So, our first panel is a really exciting panel. This is based on feedback from the Residence and Fellows Conference over the past two years. It's really exciting to go abroad, and hopefully COVID is getting under control and borders will open again. So, our next three panelists, Dr. Zhang, Dr. Shah, and Dr. Burke, will be talking about what to know before I go abroad, the types of cases I can do, teaching abroad, and going abroad as a junior attending. Awesome. Well, thank you so much, Paige, for that nice introduction, and thank you, Paige and Stephen, for organizing this awesome conference. I'm Defong Zhang. I'm one of the hand surgeons at Brigham and Women's Hospital. It's a real pleasure to be here and talk to you guys. So, me and my colleagues, Dr. Shah and Dr. Burke, are going to talk about what to know before you go abroad, and there's a lot of different scenarios and reasons that you might travel abroad as a hand surgeon or a hand surgery trainee. And my portion of the talk is going to be focused on international travel while you're a trainee or for learning purposes. I'll try to keep this to about five minutes so that my co-presenters have time for their portions. So, you might ask, well, why on earth, gosh, would I go abroad? You know, I'm busy enough in the United States with a busy orthopedic residency, plastic surgery residency, or hand surgery fellowship. There's not enough time to do EVIM electives in the U.S. Why would I take time out of my busy training to go somewhere else? Do I know the language? I've got to leave my significant other. And those are all great points to think about. You know, I think there are a lot of pros to traveling abroad as a surgical trainee. Perhaps the most obvious is to see something new and something different and something that maybe you wouldn't get exposure to in the United States. And that might be a new skill, a new technique, a different variety of cases. For me, it was brachial plexus surgery. That was something I was interested in and I wanted more exposure in a limited amount of time. So, that was one of the driving factors. You get to broaden your horizons and your viewpoints on even the common stuff. Everything from a carpal tunnel release to a distal radius fracture. I'll tell you, a cupidal tunnel release in Boston logistically is very different from a cupidal tunnel syndrome in Bangkok, Thailand. So, you get to see hand surgery in a different healthcare system. You get the chance to establish mentors and collaborations all over the world and to serve a global community. So, I've been really fortunate to have the opportunity to travel as a trainee to a number of different places, to Germany, Thailand, and to India. So, I'll just briefly touch on kind of these experiences and what I was able to gain out of them. And this will be obviously a quick survey. So, as a chief resident, as part of the AO Traveling Fellowship, I was able to go to Hanover in Germany, which is a medium to large-sized city in Germany with over a million people in the metropolitan area. This is their equivalent of a level one trauma center, so they take, they cover a super regional area in that part of Germany. And I was able to see a lot of great up hand and upper extremities trauma, but it's just also orthopedic trauma around the body. Some new stuff that they did that we don't do as much would be distraction osteogenesis, but even the more routine stuff, you know, nailing femur fractures, it was great to see just their different ways of doing it. This is just one example of the surgeon there, Dr. Christian Kretik, using a sterile iPhone goniometer to dial in a femoral version of a rotationally unstable subtrochanteric femur fracture. It's just a great example of clever German engineering. Bangkok, I got to work with Dr. Samsak Leechavanvong, he's a brachial plexus surgeon and pioneer at the radial to asteroid nerve transfer, and I was able to get exposed to a lot of brachial plexus surgery in a short amount of time. And so it was really great to learn this operation from the surgeon that really pioneered it. And then at Ganga Hospital, this is a large city in South India with a lot of mangling trauma to the extremities, and they're a great orthopedic and plastic surgery hospital, so I was, again, able to get exposed to peripheral nerve surgery, brachial plexus surgery, but also a lot of flaps and reconstructive surgery, and kind of during two months there, I was able to see really the equivalent of what would be many years of experience, I think. Obviously, it was a brief time there, but I think just to get exposure and see these techniques was really valuable. And then lastly, I think really important to find mentors, and going to all these places, you establish mentorships and collaborations, and these are just some of the surgeons from these three locations that I still regularly keep in contact with, talk with, email, and ask for advice. All right, so what do you need to know before you go? So I think the most important thing is to be open-minded. You're going to be in a different atmosphere, you're not going to speak the language necessarily that patients speak in these countries. You're going to see different techniques, but different philosophies of treatment and different cultures. So be observant, absorb, soak in like a sponge, but don't be judgmental. So this picture is really funny, it's one of my favorite pictures, but Dr. Hari Venkatramani is one of the surgeons there, one of the plastic surgeons at Ganga Hospital, driving me on a Saturday to a research conference in Coimbatore, and we passed an elephant walking on the street, which is just completely random, but kind of awesome, and not something that you see in Boston. Secondly, be friendly. Just everything that you remember from your away rotations as a fourth-year med student. Remember you're a visitor, you don't want to be a burden to your hosts, there's very little that you can really realistically do to be helpful, but you try what you can, and you're interested and you're engaged, and they'll be more than happy to take you under their wing and teach you. And then lastly, be prepared. So you want to go there with a good foundation of what you have learned in the United States, and you guys all will, you'll be well-prepared and well-trained by the time you go there. My personal advice is to not go before your last year of training in the United States, because whether you like it or not, whether you're ready for it or not, you're going to be an ambassador when you go overseas, so you're going to represent yourself, your institution, your hospital, and your country, and it's not uncommon, it's really kind of natural for people to put you on the spot a little bit and say, hey, back in Boston, how would you treat this fracture, how would you manage this wound? So you don't have to have the best answer, you're there to learn, but you want to have a answer. And then I'll just put in a plug at the very end for kind of just two opportunities that all of you can take advantage of. One I mentioned is the AO Trauma Traveling Fellowship, that's for general orthopedics, but they provide a stipend for travel and for housing, and the other is through the AFSH, the International Hand Surgery Traveling Fellowship, which is for three months, I believe, for centers in China and Ganga Hospital in India. And then with that, I'm happy to take any questions, maybe offline, just to respect my co-presenter's time. Thank you. The moment of truth when you can't find your talk, but there's someone to rescue you. Hi, I'm Charity Burke. I'm from Louisville. I've been in practice about eight years now, and I get the joy of talking to you about what I feel is the most passionate thing that I feel like I've done the least work for but got the most reward out since I started practice. I was a fellow at the Indiana Hand Center, and Michelle James has kind of a scholarship set up that you can, I'll say, win a trip to serve on a medical mission. How many of you guys have already been on a medical mission, done surgery abroad? We have some. Okay. So I'm speaking to, I'm not an expert in this, but I feel like I have learned a lot and hopefully can share with you. So I'm going to talk a little bit about preparing for teaching hand surgery in Africa. And why teach? I think Dr. McKinnon used the word exaptation. I would use the word, I stole the idea from Dr. Michelle James. She's made multiple trips back to the same hospital in Nicaragua, worked with the same person who was a resident, then they became an attending, and she's pretty much put herself out of business. She said, that's what I want to do. I want to teach people. You'd be amazed at the people abroad who want your knowledge that you have as a hand surgeon and how you go places and they just, they want to know how to take care of their patients. Just like you and your training, you want to learn how to take care of people. There are lots of people abroad who also want that. And so I first went to Nicaragua. I don't speak English, I don't speak English very well, but I definitely do not speak Spanish. I took Rosetta Stone and I tried and I said, nope, ain't ever going to be able to do this. And so I actually got in touch and I said, I want to go somewhere that speaks English. And so there are multiple colonies in Africa where everyone who has an MD degree speaks English. And so the med schools are taught there, the surgeries, the interactions in the hospital are in English. Yes, it's about a 23 hour commute and it's about an eight hour time difference. So yes, you pay for that English, but for me it was worth it. So over the last few years, I've made three trips to Moshi and three of my residents have been there. And two of the residents there at Kilimanjaro Christian Medical Center have traveled to the U.S. through scholarship for HVO, came, stayed with me at my house. They have since fed me Mbuzi, if y'all know what that is, that's goat, at their house that they slaughtered that day for me. And you know, with COVID, there's been a big transition worldwide to the Zoom. The AAHS, through Dr. Asbug, has a Zoom lecture that's been going on for many years in Kumasi, Ghana, that you can be part of. So if you're not for traveling, but you still sort of want to reach out and see the rest of the world, there are some teaching opportunities as well online. My dad, when I told him, I was like, I've won this trip to Nicaragua, and he was like, where does the runner up going? He's like, do you know? You know, that's like revolution. If I could give you or tell you anything about teaching or traveling abroad, I would tell you to go with humility. And I mean a deep, deep seated humility. If you haven't read the book, When Helping Hurts, Glen Barton, who I met on my second trip to Tanzania, recommended this book. It hurts to read this book. And it'll make you, oh, I'm going to go feel good for a while and save people, and it makes you see what you're doing from their shoes. And it's not just all medicine. They give examples like after the hurricane, like if you come in and you bring all your building supplies, and you're the store there that needs to build hardware, like how can you really dig in long term for substantial change? So I've loved it. Like I'd never done a sign nail. You know, I did a lot of intermediary nailing in residency, but I loved it. The residents there, I'm like, hey, I want you all to teach me how to do a sign nail, how to use this, you know, the targeting guide. And so I've tried to, you know, there's been cases presented where people have come in from Ghana and other, and I see that x-ray, and I'm like, yes, they probably did that with a hand drill. Hey, they probably didn't have the right length screw, and they took roof bolt, you know, cutters and cut their screws to the correct length. So yeah, I try not to judge that, but the great thing about hand surgery is there's so much of what we do is anatomy. Some of the things, you don't need great plates. You don't need great screws. Like to do a machete injury, you need to know anatomy. And so I think a lot of this is very, very teachable. So yeah, I was super worried about supplies. Another thing when you're looking about going abroad and trying to figure out how, if you want to do this short term, if you want to do this long term, a lot of you said, you know, you're fellows and you're looking for jobs and COVID and stuff. Hey, maybe this is the chance you go and experience some of this before you lock in your, you know, forever job. But yeah, there's a lot of things you can learn. It's amazing your mentors around you. There's a lot of different service models, and you're going to hear different things. There's a vertical approach, Kenya Relief, Operation Rainbow, a lot of places where you go, you take your anesthesiologist, you take all your supplies, you take everything you need. There's also, you know, some I have one surgeon at my institution who brings patients from the Middle East and operates on them in Louisville and then brings them back. You can also like, hey, we had the surgeon there come and work with us. You worry about brain drain and expense and how substantial that number two option is. Then like the cardiac folks have really made big horizontal approaches. Like how do you how do you work in a medical system that doesn't really have insurance that, you know, they get in a motorcycle accident at age 20 and they have an open femur and that kills their ability to provide for their family for their entire life. So depending on how long you want to be involved and how sustainable things are, I think most things, at least I've kind of dug into the diagonal approach where, hey, I'm a surgeon. I need some instant gratification. I can't just, you know, go into politics in that country and try to figure out how to build hospitals and how to train their orthopedic residents, you know, from the ground up. But there's no like hand fellowships that I know of in Tanzania at all. Zero. I can't fix that overnight. But hey, I can go in the residents who want to learn ortho at that hospital. Hey, I can I can help teach that. So when you're first looking at organizations, anytime anybody hears like, hey, you're going abroad, you're a doctor, everybody, I think almost always assumes you're going with doctors without borders. If you look, the shortest you can do medical mission work with them is about six weeks as a surgical subspecialist. Has anybody here traveled with? So I don't know anybody either who has, but someday maybe Cure International is also well known, especially for ortho for plastics. There's eight hospitals. My understanding is you're going to know kind of what you're getting into there, like the hospital in the Philippines that Tim Tebow is associated with. Like, it's really nice looking. And so your conditions, they're going to be much more controlled if you're really scared about your supplies and what your environment's like. Hey, that may be more for you. Mercy Ships, you know, they have floating hospitals. They go and park outside of one country, usually for about a year stint. Again, depending on how long you want to go, those are all you can find this online. Samaritan's Purse has dark teams, which usually you go for three weeks. And that's like a medical crisis like in the Caribbean. There was sometimes it's not even they have it's like a hurricane. It wiped out their hospital. They can go and do this inflatable hospital. You can go and do Glenn Barden, who I've traveled with and who I think the world has done multiple missions with them for ortho. Then there's PAX, the Pan-African Academy of Christian Surgeons, who actually has set up like orthopedic residencies in Kenjabi. And so you can go and do like long term, stay there and teach ortho or hand surgery. They also need people to come and volunteer to give their surgeons a break and be vacation. So and then the organization that I've always traveled with and I know the most of and I've just joined over their committee last week is Health Volunteers Overseas. And so I want to take just a minute to tell you a little bit about Health Volunteers Overseas. They meet at the AOS every year. They also have scholarships. Andre Ivey in Chicago, if you get to meet him, he traveled to Tanzania on one of their scholarships. And you can you know, there's a lot to be learned from Health Volunteers Overseas. If you go online, it'll it'll give you a list of where they have teaching sites. They go at countries that are pretty stable and have orthopedic residencies or general surgery residencies or plastic residencies who have reached out and said, hey, we need specialists. We want you to come in and teach. And so you go and you try to blend in and learn and work in their own system and try to teach their residents. And so that's where I've tried to fit in. And so, yeah, the experiences, it'll change you. You'll see the world in a whole new light. Like I said, I've met people abroad and just learned people story that just wouldn't happen. I've had people in my home from across the continent and and so across the world. So, yeah, I would definitely say if you haven't thought about it, think about it. If you've done it, keep doing it. If you want to learn. This is one thing I love to talk about. If you can't tell. Thank you for your time. If you have any further questions, please don't hesitate to reach out to me. Like I said, it's not work to me talking about working abroad. Thank you. Wrapping up this panel, just a little bit of a different take than our two prior speakers. I've done more of a vertical style mission in central Honduras where there's really minimal access to hand surgical care. I wanted to share some of my experiences there. So Pablo Picasso said that the meaning of life is to find your gift and I assume if you're in this room that your gift might be hand surgery. But that the purpose of that life is to give it away. I along with another hand surgeon in the American Society for Surgery of the Hand, Erica Lawler, have traveled to Honduras once annually for the last five or six years interrupted by the pandemic. It's a pediatric hand surgery mission that we complete. It's organized by a small Madison, Wisconsin-based organization called Sharing Resources Worldwide. So there are a lot of small groups that do this in addition to things like HVO, et cetera. We've been sponsored by the Touching Hands Project at ASSH and I would encourage you to check out the Touching Hands Project website for missions led by the American Society for Surgery of the Hand but also independent missions like the one that Dr. Lawler and I have done. Just some basic details of the mission work that we've done. It's been a two-surgeon team. We bring in about 15 people all together. We're there for a week. We are supported by a local nonprofit organization that has clinic space and two operating rooms. This is literally in the middle of nowhere, central Honduras. There's one orthopedic surgeon who does everything, adult orthopedics, pediatric orthopedics in the area and he provides our postoperative care and over the years we've taught him a lot of pediatric hand surgery and have completed 138 operations over the last five years. We see the entire spectrum of pediatric hand surgery when we're there, non-unions like the lateral condyle non-union you're seeing there, supracondylar malunions, leftover effects of brachial plexus injuries, epidermolysis bullosa, burns, congenital hand anomalies. You can see from that macrodactyly case in the center of the slide that a lot of congenital hand anomalies in places like Honduras are untreated. If you don't show up, they're not going to have surgery. So why do we keep returning to Honduras? Number one, I've found it to be personally really therapeutic to do what I love to do every day but to be sort of unburdened of the paperwork, unburdened of I think some of the bureaucracy in our day-to-day work and to do that for kids who are desperately in need for surgery and the gift that I've personally gotten out of traveling to Honduras certainly exceeds any time or energy I've given to them. So it's been a really rewarding experience and I feel immense gratitude for having had a chance to travel there. Number two, I think it's fostered tremendous deep authentic bonds in my team at the Children's Hospital of Philadelphia and also at the University of Iowa where our partner team is from. When we go back to work, I think we feel a renewed sense of energy that what we do is meaningful and I think sometimes that gets lost in the day-to-day provision of hand surgery care in the United States. Number three, I've learned a tremendous amount. When we go there, we bring a lot of our own equipment but we're limited and we're also taking care of incredibly complex pathology. So having to do an arthrodesis with a wire as opposed to the instrumentation you might normally use, having to operate in the dark, having to deal with congenital hand anomalies at a different stage in your career, having to take out a pen and paper which I hadn't done since I was a second year resident to plan an osteotomy since I didn't have fluoroscopy. Those are all skills that have sort of in a very bizarre way kind of translated into my practice and made me a better surgeon. And then lastly and most importantly, I think you have an opportunity to truly change someone's life. I think when you go on a mission trip, you can get hung up a little bit on how many kids there are to see or adults there are to see, how many operations you're going to do. A lot of times it comes down to whether or not you can help one specific person. This is a young lady I met when she was seven. Her name's Camila. She had bilateral ulnohumeral stenostosis and both arms were stuck in a position that she could neither self-feed nor self-toilet. And so over the years, we've done kind of two corrective osteotomies, one flexion osteotomy, which you can kind of see a clinical photograph of to give her a feeding hand, and then later down the line, an extension opportunity to give her a toileting hand. And you can see that she's able to reach her hand to her mouth for the first time and really become independent from her mother and father for the first time at the age of seven. So recommendations if you're thinking about going abroad. Number one and most important, everyone in this room is a young surgeon. Go with a friend, particularly someone who's got experience. So I went with my senior partner at the time, Erica Lawler, who had been in practice seven or eight years more than me. And it was really, really helpful to have someone smarter, more experienced, and prepared, I think, to help me kind of help patients as best as I could. And obviously, a lot of fun to travel with a friend. Number two is just go. I had the opportunity to go on a mission when I was a resident to Columbia with a pediatric hip surgeon. And once you go, I think you're going to really find yourself kind of being bit by a bug. It's incredibly rewarding. And I think that those who have traveled abroad and done surgery abroad often feel that they get more from it than they give. And the last thing is just go. I mean, I think there's a lot of reasons that you would decide not to go. We're in the middle of a pandemic being won. But it will really change your life forever. Thank you. Thank you to all our panelists for those very inspiring talks. Next, we're going to switch gears a little bit to job search, finance, and coding with doctors Wei and Saucedo. I hope everyone is doing well. James Saucedo is on his way. He's tied up a bit in another meeting. And I do have another fellow hand surgeon with me, Noah Raisman, who has graciously given his time with us to also discuss some other parts of this talk, including coding. So I guess we'll get started. All right. So this is really a review. And it really just scratches the surface on the essential business knowledge for residents and fellows. And I think it's something that's not really talked about, at least openly, in training. So we thought we would take a stab at it and at least introduce some topics to you. Okay. No disclosures from myself. So here's our agenda. We're going to try to cover as much as we can very briefly. We're going to talk a bit about coding, the revenue cycle, financial planning, and the job search. Okay. So I'm Noah Raisman. I'm a private practice hand surgeon in Washington, D.C. And I am the vice chair of the coding committee for the ASSH, which means I also represent the Hand Society to the AMA in terms of getting codes valued and getting paid. It's wonderful following on the heels of doing lots of very rewarding work for no money. Because if you do not code appropriately and document appropriately, you will also be doing very good work for no money. So it's not enough just to see patients and do surgery. And at this stage when you're learning, you're learning how to do surgery. You're learning how to make good decisions. But what you don't realize is that if you don't document appropriately, you didn't do it. And if you don't code appropriately based on appropriate documentation, you won't get paid for any of the work you did. So you need to learn how to code now. With everything that your residencies and fellowships will teach you, coding probably isn't one of them. And that's problematic. But the Hand Society provides a lot of excellent education, both at the resident fellow level and into your career. So just briefly, there are two basic types of coding in terms of coding procedures. Coding diagnoses is managed by the ICD, the International Classification of Diseases. And that tells you what your diagnosis is. That does need to be linked to whatever procedure you're doing in order to get reimbursed. But in terms of coding for procedures, there's what's called E&M, Evaluation and Management. That is the setting or the set of codes that pertains to office visits, both new and established, ER visits, consults, inpatient care. So that's non-surgical services. And those are typically 9-9 codes. All codes will have five digits, and the 9-9s are going to be the E&M codes. All of the criteria for what allows you to code to what we consider, there are five levels of codes, 1, 2, 3, 4, 5. The higher the level of the code, the more complicated the patient, the more complicated the work you did, and consequently, the more you get paid for it. In order to reach a certain coding level, you have to meet certain criteria. Those criteria changed as of January, completely rewriting the book. It used to be that you had to check a million boxes for a certain complexity of physical exam and review of systems, et cetera. It's still important to document an appropriate exam, but it's no longer the basis for your code. The basis of the code is medical decision-making and how complicated it is. So over the next year or two, you're going to see all of your electronic medical record systems adapt to that and give you the ability to check boxes for how complicated your patient was, and you should read the CPT manual and know what you're looking at. It's really only a couple of pages. It's not necessarily the easiest reading, but it's very important to get this at this stage of your training. In terms of the procedural codes, the total number of codes relevant to a hand surgeon is about 10 pages in the CPT book, which is nice. Most of it is concentrated in the upper extremity section, but then there are the skin codes, debridement codes, flap codes, and then there's nerve. And once you know where to find them in the book, it'll be easy to find them again, know what you're looking for. When you get a little further on in your training, you'll learn that your operative dictations need to match the codes you're going to build. And if you know what the definition of the code is, it'll make it a lot easier to set up your operative dictation so that you are not going to confuse a coder and they won't know what to get coded, and then you get everybody confused. So there are a couple of modifiers that you'll end up using. For example, if you're seeing a patient in clinic and you're going to or say you did carpal tunnel on them and you're in the global period, which is the 90 days following surgery, all of those office visits are considered part of your surgical code. You don't get paid separately for that. So say you see somebody four weeks later, and it's like, you know what, I also have a trigger finger and my ring finger, and you evaluate them and give them ejection. Unless you mark that with a modifier saying this is a separate E&M service in a global period, it'll get kicked out and denied. And unless you say this trigger finger injection is a separate procedure during a global period, that will get denied as well. So you'll learn a couple of the modifiers, and it will make your life a lot easier. They're on the inside front cover of the CPT book. So I would say just learn now, because what James is going to come up here and talk about is your revenue cycle, and you'll see where coding and billing fits into your revenue cycle. Sorry about that, guys. We're running a little bit late, but this is the revenue cycle. Has anyone ever heard of the revenue cycle? Just show of hands. Yeah, I'll admit I had heard it and never knew what it was until I was smack dab in the middle of private practice. But basically it's where all the magic happens or doesn't happen. And so when you're seeing a patient and you're developing a treatment plan, maybe you're assigning it an E&M code. Well, then that's going to get submitted, and hopefully you're going to get paid for it. If you determine that that patient needs surgery, and then you code for that surgery using that particular CPT code, sometimes you have to actually get pre-authorization or pre-certification for it. Not always. It depends on the insurance that's covering that patient. But once you do it, you have to submit that code as well. And those codes are then reviewed, submitted. They go through this little process in which the payer or the insurance company or whoever is going to process that. And then they're going to get to decide if they approve the claim or they're going to deny it. And you're going to get an explanation of benefits, and you're going to get an adjusted payment or an outright denial. Now, you can decide to accept that or appeal that with all the appropriate supplements to try to get that money back. But basically all this sort of process that's happening, all that money that you've worked so hard for, you don't necessarily get right away. Instead, you get something called accounts receivable. And you hope that when you get through that process, you're going to get either that payment or you're just going to settle for that denial. Well, this is important to remember because, unlike any other thing in the real world, when you do something and you get paid for it, it takes time to get paid. And so documentation and codes matter. The more you can teach to that test, the more you can document to the code in that language, the easier it is sometimes to get payment for that service. The other important point is that what you bill isn't always what you collect, which can be a little bit frustrating and at times disheartening. And finally, accounts receivable do have a shelf life, so it's something that you have to manage. Now, I'm sure this point's been made already, but because I wasn't here to hear it, I just want to reiterate that the handout – whoa, did I do that? Well, I don't know what that was, but that was pretty fun. So hopefully you have access to that handout, and that has a wealth of information. So if you go into that handout, you should find some more details here, but, of course, always reach out to us if you have any other questions. So I'm not sure why that slide's still there. What's that? Oh, yeah. Go ahead. There's also an important ethical aspect to coding. When I review codes for our coding committee, I see some horrible things done. I could give you examples in workers' comp cases where people put in an on-cue pump, which you shouldn't be able to bill for, and billed the same code you would use for a cardiac catheterization. And when he took the on-cue pump out three days later, he billed for the removal of an intrathecal implant. He got paid about $6,000 for it, but if anybody found out about that, he would likely lose his medical license. The golden rule is that if somebody you respect and trust, your fellowship mentor, were looking over your shoulder, saw what you did in surgery, would they code the same way? And if they saw what you coded, would they feel embarrassed or would you feel embarrassed at the discrepancy between the two? I would also encourage you to code ethically, and a very famous hand surgeon used to do needle aponeurotomies for Dupuytren's by the hundreds, one of the highest volume practitioners. He would bill each time for a percutaneous aponeurotomy per finger, but in the global service data for that code, which I believe is 26040, it is defined per hand, not per finger. And when Medicare and the private payers found out, they clawed back millions of dollars and essentially put the surgeon out of practice. He would be the first to tell you that ignorance is not an excuse, nor is it a justification, and it certainly would not hold up in court. So it's important to learn this for a variety of reasons. And for the record, you're the one that stands over my shoulder every time I code. Okay, now that we've sufficiently scared you about coding, let's talk about what you could do with your money once you do have it. So this little section is really about personal finance, and many of you may already be knowledgeable about this, but I think this graph is worth looking at and kind of studying. So you see three different lines, and this basically shows the power of compound interest. So if you start compounding that interest and start saving younger at 25, that money grows larger and eventually more than if you start saving at 35 or 40. I'm not suggesting that you invest in Bitcoin or something speculative like that, even though that picture sort of looks like Bitcoins. What I'm really thinking is, you know, you should really start thinking about retirement. And when I was in your shoes not too long ago, I think retirement was very far away. So you don't really think about these things, and we're not really trained to understand them. Some of these terms are also very unfamiliar. So traditional IRA, Roth IRA, even 401Ks and 403Bs, I think. Now is the time to really look into these and start to read about them. You know, these topics are big, and there's a lot of details to understand. Some of these are tax-advantaged. Some of these are provided by your employer, like your hospital. But start reading about these. I think that's the main point here. Just like those tax-advantaged tools, you should also really consider investing in insurance. When you're a trainee, when you're younger and when you're healthier, now is the time to get long-term disability. When you get older, when you make more money, that rate will go up. So a lot of times, you really need to start thinking about that now as a trainee. If you haven't heard of own-occupation disability, you should really start to read about that. It's very different than different types of disability, so another term to understand. So one final plug. We do have a new curriculum coming that discusses many of these topics. It's called the Hand-P curriculum, much led by James Lacedo, sitting right next to us. So there's more to come. We do have a podcast coming, too, that discusses many of these topics. So much more, and stay tuned. So does anyone have any questions about some of the topics already covered? Perfect, yeah. So he mentioned the Hand-P curriculum, and that's something that we're all very proud of. And so this group here, along with Greg Bird, have been working on this for probably the last 9 or 10 months, and it's a special project of Jeff Greenberg. So, again, stay tuned because I think there's going to be a lot of this information that we don't get in other places, but we need for everyday practice. So look forward to that. I want to introduce the idea of a job search discussion with this. So I think it's an important question to ask, and I think it sums up a lot of what we're going to cover here in discussion style, but will this help me practice the way I want to practice? So you can insert these words, this structure, this setting, this model, this group, this group culture. Is it going to help you, or is it going to prevent you from practicing? Because there's going to be a lot of structures, and this is all in the handout. There's going to be private practice. There's going to be employed positions, academics, so on and so forth. And I think it's important to think about, okay, how do you want to practice? What are your goals for practice? Are you looking for academic notoriety, or are you just looking to make a living and go to the lake house on the weekend? And those things are okay. I just think it's important to recognize what you're looking for and how that particular job opportunity helps you get there. So do we have time to make this more of an interactive discussion, about two minutes or so? Any burning questions from anyone? Well, then I'll ask these guys. So what were you all looking for when you looked for your first job? I'm currently in a multi-specialty practice with 25 doctors, actually growing to many hundred doctors. So I think that when I was thinking about what type of practice I was looking for, one of the biggest things that really affected my decision is the people in the practice. And I think you're going to be working with these people side-by-side, other surgeons, other ancillary staff. So I think, for me that was really the number one thing in addition to of course where my wife wanted me to be but geography counts too but you know I think looking at the practice really looking at who you're gonna be working with who are you gonna be spending the most time with I was looking at academic practices but I was very geographically limited because my wife still had a few years of residency left to go and I joined a practice where I knew everybody I was working with because I'd worked with them as a resident which is nice but it's not a luxury that most people have I was a known entity to them and vice versa and I like the way that they ran their practice it's really hard when somebody gives you their books and say here's our profit and loss statement look at this this is how you judge the financial stability of a practice you want to be thinking about what's the future of health care how is this practice like, that's good on a short term, but you should also be thinking, where is this practice positioned within the market? Is it big enough to survive? Are they aligned? Am I gonna be sold off to private equity before I get to become a partner? What is their ancillary income streams? What does the future look like for that practice? All these things you should be considering when you look at practices, it's multifaceted. But I think that if you have an eye out for... All right, I think that's all of our time. We tried to cover a lot. I hope we hit some good highlights for you. If there's any questions, please let us know. We're happy to answer them. And look out for Hand-P Launch. Next up, I want to introduce Dr. James Chang, who is a previous president of the ASSH, and he's going to talk to us about getting involved in the ASSH. Thank you, Paige. Good evening, good afternoon, everybody. I've had a lot of fun and fulfillment working with the Hand Society, and I'm going to try to show you how you can have a similar experience. What's unique about the Hand Society is that it's pretty small, so it's small enough that you can really make a difference. You can start a whole new website like HandP and do things that really have an impact, but it's big enough to matter also in terms of national advocacy, etc., etc., so you can definitely get involved. Why get involved? Well, there are all those reasons on the left, but this is a picture of one of our partners, Dr. Jeff Yao, when he was an assistant professor. At this meeting, the Flatt meeting, Adrian Flatt's in the middle there, I had him debate Dick Burton, who came up with the LRTI. So that's the intellectual challenge that's available in this room, the things you can do. As you can see from this Residence and Fellows Conference, everyone gets involved. There are various trajectories, depending on what you want to do in your entire life. The Hand Society may be a big part of it, it may be a small part of it, but there's different trajectories. You could attend the meetings and be super happy with that. You can present at meetings, you can be on some committees, you can be on a lot of committees, you may chair some committees, you may want to become a council member or on the presidential line. And I'm going to try to give some opportunities and tell you where you may fit in. There's three main steps. All of you are going to be Hand Society members, I guarantee that. So how to get from being a Hand Society member to a committee member, that's one step. The second is, if you are a committee member, how to do well in that role. And thirdly, if you want to join council, how to get involved in that way. So here's the first step. From the Hand Society member to a committee member, it's super easy. You need to understand the governance, so there's council, which is the board, and there's four main divisions, outreach and international, research, education, and practice. And you can pretty much tell yourself where you're going to fit in within that. What are your deep burning interests in relation to hand surgery? And from that, there are different committees that you may get involved with. So find your area of interest. Don't sign up for a committee that you really don't want to do. Make sure you have the time. Know the application deadlines, the super simple applications I'll show you. And then usually try to apply to more than one committee in that general area, and you'll probably at least get one of them. And just simply go on the website as shown here. You open it up. You go down to get involved. And then you'll see a whole litany of hundreds of opportunities, but in terms of committees, over 100 committees. You go down and you click on that, and you'll scroll down, and you'll see all of these different committees. And then you'll go back up to the left to the volunteer engagement platform, and then find the link to apply for that committee. Super simple process to do. But look at these. They'll tell you the description of the job and the time commitment also. So how do people get on a committee? It's a yearly process. There's a group called the committee advisory group that is chaired by the incoming president-elect. Find the committees you're interested in. Apply through the volunteer engagement platform, and then you'll get an email telling what committee you've been placed in. Key point, don't be shy. Let people know of your interest. You've heard so many people present today about their areas. You want to be involved in coding and reimbursement. Corner Noah Raisman today and say, hey, I'm really interested, I want to get involved. That's what it takes in these meetings. And then just to give you an example of the work you have to do, you can see the editor of the journal, Brent Graham, and your president, Kevin Chung, there, deep in the weeds, doing the work, reviewing different grants in Chicago for three days, and this is back in 2008. So all the people who've been on committees have done the work. One big thing to think about is the Young Leaders Program. I was in the second class of that, and I loved it. What you do is you go to Chicago to the home office, you spend two or three days there, you actually learn a kind of a mini techer course on how to do well in a nonprofit board, how to participate, how to listen to people, how to get things done. So you get that, that you can bring back to your own practice or hospital situation, but you also do several projects related to an interest in hand surgery, and you meet friends and colleagues for life, and then the key secret here is that if you do that, you'll definitely get on committees, they'll put you to work. And so every year, look for the application process, you'll see it in the weekly member update. Okay, that's step one, getting on a committee. Second step is now that you are on a committee, how do you do well? Show up to meetings. This is like high school, after school club, right? The people, the yearbook, the people who actually do the stuff will do well, other people just float through it, okay? So show up, know who's on calls, review the material, and do the work. There are many different types of assignments, and that's why it's critical to know what the committee charges are. Don't sign up for things that you're just going to drag your feet and hate to do. So you may not want to review a lot of grants, you may not want to review a lot of abstracts, but you may want to do something cool like fundraising or writing an educational material chapter, find a thing that you want to do, and then you'll be much better off. What not to do on a committee. So you realize that you can easily float through these committees and do nothing, but people kind of notice that, that you have done nothing, or you haven't returned emails. Don't complain without solutions, don't ignore or mock others' ideas, and do follow through on your assignments. You'll be evaluated, and you will evaluate the committee chair, and the key point is the more work you do, the more work you'll be asked to do. Paige Fox knows this very well from Stanford and from the Hand Society, but we can always count on Paige to get stuff done, so we go to her. The third is how to get from a committee chair to be on council. Council's the board, and I've enjoyed it so much over the last 15 years. So when you're a committee chair, you have direct contact with the division director. I told you it's four divisions, outreach, education, practice, and what's the last one? Research. Yes. I was the research director at one point. I've blocked that out, yes. So as the chair, you will have an important function. You may run the annual meeting. You may run this Residence and Fellows Conference. I can tell you the hours and hours that Steve and Paige have spent putting this day together, including choosing the menu of lunch. Thank you, Paige. All this work is done, and then you have to engage the committee members and get everyone involved. These are all the chairs, and again, you have to deliver. When you're a chair, you actually have work product that has to keep the flow going. And everyone will evaluate everyone. This is not 360. This is 720, 1080 evaluation. Everyone knows who gets the work done. And the directors will present progress of the committees to council. So your interaction with the director, you may have to lobby the director of that silo to get some money for a new project. And so that director will take up your concerns to the board or council. Here are those directors. Research is Tamara Rosenthal. Education is Warren Hammert. Practice Director is James Saucedo, Best Hair and Hand Surgery, James. And Outreach Director is Julie Katarczyk. So these are the directors. If you're interested in areas, please talk to them. And here is council, at least in 2017. And the people on council are these people. The vice president is in the presidential line. He or she has been on council before. So they're coming back for a term. But there's the treasurer. There's the four division directors. There are members at large. And notice that there's members at large under eight years. So many people starting out can be in one of these roles. And it's super important to have that input into council. So my final key points. The Hand Society is a 100% volunteer organization. Kevin Chung does not get paid a cent for the work he's doing. Ensure that you have the time and interest. There's a lot of work to do. Hard work will be rewarded with more work and responsibilities. It's clear who does the work. And the benefits, really, to me, what I've enjoyed, the benefits in terms of professional satisfaction, friendship, fun, laughter, are really significant. To me, it's the only way a California plastic surgeon has become good friends with an orthopedic surgeon from St. Louis. Thank you very much. Thank you very much, Jim. Next up is going to be our next paper session. I invite all our paper speakers to come up to the front here now. This will be moderated by Dr. Dean Smith. As we did before, we'll have the paper presenters sit down for their question, and then the next paper presenter, if you could come up and load up your slides. And for this session, to save some time for the presenters, I'll go ahead and read off the title. So, for paper 16, we have Comparison of Relative Value Units Generated in Operative Time and Hand Surgery, presented by Dr. Ali. Hi, good afternoon. My name is Kosar Ali. I'm a fourth-year plastic surgery resident at Baylor College of Medicine, and today I'm discussing the relationship between relative value units, or RVUs, generated in operative time and hand surgery. I have no disclosures. So the RVU system lists standardized fees for various medical services provided based on the cost of resources. Here we have various hand surgeries listed with their CPT codes and the RVUs assigned. So we queried this database and found the most common hand procedures listed in plastic and orthopedic surgery, and we found 26 unique hand procedures that had at least 10 cases for each of these unique CPT codes. So our cohort was actually over 29,000 hand surgeries for these 26 unique CPT codes, and here we have the median operative times listed, ranging from less than 20 minutes to greater than two and a half hours. And again, these are only for the 26 CPT codes that we queried. Looking at the linear regression model, we had a positive correlation where more RVUs were associated with increased operative time. Interestingly, the green dots suggest bony surgeries actually had less RVUs generated per operative minute expected than soft tissue procedures, which are actually listed in blue. Looking at the specific procedures, LRTI had the greatest RVUs generated per minute, more than expected, versus proximal row carpectomy actually had the least RVUs generated. Even more, multiple procedures performed at the same time, such as multiple amputations, generated higher RVUs per minute. And then bilateral procedures also had higher RVUs than unilateral. In conclusion, RVU compensation correlates with increased operative time in hand surgery, again, only for these 26 procedures that we listed. More RVUs were generated with bilateral and primarily soft tissue-based procedures, though not always. Hand surgeons can optimize their most finite resource, which is time, by performing multiple procedures only when indicated in the same operation with overall greater compensation. Thank you. Thank you, Dr. Ali. I have one question for you. As we know that basically the relative value unit is assigned by relationships between the AMA and CMS, were you able to uncover, by looking at this a little bit differently, any underweighted procedures that maybe should have a higher RVU assigned? Yeah, so that actually brings me to the point where bony procedures actually had less RVUs generated per minute than expected, but those were undervalued compared to how much labor and work actually goes into them. So I think we have to look at the difference in the soft tissue-based procedures and the bony procedures to really delineate that. Thank you. Next is paper 17, Utilization of MRI and Diagnosis and Treatment of Tennis Elbow in the United States, presented by Dr. Fogle. Good afternoon. My name's Nate Fogle. I'm one of the residents down the road at Stanford. I'm going to be talking to you about MRI and the diagnosis of tennis elbow. So as most of us know, lateral epicondylitis, pretty common, presents about 1 to 3% of adults on an annual basis. Patients will often report lengthy symptoms, but 80 to 90% will resolve at one year. There is a subset of, depending on the study, 4 to 11% of patients who go on to require surgical intervention. The role of advanced imaging in the diagnosis and treatment of lateral epicondylitis is controversial. MRI is highly sensitive in picking up lateral epicondylitis, but a good history in physical alone should do the trick most of the time. So our group wanted to look at what is the current utilization of MRI in the United States for using, for the diagnosis of lateral epicondylitis. We hypothesized that patients who underwent MRI would have increased incidence of operative intervention, utilization of PTOT services, injections, and as well as overall increased total cost of the system. So we used a de-identified private pair database, found patients using ICD-9 and 10 codes for lateral epicondylitis. We had two major cohorts, one was an all-comers cohort and the second was one with MRI obtained within 90 days of initial diagnosis, which we kind of termed as an acute MRI for lateral epicondylitis and modeled appropriate regression models. So we identified 44,000 patients. We found that annual MRI utilization increased about 65% over the time period we studied from 2008 to 2016. We also found that 20% of those who underwent MRI ultimately went on to receive surgical treatment, so almost one in five, as opposed to just 2% of patients who did not undergo MRI with an associated odds ratio of 11. Patients who underwent MRI were also more likely to undergo steroid injection and utilize PTOT services. Interestingly, about 30% of those who obtained an MRI was done so within 90 days of their diagnosis, so this acute MRI for lateral epicondylitis, and in this group about 9% of those went on to undergo surgery as opposed to less than 2% of those who did not obtain MRI. And from a cost perspective, those in the MRI cohort, the total average reimbursements were about $1,800 as opposed to $100 in the non-MRI group. So in conclusion, the utilization, at least in this private patient database, was increasing for MRI in the setting of lateral epicondylitis. About a third of these studies are being ordered in the more acute setting with only 90 days or less of symptoms. The MRI utilization does appear to drive lateral epicondylitis associated costs. And in this era of trying to rein in spending or ordering studies that might be less than indicated, more sparing use of MR in the setting of lateral epicondylitis could yield savings to the system without negatively impacting patient outcomes. All right, thank you. So as most of us understand nowadays, but cost-benefit to surgery and treatment and health care is certainly a hot topic. In your paper, you had mentioned some regional differences. Can you expand on that a little bit for us? Were these significant? And also, did you look at differences between, say, major metropolitan areas versus rural? So for the second part of that, for major metropolitan versus rural, I don't think our data was – we didn't go down that granular into the data to look into that difference. That's something we could do before we ultimately publish the study. And then to the first question, which was about regional differences, we only found one regional difference that the south region had a higher utilization of MRI than – statistically significant than the Midwest region, but no other significant regional findings. Did you have any reasons why you think that was true? Not that we could discern. Thank you. Next paper is paper 18, custom remote FIT splints via artificial intelligent technology, presented by Dr. Rivlin. Thank you for inviting me. Unfortunately, our lead author, the resident, could not make it, so Mark Rivlin presenting it. So what we know about artificial intelligence is significantly underutilized in orthopedics and in the medical field. What in general happens is that most of our orthopedic patients require some kind of brace or splint fitting after we take care of their hands. The problem is that not everybody has equitable access to orthopedic therapy or therapists or even orthotists. So what we came up with is an algorithm that essentially using a camera, using artificial intelligence and machine learning, fitting the patient with the appropriate brace without in-person visit. So we wanted to look at our AI and machine learning algorithm to see if it can accurately predict the brace that the patient would need. So the way we did this is we had multiple limbs of the study with two control groups. The first one was an AI fit, so essentially a machine decides what brace size the patient would need for the given injury. The second was the patient, which in our case was medical students and residents, would self-fit the brace based on which one fits better, which one is the most appropriate for them. And the second control limb was using the manufacturer recommendation of using a tape measure of figuring out the wrist circumference and fitting the brace and seeing which size correlates with that. So in general, the AI limb required two pictures that are calibrated with a US quarter put in the AP and lateral planes. The calibration was done by the machine learning algorithm. And essentially, the size of the brace was calculated instantaneously by the algorithm and would give the size of the brace that would be the output size. And this was compared to the control groups, both by the patient fitting itself or using the tape measure as the manufacturer required. We also had an orthotist look at the pictures to make sure that the fit is correct. The algorithm was 70% accurate in 32 out of the 54 patients. However, if we know that some of the sizes have overlaps by the comfort of the patient, you can go one size up, one size down, and it still would fit you right. The accuracy was 90%. However, according to the manufacturer chart, based on the wrist circumference measurement, the accuracy for that was only 32%. So the machine did significantly better than the manufacturer recommendation size. In general, AI can take more and more center stage in our treatment of patients. This is something, when we put our minds to it, we can give patients care that do not physically participate in the right location or the point of service. And this can be an alternative to an orthotic fitting because it tends to do better than the manufacturer recommendation. Thank you very much. Thank you. Thank you. I think the challenge here is getting this new concept to apply across the country. So do you guys think about ways that we can get this out there, get the message out there? And are other amputation clinics doing the same thing? So it seems to be that we're the first ones that thought of this, which is impressive. This is a simple app that we developed ourselves on the phone. And it's a simple machine learning algorithm. We have an AI technician that came up with most of the algorithm. It is two pictures that you need, and it can be used. We're running tests on lower extremity, upper extremity. It seems to be fairly accurate. We only had about 30 to 40 patients. But the more patients you feed the AI, the better the accuracy. So it's something that we can explore. Excellent. Thank you. Thanks. Next up is paper 19, Risk Factors for Revisions or Surgical Site Infections Following Primary Proximal Interphalangeal Joint Arthroplasty, an Analysis Over 12,000 Medicare Patients, presented by Dr. Swiggett. Hi, how are you guys? Sam Swiggett from Mamani's and PGY4. Myself and my authors have nothing to disclose. So a little introduction behind this. Some recent studies have demonstrated increasing utilization of primary interphalangeal arthroplasty for patients with end stage arthritis or rheumatoid arthritis of the PIP joint. Some studies have indicated that the PIPA can lead to better outcomes, particularly for motion for these patients. However, previous studies have shown there is a high revision rate associated with this procedure, but they're limited in their scope of assessing patient-specific risk factors for why this may occur. Therefore, the purpose of this study was to utilize a large national administrative claims database to investigate whether or not there are any patient-specific risk factors for developing one, surgical site infections, or two, having revision surgery. So how we went about doing this is we utilized the Pearl Ivor database from January 1, 2005 to March 31, 2014, which are the dates available for this procedure. We separated those into patients with and without both the surgical site infections or a revision surgery. The revision surgery was over two years. The surgical site infection was determined within 90 days of the procedure. So what we came up with was the revision group had a little over 6,000 without revision surgery and 186 requiring a secondary procedure. And the surgical site infection had a little under 6,000, but 360 of those subsequently developed a surgical site infection. What we did is we took a look at demographic variables of these patients, as well as comorbid conditions that are commonly included in various comorbidity indexes, such as the Elixhauser Comorbidity Index. And then we also did some statistics, such as Pearson's chi-squared analyses and Welch's t-test for age. And then we did a multivariate binomial logistic regression analysis to calculate odds ratios and 95% confidence intervals. So what we determined is that, first off, patients requiring revision surgery tended to be younger. And they more tended to be female compared to males. They also demonstrated a higher comorbidity index comparative to patients that did not have it. After regression analyses, what we found were that patients that were of a lower BMI had diagnosis of depression, iron deficiency, anemia, and rheumatoid arthritis were more likely to have a revision surgery. And moving on to surgical site infections, the distribution tended to be younger, on average, comparative to older patients. There was no significant difference in comparatives to males and females. But like the revision surgery, patients tend to be sicker than their counterparts. And then, again, after regression analysis, these were some of the ones that we identified that led to a higher risk for having surgical site infection. So in discussion, revision surgery was much more likely in patients with a low BMI and history of rheumatoid arthritis. It's unclear what the mechanism would be. However, it has been shown that both patients with low BMI and rheumatoid arthritis have decreased native bone stock and potentially decreased osseous integration in the components. Depression has been shown in multiple studies previously to have deuterious outcomes after surgery. And then in terms of surgical site infection, morbid obesity, rheumatoid arthritis, and renal failure were identified as the most significant risk factors for developing a surgical site infection. And studies previously have shown that these can contribute to surgical site infections and other aspects of orthopedic surgery. So in conclusion, the study demonstrates that there are some identifiable patient-related risk factors that can place certain cohorts of patient at risk for both revision surgery and surgical site infections. Being this is a database study, there are some inherent limitations to this. But further research could be done to identify exactly how these risk factors may come into play. Thank you very much. Thank you. So for PIP joint surgery, a couple of questions there. Were you able to identify or break out the implant choice? Was that a factor? And learning what we've learned from this paper, how can we apply that to current practices? And are there going to be changes? Sure. So secondary to just it being a database study, we weren't able to elicit exactly what type of implant was used for these patients. But that would be helpful to kind of know whether or not, for example, silicone implants have been shown to have higher rates of revision. So going forward, that could be another area that we could take a look at. One area that this could show is that maybe this paper could be helpful as a clinician in terms of deciding whether or not to do this procedure is if you have patients with some of these comorbid conditions, you might reconsider doing a PIP arthroplasty as opposed to more like an arthrodesis or another type of procedure that would place them at a lower risk for failure. Great, thank you. And our final paper of this session, paper 20, Gender and Letters of Recommendation for Orthopedic Surgery Subspecialty Fellowships, presented by Dr. Powers. Hello, my name is Alexa Powers. And I'm a first year orthopedic resident at St. Louis University. The competitiveness of different orthopedic subspecialty fellowships has increased. And letters of recommendation are a key component of the application process. In fact, in a questionnaire sent to hand fellowship program directors, the quality of an applicant's letters were deemed to be the most important factor in offering an interview. Despite their recognized importance, little is known about the influence of applicant gender on how fellowship letters of recommendation are written. Therefore, in this study, we sought to answer the following questions. We wanted to know, are men and women described differently? And are there differences in the way applicants are described between the subspecialties? We reviewed all applications to a single academic program in the following subspecialties. The letters of recommendation were analyzed using a text analysis software program, from which we calculated their frequency of word use in these five categories. Listed are examples of the words we looked for in each of the categories. We compared the frequency of word use in each category between men and women. And what we found was that ability words were significantly less likely to be used in female than male applicants. When comparing the frequency of word use between the various subspecialties, letters written to hand fellowships were more likely to use standout words than letters written to foot and ankle, shoulder and elbow, and trauma fellowships. Though this may just reflect the fact that hand surgeons believe any resident pursuing hand surgery is exceptional. So why does this matter? Recognizing implicit bias in letters of recommendation, an important component of advancement, is an essential step towards improving the overall diversification of the field. Focusing on more objective measures when describing an applicant is one way to combat any potential biases. Though we also found differences in word use between the various subspecialties, this may be more of a reflection of personality differences between the subspecialties. Thank you. That's very interesting. So I guess a couple comments. One, what advice would you have for those program directors on what we should be looking for in the letters if it doesn't exactly, if it's maybe exaggerated as you say? And secondly, was there any correlation between those specific hot words that are placed in your study that you found versus them not being there? Did that have any effect on the acceptance rates? So as far as acceptance rates, unfortunately we didn't have the data on where the applicants ended up for fellowship, so we weren't able to comment on that. And then as far as things to look for, really it's just making a more conscious effort on focusing on those objective measures such as the applicant's accomplishments. What are they saying about their medical knowledge or their operative skills? Focusing more on things that can be measured across the board rather than anything specific. Okay, thank you. Thank you to all of our panelists. Next up, Dr. Stepan and Dr. Contemeka will be telling us about tough consults that you'll see on call. Sitting all the way in the back. She's coming up though. Okay. Okay, hi everyone. What are we on, hour 200? You guys doing okay? Yeah, okay. We're gonna try to make this as interactive as possible. This is a chance for you to ask questions, show how smart you are, point out interesting things, show out things that we may have done wrong, how an x-ray looks horrible, whatever. This is a chance for you guys to start thinking about the next step of, okay, this is what you do in residency, this is what you do in fellowship, and now we're gonna be attendings. And so we need to start thinking about the next step and not just getting people out of the ER or the OR, but how we're gonna handle these patients and getting them into the OR as an attending, knowing your trays, knowing when people should be following up, et cetera, et cetera. So these are tough cases because there's more to it than just what the OITE asks you to do or your in-training exam tells you to do. So we want you to start thinking about the next step. Feel free to shout things out, point out things, whatever. All right, this will only be as fun as you make it. My name is Megan Konamika, and this is Dr. Stefan, from, just kidding, it's Dr. Stepan from University of Chicago. Any chance I can to make fun of him, I take it. So let's get started. Do you wanna do your case first? Yeah, I'll step first. All right, I know that we're also the only thing that stands in between you and your next break, so we'll try to make it somewhat quick as well. I'm Jeff Stepan, I'm in my first, I just finished my first year of practice, so still kind of close to where you guys all are. So call from an outside hospital, Dr. Zhang took this call, and patient cut off his hand, can we send him to you? So first thing that goes through my mind, having taken a lot of these calls, is that he probably didn't cut off his hand, because oftentimes they're not really telling the whole quite truth, but in this case he did. So no problem. So in this, I'm not gonna stand up here and tell you guys how to do a forearm replant, because you probably have better people to teach you that, but maybe how to approach the case, and maybe a few actionable items that you guys can take that might help make this a little less anxiety provoking for you. So, first things first, is don't just say yes and hang up the phone, which I kind of did in fellowship sometimes, and then they'd arrive and I wouldn't have figured out a lot of the things that I needed to figure out. So sit there and ask, what's the patient status? Or whatever you need to do about whatever consult you're getting, what's the patient status? What's the mechanism? What's the ischemia time? All of the information that you might need that's gonna help you progress. What does status mean when you say patient status? Like are they- Is he like intubated and sedated, or is he awake and just has a tourniquet on, completely fine, things like that. Kind of point you in one direction or another. If they're in ICU or unstable patient, then we're probably not rushing to the operating room necessarily for the hand, so. My only thing of status is when's the last time they ate and if you could prevent them from eating by the time they come back to the ER. But that is actually very important for the outside hospital to know if they're going to the operating room. So that's a very good point, NPO status for sure. Less relevant maybe in this particular case, but in a lot of other cases like infection and things of that nature that are getting transferred in, definitely important. Anything else you'd like to ask or add? Being a veteran. Well, I'd ask with the mechanism, you know, give me a time, where is the, this is actually a very important question that just recently was an issue for me. Where is the extremity? And is the extremity coming with them? Or did it get thrown away? Or did it get thrown away? This is very true. So anyways, we get the information and it is unfortunately, it's a 19, sad story, it's a 19-year-old male with schizophrenia who cut off his own arm with a circular saw. One and a half hour warm ischemia time, three hours of cold ischemia, patient otherwise stable with the tourniquet on the arm. So, you know, one thing that you can do is really utilize the time, because it usually transfers, so utilize this time wisely. So I've obviously never done this before, first time in practice, first year in practice. This was like two months ago. So call people if you have questions or anything like that, use your resources for sure. But I think one thing that's specifically helpful for me, especially with these big cases, is to really divide the procedure up into different portions. Because if you take it all as one whole, I think it's very difficult and very overwhelming, at least for me, and so I try to break it up, and visualize the procedure and list the things in the order you need them. So all these big procedures you need, you're dealing with a nighttime staff who don't know where anything is, and so if you come in there with a list in the order of everything that you need, I think that's super helpful. So when it's time to do your bony fixation, you're not just calling for the fracture trace or for whatever system, that they have it there and ready. Because a lot of times in the middle of the night, it's not your standard crew who are really there, who know what you need. So I think this is probably one of the most important takeaways for all these complex cases, to really break it down, write it down, especially the first few times you do it, and make sure that you're not waiting on the heparin, isaline, or whatever that is. So you get into the OR, and these are your two parts, and in fellowship, I would kind of stand there, and I'm like, okay, what next? So just get to work, I think that's the main thing. If you're dealing with this in a level one trauma center, you're gonna have residents and fellows, and luckily, I had two great residents and fellows that were working with me. So what would you start with, Dr. Kontemuka, for this? I actually would send the resident or fellow up with the extremity, and while we're doing with everything in the ER, trying to get the patient up to the OR, whatever, get a sterile mail stand and start tagging everything, because that saves you a lot of time, because these don't come in at seven in the morning. These come in at 2 a.m., and so I always tell, just take it, go upstairs, get started, and that's gonna save you a lot of time, because getting that patient to the OR, intubation, all that stuff, they've already started tagging everything, and I have them start tagging with the actual sutures we're gonna be using, et cetera, so things like that to just start the case early. Perfect. And so usually, so early on, at least what I've been doing recently is I just take the part up and start going myself. This patient went straight from the helipad to the operating room, so we didn't have that interval time, but luckily, Dr. Strzewski and Dr. Zhang were able to wash out the arm while I went to the hand and kind of identified everything, flushed everything with heparanisaline, and these are long lists of things in the interest of time. You know, we'll kind of move on a little bit. You have to debride the stomp, you have to debride both sides, and again, these should be done at the same time, just like Dr. Kontemeka had mentioned, to make sure that we're doing this in an expeditious process because this is a nine-hour case or so, or longer, at least for me. Doing your bony fixation, how much would you shorten, would you say, normally? Well, it depends on the area of trauma. So, you know, you wanna be able to, you don't wanna have anything on tension, right? So, if it looks like there's a huge area of injury, then I'm cutting the bone down because, you know, we're looking at minimal function here. So, you know, the idea of trying to keep as much length as possible is out the window. Does anyone have anything to add? Anything that they've seen, any tricks or pearls that they've seen in their tenure and residency and fellowship that's made it, that looks slick? Fantastic point. That's important for the transfer over to the hospital. Yeah, that's actually a good tip also for sedation cases in the ER. If there's no one available to do sedation in the ER I will not let them transfer the patient over. So these are things to start thinking ahead of like do we actually have the resources here at this hospital to do what we need to do. Okay, because you are you know, you can do the surgery but you need an anesthesiologist and you need also an a bed. So those are two very key things to think about. Right, so this was a segmental injury. So you start thinking about grafting, prepping the leg that should have already been done in in your visualization process at every possible thing that you may have needed. As you can see two wounds on the forearm there. So I shortened quite a bit, use a plate and screws. Did the revascularization. I think another important point that I didn't mention is at the very beginning of the case is to get during the timeout making sure that everyone's on board including anesthesia with these cases because you have to let them know that you're gonna lose blood. Not to give pressers as their first line treatment for soft blood pressures and to get the blood up and ready. And we did that in this case and patient lost a lot of blood and we communicated well, and so we didn't have any issues with that. But oftentimes in these kind of big cases you run into that issue and next you look up and there's pressers hanging while you're doing your anastomosis and but so communication is the best thing. In the interest of time, I'm gonna skip ahead and go on to the next case because we're already at 10 minutes. All right 40-year-old healthy patient sustained a fall off of a bicycle. Start thinking, okay, would they break? Distal radius fracture is not a distal radius fracture. It's not a distal radius fracture. And as you get into practice you'll see so many people who just slap a plate on it and they call it a day and you guys are learning in your in your fellowship and residency that that there's more to that than just putting a bowler plate on it. So the first thing is to make sure you do your initial exam, which all of you at this point I'm sure can knock this out of the park. And so these are the things that you know. But the next thing is you need to start thinking about is timing. So what does that mean for timing? You know that things either need to go to the OR now or it needs to go later. But the strategy of that becomes a little bit different once you're in practice. So the now stuff is pretty self-explanatory. That's now compartment syndrome, acute carpal tunnel syndrome. Well, what does urgent mean? Does that mean in the next five hours? Does that mean tomorrow? Where are you going to do it? Are you gonna do you're gonna be out in the outpatient surgery center? Are you gonna go do it out there? Well, if the patient's being admitted, are you going to admit the patient? Because it costs more money to do the surgery inpatient than outpatient. What kind of insurance do they have? So these are the things you start thinking about is okay, what can I do that I will give the patient the best care and I'm also being patient centered with my decision-making. Okay, so these are the things you start thinking about. Whenever a patient leaves, I always have a plan of what the next step is for them. It's never like I'm gonna call you in a week or whatever. I have a plan for them. For urgent, either they show up wherever I'm gonna be operating the next day and we're gonna add them on. I make sure we have the actual trays there. That's an important thing. You can promise anyone a surgery, but if you don't have a bed, you don't have the trays, you don't have an anesthesiologist, it's gonna be a hard one. So you have to start thinking about what that is. So if it's a poly trauma, probably gonna be admitted. See if you can start planning with the other surgeons who will be doing the other parts of the surgery. Open fracture versus very open fracture. What can you, you know, when I was a resident, it was, which is not that long ago, we were taking open fractures, even poke holes, pretty quickly to the OR, as opposed to now where we're washing them out, antibiotics, and then there's delayed treatment, which is fine. We've shown great data that that's the right thing to do. Can you have patients be, that you are reliable, show up the next day? Elective surgeries. When patients show up to my clinic, I have already scheduled their OR, their OR date. So when they come to see me, we're not trying to find some date in the next like 48 hours or whatever, because it's already been 10 days out from their fracture. I already have it scheduled, so that when they come in, they're just signing the consent, and we're planning their post-operative date, and I'm answering any last questions. So start thinking ahead of what that means. It's not like you can just put these patients off, because with utilization of resources becoming inundated, especially with time and COVID, you have to start really thinking ahead. What do you tell that when you schedule them for surgery? Are you calling them? Are you having someone call and let them know they need surgery? Because I've booked them, and then, you know, the first call sometimes they get is from the scheduler. Yeah, yeah, right, right. What do you do to prevent that? It depends on the conversation. So, obviously, we have the privilege of being in academics where the residents have either talked to us, or they tell the patient that they're possibly going to need surgery, as opposed to the ER physician, who either always tells them they need surgery, or they always don't need surgery. So, obviously, they need to have a conversation. So, it depends on who's talked to them. And I try to get to them with either my nurse or myself, depending on the timing of when I've been on call. But they do need to have a phone call, because the last thing they want to hear is the scheduler, who has no clinical application whatsoever, saying, I don't know, buddy, you're having surgery, I need to schedule your COVID test, you know, and these people are freaking out on them. And that's not fair to the patient, and it definitely is not going to help your Press-Ganey scores. So, you really need to communicate with these patients. Not that you should do things for Press-Ganey scores, but you really need to communicate with them beforehand. So, that's a great, great point. It could be you, once you've really built a rapport with your nurse, and they know how to talk to patients, and what your indications are, that's an easy person for them to communicate with. So, I guess my point was, call your call patients if you know that they need surgery, and let them know. Yeah. When do I need a CT? So, when would you need a CT for a distal radius fracture? You're in your board's collection, when do you need your CT? So, the answer to that is yes. Whenever you think you may need a CT, you probably do. And as you get farther into practice, and you get more comfortable, you're going to stop thinking about the CT as much, okay? So, usually it's those intra-articular fractures that you're like, holy smokes, I need to start planning something like fragment-specific, a dorsal bridging plate, something. That question in your head is going to go farther and farther out, okay? And then you're going to have a, you know, sometimes you have a bad outcome once in a while. I've heard of them. And then, obviously, you get CTs again. So, it's a cyclic thing of getting CTs, or not getting them. So, I always tell people, if you're thinking about a CT, just get it. And then, once you feel more and more comfortable, you'll see that you get them less and less. And then, in the OR, if you haven't heard us say, have all of your plans, and have all of your corresponding traits. You should know what's in the hospital, and what needs to be brought in. Because, trust me, at two in the morning, nobody knows where anything is. So, it's important that you know. So, how would you treat this fracture? With surgery? How would you treat it? These are, like, not, these are not trick questions. Bowler plate. I told you, this is not trick questions. A bowler plate. So, that's, that's what we did for this extra-articular fracture. With a little bit, actually, it was intra-articular. You can see a little split in there. But, we just put a bowler plate on it. All right. What about this? Maybe a bowler plate. Maybe fragment-specific. Maybe a dorsal bridging. Yeah. Those are all options. We did frag-specific for this one. What about this? So, this is when we did a dorsal bridge plate. So, one more. This one has a proximal extension and intra-articular involvement. Lag screws in a metadiaphysial plate. Okay. The point of it is not to show you x-rays. The point of it is to say that I have every one of those trays available because I don't know when I go in the OR what's going to happen. So, you need to plan for anything. Okay. Because there's been times where I thought we were going to just use a bowler plate and we didn't use a bowler plate. Okay. So, make sure you have everything there and you know what's available. Because if you don't have a dorsal, you know, spanning bridge plate, that's fine. You can find, you know, some 3-5 plate off of, you know, one of the, you know, small frag sets. Okay. So, there's other options. It's just you got to know what's there, what's available for you, and how to improvise because you will be improvising. All right. And this is my one thing that I have to tell you guys. The literature is real. The complication rate does increase in 65 and older. This was a patient that had been sent to me just recently. These do love to collapse. Okay. So, if they are older, read the literature. These need less surgery. Okay. They do great with a cast. Wonderful. One of the things that it's up to us to do is bone health. So, anytime you see these fractures where it looks like they have a huge high energy fracture and they just fell from standing, start a workup. Okay. You could save a patient's life because this could be the beginning of a hip fracture or a spine fracture. And as we get the program back underway, I want to invite up Eitan Melamed to tell us a little bit about the SSH's traveling fellowships. Thank you. Thank you, Steve. My name is Eitan Melamed. I'm in my seventh year of practice now. And I work in a city hospital, public hospital. So, for those of you who are familiar, that's like going on a mission trip every day. So, I'm going to talk to you about probably the most amazing experience I had as a physician, as a person this year, which is the international traveling fellowship by the SSH. So, why should someone consider going away for three months to a country like India or China during a pandemic? And I think you would do if you had an unsatisfied need. And, you know, it's not just the need to survive. We're talking about need to really be capable of becoming everything you can become and be a more versatile provider, more versatile surgeon for your patients. And you as fellows, I think you're in the best time of your career to start planning such a trip. And as you know, hand surgery is so diverse. You heard that the entire day, and that's an excellent educational day that shows you the breadth of hand surgery and how much it requires expertise in so different anatomic locations. And it's not just knowledge, it's technical skills. And some of you can teach yourself, but most of us need to follow some form, some education. So, if you choose to take care of complex hand, break your plexus in adults and children and congenital hand, acquisition of those skills to get there is really tough if you only train in the U.S. because the opportunities are fewer. And this is where the SSH traveling fellowship really comes in and bolsters your skill. So, it's a structured three-year, three-month fellowship either in India and China. It was started by Dr. Neil Jones for UCLA a few years ago. And it really exposes you to intense pathologies that you don't often see in the U.S. And if you do, the numbers and the frequency is not as much. And I will show you slides. So, you join as a formal fellow, which is nice because you usually assist as a first assistant surgery. Some of the procedures, you will be the primary together with a resident. I was fortunate to match to the Ganga Hospital in Coimbatore, and it was really hard to say no to that opportunity even in a COVID year because the SSH provides you with the funds, with the mentors, with a place to go, and they take care of you there. And there are more good news. So, unlike any other traveling fellowships or visitorship, you're part of the team and you're focusing on mangled extremities, both lower and upper. So, something that comes more naturally to plastic surgeons among us. Replantation, both the digital major replants, brachial plexus adults and kids, and pediatric hand surgery. You also interact with the hand fellows in that location, and they are eager to learn from you because you're superbly educated, and they really want to learn from you about your experience. And they probably can teach you a lot, too, from their experience in India or China. So, this is Coimbatore. It's a city in south India on the map here, and this is the home of Ganga Hospital where I traveled. It's a 600-bed specialty hospital. They see trauma, orthopedics, and plastic combined. They have special expertise in reconstructive surgery and microsurgery. And one of the best things that you can do there is the local micro course, and each of these hospitals have some type of micro course because it really can up your game even if you're doing microsurgery regularly. These are the statistics for the first month I visited, and that's during COVID. So, 21 free flaps, eight replants, and they have six free flaps trays that are ready to go at every given time. So, that speaks volumes about what you're going to be exposed to. And they have observers all around the year. So, they have visitors from India itself, and they all take pictures. So, here you can see the line for picture taking. That's a case of a bilobed groin flap, which is commonly practiced there. And here's a patient I saw. He had an injury for an industrial machine because all the manufacturing in that part of the country. And the patient had a block on arrival, and here you can see the patient relatively comfortably positioned for x-rays, getting the consent, talking to the family, and also washing out some debris before he enters the operating room. And in this hospital, one incredible thing was that the ED is completely bypassed. It's only for registration. So, instead of having resuscitated twice in the ED and the OR, they only get it once in the anteroom of the OR. So, the block is given there. The patient is resuscitated. There's a senior anesthesiologist that does it, and there's a surgeon. And I recommend everyone to read this paper because it will make you think about the things we do here compared to other places. So, the experiment was positioned for x-rays, and here you can see that segmental radius and an ulnar fracture. Then they positioned that over a draining pan, and we washed it out really thoroughly before the patient gets into the OR. So, in the same time, the scrub techs are preparing the room. And we wash out the gross contamination with sterilized tap water. They don't use saline. And this is pre-debridement. So, we found a lot of devitalized muscles, segmental radius fracture. It was a large area of degloving. Both arteries were cut. The only structure that was in continuity was median nerve in this case. And this is just post-aggressive debridement with preservation of the median nerve. And one thing I learned at that trip was to debride much more aggressively. So, since I came back, I probably debride once or twice, not more than that usually. And that's a huge lesson. So, then we move to skeletal shortening and stabilization, which really dictates, gives you the platform for nerve work, tendon work, and anastomosis later. And in this regard, if you shorten the skeleton, that's a really powerful tool because the nerves can be brought end-to-end. The arteries and veins can be brought end-to-end most of the times, whereas if you choose to do a graft, that may expose the patient to complications. And this can be done in the forum, in the forum shortening, and even a one-bone forum. And that really pushes the envelope for extremity reconstruction in a patient where the limb would otherwise be amputated. So, although this is not always looking great or necessarily has excellent function, it's better than an amputation, as you can see in this patient. So, keep shortening, skeletal shortening in one-bone forum in your armamentarium. That's a really powerful tool for reconstructive microsurgery. And this is what we attempted to do in our patient. That's a standard DC plate stainless steel, relatively straightforward. And then we move to vascular repair. In this particular case, we did radial to ulnar crossover anastomosis after it was pretty heavily shortened. And we did three veins. And we also took an artery that was intact and wasn't used, the radial artery, and interposed it to get some venous outflow to overcome a segmental defect in the veins. And we did ulnar nerve end-to-end as well. And this is what we chose to do for stage one. It's local coverage with the remaining skin and leaving the other areas open. And in the mangle extremity, it's very useful because many times the skin will survive on perforators. So, we try not to discard the skin on day one. And the portion that didn't survive, we went for a second debridement and skin grafting. And we still needed that flap to cover dorsally. Notice how much the arm is supinated. It's with a one bone forearm. This is a more useful position for people who live in India. But I guess in the Western country, mite pronation would be more useful. And he eventually acquired soft tissue reconstruction. This is a superiorly based pedicle parumbilical flap, really a workhorse flap in the hospital and really something I took with me. And this is the final outcome, better than an amputation. And since you're an integral part of the team, you get to see these patients. You get to interact with them, connect with them in the clinic and manage them post-operatively. But not everything is about medical skills. So, there are other few things that we took from the trip. So, they encouraged me as the visitor, as the fellow, to write my vision. So, I asked, what is the vision? Is that a dream? So, they said, no, not really. You have to get into it. So, it's finding a larger purpose than yourself. So, I told them, well, I want to become the best hand surgeon in the world. And they said, no, no, that's not a vision. That's not about yourself. That's beyond yourself. So, for example, solving all hand problems in your community of patients who don't have health insurance, for example, that's a vision. So, that's a vision that's actually never ending. But I have great people on my team that can help me. And once you have a vision, you will find people that will help you go to that journey. And in that process, you will become great. But that's really a side effect of the vision. Another thing that I learned there, and I really brought to our program in Mount Sinai and in Elmhurst is to expect your trainees and to expect from yourself to do more than what you're expected to do. So, there are a lot of examples to that. And it can be simple things like taking the patient to their radiology, showing the tech how to position the patient properly, instead of just complaining about the x-rays that are bad quality. Or another example that we have is just calling the clinic supervisor when equipment fails, instead of reaching in the morning and improvising with our things. And finally, to be the person that people choose when they have a choice. And in India, believe it or not, it's a very competitive country. And they have a lot of providers there. And this is something they really take into heart. And the way to do that is really to emphasize quality. The only way to get there. So, from incision to the well-molded splint. And they really drill it to the brain of their trainees. Doing the small things well and really gets you a long way. So, especially if you have a clinic without insured patients, like I do. I have 40% of my patients have no insurance. And they have a choice. Their choice is not to come and get treatment, which is not what we want. And I would leave with that. Strive for progress, not for perfection. It's really a prime opportunity to get progress in your career. Your hosts will be your lifelong friends. They will be your mentors. Today, with WhatsApp, you can consult them for anything. They even fed me cake on my birthday, which was nice. And I'm very, very grateful to that. So, I would like to thank Dr. Rajesh Sapapathy, Dr. Hari Venkatramani, and Dr. Jones for starting this program. This is my contact details. So, if you want to get in touch, I can answer any questions about the program. All right. Well, moving on to the next item in the program, which is nightmare cases. Lessons from early practice. So, we have Dr. Reed and Dr. Sears. Come on down. All right. Hello, everyone. Thanks for getting us started. Awesome. So, thanks to Paige and Steve for the opportunity to present and share some disasters with you all. But no, in reality, it's really good to get used to normalizing when things don't go the way that you hope. So, this is me doing that. It does require some vulnerability. But I love the previous quote that the previous speaker ended with. It's about the progress. So, as you all will be thinking about your transition from trainee to new attending surgeon, this is often like how you feel as a senior resident. I'm just curious, how many in the room has worked with a first-year attending? Wow. That's much higher than I would have thought. So, it's very eye-opening experience, if you probably all recall. So, the resident usually tells that person, like, hey, it's going to be great. No worries. And then this is usually how you're feeling during that time. Often losing sleep. It needs to be perfect. I'm not sure if it's going to be okay. So, just a few reminders. As you are transitioning to independence, complications are a part of surgery. And one of my senior partners who also trained me said, if you don't have complications, you aren't operating enough. And I would just encourage you to make sure you go to clinic as a senior resident. We love being in the operating room, but going to clinic, particularly as you're transitioning to independence, is really where you're going to learn how to have those difficult conversations and deal with complications. And then when things don't go as well as you like, whether it's something small, you're just struggling in the OR to get the maneuver that you want, or a bigger thing like a complication, it's really important to reflect as an opportunity for improvement. And of course, don't be afraid to ask for help or advice. Not just people who are around you with peers and your partners, but rely and lean on your mentors and people who trained you, even if you aren't with them every day. So, on to the topic of this talk, which is my nightmare cases, lessons from early in practice. I will share with you two cases that I had in my first year of practice. I'm now six years later and they definitely still are cemented in my mind. The first patient was a loss of reduction of a distal radius fracture, which was a failure on my part. And then the second patient was really just helping me going through and helping a patient with a very difficult problem of severe multidigit ischemia and our long course together. Both of these patients were selected for my ABPS oral board examination, so that helped to cement them in my mind as well as prepare for this talk because I had their cases laid out very nicely. And then, of course, we'll reflect on some valuable lessons that I learned for each patient. So, the first patient, this is a 49-year-old woman who had a history of RA, who presented with a vulnerably displaced left distal radius fracture and ulnar styloid fracture after a fall. And she underwent attempted reduction, but this is unstable fracture pattern. So, we planned that she would need an ORIF three days later. And you can probably see what my feel is going to be with not adequately supporting the ulnar column and lack of a full appreciation for the amount of comminution that was there. But you can see here 12 days later what she looked like. And you can see a little bit of loss of height there. And then this is her 26 days later and clearly more loss of height and an apparent problem here. So, this is when I started to panic. And I like the previous advice, got a CT scan, didn't get a CT scan the first time, but bought some time to try to figure out what was happening with her fracture. And you can clearly see loss of or a lack of support of her ulnar column there in multiple fragments. And so, at this point, I'm feeling panicked and some shame. This was about probably two or three months into practice. And then so, I sought opinions from my senior partner. Steve was one of them. And you can probably guess who said, they always talk about this at complication at national meetings. I've never seen it. So, that made me feel better. And then I planned to take the patient to the OR for a revision. I did get multiple differing opinions on what to do in terms of fixation and stabilization with the revision. And so, ultimately, we went back to the operating room, took off the volar plate, and then I distracted her out to length with the bridge plate. And then you can see some loss of her volar cortex and bone there. So, I supported her subchondral bone and articular surface with cancellous allograft and opted not to put the volar plate back on. And this is her three months after her plate removal, which was left in place for five months, a little bit longer than I typically would do given her history of RA and her medications. And you can see not perfect articular surface, but this is her motion overall pretty good, slightly decreased compared to the other side. And overall the patient had no pain, no limitations, and so she did relatively well despite the appearance of her retocarpal degeneration. And so one lesson that I learned here amongst multiple is that whenever you have a patient with complications and you particularly, I mean this lady was super nice and didn't want to avoid her, but sometimes you have people that are like, oh, I don't want to see them. You need to see them more often if they're having complications because they need to have an understanding that, or make it very clear that you will see them through the bad situation and it shouldn't even be a question. And so see them more often. And clearly recognize fracture patterns that are at risk for a loss of reduction, which I did not appreciate here as much as I should have. And then when you're anticipating them, then you devise a plan to minimize risk of collapse. And then lastly, ensure that critical structures, clearly here in this case, the ulnar column, are well supported with fracture fixation and don't hesitate to take more time than you need to on the first operation to, say, adjust your plate until it's absolutely perfect because it's better, obviously, to take more time during that first operation than to have to go back for another operation. And so second patient, this is a 35-year-old woman with history of Crest syndrome, had diffuse left-hand digital ulcers, as you can see here, that progressed over the previous two months. And she was initially admitted to the inpatient medicine service for Flolan. And I think this hit me hard a little bit because I was literally the exact same age as when I was treating her. And to see somebody go through something and have it imagined going through something similar yourself, which I couldn't, is a bit challenging. And so we obtained non-invasive vascular studies that showed absent digital pressures in all the digits of her hand and subsequently got an arteriogram that showed occlusion. You don't see that. Oh, here we go. Of her radial, or ulnar artery, rather, proximal, and then, or distal, rather, and then occlusion of her radial artery at the wrist as well, but reconstituted flow in her deep arch. And then you can see, even further distally, really absent flow in her superficial arch and digital arteries. And so we had a long discussion with her about potential options and ultimately recommended periarterial sympathectomies of her superficial arch, common digitals, and radial and ulnar arteries at the wrist and to perform a radial artery bypass. And so at this time, she was very adamant about not touching her fingers, was not agreeing to any amputations or debridement. So we did those procedures to try to improve her flow. And this just shows here, proximally, after laying the tourniquet down, her radial artery, and then further distally, her occlusion, before it reconstitutes at her deep arch. And then this is the reverse vein graft into side, proximally, here, and then end-to-end into the deep arch. And so this is her two weeks post-op. And we thought, okay, we'll give her some time. Most likely, she'll need some amputations, but she really didn't wanna entertain the conversation about that. And so given the lack of infection, we said, okay, we'll just keep watching this, but if things progress in the wrong direction, we'll have to move toward debridement and potential amputations of some of her fingers. And so we just had a plan to recheck her every couple of weeks. And she did come back at the four-week mark and then disappeared until four months post-op. And surprisingly, much better than I would have thought. And still at this point, we thought, okay, well, we recommend amputations of index and middle finger for this irreversible gangrene, and she still wanted to continue with dressings. And then finally, at about seven and a half months, she was playing with her nephew and hit her finger and had some exposed bone of her middle finger. And at this point, she really only wanted to excise clearly necrotic tissue and nothing more, not even to try to get full closure. And so I agreed to that and just covered her exposed bone after excising the clearly necrotic tissue with Integra and then just nibbled down her tuft of the middle finger that was exposed. And three weeks later, unfortunately, you can see, there's an arrow, she's starting to get some open wounds along her IP joints. And then we got some more non-invasive vascular studies that showed the bypass graft was patent, but some of the digital pressures were too low to obtain pressures, so that wasn't good. And then she disappeared again. And at this point, she called back and said, over the last six weeks that things had been worse and worse than when we met her, but she didn't really wanna come back in because she knew what was gonna happen. And so she was amenable at this point in angiogram to see if there was anything we could intervene upon and to come in. And so this is what she looked like at this point, not good, obviously worse than when we started and much worse than her post-op. So this is four months after the second operation. And then on that angio, there were really no targets for a bypass procedure. The previous bypass graft wasn't open on the angio. And so I discussed with her options, and which was to do nothing, but that she may eventually lose her hand if it progressed further, revision amputations, but I was really concerned about healing. And then really this was like a Hail Mary on my part. The only other option that I was comfortable with that could give her any chance of improvement was arterialization of the venous system. And she wanted to go with dressings some more. So we basically just let her do that. And you can see even from what it was before, five months later progressed even further. And now at this time, she was ready to have something done. And you can see, unfortunately, this was her final result. So this is, although not an error on my part, but you can see this was obviously a nightmare case because this had lasted for how much? 17 months from when I first met her. And what I really learned was that, some patients have disease processes that you will not be able to fix for everyone. And you just have to accept that and help them through that course. And one really important thing that you all will come in contact with, especially dealing with hand trauma patients who are going through often very difficult situations, is that they have a loss of control in the bigger picture of what's happening to them. And therefore, I think it's really important to allow them to have some sense of control over their treatment when it's safe to do so. And this example was early on, I would have been more eager to do something surgically about how her fingers looked, debridement, amputations, and actually it turned out much better than I thought it would in that intervening period, but not in the end. And then also be available for patients when they're ready for your help, even when they don't want your help right away. So I'll just end again on, complications are a part of surgery, remember that. Try to get as much sleep as you can at night. When things don't go as well as you'd like, just reflect on opportunity for improvement and don't be afraid to ask for help. Thank you. Thanks for watching! All right, way to hang in there, guys. I was thinking I'm glad those weren't my cases because I would probably lose a lot of sleep over it. But I think we've all, here's a spoiler alert. You operate enough, you're gonna have complications. I think the purpose of, I guess the objective of this case that I'm gonna present to you is I wish I had some good pearls to tell you about this case. But if anything, I just wanna tell you the sight of the attending or the attending surgeon who, when these things happen, they may, I'm sure all of your attendings are really polished and very professional, and they may not show you all the anguish that they go through. But we're all friends here, so I'm just gonna share with you exactly what I was thinking throughout this case. This case was almost nine years ago when I was early on staff. I still, my heart races when I think about this case, and this will, it's imprinted in me, and I think everyone probably has those cases, too. These complications, again, stay with you forever. But it's good. I'll tell you that at the take-home as a good cheery, cheery response. So this is a patient who had this soft tissue mass in his shoulder. It was confirmed to be a myxofibrosarcoma and had this new adjuvant radiation therapy. And just like most all of you that do any reconstructive surgery, your tumor guy says, hey, or gal, says, hey, I'm gonna track this out. Can you cover it? You're like, okay. Not quite knowing what you're gonna expect no matter how much you prepare for it. So this was really right in the deltoid area. You can see these imaging studies that show exactly where things are. And my tumor surgeon, Nicole, you know who I'm talking about. He completely undersold how much he was gonna take. So then he says, hey, here, cover it up. And luckily, you know, I was prepared for this because I've known him for a long time. And so I thought that in this situation for the patient, I thought, you know, I need a lot of muscle. I need to reconstruct his deltoid. Perfect opportunity to just use a pedicle functioning latissimus, right? That makes sense. So I was super prepared and did this just pedicle flap. Everything looked great. Skin grafted it. I didn't tunnel anything. I always open up my skin bridge so I know that nothing's being compressed. I even took the circumflex scapular down just to give a much greater arc of rotation. So basically, in other words, just anticipating any complication, I thought I did this really well. And I was really happy because for this patient, I guess to me, if I, and I remember telling my wife this, if I don't cover this, there's no limb salvage. You know, you're kind of at the end of the road and that's a lot of stress that we carry with our patients. And so, you know, it's a lot on you. And, you know, I kept him in the hospital for a couple of days. We just Doppler it out, even for a pedicle flap, you know, everything sounded great. He went home, came back in seven days and that's what it looked like. And he's like, hey, how's it look? I mean, not good. But, you know, I think at this point, I think I knew where this was going, but I convinced myself that everything was still okay. You know, I could still Doppler out at least that medial transverse branch, the lateral bench, I couldn't really detect, but I would, I even got like a 25 gauge and he like poked it, it was bleeding. And I was like, you know, I think things are okay. You know, I'll see you back next week. And then two weeks later, it comes back and a portion of it still doesn't look good. But I, you know, I was like, oh my God. So I'm like I'll see you back next week and then it's it smells just completely nasty and I'm like look I gotta take it to the OR so I cut all that off it was all dead and just got a lay of the land and here I didn't know really what to make of it, but at least here I cleaned everything out, and I said, you know, I'm going to think about this and just slow play it, because I don't want, I mean, the next stage for salvage is going to be quite big, and so this is a lot of no one to ask, because at least in my program that no one else was doing reconstructive micros, so it's just me trying to figure this out, and it's very lonely. So then I, at that stage, I kind of Doppler'd everything out just to make sure I had some potential options for doing whatever I was going to do, and got an arteriogram just to show that thoracochromial was there, I then scanned down to the arm, just having plan A, B, and C, and I thought I was pretty prepared, and we went with an ALT, and even though not functional now, I'm just in damage control, I just want to get this covered. There's a lot of text there, but bottom line, you know, I went end to end into thoracochromial, did a vein cleftation to the cephalic, and everything looked awesome, and I was like, oh, I think I saved it, you know, and this guy's now in the ICU for two days, everything's going great, and I have that sigh of relief, but for anyone that does reconstructive micro, any type of flaps, you know, you're probably on call for the next seven days anyhow, right? And so I was really relieved at this point, was super, super cautious with him, even had him in the ICU, and I just saw him after I left clinic, long day of clinic, and then at 9 o'clock. So then it's in the middle of the night. I take them back. This is me It's a training center, but this is me all by myself and by about Like midnight. I start looking at this ALT and and I'm just kind of going through like different checks to see like what could be wrong and I take down my anastomosis and You know the thorough crochromial it has some flow but not much I keep whittling it back till now at the axillary artery I just don't know what else to do. And this is now I Don't know me like four o'clock. I have a full clinic ahead and I just am helpless so really without much other option I Didn't really know what to bounce things off of I went to his leg and harvested a Saphenous graph. I think it was about 30 30 centimeters or so And this is a huge graph, nowhere else really to go. And I still think about this, that moment. I literally cried. And I did. And I think that you guys, I see Steve's like, oh yeah, I know. It's, I felt so alone. And you're going to have this. You will have this. And I tell my fellows that every time you operate on someone, it's like you're launching a satellite into space. And in your career, you're going to have thousands of satellites that when one of those come crashing down, that's you, you're taking care of that. So I don't mean to make it sound like your career is just like always a lot of pins and needles. But it is, no one else understands, like an ER doc or an anesthesiologist or a medicine, my wife's an internist, doesn't understand that these patients are your patients forever. Remember, I saw this guy months afterwards. He was disease free at the time. And he was so appreciative. And I don't think anyone, you know, realized that if, you know, we didn't go through this heroics to cover this, then he wouldn't have an arm, you know. And that's a lot to bear on you. And without getting into a whole talk on like wellness and burnout and things like that, you have to take care of yourselves because these complications will happen. So I just had some take home points with I think what may have happened, you know, pedicling it through the zone of radiation, maybe not very good. You know, I, in my initial anastomosis when I thought that I just wanted to do something easy end to end, like it was not very good flow to begin with. Like in flow, I probably shouldn't have accepted that. Just not burying your head in the sand in persistence. But probably more importantly, what I want to tell you is there are going to be times that you're going to feel very lonely. It's true. But you have people like within your practice that you can lean on. And certainly in your fellowships, you have mentors that you can reach out to. And I did that many times. You will get stressed. Just rely on each other and the best that you can, be prepared. And of all, I've had a ton of complications. I don't think I'm a bad surgeon, but I've had a lot. But those bad outcomes that I've had, I know they have benefited tenfold future patients. So I think you just have to realize that these things you learn from, and it makes you a better surgeon to help many more people. So I just thought, you know, Paul Brand had this wonderful quote, basically saying that you develop this relationship with your patient, and you are their lifeline, right? And in creating that relationship with them and seeing outcomes like this, I know so many times I did a replant or whatnot, and then walking across the skywalk from the OR to my office, like at two in the morning, just when no one else is around, just making that walk and just feeling so happy I could do that, crying a little bit, and things like that, that you may not see your attendings do that, but you will. Because you'll have those moments, too. All right, thank you very much. Thank you. I feel like I can barely see over this podium. So don't worry. This is not going to be, you know, like you're joining your job and you have to get through this DEI click through thing, pop quiz part of the day, if that makes sense. We're going to hopefully make this a little bit more exciting. And so we all know what diversity, equity, and inclusion are. We all go to, we all are in residency and fellowships, and this is trained throughout. And so what we're developing is essentially a task force. And I think of myself as the raccoon at the bottom for providing diversity. So this is Dr. Sterling Bunnell, the father of hand surgery. And he introduced this concept of bringing together several surgical specialties. You guys likely know this already, of taking care of all of the tissues of the hand and the upper extremity. And that essentially allows us to repair and reconstruct everything in a coordinated fashion, right? That's what you've heard all about today. And so, but what defines a hand surgeon? You know, we know this, right? You can be, you can either be an orthopedic surgeon, a plastic surgeon, or a general surgeon, and then you do another year of fellowship. And then besides becoming board certified in your specialty, you then get a certification in the subspecialty of surgery in the hand. But there is variability. So the starting point of who you are as a hand surgeon really depends on the amount of hand surgery that you've seen in your residency. And that's variable. And it's the same thing with your fellowship, right? You can be doing shoulder, you can be doing more hand-related things, you can be doing an orthopedic hand fellowship, you can be doing a plastic surgery hand fellowship, and that results in a variability in your level of comfort when it comes to taking care of complex problems. And so, don't take this offensively, but orthopedic surgeons can be less comfortable with microsurgery, and they're less likely to do that. That is, there definitely are many skilled orthopedic surgeons that do a ton of micro, and it's not to, not to take offense, but when you go out into the community, when you're out there seeing patients in the United States, that's the, that is the trend. And for plastic surgery, same thing with distal radius, where you're less likely to do that, even if you're hand surgery, hand surgery trained. And so we just saw another diagram, which is awesome, but no offense to neurosurgery, no offense to general surgery, but I think of it as plastic surgery, microsurgery, and orthopedic surgery, where plastic surgery has, can change the form and anatomy, can change the function. Plastic surgery is the change of form and the anatomy, and it uses cool gadgets like the microscope, and then orthopedics changes function and uses large tools to fix things. Just kidding. Uses hardware and complex fixation. And so we value this diversity in training. This is why I trained with my hand fellowship, with, in my residency, doing additional training in pediatric hand. I wanted to be comfortable to take care of any problem, and so in that same light, we should value diversity in who is trained. And really, hand surgeons, just like other medical specialties, should reflect the population at the goal of recruiting the next generation, and that's why I'm excited to talk to you guys. And so we know that at the healthcare level, there's an under-representation of cultural, gender, and ethnic diversity in training and in leadership. We see that everywhere. And this, it's not this concept of things are diverse enough, you know. We have a percentage, we met a quota. It really, I think, that diversity drives excellence, and that's a quote from Dr. Quinn Capers from UT Southwestern. And there are many benefits of diversity. There are papers written on this. For example, women physicians are more likely to follow evidence-based guidelines. African American physicians are less likely to have a negative racial bias to other groups. Minority patients are more likely to follow recommendations of their physicians that share their background. I don't need to go, there's just, there's a lot of benefits that have been described. And so it's not the diversity of thought. And when we look at our populations, right, the United States, this is looking at the Bay Area, where I, you know, I'm from the Bay Area. You know, it's, this population is, you know, white, this breakdown at least, and it's only a few populations, right. You can go into really the nitty gritty, but this is just showing white, Caucasian, Latino, Hispanic, Asian, African American, and Native American. And you can see there's differences in the Bay Area in those four graphs on the, four bars on the right side. It's a, we live in a different place here in the Bay Area, and just like that across the United States, there's different populations. And so the AAMC has said this for a very long time, but there is this definition of underrepresented in medicine. And all that means is simple question of do your physicians reflect the patients that you're taking care of. And it's well established that if that increase in gender and ethnic diversity has been correlated to increasing accessibility to healthcare resources of underserved populations, right. The pandemic, right, has been a perfect example of our broken healthcare system of how we had, we've had patients and people from underserved backgrounds and minority groups that have died in disproportionate levels. And so all this, the lack of diversity in regards to women and in regards to underrepresented in medicine continues in both orthopedics and plastic surgery. There's a paper from 2005 by Gordon Bay and Charles Day about ethnic and gender diversity in hand trainees. It seems, you know, this is about six years ago, but it's still very relevant. And this is looking at plastic surgery trainees. You can see there's an increase in Asian plastic surgery trainees, and you can see that the Hispanic population increased a little bit from like 4% to like 6%. And then the black and African-American has been stagnant at about 3%. And this is reflected the same way in hand surgery trainees. And it almost mirrors it exactly, and the orthopedic one is the same. But it's not just a problem in hand surgery, right. This is a problem throughout other surgical specialties, right. There are just, you know, they're hard to get into. They're challenging residencies, but there are definitely gatekeepers to this. And looking at gender diversity, you can see in hand surgery, 19%, at least when this paper was written, I think this one was from three or four years ago, but it's 19% for hand surgery. It's a lot worse in orthopedic sports medicine, but it's a lot better in plastic surgery. It's about 28%. And I think that's gotten even better since. There are other specialists. This is Dr. Paris Butler, a plastic surgeon who's written extensively on the scarcity, particularly within plastic surgery, about this disparity. And so we know, these are just papers out of our hand surgery literature showing that if you have limited health literacy, you're less likely to ask questions. And so what orthopedic surgeons, hand surgeons should do is take universal precautions and assume that a patient may not understand otherwise, and things may need to be explained on a more basic level. This is another paper by Dr. Ring, looking at language barriers in Latino patients and the relation to upper extremity disabilities. And it's important consideration to take, because we can be in a clinic, specifically in California, where most of our patients are Latino, and you want to think about this so that you can provide the best care and have them not comply, but have them follow directions. And so we were just going to go through our stories, just to provide some kind of background of who we are and what we're interested in. And so I am Michael Galvez. I work at Valley Children's. It's in the middle of nowhere, in Fresno, Central California. It's about three hours south, but it covers three hours north and then three hours south from there as well, so midway to Los Angeles. And this is my mentor, Dr. Amarjeet Dosanjh. He was a UCSF plastic surgery resident, taking hand call. I was shadowing in the ER, and he took me under his wing. It was amazing. I had no idea what I was doing. I went to community college and was applying to medical school, and he helped me figure things out, think about the application process for medical school. I got rejected from Stanford initially, and he's like, why don't you just appeal? And I appealed because I've been doing research, and I ended up getting in. And so this mentorship that I'm sure there's been talks about this today are so important because it makes you realize things that may otherwise not be possible. A little bit more about myself, I'm from the Bay Area. Both of my parents are from Peru, from Lima, Peru. And I did terrible in high school, but I got it together eventually. And so I'm working at Valley Children's, and I could have worked anywhere, in my opinion. I was on a trajectory to work in an academic environment just looking at my CV, but I wanted to take care of underserved patients, and I'm committed to this. And I'm very grateful that the state of California is actually going to pay off my loans to do this on top of my salary. And so what I've been doing is essentially expanding pediatric hand surgery care. They were doing some hand trauma, some congenital hand, and now I've expanded that to wrist trauma, peripheral nerve, microsurgery, with the goal of building a cerebral palsy program as well as a brachial plexus program. And so just to share a few cases, this is a girl with a myoplasia, which is a subtype of arthrogryposis. The shoulders are internally rotated. Their arms are in full extension typically. She's in a little bit of flexion here. Wrists are contracted down, and then she has a thumb and palm deformity. And so her lower extremities, her left side, she had no hip flexion. On the right side, she had some hip flexion. And so she's unable to elevate her shoulder, unable to flex her elbow, a little bit of flexion of the wrist. And so the only way she gets her hand to her mouth is by using her right knee and lifting her arm to get her hand into her mouth. And so she wasn't using her left hand. And so in combination with the pediatric occupational therapist, we decided her best interest would be to straighten her hand on the left side so she can actually use it. So this is just an intraoperative photo showing her wrist inflection. And the technique that was utilized is called a carpal wedge osteotomy. It's a biplanar wedge. What's interesting about these patients is they have carpal coalitions. And so you're able to actually excise a piece of their carpus and correct the ulnar deviation and then the flexion deformity and put their wrist in a new position of flexion. You can see that there. It's like a triangular wedge in a biplanar fashion. And here are the x-rays showing the before and after with the pin fixation holding the carpus straight. And the other thing is she had this thumb and palm deformity, which is very common in these kids. And so I did an index, a stiletto flap, getting an index flap and putting into the web space and several other aspects, including tendon transfers. We don't need to get into the details. This is her hand after the surgery. She was in flexion. Now she's in a neutral position, still maintaining a little bit of wrist motion. And so now she can hold her. This is when she was still recovering from her therapy. But she's holding a Barbie doll with that hand. So she's actually using it within her space. But you can see she's actually combing that Barbie doll with her foot. And so the other patient, just another case that I've done, is a five-year-old with a radial ulnar synostosis. So this kid sits in hyperpronation. So the hand just sits, also not in a position of function, just sitting out there. So when he grabs a cup, he holds it like this. We know radial ulnar, and for him it's bilateral. But we know that this is an unsolved problem. We can't recreate the radial capitellar joint. And so our best option is to reposition the hand in a position that's a little bit better. And so you can see the hand sitting out, wasn't using it. And so the technique, and these are the x-rays showing the proximal radial ulnar synostosis. And so the technique is what I was trained at, is essentially incising the periosteum. This is a combination of plastics and orthopedic surgery. Being very careful with that tissue, and then taking out a wedge, a one-centimeter wedge of bone, morselizing it, shoving it back in, closing the periosteum at two separate levels in the radius and the ulna, and then rotating the hand. And you also do a fasciotomies, because you don't want to get compartment syndrome. And what's awesome about this case is there's no fixation. So kids are amazing as far as their ability to heal. And so this is just through casting. And so you can see the hyperpronation in a slight position of, sorry, hyperpronation, slight position of pronation. He now can put his hands on his lap. He can put his hands together. And more importantly, he can use an iPad. The other aspect is free flap surgery. So I'm a plastic surgeon as well. And so this is just working with the hospital. This hospital's been here for 60 years. They've never done a free flap before. Had to start from the bottom, right? Had to train the nurses in the ICU, the floor. I lived at the bedside. And for this particular case, it was for doing an MFC flap, so a patient who had a proximal pole avascular necrosis and needed structural bone graft. And so this is an enticide anastomosis. And before and after with the fixation, you can see the clips and then healed. There's so much chronic pain in kids, and so it's awesome to be able to help them with that. And so to my knowledge, and please tell me and approach me if you know otherwise, but I'm the only full-time Latino, Latina pediatric hand surgeon in the United States. And there are 18 million Latino children in the United States. They make about 25% of all children. And so that shouldn't be the case. And that's why I'm here today, and that's what the advocacy is for. When I was interviewing, when I was in your space interviewing for residency, Dr. Linda Sandales, who's at Duke, and she's a general surgeon initially, and then is a hand surgeon as well, she was the first Latina that I had ever met in my many 11 years in training from medical school and residency. So that's my story. I have entered, for those that I didn't meet earlier, I'm Megan Konmika. So my story is obviously very different. The picture here is me with my father when I graduated. My dad is my hero. He was the first one to go to college. He was born in a family of factory workers and he was the American dream as far as I'm concerned. So anytime that you feel like you don't belong here, just know that that is just imposter syndrome and that you do belong here and there is a million other people who feel lonely like you and that there is a community here in the Hand Society that can support you. Here's a picture of me with my wolf pack, which is my co-residence when I was at Loyola in Chicago for residency and I was the only female in my class and at one point I was the only female in my residency. It was sometimes very lonely but I had a really good class that took great care of me and then I went to practice and did a lot of bony fixation as Dr. Galvez liked to point out about the orthopods, but I also did soft tissue stuff. So take that plastic surgeons, we can do it too. So practice started to focus on elbow and I work with a lot of athletes. Here's some of the athletes I've worked with and this is a picture of me running in the bottom corner and the only reason why I did that in there is I somehow became a stock photo for the university. So whenever they have anything to do about athletes or anything, they put this horrible picture of me up on the website and I get a call like every couple months being like, oh, I saw this picture of you running in 100 degree weather in like 100% humidity. I'm like, great, I'm glad that became my stock photo. So there's my claim to fame is that horrible picture. This is also how my department started and you could see that I'm the only female attending in a large group of males, which is fine. That's how I trained, I knew no difference. I didn't even have a female faculty or female mentorship until I was in my second year of practice. So I wasn't really aware that that was weird or that there was a part of my growth in residency and then into practice that I didn't have. But this is where my department is now. There's actually two more females in here. So we have a large female faculty. You can see Dr. Jennifer Wolf is part of my squad and I'm very thankful for that because we have a lot of wonderful, wonderful multidisciplinary female orthopods in my group. And as things changed, my life changed. So here's two pictures of me with my first and second pregnancy. Both times operating in my last weeks of pregnancy went all the way through. And actually that picture right here on your right, your left, was the highest commented and liked picture for the academy on their social media. And it broke all these records. They kept emailing me being like, oh my God, this picture. And it's just a picture of me operating. And I just got so many emails from people saying, thanks for putting it. I can be an orthopedic surgeon and be pregnant. That's crazy, right? Even people thought that that's not possible, but totally possible. I have two kids, they know who I am, so we're good. So, and things are changing. So there's a couple of articles if you're interested in reading about it, is things are changing. From maternity leave for having children, post-maternity leave, returning back to work, breastfeeding, all those things for females is changing. It's making it open so that females can be orthopedic surgeons or plastic surgeons or whatever they want and still be mothers and still be all the things that you want to be. And you don't have to be a mom if you're a female. Those are all your choices. So, right now, we have only about 5% of orthopedic surgeons are female. And of residents, only 14%. And those numbers are pretty low with plastic surgery. Does anyone know off the top of their head, those 30%? Yeah, low. 60% of female residents in orthopedics experience bias gender, bias due to their gender. I definitely did. And it wasn't meant in any harm because I knew my co-residents loved me and that I was part of the gang, but still, there are certain things that were said or done that just not, I don't even think now would be okay. So, 48% of females defer on having children, which increases complications later on by having advanced maternal age. I waited to have children until after I was on residency, but I also didn't marry my husband until after residency, so those could be correlated. Uh. Details. Maternity leave. So, our maternity leave is horrible. Residents are only taking a couple weeks off. The, actually, the average female orthopod takes about nine weeks off. Residents take about six weeks off. And our colleagues are recommending 12 weeks off. So, that just shows you, like, people are going back, even breaking their post-surgical protocols. Like, they're restricted from lifting patients and they're lifting them. And we have physicians who are going back to work because they have to, and our colleagues are saying not to, but we have no choice. So, it's something to think about for if, not only as, like, for allyship of the males in here, is supporting your female colleagues. Because it's hard. Because you're, we're treated right now as it's, like, a privilege as opposed to a right. And there's a huge financial impact for taking time off. It's over $45,000 for a surgeon. I have several female pregnant residents who I take, who I have been mentoring, who are too scared to tell their faculty that they're pregnant. Like, it's 2021. So, these are things to think about. Other things is it's high risk for females to be pregnant. Increased pre-term labor. We have a 31% complication rate opposed to, that's compared to 15% in the general population. That's, like, double. Would you recommend a surgery that had a 31% complication rate? I hope not. So, and miscarriage, stillborns, infertility, all higher. These are my two little girls. And so, as my practice has gone on, I've pulled on different roles. I'm now the Associate Fellowship Director under Dr. Wolfe, Jennifer Wolfe, who is an amazing mentor. I am the Medical Student Education Director. And just recently, I became a Simon Scholar, which is working in the diversity in our department. So, this is something I'm really passionate about. So, if we don't continue to push for diversity, we're gonna miss out on a lot of people. And we're gonna miss out on a lot of leadership opportunities. So, a lot of females have to choose between family and work. And the qualities that make women great mothers are also the qualities that make them great leaders. So, things like nurturing, passionate, empathy, those make great leaders. And we're pushing them out of the workforce because of those qualities. It's kind of backwards. So, hopefully that's a little food for thought. And hopefully, it also pushes all of you guys to think about work-life balance. I love to be with my family. I love to operate. I love to ski. I love to scuba dive. I love hanging out with my husband. I love running with my dogs. These are all things that you are not exclusive to being a surgeon. So, I push you guys to work for your work-life balance. And as millennials, we are made fun of for wanting work-life balance. But it's not a bad thing. So, it's really about changing that culture. It's understanding and not laughing when people wanna take maternity leave. And one of the best things you can do for the males in here is take paternity leave. Two weeks of paternity leave, just two weeks, have increased your relationship with your significant other. It will increase your relationship with your children. It will also start normalizing taking time off after having kids. So, that's just one thing. You can take longer than two weeks. Take as much time as you need. But at least just two weeks, the statistics have shown how much that supports. Also, transitioning back to work after having kids is a really hard thing. It's really hard. Ramping back, I've had to rebuild my practice three times. Scheduling around childcare, like picking kids up, dropping them off, is not even a joke. Trying to drop a kid off and then go to do the OR or be on call and you're freaking out because you're like, oh my god, I gotta be done with this case because I had to pick up my kid. Those are crazy things to think about. So, scheduling around childcare, breastfeeding with female surgeons, they are pumping less and we all know the benefits of breastfeeding. Obviously, these are things that we need to work on with regulations that are not being met and mentorship. So, anyone out there who needs mentorship, I'm here for you. I mentor a lot of females and males on a lot of these things. I am always a resource. And again, paternity leave is the best way that you can help people. It's not a female-only issue. These are pictures of Wade and also Chance the Rapper who both took paternity leave. They took time off to be with their families and raise their kids. Obviously, they lost a lot of money, but they didn't care about it. They were there for their kids. So, it helps normalize things. This is my husband who is a spine surgeon. And he has been doing a lot of allyship for the females in his group. For his nurse, he basically, before she left, he demanded that she got longer maternity leave. She was in her first year of being with the group, so she had no FMLA. So, he took the hit so that she could take longer. And then he set up her breasts for her to have pumping sessions, and that she had specific needs for her and her children, and that her times were changed within the group so that she could still be a mom and a nurse. So, there are things that you can do to be an ally. And I won't go too much longer, because we're way over, is a little bit about allyship. Just getting involved. Set an example, stop microaggressions, be advocates. And be present. This is just giving a lecture for medical students, and after the lecture, one of the medical students wrote me and was like, I now want to be an orthopedic surgeon. What an impact, right? Just one lecture, and now someone wants to be an orthopod? That's pretty awesome. So, be present, you don't know who you're impacting. That's one of the reasons why I share my story, is hopefully it impacts one of you. And if it's just one, that's great. But it's important to know that you're wanted, you're included, you're important. And one of the ways you can make a difference is also here in the Hand Society. We have, as Dr. Galvez had talked about, we have a long way to go. And if you want to be involved, there's a lot of different ways to be involved here, some of the different ways. But we are also the co-chairs of the Diversity Committee here on the Hand Society. So, we would love, love, love for you to show up, be involved, be part of the group. We're having a really early 6 a.m. breakfast tomorrow. I will be there. And I- You get a free ribbon. And you get a free ribbon. It's the only ribbon I put on here. So, more than welcome to join us for breakfast tomorrow. We also will be having our committee meeting, but we also have ICLs and symposiums and ways to learn how you can get involved. And if you're interested in being involved with us, feel free to email us. Our email is somewhere right here. We would love to have you part of our committee. We'd love to get you involved with social media and all different other ways. We are way over, so I'm gonna stop here. But hopefully this inspires somebody in here. So, thank you. Thank you. All right, it's time for my favorite Jeopardy category, potpourri. So let's bring up Curtis Henn, who's going to moderate this last session, and if we could have our three paper presenters come on up and take a seat on the podium, and we'll load up the first talk. Curtis Henn, who's going to moderate this last session, and if we could have our three with how many people stuck around. I think it's because there are cocktails coming after this, so thanks for sticking around. So, the first paper in this session, we just have three more papers, and then we're done with the whole program. First talk is by Dr. Bedar, Combined Effect of Certical Angiogenesis in Stem Cell Seeding of Acellular Nerve Allografts on Return to Motor Function in a Rat Cyanic Nerve Defect Model. Myon Bedar Hello. I'm Myon Bedar, and I'm a research fellow at the Mayo Clinic. We have no disclosures. Motor recovery following segmental nerve defect repair with Acellular Nerve Allografts remain inferior to autologous nerve reconstruction, and the independent addition of surgical angiogenesis and mesenchymal stem cell seeding has previously shown to improve functional motor outcomes of Acellular Nerve Allografts. The purpose of this study was to see whether the addition of undifferentiated or differentiated mesenchymal stem cells to Acellular Nerve Allografts enhanced with surgical angiogenesis would further improve the motor recovery of rat cyanic – motor recovery in a rat cyanic nerve defect model. Lewis rats were divided into five groups with two survival times. In the first group, a 10-millimeter section of the cyanic nerve was reversed and interposed as an autograft. In all other groups, the cyanic nerve defect was reconstructed with the Acellular Nerve Allograft, which was harvested from a Sprague dolly rat and decellularized according to our elastase-based protocol. In groups three to five, the nerve allograft was wrapped in a superficial inferior epigastric artery flap to provide surgical angiogenesis. And finally, in groups four and five, the nerve allograft was additionally enhanced with either undifferentiated or differentiated mesenchymal stem cells dynamically seated on the nerve graft. During the survival period, we looked at the tibialis anterior muscle cross-sectional area using ultrasound imaging. And at non-survival procedures at 12 and 16 weeks, we looked at ankle contracture angle, CMAP compound muscle action potential, and the muscle force and muscle weight. All results were expressed as a percentage of the contralateral non-operated side. So during the survival period, we did not see any significant differences in tibialis anterior muscle cross-sectional area between the groups. And this surgical angiogenesis demonstrated less ankle contracture angle and higher CMAP amplitude recovery compared to allografts alone at 12 weeks. The muscle force in autografts were significantly superior to all groups at 12 weeks, and this was similar in the muscle weight. In conclusion, the addition of mesenchymal stem cells either undifferentiated or differentiated did not further improve the functional outcomes of Acellar nerve allografts enhanced with surgical angiogenesis. The adipose tissue of the C-flap may provide adequate mesenchymal stem cells and may not necessitate local addition of mesenchymal stem cells. Further studies in larger animal models could provide more conclusive results. Thank you. So first, I'd like to congratulate you on a lot of work. That's really a lot of work you did there. I haven't done animal studies as a medical student myself. I'm really impressed that all 100 rats survived the study, so congratulations on that as well. I think your data clearly supports allograft over anything else. I think that's worth mentioning, or excuse me, autograft over anything else. And you concluded that the MSCs don't provide any additional benefit for surgically induced angiogenesis. The question I have for you is, do you think your data supports surgical angiogenesis over allograft? Thank you very much. Next paper is the effects of pre-mixing beta-methadone with lidocaine on counter-site inflammation in an in vitro model, presented by Dr. Sayegh. Sayegh. All right, thank you. So we have no disclosures. We observe that some hand surgeons pre-mix steroids with local anesthetics and then store these mixtures in pre-loaded syringes to increase efficiency during their clinic. Local steroids, like commonly used beta-methadone, can potentially form micro-crystalline precipitates that may have negative effects. We sought to determine if pre-mixing beta-methadone with lidocaine in pre-loaded syringes up to 24 hours prior to treatment decreases efficacy. And to our knowledge, this wasn't studied before. Human articular chondrocytes were cultured and expanded in solution and partitioned into a negative and positive control group and four experimental groups. Interleukin-1b and Oncostatin were used to stimulate an inflammatory environment. The four experimental groups were treated with beta-methadone alone. Beta-methadone mixed with lidocaine at either 0, 4 hours or 24 hours prior to treatment. One hour after treatment, we measured expression of these inflammatory genes listed here. So chondrocytes treated with beta-methadone alone and with beta-methadone and lidocaine mixtures prepared at 0 hours, 4 hours, and 24 hours prior to injection showed significantly decreased levels of TNF-alpha, ADAMTS-4, and MMMP3 compared to the positive control. There was a significant decrease in TNF-alpha with both the 24-hour premixture group and beta-methadone alone compared to the 0-hour premixture group. MMP1 and IL-8 also showed similar significant decreases without significant decreases amongst the experimental groups. IL-6 and MMP13 did not show significant decreases compared to the positive control, and there was also no differences among the experimental groups. So our results showed that premixing up to 24 hours did not diminish the anti-inflammatory effects of the mixture. The only time-dependent difference between the experimental groups was with the expression of TNF-alpha, suggesting that TNF-alpha may require a longer duration of inflammation or incubation with the treatment for experimental groups to exhibit adequate responses. The in vitro design and the use of chondrocytes rather than synovial cells or tenocytes may be some limitations of our study. And then Celestone is a trade name commonly for beta-methadone. It contains a preservative, but this was included from our study because it was found to be a site of chondrotoxic in vitro. So in conclusion, the study shows that beta-methadone and lidocaine premixed and preloaded into syringes at various times up to 24 hours prior to treatment does not significantly impact the ability of the mixture to reduce expression of key inflammatory mediators in vitro. And we find that our findings may reassure hand surgeons that the quality and efficiency of anti-inflammatory effects of serine injections are not reduced by premixing and preloading into syringes, which are an important diagnostic, therapeutic, and prognostic intervention in hand surgery. Thank you. Very nice job, also a lot of work, and something that's very applicable to practice. I know my staff pre-fills these syringes, I'm curious, you know, what led you to do this study? Did you notice a clinical decrease in effectiveness after preloading them? We didn't notice any decrease in clinical effectiveness. hand surgeons that what they're doing might not, you know, necessarily be impacting their patients. Great. Thank you. Final paper here is Tendon Repairs After Risk Utilizing a Novel Tendon Stapler Device, an Efficiency and Biomechanical Study Across Different Experience Levels, presented by Evelyn Reed. Dr. Reed. Thanks. Hi. I'm Evelyn Reed. I'm a third-year plastic surgery resident at the University of Utah. This was an investigator-initiated study that was funded by a grant from Connections Medical, which is the manufacturer of the stapler device used in the study, no other disclosures. So Connections is a medical device company founded in Salt Lake that recently developed a novel tendon stapler device. And in the studies they've been performing for FDA approval, they've noted both faster and stronger repairs in comparison to sutures. So our hypothesis was that compared to a traditional suture repair, the stapler device would demonstrate faster overall tendon repair times across the board in users of different abilities, as well as stronger repairs in those different users, kind of leveling the playing field. All participants, a novice student, intermediate trained resident, and a hand attending underwent identical training on the device. And then on matched cadaver arms, suture repairs were performed with a 3-0 braided polyester suture for a Kessler repair with an additional horizontal mattress stitch. And the stapler repairs were performed with the novel Connections device with a single polypropylene suture stitch for approximation of the tendon ends rather than for strength. Efficiency was timed by a non-participating data recorder. And immediately after repairs, tensile strength to a 2-millimeter gap force, as well as ultimate failure loads were measured. In total, 228 tendon repairs from 12 donor arms were analyzed. The attending surgeon was significantly faster at performing suture repairs. However, tendon repairs performed with the stapler were significantly faster and consistently fast across all experienced groups. Forces required to create a 2-millimeter gap were statistically higher in the stapler group for the expert and novice, and directionally higher for their intermediate. The mean between groups was significantly higher for the stapler. Similarly, ultimate failure loads were statistically higher in the stapler group for the novice and the expert, and directionally higher again for the intermediate. Suture repairs had a 30% device failure, whereas the stapler device had zero failures in the study. So in summary, the stapler device repairs were faster, they were stronger, and in comparison to standard suture repair, the novel stapler device produced more efficient and stronger repairs across users of varying experience level in this cadaver study. Thank you. Great. Thank you for that presentation. A couple of quick questions about that. In a couple of comments, I was struck by how little time it takes to repair a tendon, even in a novice medical student, it's really only a minute and a half difference. So next time I'm in the operating room with a third-year resident, I'm not going to worry about the time it takes to repair the tendon. But the question I have for you is, you mentioned you did a Kessler suture with a horizontal mattress. How many core sutures did you have? Four. Did you do an epitendinous repair? No. And then the next question would be, what is the next step in this device? Yeah. So I believe they just wrapped up a clinical trial in South Africa, and I don't have the results of that yet, but they have at least a few months of follow-up for that, and I know that they're excited about the results. So stay tuned. That's good? Yeah. I think that's it. Great job. Thank you. I guess there's not much else to say. A final thank you to all the presenters today and all the faculty who helped us out in putting this together. I believe we have snacks and cocktails on the terrace. Thank you all for joining us, and one final plug to give us your feedback. Grab us for a drink here or send in those evaluations when you get them in the email so that we know what you liked and what to do better next year. Thank you, guys. So those are the things to think about. That's my public PSA today. All right, questions? We're done. I think we're done, yeah.

patient cases

distal radius fracture

revision surgery

fracture stabilization

fracture patterns

loss of reduction

proper alignment

digital ulcers

crest syndrome

conservative treatment

medication

good outcome

ongoing support

complications

imaging studies