{"version":"1.0.0","segments":[{"speaker":"Charles Goldfarb","startTime":10.8,"endTime":13.62,"body":"Welcome to the"},{"speaker":"Charles Goldfarb","startTime":10.8,"endTime":13.62,"body":"upper hand where Chuck and Chris"},{"speaker":"Charles Goldfarb","startTime":13.62,"endTime":14.49,"body":"talk Hand Surgery."},{"speaker":"Chris Dy","startTime":14.7,"endTime":16.56,"body":"We are two hand"},{"speaker":"Chris Dy","startTime":14.7,"endTime":16.56,"body":"surgeons at Washington"},{"speaker":"Chris Dy","startTime":16.56,"endTime":19.65,"body":"University in St. Louis here to"},{"speaker":"Chris Dy","startTime":16.56,"endTime":19.65,"body":"talk about all aspects of hand"},{"speaker":"Chris Dy","startTime":19.65,"endTime":21.48,"body":"surgery from technical to"},{"speaker":"Chris Dy","startTime":19.65,"endTime":21.48,"body":"personal."},{"speaker":"Charles Goldfarb","startTime":22.05,"endTime":24.33,"body":"Thank you for"},{"speaker":"Charles Goldfarb","startTime":22.05,"endTime":24.33,"body":"subscribing. Wherever you get"},{"speaker":"Charles Goldfarb","startTime":24.33,"endTime":25.23,"body":"your podcasts."},{"speaker":"Chris Dy","startTime":25.44,"endTime":27.66,"body":"And be sure to leave a"},{"speaker":"Chris Dy","startTime":25.44,"endTime":27.66,"body":"review that helps us get the"},{"speaker":"Chris Dy","startTime":27.66,"endTime":28.14,"body":"word out."},{"speaker":"Charles Goldfarb","startTime":28.17,"endTime":29.07,"body":"All right,"},{"speaker":"Charles Goldfarb","startTime":28.17,"endTime":29.07,"body":"Chris."},{"speaker":"Chris Dy","startTime":29.43,"endTime":30.51,"body":"Hey, Chuck, how are"},{"speaker":"Chris Dy","startTime":29.43,"endTime":30.51,"body":"you?"},{"speaker":"Charles Goldfarb","startTime":30.81,"endTime":33.03,"body":"I'm good. I'm"},{"speaker":"Charles Goldfarb","startTime":30.81,"endTime":33.03,"body":"good. It's good to see on a nice"},{"speaker":"Charles Goldfarb","startTime":33.03,"endTime":33.63,"body":"Sunday morning."},{"speaker":"Chris Dy","startTime":33.93,"endTime":36.51,"body":"It's nice to see you."},{"speaker":"Chris Dy","startTime":33.93,"endTime":36.51,"body":"How's your weekend been going?"},{"speaker":"Charles Goldfarb","startTime":37.2,"endTime":40.59,"body":"Good, good to"},{"speaker":"Charles Goldfarb","startTime":37.2,"endTime":40.59,"body":"be with the family I, it's about"},{"speaker":"Charles Goldfarb","startTime":40.59,"endTime":42.66,"body":"to be a very different"},{"speaker":"Charles Goldfarb","startTime":40.59,"endTime":42.66,"body":"household. Maybe by the next"},{"speaker":"Charles Goldfarb","startTime":42.66,"endTime":46.65,"body":"time we record. I will have to"},{"speaker":"Charles Goldfarb","startTime":42.66,"endTime":46.65,"body":"in college and junior in high"},{"speaker":"Charles Goldfarb","startTime":46.65,"endTime":49.41,"body":"school and the landscape is"},{"speaker":"Charles Goldfarb","startTime":46.65,"endTime":49.41,"body":"changing."},{"speaker":"Chris Dy","startTime":50.13,"endTime":53.7,"body":"Goodness, that is"},{"speaker":"Chris Dy","startTime":50.13,"endTime":53.7,"body":"absolutely crazy. We're still,"},{"speaker":"Chris Dy","startTime":54.21,"endTime":56.43,"body":"we're still camping out in our"},{"speaker":"Chris Dy","startTime":54.21,"endTime":56.43,"body":"friend's basement. But we do"},{"speaker":"Chris Dy","startTime":56.43,"endTime":60.06,"body":"have a closing date in sight. So"},{"speaker":"Chris Dy","startTime":56.43,"endTime":60.06,"body":"we're hoping by the end of the"},{"speaker":"Chris Dy","startTime":60.06,"endTime":61.47,"body":"month, we are up and out."},{"speaker":"Charles Goldfarb","startTime":61.83,"endTime":64.08,"body":"Oh, wow."},{"speaker":"Charles Goldfarb","startTime":61.83,"endTime":64.08,"body":"Congrats. That's super exciting."},{"speaker":"Chris Dy","startTime":64.29,"endTime":66.87,"body":"It is exciting. We did"},{"speaker":"Chris Dy","startTime":64.29,"endTime":66.87,"body":"a you know, kind of walk through"},{"speaker":"Chris Dy","startTime":66.87,"endTime":69.75,"body":"the house last weekend. It looks"},{"speaker":"Chris Dy","startTime":66.87,"endTime":69.75,"body":"amazing. We're very excited"},{"speaker":"Chris Dy","startTime":69.75,"endTime":72.09,"body":"about it. But certainly it's"},{"speaker":"Chris Dy","startTime":69.75,"endTime":72.09,"body":"come with a fair bit of stress"},{"speaker":"Chris Dy","startTime":72.09,"endTime":75.72,"body":"to get there. So very exciting."},{"speaker":"Chris Dy","startTime":72.09,"endTime":75.72,"body":"Very exciting. So hopefully,"},{"speaker":"Chris Dy","startTime":76.02,"endTime":78.66,"body":"next time we record will be"},{"speaker":"Chris Dy","startTime":76.02,"endTime":78.66,"body":"closer to the end."},{"speaker":"Charles Goldfarb","startTime":79.17,"endTime":82.11,"body":"Well, if if"},{"speaker":"Charles Goldfarb","startTime":79.17,"endTime":82.11,"body":"you need any help on moving day."},{"speaker":"Charles Goldfarb","startTime":82.77,"endTime":84.93,"body":"I'm happy to call Dr. Boyer for"},{"speaker":"Charles Goldfarb","startTime":82.77,"endTime":84.93,"body":"you."},{"speaker":"Chris Dy","startTime":86.25,"endTime":88.26,"body":"I thought you're about"},{"speaker":"Chris Dy","startTime":86.25,"endTime":88.26,"body":"to assign a medical student or"},{"speaker":"Chris Dy","startTime":88.26,"endTime":90.84,"body":"resident to me."},{"speaker":"Charles Goldfarb","startTime":90.84,"endTime":92.94,"body":"Now I am more"},{"speaker":"Charles Goldfarb","startTime":90.84,"endTime":92.94,"body":"than happy to lend the hand. I"},{"speaker":"Charles Goldfarb","startTime":92.94,"endTime":93.36,"body":"really am."},{"speaker":"Chris Dy","startTime":93.87,"endTime":97.26,"body":"I appreciate it. Thank"},{"speaker":"Chris Dy","startTime":93.87,"endTime":97.26,"body":"you. I may just be parking my"},{"speaker":"Chris Dy","startTime":97.26,"endTime":98.04,"body":"kids at your pool."},{"speaker":"Charles Goldfarb","startTime":99.3,"endTime":100.53,"body":"That's an"},{"speaker":"Charles Goldfarb","startTime":99.3,"endTime":100.53,"body":"option too."},{"speaker":"Chris Dy","startTime":101.67,"endTime":104.31,"body":"So, a couple of great"},{"speaker":"Chris Dy","startTime":101.67,"endTime":104.31,"body":"reviews I want to share one"},{"speaker":"Chris Dy","startTime":104.31,"endTime":107.82,"body":"actually has a question. So this"},{"speaker":"Chris Dy","startTime":104.31,"endTime":107.82,"body":"would be really useful for us to"},{"speaker":"Chris Dy","startTime":107.82,"endTime":113.16,"body":"address. So this is from either"},{"speaker":"Chris Dy","startTime":107.82,"endTime":113.16,"body":"Matt Rode or Matt Rod-e. I"},{"speaker":"Chris Dy","startTime":113.16,"endTime":116.94,"body":"can't. I'm not sure how to"},{"speaker":"Chris Dy","startTime":113.16,"endTime":116.94,"body":"pronounce exactly but five star"},{"speaker":"Chris Dy","startTime":116.94,"endTime":121.83,"body":"review. subject is a fountain of"},{"speaker":"Chris Dy","startTime":116.94,"endTime":121.83,"body":"information. It says Hi, my name"},{"speaker":"Chris Dy","startTime":121.83,"endTime":124.44,"body":"is Matt. I'm a second year"},{"speaker":"Chris Dy","startTime":121.83,"endTime":124.44,"body":"medical student at Mayo Clinic."},{"speaker":"Chris Dy","startTime":124.47,"endTime":127.68,"body":"I've heard of that place. And"},{"speaker":"Chris Dy","startTime":124.47,"endTime":127.68,"body":"hopefully a future orthopedic"},{"speaker":"Chris Dy","startTime":127.68,"endTime":130.95,"body":"hand surgeon. You've got plenty"},{"speaker":"Chris Dy","startTime":127.68,"endTime":130.95,"body":"of excellent model role models"},{"speaker":"Chris Dy","startTime":130.95,"endTime":135.21,"body":"up there at Mayo for you to to"},{"speaker":"Chris Dy","startTime":130.95,"endTime":135.21,"body":"work with. The podcasts are so"},{"speaker":"Chris Dy","startTime":135.21,"endTime":137.76,"body":"full of great information, I"},{"speaker":"Chris Dy","startTime":135.21,"endTime":137.76,"body":"have to pause to make notes or"},{"speaker":"Chris Dy","startTime":137.76,"endTime":142.08,"body":"flashcards. That is a first and"},{"speaker":"Chris Dy","startTime":137.76,"endTime":142.08,"body":"that is awesome. Keep it up. I"},{"speaker":"Chris Dy","startTime":142.08,"endTime":143.94,"body":"was wondering if you could"},{"speaker":"Chris Dy","startTime":142.08,"endTime":143.94,"body":"discuss your differential"},{"speaker":"Chris Dy","startTime":143.94,"endTime":146.82,"body":"diagnosis for a patient with"},{"speaker":"Chris Dy","startTime":143.94,"endTime":146.82,"body":"catching slash snapping of"},{"speaker":"Chris Dy","startTime":146.82,"endTime":149.46,"body":"fingers. And do you have any"},{"speaker":"Chris Dy","startTime":146.82,"endTime":149.46,"body":"pearls for differentiating a"},{"speaker":"Chris Dy","startTime":149.46,"endTime":153.06,"body":"trigger finger from a sagittal"},{"speaker":"Chris Dy","startTime":149.46,"endTime":153.06,"body":"band rupture? Sincerely, Matt."},{"speaker":"Chris Dy","startTime":153.42,"endTime":156.9,"body":"So first off, Matt, thank you"},{"speaker":"Chris Dy","startTime":153.42,"endTime":156.9,"body":"for that awesome review. It's"},{"speaker":"Chris Dy","startTime":156.93,"endTime":159.75,"body":"it's amazing to hear that you're"},{"speaker":"Chris Dy","startTime":156.93,"endTime":159.75,"body":"making flashcards from it. That"},{"speaker":"Chris Dy","startTime":159.75,"endTime":165.3,"body":"is fantastic and definitely"},{"speaker":"Chris Dy","startTime":159.75,"endTime":165.3,"body":"invigorating for us. Chuck, do"},{"speaker":"Chris Dy","startTime":165.3,"endTime":166.83,"body":"you have any thoughts about the"},{"speaker":"Chris Dy","startTime":165.3,"endTime":166.83,"body":"question?"},{"speaker":"Charles Goldfarb","startTime":167.53,"endTime":171.67,"body":"Well, it's a"},{"speaker":"Charles Goldfarb","startTime":167.53,"endTime":171.67,"body":"good question. Because we and I"},{"speaker":"Charles Goldfarb","startTime":171.67,"endTime":173.98,"body":"would I would think all hands"},{"speaker":"Charles Goldfarb","startTime":171.67,"endTime":173.98,"body":"surgeons have the potential to"},{"speaker":"Charles Goldfarb","startTime":173.98,"endTime":178.33,"body":"fall into this trap. can get"},{"speaker":"Charles Goldfarb","startTime":173.98,"endTime":178.33,"body":"lulled into this sense of"},{"speaker":"Charles Goldfarb","startTime":178.36,"endTime":182.47,"body":"everything that pops is trigger"},{"speaker":"Charles Goldfarb","startTime":178.36,"endTime":182.47,"body":"finger. And we know one thing"},{"speaker":"Charles Goldfarb","startTime":182.47,"endTime":187.63,"body":"and this is one of Dr. Boyer's"},{"speaker":"Charles Goldfarb","startTime":182.47,"endTime":187.63,"body":"teaching points is that, you"},{"speaker":"Charles Goldfarb","startTime":187.63,"endTime":191.74,"body":"know, hand pain is often trigger"},{"speaker":"Charles Goldfarb","startTime":187.63,"endTime":191.74,"body":"finger even when you don't think"},{"speaker":"Charles Goldfarb","startTime":191.74,"endTime":194.59,"body":"it is mean that vague pain and"},{"speaker":"Charles Goldfarb","startTime":191.74,"endTime":194.59,"body":"you try to push on the A1"},{"speaker":"Charles Goldfarb","startTime":194.59,"endTime":197.59,"body":"pulley, it's obviously a"},{"speaker":"Charles Goldfarb","startTime":194.59,"endTime":197.59,"body":"different category. So trigger"},{"speaker":"Charles Goldfarb","startTime":197.59,"endTime":200.89,"body":"finger can be more than we think"},{"speaker":"Charles Goldfarb","startTime":197.59,"endTime":200.89,"body":"it is. But when we hear catching"},{"speaker":"Charles Goldfarb","startTime":200.95,"endTime":204.82,"body":"the finger or popping the"},{"speaker":"Charles Goldfarb","startTime":200.95,"endTime":204.82,"body":"finger, all of us immediately"},{"speaker":"Charles Goldfarb","startTime":204.82,"endTime":207.01,"body":"think of trigger finger. True?"},{"speaker":"Chris Dy","startTime":208.06,"endTime":212.14,"body":"Yeah. It's, you know,"},{"speaker":"Chris Dy","startTime":208.06,"endTime":212.14,"body":"the rule, the MIB rule of hand"},{"speaker":"Chris Dy","startTime":212.14,"endTime":214.45,"body":"surgery is it's always a trigger"},{"speaker":"Chris Dy","startTime":212.14,"endTime":214.45,"body":"finger."},{"speaker":"Charles Goldfarb","startTime":215.59,"endTime":216.34,"body":"And that's"},{"speaker":"Charles Goldfarb","startTime":215.59,"endTime":216.34,"body":"what happens."},{"speaker":"Chris Dy","startTime":216.34,"endTime":219.01,"body":"But then I think that"},{"speaker":"Chris Dy","startTime":216.34,"endTime":219.01,"body":"I think I think the asterisk is"},{"speaker":"Chris Dy","startTime":219.31,"endTime":221.14,"body":"not everything that pops is a"},{"speaker":"Chris Dy","startTime":219.31,"endTime":221.14,"body":"trigger finger."},{"speaker":"Charles Goldfarb","startTime":222.56,"endTime":224.48,"body":"I think that's"},{"speaker":"Charles Goldfarb","startTime":222.56,"endTime":224.48,"body":"right, and not all of us have"},{"speaker":"Charles Goldfarb","startTime":224.48,"endTime":229.01,"body":"that population that he has. Um,"},{"speaker":"Charles Goldfarb","startTime":224.48,"endTime":229.01,"body":"so I think of a couple of"},{"speaker":"Charles Goldfarb","startTime":229.01,"endTime":233.12,"body":"different things. First of all,"},{"speaker":"Charles Goldfarb","startTime":229.01,"endTime":233.12,"body":"I always palpate the A1 pulley"},{"speaker":"Charles Goldfarb","startTime":233.39,"endTime":237.56,"body":"and ask the patient to"},{"speaker":"Charles Goldfarb","startTime":233.39,"endTime":237.56,"body":"demonstrate their triggering A,"},{"speaker":"Charles Goldfarb","startTime":237.56,"endTime":241.58,"body":"the palpation may be painful,"},{"speaker":"Charles Goldfarb","startTime":237.56,"endTime":241.58,"body":"and B, obviously feeling the"},{"speaker":"Charles Goldfarb","startTime":241.58,"endTime":245.66,"body":"trigger can be 100% diagnostic."},{"speaker":"Charles Goldfarb","startTime":241.58,"endTime":245.66,"body":"And then I do think about"},{"speaker":"Charles Goldfarb","startTime":245.66,"endTime":248.51,"body":"sagittal band ruptures,"},{"speaker":"Charles Goldfarb","startTime":245.66,"endTime":248.51,"body":"especially with a weird"},{"speaker":"Charles Goldfarb","startTime":248.51,"endTime":252.35,"body":"mechanism born acute onset. And"},{"speaker":"Charles Goldfarb","startTime":248.51,"endTime":252.35,"body":"I think it's a matter for me,"},{"speaker":"Charles Goldfarb","startTime":252.35,"endTime":254.75,"body":"and I'd love to hear your"},{"speaker":"Charles Goldfarb","startTime":252.35,"endTime":254.75,"body":"thoughts as well. It's a matter"},{"speaker":"Charles Goldfarb","startTime":254.78,"endTime":261.68,"body":"of turning the hand over, asking"},{"speaker":"Charles Goldfarb","startTime":254.78,"endTime":261.68,"body":"the patient to make a fist and"},{"speaker":"Charles Goldfarb","startTime":261.71,"endTime":266.3,"body":"watching that extensor mechanism"},{"speaker":"Charles Goldfarb","startTime":261.71,"endTime":266.3,"body":"palpating the extensor mechanism"},{"speaker":"Charles Goldfarb","startTime":266.42,"endTime":269.72,"body":"palpating for pain typically"},{"speaker":"Charles Goldfarb","startTime":266.42,"endTime":269.72,"body":"over the radial sagittal band"},{"speaker":"Charles Goldfarb","startTime":269.72,"endTime":273.62,"body":"and typically the middle finger."},{"speaker":"Charles Goldfarb","startTime":269.72,"endTime":273.62,"body":"That was a classic article by"},{"speaker":"Charles Goldfarb","startTime":273.62,"endTime":276.05,"body":"Kettlekamp that taught us that"},{"speaker":"Charles Goldfarb","startTime":273.62,"endTime":276.05,"body":"is almost always the middle"},{"speaker":"Charles Goldfarb","startTime":276.05,"endTime":278.27,"body":"finger and it's almost always"},{"speaker":"Charles Goldfarb","startTime":276.05,"endTime":278.27,"body":"the radial sagittal band is"},{"speaker":"Charles Goldfarb","startTime":278.27,"endTime":282.68,"body":"ruptured. And then lastly, check"},{"speaker":"Charles Goldfarb","startTime":278.27,"endTime":282.68,"body":"and see if they can actively"},{"speaker":"Charles Goldfarb","startTime":282.68,"endTime":286.01,"body":"extend the finger, which again"},{"speaker":"Charles Goldfarb","startTime":282.68,"endTime":286.01,"body":"doesn't really differentiate it."},{"speaker":"Charles Goldfarb","startTime":287.0,"endTime":290.39,"body":"But passive extension is"},{"speaker":"Charles Goldfarb","startTime":287.0,"endTime":290.39,"body":"different, right? You can"},{"speaker":"Charles Goldfarb","startTime":290.39,"endTime":293.81,"body":"passively extend a ruptured"},{"speaker":"Charles Goldfarb","startTime":290.39,"endTime":293.81,"body":"sagittal band, you can't"},{"speaker":"Charles Goldfarb","startTime":293.81,"endTime":299.42,"body":"passively extend without a pop."},{"speaker":"Charles Goldfarb","startTime":293.81,"endTime":299.42,"body":"A lock trigger finger. So those"},{"speaker":"Charles Goldfarb","startTime":299.42,"endTime":300.86,"body":"are my Brief thoughts."},{"speaker":"Chris Dy","startTime":302.67,"endTime":307.68,"body":"Yeah, I think that the"},{"speaker":"Chris Dy","startTime":302.67,"endTime":307.68,"body":"the nature of the snapping"},{"speaker":"Chris Dy","startTime":307.71,"endTime":311.52,"body":"catching is different. And you"},{"speaker":"Chris Dy","startTime":307.71,"endTime":311.52,"body":"won't appreciate that unless you"},{"speaker":"Chris Dy","startTime":311.52,"endTime":313.29,"body":"turn the hand over. So you're"},{"speaker":"Chris Dy","startTime":311.52,"endTime":313.29,"body":"saying turn the hand over,"},{"speaker":"Chris Dy","startTime":313.29,"endTime":316.71,"body":"meaning inspect the dorsum, as"},{"speaker":"Chris Dy","startTime":313.29,"endTime":316.71,"body":"opposed so we're used to, you"},{"speaker":"Chris Dy","startTime":316.71,"endTime":321.42,"body":"know, inspecting patients,"},{"speaker":"Chris Dy","startTime":316.71,"endTime":321.42,"body":"Palmar volar surfaces? I think,"},{"speaker":"Chris Dy","startTime":321.42,"endTime":325.5,"body":"Matt, you're ahead of a lot of"},{"speaker":"Chris Dy","startTime":321.42,"endTime":325.5,"body":"people just because you're"},{"speaker":"Chris Dy","startTime":325.5,"endTime":329.67,"body":"recognizing the fact that this"},{"speaker":"Chris Dy","startTime":325.5,"endTime":329.67,"body":"could happen. And, you know, one"},{"speaker":"Chris Dy","startTime":329.67,"endTime":333.99,"body":"of the, one of the pearls that I"},{"speaker":"Chris Dy","startTime":329.67,"endTime":333.99,"body":"heard in residency a lot is that"},{"speaker":"Chris Dy","startTime":333.99,"endTime":338.31,"body":"the, the eye does not see what"},{"speaker":"Chris Dy","startTime":333.99,"endTime":338.31,"body":"the mind does not know. So, you"},{"speaker":"Chris Dy","startTime":338.31,"endTime":341.34,"body":"know, I think it's fantastic"},{"speaker":"Chris Dy","startTime":338.31,"endTime":341.34,"body":"that you're, you know, able to,"},{"speaker":"Chris Dy","startTime":341.43,"endTime":344.1,"body":"you know, recognize that this"},{"speaker":"Chris Dy","startTime":341.43,"endTime":344.1,"body":"entity exists. I agree with what"},{"speaker":"Chris Dy","startTime":344.1,"endTime":347.55,"body":"Chuck said, in terms of, you"},{"speaker":"Chris Dy","startTime":344.1,"endTime":347.55,"body":"know, the a typical trigger"},{"speaker":"Chris Dy","startTime":347.55,"endTime":351.18,"body":"finger. You know, I think that"},{"speaker":"Chris Dy","startTime":347.55,"endTime":351.18,"body":"it's the pain kind of going"},{"speaker":"Chris Dy","startTime":351.27,"endTime":354.33,"body":"shooting, we're not shooting but"},{"speaker":"Chris Dy","startTime":351.27,"endTime":354.33,"body":"you know, referred maybe to the"},{"speaker":"Chris Dy","startTime":354.33,"endTime":357.84,"body":"PIP joint. But then when you"},{"speaker":"Chris Dy","startTime":354.33,"endTime":357.84,"body":"palpate the PIP joint, there's"},{"speaker":"Chris Dy","startTime":357.84,"endTime":361.95,"body":"no actual effusion or tenderness"},{"speaker":"Chris Dy","startTime":357.84,"endTime":361.95,"body":"at the joint itself. And I've"},{"speaker":"Chris Dy","startTime":361.95,"endTime":366.3,"body":"seen that in kind of the, quote,"},{"speaker":"Chris Dy","startTime":361.95,"endTime":366.3,"body":"early stages of triggering and I"},{"speaker":"Chris Dy","startTime":366.3,"endTime":370.23,"body":"think that's described as kind"},{"speaker":"Chris Dy","startTime":366.3,"endTime":370.23,"body":"of the maybe phase one or stage"},{"speaker":"Chris Dy","startTime":370.23,"endTime":373.65,"body":"one of that condition or pre"},{"speaker":"Chris Dy","startTime":370.23,"endTime":373.65,"body":"stage one. Before there's any"},{"speaker":"Chris Dy","startTime":373.65,"endTime":374.49,"body":"frank triggering."},{"speaker":"Charles Goldfarb","startTime":374.99,"endTime":377.6,"body":"Yeah, I love"},{"speaker":"Charles Goldfarb","startTime":374.99,"endTime":377.6,"body":"that. The other comment I will"},{"speaker":"Charles Goldfarb","startTime":377.6,"endTime":381.86,"body":"make is that the other trap that"},{"speaker":"Charles Goldfarb","startTime":377.6,"endTime":381.86,"body":"I should just not speak for all"},{"speaker":"Charles Goldfarb","startTime":381.86,"endTime":384.95,"body":"hand surgeons I'll just speak"},{"speaker":"Charles Goldfarb","startTime":381.86,"endTime":384.95,"body":"for myself is that when I see a"},{"speaker":"Charles Goldfarb","startTime":384.95,"endTime":390.83,"body":"patient, and I make a diagnosis,"},{"speaker":"Charles Goldfarb","startTime":384.95,"endTime":390.83,"body":"it does set me up for future"},{"speaker":"Charles Goldfarb","startTime":390.83,"endTime":393.89,"body":"problems. And what I mean by"},{"speaker":"Charles Goldfarb","startTime":390.83,"endTime":393.89,"body":"that if I see a patient, and I"},{"speaker":"Charles Goldfarb","startTime":393.89,"endTime":396.95,"body":"call it trigger finger, while"},{"speaker":"Charles Goldfarb","startTime":393.89,"endTime":396.95,"body":"before the resident or fellow"},{"speaker":"Charles Goldfarb","startTime":396.95,"endTime":399.98,"body":"goes in the room, then next time"},{"speaker":"Charles Goldfarb","startTime":396.95,"endTime":399.98,"body":"the patient comes back, they're"},{"speaker":"Charles Goldfarb","startTime":399.98,"endTime":403.22,"body":"going in with the mindset of"},{"speaker":"Charles Goldfarb","startTime":399.98,"endTime":403.22,"body":"trigger finger. Before I go back"},{"speaker":"Charles Goldfarb","startTime":403.22,"endTime":405.86,"body":"in the room on that second"},{"speaker":"Charles Goldfarb","startTime":403.22,"endTime":405.86,"body":"visit, I'm thinking trigger"},{"speaker":"Charles Goldfarb","startTime":405.86,"endTime":409.01,"body":"finger. And so if I miss"},{"speaker":"Charles Goldfarb","startTime":405.86,"endTime":409.01,"body":"diagnose the patient the first"},{"speaker":"Charles Goldfarb","startTime":409.01,"endTime":412.16,"body":"time, I definitely know it"},{"speaker":"Charles Goldfarb","startTime":409.01,"endTime":412.16,"body":"increases the chances of"},{"speaker":"Charles Goldfarb","startTime":412.16,"endTime":415.31,"body":"continuing that misdiagnosis"},{"speaker":"Charles Goldfarb","startTime":412.16,"endTime":415.31,"body":"moving forward. And where that's"},{"speaker":"Charles Goldfarb","startTime":415.31,"endTime":419.9,"body":"important here is what the"},{"speaker":"Charles Goldfarb","startTime":415.31,"endTime":419.9,"body":"failed corticosteroid injection."},{"speaker":"Charles Goldfarb","startTime":419.9,"endTime":425.06,"body":"So if I miss diagnose a trigger"},{"speaker":"Charles Goldfarb","startTime":419.9,"endTime":425.06,"body":"finger, and give the patient a"},{"speaker":"Charles Goldfarb","startTime":425.06,"endTime":427.94,"body":"steroid injection, and the"},{"speaker":"Charles Goldfarb","startTime":425.06,"endTime":427.94,"body":"patient comes back four to six"},{"speaker":"Charles Goldfarb","startTime":427.94,"endTime":433.28,"body":"weeks later and says, Doc, that"},{"speaker":"Charles Goldfarb","startTime":427.94,"endTime":433.28,"body":"did not help at all. The the"},{"speaker":"Charles Goldfarb","startTime":433.28,"endTime":436.19,"body":"compounding of the error is"},{"speaker":"Charles Goldfarb","startTime":433.28,"endTime":436.19,"body":"saying, Well, let me give you"},{"speaker":"Charles Goldfarb","startTime":436.19,"endTime":438.98,"body":"another injection, or let me"},{"speaker":"Charles Goldfarb","startTime":436.19,"endTime":438.98,"body":"take it to the operating room"},{"speaker":"Charles Goldfarb","startTime":438.98,"endTime":441.44,"body":"and fix that trigger finger. I"},{"speaker":"Charles Goldfarb","startTime":438.98,"endTime":441.44,"body":"don't know why that steroid"},{"speaker":"Charles Goldfarb","startTime":441.44,"endTime":444.89,"body":"injection doesn't work. steroid"},{"speaker":"Charles Goldfarb","startTime":441.44,"endTime":444.89,"body":"injections literally, almost"},{"speaker":"Charles Goldfarb","startTime":444.89,"endTime":449.06,"body":"always work. They just don't"},{"speaker":"Charles Goldfarb","startTime":444.89,"endTime":449.06,"body":"always last. thoughts on that?"},{"speaker":"Chris Dy","startTime":450.17,"endTime":451.7,"body":"Yeah, I actually was"},{"speaker":"Chris Dy","startTime":450.17,"endTime":451.7,"body":"thinking about that the other"},{"speaker":"Chris Dy","startTime":451.7,"endTime":454.46,"body":"day, because I had a, quote,"},{"speaker":"Chris Dy","startTime":451.7,"endTime":454.46,"body":"atypical presentation of"},{"speaker":"Chris Dy","startTime":454.46,"endTime":457.1,"body":"triggering. And I went ahead and"},{"speaker":"Chris Dy","startTime":454.46,"endTime":457.1,"body":"gave her the injection in pretty"},{"speaker":"Chris Dy","startTime":457.1,"endTime":459.08,"body":"much every time when I'm making"},{"speaker":"Chris Dy","startTime":457.1,"endTime":459.08,"body":"this small talk about the"},{"speaker":"Chris Dy","startTime":459.08,"endTime":462.86,"body":"injection, I give them the same"},{"speaker":"Chris Dy","startTime":459.08,"endTime":462.86,"body":"spiel, you know, in most people"},{"speaker":"Chris Dy","startTime":462.86,"endTime":465.8,"body":"kicks in within two or three"},{"speaker":"Chris Dy","startTime":462.86,"endTime":465.8,"body":"days, I've seen it take up to"},{"speaker":"Chris Dy","startTime":465.8,"endTime":469.19,"body":"two weeks, which I've only seen"},{"speaker":"Chris Dy","startTime":465.8,"endTime":469.19,"body":"it take that long one time. But"},{"speaker":"Chris Dy","startTime":469.19,"endTime":471.41,"body":"I do tell patients, I've seen it"},{"speaker":"Chris Dy","startTime":469.19,"endTime":471.41,"body":"take up to two weeks for it"},{"speaker":"Chris Dy","startTime":471.41,"endTime":476.54,"body":"start to work. And if it's not"},{"speaker":"Chris Dy","startTime":471.41,"endTime":476.54,"body":"working by two weeks, call, let"},{"speaker":"Chris Dy","startTime":476.54,"endTime":478.58,"body":"me know. So you can come back"},{"speaker":"Chris Dy","startTime":476.54,"endTime":478.58,"body":"and make sure that we're you"},{"speaker":"Chris Dy","startTime":478.58,"endTime":482.09,"body":"know, that we got the diagnosis,"},{"speaker":"Chris Dy","startTime":478.58,"endTime":482.09,"body":"right. So that's something that"},{"speaker":"Chris Dy","startTime":482.09,"endTime":484.67,"body":"typically comes out of my mouth"},{"speaker":"Chris Dy","startTime":482.09,"endTime":484.67,"body":"when I'm talking to patients"},{"speaker":"Chris Dy","startTime":484.67,"endTime":487.37,"body":"about an injection. And the"},{"speaker":"Chris Dy","startTime":484.67,"endTime":487.37,"body":"question I had for you is kind"},{"speaker":"Chris Dy","startTime":487.37,"endTime":490.37,"body":"of a weird one. But I mean, in"},{"speaker":"Chris Dy","startTime":487.37,"endTime":490.37,"body":"terms of when you're listing a"},{"speaker":"Chris Dy","startTime":490.37,"endTime":494.57,"body":"diagnosis in the EMR, for the"},{"speaker":"Chris Dy","startTime":490.37,"endTime":494.57,"body":"atypical presentation of"},{"speaker":"Chris Dy","startTime":494.57,"endTime":497.45,"body":"triggering, at least when I'm"},{"speaker":"Chris Dy","startTime":494.57,"endTime":497.45,"body":"dictating a note, I typically"},{"speaker":"Chris Dy","startTime":497.45,"endTime":499.52,"body":"will say, you know, a very"},{"speaker":"Chris Dy","startTime":497.45,"endTime":499.52,"body":"typical, but I think this is"},{"speaker":"Chris Dy","startTime":499.52,"endTime":503.51,"body":"triggering in the assigning a"},{"speaker":"Chris Dy","startTime":499.52,"endTime":503.51,"body":"diagnosis, do you just put"},{"speaker":"Chris Dy","startTime":503.51,"endTime":506.27,"body":"finger pain? Or do you go ahead"},{"speaker":"Chris Dy","startTime":503.51,"endTime":506.27,"body":"and commit and put trigger"},{"speaker":"Chris Dy","startTime":506.27,"endTime":506.69,"body":"finger?"},{"speaker":"Charles Goldfarb","startTime":507.65,"endTime":510.02,"body":"I commit, it's"},{"speaker":"Charles Goldfarb","startTime":507.65,"endTime":510.02,"body":"interesting, because my mind"},{"speaker":"Charles Goldfarb","startTime":510.02,"endTime":512.42,"body":"goes in a different direction. I"},{"speaker":"Charles Goldfarb","startTime":510.02,"endTime":512.42,"body":"mean, in response to your"},{"speaker":"Charles Goldfarb","startTime":512.42,"endTime":515.81,"body":"question, I commit and say"},{"speaker":"Charles Goldfarb","startTime":512.42,"endTime":515.81,"body":"trigger finger in for my"},{"speaker":"Charles Goldfarb","startTime":515.81,"endTime":521.63,"body":"diagnosis code. However, for my"},{"speaker":"Charles Goldfarb","startTime":515.81,"endTime":521.63,"body":"assessment plan, I might say"},{"speaker":"Charles Goldfarb","startTime":521.63,"endTime":524.33,"body":"trigger finger, but somewhat"},{"speaker":"Charles Goldfarb","startTime":521.63,"endTime":524.33,"body":"atypical, I would just put a"},{"speaker":"Charles Goldfarb","startTime":524.33,"endTime":528.83,"body":"little, you know, I would back"},{"speaker":"Charles Goldfarb","startTime":524.33,"endTime":528.83,"body":"off a little bit in my actual"},{"speaker":"Charles Goldfarb","startTime":528.83,"endTime":532.91,"body":"note, the flip side of that, of"},{"speaker":"Charles Goldfarb","startTime":528.83,"endTime":532.91,"body":"course, is carpal tunnel. I"},{"speaker":"Charles Goldfarb","startTime":532.91,"endTime":535.97,"body":"don't call a carpal tunnel into"},{"speaker":"Charles Goldfarb","startTime":532.91,"endTime":535.97,"body":"if I'm sending a patient for a"},{"speaker":"Charles Goldfarb","startTime":535.97,"endTime":538.07,"body":"nerve study. I don't call a"},{"speaker":"Charles Goldfarb","startTime":535.97,"endTime":538.07,"body":"carpal tunnel to have my nerve"},{"speaker":"Charles Goldfarb","startTime":538.07,"endTime":541.64,"body":"say results back. Maybe that's"},{"speaker":"Charles Goldfarb","startTime":538.07,"endTime":541.64,"body":"just I don't know, probably"},{"speaker":"Charles Goldfarb","startTime":541.64,"endTime":543.95,"body":"doesn't matter. We're probably"},{"speaker":"Charles Goldfarb","startTime":541.64,"endTime":543.95,"body":"talking about something that the"},{"speaker":"Charles Goldfarb","startTime":543.95,"endTime":546.71,"body":"audience is rolling their eyes"},{"speaker":"Charles Goldfarb","startTime":543.95,"endTime":546.71,"body":"at. But I wait a little bit on"},{"speaker":"Charles Goldfarb","startTime":546.71,"endTime":549.65,"body":"the carpal tunnel diagnosis,"},{"speaker":"Charles Goldfarb","startTime":546.71,"endTime":549.65,"body":"unless it's just crystal clear."},{"speaker":"Charles Goldfarb","startTime":549.65,"endTime":552.02,"body":"Unless I'm skipping nerve"},{"speaker":"Charles Goldfarb","startTime":549.65,"endTime":552.02,"body":"studies and planning for"},{"speaker":"Charles Goldfarb","startTime":552.02,"endTime":552.56,"body":"surgery."},{"speaker":"Chris Dy","startTime":553.23,"endTime":555.6,"body":"I guess I Yeah,"},{"speaker":"Chris Dy","startTime":553.23,"endTime":555.6,"body":"probably a little eye rolling"},{"speaker":"Chris Dy","startTime":555.6,"endTime":557.82,"body":"from some of the audience. But"},{"speaker":"Chris Dy","startTime":555.6,"endTime":557.82,"body":"there probably are some that to"},{"speaker":"Chris Dy","startTime":557.82,"endTime":561.3,"body":"care about, get you know how we"},{"speaker":"Chris Dy","startTime":557.82,"endTime":561.3,"body":"document things in the EMR,"},{"speaker":"Chris Dy","startTime":561.3,"endTime":564.18,"body":"because then if you list the"},{"speaker":"Chris Dy","startTime":561.3,"endTime":564.18,"body":"diagnosis that it becomes part"},{"speaker":"Chris Dy","startTime":564.18,"endTime":566.64,"body":"of the problem list and then it"},{"speaker":"Chris Dy","startTime":564.18,"endTime":566.64,"body":"carried into you're talking"},{"speaker":"Chris Dy","startTime":566.64,"endTime":570.15,"body":"about is compounding of issues"},{"speaker":"Chris Dy","startTime":566.64,"endTime":570.15,"body":"and perpetuating and I think"},{"speaker":"Chris Dy","startTime":570.15,"endTime":574.32,"body":"that it's probably more more of"},{"speaker":"Chris Dy","startTime":570.15,"endTime":574.32,"body":"an issue if you put it listen in"},{"speaker":"Chris Dy","startTime":574.32,"endTime":578.64,"body":"your actual billing diagnosis."},{"speaker":"Chris Dy","startTime":574.32,"endTime":578.64,"body":"But anyway, Matt, thank you for"},{"speaker":"Chris Dy","startTime":578.64,"endTime":581.43,"body":"the great question. And that"},{"speaker":"Chris Dy","startTime":578.64,"endTime":581.43,"body":"didn't think that we could talk"},{"speaker":"Chris Dy","startTime":581.43,"endTime":583.89,"body":"that long about trigger finger."},{"speaker":"Chris Dy","startTime":581.43,"endTime":583.89,"body":"I don't think we've committed an"},{"speaker":"Chris Dy","startTime":583.89,"endTime":586.02,"body":"entire episode to it, nor do I"},{"speaker":"Chris Dy","startTime":583.89,"endTime":586.02,"body":"really want to."},{"speaker":"Charles Goldfarb","startTime":587.31,"endTime":589.62,"body":"No, agreed and"},{"speaker":"Charles Goldfarb","startTime":587.31,"endTime":589.62,"body":"the last thing just in closing"},{"speaker":"Charles Goldfarb","startTime":589.62,"endTime":592.74,"body":"just to be complete, there can"},{"speaker":"Charles Goldfarb","startTime":589.62,"endTime":592.74,"body":"be intra articular pathology at"},{"speaker":"Charles Goldfarb","startTime":592.74,"endTime":596.16,"body":"that MCP joint. It's pretty"},{"speaker":"Charles Goldfarb","startTime":592.74,"endTime":596.16,"body":"rare. But you can have an intra"},{"speaker":"Charles Goldfarb","startTime":596.16,"endTime":599.01,"body":"articular reason for popping it"},{"speaker":"Charles Goldfarb","startTime":596.16,"endTime":599.01,"body":"but it's just different. It's"},{"speaker":"Charles Goldfarb","startTime":599.01,"endTime":601.89,"body":"more pain and occasional"},{"speaker":"Charles Goldfarb","startTime":599.01,"endTime":601.89,"body":"popping. But I just want to"},{"speaker":"Charles Goldfarb","startTime":601.89,"endTime":604.26,"body":"close the loop there. Awesome."},{"speaker":"Charles Goldfarb","startTime":601.89,"endTime":604.26,"body":"Thank you for the review."},{"speaker":"Chris Dy","startTime":604.68,"endTime":608.31,"body":"Yes. And please,"},{"speaker":"Chris Dy","startTime":604.68,"endTime":608.31,"body":"everybody, get on the iTunes and"},{"speaker":"Chris Dy","startTime":608.58,"endTime":611.4,"body":"leave us the only option of five"},{"speaker":"Chris Dy","startTime":608.58,"endTime":611.4,"body":"stars. And then you can ask"},{"speaker":"Chris Dy","startTime":611.4,"endTime":614.43,"body":"Chuck a question. And we'll"},{"speaker":"Chris Dy","startTime":611.4,"endTime":614.43,"body":"address it just like we did for"},{"speaker":"Chris Dy","startTime":614.43,"endTime":618.18,"body":"Matt. So thank you, Matt. We"},{"speaker":"Chris Dy","startTime":614.43,"endTime":618.18,"body":"love it. And, you know, good"},{"speaker":"Chris Dy","startTime":618.18,"endTime":620.04,"body":"luck with the rest of the"},{"speaker":"Chris Dy","startTime":618.18,"endTime":620.04,"body":"academic year. I think you're"},{"speaker":"Chris Dy","startTime":620.04,"endTime":620.91,"body":"just starting off."},{"speaker":"Charles Goldfarb","startTime":622.05,"endTime":625.38,"body":"Absolutely."},{"speaker":"Charles Goldfarb","startTime":622.05,"endTime":625.38,"body":"All right. I think today we are"},{"speaker":"Charles Goldfarb","startTime":625.38,"endTime":628.83,"body":"going to talk about a really"},{"speaker":"Charles Goldfarb","startTime":625.38,"endTime":628.83,"body":"difficult case, the segment you"},{"speaker":"Charles Goldfarb","startTime":628.83,"endTime":630.93,"body":"have entitled, my toughest case."},{"speaker":"Chris Dy","startTime":630.99,"endTime":633.27,"body":"Yeah, it's my turn."},{"speaker":"Chris Dy","startTime":630.99,"endTime":633.27,"body":"It's my turn. And this one's"},{"speaker":"Chris Dy","startTime":633.27,"endTime":638.7,"body":"funny because it's um, it's a"},{"speaker":"Chris Dy","startTime":633.27,"endTime":638.7,"body":"case that I did not see in my"},{"speaker":"Chris Dy","startTime":638.7,"endTime":642.66,"body":"fellowship training. But now"},{"speaker":"Chris Dy","startTime":638.7,"endTime":642.66,"body":"I've done a few. And I think"},{"speaker":"Chris Dy","startTime":642.66,"endTime":645.84,"body":"they're really challenging. So"},{"speaker":"Chris Dy","startTime":642.66,"endTime":645.84,"body":"this is a this particular"},{"speaker":"Chris Dy","startTime":645.84,"endTime":648.18,"body":"patient is actually somebody"},{"speaker":"Chris Dy","startTime":645.84,"endTime":648.18,"body":"who's come to see me a couple of"},{"speaker":"Chris Dy","startTime":648.18,"endTime":653.16,"body":"times, and I've operated on"},{"speaker":"Chris Dy","startTime":648.18,"endTime":653.16,"body":"twice now. And they have a"},{"speaker":"Chris Dy","startTime":653.16,"endTime":657.42,"body":"condition called diffuse"},{"speaker":"Chris Dy","startTime":653.16,"endTime":657.42,"body":"systemic scleroderma. And how,"},{"speaker":"Chris Dy","startTime":657.45,"endTime":662.76,"body":"you know, with a with Raynaud's"},{"speaker":"Chris Dy","startTime":657.45,"endTime":662.76,"body":"now, and ischemic pain, and a"},{"speaker":"Chris Dy","startTime":662.76,"endTime":667.17,"body":"definite difference in the feel,"},{"speaker":"Chris Dy","startTime":662.76,"endTime":667.17,"body":"and the turgor of the fingers,"},{"speaker":"Chris Dy","startTime":667.17,"endTime":670.8,"body":"but no, frank ulcerations as of"},{"speaker":"Chris Dy","startTime":667.17,"endTime":670.8,"body":"right now, but when they first"},{"speaker":"Chris Dy","startTime":670.8,"endTime":673.53,"body":"saw me, they did have"},{"speaker":"Chris Dy","startTime":670.8,"endTime":673.53,"body":"alterations, and they've tried"},{"speaker":"Chris Dy","startTime":673.53,"endTime":677.7,"body":"all sorts of medical management,"},{"speaker":"Chris Dy","startTime":673.53,"endTime":677.7,"body":"you name it from sildenafil to"},{"speaker":"Chris Dy","startTime":677.7,"endTime":681.48,"body":"obviously nitro paste, and"},{"speaker":"Chris Dy","startTime":677.7,"endTime":681.48,"body":"they've tried everything else."},{"speaker":"Chris Dy","startTime":682.23,"endTime":685.71,"body":"And they don't have enough"},{"speaker":"Chris Dy","startTime":682.23,"endTime":685.71,"body":"relief. How do you approach"},{"speaker":"Chris Dy","startTime":685.71,"endTime":689.13,"body":"that? scleroderma? Raynaud's"},{"speaker":"Chris Dy","startTime":685.71,"endTime":689.13,"body":"patient, Chuck, what what's your"},{"speaker":"Chris Dy","startTime":689.13,"endTime":691.77,"body":"treatment algorithm and they"},{"speaker":"Chris Dy","startTime":689.13,"endTime":691.77,"body":"admittedly get to us late in the"},{"speaker":"Chris Dy","startTime":691.77,"endTime":692.55,"body":"game. So?"},{"speaker":"Charles Goldfarb","startTime":694.65,"endTime":696.42,"body":"Well, I'll be"},{"speaker":"Charles Goldfarb","startTime":694.65,"endTime":696.42,"body":"happy, very honest about a"},{"speaker":"Charles Goldfarb","startTime":696.42,"endTime":702.93,"body":"couple things. The first is that"},{"speaker":"Charles Goldfarb","startTime":696.42,"endTime":702.93,"body":"for most Raynaud's, patients, I"},{"speaker":"Charles Goldfarb","startTime":702.93,"endTime":707.04,"body":"send them to rheumatology for"},{"speaker":"Charles Goldfarb","startTime":702.93,"endTime":707.04,"body":"treatment. with the caveat that"},{"speaker":"Charles Goldfarb","startTime":707.04,"endTime":709.65,"body":"I'm happy to see them back, you"},{"speaker":"Charles Goldfarb","startTime":707.04,"endTime":709.65,"body":"know, patients get sent to us"},{"speaker":"Charles Goldfarb","startTime":709.89,"endTime":713.25,"body":"for all kinds of non surgical"},{"speaker":"Charles Goldfarb","startTime":709.89,"endTime":713.25,"body":"reasons. And I think early in"},{"speaker":"Charles Goldfarb","startTime":713.25,"endTime":716.97,"body":"one's career, my general"},{"speaker":"Charles Goldfarb","startTime":713.25,"endTime":716.97,"body":"approach personally, and also, I"},{"speaker":"Charles Goldfarb","startTime":716.97,"endTime":720.54,"body":"think it's just reasonable is to"},{"speaker":"Charles Goldfarb","startTime":716.97,"endTime":720.54,"body":"see all comers take good care of"},{"speaker":"Charles Goldfarb","startTime":720.54,"endTime":723.27,"body":"them, understand what you can"},{"speaker":"Charles Goldfarb","startTime":720.54,"endTime":723.27,"body":"treat and what you're not the"},{"speaker":"Charles Goldfarb","startTime":723.27,"endTime":726.36,"body":"best person to treat, and build"},{"speaker":"Charles Goldfarb","startTime":723.27,"endTime":726.36,"body":"your name and your community"},{"speaker":"Charles Goldfarb","startTime":726.36,"endTime":730.5,"body":"build your reputation. At this"},{"speaker":"Charles Goldfarb","startTime":726.36,"endTime":730.5,"body":"point in our career, seeing a"},{"speaker":"Charles Goldfarb","startTime":730.5,"endTime":734.22,"body":"patient with scleroderma, or"},{"speaker":"Charles Goldfarb","startTime":730.5,"endTime":734.22,"body":"maybe with Raynaud's, I might"},{"speaker":"Charles Goldfarb","startTime":734.22,"endTime":737.97,"body":"not be the best person to see"},{"speaker":"Charles Goldfarb","startTime":734.22,"endTime":737.97,"body":"them. Now, I know where you're"},{"speaker":"Charles Goldfarb","startTime":737.97,"endTime":741.69,"body":"going with this case, I think."},{"speaker":"Charles Goldfarb","startTime":737.97,"endTime":741.69,"body":"But I would say that for like a"},{"speaker":"Charles Goldfarb","startTime":741.69,"endTime":745.44,"body":"typical Raynaud's patient who's"},{"speaker":"Charles Goldfarb","startTime":741.69,"endTime":745.44,"body":"coming in for finger color"},{"speaker":"Charles Goldfarb","startTime":745.44,"endTime":749.4,"body":"changes in pain and cold weather"},{"speaker":"Charles Goldfarb","startTime":745.44,"endTime":749.4,"body":"relatedness, I would send them"},{"speaker":"Charles Goldfarb","startTime":749.4,"endTime":753.45,"body":"to rheymatology. Now for this"},{"speaker":"Charles Goldfarb","startTime":749.4,"endTime":753.45,"body":"patient, I agree with kind of is"},{"speaker":"Charles Goldfarb","startTime":753.48,"endTime":756.3,"body":"what it sounds like you started"},{"speaker":"Charles Goldfarb","startTime":753.48,"endTime":756.3,"body":"with you started with the"},{"speaker":"Charles Goldfarb","startTime":756.3,"endTime":760.08,"body":"basics, you know, keep the"},{"speaker":"Charles Goldfarb","startTime":756.3,"endTime":760.08,"body":"fingers warm mittens on a cold"},{"speaker":"Charles Goldfarb","startTime":760.08,"endTime":764.28,"body":"day. But more importantly, try"},{"speaker":"Charles Goldfarb","startTime":760.08,"endTime":764.28,"body":"to open up the blood vessels."},{"speaker":"Charles Goldfarb","startTime":764.43,"endTime":770.73,"body":"And so use of nytro paste, and"},{"speaker":"Charles Goldfarb","startTime":764.43,"endTime":770.73,"body":"consider a systemic calcium"},{"speaker":"Charles Goldfarb","startTime":770.73,"endTime":775.62,"body":"channel blocker, I would do"},{"speaker":"Charles Goldfarb","startTime":770.73,"endTime":775.62,"body":"those things for certain. Before"},{"speaker":"Charles Goldfarb","startTime":775.62,"endTime":778.95,"body":"jumping to considering surgical"},{"speaker":"Charles Goldfarb","startTime":775.62,"endTime":778.95,"body":"options, I would also think"},{"speaker":"Charles Goldfarb","startTime":778.95,"endTime":781.47,"body":"about Botox, and I don't know"},{"speaker":"Charles Goldfarb","startTime":778.95,"endTime":781.47,"body":"the literature as well as I"},{"speaker":"Charles Goldfarb","startTime":781.47,"endTime":783.96,"body":"could or should, and you"},{"speaker":"Charles Goldfarb","startTime":781.47,"endTime":783.96,"body":"probably have a better sense"},{"speaker":"Charles Goldfarb","startTime":783.96,"endTime":788.01,"body":"than me. But Botox has been"},{"speaker":"Charles Goldfarb","startTime":783.96,"endTime":788.01,"body":"demonstrated to be one"},{"speaker":"Charles Goldfarb","startTime":788.01,"endTime":791.31,"body":"reasonable treatment option. Do"},{"speaker":"Charles Goldfarb","startTime":788.01,"endTime":791.31,"body":"you have any experience with it?"},{"speaker":"Chris Dy","startTime":793.62,"endTime":797.13,"body":"You know, only to send"},{"speaker":"Chris Dy","startTime":793.62,"endTime":797.13,"body":"patients for it. And then"},{"speaker":"Chris Dy","startTime":797.13,"endTime":800.34,"body":"obviously, it's sending them to"},{"speaker":"Chris Dy","startTime":797.13,"endTime":800.34,"body":"their back to the rheumatologist"},{"speaker":"Chris Dy","startTime":800.34,"endTime":802.62,"body":"if they haven't tried that, but"},{"speaker":"Chris Dy","startTime":800.34,"endTime":802.62,"body":"you know, this patient doesn't"},{"speaker":"Chris Dy","startTime":802.62,"endTime":805.41,"body":"come come into my clinic very"},{"speaker":"Chris Dy","startTime":802.62,"endTime":805.41,"body":"often, to be honest with you."},{"speaker":"Chris Dy","startTime":805.86,"endTime":808.86,"body":"And it's usually they are sent"},{"speaker":"Chris Dy","startTime":805.86,"endTime":808.86,"body":"by their rheumatologist and"},{"speaker":"Chris Dy","startTime":808.86,"endTime":812.49,"body":"they're done with all of the non"},{"speaker":"Chris Dy","startTime":808.86,"endTime":812.49,"body":"surgical treatments by the time"},{"speaker":"Chris Dy","startTime":812.49,"endTime":815.13,"body":"they see me and this is just one"},{"speaker":"Chris Dy","startTime":812.49,"endTime":815.13,"body":"of the things for you, if you"},{"speaker":"Chris Dy","startTime":815.13,"endTime":817.2,"body":"don't have this in your"},{"speaker":"Chris Dy","startTime":815.13,"endTime":817.2,"body":"practice, you know, some but"},{"speaker":"Chris Dy","startTime":817.32,"endTime":821.19,"body":"somebody may come to your office"},{"speaker":"Chris Dy","startTime":817.32,"endTime":821.19,"body":"and you know, you haven't really"},{"speaker":"Chris Dy","startTime":821.19,"endTime":822.48,"body":"assessed this patient before."},{"speaker":"Charles Goldfarb","startTime":822.96,"endTime":825.63,"body":"Well, that's"},{"speaker":"Charles Goldfarb","startTime":822.96,"endTime":825.63,"body":"the perfect scenario. And so you"},{"speaker":"Charles Goldfarb","startTime":825.63,"endTime":828.36,"body":"know, there's we've talked a"},{"speaker":"Charles Goldfarb","startTime":825.63,"endTime":828.36,"body":"little bit about relationships"},{"speaker":"Charles Goldfarb","startTime":828.36,"endTime":830.76,"body":"and, and what kind of"},{"speaker":"Charles Goldfarb","startTime":828.36,"endTime":830.76,"body":"relationships you can have with"},{"speaker":"Charles Goldfarb","startTime":830.76,"endTime":834.48,"body":"other physicians, other medical"},{"speaker":"Charles Goldfarb","startTime":830.76,"endTime":834.48,"body":"providers and how they can help"},{"speaker":"Charles Goldfarb","startTime":834.48,"endTime":836.64,"body":"build your practice. And I've"},{"speaker":"Charles Goldfarb","startTime":834.48,"endTime":836.64,"body":"talked a lot about athletic"},{"speaker":"Charles Goldfarb","startTime":836.64,"endTime":839.91,"body":"trainers being one perfect"},{"speaker":"Charles Goldfarb","startTime":836.64,"endTime":839.91,"body":"example, obviously, primary care"},{"speaker":"Charles Goldfarb","startTime":839.91,"endTime":843.15,"body":"physicians, concierge care"},{"speaker":"Charles Goldfarb","startTime":839.91,"endTime":843.15,"body":"doctors, there's lots of good"},{"speaker":"Charles Goldfarb","startTime":843.15,"endTime":847.05,"body":"examples of how you can build"},{"speaker":"Charles Goldfarb","startTime":843.15,"endTime":847.05,"body":"your practice. This is a perfect"},{"speaker":"Charles Goldfarb","startTime":847.05,"endTime":850.95,"body":"one, you know, there absolutely"},{"speaker":"Charles Goldfarb","startTime":847.05,"endTime":850.95,"body":"should be a back and forth with"},{"speaker":"Charles Goldfarb","startTime":850.95,"endTime":855.06,"body":"rheumatology, not as robust as"},{"speaker":"Charles Goldfarb","startTime":850.95,"endTime":855.06,"body":"it used to be when when they"},{"speaker":"Charles Goldfarb","startTime":855.09,"endTime":858.3,"body":"rheumatology patients and those"},{"speaker":"Charles Goldfarb","startTime":855.09,"endTime":858.3,"body":"when we try arthritis really"},{"speaker":"Charles Goldfarb","startTime":858.3,"endTime":860.73,"body":"needed surgery regularly. But"},{"speaker":"Charles Goldfarb","startTime":858.3,"endTime":860.73,"body":"this is great. So this patient"},{"speaker":"Charles Goldfarb","startTime":860.73,"endTime":866.67,"body":"walks in, he or she has been"},{"speaker":"Charles Goldfarb","startTime":860.73,"endTime":866.67,"body":"maximally medically managed and"},{"speaker":"Charles Goldfarb","startTime":866.67,"endTime":869.7,"body":"they're coming to you for a"},{"speaker":"Charles Goldfarb","startTime":866.67,"endTime":869.7,"body":"solution. So paint a little bit"},{"speaker":"Charles Goldfarb","startTime":869.73,"endTime":873.27,"body":"more of a picture of what the"},{"speaker":"Charles Goldfarb","startTime":869.73,"endTime":873.27,"body":"hand looks like please."},{"speaker":"Chris Dy","startTime":874.02,"endTime":879.3,"body":"So the pain is index"},{"speaker":"Chris Dy","startTime":874.02,"endTime":879.3,"body":"and middle alterations at the"},{"speaker":"Chris Dy","startTime":879.3,"endTime":882.03,"body":"very tip kind of at the"},{"speaker":"Chris Dy","startTime":879.3,"endTime":882.03,"body":"hyponychium of the index and"},{"speaker":"Chris Dy","startTime":882.03,"endTime":887.43,"body":"middle the index and middle feel"},{"speaker":"Chris Dy","startTime":882.03,"endTime":887.43,"body":"different they're all not"},{"speaker":"Chris Dy","startTime":887.64,"endTime":891.03,"body":"completely would eat are"},{"speaker":"Chris Dy","startTime":887.64,"endTime":891.03,"body":"petrified but they feel firmer,"},{"speaker":"Chris Dy","startTime":891.06,"endTime":896.97,"body":"they don't have the same kind of"},{"speaker":"Chris Dy","startTime":891.06,"endTime":896.97,"body":"balance in the skin turgor and"},{"speaker":"Chris Dy","startTime":896.97,"endTime":900.03,"body":"the the ring and the smaller"},{"speaker":"Chris Dy","startTime":896.97,"endTime":900.03,"body":"okay and the thumb is totally"},{"speaker":"Chris Dy","startTime":900.03,"endTime":905.91,"body":"Fine. And then on the clinical"},{"speaker":"Chris Dy","startTime":900.03,"endTime":905.91,"body":"exam, very easily palpable"},{"speaker":"Chris Dy","startTime":905.91,"endTime":911.13,"body":"radial pulse, not a great owner"},{"speaker":"Chris Dy","startTime":905.91,"endTime":911.13,"body":"pulse. And actually, I forgot"},{"speaker":"Chris Dy","startTime":911.13,"endTime":915.84,"body":"that I have Doppler in my"},{"speaker":"Chris Dy","startTime":911.13,"endTime":915.84,"body":"clinic, I think I'd seen a"},{"speaker":"Chris Dy","startTime":915.84,"endTime":918.09,"body":"couple of these patients. And"},{"speaker":"Chris Dy","startTime":915.84,"endTime":918.09,"body":"the last time I saw him, I"},{"speaker":"Chris Dy","startTime":918.09,"endTime":920.22,"body":"didn't have doppler in my"},{"speaker":"Chris Dy","startTime":918.09,"endTime":920.22,"body":"clinic. So I made a big stink,"},{"speaker":"Chris Dy","startTime":920.22,"endTime":923.64,"body":"and I got a handheld Doppler in"},{"speaker":"Chris Dy","startTime":920.22,"endTime":923.64,"body":"my clinic. So now I've actually"},{"speaker":"Chris Dy","startTime":923.64,"endTime":927.96,"body":"went and used it. And you can"},{"speaker":"Chris Dy","startTime":923.64,"endTime":927.96,"body":"hear the radial obviously, is"},{"speaker":"Chris Dy","startTime":927.96,"endTime":930.15,"body":"great, because it's palpable,"},{"speaker":"Chris Dy","startTime":927.96,"endTime":930.15,"body":"the ulna is a little thready,"},{"speaker":"Chris Dy","startTime":930.15,"endTime":933.12,"body":"but it's there. And you can kind"},{"speaker":"Chris Dy","startTime":930.15,"endTime":933.12,"body":"of hear in a superficial arch,"},{"speaker":"Chris Dy","startTime":933.12,"endTime":937.77,"body":"but you got to work for it. And"},{"speaker":"Chris Dy","startTime":933.12,"endTime":937.77,"body":"then the radial and ulnar to the"},{"speaker":"Chris Dy","startTime":938.55,"endTime":942.33,"body":"proper digital arteries to the"},{"speaker":"Chris Dy","startTime":938.55,"endTime":942.33,"body":"index and middle are not great."},{"speaker":"Chris Dy","startTime":943.35,"endTime":947.13,"body":"The radial is, again, you got to"},{"speaker":"Chris Dy","startTime":943.35,"endTime":947.13,"body":"work for it on the index. And"},{"speaker":"Chris Dy","startTime":947.13,"endTime":949.59,"body":"then basically that second"},{"speaker":"Chris Dy","startTime":947.13,"endTime":949.59,"body":"webspace branch is not"},{"speaker":"Chris Dy","startTime":949.59,"endTime":953.61,"body":"fantastic. And then the ulnar"},{"speaker":"Chris Dy","startTime":949.59,"endTime":953.61,"body":"portion of the middle is okay."},{"speaker":"Chris Dy","startTime":955.32,"endTime":959.1,"body":"So I'm kind of in a jam. And,"},{"speaker":"Chris Dy","startTime":955.32,"endTime":959.1,"body":"you know, I don't know how you"},{"speaker":"Chris Dy","startTime":959.37,"endTime":962.55,"body":"counsel patients about, you"},{"speaker":"Chris Dy","startTime":959.37,"endTime":962.55,"body":"know, what surgery is like and"},{"speaker":"Chris Dy","startTime":962.55,"endTime":964.92,"body":"what to expect, and you know,"},{"speaker":"Chris Dy","startTime":962.55,"endTime":964.92,"body":"things like that?"},{"speaker":"Charles Goldfarb","startTime":966.09,"endTime":968.7,"body":"Well, it's a"},{"speaker":"Charles Goldfarb","startTime":966.09,"endTime":968.7,"body":"great, it's a great case. And in"},{"speaker":"Charles Goldfarb","startTime":968.7,"endTime":971.22,"body":"the in the right patient, I"},{"speaker":"Charles Goldfarb","startTime":968.7,"endTime":971.22,"body":"would consider a surgical"},{"speaker":"Charles Goldfarb","startTime":971.22,"endTime":977.64,"body":"intervention. And I have you"},{"speaker":"Charles Goldfarb","startTime":971.22,"endTime":977.64,"body":"know, it's interesting, it does"},{"speaker":"Charles Goldfarb","startTime":977.64,"endTime":981.6,"body":"raise the question of in a group"},{"speaker":"Charles Goldfarb","startTime":977.64,"endTime":981.6,"body":"like ours at a referral center"},{"speaker":"Charles Goldfarb","startTime":981.6,"endTime":984.9,"body":"like ours, should Chuck and"},{"speaker":"Charles Goldfarb","startTime":981.6,"endTime":984.9,"body":"Chris and basically, should all"},{"speaker":"Charles Goldfarb","startTime":984.9,"endTime":989.67,"body":"six of us do cases like this"},{"speaker":"Charles Goldfarb","startTime":984.9,"endTime":989.67,"body":"that are uncommon? Or should we,"},{"speaker":"Charles Goldfarb","startTime":989.7,"endTime":991.59,"body":"you know, have our micro"},{"speaker":"Charles Goldfarb","startTime":989.7,"endTime":991.59,"body":"partners do it. And obviously,"},{"speaker":"Charles Goldfarb","startTime":991.59,"endTime":995.76,"body":"you do micro a lot, I do micro"},{"speaker":"Charles Goldfarb","startTime":991.59,"endTime":995.76,"body":"some, and I certainly think it's"},{"speaker":"Charles Goldfarb","startTime":995.76,"endTime":999.81,"body":"highly appropriate for both of"},{"speaker":"Charles Goldfarb","startTime":995.76,"endTime":999.81,"body":"us to do it. And so I would, you"},{"speaker":"Charles Goldfarb","startTime":999.81,"endTime":1002.93,"body":"know, if I chose to handle this"},{"speaker":"Charles Goldfarb","startTime":999.81,"endTime":1002.93,"body":"case, rather than referring it,"},{"speaker":"Charles Goldfarb","startTime":1003.23,"endTime":1006.98,"body":"I would consider a"},{"speaker":"Charles Goldfarb","startTime":1003.23,"endTime":1006.98,"body":"sympathectomy. And when I've"},{"speaker":"Charles Goldfarb","startTime":1006.98,"endTime":1011.3,"body":"done those in the past, A, it"},{"speaker":"Charles Goldfarb","startTime":1006.98,"endTime":1011.3,"body":"can be fun, although it's not"},{"speaker":"Charles Goldfarb","startTime":1011.3,"endTime":1015.41,"body":"always a fun case. And B, you"},{"speaker":"Charles Goldfarb","startTime":1011.3,"endTime":1015.41,"body":"can make a big difference for"},{"speaker":"Charles Goldfarb","startTime":1015.41,"endTime":1015.89,"body":"this person."},{"speaker":"Chris Dy","startTime":1016.76,"endTime":1020.54,"body":"This goes into the"},{"speaker":"Chris Dy","startTime":1016.76,"endTime":1020.54,"body":"it's all good till it's not the"},{"speaker":"Chris Dy","startTime":1020.54,"endTime":1025.37,"body":"kind of case because the"},{"speaker":"Chris Dy","startTime":1020.54,"endTime":1025.37,"body":"friability of those arteries is"},{"speaker":"Chris Dy","startTime":1025.37,"endTime":1028.25,"body":"real. I mean, they're not normal"},{"speaker":"Chris Dy","startTime":1025.37,"endTime":1028.25,"body":"arteries."},{"speaker":"Charles Goldfarb","startTime":1028.82,"endTime":1031.13,"body":"So tell. So"},{"speaker":"Charles Goldfarb","startTime":1028.82,"endTime":1031.13,"body":"lay lay all your cards on the"},{"speaker":"Charles Goldfarb","startTime":1031.13,"endTime":1034.16,"body":"table. So you decide you're"},{"speaker":"Charles Goldfarb","startTime":1031.13,"endTime":1034.16,"body":"seeing the patient, you decide,"},{"speaker":"Charles Goldfarb","startTime":1034.19,"endTime":1036.92,"body":"yes, the sympathetic"},{"speaker":"Charles Goldfarb","startTime":1034.19,"endTime":1036.92,"body":"sympathectomy makes sense. You"},{"speaker":"Charles Goldfarb","startTime":1036.92,"endTime":1039.38,"body":"talk to the patient, you"},{"speaker":"Charles Goldfarb","startTime":1036.92,"endTime":1039.38,"body":"schedule the case, how does"},{"speaker":"Charles Goldfarb","startTime":1039.38,"endTime":1043.58,"body":"Chris Dy prepare for a case that"},{"speaker":"Charles Goldfarb","startTime":1039.38,"endTime":1043.58,"body":"he doesn't do all the time?"},{"speaker":"Chris Dy","startTime":1044.36,"endTime":1046.64,"body":"You're actually"},{"speaker":"Chris Dy","startTime":1044.36,"endTime":1046.64,"body":"getting a I won't? I won't"},{"speaker":"Chris Dy","startTime":1046.64,"endTime":1049.25,"body":"answer that, Chuck. Because"},{"speaker":"Chris Dy","startTime":1046.64,"endTime":1049.25,"body":"that's actually a topic for the"},{"speaker":"Chris Dy","startTime":1049.25,"endTime":1051.53,"body":"wheel of hand surgery that we're"},{"speaker":"Chris Dy","startTime":1049.25,"endTime":1051.53,"body":"going to record for next week,"},{"speaker":"Chris Dy","startTime":1052.31,"endTime":1056.15,"body":"preparing for new cases. So I"},{"speaker":"Chris Dy","startTime":1052.31,"endTime":1056.15,"body":"will sort of answer it, but I"},{"speaker":"Chris Dy","startTime":1056.15,"endTime":1061.46,"body":"won't give you the full, I won't"},{"speaker":"Chris Dy","startTime":1056.15,"endTime":1061.46,"body":"spill all the tea here. So you"},{"speaker":"Chris Dy","startTime":1061.46,"endTime":1065.87,"body":"know, I think that in, it's kind"},{"speaker":"Chris Dy","startTime":1061.46,"endTime":1065.87,"body":"of hard, because you're having"},{"speaker":"Chris Dy","startTime":1065.87,"endTime":1069.59,"body":"to think on your feet in clinic."},{"speaker":"Chris Dy","startTime":1065.87,"endTime":1069.59,"body":"Because you have to tell the"},{"speaker":"Chris Dy","startTime":1069.59,"endTime":1071.99,"body":"patient what to expect after"},{"speaker":"Chris Dy","startTime":1069.59,"endTime":1071.99,"body":"surgery, but you yourself"},{"speaker":"Chris Dy","startTime":1071.99,"endTime":1074.78,"body":"haven't had a ton of time to do"},{"speaker":"Chris Dy","startTime":1071.99,"endTime":1074.78,"body":"the reading in the literature,"},{"speaker":"Chris Dy","startTime":1074.78,"endTime":1077.75,"body":"you rely on your base of"},{"speaker":"Chris Dy","startTime":1074.78,"endTime":1077.75,"body":"knowledge that you have for"},{"speaker":"Chris Dy","startTime":1077.75,"endTime":1080.81,"body":"fellowship, so you're somewhat"},{"speaker":"Chris Dy","startTime":1077.75,"endTime":1080.81,"body":"non committal to the patient,"},{"speaker":"Chris Dy","startTime":1081.08,"endTime":1083.51,"body":"you know, you tell them what you"},{"speaker":"Chris Dy","startTime":1081.08,"endTime":1083.51,"body":"remember the success rates to"},{"speaker":"Chris Dy","startTime":1083.51,"endTime":1088.43,"body":"roughly be? No, so I talked to"},{"speaker":"Chris Dy","startTime":1083.51,"endTime":1088.43,"body":"her say, look, you know, the the"},{"speaker":"Chris Dy","startTime":1088.43,"endTime":1091.7,"body":"very last option here, which I"},{"speaker":"Chris Dy","startTime":1088.43,"endTime":1091.7,"body":"think is why you're here to see"},{"speaker":"Chris Dy","startTime":1091.7,"endTime":1095.66,"body":"me is to, you know, try to"},{"speaker":"Chris Dy","startTime":1091.7,"endTime":1095.66,"body":"reinvigorate those blood"},{"speaker":"Chris Dy","startTime":1095.66,"endTime":1099.71,"body":"vessels, what we do is that we,"},{"speaker":"Chris Dy","startTime":1095.66,"endTime":1099.71,"body":"we think that there's"},{"speaker":"Chris Dy","startTime":1099.74,"endTime":1102.38,"body":"essentially some spasming in the"},{"speaker":"Chris Dy","startTime":1099.74,"endTime":1102.38,"body":"blood vessels coming from the"},{"speaker":"Chris Dy","startTime":1102.38,"endTime":1106.07,"body":"nerve supply that goes to that"},{"speaker":"Chris Dy","startTime":1102.38,"endTime":1106.07,"body":"feeds into those blood vessels."},{"speaker":"Chris Dy","startTime":1106.43,"endTime":1108.95,"body":"And we're just going to separate"},{"speaker":"Chris Dy","startTime":1106.43,"endTime":1108.95,"body":"the nerve endings from the blood"},{"speaker":"Chris Dy","startTime":1108.95,"endTime":1112.31,"body":"vessel, and then also try to"},{"speaker":"Chris Dy","startTime":1108.95,"endTime":1112.31,"body":"open up some space for those"},{"speaker":"Chris Dy","startTime":1112.31,"endTime":1117.05,"body":"arteries. I tell them that they"},{"speaker":"Chris Dy","startTime":1112.31,"endTime":1117.05,"body":"can probably expect some element"},{"speaker":"Chris Dy","startTime":1117.08,"endTime":1121.82,"body":"of improvement, at least in the"},{"speaker":"Chris Dy","startTime":1117.08,"endTime":1121.82,"body":"short term in the pain and"},{"speaker":"Chris Dy","startTime":1121.82,"endTime":1124.07,"body":"hopefully some healing of the"},{"speaker":"Chris Dy","startTime":1121.82,"endTime":1124.07,"body":"ulcers. But I think the"},{"speaker":"Chris Dy","startTime":1124.07,"endTime":1126.02,"body":"recurrence rate is the thing"},{"speaker":"Chris Dy","startTime":1124.07,"endTime":1126.02,"body":"that I worry about."},{"speaker":"Charles Goldfarb","startTime":1127.35,"endTime":1129.78,"body":"Yeah, well"},{"speaker":"Charles Goldfarb","startTime":1127.35,"endTime":1129.78,"body":"said Well said, I do think it'd"},{"speaker":"Charles Goldfarb","startTime":1129.78,"endTime":1132.33,"body":"be fun to talk about preparing"},{"speaker":"Charles Goldfarb","startTime":1129.78,"endTime":1132.33,"body":"for cases. I look forward to"},{"speaker":"Charles Goldfarb","startTime":1132.33,"endTime":1135.51,"body":"spinning that wheel. What's"},{"speaker":"Charles Goldfarb","startTime":1132.33,"endTime":1135.51,"body":"going to be you're gonna roll"},{"speaker":"Charles Goldfarb","startTime":1135.51,"endTime":1140.97,"body":"your eyes. I know you are. So my"},{"speaker":"Charles Goldfarb","startTime":1135.51,"endTime":1140.97,"body":"16 year olds, 16 year old"},{"speaker":"Charles Goldfarb","startTime":1140.97,"endTime":1145.8,"body":"daughter talks a lot about the"},{"speaker":"Charles Goldfarb","startTime":1140.97,"endTime":1145.8,"body":"tea, which is like, the gossip."},{"speaker":"Charles Goldfarb","startTime":1145.83,"endTime":1149.76,"body":"And so I love that you work that"},{"speaker":"Charles Goldfarb","startTime":1145.83,"endTime":1149.76,"body":"in. So correct me if I have the"},{"speaker":"Charles Goldfarb","startTime":1149.76,"endTime":1153.0,"body":"origin of this expression wrong."},{"speaker":"Charles Goldfarb","startTime":1149.76,"endTime":1153.0,"body":"To me, it's it started with kind"},{"speaker":"Charles Goldfarb","startTime":1153.0,"endTime":1156.78,"body":"of reading of the tea leaves,"},{"speaker":"Charles Goldfarb","startTime":1153.0,"endTime":1156.78,"body":"which I you know, kind of"},{"speaker":"Charles Goldfarb","startTime":1156.78,"endTime":1159.75,"body":"thought, I really I don't know"},{"speaker":"Charles Goldfarb","startTime":1156.78,"endTime":1159.75,"body":"if I really understood what the"},{"speaker":"Charles Goldfarb","startTime":1159.75,"endTime":1162.39,"body":"tea leaves were. And then I was"},{"speaker":"Charles Goldfarb","startTime":1159.75,"endTime":1162.39,"body":"watching I don't watch a lot of"},{"speaker":"Charles Goldfarb","startTime":1162.39,"endTime":1165.96,"body":"TV, but I was watching Peaky"},{"speaker":"Charles Goldfarb","startTime":1162.39,"endTime":1165.96,"body":"Blinders maybe six months ago."},{"speaker":"Charles Goldfarb","startTime":1166.14,"endTime":1169.8,"body":"And they actually I guess it was"},{"speaker":"Charles Goldfarb","startTime":1166.14,"endTime":1169.8,"body":"a thing where you people"},{"speaker":"Charles Goldfarb","startTime":1169.8,"endTime":1173.85,"body":"actually read the tea leaves in"},{"speaker":"Charles Goldfarb","startTime":1169.8,"endTime":1173.85,"body":"the tea cup and can kind of help"},{"speaker":"Charles Goldfarb","startTime":1173.85,"endTime":1175.71,"body":"understand the future. So I"},{"speaker":"Charles Goldfarb","startTime":1173.85,"endTime":1175.71,"body":"don't know if I'm taking this"},{"speaker":"Charles Goldfarb","startTime":1175.71,"endTime":1179.01,"body":"analogy too far. But that's what"},{"speaker":"Charles Goldfarb","startTime":1175.71,"endTime":1179.01,"body":"I thought of and I'm sure there"},{"speaker":"Charles Goldfarb","startTime":1179.01,"endTime":1181.74,"body":"are listeners who love Peaky as"},{"speaker":"Charles Goldfarb","startTime":1179.01,"endTime":1181.74,"body":"much as I do."},{"speaker":"Chris Dy","startTime":1182.04,"endTime":1184.29,"body":"You are absolutely"},{"speaker":"Chris Dy","startTime":1182.04,"endTime":1184.29,"body":"taking it too far. I have no"},{"speaker":"Chris Dy","startTime":1184.29,"endTime":1186.75,"body":"idea what you're talking about."},{"speaker":"Chris Dy","startTime":1184.29,"endTime":1186.75,"body":"I do know that the kids talk"},{"speaker":"Chris Dy","startTime":1186.75,"endTime":1189.87,"body":"about the tea, and it is a"},{"speaker":"Chris Dy","startTime":1186.75,"endTime":1189.87,"body":"gossip. That's about as far as"},{"speaker":"Chris Dy","startTime":1189.87,"endTime":1190.83,"body":"it goes for me."},{"speaker":"Charles Goldfarb","startTime":1191.87,"endTime":1193.34,"body":"Alright, sorry"},{"speaker":"Charles Goldfarb","startTime":1191.87,"endTime":1193.34,"body":"about that."},{"speaker":"Chris Dy","startTime":1194.48,"endTime":1198.08,"body":"So what's been your"},{"speaker":"Chris Dy","startTime":1194.48,"endTime":1198.08,"body":"experience in terms of how these"},{"speaker":"Chris Dy","startTime":1198.08,"endTime":1200.78,"body":"patients do after a successful"},{"speaker":"Chris Dy","startTime":1198.08,"endTime":1200.78,"body":"so And we'll get into the"},{"speaker":"Chris Dy","startTime":1200.78,"endTime":1202.52,"body":"technical parts of it in just a"},{"speaker":"Chris Dy","startTime":1200.78,"endTime":1202.52,"body":"minute. But"},{"speaker":"Charles Goldfarb","startTime":1203.27,"endTime":1206.0,"body":"I think your"},{"speaker":"Charles Goldfarb","startTime":1203.27,"endTime":1206.0,"body":"your summary was a good one. I"},{"speaker":"Charles Goldfarb","startTime":1206.0,"endTime":1209.72,"body":"think, you know, certain"},{"speaker":"Charles Goldfarb","startTime":1206.0,"endTime":1209.72,"body":"patients, this can be a home"},{"speaker":"Charles Goldfarb","startTime":1209.72,"endTime":1215.3,"body":"run, maybe not lifelong, but you"},{"speaker":"Charles Goldfarb","startTime":1209.72,"endTime":1215.3,"body":"can really dramatically improve"},{"speaker":"Charles Goldfarb","startTime":1215.3,"endTime":1219.44,"body":"their situation. You can get the"},{"speaker":"Charles Goldfarb","startTime":1215.3,"endTime":1219.44,"body":"ulcers to heal, you can help the"},{"speaker":"Charles Goldfarb","startTime":1219.44,"endTime":1223.97,"body":"pain and set them on a on a"},{"speaker":"Charles Goldfarb","startTime":1219.44,"endTime":1223.97,"body":"different course, I do agree the"},{"speaker":"Charles Goldfarb","startTime":1223.97,"endTime":1228.26,"body":"risk of recurrence is very high."},{"speaker":"Charles Goldfarb","startTime":1223.97,"endTime":1228.26,"body":"But that's why I say it is a"},{"speaker":"Charles Goldfarb","startTime":1228.26,"endTime":1232.43,"body":"procedure that I did I don't"},{"speaker":"Charles Goldfarb","startTime":1228.26,"endTime":1232.43,"body":"mind doing that, because the"},{"speaker":"Charles Goldfarb","startTime":1232.43,"endTime":1236.09,"body":"results are reliable. And so I"},{"speaker":"Charles Goldfarb","startTime":1232.43,"endTime":1236.09,"body":"think you did the right thing"},{"speaker":"Charles Goldfarb","startTime":1236.09,"endTime":1236.54,"body":"for sure."},{"speaker":"Chris Dy","startTime":1237.44,"endTime":1241.43,"body":"So when you book them"},{"speaker":"Chris Dy","startTime":1237.44,"endTime":1241.43,"body":"for a sympathectomy, what do you"},{"speaker":"Chris Dy","startTime":1241.43,"endTime":1244.07,"body":"what does that mean to you?"},{"speaker":"Chris Dy","startTime":1241.43,"endTime":1244.07,"body":"Well, what are you intending to"},{"speaker":"Chris Dy","startTime":1244.07,"endTime":1245.99,"body":"do and to which arteries?"},{"speaker":"Charles Goldfarb","startTime":1247.01,"endTime":1248.9,"body":"So first of"},{"speaker":"Charles Goldfarb","startTime":1247.01,"endTime":1248.9,"body":"all, I book it on the main"},{"speaker":"Charles Goldfarb","startTime":1248.9,"endTime":1252.44,"body":"campus with a microscope. I"},{"speaker":"Charles Goldfarb","startTime":1248.9,"endTime":1252.44,"body":"don't I don't know that's 100%"},{"speaker":"Charles Goldfarb","startTime":1252.83,"endTime":1260.87,"body":"mandatory but for me, it is. And"},{"speaker":"Charles Goldfarb","startTime":1252.83,"endTime":1260.87,"body":"I book it for, you know, again,"},{"speaker":"Charles Goldfarb","startTime":1260.9,"endTime":1264.44,"body":"I'm not in the or everyday doing"},{"speaker":"Charles Goldfarb","startTime":1260.9,"endTime":1264.44,"body":"micro, but I probably do book it"},{"speaker":"Charles Goldfarb","startTime":1264.44,"endTime":1266.66,"body":"for two hours, and I'm part of"},{"speaker":"Charles Goldfarb","startTime":1264.44,"endTime":1266.66,"body":"that is just set up and the"},{"speaker":"Charles Goldfarb","startTime":1266.66,"endTime":1270.74,"body":"microscope and, and so I did two"},{"speaker":"Charles Goldfarb","startTime":1266.66,"endTime":1270.74,"body":"hours and two hours in the room,"},{"speaker":"Charles Goldfarb","startTime":1270.89,"endTime":1275.45,"body":"two hours in the room. Okay. And"},{"speaker":"Charles Goldfarb","startTime":1270.89,"endTime":1275.45,"body":"for me, that's a longer case."},{"speaker":"Charles Goldfarb","startTime":1275.45,"endTime":1278.3,"body":"But again, I don't want to be in"},{"speaker":"Charles Goldfarb","startTime":1275.45,"endTime":1278.3,"body":"a two room day trying to do a"},{"speaker":"Charles Goldfarb","startTime":1278.3,"endTime":1281.42,"body":"case like this, and I need to"},{"speaker":"Charles Goldfarb","startTime":1278.3,"endTime":1281.42,"body":"have a microscope. And then I"},{"speaker":"Charles Goldfarb","startTime":1281.42,"endTime":1286.49,"body":"would plan on addressing the"},{"speaker":"Charles Goldfarb","startTime":1281.42,"endTime":1286.49,"body":"radial artery and the ulnar"},{"speaker":"Charles Goldfarb","startTime":1286.49,"endTime":1291.53,"body":"artery, at least examining them"},{"speaker":"Charles Goldfarb","startTime":1286.49,"endTime":1291.53,"body":"in the distal forearm, and I'd"},{"speaker":"Charles Goldfarb","startTime":1291.53,"endTime":1295.61,"body":"follow the radial artery"},{"speaker":"Charles Goldfarb","startTime":1291.53,"endTime":1295.61,"body":"distally. And then I certainly"},{"speaker":"Charles Goldfarb","startTime":1295.64,"endTime":1300.65,"body":"would address the digital"},{"speaker":"Charles Goldfarb","startTime":1295.64,"endTime":1300.65,"body":"arteries from the arch heading"},{"speaker":"Charles Goldfarb","startTime":1300.65,"endTime":1303.89,"body":"distally. Now, for the radial"},{"speaker":"Charles Goldfarb","startTime":1300.65,"endTime":1303.89,"body":"index finger, obviously, that"},{"speaker":"Charles Goldfarb","startTime":1303.89,"endTime":1306.83,"body":"may be a branch from the"},{"speaker":"Charles Goldfarb","startTime":1303.89,"endTime":1306.83,"body":"princeps. So may may look a"},{"speaker":"Charles Goldfarb","startTime":1306.83,"endTime":1309.32,"body":"little different. But I would"},{"speaker":"Charles Goldfarb","startTime":1306.83,"endTime":1309.32,"body":"address all four arteries,"},{"speaker":"Charles Goldfarb","startTime":1309.5,"endTime":1313.7,"body":"focusing on the ulnar digital"},{"speaker":"Charles Goldfarb","startTime":1309.5,"endTime":1313.7,"body":"artery to the index and the"},{"speaker":"Charles Goldfarb","startTime":1313.7,"endTime":1318.14,"body":"radial digital artery to the to"},{"speaker":"Charles Goldfarb","startTime":1313.7,"endTime":1318.14,"body":"the middle. But it's a big case"},{"speaker":"Charles Goldfarb","startTime":1318.14,"endTime":1318.47,"body":"for me."},{"speaker":"Chris Dy","startTime":1319.16,"endTime":1321.89,"body":"So would you book it"},{"speaker":"Chris Dy","startTime":1319.16,"endTime":1321.89,"body":"on the main campus? Say, for"},{"speaker":"Chris Dy","startTime":1321.89,"endTime":1325.37,"body":"example, see your surgery center"},{"speaker":"Chris Dy","startTime":1321.89,"endTime":1325.37,"body":"had a microscope? Would you just"},{"speaker":"Chris Dy","startTime":1325.37,"endTime":1327.47,"body":"do it there on a day where"},{"speaker":"Chris Dy","startTime":1325.37,"endTime":1327.47,"body":"you're not as busier at the end"},{"speaker":"Chris Dy","startTime":1327.47,"endTime":1330.32,"body":"of the day? Or is you doing it"},{"speaker":"Chris Dy","startTime":1327.47,"endTime":1330.32,"body":"at the main campus? Because you"},{"speaker":"Chris Dy","startTime":1330.32,"endTime":1332.9,"body":"want access to other things?"},{"speaker":"Chris Dy","startTime":1330.32,"endTime":1332.9,"body":"Other people maybe?"},{"speaker":"Charles Goldfarb","startTime":1333.2,"endTime":1336.29,"body":"No, I don't"},{"speaker":"Charles Goldfarb","startTime":1333.2,"endTime":1336.29,"body":"think I would worry about it."},{"speaker":"Charles Goldfarb","startTime":1336.8,"endTime":1338.72,"body":"That's a good? That's a great"},{"speaker":"Charles Goldfarb","startTime":1336.8,"endTime":1338.72,"body":"question. I wouldn't worry about"},{"speaker":"Charles Goldfarb","startTime":1338.72,"endTime":1342.32,"body":"risks. I wouldn't worry about"},{"speaker":"Charles Goldfarb","startTime":1338.72,"endTime":1342.32,"body":"meeting a partner, I don't think"},{"speaker":"Charles Goldfarb","startTime":1342.32,"endTime":1345.2,"body":"I would get into that kind of"},{"speaker":"Charles Goldfarb","startTime":1342.32,"endTime":1345.2,"body":"trouble. It's just a matter of"},{"speaker":"Charles Goldfarb","startTime":1345.2,"endTime":1348.71,"body":"being able to take my time and"},{"speaker":"Charles Goldfarb","startTime":1345.2,"endTime":1348.71,"body":"do the right thing. In this"},{"speaker":"Charles Goldfarb","startTime":1348.71,"endTime":1351.83,"body":"case, I'm not worried about"},{"speaker":"Charles Goldfarb","startTime":1348.71,"endTime":1351.83,"body":"admission. So yeah, if my"},{"speaker":"Charles Goldfarb","startTime":1351.83,"endTime":1355.07,"body":"surgery center had a microscope,"},{"speaker":"Charles Goldfarb","startTime":1351.83,"endTime":1355.07,"body":"and I could put it at the end of"},{"speaker":"Charles Goldfarb","startTime":1355.07,"endTime":1358.76,"body":"the day or under protected time,"},{"speaker":"Charles Goldfarb","startTime":1355.07,"endTime":1358.76,"body":"I would do it there. I have no"},{"speaker":"Charles Goldfarb","startTime":1358.76,"endTime":1361.34,"body":"idea about reimbursement or"},{"speaker":"Charles Goldfarb","startTime":1358.76,"endTime":1361.34,"body":"things like that. But"},{"speaker":"Charles Goldfarb","startTime":1361.91,"endTime":1363.95,"body":"absolutely, I would do it, I"},{"speaker":"Charles Goldfarb","startTime":1361.91,"endTime":1363.95,"body":"would do it in an outpatient"},{"speaker":"Charles Goldfarb","startTime":1363.95,"endTime":1365.63,"body":"environment, if I could find the"},{"speaker":"Charles Goldfarb","startTime":1363.95,"endTime":1365.63,"body":"right environment."},{"speaker":"Chris Dy","startTime":1367.43,"endTime":1370.64,"body":"So and then would you"},{"speaker":"Chris Dy","startTime":1367.43,"endTime":1370.64,"body":"get an angiogram ahead of time?"},{"speaker":"Charles Goldfarb","startTime":1372.71,"endTime":1376.94,"body":"I would not, I"},{"speaker":"Charles Goldfarb","startTime":1372.71,"endTime":1376.94,"body":"tend not to do that. I'm sure"},{"speaker":"Charles Goldfarb","startTime":1376.94,"endTime":1379.76,"body":"many would. And if any of our"},{"speaker":"Charles Goldfarb","startTime":1376.94,"endTime":1379.76,"body":"listeners have experienced with"},{"speaker":"Charles Goldfarb","startTime":1379.76,"endTime":1383.93,"body":"this, we would love for you to"},{"speaker":"Charles Goldfarb","startTime":1379.76,"endTime":1383.93,"body":"share your thoughts with us. But"},{"speaker":"Charles Goldfarb","startTime":1383.93,"endTime":1388.52,"body":"I would at the beginning of the"},{"speaker":"Charles Goldfarb","startTime":1383.93,"endTime":1388.52,"body":"case really doing more in depth"},{"speaker":"Charles Goldfarb","startTime":1388.52,"endTime":1391.7,"body":"Doppler exam than you did. So"},{"speaker":"Charles Goldfarb","startTime":1388.52,"endTime":1391.7,"body":"when the patient's on the table,"},{"speaker":"Charles Goldfarb","startTime":1391.7,"endTime":1394.82,"body":"I would plot things out, it"},{"speaker":"Charles Goldfarb","startTime":1391.7,"endTime":1394.82,"body":"would help guide my planning."},{"speaker":"Charles Goldfarb","startTime":1395.39,"endTime":1399.77,"body":"But I would still plan on"},{"speaker":"Charles Goldfarb","startTime":1395.39,"endTime":1399.77,"body":"addressing distal forearm. And"},{"speaker":"Charles Goldfarb","startTime":1400.01,"endTime":1401.27,"body":"also the digital vessels."},{"speaker":"Chris Dy","startTime":1402.14,"endTime":1403.97,"body":"I though my Doppler"},{"speaker":"Chris Dy","startTime":1402.14,"endTime":1403.97,"body":"exam was pretty thorough, but"},{"speaker":"Chris Dy","startTime":1404.0,"endTime":1410.42,"body":"that's okay. So, so would you go"},{"speaker":"Chris Dy","startTime":1404.0,"endTime":1410.42,"body":"into the finger? You know, you"},{"speaker":"Chris Dy","startTime":1410.42,"endTime":1414.2,"body":"mentioned working on the"},{"speaker":"Chris Dy","startTime":1410.42,"endTime":1414.2,"body":"arteries to the finger at the"},{"speaker":"Chris Dy","startTime":1414.2,"endTime":1417.26,"body":"level of the distal palm, would"},{"speaker":"Chris Dy","startTime":1414.2,"endTime":1417.26,"body":"you cross at Palmar digital"},{"speaker":"Chris Dy","startTime":1417.26,"endTime":1417.77,"body":"crease?"},{"speaker":"Charles Goldfarb","startTime":1418.64,"endTime":1420.47,"body":"I guess it"},{"speaker":"Charles Goldfarb","startTime":1418.64,"endTime":1420.47,"body":"would depend a little bit on"},{"speaker":"Charles Goldfarb","startTime":1420.47,"endTime":1424.67,"body":"what the vessels look like but I"},{"speaker":"Charles Goldfarb","startTime":1420.47,"endTime":1424.67,"body":"traditionally have not. I work"},{"speaker":"Charles Goldfarb","startTime":1424.67,"endTime":1429.26,"body":"on the arch. And I go out to the"},{"speaker":"Charles Goldfarb","startTime":1424.67,"endTime":1429.26,"body":"Palmar digital priests, I don't"},{"speaker":"Charles Goldfarb","startTime":1429.26,"endTime":1432.98,"body":"typically go into the fingers"},{"speaker":"Charles Goldfarb","startTime":1429.26,"endTime":1432.98,"body":"and less a I'm not making"},{"speaker":"Charles Goldfarb","startTime":1432.98,"endTime":1437.0,"body":"progress. And be it seems like"},{"speaker":"Charles Goldfarb","startTime":1432.98,"endTime":1437.0,"body":"the vessels are more problematic"},{"speaker":"Charles Goldfarb","startTime":1437.0,"endTime":1437.45,"body":"distally."},{"speaker":"Chris Dy","startTime":1438.71,"endTime":1441.02,"body":"So this is actually a"},{"speaker":"Chris Dy","startTime":1438.71,"endTime":1441.02,"body":"case that I did a few years ago."},{"speaker":"Chris Dy","startTime":1441.89,"endTime":1447.5,"body":"And now shape have now re"},{"speaker":"Chris Dy","startTime":1441.89,"endTime":1447.5,"body":"operated upon but the patient at"},{"speaker":"Chris Dy","startTime":1447.5,"endTime":1451.43,"body":"that at that point we did what"},{"speaker":"Chris Dy","startTime":1447.5,"endTime":1451.43,"body":"you described out at the level"},{"speaker":"Chris Dy","startTime":1451.43,"endTime":1455.57,"body":"of the distal palm and found"},{"speaker":"Chris Dy","startTime":1451.43,"endTime":1455.57,"body":"those four arteries that you"},{"speaker":"Chris Dy","startTime":1455.57,"endTime":1461.51,"body":"discussed. I did the you know"},{"speaker":"Chris Dy","startTime":1455.57,"endTime":1461.51,"body":"the sympathectomy and then I did"},{"speaker":"Chris Dy","startTime":1461.51,"endTime":1464.48,"body":"adventitial stripping for"},{"speaker":"Chris Dy","startTime":1461.51,"endTime":1464.48,"body":"probably about a two or three"},{"speaker":"Chris Dy","startTime":1464.48,"endTime":1467.33,"body":"centimeter segment for each of"},{"speaker":"Chris Dy","startTime":1464.48,"endTime":1467.33,"body":"those and did go out into the"},{"speaker":"Chris Dy","startTime":1467.33,"endTime":1470.42,"body":"fingers and I can't remember"},{"speaker":"Chris Dy","startTime":1467.33,"endTime":1470.42,"body":"exactly now why I did that but"},{"speaker":"Chris Dy","startTime":1470.42,"endTime":1472.91,"body":"I'm pretty sure it was based on"},{"speaker":"Chris Dy","startTime":1470.42,"endTime":1472.91,"body":"like you're saying the"},{"speaker":"Chris Dy","startTime":1472.91,"endTime":1477.29,"body":"description. She did Oh and I"},{"speaker":"Chris Dy","startTime":1472.91,"endTime":1477.29,"body":"did it as surgery center because"},{"speaker":"Chris Dy","startTime":1477.29,"endTime":1482.66,"body":"I have a microscope at my"},{"speaker":"Chris Dy","startTime":1477.29,"endTime":1482.66,"body":"surgery center. And and honestly"},{"speaker":"Chris Dy","startTime":1482.66,"endTime":1484.58,"body":"that was a little bit of a fight"},{"speaker":"Chris Dy","startTime":1482.66,"endTime":1484.58,"body":"to get that scope at the"},{"speaker":"Chris Dy","startTime":1484.58,"endTime":1487.25,"body":"beginning but it has opened up a"},{"speaker":"Chris Dy","startTime":1484.58,"endTime":1487.25,"body":"lot of opportunities for me to"},{"speaker":"Chris Dy","startTime":1487.25,"endTime":1489.44,"body":"do things with a lot of comfort"},{"speaker":"Chris Dy","startTime":1487.25,"endTime":1489.44,"body":"out there."},{"speaker":"Charles Goldfarb","startTime":1489.62,"endTime":1491.18,"body":"Oh, that's so"},{"speaker":"Charles Goldfarb","startTime":1489.62,"endTime":1491.18,"body":"interesting. Well, I'd love to"},{"speaker":"Charles Goldfarb","startTime":1491.18,"endTime":1493.64,"body":"talk more about that. Keep going"},{"speaker":"Charles Goldfarb","startTime":1491.18,"endTime":1493.64,"body":"though. You should we should."},{"speaker":"Chris Dy","startTime":1494.77,"endTime":1499.99,"body":"So she did great. She"},{"speaker":"Chris Dy","startTime":1494.77,"endTime":1499.99,"body":"loves me for that. And also"},{"speaker":"Chris Dy","startTime":1500.23,"endTime":1504.73,"body":"healed, pain was gone. This was"},{"speaker":"Chris Dy","startTime":1500.23,"endTime":1504.73,"body":"three years ago, she comes back"},{"speaker":"Chris Dy","startTime":1504.73,"endTime":1508.84,"body":"recently sends a few messages in"},{"speaker":"Chris Dy","startTime":1504.73,"endTime":1508.84,"body":"the chart saying I'm not doing"},{"speaker":"Chris Dy","startTime":1508.84,"endTime":1513.55,"body":"so great, we get her into the"},{"speaker":"Chris Dy","startTime":1508.84,"endTime":1513.55,"body":"clinic. And, and the fingers are"},{"speaker":"Chris Dy","startTime":1513.55,"endTime":1516.07,"body":"back to where they were no"},{"speaker":"Chris Dy","startTime":1513.55,"endTime":1516.07,"body":"ulcerations. But you know, it"},{"speaker":"Chris Dy","startTime":1516.07,"endTime":1519.1,"body":"hurts, it hurts a lot. I mean,"},{"speaker":"Chris Dy","startTime":1516.07,"endTime":1519.1,"body":"she's like, you know, start"},{"speaker":"Chris Dy","startTime":1519.1,"endTime":1521.83,"body":"saying the a word, you know,"},{"speaker":"Chris Dy","startTime":1519.1,"endTime":1521.83,"body":"that you don't want to hear as a"},{"speaker":"Chris Dy","startTime":1521.83,"endTime":1525.13,"body":"hand surgeon. For those that"},{"speaker":"Chris Dy","startTime":1521.83,"endTime":1525.13,"body":"aren't initiated the, when a"},{"speaker":"Chris Dy","startTime":1525.13,"endTime":1529.66,"body":"patient brings up amputation,"},{"speaker":"Chris Dy","startTime":1525.13,"endTime":1529.66,"body":"you have to really pause a bit"},{"speaker":"Chris Dy","startTime":1529.66,"endTime":1533.32,"body":"and realize that it's really"},{"speaker":"Chris Dy","startTime":1529.66,"endTime":1533.32,"body":"bothering them. So we have the"},{"speaker":"Chris Dy","startTime":1533.32,"endTime":1539.86,"body":"same talk about, you know, how"},{"speaker":"Chris Dy","startTime":1533.32,"endTime":1539.86,"body":"challenging This is. And now, if"},{"speaker":"Chris Dy","startTime":1539.86,"endTime":1545.26,"body":"you've done this sympathectomy,"},{"speaker":"Chris Dy","startTime":1539.86,"endTime":1545.26,"body":"you there really is no reason"},{"speaker":"Chris Dy","startTime":1545.29,"endTime":1548.38,"body":"for, you know, spasm to be part"},{"speaker":"Chris Dy","startTime":1545.29,"endTime":1548.38,"body":"of it. But all that scar that"},{"speaker":"Chris Dy","startTime":1548.38,"endTime":1551.62,"body":"it's encased in can, you know,"},{"speaker":"Chris Dy","startTime":1548.38,"endTime":1551.62,"body":"choke off and scar those blood"},{"speaker":"Chris Dy","startTime":1551.62,"endTime":1555.13,"body":"vessels and make it difficult"},{"speaker":"Chris Dy","startTime":1551.62,"endTime":1555.13,"body":"for blood to follow through. So"},{"speaker":"Chris Dy","startTime":1555.13,"endTime":1558.82,"body":"you know, the plumbing really"},{"speaker":"Chris Dy","startTime":1555.13,"endTime":1558.82,"body":"gets messed up. So this time I"},{"speaker":"Chris Dy","startTime":1558.82,"endTime":1561.58,"body":"actually, because it was a"},{"speaker":"Chris Dy","startTime":1558.82,"endTime":1561.58,"body":"revision case, I emailed one of"},{"speaker":"Chris Dy","startTime":1561.58,"endTime":1565.66,"body":"our partners, and David Brogan"},{"speaker":"Chris Dy","startTime":1561.58,"endTime":1565.66,"body":"was kind enough to share some"},{"speaker":"Chris Dy","startTime":1565.66,"endTime":1568.96,"body":"insights and he suggested an"},{"speaker":"Chris Dy","startTime":1565.66,"endTime":1568.96,"body":"angio because he had a case"},{"speaker":"Chris Dy","startTime":1568.96,"endTime":1571.69,"body":"where a patient had an odd"},{"speaker":"Chris Dy","startTime":1568.96,"endTime":1571.69,"body":"thrombosis and an unexpected"},{"speaker":"Chris Dy","startTime":1571.69,"endTime":1574.81,"body":"location. And with that"},{"speaker":"Chris Dy","startTime":1571.69,"endTime":1574.81,"body":"information, he had planned to"},{"speaker":"Chris Dy","startTime":1574.81,"endTime":1579.01,"body":"do some vein grafting or"},{"speaker":"Chris Dy","startTime":1574.81,"endTime":1579.01,"body":"arterial grafting versus vein"},{"speaker":"Chris Dy","startTime":1579.01,"endTime":1582.34,"body":"grafting for that thrombosis"},{"speaker":"Chris Dy","startTime":1579.01,"endTime":1582.34,"body":"segment. So we got the"},{"speaker":"Chris Dy","startTime":1582.34,"endTime":1586.75,"body":"angiogram, angiogram came back"},{"speaker":"Chris Dy","startTime":1582.34,"endTime":1586.75,"body":"with no thrombosis, but an"},{"speaker":"Chris Dy","startTime":1586.75,"endTime":1590.53,"body":"incomplete arch, great flow"},{"speaker":"Chris Dy","startTime":1586.75,"endTime":1590.53,"body":"through the radial and not great"},{"speaker":"Chris Dy","startTime":1590.53,"endTime":1593.83,"body":"flow through the owner. So with"},{"speaker":"Chris Dy","startTime":1590.53,"endTime":1593.83,"body":"that in mind, we went back to"},{"speaker":"Chris Dy","startTime":1593.83,"endTime":1598.63,"body":"the OR. And this was hard, you"},{"speaker":"Chris Dy","startTime":1593.83,"endTime":1598.63,"body":"know, the, the radio and the"},{"speaker":"Chris Dy","startTime":1598.63,"endTime":1601.63,"body":"owner part, you know,"},{"speaker":"Chris Dy","startTime":1598.63,"endTime":1601.63,"body":"sympathectomy and you know,"},{"speaker":"Chris Dy","startTime":1602.05,"endTime":1605.23,"body":"adventitial stripping, that all"},{"speaker":"Chris Dy","startTime":1602.05,"endTime":1605.23,"body":"went really well, obviously,"},{"speaker":"Chris Dy","startTime":1605.23,"endTime":1608.83,"body":"because that's a bigger, those"},{"speaker":"Chris Dy","startTime":1605.23,"endTime":1608.83,"body":"are bigger pipes went to the"},{"speaker":"Chris Dy","startTime":1608.83,"endTime":1614.68,"body":"superficial palmar arch. And you"},{"speaker":"Chris Dy","startTime":1608.83,"endTime":1614.68,"body":"know, those look fine, you know,"},{"speaker":"Chris Dy","startTime":1614.68,"endTime":1619.0,"body":"that arch looked okay, but then"},{"speaker":"Chris Dy","startTime":1614.68,"endTime":1619.0,"body":"getting out to the radial index"},{"speaker":"Chris Dy","startTime":1619.06,"endTime":1622.81,"body":"and to the honor index, and to"},{"speaker":"Chris Dy","startTime":1619.06,"endTime":1622.81,"body":"the radial middle, those were"},{"speaker":"Chris Dy","startTime":1622.81,"endTime":1626.89,"body":"really diminutive and really"},{"speaker":"Chris Dy","startTime":1622.81,"endTime":1626.89,"body":"caught up in a ton of scar. So"},{"speaker":"Chris Dy","startTime":1626.89,"endTime":1629.68,"body":"that was really challenging and"},{"speaker":"Chris Dy","startTime":1626.89,"endTime":1629.68,"body":"almost felt like in a weird way"},{"speaker":"Chris Dy","startTime":1629.68,"endTime":1630.85,"body":"kind of felt like a dupes."},{"speaker":"Charles Goldfarb","startTime":1632.26,"endTime":1633.46,"body":"And you do"},{"speaker":"Charles Goldfarb","startTime":1632.26,"endTime":1633.46,"body":"this with David?"},{"speaker":"Chris Dy","startTime":1634.39,"endTime":1637.69,"body":"No, David was around,"},{"speaker":"Chris Dy","startTime":1634.39,"endTime":1637.69,"body":"fortunately, but I did not need"},{"speaker":"Chris Dy","startTime":1637.69,"endTime":1641.41,"body":"David. David was gonna be there,"},{"speaker":"Chris Dy","startTime":1637.69,"endTime":1641.41,"body":"it was gonna we are just going"},{"speaker":"Chris Dy","startTime":1641.41,"endTime":1643.51,"body":"to move with David's OR we"},{"speaker":"Chris Dy","startTime":1641.41,"endTime":1643.51,"body":"thought we're gonna have to do"},{"speaker":"Chris Dy","startTime":1643.51,"endTime":1646.72,"body":"the grafting if there was a"},{"speaker":"Chris Dy","startTime":1643.51,"endTime":1646.72,"body":"thrombosis. But we kept it in"},{"speaker":"Chris Dy","startTime":1646.72,"endTime":1649.57,"body":"mind. Just because, you know,"},{"speaker":"Chris Dy","startTime":1646.72,"endTime":1649.57,"body":"logistically is a little bit"},{"speaker":"Chris Dy","startTime":1649.57,"endTime":1653.29,"body":"easier because there was no plan"},{"speaker":"Chris Dy","startTime":1649.57,"endTime":1653.29,"body":"to do any grafting. Although I"},{"speaker":"Chris Dy","startTime":1653.29,"endTime":1655.69,"body":"did talk to the patient, it was"},{"speaker":"Chris Dy","startTime":1653.29,"endTime":1655.69,"body":"on the consent about possible"},{"speaker":"Chris Dy","startTime":1655.69,"endTime":1658.72,"body":"grafting even in the absence of"},{"speaker":"Chris Dy","startTime":1655.69,"endTime":1658.72,"body":"a thrombosis, just because you"},{"speaker":"Chris Dy","startTime":1658.72,"endTime":1660.28,"body":"never know how those vessels are"},{"speaker":"Chris Dy","startTime":1658.72,"endTime":1660.28,"body":"going to handle."},{"speaker":"Charles Goldfarb","startTime":1661.54,"endTime":1663.34,"body":"Yeah, and the"},{"speaker":"Charles Goldfarb","startTime":1661.54,"endTime":1663.34,"body":"you know grafting is really"},{"speaker":"Charles Goldfarb","startTime":1663.34,"endTime":1667.99,"body":"tough. Because even if you can,"},{"speaker":"Charles Goldfarb","startTime":1663.34,"endTime":1667.99,"body":"you know, put it into the arch,"},{"speaker":"Charles Goldfarb","startTime":1668.17,"endTime":1671.56,"body":"for example, where do you"},{"speaker":"Charles Goldfarb","startTime":1668.17,"endTime":1671.56,"body":"tighten distally? If you have"},{"speaker":"Charles Goldfarb","startTime":1671.59,"endTime":1674.95,"body":"four vessels all the way? So"},{"speaker":"Charles Goldfarb","startTime":1671.59,"endTime":1674.95,"body":"it's tricky, and obviously not a"},{"speaker":"Charles Goldfarb","startTime":1674.95,"endTime":1679.39,"body":"situation you want to be in."},{"speaker":"Charles Goldfarb","startTime":1674.95,"endTime":1679.39,"body":"Yeah, I revision sympathectomy"},{"speaker":"Charles Goldfarb","startTime":1679.39,"endTime":1682.0,"body":"is not something I've"},{"speaker":"Charles Goldfarb","startTime":1679.39,"endTime":1682.0,"body":"undertaken, probably not"},{"speaker":"Charles Goldfarb","startTime":1682.0,"endTime":1685.39,"body":"something I would undertake,"},{"speaker":"Charles Goldfarb","startTime":1682.0,"endTime":1685.39,"body":"honestly. And do you have any"},{"speaker":"Charles Goldfarb","startTime":1685.39,"endTime":1688.39,"body":"type of results from operation"},{"speaker":"Charles Goldfarb","startTime":1685.39,"endTime":1688.39,"body":"number two?"},{"speaker":"Chris Dy","startTime":1689.41,"endTime":1695.08,"body":"Very, very short term,"},{"speaker":"Chris Dy","startTime":1689.41,"endTime":1695.08,"body":"we're happy. Nothing, nothing,"},{"speaker":"Chris Dy","startTime":1695.26,"endTime":1697.81,"body":"nothing yet. And I think that"},{"speaker":"Chris Dy","startTime":1695.26,"endTime":1697.81,"body":"the proof will be in the pudding"},{"speaker":"Chris Dy","startTime":1697.81,"endTime":1700.54,"body":"there in terms of you know, as a"},{"speaker":"Chris Dy","startTime":1697.81,"endTime":1700.54,"body":"follow up comes and we've had"},{"speaker":"Chris Dy","startTime":1700.54,"endTime":1702.88,"body":"this discussion that we're"},{"speaker":"Chris Dy","startTime":1700.54,"endTime":1702.88,"body":"probably going to be in the same"},{"speaker":"Chris Dy","startTime":1702.88,"endTime":1706.09,"body":"boat in terms of you know, we're"},{"speaker":"Chris Dy","startTime":1702.88,"endTime":1706.09,"body":"battling a systemic condition."},{"speaker":"Chris Dy","startTime":1706.51,"endTime":1709.93,"body":"And you know, this probably will"},{"speaker":"Chris Dy","startTime":1706.51,"endTime":1709.93,"body":"recur. And we're again, running"},{"speaker":"Chris Dy","startTime":1709.93,"endTime":1713.17,"body":"out of options, and prepping for"},{"speaker":"Chris Dy","startTime":1709.93,"endTime":1713.17,"body":"this case, and looking into"},{"speaker":"Chris Dy","startTime":1713.17,"endTime":1715.84,"body":"literature, there was a really"},{"speaker":"Chris Dy","startTime":1713.17,"endTime":1715.84,"body":"nice case series of revision"},{"speaker":"Chris Dy","startTime":1715.84,"endTime":1718.21,"body":"sympathectomy is that"},{"speaker":"Chris Dy","startTime":1715.84,"endTime":1718.21,"body":"fortunately, our colleagues at"},{"speaker":"Chris Dy","startTime":1718.24,"endTime":1722.26,"body":"Wake Forest have published in"},{"speaker":"Chris Dy","startTime":1718.24,"endTime":1722.26,"body":"the European Journal with, you"},{"speaker":"Chris Dy","startTime":1722.26,"endTime":1726.58,"body":"know, good measured, you know,"},{"speaker":"Chris Dy","startTime":1722.26,"endTime":1726.58,"body":"but good results. So I think"},{"speaker":"Chris Dy","startTime":1726.58,"endTime":1729.43,"body":"that that is reassuring. And"},{"speaker":"Chris Dy","startTime":1726.58,"endTime":1729.43,"body":"that's a really hard case."},{"speaker":"Chris Dy","startTime":1730.0,"endTime":1732.76,"body":"slogging through scar is one of"},{"speaker":"Chris Dy","startTime":1730.0,"endTime":1732.76,"body":"those days that you come home,"},{"speaker":"Chris Dy","startTime":1733.03,"endTime":1737.98,"body":"just physically and mentally"},{"speaker":"Chris Dy","startTime":1733.03,"endTime":1737.98,"body":"exhausted. Because, you know,"},{"speaker":"Chris Dy","startTime":1737.98,"endTime":1740.32,"body":"you're like cracking your neck"},{"speaker":"Chris Dy","startTime":1737.98,"endTime":1740.32,"body":"to get into different angles, we"},{"speaker":"Chris Dy","startTime":1740.32,"endTime":1742.9,"body":"did it all under the scope in"},{"speaker":"Chris Dy","startTime":1740.32,"endTime":1742.9,"body":"terms of the sympathectomy. I"},{"speaker":"Chris Dy","startTime":1742.9,"endTime":1746.14,"body":"mean, the gross dissection we"},{"speaker":"Chris Dy","startTime":1742.9,"endTime":1746.14,"body":"did on loops, but the"},{"speaker":"Chris Dy","startTime":1746.14,"endTime":1748.54,"body":"sympathectomy part on the the"},{"speaker":"Chris Dy","startTime":1746.14,"endTime":1748.54,"body":"scope, but the gross dissection"},{"speaker":"Chris Dy","startTime":1748.54,"endTime":1753.07,"body":"was challenging, you're"},{"speaker":"Chris Dy","startTime":1748.54,"endTime":1753.07,"body":"obviously working through tissue"},{"speaker":"Chris Dy","startTime":1753.07,"endTime":1756.67,"body":"plans that are not normal. So"},{"speaker":"Chris Dy","startTime":1753.07,"endTime":1756.67,"body":"then you're just you're, you're"},{"speaker":"Chris Dy","startTime":1756.67,"endTime":1759.88,"body":"on edge, I think a lot for a lot"},{"speaker":"Chris Dy","startTime":1756.67,"endTime":1759.88,"body":"of it. And it's a you know,"},{"speaker":"Chris Dy","startTime":1759.88,"endTime":1761.65,"body":"obviously really small"},{"speaker":"Chris Dy","startTime":1759.88,"endTime":1761.65,"body":"structures,"},{"speaker":"Charles Goldfarb","startTime":1762.25,"endTime":1764.86,"body":"You probably"},{"speaker":"Charles Goldfarb","startTime":1762.25,"endTime":1764.86,"body":"had a very skilled set of hands"},{"speaker":"Charles Goldfarb","startTime":1764.89,"endTime":1768.82,"body":"to help in that, in that"},{"speaker":"Charles Goldfarb","startTime":1764.89,"endTime":1768.82,"body":"experience, fellows, I'm"},{"speaker":"Charles Goldfarb","startTime":1768.82,"endTime":1772.81,"body":"guessing. But these the kind of"},{"speaker":"Charles Goldfarb","startTime":1768.82,"endTime":1772.81,"body":"cases that even if you don't"},{"speaker":"Charles Goldfarb","startTime":1772.81,"endTime":1776.56,"body":"technically need your partner,"},{"speaker":"Charles Goldfarb","startTime":1772.81,"endTime":1776.56,"body":"doing a case like this with a"},{"speaker":"Charles Goldfarb","startTime":1776.56,"endTime":1782.05,"body":"partner really can be a game"},{"speaker":"Charles Goldfarb","startTime":1776.56,"endTime":1782.05,"body":"changer, in the sense of, you"},{"speaker":"Charles Goldfarb","startTime":1782.05,"endTime":1785.11,"body":"know, two minds working together"},{"speaker":"Charles Goldfarb","startTime":1782.05,"endTime":1785.11,"body":"on how to address things, how"},{"speaker":"Charles Goldfarb","startTime":1785.11,"endTime":1788.14,"body":"aggressive to be tactically, you"},{"speaker":"Charles Goldfarb","startTime":1785.11,"endTime":1788.14,"body":"know, you're going to bring"},{"speaker":"Charles Goldfarb","startTime":1788.14,"endTime":1790.84,"body":"excellence with one of your"},{"speaker":"Charles Goldfarb","startTime":1788.14,"endTime":1790.84,"body":"partners, and just the"},{"speaker":"Charles Goldfarb","startTime":1790.84,"endTime":1794.29,"body":"interaction. You know, we don't"},{"speaker":"Charles Goldfarb","startTime":1790.84,"endTime":1794.29,"body":"you are, I think we are both"},{"speaker":"Charles Goldfarb","startTime":1794.29,"endTime":1797.71,"body":"fortunate, because we both"},{"speaker":"Charles Goldfarb","startTime":1794.29,"endTime":1797.71,"body":"operate with partners, not"},{"speaker":"Charles Goldfarb","startTime":1797.71,"endTime":1801.73,"body":"infrequently and I know that we"},{"speaker":"Charles Goldfarb","startTime":1797.71,"endTime":1801.73,"body":"As I say, you know, speak to the"},{"speaker":"Charles Goldfarb","startTime":1801.73,"endTime":1806.68,"body":"audience, many people do not."},{"speaker":"Charles Goldfarb","startTime":1801.73,"endTime":1806.68,"body":"And that is while Yes, there are"},{"speaker":"Charles Goldfarb","startTime":1806.68,"endTime":1810.34,"body":"financial costs to working"},{"speaker":"Charles Goldfarb","startTime":1806.68,"endTime":1810.34,"body":"together. There's nothing like"},{"speaker":"Charles Goldfarb","startTime":1810.34,"endTime":1813.4,"body":"it. I mean, it is really one of"},{"speaker":"Charles Goldfarb","startTime":1810.34,"endTime":1813.4,"body":"the joys of my practice when I"},{"speaker":"Charles Goldfarb","startTime":1813.4,"endTime":1814.75,"body":"get to operate with my partners."},{"speaker":"Chris Dy","startTime":1815.68,"endTime":1817.54,"body":"Yeah, I think I think"},{"speaker":"Chris Dy","startTime":1815.68,"endTime":1817.54,"body":"it's fantastic. And, you know, I"},{"speaker":"Chris Dy","startTime":1817.54,"endTime":1820.66,"body":"enjoyed, you know, every big"},{"speaker":"Chris Dy","startTime":1817.54,"endTime":1820.66,"body":"Plexus reconstruction, David and"},{"speaker":"Chris Dy","startTime":1820.66,"endTime":1822.97,"body":"I will do together. And then"},{"speaker":"Chris Dy","startTime":1820.66,"endTime":1822.97,"body":"I've been fortunate enough to"},{"speaker":"Chris Dy","startTime":1823.45,"endTime":1826.15,"body":"that Lindley's asked me to come"},{"speaker":"Chris Dy","startTime":1823.45,"endTime":1826.15,"body":"help her with some of the the"},{"speaker":"Chris Dy","startTime":1826.18,"endTime":1829.9,"body":"birth plexus. And it's just fun,"},{"speaker":"Chris Dy","startTime":1826.18,"endTime":1829.9,"body":"even if Yeah, technically, you"},{"speaker":"Chris Dy","startTime":1829.9,"endTime":1832.27,"body":"can absolutely do the case on"},{"speaker":"Chris Dy","startTime":1829.9,"endTime":1832.27,"body":"your own. And, you know, very"},{"speaker":"Chris Dy","startTime":1832.27,"endTime":1836.62,"body":"beginning of my career, I did"},{"speaker":"Chris Dy","startTime":1832.27,"endTime":1836.62,"body":"the Plexus cases on my own, you"},{"speaker":"Chris Dy","startTime":1836.62,"endTime":1840.13,"body":"know, and then obviously had"},{"speaker":"Chris Dy","startTime":1836.62,"endTime":1840.13,"body":"some help from, from like Marty,"},{"speaker":"Chris Dy","startTime":1840.13,"endTime":1843.22,"body":"when he would come in. So"},{"speaker":"Chris Dy","startTime":1840.13,"endTime":1843.22,"body":"remember asking Marty to harvest"},{"speaker":"Chris Dy","startTime":1843.22,"endTime":1846.25,"body":"or all nerve and still hearing"},{"speaker":"Chris Dy","startTime":1843.22,"endTime":1846.25,"body":"about that story. still hear"},{"speaker":"Chris Dy","startTime":1846.25,"endTime":1851.2,"body":"about that now. But you know,"},{"speaker":"Chris Dy","startTime":1846.25,"endTime":1851.2,"body":"even if it's not for the the"},{"speaker":"Chris Dy","startTime":1851.23,"endTime":1853.48,"body":"technical things that David"},{"speaker":"Chris Dy","startTime":1851.23,"endTime":1853.48,"body":"brings to the table in terms of"},{"speaker":"Chris Dy","startTime":1853.48,"endTime":1855.97,"body":"being able to do the free"},{"speaker":"Chris Dy","startTime":1853.48,"endTime":1855.97,"body":"functioning, muscle transfers,"},{"speaker":"Chris Dy","startTime":1855.97,"endTime":1858.37,"body":"etc. But just like you're"},{"speaker":"Chris Dy","startTime":1855.97,"endTime":1858.37,"body":"saying, bouncing things off of"},{"speaker":"Chris Dy","startTime":1858.37,"endTime":1860.17,"body":"each other, what do you think"},{"speaker":"Chris Dy","startTime":1858.37,"endTime":1860.17,"body":"about this? Do you agree with"},{"speaker":"Chris Dy","startTime":1860.17,"endTime":1865.18,"body":"that, in real time, it can be"},{"speaker":"Chris Dy","startTime":1860.17,"endTime":1865.18,"body":"tremendously useful. So maybe we"},{"speaker":"Chris Dy","startTime":1865.18,"endTime":1868.09,"body":"should do it more in terms of"},{"speaker":"Chris Dy","startTime":1865.18,"endTime":1868.09,"body":"partners. But it is, it is"},{"speaker":"Chris Dy","startTime":1868.09,"endTime":1870.88,"body":"something that when it happens,"},{"speaker":"Chris Dy","startTime":1868.09,"endTime":1870.88,"body":"it is absolutely worth it."},{"speaker":"Charles Goldfarb","startTime":1871.58,"endTime":1874.31,"body":"Right, there's"},{"speaker":"Charles Goldfarb","startTime":1871.58,"endTime":1874.31,"body":"an opportunity cost. But again,"},{"speaker":"Charles Goldfarb","startTime":1874.34,"endTime":1878.0,"body":"playing the long game, it makes"},{"speaker":"Charles Goldfarb","startTime":1874.34,"endTime":1878.0,"body":"cases can make cases like that,"},{"speaker":"Charles Goldfarb","startTime":1878.0,"endTime":1881.78,"body":"or other cases a lot more"},{"speaker":"Charles Goldfarb","startTime":1878.0,"endTime":1881.78,"body":"rewarding, and just builds that"},{"speaker":"Charles Goldfarb","startTime":1881.78,"endTime":1884.96,"body":"camaraderie which I think we are"},{"speaker":"Charles Goldfarb","startTime":1881.78,"endTime":1884.96,"body":"so fortunate to have in our"},{"speaker":"Charles Goldfarb","startTime":1884.96,"endTime":1887.84,"body":"relationships, but good job"},{"speaker":"Charles Goldfarb","startTime":1884.96,"endTime":1887.84,"body":"sounds like sounds like a"},{"speaker":"Charles Goldfarb","startTime":1887.84,"endTime":1888.71,"body":"homerun for the patient."},{"speaker":"Chris Dy","startTime":1889.13,"endTime":1891.02,"body":"Yeah, yeah, we'll see."},{"speaker":"Chris Dy","startTime":1889.13,"endTime":1891.02,"body":"I mean, you know, we gave it"},{"speaker":"Chris Dy","startTime":1891.02,"endTime":1894.83,"body":"everything. So, you know,"},{"speaker":"Chris Dy","startTime":1891.02,"endTime":1894.83,"body":"revision sympathectomy. For"},{"speaker":"Chris Dy","startTime":1894.83,"endTime":1898.13,"body":"sympathectomy. I think that in"},{"speaker":"Chris Dy","startTime":1894.83,"endTime":1898.13,"body":"fellowship, I just, I don't know"},{"speaker":"Chris Dy","startTime":1898.13,"endTime":1900.86,"body":"if it's because of the way that"},{"speaker":"Chris Dy","startTime":1898.13,"endTime":1900.86,"body":"the cards fell, but I didn't see"},{"speaker":"Chris Dy","startTime":1900.86,"endTime":1905.21,"body":"it at all. I did it pretty early"},{"speaker":"Chris Dy","startTime":1900.86,"endTime":1905.21,"body":"on in practice, one or two"},{"speaker":"Chris Dy","startTime":1905.21,"endTime":1910.19,"body":"times. And now, you know, first"},{"speaker":"Chris Dy","startTime":1905.21,"endTime":1910.19,"body":"revision, but I think that the"},{"speaker":"Chris Dy","startTime":1910.19,"endTime":1913.97,"body":"principles, you know, in terms"},{"speaker":"Chris Dy","startTime":1910.19,"endTime":1913.97,"body":"of technique and everything, try"},{"speaker":"Chris Dy","startTime":1913.97,"endTime":1916.01,"body":"to pick them up somewhere along"},{"speaker":"Chris Dy","startTime":1913.97,"endTime":1916.01,"body":"the way. And if you're a fellow"},{"speaker":"Chris Dy","startTime":1916.01,"endTime":1918.95,"body":"and you see these, if these are"},{"speaker":"Chris Dy","startTime":1916.01,"endTime":1918.95,"body":"not cases that are common at"},{"speaker":"Chris Dy","startTime":1918.95,"endTime":1921.08,"body":"your institution, and you scan"},{"speaker":"Chris Dy","startTime":1918.95,"endTime":1921.08,"body":"the schedule, and you see"},{"speaker":"Chris Dy","startTime":1921.08,"endTime":1924.47,"body":"somebody with it, go check it"},{"speaker":"Chris Dy","startTime":1921.08,"endTime":1924.47,"body":"out, or even a resident like me,"},{"speaker":"Chris Dy","startTime":1924.47,"endTime":1926.87,"body":"because I still remember cases"},{"speaker":"Chris Dy","startTime":1924.47,"endTime":1926.87,"body":"for my residency that I didn't"},{"speaker":"Chris Dy","startTime":1926.87,"endTime":1930.23,"body":"get to see during fellowship. So"},{"speaker":"Chris Dy","startTime":1926.87,"endTime":1930.23,"body":"you never know. You rather you"},{"speaker":"Chris Dy","startTime":1930.23,"endTime":1932.12,"body":"rather be somebody else's"},{"speaker":"Chris Dy","startTime":1930.23,"endTime":1932.12,"body":"patient first."},{"speaker":"Charles Goldfarb","startTime":1932.54,"endTime":1936.86,"body":"It's true. I"},{"speaker":"Charles Goldfarb","startTime":1932.54,"endTime":1936.86,"body":"joke about you know, not doing"},{"speaker":"Charles Goldfarb","startTime":1936.86,"endTime":1940.88,"body":"much micro and I prefer when my"},{"speaker":"Charles Goldfarb","startTime":1936.86,"endTime":1940.88,"body":"micro is elective. I don't know"},{"speaker":"Charles Goldfarb","startTime":1940.88,"endTime":1943.73,"body":"that I would prefer that this"},{"speaker":"Charles Goldfarb","startTime":1940.88,"endTime":1943.73,"body":"case be my elective micro."},{"speaker":"Chris Dy","startTime":1945.67,"endTime":1947.35,"body":"Yeah, you probably"},{"speaker":"Chris Dy","startTime":1945.67,"endTime":1947.35,"body":"will send that to one of our"},{"speaker":"Chris Dy","startTime":1947.35,"endTime":1947.89,"body":"partners so."},{"speaker":"Charles Goldfarb","startTime":1948.82,"endTime":1950.05,"body":"I most"},{"speaker":"Charles Goldfarb","startTime":1948.82,"endTime":1950.05,"body":"definitely will."},{"speaker":"Chris Dy","startTime":1950.44,"endTime":1953.08,"body":"Alright, well, great."},{"speaker":"Chris Dy","startTime":1950.44,"endTime":1953.08,"body":"Let's get together again soon. I"},{"speaker":"Chris Dy","startTime":1953.08,"endTime":1954.79,"body":"think the wheel of hand"},{"speaker":"Chris Dy","startTime":1953.08,"endTime":1954.79,"body":"surgery's going to be calling"},{"speaker":"Chris Dy","startTime":1954.79,"endTime":1955.15,"body":"us."},{"speaker":"Charles Goldfarb","startTime":1955.27,"endTime":1957.64,"body":"The wheel of"},{"speaker":"Charles Goldfarb","startTime":1955.27,"endTime":1957.64,"body":"hand surgery. All right. I look"},{"speaker":"Charles Goldfarb","startTime":1957.64,"endTime":1959.08,"body":"forward to it. Have a good day."},{"speaker":"Chris Dy","startTime":1959.41,"endTime":1959.86,"body":"Take care."},{"speaker":"Charles Goldfarb","startTime":1961.09,"endTime":1962.41,"body":"Hey, Chris."},{"speaker":"Charles Goldfarb","startTime":1961.09,"endTime":1962.41,"body":"That was fun."},{"speaker":"Chris Dy","startTime":1962.44,"endTime":1965.2,"body":"Let's do it again real"},{"speaker":"Chris Dy","startTime":1962.44,"endTime":1965.2,"body":"soon. Sounds good. Well, be sure"},{"speaker":"Chris Dy","startTime":1965.2,"endTime":1968.11,"body":"to check us out on Twitter"},{"speaker":"Chris Dy","startTime":1965.2,"endTime":1968.11,"body":"@handpodcast. Hey, Chuck, what's"},{"speaker":"Chris Dy","startTime":1968.11,"endTime":1968.8,"body":"your Twitter handle?"},{"speaker":"Charles Goldfarb","startTime":1969.13,"endTime":1971.74,"body":"Mine is"},{"speaker":"Charles Goldfarb","startTime":1969.13,"endTime":1971.74,"body":"@congenital hand. What about"},{"speaker":"Charles Goldfarb","startTime":1971.74,"endTime":1971.98,"body":"you?"},{"speaker":"Chris Dy","startTime":1972.13,"endTime":1975.52,"body":"Mine is @ChrisDyMD"},{"speaker":"Chris Dy","startTime":1972.13,"endTime":1975.52,"body":"spelled d y. And if you'd like"},{"speaker":"Chris Dy","startTime":1975.52,"endTime":1978.79,"body":"to email us, you can reach us at"},{"speaker":"Chris Dy","startTime":1975.52,"endTime":1978.79,"body":"handpodcast@gmail.com."},{"speaker":"Charles Goldfarb","startTime":1979.939,"endTime":1982.069,"body":"And remember,"},{"speaker":"Charles Goldfarb","startTime":1979.939,"endTime":1982.069,"body":"please subscribe wherever you"},{"speaker":"Charles Goldfarb","startTime":1982.069,"endTime":1983.179,"body":"get your podcast"},{"speaker":"Chris Dy","startTime":1983.21,"endTime":1985.43,"body":"and be sure to leave a"},{"speaker":"Chris Dy","startTime":1983.21,"endTime":1985.43,"body":"review that helps us get the"},{"speaker":"Chris Dy","startTime":1985.43,"endTime":1985.82,"body":"word out."},{"speaker":"Charles Goldfarb","startTime":1986.21,"endTime":1988.49,"body":"Special thanks"},{"speaker":"Charles Goldfarb","startTime":1986.21,"endTime":1988.49,"body":"to Peter Martin for the amazing"},{"speaker":"Charles Goldfarb","startTime":1988.49,"endTime":1992.48,"body":"music. And remember, keep the"},{"speaker":"Charles Goldfarb","startTime":1988.49,"endTime":1992.48,"body":"upper hand. Come back next time."}]}