And so without further ado, I'm going to ask my moderator for the third symposium, Dr. Amitad Iyer, one of my close friends and former fellow, to come up and also the speakers for the third symposium. This is going to be a really interesting topic. We're going to talk about risk reduction and how we deal with complications. Dr. Amitad Iyer. Hey everyone, glad to be here and hope everyone has a great meeting. I think this is a particular session I'm really honored and happy to be a part of and I think there's a lot of great topics that you will see that come through momentarily. And as the speakers are coming through, we'll be discussing avoiding complications in your practice, managing complex deformity and figuring out where, when, and where to refer, managing complications on call, dealing with difficult patients, and then of course second victim syndrome. So without further ado, I'd like to hand the mic over to to Dr. Anish Kadakia, who will be discussing complications and avoiding complications in practice. Thanks, Anish. Thanks. Thanks, Tabs. I appreciate the invitation. Hopefully we'll come back from the break because this is probably one of the most relevant sections of the meeting. So the question is avoiding complications in practice. I've been out for about 18 years now and I have experience in the legal realm and I don't know if a lot of you do or not, but the way we practice medicine is not the way legal medicine is practiced and it's two different things and we've not, we don't get any training or minimal to training in residency and fellowship of what this actually is and how we should adjust our practice. These are my disclosures. They're not relevant for this talk at all. So why is this important? Well, no one went into this profession to harm anyone. In general, it's not our goal. It's impossible to avoid a complication forever. No matter how great a surgeon you may be, you're just not going to make it zero. So we're trying to minimize that. One of the big things is communication. We're surgeons. We're not communicators. It's not our skill set in general and surgical skill acumen and being the best is not enough. It's not going to keep your complication rate to zero and I was just talking to Aaron Geyer. The stress is getting worse every year and you have to figure out how to have technology which you may hate to actually help and minimize your risk and no one's a captain on the boat alone. So you have PAs, you have ATCs, MAs, whatever, nurses. You have people that are in your team that you should utilize to minimize the complication risk. So minimizing error, this is not a medical lecture. It's not about how to practice orthopedics or foot and ankle in any way shape or form. So the first thing, what is a medical error? You have to understand what that means. So they define it as an unintended act, omission counts, commission as you're doing it, or something that does not achieve the intended outcome, the failure of a planned action to be completed as intended, so you just did a bad job, wrong plan to achieve an aim, so you don't even know what job you're supposed to do that day, and then deviation in the process of care. That's your quote-unquote standard of care and processes like, you know, did you do a timeout, etc. What we're going to cover today is unintended acts and deviation in the process of care. I cannot fix these two things. If you're bad at your job, you're bad at the job, and that's not my problem, and I can't fix that in 10 minutes, and if you don't know what you're doing, again, read a book. That's not my job today. But you're responsible for your quality. You can't just say, well, that's all I can do. That doesn't, that's not an answer. So estimated debts from medical error. This is what patients, and this is primarily what lawyers are, have access to, and are going to tell their patient, their clients. So about 10% of all debts in this country, hospital debts, are attributed to us, medical error. What they call is preventable debt, so if we, they didn't, they, we didn't make a mistake, they wouldn't have died. Now, whether it's true or not, and you want to argue about that, it doesn't really matter to me. This is what is out there, and this is what the patients know, and unfortunately, you have to deal with it. They don't trust us as much as we think. You may think they trust you, they may come off as trusting you. They don't. They trust you until something goes wrong. So one of the big things are, that we have, complaints are, is that we don't listen to their concerns, and that actually may be more true. When you, there's a recent article, I think it was JAMA or NEJM, but men in general are worse than women with regards to listening to their patients. But everybody's bad at it, so everybody needs to sit down and listen to the complaints more, because that's the, one of the big reasons why we make mistakes, and why we get sued. So how do you avoid an unintended act? Well, listen to your patient. Most patients go 11 seconds before we interrupt them. That's it. 11 seconds. You may think you're sitting there for an hour. They don't, we interrupt them way, way earlier. So it's a huge problem. Why? Because before you see the patient, your MA, somebody's telling you, oh, this person has not, insertional Achilles tendinosis, right? Dr. Chang's in the back of the room there, my fellow, and you assume that's their problem. When you examine them, it's a non-insertional. That's a minor issue. Sometimes you'll be like, this, the problem is totally irrelevant to what you were told. So if you don't sit down and listen, and you assume that what your assistant is telling you is true, you're going to miss the main problem. So you've got to listen. You can't assume what you've been told is true. What can you do? Well, most patients will stop talking after 30 seconds. That's kind of the rule of thumb. When you look at a lot of the sociological data, they'll just stop talking. Sit down and listen. What can I help you with today? Just sit down and just shut up. You can, I have an internal monologue in my brain. I may not even be paying attention to half of what they're saying. But you give them the opportunity. If you've heard of what you think you need to hear, but don't stop and be like, okay, I heard enough. If you have residents or PAs, you can tell them, I know you've told your story, but I want to hear it myself. You know, validated the actual interaction they had with the person that came before you, but you're also validating their ability to tell you what's going on versus assuming that you've been told the right thing. At the end of the visit, ask them, what are you looking for today? Are you looking for surgery? No surgery. What are your expectations? These are all, you may never, you may be surprised. I actually interact with my patient like this, but this is the most important things you got to do so that you close the visit and they have the right to ask. Half the time, like, I don't want any surgery or I just need a note for work or what have you. You just have to ask them so you, they feel validated versus you have plantar fasciitis, here's some exercises, do PT, don't come back and talk to me again. I'll see you later. That's what you want to say. It's what you can't say. So how to avoid it? Don't assume is what you see on the x-rays, the radiology. Everybody in this room has probably missed a fracture. I had a gentleman with a, this is the one that I remember, so there's probably ones that I've missed. He had a fifth metatarsal fracture. He's six weeks out, he's like, it hurts a lot on my ankle. I'm like, you didn't hurt your ankle, stop crying about it. Six more weeks later, went by, got an MRI. He had a tailored body fracture I did not see. I fixed it, said I'm really sorry. It's, but that's on me. I assumed he had one injury, couldn't see the x-ray, and I didn't listen to my patient. So Paul Fortin, one of our colleagues, has published on this in the ER, but we're as guilty as the ER as well. Just ask them. If it says it hurts too much to walk, don't force them. Don't call them weak. Don't say you have to walk. If they say it hurts somewhere else besides where the fracture is, examine it. Get a new x-ray, and if you have no idea what's going on, but they say it hurts, just get an MRI or a CT. Get advanced imaging. If they're telling you it doesn't match up with what you see, do something else. Do not tell them they're being weak. That's the wrong thing to do. I was told it was a sprain. Well, that's a lawsuit, and I've been, I've involved in a lot of medical legal work, and I don't go against our own colleagues, but I've seen this a lot, and you have to understand that it's just based on the fact they don't feel you're listening to them, and there's no need to flex, right? We're not here to flex to our patients. I'm the greatest surgeon in the world. I'm world-famous. I know the answer. If you don't know or the patient think, you know, just get another opinion. Get advanced imaging. You don't have to be right every time. There's no award for that. So communication is critical. Why doesn't my toe move? After a toe fusion, I've been asked that question too, and I look at them dumbfounded because I didn't explain to them a fusion means your toe doesn't move. Why do I have metal in my body? That's happened to me as well. So it's all my fault. Is it the patient's fault? Probably. I mean, it's not like we don't tell them what's going on, but remember, you may have said it, but they may not remember it. So communicate. Use EMR. Use your notes. Everybody can see your note. There's a new federal law that says patients have access to all of their notes and all of their radiology now. Use it to your advantage. Instead of being angry about it, which is my reaction, like I don't want them to read my notes, well, then flip it on so it helps you. Put the post-op recovery, put the complications in your notes, and for those of you that use kind of repetitive notes all the time that are pre-documented, those are the worst for litigation. Those pre-printed repetitive notes, if you get, unfortunately, if that ever happens to you, you get sued, those are the worst because they're indefensible because they're just garbage upon garbage upon garbage. Make sure you edit it and speak in there. It's like, this is what I do for a toe fusion. I'm not going to read it, but it's the recovery, the details, the complications. You can make smart sets. That way the patient has access to it, and you can state you had access to all your records. It's dictated in my note. Expectations are going to read it. Have your staff do a pre-op phone call. Did you read the note? Send them information. Document, document, document. If you didn't document, it didn't happen. That's the bottom line. If you documented, it happened. You can think about that just for a second. So, this happens. How to go to an intact during the day of surgery. Wrong side is obvious. You will cut off, not you, we have in society, cut off the wrong leg. One of my resident, my medical student mates, cut off the wrong testicle. Ended his career two years into practice. It is not because he's a bad person. It is because we are rushing, rushing, rushing. We trust other people. So a few things. See the patient pre-op before you roll back. We all want to run two rooms. We want to make as much as we can, be efficient, get home. Do not let the patient go back until you've laid eyes on them, said hello. See them with the family. They're not going to sue you if they die. They're not going to sue you if they get into a coma. The family is going to. Make sure everybody knows what's happening here. Who's going to take care of this patient post-op? Not the patient, the family. So just spend an extra minute. Don't roll back until you said hi to the patient. I'm still guilty of letting that happen and for the love of God, this happens. Do not make a habit of doing that because we had a case, patient rolled back without the attending in the hospital. Can't argue that one out, that there's no mistake except that's all on you. So slow down a little bit. If you get home 20 minutes later, or you do one less case that day, that's fine. But don't just be firing them back all day. You'll do the wrong thing. Post-op instructions. We're very bad about this. Pre-op instructions should be printed. Post-op instructions should be printed so that it's set for the patient. It should not be done by the resident or the PA that day, brand new. Mistakes happen. Post-op complications happen. Medication errors happen. You should have all this set before. Protocols, just like they do in planes. For follow-up, clear guidelines when the PA or NP is supposed to call you. I'm going to run over a couple of minutes, but bear with me. Clear guidelines. You're responsible medical legally for your PA and NP. If they see your patient post-op for six months and they screw the whole thing up, if you have hired that and they're not working under your license, you're responsible. And you have to have the legal ramification is they are practicing under your license. So you have protocols. Call me when this happens. These are what you have to do. If you have no protocol, you're liable because you're not practicing appropriate medicine. So just because you're not seeing it doesn't mean you're not liable. If a complication occurs, even minor, well, there's the end of the talk, call the patient yourself. That's also very critical. And that's really the rest of this is medical legal stuff. How do you avoid complications? Communication. Sit down, listen to the patient and make some protocols. And you do not have to be right all the time. Tell them to get another opinion and just slow down just a little bit and you'll save yourself a lot of headache. Thank you. Thank you, Dr. Akedakia. That was wonderful. Even though you didn't get to finish up the slides right there. But next will be Dr. Maloney talking about managing complex deformity and when to refer patients out. I'll just try and look off to my shoulder here. Good morning, everyone. My name is Pat Maloney. I'm from Mercy Medical Center in Baltimore. Thanks to Becky and to Dr. Akedakia for inviting me to be a part of this talk. I'm going to talk a little bit about what we do at Mercy Medical Center. I'm from Mercy Medical Center in Baltimore. Thanks to Becky and to TABS for the invitation to come speak today. Here are my disclosures. So, you know, my topic and I gave Becky a lot of grief for this is unbelievably broad and, you know, try to narrow it down a little bit with all the various deformities we see and treat every day. So I'm going to touch on three main things. Ankle arthritis, specifically when it relates to considerations for total ankle. We're going to do a little bit on Charcot and then at the end a little bit on progressive collapsing foot deformity. So in general for total ankles, you know, what's the concern in a higher deformity patient? Are you worried about greater risk of complication? Are you worried about poor patient report outcome scores? Survivorship of your implant? You know, what is the concern? And, you know, first off, let's talk about complication. And there's no consensus for what makes or what is a complication. Like with everything else in orthopedics, there are classification systems mainly from our Canadian colleagues. But in the total ankle literature, to boil it down quickly, intraoperative fractures and then some type of impingement, usually gutter impingement, are the two more common complications that we may see. So what are the factors that may affect those complications? One thing to consider is reoperation rate. Younger patients in general, because they're going to outlive their implant, so to speak, are going to have a higher reoperation rate. The Duke group published that on mobile bearing designs, you may see a little higher rate of reoperation. Another major consideration is wounds. Steve Rake and his group kind of broke it down into risk factors for wounds. Major wounds usually requiring a return trip to the OR versus minor wounds that are managed in the office. And there are some associated risk factors that you do have to consider. What about the number of totals you do? So mainly over across the pond, the UK registry gave us some data and they found that centers that did less than 20-20 ankles per year, this was a risk factor for early implant failure. Conversely, our Norwegian and Dutch colleagues published on their kind of registries and did not find that the number of totals performed at a given hospital correlated with poor survivorship. And then for each of us as an individual, what is our own personal surgeon experience? And the Swedish registry has taught us that survivor rate in general tends to improve after we've completed our first 30 total ankles out into practice. So that's kind of the backdrop. So now let's talk about the deformities themselves. And what are the concerns? We're worried about edge loading, we're worried about uneven wear on the poly, we're worried about ligament insufficiency leading to a poorer outcome. So when you're considering are you doing a more deformed ankle, there are more elaborate steps or more procedures that have to be performed, whether those are concomitant osteotomies, fusions to help your hind foot alignment. Oh, now we're back online, there we go. Then do you have to do a more aggressive gut or debridement? Are there more aggressive or different type of bone cuts or bony resection that may need to be considered? Some more classic articles reviewing kind of a neutral versus more varus and deformed ankles, in general found that once you can restore good joint congruity, once you can reduce them to a more neutral alignment, that the degree of deformity is not necessarily a contraindication to considering arthroplasty. Another good review article from JBGS about 10 years ago reviewed 37% neutral ankles versus kind of mild to moderate deformity, 5 to 15 degrees, versus a greater deformity of over 15 degrees, and they were able to reduce 95% of them to a neutral alignment postoperatively, and they found the outcomes in the functional gait measurement improved across all the different cohorts. Constantine and his group published on more significant valgus deformity, a minimum of 10 degrees and average of over 15 degrees, and they found that they were able to correct them to within one degree of neutral, correlated with significant improvement in their outcome scores. What about mobile bearing? Less popular here in the States, but still across the pond, this is still a very popular implant type. And again, regardless of whether they're neutral, varus, or valgus ankles, as long as you can correct them to neutral, then the outcome's improved. So the overall goal of your correction is you've got to get them to neutral, kind of by any means necessary. So how are we going to do that? One way is with patient-specific guides and instrumentation. There are a host of different companies now who have these available. Some decent studies to support patient-specific guides, and some of them even postulated and concluded that with the PSI guides, less OR time, less use of fluoroscopy. What about pre-op weight-bearing CT? And I'll touch on this a little bit in the flatfoot component, but one recent study found that with a pre-operative weight-bearing CT for their PSI, they were able to get accurate and reproducible results, although admittedly, this was in a relatively small degree of deformity in their population. Another consideration is how are you going to approach it? So as opposed to from the front, we can certainly do a lateral approach. There's a pretty good recent study of 19 patients with greater than 10 degrees of valgus deformity with the lateral approach, found no difference in their radiographic outcomes compared to the less deformed and equal patient-reported outcomes short-term. And we're out again. And then another kind of interesting thing for those of you who are doing or at least considering the lateral approach is, again, kind of the improvement after a certain number. One recent study found that after the first 18 cases, they improved the positioning of their implant. And after the first 16, their OR time decreased. So here's just a quick case example of mine. Active 57-year-old male, pretty significant deformity. I'm fortunate enough to have a colleague who's one of the designers of this implant, so I've gotten reasonably comfortable with this system in my hands. One of the nice parts of this, similar to kind of the old-school in-bone, is you correct the deformity in the frame first before you do your coupled milling and cuts. They even have templates available nowadays before you definitively put in your implant. And here he is one year post-op, at least back to playing half-court basketball. So let's shift gears quickly and move on to Charcot. Again, each of these topics could be an hour-long conversation, but we'll try and boil it down quickly. Mickey Pinzer back in 2004. And I think, you know, this kind of guides my practice when dealing with Charcot patients. I try and tell our fellows, you know, my kind of three pillars are give them pain relief, I don't want any wounds, and I want a foot that can fit into a shoe. And if you've kind of checked those three boxes, whether it's by operative or non-operative management, then I think that's a successfully managed Charcot patient. Jim Brodsky also published, and, you know, he has certainly done more work on this than almost anyone else, or at least is brave enough to publish his work on this, his surgical indications, non-healing ulcers, infections, and a non-braceable or non-plantigrade foot. So how are we going to achieve this? You know, if you look at a larger study of over 285 patients, their risk of amputation, and what kind of stands out to me is, you know, a lot of these factors are not ones that we are controlling. So I would postulate, if you're thinking about referring out... Oop, I can't go back. If you're thinking about referring out a Charcot patient, it may be that you don't have a multidisciplinary team. You need a nephrologist, you need a vascular, you need endocrine, and even within your own house, you need to have a good prosthetist and orthotist to help them, whether it's with a crow boot, a brace in Arizona, custom orthotics, whatever. So, you know, these are parts of managing these Charcot patients that's going to determine their outcome almost equally as much as your surgical technique. When it comes to technique, again, a variety of different options, not the scope of this talk. One thing that I would personally like to highlight, and Rosalind Mill is kind of the godmother of this, but her more minimally invasive correction, if you go back, you know, she initially talked on this in 2018 here at the meeting, has subsequently published a very nice article, and I would encourage, if any of you were thinking about kind of diving into the MIS Charcot, this would be the article that I would read once or 15 times before you tackle your first one. Here, again, is a quick case example of mine, you know, kind of classic, morbidly obese, rocker bottom foot, pretty significant deformity. Now she had ulcerations for over three years. Thankfully those got resolved with total contact casting. And ultimately we decided to jump on her as a surgical candidate. Here's her pre-op films. So planned just as we would for an open approach would be a biplanar closing wedge using the MAS burrs. And then at least in my hands, I find the beaming system to be the most reliable. So that's what we went with. Here she was at two weeks. And then here she was now at six months and deformity nicely corrected through pretty small incisions. So I would postulate throughout there to the audience, can MAS help correct some of these risks? Obviously it's not gonna deal with their peripheral disease. It's not gonna make their kidneys function any better. But maybe if we can deal with a little bit of a less of a wound issue before we have to deal with a little bit poor blood flow concerns, maybe MAS can help your surgical indications in these difficult patients. Finally, we'll touch briefly on progressive collapsing foot deformity. The consensus group for 2020, here's their staging system. I'm not gonna read it verbatim to you. And I'm sure you all are aware of this, but the basic idea, and I still struggle with this in my practices, what's really going on? So the whole idea with this coronal plane deformity or the Perry-Taylor subluxation is the foot is moving and rotating kind of under or relative to the talus. You get this external rotation, eversion and abduction moment arm essentially that happens as part of this progressive, excuse me, deformity. And weight bearing CT really can help assess this. So better assessment of the degree of the deformity, certainly if there's any degree of bony derangement or arthrosis that is just not as visible on your plain films. You can calculate all kinds of different measurements on the degree of coronal plane deformity. And you may get a good explanation for why they may be having lateral hind foot pain, whether it's from sinus tarsing impingement or true subfibular impingement. So maybe this is a reason to refer them out. I would argue that it is not mandatory that you have to get a weight bearing CT before every flat foot case you do, but it sure is helpful. And obviously, this is not something that's available to every one of our practices, but maybe a group next door or the academic center in your town or in your city does have a weight bearing CT. And by no means am I saying send all those patients there, but maybe at least go get them scanned there. And why does this matter? Why are we so big on the weight bearing CT? So Cesar has, I would say, championing this beyond anyone else. And just this month, he published in FAI the effects of peritaler subluxation on the progressive collapsing foot deformity. So they took a subset of patients pre-op, three month post-op, final follow-up weight bearing CT scans and assessed their degree of subtalar coverage, as well as found that they significantly correlated with their patient reported outcomes. And this is just an image from their article. And if you see kind of on the left side is the pre-op scan, how they're kind of overloading in that sinus tarsy area. So this is kind of like 3D CT justification of what sinus tarsy impingement really is. Then you can see on the right side, the post-op weight bearing CT, how that overload has been abated by their combination of procedures. In conclusion, to kind of wrap up, oh, I'm right on time. So for ankle arthroplasty, when to do, when to refer, you want to correct them to neutral, regardless of the degree of deformity. With Charcot, it really is important to have a multidisciplinary team and you have to have appropriate techniques, and I would say emerging techniques, for how to manage these challenging cases. And with progressive collapsing foot deformity, I would throw out there that it does make sense to consider the weight bearing CT. Again, not mandatory, but maybe if you can find one in your area, it'll be interesting how our practices evolve as this technology becomes more universal. All right, thank you for your time. Thank you. Thank you, Dr. Maloney. Next, we'll transition to Dr. Ariel Polanka discussing managing complications on call. Thank you. These are discussion points. All right. Can you guys hear me okay? All right. My name's Ariel Polanka. I'm out of San Diego. I have about 50-50 trauma practice and elective foot and ankle practice, which is probably why Dr. Serrato asked me to give this talk. And thank you for being here. I am honored. And I take a lot of call and I've seen a lot of complications. So my talk is going to be managing or hopefully preventing complications on call. So no really relevant disclosures to this talk. So some of the things I'm going to talk about we've heard all of the time. I promise not to just talk about platitudes the whole time, but honestly, number one is come in. If you're nervous, if the ER doctor's nervous, if the nurse is nervous, you need to come in and you need to evaluate the patient, especially if you're in your first one to two years of practice or in a new practice where they don't know you and you don't know them. It's important to come in first for patient care, to check compartments, to look at wounds, et cetera. Second, for you, so you can sleep at night, so you can kind of see that patient and know that you're doing the right thing and prevent a complication because you personally evaluated the patient. And third, it's for the ancillary providers. If you become that reliable person that comes in when they want you to see a patient, you're going to get a good reputation in the hospital. You have a good reputation in the hospital, they're going to refer you patients. They're sort of the window or the door, I would say, to get patients into your clinic. So if you establish that good, solid relationship in the beginning, that's going to pay off in dividends down the road. So come in. Also, trust no one. Trust no one. I think it's an open fracture. It might just be an abrasion. Don't trust it, see it. Dr. Palonka, I have this bimal fracture in the ER. Can I put it into a splint and send it to your clinic? Sure, that's what I said. Didn't look at the X-ray. Came back, it was a distal third tibia fracture with anterior necrosis of the skin once I got to see it in clinic. I didn't look at the X-ray. I should have looked at the X-ray. So don't trust anyone. You need to look at the images. You need to look at the wounds yourselves. Also, make sure that you review the formal radiology report that usually comes out 24 to 48 hours after you see a patient on call. If the radiologist saw something and you didn't see it, you are on the hook for that. So I always review all the formal radiology reads afterwards to make sure that I didn't miss something. This one's key. This has saved my butt and it's such a good slide. Know exactly what you're responsible for in every hospital that you work for. Know what orthopedics is on the hook for when you are on call. Do you take NECFASH? Do you do hand call? Do you take PEDS? What's the cutoff, 16, 13? Do you do soft tissue injuries? What if a plate glass goes through a forearm but doesn't break a bone? Is that you? Is that plastics? What about diabetic foot? What about diabetic foot ulcers? What about osteo? If you clearly know what you're responsible for on call, then you can talk to the person that's consulting you clearly and they know that you're not shirking responsibility. You simply are not on call for that. I know my hospital policy bylaws for call like the back of my hand. They call me for NECFASH. Okay, I'm at Palomar Hospital, NECFASH. First you have the ICU doctor come evaluate the patient. Then you have the general surgeon come evaluate the patient. If they think that they need my help or expertise, they will call me directly and I'm happy to go in. So that way you know they know that you're not shirking responsibility and also you're directing them. The ER doctors don't know who to call. The hospitalists don't know who to call. It's not their fault. And so just to say, that's not me. That's not gonna be helpful. So to know the policies and know, hey, it's not me but this is the person and this is the person on call that you need to contact. Load the boat. I was bad at this in the beginning. I was a cocky young surgeon and didn't really wanna bother anyone. I didn't wanna call someone that I didn't know in the middle of the night. Oh, I'll just call them in the next couple days. I'll call Plastics if I need them for some wound coverage afterwards. That's the wrong move. The right move is to load the boat and to load the boat early. Complex injuries, complex patients need complex care. Diabetics get endocrinology. My end stage liver disease patients, they get nutrition. If I have any questions about anything vascular, infection, Plastics coverage, they get consulted and they get consulted early. Doesn't mean that they need to come in in the middle of the night but I always set a timeline. I might call them at 10 p.m. and I say, I need you to see this patient in the next 24 hours. They agree, I then document in my note, spoke with a Plastics surgeon personally, they will come to see the patient within the next 24 hours. That way you've documented and you have that verbal agreement. I also don't let anyone else consult. I don't have the hospitalist consult for me, the ER doctor consult, the vascular surgeon consult. I make the surgeon to surgeon consult so you have that face time and that conversation so you can manage expectations. This was a patient of mine, he was a 23-year-old male. He had a crush injury to his left lower extremity from a crane that ran over him. I was called in to close reduce this Liz Frank because he didn't have a dorsalis pedis pulse. I said, I'm gonna come in anyway. That's kind of weird but either way, I got it close reduced and he still did not have a dorsalis pedis pulse. I said, we need to get a vascular involved and vascular needs to come see the patient. They said, no, he doesn't. We got a CTA, the vascular surgeon looked at it, there's no vascular injury, no need for the vascular surgeon to come in. They would only come in if the CTA showed something. And I was about six months at the hospital, didn't wanna argue with the trauma general surgeon and I didn't. So I took him back to the operating room the next day and I fixed his femur and then this is what his foot looked like afterwards. Dusky, dark, cold and demarcating. So my initial reaction is, did I do something? Did I get an artery during the surgery? Did I ream wrong? It didn't make any sense but this is what I was looking at and that's not how it looked at the beginning of the case. So I'd have a vascular surgeon come in intraoperatively, do a CTA on the table intraoperatively and it turns out that the patient had intimal tears to two of his three major arteries at the level of where the ankle met the foot. And he ended up, despite best efforts, with a BKA. Now the formal radiology read from the CTA the night before also showed that. The initial read was wrong and I should have insisted and I should have had vascular surgeons come in. Now, would we have prevented this? No, it wasn't a fixable injury. There was no revasc possible, it was too distal. However, I don't ever want to feel that way in the operating room ever again and it's much better to have a timely, consistent consult with documentation as opposed to an emergent intraoperative consult for a complication. So load the boat, load the boat early. Plan for the future. This can be tricky. When you're on call, you're just trying to survive, you're just trying to manage damage control. But it's really helpful to be thoughtful with your initial surgery to plan for the next surgeries. Also, I'll show an example, but I would be very wary of using an extended external fixator, particularly if pins are going into bones that you're planning on fixating later. Also, this is sort of the pendulum swinging, but stabilize Charcot early and robustly. I was taught in training, Charcot, you let it go, you let it ride. Put it in a total contact cast, let it ride for a year, year and a half until it consolidates and then deal with that. Well, at that point, the joint's pretty much dissolved, the foot's not underneath the body and it's a much, much harder reconstructive case than if you started it and you got it early. So this was a patient of mine on call, got hit, motor vehicle accident at high speed. She had an open calc fracture and a dusted pilon, which you guys can see here. Took her back for an IND of the open calc, put her into an X-fix. I'm like, man, this is looking good. Well, turns out, hospital policy is that you can't get an MRI if you have an X-fix on, even though that's ridiculous and I fought it and I couldn't fight it, and she had a spine injury that needed an MRI. So I had to take her back the next day and I had to take her X-fix off so that she could get the MRI. So pretty much an unnecessary surgery because I didn't know the hospital policy, I didn't plan ahead, I know now, and so now, if I'm putting an X-fix on a patient that's a polytrauma, I look at their spine things and I call neurosurgery and I make sure that they're not gonna get an MRI before I put the X-fix on. It ended up working out to my favor because fortunately, the patient didn't need her calc fixed because somehow, some way, that one day in the X-fix actually brought her calc into reasonable alignment. It's, I'm not doing that, I'm sorry. So there was that, okay. So here's another case, a 50-year-old HIV-positive male, I didn't know he was HIV-positive, he didn't tell us. He fell down an elevator shaft 80 feet, he had bilateral pylons, bilateral calcs. His soft tissues were terrible so I put him in an X-fix and left him there for a long time. Came back two and a half, three weeks later, fixed both of his pylons, then waited about another week, came back and fixed his calcs. Pylons did great, but about post-op day 10 from his bilateral calcaneus fractures, I came in to change his splints because he was complaining of more pain and pus just poured out and this is what I was looking at. And I had left the pins in his calcs for about three weeks and that's just too long. I really don't think that if you, you should use an external fixator for longer than five days, particularly if it's in a bone that's gonna need a fixation later. Your risk of osteo goes way up, your risk of wound complications go way up. I'm running a little short on time. This is a 72-year-old male diabetic vascular path, hemodialysis three days a week, blind in one eye from his diabetes, who came in with his bimal. I thought it was gonna be a really good idea just to put him into a splint. Put him into a splint, he's too sick. He's too sick, I don't wanna fix this. I'm sure it will consolidate. He doesn't really walk much anyway. Well, long story short, it dislocated, he had wounds. I tried to put an X-Fix on, terrible idea. Came back, looked like this. His X-Fix sites are the size of silver dollars. They're necrotic, they're infected. Gets this antibiotic nail, and he still has this antibiotic nail. And even though I've now loaded the boat and done everything that I should have done in the beginning, he will likely get a BKA. Currently he's freezing, but he will likely get a BKA. In retrospect, I would have admitted him, medically optimized him, and put in a TTC nail right away, and possibly a fine wire frame, knowing how high a risk of Charcot that this patient was. Release compartments, just release him. Just release him. If you do a both bone forearm fracture, don't close the fascia, just close the skin. I know this from personal experience, don't get called in the middle of the night. And if you feel like the closure is tight, leave it open, put a wound back on, come back three days later. It's inconvenient, but much more convenient than doing it in the middle of the night. Lay the crepe, this is really important. Your patients need to know that they have devastating, life-changing injuries. And that's not a fun conversation to have. I like to be a cheerleader for my patients, let them know that I'm there for them. But you need to have this conversation, you need to have it early, so they don't come back in your clinic six months later, wondering why they still have pain, wondering why they're still on crutches. You need to let them know that you're gonna be their doctor, you're gonna optimize their outcome, you're gonna be there with them the whole way, make sure that they get the best treatment possible. However, they have a life-changing, devastating injury. And it really is important to say that and say that early to manage expectations. Ask for help, get a second opinion. Anytime I'm gonna do an amputation, I ask for a second person to take an eye, look at the patient and leave a note in the chart as long as it's elective. So that way there's two people, two physicians with notes in the chart documenting that the patient would do better with an amputation. This was a patient that I had that had all four limbs with compartment syndrome, which I didn't think was possible. And my partner was operating next door, came in, asked what was going on, and just said, give me a limb. So he took a leg. And just having him take one extremity off my plate was such a big deal. So ask for help, people wanna give help, people are there to help you. And communication, Anish talked about this and I think it's just really important. University of Michigan had a great study that showed if you're upfront, open, honest with complications or bumps along the road, your chance of a lawsuit actually goes down by 80%. Patients just don't wanna be lied to. They wanna be kept in the loop, they wanna have frequent communication, they wanna know what's going on. So communication is key. So that's it. In conclusions, complications will happen. They're tough, talk to people about them. We're all here, we all have them. Best to prevent, obviously, rather than treat. Don't bury your head in the sand. Talk about it if it happens, and communication is key. Thank you. Thank you. Thank you, Dr. Pavanka. Next, we'll have Dr. Joe Park, talking about coping with difficult complications and unhappy patients. All right, thank you for allowing me to speak today. This is a talk that I think 13 years into practice, it's easier to give this talk than two years. And as you probably know, you let the people who are doing well leave your practice and the people with complications, you keep forever. So I think this is a really important topic for me. So here are my disclosures, nothing pertinent. Well, why is this topic important? Well, whether it's gun violence, medical legal risk, these are very, very pertinent things that we as orthopedic surgeons have to think about. So for me, I've been very blessed to be at the University of Virginia. We've had a lot of success, but a lot of tragedy. So this was three of our football players who were murdered and the shooter was actually one of my patients. And the day that this happened, I found out who the shooter was and I actually called the police and they were patrolling my neighborhood because I didn't know what the rationale was for why this person was killing people. But just a reminder, these are real, they can be scary and you have to think about them. But I think it starts before the surgery. So for me, the most important parts of this are to set realistic expectations. You should try all non-op measures first. I try never to comment on previous surgeries or outcomes other than to state the facts. So for example, your subtalar fusion is not fused appropriately, there's a screw that's crossing the ankle and into your tibia and just, you don't wanna be inflammatory because I think it starts off a challenging interaction. So try really hard to talk your patient out of surgery. This is one of the things I believe very strongly. Tell them about every complication you can think of. I try to list them on my consent when I do the consent and discuss the difficult post-op course, right? Like all the things they have to go through, whether it's prolonged non-weight bearing, the pre-op physical therapy that I try to do for my especially older patients. And then also, just like the missed work, all the things that they have to go through to successfully heal from these surgeries. And when you inevitably have an unhappy patient, you really have to understand why they're upset. It is okay to let the patient know that you are unhappy about the outcome. So when I first started, I tried to be very matter of fact and like a robot and not tell them that I was upset. But the reality is, they know you're upset and so it's okay to share that with them. Patients really just wanna know that you're listening. Sometimes you can't solve their problem. Sometimes it's a family problem. I've had many patients who've lost family members during their post-op course and that they're just depressed and devastated, right? But this patient was 80-year-old female. I did this forefoot reconstruction on. And about six weeks post-op, she slammed her big toe on a dresser and broke her proximal phalanx. And she had a little more pronation than what I had hoped through the fracture site. And I saw her like every two to four weeks for like four months. And this patient, to make things worse, was just like one of the meanest patients I've ever cared for. And it wasn't just to me, it was to my nurse, it was to the person registering her and even her personal caregiver who came to clinic every day with her. And so finally, I got it to heal and she was doing, I thought, okay. And I said, perfect. You know, come back and see me if you ever have a problem. And I just thought I was done. And she says to me, wait, Dr. Park, what about my right foot? And I didn't know how to have this conversation, but I told her, I said, look, it's okay if you're mean to me, but you're mean to literally everyone else in my clinic. And until we address this with a contract, you know, I can't proceed with your right foot. And so we came to an agreement about how she would behave, and I ended up fixing her right foot, and she did very well. So strategies for how to get over these, I think it starts intraoperatively. If you have a complication, you should be honest, whether that's a nerve injury, a tendon laceration, whatever it might be. Even if you cut a tendon and you repair it, you should tell the patient that, because it could always re-rupture in the post-op course, and always ask for help. So I'm fortunate, I have a plastic surgeon, a hand surgeon who helps me, and he puts in nerve stimulators for nerve injuries, and it's been life-changing. He's helped myself and my partners at UVA. One of the hardest things I deal with, I would say, is CRPS. Those of you who've had a patient with CRPS, I would recommend just get everyone involved right away, right, anesthesia, pain management, get a nerve conduction study. Make sure that they know it's a team approach. It's not like you're blaming the regional anesthetic or whatever it might be, but I just tell them. I say, look, it doesn't matter why it happened. What matters is we need to get to the bottom of it and try to make you better. So I think that's very important. This is probably the most important thing I've learned, is offer to send patients for second opinions. I'm fortunate, I have two excellent partners at UVA, and we go through all our cases every Thursday. So for me, when I have a challenging case, I tell them, I tell the patient, I say, look, I'm gonna present this to my partners and see what they say, and they actually really respond well to that. It's not me saying I don't know how to do orthopedic surgery, it's just saying, sometimes getting another opinion helps a lot. And then, if it goes beyond that, I send them to wherever they wanna go. I send them to Charlotte, Baltimore, Raleigh, wherever they wanna go, I just give them four or five names of people who I trust, and that's helped me many times. And then ask your mentors for advice, okay? It's not a sign of weakness that you're having a complication and you're not sure what to do. But this patient, 60-year-old guy in finance, very active, has had this horrible midfoot for many years, but he decided to come to me. I did this kinda cutesy surgery where I put a metal wedge at the first TMT to try to lower the first metatarsal. And I was feeling pretty good at six weeks, although he showed up in tennis shoes at the six-week visit and said that he was doing fine. But this is what he was at six weeks. And I was feeling pretty good about the correction. But over time, he slowly started breaking the hardware, and it took a year for him to really decide he wanted to do something about this. And he was frustrated, but really, it was the wife that was so angry at me and the patient and just the whole team. And she was also the one that pointed out he probably didn't protect this in the post-op course, but she was the one who was very, very angry about this whole process. I sent her to get some opinions in Charlotte, and he ended up getting a revision surgery by one of our members of the AOFAS and did very well. But I was very grateful to have that help. For the younger people out there in practice, this really is tough, but you have to see your complications more frequently, not less frequently. If you have something that needs to happen, revision, irrigation, debridement, removal of hardware, do not pass this off to your partner. Don't hope that the on-call person can take care of it. Do it, okay? Like, establish that they're your patient. Make sure you do the right thing, okay? And if a patient, this is just a tip I've seen. If I see a patient with normal imaging, my own, someone else's, they're just miserable, always consider nerve injury. I think that's bared itself out many times in my practice. But, for example, if you have someone who's had four perineal tendon surgeries, think of a seral nerve injury. My own patients, others, I think that's a common thing to think about. And this patient here on the right, failed STAR, ended up with this in my hands and did okay. But I had talked to her about this possible complication pre-op. When you discuss revision surgery, discuss all options, including below-knee amputation. I always say to patients, if we're gonna try to revise this failed STAR on the right, you have to have the conversation about BKA before you go down the path of multiple revisions. And don't blame the patient. If the patient was non-weight-bearing, but they couldn't follow those restrictions, there's lots of reasons. Upper extremity weakness, spine problems, lack of resources, so many things that we kind of take for granted that are right. Always check vitamin D levels for non-unions. Nicotine, make sure that you understand the impact that that can have. So for conclusions, you should always describe the options for continued treatment. I give them the options, and then I say, okay, if you are my family member, this is what I would recommend. And that's not always the right answer for them, but I think it's important. And then be empathetic. These complications are devastating in terms of missed work, pain, swelling, and dysfunction. Patients hate seeing broken hardware on X-ray. That's what I've learned over 13 years. It's hard to kind of rationalize it away in a patient's mind. Build relationships pre-op. Make them do injections, bracing, therapy. And the best approach to avoid lawsuits is to always behave with honesty, compassion, and respect. So this is advice from one of our malpractice attorneys at UVA, and he's been there for 16 years. And so he commented, over his 16 years, the most common reasons to get sued. One, improper performance of a procedure, like cutting the sciatic nerve during a total knee. You can't really defend that. Error in diagnosis, missed compartment syndrome, or cancer diagnosis. But the others are ones that we can be involved in. So don't make disparaging comments about other providers in the medical record. Sometimes there's other factors that you don't know that can come into play. And don't make promises that you can't keep, like the hospital will write off your expenses because of your bad outcome, or this surgery will make it so you can go back to work. And then finally, should we say that we're sorry? When I have a bad outcome, I do say, I say, I'm sorry that you did not have the outcome that we both had hoped for, but I do not say, sorry I made a mistake, unless it's something very, very egregious and indefensible. Thank you guys very much. Thank you, Dr. Park, and our final talk is by Dr. Casey Humbert, Second Victim Syndrome. Thank you so much. I'm going to be speaking on Second Victim Syndrome, and since I've had multiple people ask me what that is today, hopefully this is really useful. These are my disclosures. I always like to point out that royalties in academic medicine don't pay. So what is Second Victim Syndrome? So Second Victim Syndrome was first coined by Dr. Albert Wu in 2000 in the British Medical Journal, and it was an editorial that he wrote, and this is a direct quote from this editorial. Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed, seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later the event replays itself over and over in your mind. You question your competence, but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient's anger. You may become overly attentive to the patient or family, lamenting the failure to do so earlier, and, if you haven't told them, wondering if they know. So the Second Victim Syndrome is now defined, also called the phenomenon, as the emotional and psychological impact that health care providers, such as doctors, nurses, and other medical staff can experience after being involved in a medical error, adverse event, or unexpected patient outcome. And we are considered second victims because the first victims are the patient and their families who are more directly affected. One of the great things that I feel like everyone should read in medical school residency, or if you haven't already, now in practice, is written by Charles Bosk. He passed away earlier this year. And he wrote this book, Forgive and Remember, and it talks about how to manage medical failure. So he spent a year embedded with surgeons in training and followed them and their emotional responses and what happened on rounds and what the communications were between folks. For me, I found it a helpful read just in remembering that everyone goes through this. The only surgeons without complications are liars, retired, or dead. So when we look at the literature and work has been done about the consequences of patient complications on our surgeons' well-being, there were kind of four themes that were found. So the first theme was that there's real emotional influence of these complications on the surgeons. And these go from anxiety and guilt, sadness, shame, challenge to enjoy, leisure activities, we bring these things home. And the coping mechanisms was the next theme. Often folks have pretty limited discussion with colleagues. Many folks use exercise, guilty, that's my coping mechanism of choice. Other folks, artistic or creative outlets. And then more problematically is alcohol and substance abuse. There's sometimes institutional support mechanisms. There are also institutional barriers to support. Sometimes conferences are great for recovery. Other times I think they're really traumatic and problematic. Discussion with mentors. There's also this feeling for many of us that if we say that we're upset about it, we're going to be seen as weak and so you need to bottle it up. And then there are real consequences of how we respond to our complications in future clinical practice. I had a partner when I was at Hopkins who would say that we're always replaying our worst case and our last case. And I think that's really true. We learn from mistakes, but it's a painful way to learn. So we end up with changes in practice. Sometimes introductions of protocols, especially with major errors at the hospital level. We work on educating staff members and sometimes we'll actually do what you're supposed to do, which is root cause analysis. So this was from a piece written up by Dean Taylor about how his ulnar nerve was transected when he was doing surgery. It was published in 2018 in JBJS. It's an excellent read. They talk about the two predictable strategies that folks do. And one is defensive, and this is the opposite of constructive. So folks will keep the error to themselves, they'll avoid it. And as other folks have pointed out, that's not a great strategy, not only for your emotional well-being, but for avoiding litigation and other problems. Trying to lie to patients isn't the right move. So the other more predictable strategy that I'd recommend is the constructive one. So ask colleagues what they might have done and really seek out their advice. Importantly, and I really love that JBJS stood up and published this piece, and it was about folks who are leaders in our field writing up their own screw-ups. And it's part of the orthopedic forum, and I found this to be a really helpful read just as a reminder that this happens to all of us. And just as a plug, there's been a lot written about shame, resilience, and how do we work through when bad things happen by Brene Brown. She's a pretty popular author. And part of what her theory is on shame is that it derives its power from being unspeakable. So I would like to salute the AOFAS for having created a lot of opportunities within our meeting structure, as well as with online forums, to be able to discuss with folks and get colleagues' input about our complications, about our tough cases, because I really think that this is protective against the shame that can occur when bad things happen. Thank you so much for having me. Thank you. How do we, you know, we're kind of in this rush day to day, how do we, you know, seeing as, you know, many patients, depending on your clinic volumes, how do you kind of optimize that listening piece that you mentioned being so critical with managing various situations you described? You know, it's not easy, but I've read a lot of sociological books, and what you, there's a few things. Patients have made the decision about you within 30 seconds. It doesn't matter if you spend 30 minutes with them, they hate you or love you within, don't think you're competent, literally within 30 seconds. And that's why, when you look at it, they usually stop after 30 seconds, so all you have to do, the best thing you can do is to walk in, hi, my name is so and so, acknowledge everybody in the room, because they may come with a friend, partner, whatever. Sit down, how can I help you today, and if somebody's already talked to them, said I know what they've said, but I just want to hear from you, and just sit. It doesn't require 30 minutes in each room. My partner was, you know, I've got lots of advice over my lifetime, and so if I'm late, I spend an extra 10 minutes with that patient, that math doesn't add up, you're just ruining the entire thing. It's not you talking more, nobody cares what you want to say. Let them speak that 30 seconds or 45 seconds, and then, honestly, you can be out of the room in five minutes. And if it's really long, some patients will just keep talking, and I tell them, look, it's been 15 minutes, this is longer than I'm allowed to spend with any patient, if you want to wait until the end of the day, I'll come and talk to you, you can reschedule the appointment. I can't sit here for half an hour. And I'm like, it's just not fair to the others, the patients, and that's the long and short of it. But 99% will be happy if you just give them 30 seconds. Jeff Johnson from St. Louis. Just a question about how best to utilize physician extenders in your practice in terms of complications and patient satisfaction. In doing medical legal work, just an observation is that in a lot of cases, it's all about the fact that the surgeon didn't see the patient, it was weeks later, then the antibiotics got started three or four weeks later, doctor, if these antibiotics had been started at the time you would have seen the patient, would the outcome have been different? It's all kinds of scenarios like that. So physician extenders are really important, but how do you think is the best way to utilize them? I know there are some practices where you set them up to see all the post-ops. I love those visits. They're easy. The patient wanted to know what happened in the OR, and I did not give up those. In our practice, we utilize them to see new patients and feed the surgeons. So just get your comments on that. I'll direct that to Dr. Park to start. Oh, great. That's a great question. I have our PAC, my two-week visit, just when it's like suture removal and maybe, like I always put a plan, but I always see them at the six-week visit. For example, speaking of complications, if I have a person who has a wound problem or something, my PAs will let me know, and I'll try to call them, the patient directly, try to put a short note in Epic at least. I think just making sure they know you're still looking out for them. Again, I see them at six weeks, but everyone here may have a different protocol. I think the best way, because again, having experience in that legal world, what you're saying, Jeff, is absolutely correct, is that you are obligated to have a written protocol. I can only emphasize this a million more times for your physician extenders. That means if there's a concern for infection, do they write antibiotics? Do they call you first? If there's a wound, what do you do? You actually have to have a written protocol. That's your obligation. That's just to protect yourself. Practically, if anything is outside of the norm of practice, it's not a routine outcome, they should call you, and you need to either see that patient that day, the next day, and any wound concerns, they take a picture and put it into Epic. That's the obligation. If it's not outside of the norm of that outcome, you need to be involved. They're not allowed to make decisions on your behalf if it's outside the expected outcome. That's the best way to use them. You can have them see all your post-ops. I have a friend of mine, she never sees the patient post-op, but she trusts her PAs, she calls when there's a problem. I don't do that. I do exactly what Joe does. But that's the best line. If it's not expected outcome, they're not allowed to make decisions, because they're making decision for you, and the patient did not have the PA do their surgery. That's your ethical and legal obligation. Yeah, I would just chime in. I think the communication piece is key, and certainly with my PA, we have a very, you know, kind of constant communication. I'd rather know about everything and then be able to give feedback than not know about it. You know, I think depending on your EMR specifically, and as Dr. Kodaki was alluding to, patients can now not just access the chart, but obviously for many of us, they can directly message. And while it's set up differently in many practices across the country, I personally, to every message that I get, which is many, I respond usually within a few minutes. That's just because I'm very efficient at responding to them. So if there's an issue, a patient will send a message, and I've definitely caught a lot of things as a result to try to help afford the best care while, you know, trying to avoid complication at the same time. A question for Dr. Polanka. When you're dealing with so many, like, trauma patients, you know, kind of how do you utilize your colleagues, especially with you being the only foot and ankle person there? You know, how do you kind of, what's your sequence of triaging things that you use, especially given the system that you're in? Yeah, so I don't just do foot and ankle trauma. I obviously cover the other hot trauma too. Usually my trauma colleagues and my other colleagues will give me the pylons and calcs, etc. But before I took this job, because I've done uncovered trauma jobs, so I've done where it's just me doing the trauma, I'm responsible for that patient, plus an elective foot and ankle practice. And when I took this new job, I knew that I wouldn't do that again. So I have two traumatologists that are more than happy to take on cases that I don't want to do or cases that I've stabilized that are going to be in the hospital for three weeks from then from all of their different, you know, polytraumas that they had so that I'm still able to dedicate that time to my elective practice. But I made sure that that was in place before I took the job. So pretty much it's when I'm on call, I stabilize or do whatever fractures that I want. If I don't want to do those, I have an orthotrauma room with two traumatologists that will cover the next day. So it's mainly the practice setup more than anything else. Awesome. Thank you. Well, we're at time right now. We're just at 1130 and we're respectful of everyone's time. Thank you so very much. Really appreciate all of our speakers.

complications

deformities

communication

patient outcomes

medical errors

support from colleagues

effective communication

patient satisfaction

proactive management