educated today. I hope I am. Asif, what do you do on a daily basis?
00:27:50.599 --> 00:29:21.589
Well, so I would just say a couple things. So firstly, Chuck, the fact that you're customizing your prescribing is a huge leap forward. And you know, when I talk about this with with with docs, when I hear that I'm heartened by that, because that's really, that's 90% of the game, right is is to make sure that we are customizing what we're doing. If you're a hand surgeon versus spine surgeon versus a urologic surgeon, you have to look at what your patients need, and give them that none of us want our patients to suffer. You know, and we've looked at why we were giving the numbers we were giving it you know, we assume it's laziness or habit. But it's for the reasons you mentioned, we don't want them to suffer, we don't want them to come try to find us in the middle of the night. We don't want them have to go to the emergency room because they ran out. We don't want them to use co pays. We don't want to get complaints in the office, we don't want to get bad reviews online, all of those things came into play and a lot of states and I hearken from Pennsylvania, we up until two years ago had to give an opioid on a paper prescription pad, you couldn't do electronically. So that's very limiting. So you would give them more because you don't know when you might be able to get in front of them again. And so but now we can go we've gone into electronic prescribing which we you know, we, my work on with the Pennsylvania orthopedic society was really centered around that is going to an electronic based system so that we don't have to over prescribe, we want to give them whatever they want, whatever they need, rather. But if we can give it easily then we don't have to give them 30 at a time we can give five at a time.
00:29:21.950 --> 00:29:56.480
And you know, then it's then it's a much safer way. So to- to answer your question. I do something similar I have my system is 5-10-20 everything that's soft tissue, hand, carpals, triggers, de Quervain's, they all they all get five. If you do if you do distal radius, tennis elbow, distal biceps, you get 10 and if I'm doing something big, like say a proximal humerus repair, a total shoulder, I'll give them 20 and it's uncommon but more important than that is so that's the first step right? You know, customizing based on strength.
00:29:56.509 --> 00:31:24.259
The second part is we haven't talked about yet is what are the other things you can do to control their pain right and I'm not just talking ice, patients love ice. So they're always like can I use ice? Absolutely knock yourself out as much ice as you want. It's on the house all the ice you want but but it's all the other things right it's the it's the counseling of patients before surgery talking to them about it. It is the use of anesthetics well in the OR in not just a proximal block but even in the surgical site. The site infiltration. It is the use of you know, other agents in during the operating during the procedure such as IV Tylenol and, NSAIDs. It's a use of multimodal agents such as gabapentin and Celebrex. And it's about really having them use that. So take your son, for example, you know if he was if I was operating on him, and that was what I did a slap repair on him, I would say listen, first thing is, you're going to get I'm going to give you toradol and trop you're going to go home on on either toradol, if they can take it, a young kid like him could take it. If not, I'll give I'll give you Naprosyn or Celebrex, you're going to take it for two weeks, you're going to take that round the clock twice a day, you goint to take it. Tylenol every four hours, you're going to take at least for three to five days. And then you're going to go to your to your opiate. And if you have that kind of thoughtful prop, you know, procedure of managing their pain and they know that you're thinking about it, and you're and you're and you're prescribing a certain strategy.
00:31:24.529 --> 00:31:47.299
Particular like your wife, I'm sure your wife is all over it, she probably wouldn't even ask you one thing, she didn't ask a single input from you, I'm sure because my wife would never ask me anything about this, she would take over complete control of this. And I would just stand there as an innocent bystander as an expert in the field she would ask not to. And so when she heard from her surgeon, her son's surgeon, this is a strategy, she would implement that. And I don't think your son will need more than three to five pills, even with the slap show which hurts.
00:31:47.660 --> 00:31:50.089
That's it.
00:31:47.660 --> 00:32:00.259
That's exactly right and the key for my son. And we are fortunate to have really talented anaesthesia partners. And you know, his block lasted probably 28 hours. And so that was huge.
00:31:56.000 --> 00:32:12.980
That was huge. So one one funny thing about our show Asif is that, despite the fact that I try to keep it general, I don't talk about congenital, sports is a minor part, it always comes back to nerves. So I'm going to beat Chris to the punch here.
00:32:09.680 --> 00:32:20.930
And and just put the hypothetical out there. Let's say I am doing God forbid I ever do a big brachial plexus case.
00:32:16.730 --> 00:32:36.650
So had that, you know, nerve pain and bigger exposure. Chris, jump in here at any point. Like To me, that's a very different case. And I don't know, I mean, multimodal for sure. But I guess maybe I'll put the I'll put a little burden on Chris to comment first, how do you think about that patient? Chris?
00:32:34.519 --> 00:32:38.089
Because I know you start with admitting some of those patients.
00:32:38.420 --> 00:33:36.559
Yeah, I mean, that's the top tier, right. You know, each of you, all of us have our three tier system. So that's the patient that is, you know, getting kind of a bigger prescription. But I do try to take steps, like Asif said, to mitigate the need or the subsequent potential dependence on the opioids, like a Plexus reconstruction, you know, is going to get admitted they're going to stay in the hospital overnight. Except if maybe it's only a couple of distal nerve transfers and no big exploration. You know, usually these patients are already on gabapentin or pregabalin or something of that nature. And then all of my patients who are having surgery, regardless of whether it's a Plexus or a trigger finger are getting a two week prescription of Meloxicam, that's my preferred anti inflammatory or NSAID, but other than that, I mean, you know, I tried to explain to them ahead of time, this is a big surgery, and you've already got nerve issues. How do you approach it?
00:33:33.049 --> 00:33:38.509
In your world Asif, I don't know how much nerve work you're doing?
00:33:39.410 --> 00:33:46.910
I mean, as hand surgeons we all have to right so, and I enjoy nerve surgery a lot. Actually.
00:33:43.519 --> 00:33:53.720
Let me let me reframe the question a little bit. You know, the work that we're doing with opioids and pain management, it's not about the exceptions.
00:33:53.720 --> 00:34:32.690
It's about the it's the general public, right? It's the general that we have to be cognizant of what we're doing and the harm we could be doing inadvertently, right. So the basal joints, the distal radius, the tennis elbows, the triggers. That's where the problem lies. If someone's got a complicated problem, and they end up taking 40 Norcos, I have no problem with that. They're the exceptions, right. So the mistake that's been made in the past is that we prescribe to the exceptions, not the average, right? So we should be prescribing to the average and we'll manage the exceptions with what they need, we're more than happy to help them and do what they need. But if we're managing every patient with, you know, a certain procedure or a certain condition exactly the same.
00:34:33.139 --> 00:34:59.539
That's where that's the that's the mistake. So, to not answer your question. Um, it's just like Chris said, it's multimodal, right? They got to be on they got to be on on nerve modulator, be it on gabapentin or pregabalin. They got to be on an anti inflammatory. They got to be on acetaminophen, that's the base that's the floor right and then on top of that, you're going to have to go to some strong opiates often and so be it and that's okay.
00:35:00.170 --> 00:35:18.289
Question, both of you mentioned that you have different tiers in terms of the number of pills you prescribe it. Do you have tiers in terms of which medications you prescribe? Because I tend to for carpals, and triggers I have a lower number, but I'll also use something like, I'll use acetaminophen with codeine. Is that something that you utilize?
00:35:18.289 --> 00:35:25.039
Do you use something like Tramadol or anything else? Or do you go mainly to the hydrocodones and even the
00:35:25.000 --> 00:35:25.280
You know, Chris, um, that's a great question. It oxycodones?
00:35:30.190 --> 00:35:41.409
really doesn't matter to me, you know, at that number three, four, or five pills, I'll ask the patient every time you know, when I'm doing my paperwork, you know, we're gonna be giving you this and I want to talk when we get some time about counseling.
00:35:42.010 --> 00:36:23.829
And I'll ask them, have you had any painkillers before? Is there anything that works or doesn't work for you? Right? And I will say the majority of time people have had some experience and say it I'm fine with whatever or I can't take x, y and z or what have you. And really, even though To be fair, the MEU or the MME whatever acronym you like to use for morphine equivalent is different between Tylenol with codeine, hydrocodone or Vicodin or Norco or, or oxycodone or Percocet or roxicet. To me at three to five pills, it doesn't matter a whole lot. So I'm okay with any of those. I tend to answer your question fully. I usually start with oxycodone. Because I can add Tylenol to it, no problem.
00:36:21.070 --> 00:36:30.010
It's well tolerated amongst them, and people seem to be familiar with it. So it's an easier explanation to people what that is, but it doesn't matter to me otherwise.
00:36:31.079 --> 00:37:11.159
You know, I was and I honestly don't know the science behind this. But I was told that I can't give Tylenol with codeine to my kids anymore at the Children's Hospital. And so I've kind of just along with losing Darvocet, which I love for kind of a low impact pain pill. And I don't give TC threes anymore, or tylenol with codeine. So for me, my baseline is Norco. I do ask patients, I tell them in the preoperative holding area or in the clinic that I'm going to give you six or eight pain pills. I typically give hydrocodone most of them say great. Some of them say that one doesn't work for me. Can I have Percocet? I'm like, Sure, no problem, you know, because I'm not giving you 30 pills. But that's that's my strategy, which I think mirrors what we just heard. Chris, any other thoughts?
00:37:11.570 --> 00:37:31.909
I mean, I think that the thing that I think led lots of us to change our practices were a lot of the papers that came out and some of them were from you Asif about how many pills patients actually take after these surgeries. And so having been involved in some of that research, how has your own work and perhaps those of some of our colleagues, how has that informed your practice, as of 2020.
00:37:32.769 --> 00:37:48.909
Yeah, so Chris, I have like four very basic advice to, you know, my peers, my practicing docs who give this is, number one, have a counseling strategy with your surgical patients. And I'll talk a little bit more about that.
00:37:48.909 --> 00:38:52.570
And when we have some time about how I do that, so that they understand what they're getting, they understand your your kind of strategy. And your goal to provide them a good pain relief without over treating them. Two, to utilize a multimodal pain strategy during the perioperative course, three to customize the pain medication to the procedure you're doing right? So it shouldn't be like we used to 30 for everybody, it should be deliberate to the type of procedure you're doing. And that requires informally surveying your patients. You know, you don't have to do a research paper you don't have to publish something on it, you can just ask them and say what did you end up using, you know, in terms of that process, and then on the back end, making sure that they are they're not only going home with just take you know, painkillers when they need it, but there're all these other things that they're very comfortable using, like ice but beyond ice, NSAIDs and Tylenol as their base treatment and then the painkiller goes on top.
00:38:53.170 --> 00:39:08.110
Because I think there's a cultural problem in America where I'll give you a challenge, next time you want to send a patient out of the PACU after a carpal tunnel trigger, which is the most basic thing that we do try to send them out without a pain medication prescription.
00:39:05.590 --> 00:39:16.630
Let me see how far they'll get without you getting a phone call. I'm going to tell you right now they won't even hit the elevator before three nurses call you and say Where's their pain medication prescription?
00:39:16.630 --> 00:39:50.469
Right? So that's the culture that we have to, you know, operate within and possibly change hopefully change. And that that can that can that'll start with you having a deliberate strategy when you have a deliberate strategy, everyone notices a patient notices a family notices, and the staff notices that the doc wants them to do this. And if you do those things about counseling, perioperative analgesia, customized opioids and multimodal pain strategy afterwards. That's it. That's that's, that's that that's all you really have to do. You'll be in great shape for your for your community.
00:39:51.690 --> 00:40:04.289
So you've done a lot of advocacy work and you've obviously done a lot of education of, you know, our colleagues and our peers and tell us about this foundation that you're working On now and, you know, it's clearly a big initiative.
00:40:05.260 --> 00:40:08.260
Yeah. Thanks, Chris.
00:40:05.260 --> 00:40:18.730
Yeah, it is, um, you know, as you mentioned, we've done a lot of work in the pain management space. And I practice that at the Rothman orthopaedic Institute in Philadelphia. It's a big orthopedic practice, I would say the preeminent No, no offense to you guys, but the preeminent-
00:40:18.760 --> 00:40:19.929
Excuse me, excuse me, excuse me
00:40:19.929 --> 00:40:21.190
orthopedic practice nationally.
00:40:21.219 --> 00:40:23.050
I didn't meant to block you out there.
00:40:27.849 --> 00:40:30.670
You can bleep that out later. I guess I said that, but
00:40:30.599 --> 00:40:38.969
I'll give you Pennsylvania. I mean it's a classic in Penssylvania and you know, I trained in some places that are East of you and I think that they're being special for that too.
00:40:39.840 --> 00:40:42.630
You guys have a wonderful practice No, no doubt about it.
00:40:42.630 --> 00:41:14.519
Well, one of the one of the things that's really strong about what we do is the embrace of research. So for a practice that is, is 100%. So I'll give you just a quick two seconds story. When I when I joined the organization about 10 plus years ago, the chairman was Todd Albert at the time, and a great guy who's moved on to New York and now is semi retired, I believe. He said, in this practice were both 100% academic and 100% private practice. And obviously, that math doesn't make sense. But he was making a point what the priority is. So that's always been the priority.
00:41:10.980 --> 00:41:18.030
So for, for nerds, like me, it's a great place to be because it embraces the scientific process.
00:41:18.329 --> 00:42:21.389
So you know, we we've done a lot of research in this space and our research sort of spillover beyond just one or two services across the entire practice. And we decided, as an organization that we should really embrace this work and take it to the next level, because it's very impactful, we can really, you know, improve the lives of our community, and help the practice of our of our, our peers. So that was the rationale and the mission of the foundation. So first of all, it's a it's a nonprofit. So it's an IRS designated 503c, so it's 100% nonprofit. So all of it shares the name Rothman and it's, it's its own entity. And the mission is threefold. So number one, it's education. Number two, it's research. And number three it's advocacy. So just drilling down further on the education, we're educating both patients and prescribers on safe opioid consumption and prescribing habits respectively. Number two, we're performing research on pain manage- opiate sparing pain management strategies. And I can drill down more on that, because we've got some interesting things that we're working on.
00:42:21.840 --> 00:43:30.869
And number three, we do advocacy work almost like a think tank where we synthesize information that's out there, some of it's data we produce, and a lot of it's data from the outside. we synthesize it for analyses that we then give our policymakers and we, we advocate for certain laws and policies that we think are going to help the community, help the community and the country at large. So that's broadly what we're doing. And it's been really, it's been really great, there's been a lot of support a lot of interest, we are already making a lot of traction. And just to drill down a little bit on the research part just for a second, because as you as scientists, you guys will appreciate this, is that we're doing a lot of different things, some of the stuff that we're doing is things that you're very familiar with, like, you know, the pain management research in orthopedics and hand surgery about, you know, prescribing better and multimodal pain strategies, opioid sparing strategies. But we're also doing a lot of research on on public health data that we now have access to, through the CDC and through Pennsylvania, it's fascinating to see the different trends and weaknesses across the country where there's certain areas more susceptible to other areas. And those strategies need to be made customized and targeted for the areas that need help. And thirdly, we're doing a lot of work in medical cannabis now.
00:43:27.539 --> 00:43:47.820
Because we're really seeing a strong role for medical cannabis as an alternative to opioids in the chronic pain and neuropathic pain category. And that kind of touches a little bit with what we talked about, about the nerve pain, patient, there's really a strong role for that. But we're still trying to distill that a little bit more, so we can have some strong evidence to support its usage.
00:43:48.840 --> 00:44:11.070
That's fantastic. You know, kudos to you on you and your colleagues, for that work, and to your institution for having the foresight and the guts to really invest resources in that. I think the advocacy stuff is going to be really interesting, as you're compiling all these white papers and everything. What do you think the general public or at least physicians are going to be seeing in 2021, in terms of advocacy pushes?
00:44:12.000 --> 00:44:21.659
Well, you know, I think Chuck mentioned earlier, I've been impressed by how receptive patients and policymakers have been on this.
00:44:18.960 --> 00:44:29.639
I think part of the reason is that no one's really immune to this, this is not a problem that's limited to a certain demographic, age, gender region.
00:44:30.360 --> 00:44:50.849
So everyone has stories of people they know, who've had opiod related problems. So and it's a concept people also understand it's not you try you know, we have to deal with all the time, trying to explain to someone an inner carpal fusion versus a PRC for a SLAC wrist and look at you like you have three heads. It's, it's bizarre, there's nobody other than hand surgeons who understand why you would do those things, right.
00:44:51.300 --> 00:45:07.380
But opioids, on the other hand, is a concept that people really understand and have embrace and it's been actually a very natural crossroads where we can positively impact the community and positively engage with our policymakers, our legislators.
00:45:07.860 --> 00:45:24.780
And frankly, the legislators have been very receptive. In Pennsylvania as an example, there's two big things that we've done. One is to help drive the installation of the PDMP, the prescription drug monitoring program, I think your state may already have had it. We were one of the later states to pick it up. We're, you know,
00:45:25.079 --> 00:45:33.329
yeah, so yeah, let me interrupt you to tell you a not so proud fact, we're the only state in the union that does not have a statewide prescription drug monitoring program.
00:45:33.349 --> 00:45:36.739
I was giving you guys some credit, but I guess I was wrong. So, so but
00:45:36.860 --> 00:45:39.409
The only state, if I didn't say that the first time.
00:45:39.480 --> 00:46:23.219
Well, we were we were we were slow to the game as well. And you guys will get there where, you know, you can, you know, monitor and query people's opioid use. And the second thing that we really fought hard for in the legislature, we champion was e-prescribing. And for the reasons, you know, previously mentioned that if we can electronically prescribe from our laptops or phones, through a secure mechanism, we don't have to over prescribe. So if you need, if I if Chuck gives five for his carpal tunnel, and they need five more, it's not a big deal. He can do that from home at any time or from his phone versus giving 30 because somebody might need a little bit more than five, right? So those are two things that we we worked hard to achieve. And that has a very positive effects. And we're about to publish some data.
00:46:23.519 --> 00:47:11.730
We're looking at the the decrease in opiate prescribing, and it's astronomical, I mean, the number the drop off of opioid pills being prescribed across Pennsylvania, is unbelievable, since the institution of this statewide, not orthopedics, not hand surgery, but statewide, by putting these things through, and the hope is that in time, that will translate to, you know, decreased opiate abuse, addiction and deaths. And that's gonna, we're going to have to see so, you know, when we deal with this opioid issue, there's different ways to tackle it, we're tackling it more on the prevention side, where we're trying to mitigate exposure sensitization and distribution of opioids, there's other sides in terms of treatment of those who have and an access to treatment. That's a whole other arena. But I think where we can have an impact is on the on the prevention side of not even getting it out there.
00:47:13.579 --> 00:47:43.789
That is fantastic. Obviously, congratulations on your work, it is incredibly impactful. And I do think you've found a way to really change the practice of of hand surgery for sure. But even much bigger than hand surgery, I would like to close with a question, which is, I my favorite book on this topic, is Sam Quinones' book, I think I pronounced that correctly, you know, Dreamland? Are there other impactful books that you have read that you might share with the audience? Or is that one hit home as one of the best,
00:47:44.199 --> 00:48:12.190
You know, I've read that book as well. And, and, and actually, it's funny, you mentioned Sam, because I had invited him to be our keynote back in 2019, at our annual meeting, because I thought his book was so impactful. You know, books like that really hit home in terms of kind of making it more understandable. Another book that also had, I think, a positive effect, which is wasn't dedicated to opioids, per se, but kind of brought it to light was Hillbilly Elegy by JD Vance.
00:48:12.760 --> 00:49:10.360
It wasn't about opioids, but it showed the underside of the parts of the country that have their own socioeconomic stresses and how they can be more susceptible to opioid abuse as an outlet if they have that opportunity. So, you know, and work like that, books like that really help, you know, make it more understandable for the public and even for us. So that was a great book, if you haven't read it, it's a great book to read. It's an easy read, and he really tackles it from with the eyes of a journalist because that's his, his background is journalism. And he he tackles it from that perspective, and moreover, he tackles it from from the from the drug side, the drug cartel side, I'm blanking on the on the town in Mexico he always referenced but from the drug cartel side, from the government side, from pharma side and from the the physician side as well and how it contributes, you know, to has contributed to this problem.
00:49:11.019 --> 00:49:26.739
Now Asif, my generation and those younger than me, we tend to be more video learners. So those that are listening will be excited to know that Hillbilly Elegy is actually coming out on, as a movie pretty soon so you can also get to get the knowledge that way.
00:49:28.059 --> 00:49:29.949
Chris, I did hear it got bad reviews though on that.
00:49:29.949 --> 00:49:31.000
Just so you know, so
00:49:31.119 --> 00:49:42.250
I'm sure the book is better, but it's a lot harder to sit through the book. Asif, this is fantastic. If anybody wants to learn more about the Rothman opioid Foundation, how can they learn more?
00:49:42.690 --> 00:50:21.389
Sure, first of all, I think starting at our website at www.Rothmanopioid.org is the way to best way to kind of get a sense of what we're doing and to connect with us. I'm happy to connect with anyone on this topic. And it's a nonprofit so if anyone wants to donate by By all means we accept donations through the website and I want to make a call out to my my board and our contributor contributors you know no member of the board and and and neither myself take any kind of compensation for our work everyone is just contributing their time and and and expertise to this for the greater good so all money donated go to to the work itself
00:50:23.010 --> 00:50:37.380
That that's awesome Chris and I are also nonprofit and unfortunately our pleas for financial support are are shamed compared to your pleas for financial support so support Rothman, not Chris and I, we've accepted that ours is a money losing proposition.
00:50:37.590 --> 00:50:40.349
I will include support the Rothman opioid foundation.
00:50:41.280 --> 00:50:44.010
Yeah, that's well, that's correct. That's correct.
00:50:44.010 --> 00:50:44.340
You're right.
00:50:45.179 --> 00:51:01.980
Thank you for joining us. And if anybody has any other inquiries, feel free to email us handpodcast@gmail.com we can get anything that you send along to Asif as well. And Asif, thank you for joining us, you've truly made a difference for your community, which is fantastic.
00:50:59.760 --> 00:51:01.980
So thank you.
00:51:02.309 --> 00:51:03.780
Thank you, Chris.
00:51:02.309 --> 00:51:05.670
Thank you, Chuck. It's been a pleasure. Always a pleasure.
00:51:03.780 --> 00:51:05.670
Anything Great job, by the way.
00:51:05.670 --> 00:51:12.480
This podcast is great. And, as mentioned, today's generation likes to listen and watch and you guys have hit the nail on the head. This is great.
00:51:13.710 --> 00:51:16.230
Hey, Chris, that was fun. Let's do it again real soon.
00:51:16.469 --> 00:51:21.420
Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
00:51:21.750 --> 00:51:24.599
Mine is@congenitalhand. What about you?
00:51:24.750 --> 00:51:31.920
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
00:51:32.579 --> 00:51:35.789
And remember, please subscribe wherever you get your podcast
00:51:35.849 --> 00:51:38.460
and be sure to leave a review that helps us get the word out.
00:51:38.820 --> 00:51:45.119
Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time.
00:00:10.769 --> 00:00:14.460
Welcome to the upper hand, where Chuck and Chris talk hand surgery.
00:00:14.789 --> 00:00:21.480
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
00:00:22.050 --> 00:00:25.230
Thank you for subscribing wherever you get your podcasts.
00:00:25.440 --> 00:00:28.170
And be sure to leave a review that helps us get the word out.
00:00:28.350 --> 00:00:29.039
Oh, hey, Chris.
00:00:29.070 --> 00:00:30.089
Hey, Chuck, how are you?
00:00:30.899 --> 00:00:32.700
I'm doing great. How are you?
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I'm good. It's always nice to do our little shtick in front of a guest.
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I know and we're lucky to have a guest, but we're gonna keep the audience, if they haven't read that read the title of the podcast, we're gonna keep them in suspense for a couple of minutes.
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How was your Thanksgiving?
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My Thanksgiving was good. It was a probably a certifiably appropriate Thanksgiving, it was my immediate five. My wife and myself and my three kids, and they were all eager to go elsewhere and be with people.
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And we didn't do it. So it was it was great. It was really good food and good time.
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Excellent. I cooked for 16. And I think just my wife and I ate most of it. My kids didn't really like most of what I prepared. But it was really for me. So I enjoyed it.
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Excellent.
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Excellent. All right. So let's jump into the routine things that we do here. Do you have a review to share with the audience at all?
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Yeah, we're always really thankful for our, for the reviews that our audience, community leaves. So this one is on iTunes, and it's from bikes and beer was left about 12 days ago. So thank you, for the five star review. We always love the five star reviews, we'll take anything we can get. But this one says I'm a Midwest shoulder and elbow surgeon who dabbles in some basic hand surgery, the podcast has been great for me to brush up on some basic hand topics and confirm my treatment algorithm. Thank you so much for your time and teaching. You're very welcome bikes and beer. And we like bikes and beer as well.
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And thank you for the review.
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Again, we appreciate when anybody goes on either iTunes or wherever you get your podcasts and, you know, rates us reviews us it is helpful keeps us going.
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So thank you again.
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Yeah, absolutely that's a that's a great review. And thanks for all the others have given us a review. But it's a nice segue.
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Because Chris and I are trying to figure out who our listeners are. It may seem like a silly question, but and we want to talk about what we want to talk about. But I think understanding who's listening helps us provide a better podcasts for everyone.
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Which leads us to our To our listener survey! So Wow, what a wonderful transition Chuck. So if you wouldn't mind going on. And filling out the listener survey, you can find it on social channels, as well as theupperhandpodcast.wustl.edu, there's a link to that, you will be entered for a chance to win the coveted upper hand coffee mug and I believe we're going to be doing a, do a drawing for the next episode. So we have to remember to do that.
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Yeah, we're keeping our guest in the dark here for just a little longer, but our guests should know that they will receive as a thank you an upper hand coffee mug. So you know, there's no monetary appreciation for you joining our podcasts. But there is a highly coveted mug. So that's coming your way soon.
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Any fun cases recently, Chuck?
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You know, I did an interesting one. And I would like to share briefly with you. I think I'm gonna keep it really simple. But, you know, I feel like I've been doing this for a long time. And hope that my my, some people call it their spidey sense if you're a spider man fan, but you know, when you when you look at an X ray or look at a patient and something just doesn't seem right. I think you have to listen to your intuition. And obviously, that's challenging when you're just out of fellowship, or even if you're in residency or fellowship. But what I tell my trainees is, I want them to talk to me when I'm doing a surgery. And if something seems like the wrong direction, or they're confused about why we're doing a surgery on a patient or inter operatively, the whole thing I want people conversing about what we're doing and why we're doing it. And I'll say that I'd had an unusual case where the X rays just didn't look right, it was a scaphoid fracture. And I'll just say that I did a scope. And I don't usually do that. And that was helpful to clear up a confusing picture for me, but I think my main point is without going into the details of the cases, you know, conversation is good. And I know, in the in the olden days, as we sometimes refer to them, you know, having a resident or fellow speak up or speak out was foreboden. And now there's so much talk about safety and stop the line and communication. I think that for me, it's incredibly important in who I am as a surgeon, that people feel comfortable with their thoughts, and that's why we have an indications conference, and we just want everything out front.
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And so Chris I don't know your thoughts on that in general, and I'd love to ask our guest opinion once we do a formal introduction.
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Yeah, I agree with you. I mean actually, as part of my orientation. I have in the bullet points that I go through with trainees like I will tell you when we are deviating from the board or the book answer and the reasons why if I remember, you know, when I walk out of room, there are just some patients you know what you're saying your spidey sense, your gumption, your intuition that you know, you're gonna have to do something differently, either based on the radiographic characteristics, or a lot of times it's patient personality.
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And you're going to do something a little bit different than how they would answer on the in training or on the on the CAQ.
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Perfect. All right, well, let's get into the meat of this podcast. So it is my great pleasure to welcome Asif Ilyas who is at the Rothman orthopaedic Institute in Philadelphia. He is a professor of Orthopedic Surgery at Jefferson. He is the fellowship director. He is also the president of Rothman opioid Foundation, which is really probably the key reason we're so grateful that he's joining us today. He's the past president of the Pennsylvania orthopedic society. And he's an outstanding hand surgeon, near and dear to my heart is also his sport, his love of sports, and the fact that he is a consultant for both the Philadelphia Eagles and the Philadelphia 76ers who have by the way, done a nice pivot this offseason, I'm interested to see what they can pull off. So they've they've done some interesting things. All right, so first of all, welcome. And thank you for joining us.
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Thank you guys.
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Chris, Chuck, thanks for that introduction. Thanks for having me. Happy to be here.
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Absolutely. So So how does what is what is your strategy in the OR to minimize risk of adverse events? and complications? Are you do you have an operating room that's easy going and flowing and trainees feel empowered to talk?
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Are you more kind of old school?
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What's your strategy?
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You know I'm not sure entirely where you are, where I definitely encourage open communication. I think it's really important, discussing the case beforehand. And then when things go a little bit off in terms of what we would normally do or what have you, we talked about it. And you use the term spidey sense. I use the term the force. So I find residency and fellowship is essentially Jedi training. And I tell all my trainees that really residency and fellowship training is about learning to see what you can't see, and to feel what you're doing. Because anyone can do what's directly in front of them. But it's knowing what's lurking in the soft tissue planes or in in the in the X ray that you can't obviously see that inference, that gumption that you also mentioned, I think that's the key. And when you're and when you're when you feel that disturbance in the force, you need to speak out and say, Listen, this doesn't seem right.
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And kind of act on that.
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I love that. That's, the force. I think the spidey sense is taking a backseat to the force, we are now going to start referring to it as the force.
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Well, I will just say one thing, though. So I, you know, I've been saying this since I was, you know, starting out in practice, and I really do feel that it's Jedi training.
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But it's funny, you know, I'm starting to I don't really feel old. But more and more residents are like I hadn't seen Star Wars before. And it really, it's like, it's a kick in the gut.
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And like, really, you've never seen it. I've actually made fellows watch Star Wars so they can understand my inferences.
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Otherwise, they just stand there staring at me. And that's no good. That's just makes for a really awkward one year if they don't know what I'm referring to.
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Well, we are in fellowship application season.
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So for anybody that's gonna be applying to fellowships, you have to laugh and understand your attending's references and really prepare for that rotation when you're with old guys like Chuck and Asif, I mean, you really got to be ready.
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Yeah, you know, it's funny, because we do joke about that all the time. I mean, I referenced Seinfeld, for example, which is, it's inconceivable that this generation would not know exactly what I mean with every Seinfeld reference. But it's not just the music anymore. Old school, TV, movies, everything.
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I still watch Seinfeld almost every day, because I have it on record. And it's like a warm blanket. I just put it on in the background. I could I could recite those episodes by heart, but they don't know. So there was, I had a medical student in the room the other day, and Nirvana was playing. And I asked him who sings this and they didn't know so I said it's Nirvana. And they said, Oh, that's classic rock.
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And it was just it was too much for me. I was like, Are you kidding me? But I guess from their perspective, it is 30 some years old. So they're not wrong.
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It is a classic.
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And it is a classic. That's true. So Asif we just had a, what Chris and I thought at least, we're biased, was a good three part series on distal radius fractures. And we would love if you shared a single pearl. We could probably talk all day about distal radius fractures, but share a single Pearl, about your how you think about distal radiuses or how you treat distal radiuses something that that we can latch on to and maybe talk about briefly.
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Sure, I mean, if you want to keep hand surgeons busy, have them talk about distal radius fractures and thumb basal during arthroplasty, they'll talk all day about that. And because we see a lot of it, we find it interesting. We're fairly good at it. There's a lot of nuances, a lot of little, you know, aspects to it that drive what we do. And you know, first to be kind of cynical, we probably over treat them surgically. I think nowadays, I think we've been very aggressive in managing them surgically. I think because, you know, they do well, we can mobilize people quickly. It's very consistent, the complication profile is pretty low. But it's also, I think, a fun case to do, and we can really help people with it.
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I think from from my practice, you know, being out now almost 15 years, it's I think the big advance for me was, I kind of grew up with the volar plate. I remember as a Junior resident, we started using volar plate.
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And we're still dorsal plating a lot. And then went to the volar plate, but I kind of trained through that period. So I'm very comfortable with that. And we've seen a big embrace broadly. But I think some of the alternative treatments and sometimes when a volar plate doesn't work is not the right choice. And I think I know you guys had talked about that, where it's a mistake to use a volar plate. And we always I had a mentor, who always said, you can't be a one trick pony you have to be able to, you know, manage different fractures in different ways. For me, I think one of the really interesting techniques that have come around and it's not new, but I think it's just been more normalized is bridge plating, where you span the wrist, and the fracture with the plate, either an anatomically designed plate specifically for that purpose, or just a DCP that you use. And what's the concept I like is this concept of an internal x fix, where you can really stabilize the wrist, you can really hold a fracture in the wrist out to length, you don't have to worry about pin track issues, there's not a rush to remove it, but you will need to remove it. And for me, I think where it helps in is, is in a polytrauma situation, I'm in a center where there's a lot of older folks who will often fix their hip or ankle along with the wrist fracture. So for me, I've come to use bridge plating a little bit more frequently by no means a high volume relative to volar plating, but more substantial to say 5-10 years ago where if I have someone who's has a lower extremity injury that needs to weight bear with that, where we would normally use a platform Walker, if you put a bridge plate and they can, they can weight bear normally on a regular Walker. It's well tolerated, it's comfortable. And the other issues I find where it's helpful are for you know, radial carpal instability patterns where there's a fractured distal radius and the wrist has been unstable, you can neutralize, or in cases of severe articular comminution where you don't think you're going to get a perfect reduction or stable reduction. I think a bridge plate is also a nice bailout, if you will, either by itself or as an adjunct to a volar plate. So it's a nice little technique, relatively easy to do with a good profile in terms of problems.
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Yeah, it's interesting. That's a great summary for sure. Maybe we can talk briefly about it. So I like bridge plating, and I certainly will do it, I probably do 60 distal radius fractures a year give or take mixed population of, you know, sick patients or older patients in the hospital and elective outpatient, I probably only do two or three bridge plates, I don't know what your ratio looks like. The other thing we should touch on and Chris and I are planning do a distal radius therapy session.
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To me, the most remarkable thing about bridge plating is you're locking up a joint completely for three or four months, then you take the bridge plate off, and patients are like, Okay, well, you know, go move my wrist, it's not that big a deal.
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It's, it's stunning to me. So is your ratio similar?
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It's exactly the same. We've studied our series here, and I'm about 5%, you know, we'll get we'll get a bridge plate, I'm probably doing about 75 distal radius a year, you know, I might do four to five, you know, and it's usually those type of scenarios enough that you notice enough that you're taking care of them, but not nowhere near, you know, take them all. But and I totally agree with you the motion, there's no motion loss, which is really remarkable. We have a series coming out where we looked at our outcomes and their motion is normal, it's like a like a volar plate motion once you're out far enough. The main if we're talking about it, I'll say there's two complications that I've noticed with them. One is a index MP joint and or middle MP joint tightness, where I think with the extensor mechanism has to run over top of the bridge plate, I think it tightens up those joints, they can usually get that back. And I'll often just do a manipulation under anesthesia when I take the plate out and just have to have a contraction just to you know, make, you know, manipulation just to loosen up that joint. But I think those joints get tight and I'll often go to the index or the middle depending on what, where it lines up better. And then the other issue I've had that I've corrected with changing my plate is I had I had a few fractured plates. So a lot of plates have holes in the middle segment. So if we're if you're applying it for someone who's weight bearing through so I use an analogy of someone, one of, my trauma partner Jim Creek uses this term called a functional quadraped someone who has used all four limbs to ambulate. So if you have a lower extremity injury, like a hip fracture using a walker, you're bearing weight through it so if you've got those holes in the middle of your plate, they're a huge stress risers and I've had two cases where they've they the plate broke, which is in and of itself, not a big deal. It's almost like dynamizing, if you will, but one of my cases resulted in a EPL rupture from that broken plate. So I've gone to a plate now that doesn't have holes in the middle to avoid that.
00:15:05.730 --> 00:15:13.379
So quick question, technical thing, I know that there are some surgeons that believe in going to the index versus the middle finger metacarpal for various reasons.
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Sometimes it's the fracture displacement. Sometimes it's the prominence with regards to the extensor mechanism. Where do you
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You know, honestly, Chris, I think I'll put a word go?
00:15:24.409 --> 00:15:49.610
where it sits the best. The logic of going to the index metacarpal. The best logic I've heard, I've heard different arguments for it. And it's probably 50/50, for me, to be fair is that the index metacarpal puts the wrist and slight ulnar deviation, which is mechanically advantageous, so if you grab a plate and grab a glass, use your walker, you're in a little bit of ulnar deviation. When you go in the middle, sometimes you're neutral to slightly radially deviated.
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And so I find that's a little bit better. But again, I'm happy to go middle. And I think to slide the plate in, it slides better through the third compartment, third, and fourth, and then the second, it's just a tighter compartment to get it through. But I think it wherever it fits the best and it gives the best alignment to hold the wrist for several weeks. I'll just add one thing. So what I do one thing I do from a technical perspective, I placed the incision in over the second webspace, I put it between the index and middle metacarpal. So I'm not I don't I don't commit to one or the other. So when I put the plate in, say the index metacarpal doesn't seem right, I can go to the middle metacarpal through the same incision, not burning bridges.
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Yeah, that's nice. And do you make multiple small incisions or you make one big incision?
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I make two small, so like, small and like three centimeters distal three centimeters proximal and I fixed distal first, then use your ligamentotaxis bring it out to length, I'm exposed proximately at this point. And then once I bring it out to length, then my second screw goes proximally in the shaft and I use a non locking in the beginning to kind of be able to crank down on it and compress the plate to the bone. And then I neutralized it with a locking screws above and below. I may or may not take out that that cortical screw based on how much stability I think it needs. I probably three locking screws above and below and one cortical shouldn't make a difference. So for the most part, I leave it be, but you can convert them all to lock or if you want to maximize rigid rigidity with the construct.
00:17:14.430 --> 00:17:19.500
maximize rigidity and maximize the reps monetary take home. Yeah, absolutely.
00:17:19.529 --> 00:17:22.980
Well, those, those heated seats aren't going to pay for themselves.
00:17:26.079 --> 00:17:40.359
All right. So let's I have an interesting segue into our topic. So my son had shoulder surgery on Wednesday. And we've there's been some surgeries in our house, but not a lot. And he had a slap lesion and instability, and it's been long standing. And this has been long term plan.
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And he's doing great, thankfully. And he was given 30 narcotic pills to take home. And it's been interesting, I haven't, you know, like most things my house, I'm an observer of most things in our house, not an active participant. But my wife is doling out she's doling out the narcotics to my 21 year old, which is good. And there has probably and he's doing great. Like he does not have much pain. And he's doing the Motrin, and you know, as well, but I think he's probably taken six pills since Wednesday, and I think he might be done. Which to me is somewhat remarkable. And I don't give him kudos for being the toughest kid, although clearly he's you know, at least reasonably tough. But it's just a really super interesting thing, my wife's fear of narcotics, which I think is appropriate. We've never had an issue in anyone in our extended family or friends that I'm aware of, but it's such a unbelievable crisis in our country that, you know, your expertise is going to be a really interesting discussion. And so I guess, Chris, any any opening comments, before we turn to our expert?
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Well, I mean, I'd like to know how, you know, clearly Asif you've made this a big part of your, you know, academic enterprise, you clearly have dedicated a lot of efforts and done an incredible amount of research and you know, you put in your effort where you're you're, you're walking the walk.
00:19:04.240 --> 00:19:09.819
So tell us about how you even started working in this space, because there's not a common area for hand surgeons to be working in.
00:19:11.220 --> 00:21:21.539
Yeah. So first of all, Chuck I'm happy your son's doing well, I'm going to be judging and say 30 pills were too many. And I think it's a great example of a concept of diversion, which we'll talk about is you know, we always had to be careful why the numbers we prescribe because, you know, opioids have value but street value plus abuse value. So you know, when you give someone too many Tylenols or too many Cephalexins it doesn't matter, right? But when you give too many and now you've got 24 in your medicine cabinet, your son may not do anything with it, but your son's friend comes over to play, you know, Xbox with them can grab them. So we got to be really careful about dissemination of opioids into the community because it's diversion potential. And if you look at studies that Have and I know I'm going off topic right away. But where people get their opioids from to abuse for those who do abuse 70% have come from friends and family, and typically not from their own doc. So it's not always that person is going to be the one necessarily it's that it's disseminated. But I digress. I'm sorry. So, um, so to answer your question, Chris, um, you know, it started kind of slowly, um, you know, I've been involved in research for a long time I enjoy doing research, I find that I know, you guys agree with this because I know you're, you're academic docs too, is that research just really adds that kind of, you know, that special seasoning to what we do, at the end of that, at the end of the day, you know, we're all in practice, we're doing our work, and we get pretty good at it and at the end of the day, we're just making the donuts, right, I mean, we can do 95% of our surgery without thinking about it at this point, just like any other. Any other you know, labouring specialist, guy who changes your tires versus builds your transmission versus fix your, fixes your distal radius, you get into rhythm, you know, how to problem solve, you know how to do it. To me research is where you kind of add that extra layer of challenging dogma. You know, seeing if we can do things better, trying to trying to get past like, I do this because of fill in the blank and actually seeing if it makes a difference.
00:21:17.880 --> 00:21:27.720
But, you know, in orthopedics, as you guys likely know, most of the research that we do doesn't make a huge lot of difference.
00:21:24.569 --> 00:21:45.839
It's incremental, you know, findings. Oh this is 10% better, this is 3% better, there's no difference, which I find frustrating. And then I had a few experiences early on in the pain management sphere, where I saw several patients who had some real complications from opioids, several of my own and several of my of my partners.
00:21:46.440 --> 00:22:58.019
And I realized that this is kind of a big deal. You know, we take this oath to do no harm and and I think we all believe that. But then we're inadvertently doing harm with the way that we're being nonchalant in terms of managing our patients pain. And then Chris, you mentioned as hand surgeons that's uncommon, but I would push back in that majority of hand surgeons today, are orthopedic surgeon, so we're used to, you know, the orthopedic world and management of musculoskeletal pain in an aggressive manner, we've all trained in residencies that had aggressive pain management strategies for the most part, and, and secondly, we're high volume surgeons. So, you know, we'll typically I'm sure you guys do 400, 500, 800, 1000 cases a year so imagine, if you're that shoulder surgeon who gave your son 30 pills and no offense to that person that's not an unreasonable number, it's a common number to give you multiply that by 500 800 cases per year by one person in one town in one area, that's you just start extrapolating that out, the inf- the impact we can have negatively is enormous. But at the flip side of that is the impact we can have positively if we look at this critically and improve on our practice habits is also enormous. And that's where I find that there's real value in this.
00:22:58.049 --> 00:23:03.839
So what was your normal standard prescribing pattern before you started paying attention?
00:23:05.069 --> 00:23:56.130
30 pills. 30 pills, just like Chuck said, I mean, you know, first water them but you guys in residency we used to write the the pain medications for our attendings. And it was not uncommon after a joint or spine case to write 50 or 100 pills at a time and to discharge them home. And my first couple years in practice, I gave everybody 30 pills, it didn't matter if I was doing a shoulder replacement, I was doing a distal humerus or after a carpal tunnel, they were getting 30 pills. And it was I don't think I was an anomaly. I think that was we didn't really pay attention to it. And we just gave those medications. And I think it was only a matter of time and the data kind of, you know, cropped up and snuck up on us and show that, you know, the medical field collectively might be doing some harm. And and I'm going to just drop a quick preface here because, you know, I often have this discussion.
00:23:56.549 --> 00:24:10.559
And sometimes I sound like someone who's beating on the medical profession and beating on doctors. That's not the point and also that I'm beating on opioids. That's not the point either. I think, firstly, let me just preface we can't do the work that we do without opioids.
00:24:07.019 --> 00:24:36.630
So this is not opiate bashing by any means. I mean, it is amazing what it allows us to do in helping people. That's the first thing. And the second thing I will say is that the opioid epidemic in America is multifactorial, we are not the problem singularly. We are one of the many, you know, contributors to the problem. And I would say first that we inadvertently have been contributing to this problem by by being, you know, not being aware of what we had been doing.
00:24:33.029 --> 00:25:17.309
But now we're embracing that now. But there's many other variables as well, including patients, by the way, the patients are a huge problem in this in terms of their own issues, psychiatrically, emotionally, substance abuse, expectations. pharma is a big problem in this and then the government's been a big problem with this in terms of their, you know, and societal bodies who have driven aggressive pain management. So it's very complicated. So I always want to put that out there that this is not doctor bashing, and what have you. But as doctors, and as scientists, we have a lot of authority here and credibility to impart positive change. And when we say things, and I can tell you being in the advocacy sphere, people listen to us, especially when you have strong evidence behind it. People absolutely, listen.
00:25:17.990 --> 00:26:01.519
It's a really interesting thing. Two additions, number one, it I have been really pleased to see that my patients understand the problem. And so when we talk about narcotics for post operative use, they get it. And most of them don't want anything special. And it's just a very different conversation that I had 15 years ago. So my mentality 15-20 years ago was two things. One, I don't want my patient to have to go back to the pharmacy pay another copay to get another prescription. So I want to give them enough that they're, you know, the, I don't want them ever to have to go back for for a refill. And second of all, I don't want them to call the office, right. And we want to minimize the burden on the patient and on our staff.
00:25:58.579 --> 00:26:17.539
And so we don't having to call back to ask for more narcotics, and so we gave them too many pills. But it is the work that you have done amongst others that have that have really shown us and, and I will share my son's experience with his shoulder surgeon that you know, even 30 pills may be way too many for a shoulder procedure.
00:26:17.539 --> 00:26:23.930
And again, I'm sure it runs the gamut from patient to patient, but it's really impactful stuff.
00:26:19.849 --> 00:26:28.069
And it's it is very different than an incremental improvement in a carpal tunnel, you know, surgery.
00:26:28.339 --> 00:26:45.859
So Chuck, what were you giving, say 10 years ago for carpal tunnel, or were you doing anything differently for a carpal tunnel versus a cubital tunnel versus a distal radius fracture? And what what is for both of you what's changed in terms of you know, what your standard prescribing is?
00:26:46.619 --> 00:27:08.579
Yeah, so my I'll go first, and then I'd love to hear Asif's thoughts. So my standard back in the day was essentially 30 pills across the board, any procedure you got, whether it be maybe maybe even a trigger finger, but definitely a carpal tunnel, and anything more significant was 30, Norcos, so hydrocodone with with Tylenol.
00:27:03.509 --> 00:27:18.150
And nowadays, I generally have three levels, the lowest level is carpals, and triggers. And I may get judged here and you should judge me, Asif if you think this is inappropriate, I have three levels,
00:27:18.210 --> 00:27:20.730
Chuck, this is a friendly place, we can, this is, it's okay,
00:27:21.539 --> 00:27:24.269
I can take it.
00:27:21.539 --> 00:27:45.029
But the first level is like a carpal or a trigger. And I still still I still do give almost every patient narcotics, so six or eight pills. The next level, I don't know would be a straightforward distal radius or something like that, which is typically 12 to 14 pills. And then I have another level which I rarely go to which is like 20 pills for something really big.
00:27:41.549 --> 00:27:50.190
So that's how I think about it, which again, I may be educated today. I hope I am. Asif, what do you do on a daily basis?
00:27:50.599 --> 00:29:21.589
Well, so I would just say a couple things. So firstly, Chuck, the fact that you're customizing your prescribing is a huge leap forward. And you know, when I talk about this with with with docs, when I hear that I'm heartened by that, because that's really, that's 90% of the game, right is is to make sure that we are customizing what we're doing. If you're a hand surgeon versus spine surgeon versus a urologic surgeon, you have to look at what your patients need, and give them that none of us want our patients to suffer. You know, and we've looked at why we were giving the numbers we were giving it you know, we assume it's laziness or habit. But it's for the reasons you mentioned, we don't want them to suffer, we don't want them to come try to find us in the middle of the night. We don't want them have to go to the emergency room because they ran out. We don't want them to use co pays. We don't want to get complaints in the office, we don't want to get bad reviews online, all of those things came into play and a lot of states and I hearken from Pennsylvania, we up until two years ago had to give an opioid on a paper prescription pad, you couldn't do electronically. So that's very limiting. So you would give them more because you don't know when you might be able to get in front of them again. And so but now we can go we've gone into electronic prescribing which we you know, we, my work on with the Pennsylvania orthopedic society was really centered around that is going to an electronic based system so that we don't have to over prescribe, we want to give them whatever they want, whatever they need, rather. But if we can give it easily then we don't have to give them 30 at a time we can give five at a time.
00:29:21.950 --> 00:29:56.480
And you know, then it's then it's a much safer way. So to- to answer your question. I do something similar I have my system is 5-10-20 everything that's soft tissue, hand, carpals, triggers, de Quervain's, they all they all get five. If you do if you do distal radius, tennis elbow, distal biceps, you get 10 and if I'm doing something big, like say a proximal humerus repair, a total shoulder, I'll give them 20 and it's uncommon but more important than that is so that's the first step right? You know, customizing based on strength.
00:29:56.509 --> 00:31:24.259
The second part is we haven't talked about yet is what are the other things you can do to control their pain right and I'm not just talking ice, patients love ice. So they're always like can I use ice? Absolutely knock yourself out as much ice as you want. It's on the house all the ice you want but but it's all the other things right it's the it's the counseling of patients before surgery talking to them about it. It is the use of anesthetics well in the OR in not just a proximal block but even in the surgical site. The site infiltration. It is the use of you know, other agents in during the operating during the procedure such as IV Tylenol and, NSAIDs. It's a use of multimodal agents such as gabapentin and Celebrex. And it's about really having them use that. So take your son, for example, you know if he was if I was operating on him, and that was what I did a slap repair on him, I would say listen, first thing is, you're going to get I'm going to give you toradol and trop you're going to go home on on either toradol, if they can take it, a young kid like him could take it. If not, I'll give I'll give you Naprosyn or Celebrex, you're going to take it for two weeks, you're going to take that round the clock twice a day, you goint to take it. Tylenol every four hours, you're going to take at least for three to five days. And then you're going to go to your to your opiate. And if you have that kind of thoughtful prop, you know, procedure of managing their pain and they know that you're thinking about it, and you're and you're and you're prescribing a certain strategy.
00:31:24.529 --> 00:31:47.299
Particular like your wife, I'm sure your wife is all over it, she probably wouldn't even ask you one thing, she didn't ask a single input from you, I'm sure because my wife would never ask me anything about this, she would take over complete control of this. And I would just stand there as an innocent bystander as an expert in the field she would ask not to. And so when she heard from her surgeon, her son's surgeon, this is a strategy, she would implement that. And I don't think your son will need more than three to five pills, even with the slap show which hurts.
00:31:47.660 --> 00:31:50.089
That's it.
00:31:47.660 --> 00:32:00.259
That's exactly right and the key for my son. And we are fortunate to have really talented anaesthesia partners. And you know, his block lasted probably 28 hours. And so that was huge.
00:31:56.000 --> 00:32:12.980
That was huge. So one one funny thing about our show Asif is that, despite the fact that I try to keep it general, I don't talk about congenital, sports is a minor part, it always comes back to nerves. So I'm going to beat Chris to the punch here.
00:32:09.680 --> 00:32:20.930
And and just put the hypothetical out there. Let's say I am doing God forbid I ever do a big brachial plexus case.
00:32:16.730 --> 00:32:36.650
So had that, you know, nerve pain and bigger exposure. Chris, jump in here at any point. Like To me, that's a very different case. And I don't know, I mean, multimodal for sure. But I guess maybe I'll put the I'll put a little burden on Chris to comment first, how do you think about that patient? Chris?
00:32:34.519 --> 00:32:38.089
Because I know you start with admitting some of those patients.
00:32:38.420 --> 00:33:36.559
Yeah, I mean, that's the top tier, right. You know, each of you, all of us have our three tier system. So that's the patient that is, you know, getting kind of a bigger prescription. But I do try to take steps, like Asif said, to mitigate the need or the subsequent potential dependence on the opioids, like a Plexus reconstruction, you know, is going to get admitted they're going to stay in the hospital overnight. Except if maybe it's only a couple of distal nerve transfers and no big exploration. You know, usually these patients are already on gabapentin or pregabalin or something of that nature. And then all of my patients who are having surgery, regardless of whether it's a Plexus or a trigger finger are getting a two week prescription of Meloxicam, that's my preferred anti inflammatory or NSAID, but other than that, I mean, you know, I tried to explain to them ahead of time, this is a big surgery, and you've already got nerve issues. How do you approach it?
00:33:33.049 --> 00:33:38.509
In your world Asif, I don't know how much nerve work you're doing?
00:33:39.410 --> 00:33:46.910
I mean, as hand surgeons we all have to right so, and I enjoy nerve surgery a lot. Actually.
00:33:43.519 --> 00:33:53.720
Let me let me reframe the question a little bit. You know, the work that we're doing with opioids and pain management, it's not about the exceptions.
00:33:53.720 --> 00:34:32.690
It's about the it's the general public, right? It's the general that we have to be cognizant of what we're doing and the harm we could be doing inadvertently, right. So the basal joints, the distal radius, the tennis elbows, the triggers. That's where the problem lies. If someone's got a complicated problem, and they end up taking 40 Norcos, I have no problem with that. They're the exceptions, right. So the mistake that's been made in the past is that we prescribe to the exceptions, not the average, right? So we should be prescribing to the average and we'll manage the exceptions with what they need, we're more than happy to help them and do what they need. But if we're managing every patient with, you know, a certain procedure or a certain condition exactly the same.
00:34:33.139 --> 00:34:59.539
That's where that's the that's the mistake. So, to not answer your question. Um, it's just like Chris said, it's multimodal, right? They got to be on they got to be on on nerve modulator, be it on gabapentin or pregabalin. They got to be on an anti inflammatory. They got to be on acetaminophen, that's the base that's the floor right and then on top of that, you're going to have to go to some strong opiates often and so be it and that's okay.
00:35:00.170 --> 00:35:18.289
Question, both of you mentioned that you have different tiers in terms of the number of pills you prescribe it. Do you have tiers in terms of which medications you prescribe? Because I tend to for carpals, and triggers I have a lower number, but I'll also use something like, I'll use acetaminophen with codeine. Is that something that you utilize?
00:35:18.289 --> 00:35:25.039
Do you use something like Tramadol or anything else? Or do you go mainly to the hydrocodones and even the
00:35:25.000 --> 00:35:25.280
You know, Chris, um, that's a great question. It oxycodones?
00:35:30.190 --> 00:35:41.409
really doesn't matter to me, you know, at that number three, four, or five pills, I'll ask the patient every time you know, when I'm doing my paperwork, you know, we're gonna be giving you this and I want to talk when we get some time about counseling.
00:35:42.010 --> 00:36:23.829
And I'll ask them, have you had any painkillers before? Is there anything that works or doesn't work for you? Right? And I will say the majority of time people have had some experience and say it I'm fine with whatever or I can't take x, y and z or what have you. And really, even though To be fair, the MEU or the MME whatever acronym you like to use for morphine equivalent is different between Tylenol with codeine, hydrocodone or Vicodin or Norco or, or oxycodone or Percocet or roxicet. To me at three to five pills, it doesn't matter a whole lot. So I'm okay with any of those. I tend to answer your question fully. I usually start with oxycodone. Because I can add Tylenol to it, no problem.
00:36:21.070 --> 00:36:30.010
It's well tolerated amongst them, and people seem to be familiar with it. So it's an easier explanation to people what that is, but it doesn't matter to me otherwise.
00:36:31.079 --> 00:37:11.159
You know, I was and I honestly don't know the science behind this. But I was told that I can't give Tylenol with codeine to my kids anymore at the Children's Hospital. And so I've kind of just along with losing Darvocet, which I love for kind of a low impact pain pill. And I don't give TC threes anymore, or tylenol with codeine. So for me, my baseline is Norco. I do ask patients, I tell them in the preoperative holding area or in the clinic that I'm going to give you six or eight pain pills. I typically give hydrocodone most of them say great. Some of them say that one doesn't work for me. Can I have Percocet? I'm like, Sure, no problem, you know, because I'm not giving you 30 pills. But that's that's my strategy, which I think mirrors what we just heard. Chris, any other thoughts?
00:37:11.570 --> 00:37:31.909
I mean, I think that the thing that I think led lots of us to change our practices were a lot of the papers that came out and some of them were from you Asif about how many pills patients actually take after these surgeries. And so having been involved in some of that research, how has your own work and perhaps those of some of our colleagues, how has that informed your practice, as of 2020.
00:37:32.769 --> 00:37:48.909
Yeah, so Chris, I have like four very basic advice to, you know, my peers, my practicing docs who give this is, number one, have a counseling strategy with your surgical patients. And I'll talk a little bit more about that.
00:37:48.909 --> 00:38:52.570
And when we have some time about how I do that, so that they understand what they're getting, they understand your your kind of strategy. And your goal to provide them a good pain relief without over treating them. Two, to utilize a multimodal pain strategy during the perioperative course, three to customize the pain medication to the procedure you're doing right? So it shouldn't be like we used to 30 for everybody, it should be deliberate to the type of procedure you're doing. And that requires informally surveying your patients. You know, you don't have to do a research paper you don't have to publish something on it, you can just ask them and say what did you end up using, you know, in terms of that process, and then on the back end, making sure that they are they're not only going home with just take you know, painkillers when they need it, but there're all these other things that they're very comfortable using, like ice but beyond ice, NSAIDs and Tylenol as their base treatment and then the painkiller goes on top.
00:38:53.170 --> 00:39:08.110
Because I think there's a cultural problem in America where I'll give you a challenge, next time you want to send a patient out of the PACU after a carpal tunnel trigger, which is the most basic thing that we do try to send them out without a pain medication prescription.
00:39:05.590 --> 00:39:16.630
Let me see how far they'll get without you getting a phone call. I'm going to tell you right now they won't even hit the elevator before three nurses call you and say Where's their pain medication prescription?
00:39:16.630 --> 00:39:50.469
Right? So that's the culture that we have to, you know, operate within and possibly change hopefully change. And that that can that can that'll start with you having a deliberate strategy when you have a deliberate strategy, everyone notices a patient notices a family notices, and the staff notices that the doc wants them to do this. And if you do those things about counseling, perioperative analgesia, customized opioids and multimodal pain strategy afterwards. That's it. That's that's, that's that that's all you really have to do. You'll be in great shape for your for your community.
00:39:51.690 --> 00:40:04.289
So you've done a lot of advocacy work and you've obviously done a lot of education of, you know, our colleagues and our peers and tell us about this foundation that you're working On now and, you know, it's clearly a big initiative.
00:40:05.260 --> 00:40:08.260
Yeah. Thanks, Chris.
00:40:05.260 --> 00:40:18.730
Yeah, it is, um, you know, as you mentioned, we've done a lot of work in the pain management space. And I practice that at the Rothman orthopaedic Institute in Philadelphia. It's a big orthopedic practice, I would say the preeminent No, no offense to you guys, but the preeminent-
00:40:18.760 --> 00:40:19.929
Excuse me, excuse me, excuse me
00:40:19.929 --> 00:40:21.190
orthopedic practice nationally.
00:40:21.219 --> 00:40:23.050
I didn't meant to block you out there.
00:40:27.849 --> 00:40:30.670
You can bleep that out later. I guess I said that, but
00:40:30.599 --> 00:40:38.969
I'll give you Pennsylvania. I mean it's a classic in Penssylvania and you know, I trained in some places that are East of you and I think that they're being special for that too.
00:40:39.840 --> 00:40:42.630
You guys have a wonderful practice No, no doubt about it.
00:40:42.630 --> 00:41:14.519
Well, one of the one of the things that's really strong about what we do is the embrace of research. So for a practice that is, is 100%. So I'll give you just a quick two seconds story. When I when I joined the organization about 10 plus years ago, the chairman was Todd Albert at the time, and a great guy who's moved on to New York and now is semi retired, I believe. He said, in this practice were both 100% academic and 100% private practice. And obviously, that math doesn't make sense. But he was making a point what the priority is. So that's always been the priority.
00:41:10.980 --> 00:41:18.030
So for, for nerds, like me, it's a great place to be because it embraces the scientific process.
00:41:18.329 --> 00:42:21.389
So you know, we we've done a lot of research in this space and our research sort of spillover beyond just one or two services across the entire practice. And we decided, as an organization that we should really embrace this work and take it to the next level, because it's very impactful, we can really, you know, improve the lives of our community, and help the practice of our of our, our peers. So that was the rationale and the mission of the foundation. So first of all, it's a it's a nonprofit. So it's an IRS designated 503c, so it's 100% nonprofit. So all of it shares the name Rothman and it's, it's its own entity. And the mission is threefold. So number one, it's education. Number two, it's research. And number three it's advocacy. So just drilling down further on the education, we're educating both patients and prescribers on safe opioid consumption and prescribing habits respectively. Number two, we're performing research on pain manage- opiate sparing pain management strategies. And I can drill down more on that, because we've got some interesting things that we're working on.
00:42:21.840 --> 00:43:30.869
And number three, we do advocacy work almost like a think tank where we synthesize information that's out there, some of it's data we produce, and a lot of it's data from the outside. we synthesize it for analyses that we then give our policymakers and we, we advocate for certain laws and policies that we think are going to help the community, help the community and the country at large. So that's broadly what we're doing. And it's been really, it's been really great, there's been a lot of support a lot of interest, we are already making a lot of traction. And just to drill down a little bit on the research part just for a second, because as you as scientists, you guys will appreciate this, is that we're doing a lot of different things, some of the stuff that we're doing is things that you're very familiar with, like, you know, the pain management research in orthopedics and hand surgery about, you know, prescribing better and multimodal pain strategies, opioid sparing strategies. But we're also doing a lot of research on on public health data that we now have access to, through the CDC and through Pennsylvania, it's fascinating to see the different trends and weaknesses across the country where there's certain areas more susceptible to other areas. And those strategies need to be made customized and targeted for the areas that need help. And thirdly, we're doing a lot of work in medical cannabis now.
00:43:27.539 --> 00:43:47.820
Because we're really seeing a strong role for medical cannabis as an alternative to opioids in the chronic pain and neuropathic pain category. And that kind of touches a little bit with what we talked about, about the nerve pain, patient, there's really a strong role for that. But we're still trying to distill that a little bit more, so we can have some strong evidence to support its usage.
00:43:48.840 --> 00:44:11.070
That's fantastic. You know, kudos to you on you and your colleagues, for that work, and to your institution for having the foresight and the guts to really invest resources in that. I think the advocacy stuff is going to be really interesting, as you're compiling all these white papers and everything. What do you think the general public or at least physicians are going to be seeing in 2021, in terms of advocacy pushes?
00:44:12.000 --> 00:44:21.659
Well, you know, I think Chuck mentioned earlier, I've been impressed by how receptive patients and policymakers have been on this.
00:44:18.960 --> 00:44:29.639
I think part of the reason is that no one's really immune to this, this is not a problem that's limited to a certain demographic, age, gender region.
00:44:30.360 --> 00:44:50.849
So everyone has stories of people they know, who've had opiod related problems. So and it's a concept people also understand it's not you try you know, we have to deal with all the time, trying to explain to someone an inner carpal fusion versus a PRC for a SLAC wrist and look at you like you have three heads. It's, it's bizarre, there's nobody other than hand surgeons who understand why you would do those things, right.
00:44:51.300 --> 00:45:07.380
But opioids, on the other hand, is a concept that people really understand and have embrace and it's been actually a very natural crossroads where we can positively impact the community and positively engage with our policymakers, our legislators.
00:45:07.860 --> 00:45:24.780
And frankly, the legislators have been very receptive. In Pennsylvania as an example, there's two big things that we've done. One is to help drive the installation of the PDMP, the prescription drug monitoring program, I think your state may already have had it. We were one of the later states to pick it up. We're, you know,
00:45:25.079 --> 00:45:33.329
yeah, so yeah, let me interrupt you to tell you a not so proud fact, we're the only state in the union that does not have a statewide prescription drug monitoring program.
00:45:33.349 --> 00:45:36.739
I was giving you guys some credit, but I guess I was wrong. So, so but
00:45:36.860 --> 00:45:39.409
The only state, if I didn't say that the first time.
00:45:39.480 --> 00:46:23.219
Well, we were we were we were slow to the game as well. And you guys will get there where, you know, you can, you know, monitor and query people's opioid use. And the second thing that we really fought hard for in the legislature, we champion was e-prescribing. And for the reasons, you know, previously mentioned that if we can electronically prescribe from our laptops or phones, through a secure mechanism, we don't have to over prescribe. So if you need, if I if Chuck gives five for his carpal tunnel, and they need five more, it's not a big deal. He can do that from home at any time or from his phone versus giving 30 because somebody might need a little bit more than five, right? So those are two things that we we worked hard to achieve. And that has a very positive effects. And we're about to publish some data.
00:46:23.519 --> 00:47:11.730
We're looking at the the decrease in opiate prescribing, and it's astronomical, I mean, the number the drop off of opioid pills being prescribed across Pennsylvania, is unbelievable, since the institution of this statewide, not orthopedics, not hand surgery, but statewide, by putting these things through, and the hope is that in time, that will translate to, you know, decreased opiate abuse, addiction and deaths. And that's gonna, we're going to have to see so, you know, when we deal with this opioid issue, there's different ways to tackle it, we're tackling it more on the prevention side, where we're trying to mitigate exposure sensitization and distribution of opioids, there's other sides in terms of treatment of those who have and an access to treatment. That's a whole other arena. But I think where we can have an impact is on the on the prevention side of not even getting it out there.
00:47:13.579 --> 00:47:43.789
That is fantastic. Obviously, congratulations on your work, it is incredibly impactful. And I do think you've found a way to really change the practice of of hand surgery for sure. But even much bigger than hand surgery, I would like to close with a question, which is, I my favorite book on this topic, is Sam Quinones' book, I think I pronounced that correctly, you know, Dreamland? Are there other impactful books that you have read that you might share with the audience? Or is that one hit home as one of the best,
00:47:44.199 --> 00:48:12.190
You know, I've read that book as well. And, and, and actually, it's funny, you mentioned Sam, because I had invited him to be our keynote back in 2019, at our annual meeting, because I thought his book was so impactful. You know, books like that really hit home in terms of kind of making it more understandable. Another book that also had, I think, a positive effect, which is wasn't dedicated to opioids, per se, but kind of brought it to light was Hillbilly Elegy by JD Vance.
00:48:12.760 --> 00:49:10.360
It wasn't about opioids, but it showed the underside of the parts of the country that have their own socioeconomic stresses and how they can be more susceptible to opioid abuse as an outlet if they have that opportunity. So, you know, and work like that, books like that really help, you know, make it more understandable for the public and even for us. So that was a great book, if you haven't read it, it's a great book to read. It's an easy read, and he really tackles it from with the eyes of a journalist because that's his, his background is journalism. And he he tackles it from that perspective, and moreover, he tackles it from from the from the drug side, the drug cartel side, I'm blanking on the on the town in Mexico he always referenced but from the drug cartel side, from the government side, from pharma side and from the the physician side as well and how it contributes, you know, to has contributed to this problem.
00:49:11.019 --> 00:49:26.739
Now Asif, my generation and those younger than me, we tend to be more video learners. So those that are listening will be excited to know that Hillbilly Elegy is actually coming out on, as a movie pretty soon so you can also get to get the knowledge that way.
00:49:28.059 --> 00:49:29.949
Chris, I did hear it got bad reviews though on that.
00:49:29.949 --> 00:49:31.000
Just so you know, so
00:49:31.119 --> 00:49:42.250
I'm sure the book is better, but it's a lot harder to sit through the book. Asif, this is fantastic. If anybody wants to learn more about the Rothman opioid Foundation, how can they learn more?
00:49:42.690 --> 00:50:21.389
Sure, first of all, I think starting at our website at www.Rothmanopioid.org is the way to best way to kind of get a sense of what we're doing and to connect with us. I'm happy to connect with anyone on this topic. And it's a nonprofit so if anyone wants to donate by By all means we accept donations through the website and I want to make a call out to my my board and our contributor contributors you know no member of the board and and and neither myself take any kind of compensation for our work everyone is just contributing their time and and and expertise to this for the greater good so all money donated go to to the work itself
00:50:23.010 --> 00:50:37.380
That that's awesome Chris and I are also nonprofit and unfortunately our pleas for financial support are are shamed compared to your pleas for financial support so support Rothman, not Chris and I, we've accepted that ours is a money losing proposition.
00:50:37.590 --> 00:50:40.349
I will include support the Rothman opioid foundation.
00:50:41.280 --> 00:50:44.010
Yeah, that's well, that's correct. That's correct.
00:50:44.010 --> 00:50:44.340
You're right.
00:50:45.179 --> 00:51:01.980
Thank you for joining us. And if anybody has any other inquiries, feel free to email us handpodcast@gmail.com we can get anything that you send along to Asif as well. And Asif, thank you for joining us, you've truly made a difference for your community, which is fantastic.
00:50:59.760 --> 00:51:01.980
So thank you.
00:51:02.309 --> 00:51:03.780
Thank you, Chris.
00:51:02.309 --> 00:51:05.670
Thank you, Chuck. It's been a pleasure. Always a pleasure.
00:51:03.780 --> 00:51:05.670
Anything Great job, by the way.
00:51:05.670 --> 00:51:12.480
This podcast is great. And, as mentioned, today's generation likes to listen and watch and you guys have hit the nail on the head. This is great.
00:51:13.710 --> 00:51:16.230
Hey, Chris, that was fun. Let's do it again real soon.
00:51:16.469 --> 00:51:21.420
Sounds good. Well, be sure to check us out on Twitter@handpodcast. Hey, Chuck, what's your Twitter handle?
00:51:21.750 --> 00:51:24.599
Mine is@congenitalhand. What about you?
00:51:24.750 --> 00:51:31.920
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
00:51:32.579 --> 00:51:35.789
And remember, please subscribe wherever you get your podcast
00:51:35.849 --> 00:51:38.460
and be sure to leave a review that helps us get the word out.
00:51:38.820 --> 00:51:45.119
Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time.
