Welcome to the upper hand, where Chuck and Chris talk hand surgery.
Chris Dy :We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal. Thank you for subscribing, wherever you get your podcasts. And be sure to leave a review that helps us get the word out.
Charles Goldfarb :Oh, hey Chris. Well, hey Chuck, here we are. Here we are. I am so excited about today.
Chris Dy :Yeah, we have a special guest joining us. We have Dr. Sam Moghtaderi, joining us from all the way from Washington, DC.
Unknown Speaker :Hi, guys.
Chris Dy :Welcome. Sam is a as an orthopedic surgeon. He practices at George Washington University. He trained (did undergraduate) at Yale, went to med school and Einstein and then subsequently did his residency at Einstein as well did his fellowship at Pitt and was in practice back in the Bronx before he moved down to Washington, DC. So thank you for joining us, Sam.
Sam Moghtaderi :It's great to get to join. Thanks for having me.
Charles Goldfarb :So Chris, how, or Sam- how did you guys you guys know each other and gotten to know each other I should say, is that through your advocacy work or how what's the relation?
Sam Moghtaderi :I wish it was that fancy. But no, I think actually, we probably crossed paths first on Twitter, believe it or not,
Charles Goldfarb :I love it.
Sam Moghtaderi :And then probably the subsequent annual meeting in Vegas was the first time that we hung out together. I think the first time we really met was at the bowling alley.
Chris Dy :Yeah, it's kind of funny. I met Sam on Twitter because he posted that really cool case. So I can't remember what the case was- it was a crps case. It was some kind of
Sam Moghtaderi :it was the median nerve with the dry skin and median nerve distribution, I think
Chris Dy :Yeah, I know who wrote that paper Dr. Goldfarb. But, yeah so we first interface on Twitter and then realized the we actually knew a bunch of the same people anyway. When we were at the the annual meeting in Las Vegas, there was the social at the Brooklyn Bowl, and our hand clubs were rivaling next to each other.
Charles Goldfarb :That is so awesome. I, you know, people say, you know, why are you on social media? Why are you on Twitter and people like me don't meet anybody on Twitter, but this is how Twitters supposed tofacilitate I love it. So cool.
Chris Dy :It is it has brought us all together.
Charles Goldfarb :Yeah, right. Except for half and half.
Chris Dy :So we have a special topic to discuss with with Sam today. You know, one of the things that is it, I think it's timely as we think about costs in medicine as well as environmental considerations and patient considerations. It's wide awake local anesthesia, no tourniquet hand surgery, aka Walant.
Charles Goldfarb :Outstanding. It is and has been certainly over the last couple of years a hot topic. It seems like I guess my editorial is it seems like it's a no brainer. Why is everyone not doing WALANT for every appropriate case, but it's not that easy. So it'll be interesting to hear the different perspectives.
Chris Dy :But why don't we star.t Sam, why don't you tell us what your experience has been with WALANT, how you learned it in training, or whether you didn't learn it in training and kind of taught it to yourself in practice and how you've incorporated it into your practice now?
Sam Moghtaderi :Sure, let me first start with how I do it now or what I do now and then I'll jump back and tell you how I got here. The short answer is right now it's a huge part of my surgical practice, I would estimate that probably 80% of my cases I do with the patient awake. And with no anesthesiologist there, just me. Now that's a long way from where I started. I didn't really do any training at all. When I was a resident, we had you know, one attending who wanted to come on hours where there was no anesthesiologist. And before he did his total knees, he'd do like one de quervains under local. But there was nothing WALANT about that he used a tourniquet, there was none of the principles that I think we'll talk about today were there. But essentially, I had never, never really done it until I heard about it and read about it in the last few years. I also have this interesting scenario where I changed jobs about four years ago. So for the first six years of my practice, I was practicing in New York, and then I completely changed cities and institutions. And that was really the turning point for me, because in the last year at my previous job, I had tried to implement this and hit a lot of hurdles, which we can talk about later, and was frankly completely unsuccessful at doing any of it really. And then when I had had this bad experience and kind of knew about the hurdles, and then I walked into a fresh slate, I was able to say, you know Hi I'm Dr. Moghtaderi. This is how I do carpel tunnels and sort of build it up from there and be able to hit a reset button and it's been very successful.
Chris Dy :I will I will be very clear my experience doing hand surgery in the Bronx was limited to the Bronx VA. And the only way to get cases on on certain days were to do them under local. So for better or worse, my first true WALANT experience was in the Bronx at the VA. We didn't use an epi, which we probably should have. But it made it very interesting. But it was the only way to get a carpal tunnel done on a Friday.
Charles Goldfarb :I was just gonna say it that's a really interesting story, Sam. And first of all, my jaw dropped when you said 80% of your cases are done under WALANT. But there's a lot of truth to what you say. And as Chris and I can attest, we're in a situation where there are a lot of hurdles some of them potentially insurmountable to, I would say not, not possibly, some of them are insurmountable to developing a practice like you have. So then, we'll get to that but that is that's awesome. And I think that changing of the jobs, people see it as as a negative And you know, as a big change? And it of course it is. But it does bring certain opportunities that come with experience. And so that is, that is really interesting.
Chris Dy :Well, so Chuck, what do you think the advantages are of WALANT
Charles Goldfarb :From a patient care perspective, or systemically, one at a time?
Chris Dy :Pick one and we'll have Sam do the other
Sam Moghtaderi :I think before you answer, I think that's a great point, right there is that there are advantages in several domains.
Charles Goldfarb :Why don't I talk systemically, because you guys do more of this than I do. It's a small part of my practice, definitely less than 5% driven by you know, patient desire, primarily, although it's offered to a lot of patients. So systemically, the advantages are pretty clear. And you guys may be able to add to my list, but number one would be cost to society and cost to the system. Number two, I would say, you know, probably in general safety, I think it's a greener approach. meaning less wasted equipment, less non recyclable materials, less cost to sterilization, more efficient type practices. It systematically I guess I would say it has the potential to be a win- win financially for the surgeon and for the insurance company. It does take out one player which would be the hospital so I guess they would not see it as a win. So, yeah, those are the ones that immediately popped to mind, certainly transferable meaning if you're in a, in a different situation, if you're traveling for mission work, is more easily implemented there. If you're familiar, those are, those are my top ones. I'm again I'm sure you guys can add to that list systemically.
Chris Dy :Sam, do you have any thoughts about systems advantages for WALANT? I think Chuck it a lot of them but
Sam Moghtaderi :Yeah, I think the system advantages are sort of obvious when you think of them that way. What I find surprising is that those system advantages don't automatically, like pave the way for you. Right? You just said it was practically impossible in some cases, even though you can make such a greatsuch a great case for it. And I don't think the patient advantages should be discounted at all. And and that's not obvious to patients. Patients, you know, it really depends on how you present it to patients. But the patients that have undergone it, I would certainly say I will tell you that they were very happy with with how it went. And I kind of use that strategy. You know, I one of my anecdotes is a number of years ago, I was at the Hand Society meeting and I was talking to one of my co fellows and this was about a year into me really doing a lot of WALANT and we were chatting over dinner and he said you know I that just hasn't taken off in my practice. I tried to offer it to my patients. Maybe you know, you live in DC and people are fancy. But, you know, here in the Midwest, I tell my patients I say, you know, I could do it without anesthesia, or I could like sedate you and you know, it's your choice. And I said, well, of course, if you're presenting it to your patients as I could do this without anesthesia or not, they're not going to pick that.
Chris Dy :I think that's so interesting, because I actually, when I started doing it, I had the same kind of issues. But then I said, Okay, this is how I do my carpal tunnel. And then if they start to cringe when I talk to them about being under local and awake, then you know, I give them the other options. But, you know, I know that there are some people that say, I only do it this way, and if you want to do some work, they in a different way. Go somewhere else.
Sam Moghtaderi :Yeah, I don't I don't hold patients to that line. But I would say the last time I did a carpal tunnel or the like with sedation was probably two years ago. So I do about about once a year, but I tried to be pretty firm and not not to force the patients, but to win them over. So the way the conversation goes, usually, there's no particular conversation, they asked me- so how does this work? And I say, Well, I know I'm up your hand and stuff like that. Sometimes the patient comes in from one side or the other. So Oh, do I have to go to sleep for this? And I say, Oh, no, that would be overkill. This is a little surgery, right? You just come in, I numb up your hand. And then I start listing that you don't have to eat, you can have a breakfast, you can take yourself home, you don't have any testing, etc. And when presented that way, when I presented as 'it would be overkill to do it any other way' that essentially frames the conversation the way I want it to be. But of course, I have patients on a very regular basis. Well, I'm not sure about this. Can you just give me something, can you give me something. And to those patients, it takes a lot of handholding. It takes a lot of coaching them through and that's a big part of this. If you're not ready to do a lot of talking to your patients. And a lot of psychological and holding, you're not going to be able to make this a big part of your practice, it's not just going to walk in and change how you do things. So I say you know, and ultimately I sometimes just have to have them take my word, and that really is the doctor patient relationship that I've tried to build with them even if it's only been for a visit or two. I had a patient just in the last couple of weeks who was doing a nerve repair on digital nerve repair- for you, Chris. And she was a you know, young, smart person, but she was really nervous. She was really, really nervous about this and I just said, look, we've had one visit together, you seem to trust my counseling to you on this. I'm gonna ask you to just totally trust me that I can get you through this without discomfort. And that a lot of her case actually interestingly and in a lot of other patients, patients are already scarred by the experience of local anesthesia that they had in the ER for the injury that they're seeing me for. Right? Like this patient is now a little bit post op, and I've seen her on subsequent visit and the most pain she experienced in her whole episode for this injury was the local anesthetic that she got for the stitches in the ER. Right. So you have a little bit of an uphill battle, but how you present it can normalize it and calm it and the staff too. We can talk about the staff. If they see this as a normal thing that helps the patient as well, as opposed to the staff thinking you're doing something crazy. That relation, the patient consents that?
Charles Goldfarb :Yeah, so definitely true. So go back to the handholding for those who are skeptical, and I wouldn't include myself in that group, even though I don't do a ton of this. But for those who are skeptical, talk about the hand holding because I do think that physicians sometimes see that as not a win but potentially as a challenge with this. So in the office, you have to potentially work a little harder for some patients to convince them this is the right approach for them. And then inter operatively. Sometimes there's more hand holding. And it's just a different flow. So, do you enjoy the inter operative relationship you develop with a patient? Or is that a neutral? Or how do you how do you think about that?
Sam Moghtaderi :I think I think those are two subtly different questions. And so I'm going to divide your question. The part in the office that I told you about is really confined to what I just said. Like that's not a hard part. It's just knowing that I have to present it from the angle of this being normal, as opposed to not and I rarely have issue with that. But when the patient is nervous, that takes more work on my part, and would it be nicer if I didn't have to do that? Yes. Right. Certainly from my flow standpoint, as a surgeon, even with normal patients who aren't having trouble with it, it's a much more hands on day to do three or four, let's say carpels and triggers in a row that are all local. I mean, I have zero downtime. And we could talk about the flow of that. Then if I was doing Mac, I just step away and wait for the next patient to get their IV kind of a thing. So yes, that part is a little bit more work, but the patient relationship and the interaction with the patient, I would say, overall is a positive. The fact that I can talk to the patient during the entire case. And the truth is, I don't usually right, most of the patients just tune me out, and I chat or chat with the resident and I tell them at the beginning, you know, you'll hear me and Dr. So and So talking. Not all it's about you, like we'll discuss other topics that come up. So don't get worried by anything. There are certain things that are routinely say to the patient like that, but I have developed a sort of internal script for that our staff is tired of hearing me say the exact same script every time but that's part of it that we all deal with. And at It's really great to be able to explain things to patients. Explain my post op regimen very slowly and carefully and have them tell it back to me all while I'm doing the surgery or while I'm closing up, My favorite sort of aha moment is right at the end of the release or what have you. Before we stitch up, I tell them you know, your surgeries done, basically. And inevitably, and the more nervous a patient is, the more satisfying that moment is when they're like, that's it? That was easy. I'm glad you did it this way.
Chris Dy :One of my favorites is the big reveal after the trigger finger, showing them the fingers not catching any more- they love that. To speak to a couple of your points. I mean, I one of you know, when I have a nurse at, you know, up with the patient, which you know, our setup is that we still have to have a nurse monitoring things. And I love it when there's a very chatty nurse up there because that can make the most nervous patient at ease, and then frees me up not to be the surgeon and the performer at the same time. And you mentioned you know, not having downtime between cases. I mean, you have to be on the whole time because you're either doing the surgery, or you're blocking the next patient when you have, you know, series of back to back to backs. And during the block, you also have to be, you know, calming and, you know, talking to the patient distracting them from what's going on.
Sam Moghtaderi :Yes, definitely the case.
Charles Goldfarb :Yeah, so let's, why don't we talk through how we can I will be the moderator here, because you guys do more of this than I. Why don't we talk through kind of your practice settings. So where are you doing these cases and your flow? You know, enough detail that the listeners get the idea without overdoing it. And then Chris I'll ask you the same question, and then we can talk about the differences in your setups because I'm sure there are some. So Sam, give us a quick rundown.
Unknown Speaker :Sure, and my setup isn't the setup I would design from scratch, but I work in a university hospital setting. I'm You know, full time faculty at the University Hospital. So I do all of my elective surgery at the hospitals ambulatory surgery center. So it's on paper, a part of the hospitals OR system, but it's a different building two blocks from the hospital. That has been helpful because it's a smaller staff that has less turnover and so easier to build things like this. I don't have any procedure room or anything in our office to do it. There's also no little procedure room in the ambulatory surgery center. So I use up a full OR when I do this, which is a systems based thing we can talk about, and demonstrates that it's not all or nothing you don't like do it all, you know, the Don Lalande way, or, you know, put the patient's asleep. And I try to so it's part of my regular OR day. The way I try to set up my cases, that the cases that can be done that are little predictable cases or that can be done awake. I do them in a row at the beginning so that the anesthesiologist joins my room later in the day, or I stagger them in between bigger cases that require regional bloc administration by the anesthesia. In our ambulatory surgery center. The same anesthesiologist does the block pre op that does the case. In our main hospital, we have a separate block team that will block the the patients but we don't have that so I take advantage of that. And I will you know, if I'm doing two distal radius fractures, I can put up a carpal tunnel in between and while the anesthesia team is blocking my second distal radius, I can do my carpal tunnel case and quick turnover. When I do a bunch in a row, I will block my first two patients. So I will block the first patient block the second patient, then operate on the first patient and block the third patient and so then I get into a flow or I'm always blocking one patient ahead
Charles Goldfarb :And you're blocking in the preoperative area, not in the operating room,
Sam Moghtaderi :Correct? Correct. That's kind of key. If I had to do it in the operating room, the system will not give you any advantages, at least efficiency- wise
Charles Goldfarb :Slowing you down too much.
Sam Moghtaderi :Well, I do want to let the epinephrine work for 20 minutes or so at least between doing the block and cutting the skin. So yes,
Charles Goldfarb :Do you or is your local anesthetic assigned to a patient? So is there or is it like owned by the surg by the surgery center? You know what I mean? So if you're gonna go see Miss Jones and block her for carpal tunnel, do you have to get you know lidocaine with epinephrine for Mrs. Jones? Yes,
Sam Moghtaderi :Yes. And it's not a big problem because we get you know, my Lidocaine comes in like a 30 cc vial and I like for carpal tunnel, my use 17 cc of it. Well, the flow that I've developed and this is part of the staff mind and like when I came to my new job, and I presented this is the new way, everyone bought in- althought at first there was a little, you know, head turns, but then they're like, Oh, cool. My pre op nurses actually have a little kit that they put in the pyxis for me, which is just, you know, a basin and the lidocaine and the bicarb. So at the beginning of the day, I'll put orders in the computer for all my patients that are getting it so they don't have to hassle me about that- the orders better when they're ready for it. And they'll just put a little thing on the right next to the consent form at the bedside table.
Charles Goldfarb :That's awesome. Chris, what is your setup look like?
Chris Dy :So you know, I'm not that dissimilar. It's a hospital owned, or academic ambulatory surgery center. We don't have a procedure room, I still do these in OR, I block the patients in holding. And yes, we have to order individual, you know, vials of lidocaine with epinephrine for each patient. That's done ahead of time and the flow has worked out where that's basically like Sam's sitting next to the consent when I go off to block. You know, I think the biggest thing for me is making sure that I get the block done in time. And that can be tricky when you're staggering cases. You know, it kind of depends on what's going on in the OR the same day. If I have one room, I will typically put them all at the end of the day. Unlike Sam's situation, I think that's very much an anesthesia preference on our end, because they want to have the anesthesiology either the anesthesiologist or the CRNAa staffed in the morning and then sending them home. So and also, you know, obviously, the patients that are coming in for wide awake surgery don't have to fast, so they're not sitting there hungry. So that's a practical consideration. I'd rather get my patients who are NPO done first. The block itself, you know, done in holding after we do a brief timeout. And I don't use as much as you do for carpal tunnel, Sam. You know, one of the things that I actually wanted to ask you about was, you know, how much do you do- what field do you block for your carpal tunnels and your triggers. You know, I know the way that it's described by Dom Lalonde is to do a formal carpal tunnel block, you know, in the carpal tunnel. And I found that to be an uncomfortable step for patients. So I've actually bypassed that, and it hasn't been an issue for me.
Sam Moghtaderi :I was gonna say my initial response was I do everything exactly as he teaches it. But then when you got to that last point, I had to pause because I didn't realize that that's what- he that's what he does, and I definitely do not do that. And in fact, I counsel my residents against doing that.
Charles Goldfarb :Yeah, be clear. Tell us exactly what you do, because I'm not sure 100% follow.
Sam Moghtaderi :Yeah, the part that I was referring to was blocking the carpal tunnel itself. So I start kind of like Dr. Lalonde, does about probably two or three centimeters proximal to the wrist crease. I do a very superficial puncture with my needle, just get through the dermis and just infiltrate. Basically, I go in as little I can and I inject as little as I can. And then under the subcutaneous layer and the distal forearm, I stay there for a minute or two and I slowly give three four cc's. Once I have a nice size wheel, then I angle my needle pointing distally and I slowly walk it distally and I probably take the needle out and physically move it probably two or three times. By the time I get into the palm, I'm going a little bit faster because they're numbed up already. For a small person, sort of petite hand, I'll probably do 10 or 12 cc's. Maybe for carpal tunnel, I basically do it until I get blanching, distal to where I might even possibly do any dissection sort of sort of the mid palm, just past my incision. For for a big guy, you know, big hands, I might do 17 or 18 cc's. Like I said, I never get to 20 cc's for a carpal tunnel. So I was when I threw that number out there. That was certain on the on the high side, I don't block into the carpal tunnel, so my entire infiltration is subcutaneous. That has been totally fine unless I poke at the nerve intraoperatively, which I don't do- anyway, I try not to do. And the reason I don't do that is I don't want to be blindly putting a needle into the carpal tunnel without the patient being able to respond to me. And because I do this slow technique, and I've already halfway numbed them by the time my needle gets anywhere near the carpal tunnel, I don't want at that point in time to be putting a needle in their carpal tunnel, when they're potentially not sensitive enough to give me feedback. If I'm in the middle of surgery, occasionally, when I start cutting the ligament, that patient will, you know, tug on their arm a little and be a little uncomfortable. I just pause there and I pool like a couple of cc's of light came into the wound and I just let it sit for 10 seconds. mop it up and move on.
Charles Goldfarb :So interesting when I was a fellow, we were not doing this. But you know, the fellow would generally be in the room closing and would inject plain marcaine for post operative analgesia. And we got some feedback that we were injecting too deeply. And patients were complaining of, I guess, nerve pain after surgery, which could last a couple of weeks. And so that's when I learned not to inject the carpal tunnel. And so when I do my local- only cases, I call them, I do exactly as you described. I think that's a perfect description. I think that wheal proximal to the wrist crease, that is the most important thing for me.
Sam Moghtaderi :And as I've done more and more, I've learned to be more generous with that wheal because nobody including the surgeon really thinks about just how proximal you go in carpal tunnel, right? So it would do the whole case and it's all going great. And then at the very end, you know, for me, it's my last step when I released that distal forearm fascia and whole case has been going great. And then I do that and the patient would go 'ow'. What did you just do there? And I did that early on and then learned, you know, be very generous with that part of the anaesthetic.
Charles Goldfarb :Thanks, Sam. That was awesome. I think it's probably a good time for us to stop and we can revisit this topic next week. Does that sound reasonable, Chris?
Chris Dy :I think that sounds good. Why don't we pick back up, right where we left off.
Charles Goldfarb :All right, perfect. Sam see you soon.. Hey, Chris. That was fun.
Chris Dy :Let's do it again real soon. Sounds good. We'll be sure to check us out on Twitter at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb :Mine is at congenital hand. What about you?
Chris Dy :Mine is at ChrisDY MD spelled D-Y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb :And remember, please subscribe wherever you get your podcast
Chris Dy :and be sure to leave a review that helps us get the word out.
Charles Goldfarb :Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand and come back next time.