Joint Effort PAs
We're two orthopedic surgery physician assistants discussing PA school, life as a PA, cases and topics related to orthopedics, and much more!
Joint Effort PAs
Things that Keep Us Awake at Night : Total Joint Infections
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In this episode of Joint Effort PAs, we’re talking about the cases that keep orthopedic providers up at night—starting with the big one: joint infections.
From septic joints to postoperative infections -we break down the clinical red flags that make your stomach drop and the decision points that matter most. We also talk through the real-life scenarios that every ortho PA eventually encounters: the “angry joint” that might be more than gout, or the patient message about redness around an incision.
Along the way we share clinical pearls, common pitfalls, and the mental side of practicing medicine—how experience shapes your instincts, when to trust your gut, and why some cases stick with you long after clinic ends.
Whether you're an orthopedic PA, student, ATC, or just love hearing how clinicians think through tough cases, this episode dives into the infections and complications we never want to miss.
Tempo: 120.0
SPEAKER_02Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine. From tips and tricks to professional growth, work-life balance, and everything in between. We're here to share what we've learned and what we're still figuring out. Let's get into it. Okay, we're back. We're delayed. A little bit delayed. But I'll probably post this tonight. We don't have to, we don't have to take blame. I know, but if we were, it is my fault.
SPEAKER_01I tried for a good reason. I know. I tried. I really hoped that I would be available yesterday until I wasn't available. Like I forecasted I wouldn't be available and then it played out that I wasn't. I still waited an hour to tell you I wasn't. Do you did you think that they weren't gonna win? Okay, no. So I was I was out of town with two of two of my three kids played in a soccer tournament, and it sounds like, oh my god, you gotta go away. Like, no, it was mass chaos. I like got off on Friday, three-hour drive, like trying not to stop. Nobody can drink anything. We had to get to the hotel for one of my 11-year-old's friends' birthdays was that day, and there was like cupcakes in the lobby at seven. Do you think I got there at seven? No, I didn't. Um, but anyway, it was a girl, it's an 11-year-old girl and a 15-year-old boy, and their teams were staying at different hotels, so I had to pick a hotel. So I heard about the whole time there why I didn't pick the other hotel. And then there's group dinners, and the group dinners were 30 people. Oh, but my son's team won their first game Saturday morning, and one of the parents said, Oh, I think that was the hardest competition, and they they won four to one. Like it was easy. And at that moment, I said to myself, We're gonna be here till the finals on Sunday. Like I knew it. You knew it. I knew it.
SPEAKER_02Yeah, yeah, you know I had it.
SPEAKER_01We were good for them. Like, I mean, yeah, but it's soccer, and they um the finals were at 2.15. It didn't start till 2.30. The game was supposed to be over at 3 30, but they went into overtime, so now it's 3 45. Then they went into PKs. Oh my gosh. And it was supposed to be five PKs, but they kept making, and then it was seven PKs, so they won. So every possible game expensive. Well, so they won, and then we had to do the award ceremony. So we didn't not leave until whatever. So, anyway, long story short, we're back.
SPEAKER_02We are back, yes. Um, how was your week leading up to that? I mean, that was an exciting part of your week too, but no, that was that was good.
SPEAKER_01It it made that last week flow right into this week, literally. Um, but no, it was it was good. Last week there were items on my list that had to get done a very certain way, and I will go into it more with this episode because it's kind of what this is about. Um, I had stuff on my list that had to be done a certain way so that I could go away this weekend to do the things I had to do and not have the lingering work stuff. But you were still stressed, I'm sure you were thinking about it. It was so dramatic. It was so dramatic. So the things that needed to happen ended up happening, but oh my god, so convoluted getting there was ridiculous. But I'll tell you guys about it. Um, but no, uh the week last week was good. We had great surgery days. Um, yeah, so two uh three clinic days, two very full surgery days. Yeah. Did another Misha in 40 minutes. That was that your fastest Misha? Uh it must have been. Wow. It must have been. It was it was rapid Misha. No, it was smooth. It was great.
SPEAKER_02Smooth, rapid Misha. Yeah, it was good.
SPEAKER_01That's what they all should be smooth and rapid.
SPEAKER_02They they will be. That is that's what's happening.
SPEAKER_01Yeah, but no, it was um, it was good. Yeah, so good cases, interesting, challenging, and in very different ways, but all good. What about you?
SPEAKER_02I love that. Yeah. Um, we were slated to have a pretty busy week, and then we had some big cancellations at the beginning of the week, and I always hate that because it was like it was a case that we were like prepping for for months, and then you know, they got sick and canceled, and then a full busy day ended up being like a pretty light day, and that's a little sad. Um, and then had my walkabout day Wednesday, uh Thursday. Uh I'll briefly get into this. This is a whole other uh thing. I have a patient that I saw probably like five months ago. Um came into my clinic. I think I actually got him from you guys. This is how we inherit. I don't know why, but all of like the craziest unhinged things are always like someone from y'all's team reaching out and being like, hey, we're gonna take this.
SPEAKER_00Can you actually take this?
SPEAKER_02Um, so it was a uh a stab wound. Okay. Um yeah, so stab wound. The guy had gotten stabbed like seven to nine months before seeing him.
SPEAKER_01I was gonna say times.
SPEAKER_02I was like, oh I don't know, maybe seven to nine times. We didn't get into detail. I didn't ask him that question. I was not very thorough with that. Um, but yeah, he had gotten stabbed in his arm and it severed his radial nerve. And so he had a complete wrist drop, radial nerve palsy. Um, so I see him again seven to nine months later, and uh no function. This is the first time he's getting any care for it. Nerve injuries like that are typically best dealt with acutely if you're looking to try to repair it uh at that far out. It's not impossible, but it definitely makes it more challenging. So um I examine him, we kind of came up with a game plan we're gonna try to repair, but we, in order to do that, needed to get this very special nerve graft because you probably won't have the length that you need at this point. And he also has a neuroma or a painful nerve bundle. So we're gonna excise that um to at least help with his pain, repair if possible. So we get this this whole thing coordinated for this big case. Um, the guy unfortunately lives in like I don't I don't know what you call it, but he's um in rehab for like addiction facility. Yeah, he's inpatient or halfway house. Well, yeah, yeah, like halfway house. I don't know, is that the PC term halfway house? But yes. Um, and so you can only communicate with him through that facility. He like doesn't have a personal phone, which makes things challenging.
SPEAKER_01And you were not given this information when we referred this patient correct, correct.
SPEAKER_02But all this still fine. I would hope that a facility like this would like coordinate with the people that they were with. Um clearly they don't. So getting him scheduled in the first place was like very challenging. Got the graft ordered, had everything set to go. He was scheduled. We had like confirmed the time and date with him and the facility. And come the day of surgery, this was sometime in December, I believe, that this happened. He did not show up. He was not there at the day of surgery. He eventually showed up as we were like leaving the hospital four hours after his slated arrival time and had eaten.
SPEAKER_01Oh my god.
SPEAKER_02So we're like, okay, we can't, we can't do the surgery. Um we decided to give him the benefit of the doubt and say, like, hey, you know, you can get back on on the schedule and we'll try to re-coordinate, but like it's obviously not happening today. He no-showed my appointment for that. Stop. Yes. So um I in my mind, I'm like, all right, we're done. Like no-showed too many times, lost trust. Like, this is not happening. Cause from our perspective, like, that's a big deal. That's a a big 90-minute scheduled case that we could be doing something else, um, an expensive graft, like all these things that go into it.
SPEAKER_01Big no-nos across the board. Yeah.
SPEAKER_02So um, fast forward two months later, one of my clinical assistants sees him on my schedule and is like, Hey, did you okay this? I'm like, no, thought we weren't seeing him anymore. Right. Um, we still decide to give him the third chance. I order a nerve test at this point because we're thinking about the potential of having to do nerve transfers and we need to make sure his function in the other ones is good because his exam was kind of weird. So I order a nerve test. He apologizes to me profusely. He's like, Hey, I'm so sorry, like all this happened. I wasn't there, I will be there next time. And I'm like, Can you believe okay? No, I didn't believe him, but like I wanted to. Yeah. I wanted to. Um, so we get him rescheduled. I make everybody like hyper confirm with the facility. Like, he will be here this time. I still schedule him last case of the day, regardless. Because I know I know the day before he's scheduled for the EMG. The girl who's gonna do the EMG reaches out to me and is like, hey, he knows showed. And I'm like, Oh my god, this he's not coming tomorrow. He's not coming. Oh my god, he's not coming.
SPEAKER_01And then he didn't show up. Oh my god, so you know you are, but you are in this guy's like addiction profile. I like he may he's making empty promises to you and you believed him because you wanted to.
SPEAKER_02No, like, do I need to go to a halfway house? I don't know. Or I think for whatever dis disorder I have because of this.
SPEAKER_01No, it's not your disorder. It is uh they do. They have support groups for loved ones of those that have addictions for this exact group. Oh my god.
SPEAKER_02Give them a hundred chances. I need a support group for all the things happening in my life at this point. So so you didn't do it. We didn't do it, yeah. And now we are at the point where I can um write it off, I guess. And it's actually because I really like it. It would have been really cool. Like, I would have loved to have seen what came of that. But if he calls again, like it's a no. Like, I thought it was a no for me last time. I think my team wanted to give him the benefit of the doubt again. I knew deep down in my soul that this was going to happen, but I was hoping um every moment. So I talked about it a lot all day to people, and I was like, he's not gonna show up, he's not gonna show up. Because I think I hoped deep down that like reverse psychology, I would be wrong. Um, but it wasn't. So sad. Yeah. So I was a little feisty this week. Yeah, but okay.
SPEAKER_01It's okay. But you you promised to rebound this past week.
SPEAKER_02Last week, I don't know that I rebounded. I still feel like it was, yeah. Like so the the week before was good. Yeah. This past week, I feel like I had like a I was just uh I was very melancholy, melancholy week. Really? Yeah, I know.
SPEAKER_01I um I hit the week like with a plan. So the PA that I work with, he was out second half of the week, and we had a scheduled washout on Wednesday. So this like consumed my entire week because a midweek washout that requires a pick line is a Friday discharge if everything goes right. If it's not a Friday discharge, it's a Monday discharge. And when you're out of town Saturday and Sunday, it's very, very stressful. So I was like, I need to control this entire situation. So when I had scheduled the washout, prior to the washout, I scheduled blood cultures, okay? And blood cultures normally I would get post-surgery, post-washout, um, when they're in PACU or when they're on the floor. They have to be negative for 48 hours before ID will place a PIC line. I know that, but I didn't want to wait till Friday to then get the okay to place a PIC line to not get the PIC line and then not discharge this patient. So I told the patient Monday, go get your blood cultures. So I told my team, I said, put in blood cultures times two. Don't put it in one order and then wrote X2. Put it in twice and say, please reference the other order. I am ordering this twice, right? I like cover all bases, yeah. Over their shoulder, did it, called the patient 8 a.m. and said, go get them now. So the um 48-hour result would result on Wednesday, right when she was done with the washout. So I was like, I'm I'm amazing. I've never done that before. Like I've coordinated it perfectly. I've coordinated it perfectly. So the patients admitted it's on the day that I'm not operating, so I'm stalking like the epic system, and I'm like, she's in the or she's in the or great. I get her blood culture results on Wednesday, and it says something stupid like no growth to date. Um, collection sample was suboptimal, may need to redraw for more volume. Okay, first of all, I remember you telling me this. First of all, like your lab, like it says blood cultures times two, so automatically you didn't draw but you didn't draw two.
SPEAKER_02Yeah.
SPEAKER_01Because you referenced one, and then you also referenced that it wasn't enough blood. Like, get out of here. Like get more blood. Yeah, but so now that result's gonna be seen by infectious disease. And if they agree that it was not good enough, then they would redraw and then it was all for nothing, right? Yeah.
SPEAKER_02Um, but anyway, I'll pause on that story for now because it kind of But so frustrating because like you're doing all the right things and you're thinking ahead, but and sometimes this is just me being negative. I feel like when I think too far ahead and try to do all the right things, that's when disaster strikes.
SPEAKER_01Yeah, well, it's like what is this saying? Like, um, all good deeds. All good deeds go unpunished or all the best laid plans are, you know, oh yeah, they all something worse. No good deed goes unpunished. Yeah, variation of that, but that's exactly how it felt. Yeah, that is how it feels. But anyway, so the patient was admitted, they had their washout. I consulted ID, and ID was like, no, we don't need another blood culture. And I was like, oh my god, this is so smooth. This is amazing. So fast forward to Wednesday, I see the patient. Um, and then uh Thursday, I saw the patient. Thursday, the order goes in for the PIC line. Awesome, great. This is so being discharged by Friday, right? So she gets her PIC line Thursday. I'm reading the notes from case management. Case management just sees her. Now it's like four o'clock, and then I happen to read a note that's like 4:32, almost five o'clock. And it was um the patient, we we are in North Carolina, the patient is in South Carolina, right? So infectious disease says, here's her regimen, this we're gonna do. We're now on day one of 42 days, six weeks of antibiotics, whatever. We'll need to coordinate with infectious disease in South Carolina to quote accept the patient. Okay, like I get that. Those that are inpatient here don't want to manage someone who's not living here. Yeah, okay, fine, whatever. Um, case manage, then it says case management to send referral in the AM. Okay, that bothers me on so many levels, but it's getting no longer a Friday discharge. So I go see the patient Friday before our surgeries at another site to do her discharge summary. So I'm like a rolling at six. I'm like, hey, let's like, you know, whatever. Um and the patient's like, oh my God, am I gonna go home today? Yeah, I just want to make it clear right now, if you don't, this has nothing to do with me. But this is what I said. I said the um referral went in. Sorry, referral didn't go in. It said referral will go in at eight. And she said, Oh, well, the infectious disease that I want to go to, they close at noon on Friday. Oh, great. So I was like, All right, what I want you to do is you start calling them. I will have my office, not the hospital, call them, like the infectious disease, and like, did you get it? Did you get it? Did you get it? Yeah, wait for this. Yeah. So anyway, so long story short, Friday comes and goes. It's past noon.
unknownOkay.
SPEAKER_01Um, I was told at 9 30 referral was sent, 11:30 wasn't received. They sent it again. 1158, the case management worker was like, it was sent, like emoji, like smiley face. And I was like, Yeah, but perfect. But they didn't accept the patient. Yes, they didn't accept the patient. It was sent and nothing happened. So again, I'm talking like via Epic at a different facility. I was like, what is the what needs to happen for her to go home today? And infectious disease says, I need someone to in South Carolina to sign the home health orders. And I was like, is there a specification with who the someone is? Yes, an MD. Perfect. I call the patient. I was like, you need to call your primary care doctor immediately, explain the situation, and see if they'll sign. So she did. So she said, so I call her back and she said, he said he would. He said just send the orders, but you have to call him first. And he said, when you call him, tell his staff to quote, get him out of the room, right? Like pull him out of a patient account. So I'm in the OR. So now I've got the rep on my phone. I'm telling him what to text my medical assistant to get on the phone to call. My medical assistant continues to be hung up on. And I'm like yelling at the rep because he's like not hearing my phone ding, even though I'm hearing it ding over the suction that we're operating on, right? So he's like, he's you know, he's reading it and then he's reading out loud that I'm telling him what to say.
SPEAKER_02It's like super annoying. Yeah, yeah. Like, yeah.
SPEAKER_01Long story short, the doc calls back. We talk to him, and he's like, no problem, right? So I communicate that, and it's like just before four, I told the patient she can go home, right? And she ended up leaving for the weekend, but like down to the wire.
SPEAKER_02Wow, that worked. It did work. As you were explaining it, I was like, there's no way this is gonna happen.
SPEAKER_01Fast forward to today, she messages first thing this morning and she was like, Hey, the home health referral, they're out of network. So, like, no one came to do her antibiotics. It's all like anyway, um Foiled. No, so but the It'll work the segue from that, hopefully, consuming um, you know, everything is what we're gonna talk about. Because no one would come on and talk with us, aka, like our physicians we look up to, those that we're gonna do.
SPEAKER_02I wanted to talk one because as I was leaving today and discussing what we were doing, yeah. So my doc was like, wait, where are you going so fast? I was like, we have to record. He's like, Oh my god, you didn't record already? I'm like, Oh my god, how do you not know that you must not listen? Yeah, he's listening. Yeah, my doc was like, Why did I not get a new episode? Yeah, no, he did he definitely pays attention to it.
SPEAKER_01But he he did say he was like, Well, I'll Well, I I wanted one of our total joint surgeons to talk about it because again, I'm not like placing blame, but like statistically, joint infections are gonna happen a little bit more than you know, our hand or shoulder or knee, whatever. Um but they're also a bigger deal, they are a bigger deal. And the ones that I remember and are gonna talk about are are joint infections. Yeah, but um no one wants to be the poster boy for joint infections. I get that. Yeah, like I'll be a poster boy.
SPEAKER_02And yeah, no, I like I feel like there's a a thing with it. Like if anybody had come on to discuss this, they would have been nervous that they were about to get plagued with three.
SPEAKER_01Yeah, but they're getting playtime for talking about infections. Like nobody wants to be known and like for talking about that. Like you had one. Oh, let me associate your name with joint infection. Totally. Um I get that. But anyway, so yeah, we'll talk about why we hate them. I mean, we've for more than just the obvious reasons. Yeah, I mean, nobody loves them, but it's just like whether it's happening in real time or it's happening over the phone or you're reading labs, like we'll talk through the process of the reality of it. Like you, you do the patients pre-op, you educate them, you say the word infection as a risk, but it's hypothetical.
SPEAKER_02Well, it's not gonna happen to be. So, like, what is your verbiage? What do you say when you like brush over the risk of blah blah blah? Infection, blah, blah, blah. Yeah, I know, right. And it risks include death and death, right?
SPEAKER_01No, so we um pre-operatively have our patients wash with benzyl peroxide, and it very naturally works its way into a shoulder conversation. I will say, and I'm gonna send this pre-surgical scrub. This is overkill, but the number one um uh you know complication for shoulders is joint is infection, and the infection comes from you know, like armpit, skin, bacteria. Bacteria.
SPEAKER_02Do you do you do pre-scrub for all of your uh benzyl peroxide?
SPEAKER_01Okay, and why did we add that, Hannah? Because of a previous joint infection.
SPEAKER_02Yeah, I'm gonna just start doing it. We actually had this conversation so we don't we don't do pre-washes for anybody.
SPEAKER_01We do just because I want to know that I tried everything to prevent. So I will say that it'd be up and I will mention that it's also in their consent, but I don't not mention it. And even for our ACLs, I will say that as well.
SPEAKER_02Do you guys like give them a bottle at the time that they buy it? I will I send it as a prescription.
SPEAKER_01Okay.
unknownYeah.
SPEAKER_01And I give them a handout if they want to buy it on Amazon. And some of them, when they're waiting for me to come in, are like, just bought it, you know. Yay! Yeah, and I'll tell them a week before, but I don't care if they do it like once, you know, just like try, like try. Yeah, do something like that. Yeah, some is better than none. Yeah, some is better than none. Yeah. Um, but anyway, I will work it in the conversation at Priya. Yeah, and I will mention that it is a thing, right? Yeah. Um, but the scary thing about shoulders is that the way that they present um, and again, this one that we had this week is Cutiobacterium acne or probacter acne. I don't know why it like got a promotion and got a name, but um, it is super slow growing, um, low virulence. It's not really gonna give you sepsis, but its biggest signs and symptoms are stiffness and pain, which is everybody has stiffness and pain. Has a variety of stiffness and pain, but the serology is normally negative. So, like with our lady, and again, I'll work through like, you know, education-wise, how do you work up an infection? But our lady had negative blood work, right? And then nothing. Like ESR CRP, I mean, yeah, CRP, CBC, um, and said rate were all completely normal. Not like kind of high normal, they were completely normal. Um, and then, you know, you get to the point where you do a joint aspiration and then send the culture. And guess what? The culture takes up to 14 days to grow. Yeah. So the fact that I had this lady planned for a washout and didn't have to like drop everything and like whatever is because it took a while to get the result. Like it was, it was crazy. But um anyway, it's um it is an art. And for those that deal with orthopedic patients, when someone has an infection, and again, I'm speaking from a clinical brain because I experienced it on my end, not on the patient end, I want to absolve all responsibility. Like, I don't want them to say that it was you infected my shoulder. And for some reason, that's always my biggest fear.
SPEAKER_02Yeah, no, I it is because I feel like so much work goes into it to like everything about it is meticulous down to like the draping. I don't want to take it personally.
SPEAKER_01You don't want to communicate with the patient that I'm taking it personally, it's their fault or that it's our fault. Like I you don't want to it's nobody's fault, it's nobody's fault. But you don't want to pin yourself against patients. But anyway, so um we like to fix things. Infections are unpredictable. You hope they go a certain way, but sometimes they're so traumatic and it results in so many bad things. Yeah. It's emotionally super heavy. The patients, even though you're walking them through like how to treat this, and as they go through it, it affects everything.
SPEAKER_02Yeah, it makes them like I don't know, they they like lose this trust.
SPEAKER_01Yeah, but their weight, like their lives change. Like they might not get their full function back. They might not go back to work, they may lose their job because now their easy recovery turned now into like a pickline. Yeah, like all antibiotics forever. Yeah, but it does. It does test the relationship of the surgical team and then your relationship with the patient. Yeah.
SPEAKER_02So those are the things that um that hopefully we can. And it's stressful from our standpoint too, because I like typically the PAs are the ones that are seeing post ops, especially initially. So like the threshold of like when to have concern versus not have concern for it, and like when do you bring those things up? And we've seen that situation go wrong a couple of times and like how yucky that feels.
SPEAKER_01Yeah, again, for example, and again, when these pop up, God help me, they pop up like in threes, and we always everything's in three. We have two was in the past week that affected both of our teams, but like for example, I saw a patient that was an elbow patient, known this guy for years, actually operated on both of his shoulders. Um, he came in for swelling and redness on his elbow. Casual. Casual. Added him on the same day, was on the other PA schedule because he had an opening, and he kind of he second guessed that. He was like, I don't really see anyone else. I kind of want to see like you. And I just didn't have any availability. I was like, Why don't you come in? I will quote pop in.
SPEAKER_00Yeah.
SPEAKER_01So the guy had a proximal ulna plate from a car accident that he was in. And he had come in like five months earlier for elbow bursitis. Uh, nobody aspirated it. It was kind of like, let's just take a look at it. Um, when he came in, it looked beefy red. It was fluctuant in like a very small area and like really indurated in the rest of it. So I told the other PA, I'm like, all right, just aspirate it. So PA went in, tried to do it, came out. I was like, I didn't get anything out of it. I'm like, dude, there's no way you didn't get anything out of that. So I was like, all right, let's grab the ultrasound. Here's the pocket, aspirate. And as I'm aspirating it in the clear syringe, you're seeing the color. Yeah, you can tell. You know, yeah. So I'm aspirating it, and I was like, well, the nuggets have got to start being laid. So I said, well, this looks a little cloudier than I'd like, aka orange and thick. Um, we're gonna send this to the lab. Uh, it does look infected. So because you have hardware right underneath there that I hit with my needle, um, I, you know, this is kind of a big deal. So let's start you on antibiotics. We'll call you. I'll get, you know, a couple of labs back. The CRP will take probably a day. But let's just, let's just, you know, get get going on this. And he was like, all right, like you're gonna call me, like, what is the plan, whatever? So again, you the patient leaves and there's no real clear plan. Like, I'm not like I will see you back tomorrow. It's like, hey, I will call you. Yeah, hang in there, yeah. Yeah, yeah. So I said enough to alarm him, but not enough to like make him go straight to the ER. Right. So I knew long story short, it was infected. Of course, it was going into a weekend, right? So the guy's on antibiotics, and he ended up following up with you guys, and things escalated really quickly. Things did escalate very quickly. Yeah.
SPEAKER_02So very quickly. I actually knew nothing about this case. Um, ironically, I don't know if that's the right word to use in this. I I didn't, I was not made aware of this case leading up. The first I found out about this case was when I was called over or to help close because his arm was filleted open.
SPEAKER_01Yeah, because he recorded a lot of things. Extensive expensive. But like the difference, right? So let's talk about that one. That was like, you know, the acute. Yes. The guy you haven't seen in three years calls out of nowhere and was like, hey, oh my god, I'm a I'm a little red, right? So that is how total knees, like total knees that we'd signed off on 10 years ago, we'll call and say, Hey, my knees kind of swollen. And you're like, Well, if it's been years, I'm like, you know, patients think they're swollen and they're not. Yeah, let's just have them come in. They come in, they're always an add-on, it's not in a spot, and then you come in like this guy, and you're looking at it, and I was like, This is infected, like you already knew it. Um, but you have the acute ones like that, and that goddamn shoulder that we did, we did it in September. Yeah. And she wrote us in November, eight weeks to the day, and was like, Hey, my shoulder's killing me. Nothing has changed. I don't know what's going on. And with that patient, again, this is three hours away. Yeah, I said, go get some blood work. Got some blood work, it came back normal. I was like, Okay, it's normal. Get on the schedule. I need to see you in person.
SPEAKER_00Yeah.
SPEAKER_01Um, saw her in person. She looked miserable. So that patient who is miserable, who's kind of painful, kind of stiff, labs are normal. What else do you go to? It's probably your neck, right? So get an MRI. Guess what? It was her neck. It was like a C5, C6, left sided. I was like, okay, we need to get you in for an injection with your neck, but added an abundance of caution because your shoulder also is a little jacked up. Let's MRI your shoulder. Now a month goes by. This is November, now it's December, now it's January. So we get the MRI of her shoulder. It shows like a crazy amount of sinovitis. So I was like, all right, now you gotta come in to aspirate the shoulder, right? So now it's from November, December, January. Now it's February. Aspirator shoulder and it freaking brow grew Cudi bacterium.
SPEAKER_02So I assume this was cuff repair. Cuff repair start with. So like at this point, are you just uh doing like I and D with the hopes to go back in?
SPEAKER_01And then do like uh Yeah, so when I saw the patient came in, so the patient came in for her MRI discussion slash aspiration. And the the note on the appointment line said, would like to meet with the physician physician to quote, finally figure out what's going on. And I was like, one offended, two, I'm going in like guns blazing. So I did it. I said, listen, you you were doing great until you weren't. Your labs are normal, right? The next thing we go to is your neck and your shoulder. We MRI'd both are abnormal. She actually has a retar and she's got a neck issue. She's actually scheduled for a fusion in May, right? Oh, yes. Okay. So, um, but the most abnormal thing is with your recurrent tear, which maybe was attrition, maybe it was, I don't know, she's doing a therapy three hours away, but it's so much cinnavitis. Like, I need to make sure your shoulder's not infected. Yeah. Because if it is, and I had the conversation, I said, because if it is infected, that kind of takes priority. If it's not, then go get your neck fused. We'll eventually we'll fix your rotator cuff again. Right. So um, what I'm gonna do is I'm gonna send this for you know culture, and then we'll whatever. So she goes back to South Carolina. Now I'm on the phone with her. Now she wants to call her three-way back with her husband. Now they want to call again because they now have like 500 questions. So this is like it's a lot.
SPEAKER_00Yeah.
SPEAKER_01Schedule her washout. So I educated her along the way, which is crazy because like had we not MRI'd her shoulder or aspirated her shoulder, she would have got her neck fused and then it would have got another six months. Like, who knows? Right.
SPEAKER_02Yeah, yeah.
SPEAKER_01Um, so anyway, so I told her, I was like, listen, in person, when it was no negative, when it was a negative culture or I didn't have a culture, it's your neck. But now the game changes a little bit. So now the priority is we wash out your shoulder. We're not gonna fix your rotator cuff. We're actually gonna take out whatever's in there and pack it with stimulant banco and reaspirate as long as it's negative. Go get your neck done. Yeah, then we'll do your shoulder. We're talking this will be her whole year, dude. Right?
SPEAKER_02And I think like patients get mad too because they want to like it's obviously natural to, and I don't want to say she was mad or anything, but like they want to put the blame on somewhere, like why did this happen? Like there has to be a reason for it. Some somebody has to be at fault.
SPEAKER_01Yeah, so she said the the like letting her know what was going on along the way was super helpful. She's wrote me back three times, even over the weekends three times this weekend. Thank you so much. You've been amazing. And I'm like, okay, I feel like our relationship is good. But one of her questions was because I've been so heavily involved, like, has the surgeon done many of these? Right. And part of me is like, okay, if I answer that with Do you wash out a lot of infections? Loaded question. Yeah, loaded question. Do infections happen a lot? No. Do we wash out all of them that do? Mostly, right? Well, you hope, right? All the ones you know about. But like, you know, the patient is second guessing, right? And then it's like, I'm like guilty because I don't know. And part of cootybacterium, but it's also a contaminant. Like, is it really infected? Did I like, did I not send the culture correctly? Like, am I overreacting? Should I try doxycyclicket first?
SPEAKER_02Yeah, those are it's hard with shoulders too, because of like, yeah, because it can be so many yeah, other things.
SPEAKER_01I mean, but also part of me was like, we telehealth we, our team telehealthed her three or four times. Like, yeah, we should have brought her back in in person. Would I have done anything different had I saw her in person? Like, I can't like x-ray vision see an infection, but like you, it's hard even when they're in person. Yeah, gosh. The the shoulders are hard, those are tough. Yeah. So, like, again, after I talked to the patient, I felt good about it. I had asked the doc, I was like, you know, do we wash it out? Should I try to oxycycline? And he he said, present her her options and let her decide. But also, like, let's wash it out. Yeah, you know, so did I whatever you want to do, but this is what you want to do. Did I appropriately convey the conversation?
SPEAKER_02Did I make her feel like I was rushing her? Did I lead in one direction versus the other? Like, is my language leading that you should do this versus not that?
SPEAKER_01But anyway, so that one we were just at the start of that one. She went home, she got her pick line, she seems to be happy. She seems to not, we're on the same team right now. Her husband, again, so sometimes you have the dynamic of the you know, the patient and their significant other where the patient trusts you, but the significant other's like, how come you didn't ask this? Yeah, blah, blah, blah, blah. So I mean, we're all on the same page, I think. Um, but again, yeah, that's a lot. Now let's compare that, but let's compare that to a total joint. So total joint comes in, they've been, you know, cleared for several years. They went to get their freaking toes like filed or something, and they get some stupid infection in the toe, and they come in like, hey, my knee's kind of swollen, haven't seen you in three years. I'm like, send a picture. That's kind of swollen. They come in, you put your hands on their knees, and you're like, Oh my god. Yeah. Like that's a huge effusion. Aspirate it, you see the sludge coming out, sludge. You're like, oh my God. So let's talk about knee infections.
SPEAKER_02Have you done a lot of knee infections? Um, no, my experience with knee infections is all via our urgent care. Um and so I feel like uh, you know, fortunately or unfortunately, well, definitely fortunately. Yeah, definitely fortunately.
SPEAKER_01Um haven't had to deal with a lot of those. So we yeah, when knee infections happen, it is like you see the patient walk down the hall. And if it's if it's to the point where it's just starting, yeah, it's like a big effusion. Yeah, you know, um, again, you're a PA, you're just a new PA starting out. Maybe you're an urgent kid, maybe it's not your patient. Like, do you aspirate the table joint sneak?
SPEAKER_02Yeah, and it's also so highly dependent on which surgeon it is and what their response is to that and like what their threshold is with it. It's it's tough working with different uh different surgeons and different personalities and different thresholds because they all, you know, one of them might say, if you look at the knee and like any part of your what you had one half of one brain cell that thought infection, we're going to the OR tonight and we're just gonna wash it out. Some of them are like very casual. Yes. So aspirate first, right? And get the cultures, and some don't care about that, and some want pictures, and some want you to call them, and some are like, don't call me at nine o'clock at night. This isn't an emergency. Like, why didn't you just do XY? So it's learning that.
SPEAKER_01So we we we collectively have worked with a physician in the past that one suture, like one vitral sub Q suture starts to pop out. This surgeon will wash out the knee. Right? So super aggressive. Okay, wash out liner exchange, close it back up. Another surgeon, this joint's infected. I have aspirated a knee, 120 cc's of yellow, brown, orange garbage. So it's a and I'm and I've caught, and like, hey, uh, so this does not look good. This looks infected. Do you want me to, you know, I'm gonna send everything, send for a culture, send for silicon blood work, whatever. Do you want me to inject this guy's knee with a gram of anchomycin? No, let's just see what the culture shows. I'm like, uh. But what if I just injected it with a gram of anchomycin? You know, um, but some some will wait, some will wait for the culture, then they'll wait till it's business hours to wash out the knee, and then the physician I've worked with in the past, aspirate it. I know it's infected, tell them to go home, not eat anything, call the hospital, book the case, inject their knee with a gram of bang. Like, we're rolling on this.
SPEAKER_02Yeah, no, and those are things like I think personality-wise, it depends on like how okay are you having things linger over your head. I'm not, I'm not I can't handle it. Like, I can't sleep at night if, and this is the title of this episode things that keep us awake at night. I can't sleep at night if I'm thinking about somebody who possibly could have an infection.
SPEAKER_01Yeah, no, I detrimental. So, um anyway, I've had enough experience with aspirating knees. Some of them I will tell, you know, why don't you just go home, grab some clothes, and go right, you know, go right to the hospital. Let me just figure it out, right? Um, we had one lady who had, you know, she called and said, I've told you this story like a hundred times. She called and she was like, Hey, my incision's draining a little bit. And I was like, All right, come in. So she came in. She couldn't not hold it. There was like yogurt-colored stuff pouring out of her knee. A little bit, yeah, a little bit. And I was like, oh crap. So cultured it. The next and what we ended up doing, I think we cultured it. Um at the time, I mean at the time, I think it was it, it built, it built up. I think it was like a scant bit of whatever. The next day, half of the woundy hissed. By the time she went home, because again, she doesn't drive, she's living with her sister, whatever, whatever. She texted me that night and said, Hey, I think some of the stitches are also coming out. She sent me a picture of the metal in her knee because her skin was wide open. And I was like, that happened quick.
SPEAKER_02Yeah, like go to the hospital right now. Oh gosh.
SPEAKER_01This was like midnight. Like admitted the patient, started her on antibiotics, IV antibiotics, washed her out the next day. There's not enough skin to close. Like, she ended up having three or four revisions, and she kept asking me, like, like, but Home Depot needs me to come back. Like, when am I gonna go back to Home Depot? And I'm thinking in my head, like, I don't know that that's happening. Never, like, Jesus. Yeah, but anyway, so these they do, they keep you up at night because they're just so they make you not go back to sleep. But all right, so let's talk, let's talk about things. So ritualistic process to minimize risk of infection, right? So pre-op optimization. You're not gonna take your, you know, uncontrolled diabetics, your pack a day smokers, right, to the operating room and no, no, and no, and think that your risk of infection is low.
SPEAKER_02Okay, no, no, no, it's it's not. And I always have like the increased risk conversation with those people. Actually, we're about to do a total shoulder tomorrow on a lady who's on hemodialysis.
SPEAKER_01So yeah, I mean, but again, you know that like that's that's raising some different things.
SPEAKER_02Yeah, so you're gonna be like so much more cautious about it. So in my mind, I'm like, we're we're taking all the measures, you know, we're not going into this with blind hope. Like it'll be fine.
SPEAKER_01But but isn't it crazy though that like you will take all the measures with her and she'll be fine, and then you'll take all the measures with like your stiller that's like super athletic, yeah, super clean, everything's clean cut, and it gets an infection. I know. That's not fair.
SPEAKER_02It is not fair, yeah. But yeah, I mean, like down to a T. So you start that just from like a patient optimization standpoint, or at least from our perspective, because I I know some surgeons are very, very strict about oh, I will only operate within these parameters. BMI has to be under a certain level. Um, definitely not smokers, you know. Uh A1C in the sevens or below seven. And um uh, what's the other thing that I'm thinking? Like MRSA status, like totally negative. Yeah.
unknownYeah.
SPEAKER_02Some people, not so much.
SPEAKER_01Yes, some people think those are important, some people think they're less important.
SPEAKER_02Yeah. No, and I I still think they're important, but I think they're like, I don't know. My my approach to all this stuff is a lot more um risk mitigation and education. Yeah. Right. Because I also get that, like now, granted, BMI is not as important for shoulders per se. Yeah. Um, it doesn't put as much risk as the knees and hips, but um, smoking is obviously still a risk. Do we operate on people who actively smoke? Yes, we do. Do I tell them beforehand you're a much higher risk of having wound healing complications and a and a joint infection? Yes, I do. Will that help us though when it's 10 o'clock at night on a Friday and somebody calls and sends us a concerning picture? Yeah. No, that's still gonna make for a shitty weekend.
SPEAKER_01So it you know what's crazy about it? It's always 10 o'clock at night. Yeah. It's always when you're gonna go out of town.
SPEAKER_02Oh, it's always. Yes. We have to touch on that too. Yeah. Nighttime, definitely a thing. I actually took a call, it was like three months ago now, just to speak at how over speak on how over time this starts to like ding your, you know, it raises the the flags. And I'm on call. I get a call at 3 a.m. from one of our total shoulder patients, who I haven't seen in two months, because he's like appropriately post-op where we're not following him that closely anymore. Call and he's like, oh my god, my shoulder's just killing me. If somebody could call me back, and I'm like, he's oh my god, yeah. Disinfected. Like, oh my god, oh my god. That's all the first thing in the morning. I'm like, what's going on? I mean, not great, but still better story. He dislocated it spontaneously and then went to the ER and they reduced it. So that's actually a win in my book. I'd much rather that. Easier fix. Yeah, definitely. Um, but it is always the vacations.
SPEAKER_01Yeah, I we had a guy that it was an infected knee. He came in, we aspirated his knee. Um, again, I'm just pause real quick. If someone you think is infected, said rate CRP, CBC, blood work. Yep. If you think something is infected, you culture it, send it for culture, you send it for cell count. The first thing to come back is your cell count. And you will get the neutrophils, you get lymphocytes, you get red blood cells, you get all that. You can you know based on your neutrophils where you're at.
SPEAKER_00So that's not true.
SPEAKER_01I mean that for those that are listening, and like the textbook answer, I don't know what that is, but the real answer is get your damn cell count because that will come back the fastest, and you can move from there. The culture is confirmatory and it'll kind of guide you with what antibiotics you're gonna use. But if you see it, someone who has a joint infection looks miserable. And when you get to the point where they look miserable, it's it's too late. Yeah, it's too late. Um, but anyway, so oh god, I lost my train on the phone. The vacations. Okay, so we saw this guy, we aspirated this guy, I knew it was infected, and uh, we admitted him to the hospital he wanted to go to, which is a rural hospital. They freaking airlifted him to another hospital. Oh my god. When he and these stories always go like this to some extent. The guy um was admitted to another hospital and ended up washing out his knee. So washed out his knee. Um, I believe we took all the hardware out and put in like a big old cement vancomycin block where he was gonna walk on that for X amount of time while I got his pick line. While he's in the hospital, he develops neck pain and he can't move his arms, right? And I'm like, all right, he had a stroke, something. MRI's neck, he's got this massive tumor on his neck, like something that is like terminal, right? So now he's in the hospital. Now you've got all these other teams involved. In the midst of all this, he becomes septic, right? Um anyway, long story short, he died. Guy was admitted. We washed out his knee, the knee stuff, he was already with infectious disease. We kind of had our plan ready to go. Then it escalates into the neck thing. Then it escalates into he can't move his arms. Now he's got terminal cancer. Anyway, so they're consulting me um about like his dressing change. Can the guy shower? Now I one was going out of town, two was already out of town, three lost my voice, right? So I am on the phone and I'm like, I need you that I cannot communicate because I have no voice. And I remember yelling in the phone and you also always get sick before you go on vacation. Always go sick, yeah, because you're trying to do all the things. But anyway, um it was like a total mess. I will never forget that.
SPEAKER_02Isn't like that? Literally is the worst case scenario of every possible thing that I can imagine.
SPEAKER_01But I have also been out of town. And again, I've been out of town where like, and I don't go out of town much. Yeah. Just to be. But every time you do. No, I remember being on the beach and getting a call from one of our providers that was here, and it was something we were watching, and it was fine, and then it turned very not fine. And I was admitting the patient underneath my towel and the blanket because it was so windy you couldn't hear anything. And I was like in my little cocoon calling to get a bed for the patient, because that's like what we normally first do. And everyone's like, Why are you waiting like what are you doing? Come out from under the word working.
SPEAKER_02I'm like, Yeah, everybody, that's especially when your family's like having fun. They're like drinking margaritas, and they're like, Come on, like, no work allowed.
SPEAKER_01And you know, no, I'm no, I'm literally like a turtle under the blanket. And I was like, nobody talked to me. Like, why hot spotting to my phone?
SPEAKER_02Yeah, it's crazy. Jesus. I mean, but like, I don't know, like a like obviously we care. Yeah, it is so chaotic. We love the chaos of it. It's like drinking our uncovered coffee in the car.
SPEAKER_01So another crazy thing about orthopedics is we, and I've done it both ways, we require infectious disease to help us. Okay. They're gonna collaborate with us. I would rather, like we did with this lady, tee it up. Blood cultures are negative. Here's your bug. Just tell me what antibiotic we need to do and send them home, right? They will manage like the weekly blood draws, they'll take the PIC line out. We have gotten so fed up with infectious disease because orthopedists sometimes clash with infectious disease as far as how a problem should be treated. Okay. With like a total joint or hardware in the shoulder or whatever. We want to remove it. Take it out, wash it out, take it out, wash it out.
SPEAKER_02Yeah.
SPEAKER_01Exchange it, don't exchange it, whatever. Infectious disease is like, no, no, no. You have to keep that. You have to keep it. Don't start antibiotics until you know what the bug is. No.
SPEAKER_02We're all like they've already been on banko for time. Like, sorry.
SPEAKER_01No, that that ship has sailed. This has got to be culture specific. Um, you know, and they'll I appreciate them, but even the the lady that I had, I was like, oh, she's gonna be on this med. And they wouldn't give her this one med because it it interacts with two of her psychotic meds that she takes.
SPEAKER_02But that's methodical medicine. We're practicing chaotic action medicine.
SPEAKER_01So we have said in the past, screw this, yeah, we are gonna do this all ourselves. So I've like, we've washed out a patient at an outpatient surgery center, sent them home. We put Vank in their shoulder, they're good for like 10 days. Now the doc says, order the PIC line.
SPEAKER_02I'm like the outpatient PIC line placement.
SPEAKER_01It's never easier to coordinate. Okay, so order the PIC line, fine. Now, PIC line is in, home health will do the first dose of antibiotics. But wait, you can't do the first dose of antibiotics. You have to be at an inpatient facility in case there's a reaction. So then I have to bring the patient back to our surgery center so one of our nurses can administer the antibiotic. The guess what is already in their shoulder and I know they're not gonna react to it.
SPEAKER_02Because it's there.
SPEAKER_01Yeah. So then coordinating the weekly blood draws. Um like the Venc trough stuff. Yeah, yeah, yeah. Or like, you know, the sed rate CRP as they go weekly. Um, then having the patient come back in because we don't want to do home health. We just want home health to deliver the med. We want them to administer their IV antibiotics. Right. So I've shown a patient how to watch, you know, how to flush their line, how to put saline and the heparin or all those other things.
SPEAKER_02But you could work in ID.
SPEAKER_01Yeah. And then I've had them come in for their first dose, literally tape it on the wall. You should ask one of our medical assistants when you did this like COVID time because I don't want to admit them, right? And then um removing the pick line on that time. But we've done that, and it's just, I mean, infectious disease when they're involved, way easier. But like there's a little bit of a clear. Yeah.
SPEAKER_02But like easier in some ways, harder in other ways. Yeah. Sometimes it's easier, even though it's more work on your end, to just be in control of everything. And I feel that for a lot of things.
SPEAKER_01Yeah. So do you feel like in any of the infections you've had where it needs to be a washout or something, like what role do you play with a patient? Like, is this like the surgeon handles it and you're just like doing the things, or are you like all in?
SPEAKER_02I mean, I personally feel all in, but I feel like we have a very collaborative relationship, less not less like.
SPEAKER_01But like I guess what I'm asking is like when the patient inevitably hits their rock bottom and needs to like uh like you mean who's who's talking to the patient that we're the mutual patient we're discussing for 45 minutes on the phone.
SPEAKER_02You're asking. Yeah, yeah, no. Um, but like I feel very um, very much like I need to take ownership of those situations, like do something. Because I know that it's so bad, and like the surgeon is always gonna hate it, and they're always gonna, it's gonna make them stressed out and it's gonna make them on edge and like not happy and not super nice. So like I'm trying to alleviate that as best I can and like take away whatever badness I can from it.
SPEAKER_01Well, I think no matter what we hold mentally, the surgeon holds more of that because they're the hands, not that we're not the hands, but like they're the surgeon. Yeah, yeah. Like that's they're so if someone wants to go online and blast them, they're not like that goddamn PA. I mean they might still be able to do that. I know they might still they probably will.
SPEAKER_02Yeah, ultimately it comes down to that.
SPEAKER_01But I think if you're handling the emotional baggage of the patient, the surgeon has whatever emotional baggage that they have from that, just from it happening. Um but normally, like my method is explain to the patient these things happen. Like they happen even if we control for everything. Um, now we as a team are going to go through this. Like we're gonna tackle it. We're gonna get through it, we're gonna get through it. Um, and again, this is not something you cause, it's not something that happened because of whatever you did or didn't do, or you know, you showered too early or too late or something like that. Um, but also talk early. Like I will vaguely outline like we're gonna wash out the shoulder, and that's step one. Yeah. Step two is usually the pick line. Step three is probably a course of oral antibiotics. Step four, reaspirate and make sure it's gone. And also with the total joints, some of them like it just they're on long-term antibiotic suppression.
SPEAKER_02And I think that's what we're gonna do for the well, yeah, actually. Uh my doc talked to an uh one of his ID friends uh today, and apparently we don't need to keep them on lifelong, but they do need to do chlorhexidine scrubs before their hemodialysis. So but yeah, I mean, I think the patients who and this is something that I personally like, I don't want to say take pride in, but like I think it matters and makes a huge difference when something like this does happen. I'm all over it. Like they have they're becoming my new best friend. We're gonna talk on the phone daily, and I'm going to be very receptive to them and like I'm gonna stay on top of it. They're not gonna feel like I don't care or am not involved. And I think that helps them like appreciate, okay, they don't just not care about me and like, oh, it got infected, and they're like, whatever, go die off in a corner somewhere, you know. Like, no, you're you're yeah, you're now my number one priority.
SPEAKER_01One of the things that we will do in our clinic is when they come in for their post ops or their wound checks or whatever, the second they check in, they come back. Yeah, like they do not wait. We just we just bring them back and yeah, you're gonna have a red carpet experience. You are, but like the first, but no, no, no, not that we're like making up for something we did. Like it's not anything like that. It's just that now you're gonna come back frequently. I don't need you to pile on top of everything you're going through. I don't need you to to hate it too. Yeah, but um you know what's you know what's crazy though? Like, have you ever gone through like when you're seeing a patient and you're like this is infected, where you're saying to yourself, this is infected, but it takes you like a minute to like verbalize it, or you convince yourself it's not. Like there's this is not, this is not happening.
SPEAKER_02Like, I'm not, yeah. Like I'm living in an alternate reality, right?
SPEAKER_01No, I'll have like a little I'll have a little stall where I'm like, Is this happening? This is happening. Yeah, is this really happening right now?
SPEAKER_02And it's but it's the vacations too. I vividly remember two very specific times. One that I was like choking because I had to call your doctor. Do you remember that? Yes, I do. I was working urgent care and I was only like part-time with the surgeon I'm with, and I was working urgent care on like a Saturday.
SPEAKER_01Yes, it was the pinning.
SPEAKER_02Yes, it was a pinning. Yes, and um, yeah, yeah, yeah, yeah. So it was bad. She comes into urgent care, and I'm like, holy crap. So I start calling the doc that I am working with, and he's literally in the air flying. And in my mind, I'm like, why don't you have inflate Wi-Fi now? Yeah, why would you why why are you making yourself unavailable for me right now? Yeah. In the freaking air. Jeez. Uh, be available 24-7. No, um, that's unreasonable, obviously. But I ended up trying for a long enough period of time that I eventually caved and gave in, and I was like, What do I do? Yeah. So I called your doctor and we washed it out on a Sunday the next day. I remember that. Yeah. Um, and I mean, you know, it wasn't a total join or anything. So at least there's she she actually is fine now and got better, and she still does her same job and all is well. Um, and then literally another time where when you guys go on vacation, like, do you try to plan them at the same time as your doc? So that like you're out at the same time or different times.
SPEAKER_01You try to stagger it in effect. It's funny you said that. I got an email today of when our doc is off in the summer. He takes one week. It's either before it's 4th of July. It's either before 4th of July or after. So this year, 4th of July is on a Saturday. So it's like, oh, cool. He'll probably take first week last week of June or the first week of July. The first week of July. So I am taking the 11th through the 18th. So it's like second week of July. He sends a message today. He goes, I'm off the 12th through the 19th. I'm like, you motherfucker. Like that was mine. But I booked this in December.
SPEAKER_02I was like, Yeah, it's good and bad because we decided we're gonna leave it alone. Yeah, leave it be because you know what? Like, I can't do anything by myself either, other than call your your talk. Yeah, so like it it works out sometimes better that way. Again, like these things happen to everybody. Like there, I don't there's no ortho team out there who doesn't deal with infection. Infections happen to people. Um even if you do all of the right things, they can still happen. And so it's better to just have a good system for dealing with it and be honest with yourself and recognize it.
SPEAKER_01Yeah, but I think preventative, obviously, doing as much as you can to control the uncontrollable, right? So making sure your smokers try to quit smoking, right? Making sure those that have A1C is optimal, making sure those that have an elevated BY BMI, maybe they they decrease that a little bit, right?
SPEAKER_02We swap for MRSA for our totals and we treat differently for those. Um side note, don't inject Alecronombersitis with steroids.
SPEAKER_01Don't do that.
SPEAKER_02I've seen it a couple of times where it has been done and we wash it out. That's what ends up happening. Yeah, yeah. Um, because I get brown things that come out of the elbow after that happens.
SPEAKER_01Um But I think like I think if you ever want to test your relationship with a patient, involve yourself in joint infection. Like just, I mean, it unfortunately is it's one of those things I think that it truly defines you as a great PA because you are you'll be brought closer together. Well, you'll be brought closer together, but you're also navigating a situation that is not like you your slam dunk is your post-op care, your slam dunk is your diagnosis. This is uncharted territory, and you got to manage it because the patient's looking to you for you know reassurance and like let's tell tell me the other ones have gotten through this too, you know. So you really need to take the reins on that. But also, um, you know, with the hospital stuff, when you're coordinating with other teams, God help me.
SPEAKER_02Coordinating with other teams and coordinating with the hospital is like, I don't know, maybe I just have not been lucky recently.
SPEAKER_01No, I think like when it said at four o'clock, we'll send out referral in the a.m. I was like, oh, that's funny. My a.m. is 6 a.m. I'm gonna start bothering people right now. Their a.m. was 9 30. Yeah, their a.m was 9 30. Like, I mean, I I was relentless. And had I not said for our lady that we just had, what is the requirement? And they were like, Oh, we just need someone in South Carolina. I will find someone. Like, can I write that? I live in South Carolina. No, I know, but like you guys didn't do that. Like, I and I told the patient, I said, I am working for you right now, sister. Like, I will I will call your primary care. Do all these things for you. Yeah, um, and I think they were grateful because at the end of the day, that would have they would have still been there today like morning. Could have been the weekend. Yeah.
SPEAKER_02But yes, so this was good. I mean, takeaway, it should be a low threshold of suspicion.
SPEAKER_01It should be on your radar and know what to do. Um, as we talked about, like each physician will require something else. Like, will everyone want a knee aspirated? No, right?
SPEAKER_02Yeah.
SPEAKER_01Um, uh are you expected to do a shoulder aspiration? No, man, those are hard. I haven't done, you know, I did those until I did those. Um, but systematically working through, gathering more information, confirmation, then action. Yes. In kind of that order sometimes.
SPEAKER_02Agreed. All right, guys. Well, we'll see you next time.
SPEAKER_01Bye. Thanks for tuning in to Joint Effort PAs. If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med-minded friend. You can also follow us on Instagram at Joint EffortPAs for updates and extra content. See you next time.