Operating theater

We'll be discussing three articles, and I'm excited to start with our first with Dr. Lely.

This is Healthcare System Cost Analysis of Common Ophthalmic Procedures Performed in an Operating Room versus an Office Procedure Room.

This is from the authors out of Jules Stein, Ethan Osias is the first author, and Daniel Rootman is our senior author.

And Gary, I think you're the perfect person.

Some of them we do, some of them I don't actually do, but that's okay.

Posteritosis, sectropian, entropian, pterygium, and chelation for band keratopathy.

And they basically looked at the cost of these procedures, whether they're performed in an operating room setting or in the office-based setting.

They also looked at the reimbursement that goes to the physician depending on where these two procedures are performed.

But in the acute setting, the person with, say, the femur fracture who crashes his motorcycle, they come into the emergency room or the trauma bay.

and they could potentially have other injuries going on from an orthopedic surgery perspective, that patient is added on to the OR schedule either that day or the next day and taken to the operating room by an orthopedic surgeon or traumatologist to fix their femur.

Now, an orthopedic trauma surgeon, if it's just that one femur that came in, that's all they're doing.

But that tends not to be the case.

Now, that being said, you do this long enough, you start to understand that and you change your style in those moments, right? And if I think that people who have been doing this long enough and that are successful at it, can see that and see that coming and have a different way of working, right? And adapt to that environment to still optimize outcomes.

Can you press on this? Could you give us an example of what, like, what would you do differently or what type of thing would you change in that moment?

Yeah, I think fortunate to have a couple people in the operating room with us.

And so if at that time, if I have a medical sales consultant for, so for trauma and actually almost all of orthopedics that are very implant dependent, companies have representatives that kind of bring the implants in or are, we'll call them set experts for lack of a better term.

Part of the reason for selecting this project is that this is an area I've had some experiences.

This is a picture of me from about 15 years ago in the operating room.

And this is some of our early work.

It's from 2009 to design software in the operating room.

And this is a particular piece of work that we designed a network interface that allowed a research computer to talk to the system that was actually running the surgery over a network protocol to get data out in real time so we could do research visualizations and other measurements without actually disrupting the process of surgery.

So the surgeon used the system on the left.

Where are you right now? Where are you touching? So this is the guidance.

So this is the triptych of planning, initialization, and guidance that constitutes this process.

yeah that's

embarrassing that's not something that i didn't want to be known as that type of surgeon so i just always made sure that i was somewhere in the operating room because it goes back to my dad he's like you put in the work you're going to be prepared and i tried to put in the work by being in the or as much as i could

No, that's great.

So obviously you've done that work, which is amazing.

I'm from the University of Arizona.

So today's episode shifts the focus squarely into the operating room, so specifically how we navigate the moment in total hip arthroplasty when things don't go exactly as planned.

We spend a lot of time in arthroplasty talking about preoperative optimization, patient selection, and risk stratification, but the reality is even in well-selected patients, intraoperative challenges are inevitable, and how we respond to those moments is often what defines those outcomes.

So this episode centers on a symposium review from the twenty-twenty-five AAOS annual meeting that breaks down intraoperative challenges in primary total hip arthroplasty in four key domains: exposure, acetabular preparation, femoral management, and restoration of leg-leg offset and stability.

Yeah.

I really appreciate that too.

I think y- we were saying that outs- outside, like just being able to be flexible is so important in the operating room because you're also like guiding your whole team.

So if you respond poorly, like the stress level in the whole OR just kinda goes up.

Absolutely.

And when you suspect an NSTI, that duty demands immediate stat debridement in the operating room.

You cannot afford to just wait and see if the labs trend up tomorrow.

Because time is literally tissue here.

You’re killing the soldier with penicillin and simultaneously taking away his weapon with the clindamycin.

Exactly right.

Now let’s transition from the trauma bay into the operating room.

Ugh.

Because I go back and look at my video and I'm like, well, I think I did the surgery well.

I'm not sure what else I would do in the operating room.

And at that time, I didn't have the experience to say, you know what, we need to give it more time.

And now what I've seen is that a subset of patients will take four, six, sometimes even a little longer to feel the benefit of what we've done.

Yeah,

if there's a reflexive coughing or emesis.

So in the old way we used to do it, we tell people don't eat or drink, you had people coming into the operating room dehydrated potentially.

And that delayed recovery.

And this concept's really important not only for diagnosis, but it's kind of critical or crucial in choosing the types of activities that may support you through your career.

We did find in our survey study that if you exercise more than five hours a week, you were less likely to modify your operating room practice.

Interestingly, we found no correlation with BMI.

And about 20 years ago, there was a study in ophthalmologists, not oculofacial surgeons, ophthalmologists, and they found that performing more than four cases a week or seeing more than 100 patients in a clinic a week was associated with increased neck, upper extremity, and lower back symptoms.

Yeah, absolutely.

I think the thing that is really coming through to me listening to both of you is that there is good data that sort of correlates the symptoms we have with the amount of time we spend in awkward positions.

And it's not just the awkward positions in the operating room.

It's the awkward positions that happen throughout our entire workday, really, in a variety of settings.

And The nice thing is that you get really good accurate representation, so you can really take that motion out and look at it on a computer, or as I said, if they're making animation, they put a character on top of that and stuff like that.

But the challenge is you need all the cameras there and you need to do it in a controlled environment, so you can't really do it in an operating room or those environments.

The marker-less systems, one is still sensor-based, which is wearables.

So that's where you have your IMUs, right? So these are sensors that, again, people put on body and then it tracks movements of different body parts.