We all have our own pet villain (insurance companies, pharmaceutical companies, pharmacy benefit managers, hospitals, doctors, pharmacists, nursing homes, CMS, malpractice suits, etc.) for the cause of the high cost of health care in the U.S. But deep down, we all know that the growth in the cost of health care in the U.S. is unsustainable and changes must be made.
My PERSONAL belief is that the campaign entitled, “Pain is the fifth vital sign,” is at the root of this country’s current, tragic, opioid epidemic. This approach was grossly misguided – at best! Firstly, signs tend to be objective, whereas pain is subjective. Secondly, the words “vital signs” literally mean “signs of life” or “signs of being alive.” For millennia, the very evidence of a person being alive depended on: temperature, pulse/heart rate, and respiration. Later, upon the invention of the sphygmomanometer, blood pressure was added as a fourth vital sign.
With summer now in full swing, the temperature outside has risen to uncomfortable levels for many of us. However, one place we don’t expect to deal with excessive heat is in the operating room. Unfortunately, if your hospital is like mine, you may find yourself in a battle with anesthesia and nursing staff over the thermostat setting. Most frequently they will cite patient safety as a rationale for increased OR temperatures.
The opioid epidemic continues to be an issue of growing concern across the U.S. The WOA has had several Touches and lively forum discussions on the matter.
I recently returned from a three-week AOA traveling fellowship in Japan and part of our charge while there was to develop and perform a research project. Given the nature of this topic in America, my co-fellows and I conducted a survey of Japanese surgeons’ attitudes and practice patterns regarding opioid use and prescribing.
As many of you may know, this year’s incoming First Vice-President of the American Academy of Orthopaedic Surgeons is Dr. Kristy Weber. I found myself surprisingly emotional and proud listening to her speech at the annual Academy meeting in New Orleans a few weeks ago, and laughed as she referenced the fact that she was “the first person in heels” to address the crowd in the First VP role. As such, she is slated to be the first female President of the AAOS in 2019.
As I was placing the last stitch of the skin closure on a total hip surgery, the tip of the needle broke off. To remove the 1-cm fragment, I would probably have to reopen part of the skin incision (which could increase the risk of prosthetic joint infection), would possibly have to convert from spinal to general anesthetic, and there would be additional radiation exposure for the patient. I had intended to leave the fragment, but the hospital where I practice informed me that I HAD to remove it prior to the patient leaving the OR. It made no difference to the hospital whether this was a broken drill bit, a needle fragment or any other RSI. I subsequently had to answer to the hospital’s Peer Review Committee.
I read Dr. Ilahi’s recent Touch with interest and admiration and I applaud his efforts to reduce his patients’ need for strong opioids. With the recent attention focused on opioid abuse in America, reports like Dr. Ilahi’s are becoming more common, and there is a push for doctors to standardize their prescribing in order to reduce opioid usage. However, as an Orthopaedic Oncologist, I have some patients that require strong opioids. Do they require them because I have over-prescribed? No, they require them because they have a condition that results in severe pain. Should I try less potent drugs initially? Absolutely. But, I should also tailor a medical regimen on an individual, per patient basis.
I haven’t prescribed any opiate stronger than codeine in over 3 years. Before that, my routine post-operative prescription was hydrocodone, which was fairly standard for U.S. orthopaedic surgeons. But after learning of the gross disparity in postoperative narcotic prescriptions here compared to other countries and given the changing attitudes in America regarding post injury/postoperative pain control, I was able to significantly reduce the strength of my opioid prescriptions.
As the weather warms up, it is only natural that we all head outside for sunshine and fun, especially our kids. So, this seems like a good time to quickly review safety regarding a warm-weather favorite: trampolines.
The Western Orthopaedic Foundation (WOF) is pleased to announce its first 2018 Resident Research Grant Recipient, Caitlin Rugg, MD of UC San Francisco. Dr. Rugg has been awarded a grant to study “The Impact of Early Sport Specialization on the Collegiate Athlete.” With young athletes participating in organized sports at an ever-increasing pace, there has been a growing number of injures as well as “specialization” in sports played year-round. This continuous activity may lead to injury patterns and biomechanical changes in the musculoskeletal system, warranting in-depth study of major clinical significance to orthopaedists.
At the urging of state societies, such as the California Orthopaedic Association (COA), and regional societies, such as the Western Orthopaedic Association (WOA), the American Academy of Orthopaedic Surgeons (AAOS) has been working diligently with the American Board of Orthopaedic Surgery (ABOS) to push for changes to the unpopular Maintenance of Certification (MOC) program.
As a fourth-year resident, there are many demands on my time. Nonetheless, when presented with an opportunity to serve the WOA, I wasted no time applying. I'm one of two residents currently serving on the WOA’s Board of Directors; I am in my second year on the Board.
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