Omakase

Monday, March 28, 2011

MJH Outpatient Surgery & Dr. Grant: two thumbs up!

Last week I had arthroscopic surgery performed on my left knee by Dr. Grant of Albemarle Orthopaedics at the Martha Jefferson Outpatient Surgery Center. I am now 5 days post-surgery and stunned at the ease and quality of the surgery, care, and facilities.

I first went to Dr. Grant in early fall 2010, though the injury was noticeable months before (I stupidly ran three triathlons on it before giving in to the pain.) I found Dr. Grant's practice through blind luck: I had been calling for an appointment at UVA's Sports Medicine practice, but after three days without a callback to schedule an appointment, I did a search online for local orthopaedists and stumbled onto Dr. Grant's web site.

My initial diagnosis last fall was a torn meniscus - a straighforward injury with non-surgical therapy - and was prescribed a cortisone shot and physical therapy at Move Better Physical Therapy in order to strengthen muscles near the meniscus to compensate.

The knee pain continued and a January cortisone shot had almost no effect. This lead to an MRI for my knee, and the finding that I had a chondral displacement, specifically that I had a roughly 10mm x 10mm area of my chondral cartilage completely missing, with significant deterioration of the remaining cartilage. This injury is typical only in the elderly - it's an accumulated injury. At one point, I was asked if I had an injury that precipitated this, as I was very, very young for this diagnosis. I answered no, but that I had played catcher in baseball for approximately 30 years. The response: "That'll do it."

So I had an osteoarthritic condition which would only get worse with time, severely limiting my mobility, fitness, and quality of life. (No more running or biking for me.) Treatment options were 1) treatment with euflexxa (an injectable acid) to artificially lubricate my knee, 2) simple chondral debridement (arthroscopic clean-up of the messy cartilage. No  permanent improvement resulting, but likely less pain and greater mobility), 3) surgical procedures to regrow/replace cartilage (more on this later), or 4) full knee replacement.

I immediately ruled out the full knee replacement, and began researching option#1. Euflexxa was appealing, but had 2 problems: it only treated the symptoms (i.e. the knee problem never went away - it would just hurt less frequently), and each injection provided benefit for only 2-4 months at a time, meaning that I would become a Euflexxa junkie - also bad because Euflexxa is expensive.

So surgery was the answer. The options, were simple clean-up (chondral debridement - a clear preference, though it's long term benefits are debatable), micro-fracture surgery to encourage growth of new cartilage, the "OATS Procedure" (another, more intense way to encourage cartilage growth), or
autologous chondrocyte implantation (ACI).

ACI is an amazing surgery - a portion of the injured cartilage is collected then sent to a lab in Boston to be grown into a larger piece of cartilage for re-implantation. This procedure is still new and quite expensive, but ideal for "young, healthy patients with medium to large sized damage to cartilage."


An indication of my extreme interest in my knee health is that even though ACI and the other knee procedures are expensive, I never blinked an eye at the financial commitment. (ACI alone is $20-35,000k. I'm pretty sure that I'll end up paying 20% of the final bill, but it is definitely worth it.)

The unnerving thing about surgery is that the most effective treatment option can't be determined until the surgeon sees the injury up close - in surgery. Surgery involves general anesthesia, so I could not participate in choosing the treatment while Dr. Grant was operating on my knee. I was more freaked out by this than the notion of undergoing surgery (with all of its' risks) or being knocked out. I guess I like to be in control.

The day of surgery came, and while I was nervous, it was a fantastic experience from start to finish.

To begin with, I was instructed to mark which knee was NOT to be operated on - a low tech, but effective step. I also had to go 12 hours without food or water, which was darn hard.

Martha Jefferson's outpatient facility is just a few years old and modern in every way. Given the lobby receptionist, my intake felt more like was visiting someone's business offices than I was about to undergo a medical procedure.

The day unfolded as I had been told to expect - except where MJH and the team exceeded expectations. For example, I had been told that the recovery from anesthesia would take 2-3 hours. However, I was conscious and eating animal crackers 45 minutes post-surgery. Dr. Don Mathes - my anesthetist - was an absolute maestro - verbally walking me thru the procedure, then delivering me on the other side quickly and with absolutely no nausea or side effects.

Dr. Grant was fantastic (as expected) on the day of surgery, and received high marks from someone who would know - my Mom.

My Mom just retired from a 40+ year career as an OR nurse in an outpatient surgery center very similar to MJH and was able to appraise the MJH facility and team (excellent), and got her peer's appraisal of Dr. Grant prior to my surgery. (From one nurse to another, my Mom was pulled aside and told that Dr. Grant was excellent. (You'd be surprised how often the nurse appraisal is "that Doc isn't very good," or "Dr. ______ is the one you want to see." A nurse's appraisal is worth any 100 other reviews.)

I have nothing but high praise for everyone else who worked on me that day. I wish I had a full list of the team that worked on me, but unfortunately I can only go by memory (hazy, due to the anesthesia). The two additional names that standout are Maggie Lebo (who prepped me for surgery), and Judy, an R.N. who screened me and walked me through the procedures.

I'm now 5 days post-surgery and feeling great. I used crutches and pain killers for the first 4 days post-surgery, but I am fully ambulatory (though tender) and have already had 2 physical therapy sessions.

I am under orders to take it easy for the next month. (I haven't even tried to climb a flight of stairs yet) and won't be allowed to bike or swim for about three weeks. In about 10 days I will see Dr. Grant for the post-surgery analysis. My hope is that the chondral debridement (clean-up) will be enough to get me back to pre-injury health, but it is probably 75% certain that I will undergo an additional surgery in 2-3 months to re-implant the replacement cartilage (ACI.) Unfortunately this is going to mess with my cycling and baseball goals this spring/summer, but I know that I will appreciate my improved knee health in the long term.

I'll also increase my appreciation for the US health care system. Politicians keep creating one-size fits all healthcare solutions, but my improved knee health (and overall experience) is only possible (and available at a reasonable price) through specialization. Instead of an expensive hospital stay, I was in and out in ~2 hours, and was able to benefit from the expertise of an orthopedics specialist.

Political solutions like Obamacare are firmly aligned against specialist practices. For example, there are all kinds of regulations against physician-ownership of outpatient facilities, and intense regulation of outpatient competition through things like "certificate of need" legislation. (In Florida, for example, you can not open a new hospital or surgical facility unless the nearby hospitals sign-off that there is a need for additional surgical capacity. In practice, this squishes competition.)

This most often takes the form of a big hospital lobbying to stop the permitting of a specialized center, such as for heart surgery. Heart surgery is fairly profitable for a large hospital, but a specialized (focused) center will deliver better results at a lower price. The big hospital fears that eventually the focused heart center will take customers away, raising the fixed price of all of the healthcare they deliver (e.g. still paying for the costs of establishing their heart center.)

In much the same spirit, my therapy was only possible due to R&D incented by the American healthcare system and profit motive. Only ~10,000 patients have had my surgery so far, and this would not be possible without clinicians mindful of adopting new, advanced procedures (due to the pressure of market competition, rather than the status quo of nationalized healthcare), and my ACI therapy would not be possible without the R&D and regulatory effort by Genzyme (an American biotech company.)

The regulatory pressures (as from Obamacare) combine to make our healthcare more expensive and less effective as possible. There are additional dimensions to the US system that I experienced that will make for another post (for example, I was ~3 weeks from decision to surgery. In Canada or the UK, I'd be lucky to experience 3 months from decision to surgery), but suffice to say, I had an excellent experience with Dr. Grant, his team, MJH, and the US healthcare system.

Monday, March 14, 2011

Two different tsunami stories of huge magnitude

Something about the Japan tsunami and quake that blew me away: as reported by CNN, the quake moved the main island of Japan 8 feet and moved the Earth's axis 4 inches. This was caused by the 18-meter (~59 foot) movement of two tectonic plates off of Japan. Unbelievable, as is this picture:

(My guess is that the airbase didn't have enough pilots on duty to move the plane in advance of the tsunami.)

and.....

Apparently, researchers believe that Atlantis has been found (in Spain), and that Atlantis was the victim of.....you guessed it, a tsunami

With my new friends on the Great Wall of China

With my new friends on the Great Wall of China
Click to go to my online photography

World sun clock

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Uncommon Man's Creed

"I do not choose to be a common man. It is my right to be uncommon -- if I can. I seek opportunity -- not security. I do not wish to be a kept citizen, humbled and dulled by having the state look after me. I wish to take the calculated risk; to dream and to build, to fail and to succeed. I refuse to barter incentive for a dole, I prefer the challenges of life to the guaranteed existence; the thrill of fulfillment to the stale calm of utopia. I will not trade freedom for beneficence, nor my dignity for a handout. I will never cower before any master, nor bend to any threat. It is my heritage to stand erect, proud, and unafraid, to think and act for myself, to enjoy the benefit of my creations, and to face the world boldly and say, "this I have done." All this is what it means to be an American." -- Anonymous