Welcome to The Hand to Shoulder Center

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Are we on My name is Truitt Rodgers and I am a photographer here in Fort worth. I have been doing Photography for about 35 years, been around Fort Worth most of my life. Enjoyed doing art and all kinds of stuff. Went to the University of North Texas. Always loved Guitar. The minute the Beatles hit I was a fan and a guitarist. I always loved being able to play that. I didn't really work at it that hard, but you know. My grandad gave me a guitar and I started playing. I was never really in a band or anything. I was kind of like a loner dude. Y0u know I would sit in my room and play James Taylor stuff, it was quite peaceful, that kind of stuff. Lately I've been able to get into a band it's kind of weird with people looking at me and that kind of stuff. We had a rental property. It was our first house on clover lane not too far from here. It needed some work and I was trimming a board. I was trying to rip a board. Ripping is a long cut on a 6 foot board or something like that and you need it to be a little narrower than it is, so I was trying to rip the thing. And so I had my table saw up there and I was doing my thing. The funniest part of it is, if any of this can be funny, I wasn't using his hand. I was using this hand. I was being very careful, and pushing and should have been using a stick but I wasn't. But I was watching this thumb. And this hand just sort of relaxed on me and fell into the blade you know and I wasn't even thinking about it. I thought he was safe over here, you know. I had just about this much left to go and then all of sudden… it was what was that, what’d I do. And I'm seeing fingers laying around and I'm “Oh my gosh, I can't believe I did this” We went and Met with Dr. Tobias and he told me what he was going to try to do. And I kept telling everybody from the very beginning I like to play guitar, I love to play guitar. So whatever you do I’d like you to do whatever you can do to save as much as you can, so I can still play guitar. We even had the little finger things in the bad you know, I kept carrying those around. They were like we don't need those, I was like oh great. I don't really remember a whole lot until I came out of it and my arm was in a thing and I had this doodad here. Of course it was my left hand. I could still function and do my photography and everything but. A little concerned how I was going to be able to function once I got done with it, the different stories I was getting about “oh well you know.. because I cut mine off you know , I did this I did that whatever the thing is. I haven't had any problems. I still have some flexibility in it and I immediately went back to trying to figure out how I was going to play the guitar. One thing I did do was I practiced a lot more than I ever did. Kept practicing at it, found that there were several chords that were really hard to do and certain chords that I couldn't do. And so I had to find new ways to make those cords and adapt. He gave me all the care, a lot of hope and encouragement, and was realistic about it. I just do everything like I always did you know. I feel really blessed to have come across Dr. Tobias you know. Awesome, That is awesome. I have Ringo Fingers!

I'm Rebecca Shingledecker and I just competed in the 2021 crossfit games after having a wrist reconstruction done by Dr. Lesley. And for those of you who don't know what crossfit is, the crossfit games are, its the superbowl or the olympics of our sport. Its a really big deal to which I am honored to have participated. And I am now the fittest adaptive gramma on earth, and 5th in the world. I was in cross first for about 9 months and then I was diagnosed with a brain tumor March of 2018 and throughout that year I got two other brain injuries so that's affected me greatly.During the pandemic shut down, my brain, so I didn't listen to my brain that was tired and I did a heavy lift and I fully tore my scaphoid lunate ligament in my wrist and finally I was referred to Dr. Nathan Lesley who first looked at the MRI and said yep were going to have surgery. I did the surgery in July of 2020, and he did a great job. Lindsey Snow was my Occupational Therapist for my hand and she has become a personal friend of mine. She has cheered me on through my journey and even helped me get ready for competition, the first one I was still in therapy while I was doing my competition, and so she made sure and gave me good tips and stuff to protect my hand and to be able to keep going. They helped me alot and they were so caring. By November I did the Wheelwad games open and I did really really well. And by January or February I think it was in 2021. I did the cross fit games open and placed 5th in the world and I got two second places and the third week is where I ended up 5th overall. So he did really good for me.  Take the most sourest lemon life has to turn and turn it into something resembling lemonade, so thats the motto that I took on the very day March 14th 2018 when I found out I had a brain tumor I figured  that I was going to take this terrible thing that's been hoisted on me and turn it into something good by sharing my story by showing people that life is not over. YOu know when you have a major even like my wrist , you know I could have just said well I’m done. But no, that's not perseverance. And so I think my whole life now is about showing people that you have hope and you have a future 

CJ Brock CEO of TexAssist Surgical Staffing and Consulting Next podcast we're going to be talking about Wide Awake surgery should be interesting don't miss out. Everybody we're here for the dawn of season 2 of the cutting-edge podcast hard to believe it's been almost six months and we've been on break but man I'm super excited to get this season started I think our lineup of guests is going to be better than it's ever been. Not that I ever have a bad guest but it's it it's just going to be a lot of fun we just learn so much every season and we're really blessed to be joined by 3 very sharp orthopaedic surgeons. We’re here in order for us to talk about a topic that I had absolutely no awareness of before their marketing director basically said hey we'd love to come talk to you about this so today's topic is orthopaedic surgery, and wide awake orthopaedic surgery in particular which is the dawning of a new era in orthopedic surgery as they say. But before we get started what we're going to do is make a few mentions thanks to TexasAssist Surgical staffing for supporting the cause, Carrington Advisors and unfortunately Tyler you're not here today but hopefully you'll be listening soon and you're taking good care of that little baby and yours, The Hand To shoulder Center of Fort Worth which the esteemed gentleman to my right are a part of. We always want to think Jen Eaton and her efforts and Moonshot Marketing Group for helping us get this whole thing getting started, branded, etcetera so you can always find us on multiple different social media channels you can find us on Facebook and Linkedin just follow us there the cutting-edge podcast this how you'll find us there we recommend you follow us on Twitter. It's not super active, but man when we put something out it's important to note. That is @TCEmedpod Twitter handle, instagram @thecuttingedgepod and my favorite because you get to see all of our beautiful faces every time: is our YouTube channel. So follow us if you can. We're going to have a heck of a season this year and man let's get started I'm going to do some introduction to my right where the start near the far we got Doctor Lesley really glad you're here we got Doctor Guevara one of his Partners here next to him and then we got Doctor Bates all the way down on the end they been gracious enough to come over here from Fort Worth and battle the the brutal traffic that is DFW, and help educate us on what is wide-awake surgery today. I think a great place for us to start would be for the audience to get to know you guys. Get to know a little bit about your background. And we going to start with you Dr Bates. Help us to know where you’re from, how you got interested in surgery and what helped you focus on becoming a hand & upper extremity Specialists. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas My name is Christopher Bates, I group in Southern California for about 15 years then moved to Washington State and really small rural town and my education to be kind of all over the country Wake Forest for Med School, Fort Worth Orthopedics Surgery training in up to Ohio to do my hand Fellowship. Now, I fell in love with ortho working with my dad throughout middle school and high school and even in the college he's a one-man construction company and they did a lot of finish work so I grew up doing a lot of things in the house and hanging and casing doors put in tile kitchens etcetera and I really realized that I was very satisfied with the end of my day when I could see what I had accomplished and I was always interested in medicine once I got into college and sure enough those two things meshed really well orthopedic surgery being able to see on x-rays fixing bones, putting tendons back together all those kinds of things In hand I absolutely loved it because we pretty much do anything in the hand area almost anything that has to happen in the hand we can take care of, that level of specialty just really excited me about orthopedic surgery and hand surgery… CJ Brock CEO of TexAssist Surgical Staffing and Consulting You know what, I bet your partners love you to because if they ever have an issue with a door or have an issue with the Home Improvement project, hey, just call Chris. What you’re a little rusty there? Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas Oh yes its been years-all the training residency it all takes a long time. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Its like riding a bike they say. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas I’m down to give it a shot. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Ill call you the next time I have an improvement because for me just to update any little thing in my house turned into an all day project. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas Oh yeah, you plan for five minutes it takes five hours. CJ Brock CEO of TexAssist Surgical Staffing and Consulting I am the guy that goes back and forth from the hardware store eight times. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas You are not alone. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Dr Bates we are going to move on from you to Dr Guevara-Share with the audience a little bit about your upbringing and what brought you into orthoapedic surgery. Dr Jonathan Guevara Orthopaedic Shoulder and Elbow Surgeon The Hand to Shoulder Center, Texas That's great I am similar to Chris I had an up bringing that exposed me to the ability to help around the house, fix stuff, I was always mechanically inclined I liked the idea of taking something and getting it restored. Taking science classes and math classes I really didn't have a career direction but when I shadowed an orthopaedic surgeon I said “thats it, I’m going to do that”. So that took me to undergrad, then med school in San Antonio, training in St Louis at St. Louis University all the way out to Cleveland Clinic for Fellowship…finally back in Texas. I was born and raised in Houston so the ability to come back I owe to Dr. Lesley who gave me a phone call and started that whole process and I was able to come back here and establish a total upper extremity group. The idea that I can specialize and focus on just the shoulder, just the elbow take what I have and build it within a team and then really just you know I don't feel like I'm enough of a surgeon to do everything in the body, right, I'm going to focus I'm going to be good at what I'm good at and then that's where I deliver my care. CJ Brock CEO of TexAssist Surgical Staffing and Consulting You know I think that’s an interesting comment, right. We see General Practitioners in healthcare all the time especially in a lot of other specialty Orthopedics that's that's more common to be the Rarity or the exception than the standard so I find it interesting that you make that comment and you kind of you have knowledge that on your own because I think my experience with orthopedic surgeons is that although they may really love or an area that they really cater to, they feel like they can do anything, right. They will do anything. Sometimes at great cost to the patient. So this is refreshing to hear you guys admit that I've really not good at everything but I'm really good at this right I think that's something that that's a little nugget whether you're a patient or your family or your Administration that's a great little nugget for people to take away today. Moving away from that Doctor Lesley thanks for joining us and glad you can make it Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas Thank you so much. My name is Nathan Lesley and my path into orthopaedics and hand surgery was a little more serendipitous than these guys. I come from a small town in West Texas. DeLeon is about 2, 3 hours west of here. And going in to medical school my intention was a general practice doc, these are the guys that I admired back home good friends of mine and I just through med school it at Texas Tech through some exposure there I met some great folks who did Hand surgery. At that point orthopaedic surgery was kind of new, I mean I’d never really heard of the field. Loved it and threw that I went on to apply for residency and was accepted there in Fort Worth, had an outstanding chairman Dave Lichtman pretty internationally known, well known hand surgeon. He encouraged me along the way to pursue upper extremity surgery as a specialty and help me get a fellowship at Brown University in Rhode Island where I spent a year back in 2010 and so I began private practice back in 2011. CJ Brock CEO of TexAssist Surgical Staffing and Consulting So you’ve been in private practice here in the DFW area your whole career? Yes I have. So it's been great yes I have some kind of scary to think that I'm a senior partner to these guys but thats true. You know we’re not going to measure it by the volume of gray hair because that makes me the senior partner if thats the case. Once of the things that I look forward to it really talking about was getting young physician perspective on what we’re doing here because often times equate expertise with age and years of experience, and to a degree, yes but all surgeons go through the same number of years to get to the point where they can go practice on their own. So for me this will be a refreshing opportunity to hear from a different almost a different generation than other guests I’ve had on the show. So let's let's move on from there cuz you know we don't have a lot of time a wide awake surgery, what we’re going to do is talk about the aspects of wide-awake surgery. Like I said the beginning something I'm completely aware of a month ago basically and I've really become a fan of it and a student of it at the same time. So I’ll volley this out and you guys decide who wants to handle the questions but you don't mind my first question is really relative to your practice to hand and shoulder Center of Fort Worth when did that get started. Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas So I began practice here in Fort Worth in 2011 and I noticed some limitations right out of the gate it one of the main ones being I think they made I think the main one being for upper extremity surgery specifically of the the cost involved in getting even the simplest procedure performed we've been reading about this “WALANT” or Wide Awake surgery which I'm really excited to talk about. I realized pretty early on that maybe this could be an avenue that patients could get treatment that they need, without being saddled with debt for ten years. So the Hand to Shoulder Center was developed with a couple things in mind, number one we wanted to make the overall scope of care as accessible as possible. We certainly don’t do just surgery, in fact the bulk of our patients are treated non-operatively and we have therapy there in the office certified hand therapists, Physical Therapists… CJ Brock CEO of TexAssist Surgical Staffing and Consulting In fact I think we’ve got either a video short video or photo of your therapy centers beautiful your old buildings beautiful really Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas Thank you thank you yes we we are really fortunate to have I'm telling you what I believe to be the the best therapist hand therapist and physical therapists that I've ever worked with. So that was a key part of getting this going another limitation I found is a lot of times pathology of the hand is contiguous with something going on up stream and the elbow the shoulder. As Jonathan said and we’re all pretty well-defined and what we do and I've never considered myself a strong shoulder surgeon so I wanted to have somebody in the group that they could do that and focus on that primarily but then I think that's the most distinguishing feature of our practices the fact that this was built with the idea of performing surgery they're in the office this is not really that revolutionary it has been done and Dr Bates can tell you a lot about the history of this as he’s really looked into it. It’s really kind of cool how the hand is really amenable to just local anesthesia there's really not that much that has to go under General sedation. CJ Brock CEO of TexAssist Surgical Staffing and Consulting You just have patients kind of lean on their arm like this and wait until it goes numb? Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas You discount the fact that when you go to the surgery center listen an IV is not a benign thing it hurts and general sedation can have side effects and all that goes into that, you got to get somebody to drive you to the facility you can't eat or drink, you have to change clothes and and then someone and in Canada Dr Lalonde kind of challenge that a while back and said hold on can you do this in an office-based setting. Is his hand surgery the same as total joint replacement you know and and basically they've proven of course that's a lot of this stuff was unnecessary and by avoiding these things not only do you avoid complications you avoid unnecessary expenditure has and inconvenience. CJ Brock CEO of TexAssist Surgical Staffing and Consulting You know obviously the Hand to Shoulder Center is in Fort Worth. But I mean how do people find you guys have a website, do you have social media pages and what part of Fort Worth are you in, because Fort Worth is a big place. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas I'll take that we have the social media we have youtube we have a web site our website is handtoshouldertexas.com, the YouTube channel to search “hand to shoulder Texas”, Instagram same thing we also have some like a LinkedIn accounts in those kind of things that we post on a very active Facebook group or a lot of people have found us a course. CJ Brock CEO of TexAssist Surgical Staffing and Consulting So who is the most active in social media Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas That’s me a hundred percent That's okay we all have our strength, thats definitely something I take on and help run. We actually hired someone who reached out to you to help us with that whole Endeavor because eventually it becomes too much for somebody who is an active busy surgeon to handle everyday. CJ Brock CEO of TexAssist Surgical Staffing and Consulting It amazes me because I see some of these surgeons who are doing 400 cases a year and they’re posting twice a day everyday on linked in, Facebook. I’m like okay do you ever sleep. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas Some of them don’t, you’re right some of them don’t. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Well obviously you got your website you got your social media channels you know I'm also curious for people who are trying to find you with you through referral Partners out most specialist live off primary care referral. Would you guys say thats a commonality with you guys as well or do you have people find you a different way. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas People find us and lots of different Avenues Primary Care Google Google reviews have been very kind of so far and a lot of people have come to us for those reasons so social media our internet presence Primary Care referrals and then we've got patients who specifically come to us for the in office procedures people who google it and are trying to find a place to get it done I don’t know, Nathan do you want to talk about. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Let’s talk a little bit here about the history here of wide awake surgery. Let’s start there and blend in how people find you. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas So wide awake surgery is defined as just that you are completely numb to the pain of the surgery but you're wide awake just like your sitting here having this conversation you're aware of everything you can actually talk to the surgeon during the procedure but the entire surgical area but I tell you what you do this and there have been studies that have shown that over 90% of patients who have it this way would have it the same way again they liked it they felt good about it they got to spend more time with us normal on the day of surgery you walk into a surgery center do you see the surgeon for a very short period Of time and then you're off to anesthesia and you don't remember the rest of the day you have amnesia, you might have postop nausea and vomiting but during the case we can actually say hey we found this we got it released will you test it and sees patients being awake or they can close their finger open it they couldn't do that before we did the surgery sure enough they can. CJ Brock CEO of TexAssist Surgical Staffing and Consulting So where did wide awake surgery originate, you made a reference to a physician in canada, but in our prior conversations you also made reference to Europe so touch on that a little bit. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas Wide Awake surgery is something that has been published on part of the techniques way as back is the early 90s and it was around by lost different positions but it's very much popular guy named Donald Lalonde who's the Canadian plastic surgeon and does hand surgery and about 95% of his cases now or all done in this technique now and really started the ball rolling on getting the research out there to disprove that the old technique was not necessary so the old techniques would be to put a tourniquet up on your arm we put you to sleep with sedation so you don't feel the pain of the tourniquet and we had to do that cuz we had to be able to see because of the little bit of bleeding that happens and there was this old Mantra about putting epinephrine in the hand that you could never do. so there were all these stepping points in the research to disprove a lot of things that we had assumed true and so slowly over many years we've disproven that you can’t put Lidocaine with epinephrine in the finger and that's the anesthetic that we used which he'll squeeze down the blood vessels so we can see so you don't have to have the tourniquet so there's no pain from the they also studied antibiotics and if you actually have to give this because that's another reason you have to have an IV during surgery turns out for clean elective hand surgery which is what we do almost primarily infection reasons exactly the same less than 0.4%. CJ Brock CEO of TexAssist Surgical Staffing and Consulting I mean that’s incredible right because what you guys are talking about is the antithesis of status quo. Traditionally physicians are very very slow to change even to the to the detriment to the patient. so it's really encouraging to hear you guys talk about the challenge of the status quo the fact that you guys are starting to push and you guys are really trying to be trailblazers. So it takes me to my next question which is why right why when there's so many patients in DFW you could build a practice with a traditionally what's the motivation here Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas it's better for patients, its better for health care. patients who can handle any kind of dental procedure without local numbing medicine they can take this kind of surgery most of my patients when they're done with the procedure they say is that it because they're amazed and they they studied how painful is it they said it's less painful or the same as getting a single IV so us we believe that this is better for patients it's faster and more efficient its less costly to healthcare as a whole and a patient gets the same or better results, CJ Brock CEO of TexAssist Surgical Staffing and Consulting So who else is doing this? Because there’s got to be somebody else in DFW or Texas, or some part of the country doing this. Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas I don't know if anyone local that’s really doing it there are there are people its becoming adopted and I've actually sought advice from from colleagues Peter Jepsen up in Michigan and some other folks around the country when we are largely being led by our colleagues in other countries are predominantly Canada in Europe and that has to do a lot with how the health care system is setup. CJ Brock CEO of TexAssist Surgical Staffing and Consulting So speak to that, because thats a curiosity of mine. You know obviously we don't live in a country where you have government owned and Run Healthcare so maybe speak to why why is that a limitation I always think of the United States being leading-edge and we’re always a head of the curve because we have the ability to be so much more liberal with the way we spend dollars why is it the opposite of that really then somebody else is leaving his charg Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas So Doctor Lalonde would I think, I’ve heard him speak, many times. And that was part of it for him was because they have a different type of healthcare system in which elective procedures a lot of time patients had to wait extended amount of time because it just limited operating room availability he was incentivized to find a way to get the care to his patients quicker Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas I think that's the key word there “incentivised” right does that exist in the United States no not at all. I think that's a big to just talk about it plainly like surgeons are not financially incentivize to do this if you do this surgery in your office there a cost associated with that whether its suture, the numbing medicine, having your staff work on it… CJ Brock CEO of TexAssist Surgical Staffing and Consulting So I think that's really you know that's an interesting comment that you made because I think as a patient and as a non-physician I've always assumed that you know what the assumed means right so I've always assumed that the physician always had my best interest in mind and not just my clinical best felt like the physician would think of me as family and I don't on Gathering that you guys would agree that that's not the case in terms of they might care of clinically what's best but they're not really watching the financial side of the equation well Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas I don't know…certainly our colleagues, I think they have the best intentions at heart. This requires some motivation and a big financial expenditure to get this going and and I think there are multiple limitations I've experienced these limitations this is what took me 10 years to get the ball rolling you know, for us. For those who don't understand the way surgical billing works in the United States, effectively if you're going to have a procedure you can expect three bills. You’re going to get a bill from the surgeon, which is pretty reasonable I think everyone expects that. And then there will be a bill coming from anesthesia, because typically that is not performed by the surgeon. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Yeah you’re not paying the guy to put you to sleep, you’re paying him to wake you up. Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas Thats right. But then what’s really crazy and the bill people don't really consider it ends up being by far the largest which is the facility. So quick example you can have a simple carpal tunnel release. A surgeon fee on that likely in the neighborhood of 7 to $800 and anesthesia is more or less the same facilities going to be significantly more going to be three to four thousand dollars. And there are reasons for that. You know these facilities they have big overhead, they have the capability to do a major surgery but this really isn't necessarily a major surgery so why do we have to participate in that high overhead. CJ Brock CEO of TexAssist Surgical Staffing and Consulting It’s interesting you talk about that. Think about other specialties that do office based procedures add there's office paste labs, and I've been made aware of that through my learnings with the with cardiac surgery especially peripheral interventions are now starting to do something office based labs it just blows my mind that it's taken this long for Orthopedics to kind of pull the veil back and say we really could do this Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas What will blow your mind is watching one of these procedures especially the smaller ones trigger finger release carpal tunnel release and saying really, its taken us this long to figure out how to do this? Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas I think one of the main reasons for that is there were a lot of really good questions that needed to be answered that required long-term studies over many years we had to answer whether or not we could even use that epinepherine in the finger that took thousands of patients, one of the studies had three thousand patients. One of the studies from the UK has got 10 years of data to support it to evaluate whether this is safe right. Then we had to study the infection rate. Then we had to study the cost rate. How do we do the sterility. There’s a lot of factors that went into it systematically over 20 plus years we've been able to debunk a lot of those myths and prove that it is safe that it is effective that the results are just as good. So slowly were starting to turn the tide was good data CJ Brock CEO of TexAssist Surgical Staffing and Consulting One of the questions that I have you say in office surgery and I think okay they come in the exam room yep you need it and they put a drape over your face and they cut your hand open. I don’t know any different, I think the average American doesnt, right. You know I think we have a couple of pictures that are examples of actual procedures that have happened. Help patients understand: Is this a standard operating room that you just build out and in your office or what is this where is this happening so this is our procedure room it's not outfitted like a full-blown operating room, but it has everything that we need and so this is a mock patient to kind of demonstrate what we do and how we do it and a lot of things you see in this image are some of the things that we've proven with those research studies over time. You notice the surgeon has a mask on and gloves but no big right we've proven that in his study for these kind of procedures that's not necessary okay. So that patient right there is completely numb to what he's doing but they're awake they can talk they can tell you hey I have some discomfort luckily that happens if a very rarely, but if it does guess what you can say something right there is that really uncommon risk when you go under anesthetic or “General” where you feel the pain but you can't respond–that's so uncommon–but here it can’t happen. CJ Brock CEO of TexAssist Surgical Staffing and Consulting that's really interesting Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas Some patients actually want to see right when we do something they actually want to see inside and see what we're doing we can show them that was an example of us showing that patient where we had released CJ Brock CEO of TexAssist Surgical Staffing and Consulting Wow Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas That's really kind of pulling back the curtain a little bit because there is always this mystery about surgery… CJ Brock CEO of TexAssist Surgical Staffing and Consulting It’s kindof wizard of Oz, right? Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas Yes and we show patients, you know what as much as we like to think we are smart or whatever this isn't that hard. You open the skin, fix the problem and close the skin. And those patients are just blown away, as I said. CJ Brock CEO of TexAssist Surgical Staffing and Consulting What kinds of cases are most common in this setting that you guys are doing you a Doctor Guevara here I'm thinking about shoulder and the first thing I think is rotator cuff repair and I'm thinking oh God no way. Dr Jonathan Guevara Orthopaedic Shoulder and Elbow Surgeon The Hand to Shoulder Center, Texas That’s a good question. I definitely utilize anesthesia to the extent that it makes things safe and comfortable for the patient a rotator cuff repair in the office is not feasible. So that's a surgery center procedure same thing with the shoulder replacement fracture care elbow surgery. You can blur the line a little bit as to what is safe to do in the office and what's not, but I still push the envelope to keep the patient comfortable and really recovery is where I push the envelope I want them to wake up quick I want them to be able to not be groggy not be overly sedated. Recover from anesthesia as quickly as they can, and that takes a lot of conversation with your anesthesiology team and your recovery team but when you have everything in place it's not wide awake, it can be, but I'll tell you that not everybody wants to listen to you pound away and strike hammers right? So for the patients that are not interested in listening to what we do in the operating room, you can keep them sedated and keep them comfortable and still have them wake up very quickly. It's you know it's not uncommon for it to be 20 to 30 minutes and you're up walking go to the bathroom get in the car and get out of there. CJ Brock CEO of TexAssist Surgical Staffing and Consulting So hand and wrist procedures, because it sounds like below the elbow is where this is at. How many patients exhibit symptoms and how many people have surgery every year where this could potentially be applicable. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas The top three that we usually talk about our carpal tunnel where you have numbness in the hand in these three fingers usually wakes you up in the middle of night that kind of thing. trigger finger where the patient goes to close the hand it gets stuck, and it has to click open and that is painful. Then dequervain surgerywhich is another tendonitis here on the wrist. Now carpal tunnel 2 per cent of the population about 9 million people a year get diagnosed with that and not not that's not how many get surgery but that is how many get diagnosed. Trigger fingers about the same about 8 or 9 million and then if you have actually add up all the surgeries that are done per year for those 3 diagnoses alone you're talking about a million people total several hundred thousand carpal tunnel release one a year in the US alone, several hundred thousand trigger fingers done in the US alone. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Yeah I’m just running the math in my head, right. What Dr Lesley said about the potential facility fee costs to this being several thousand dollars times a million. That number gets runaway expensive really quick when in fact, it appears there is a fantastic alternative that's better on all fronts. Dr Christopher Bates Orthopaedic Hand and Upper Extremity Surgeon Hand to Shoulder Center, Texas Some of the studies that have been done in the United States specifically have done cost analysis of in-office versus formal operating room and the average is usually savings about 50 to 75% in the overall Cost, Plus in Improvement in efficiency. Some some of the study showed you can do 2 times as many surgeries same amount of time at a lower cost. I mean by AND the same results but you don't get a better definition of value than that right. CJ Brock CEO of TexAssist Surgical Staffing and Consulting So what what procedures are just a no-go that you would commonly perform as hand and wrist surgeons or upper extremity. Dr Nathan Lesley Hand and Microvascular Orthopaedic Surgeon Hand to Shoulder Center, Texas So part of this is becoming more Adept at the technique is the answer to that question because currently for us a no-go I haven't repaired in the wrist or forearm fractures that's not to say that it hasn't been done with this technique. If you read dr. Lalonde’s work and I think we may get to that point where there are other considerations that come into play such as implants in those kind of things. Learning how to expand this to other procedures, some of my most commonly performed procedures are release of a nerve at the elbow called cubital tunnel release, you know I’ve had patients with severe lacerations of the forearm where tendons or nerves were cut in the forearm certainly tendons in the hand which is a pretty common injury. So currently I think the answer to your question would be: fracture work at the wrist or above and we can do some some fracture work on the fingers but I think slowly we’ll even expand those indication as well. CJ Brock CEO of TexAssist Surgical Staffing and Consulting Wow. This this brings us to the end of the segment one I mean this went really quick right, this is this is interesting stuff and I think we’ll wind the conversation down from here and we’re going to talk next about benefits, risks and outcomes in segment 2 of this episode so folks will be right back