This is Alan Condon with the Becker's ASC
podcast, and I'm thrilled to be joined today
by doctor Armin Voskiridyan,
director of anesthesia
services at Jefferson Surgical Center at the Navy
Yard in Philadelphia.
Arman, a real pleasure to have you on
your podcast today with us. Before we dive
into our discussion,
could you I'm gonna turn the floor over
to you just to hear a little bit
more about your role and your background at
Jeff Jefferson Surgical Center.
Sure, Alan. It's a pleasure to be here.
So I'm double boarded in internal medicine and
anesthesia.
I started out in education
in terms of working at my residency program
for 2 years. I did private practice for
2 years,
and then I moved down to Philadelphia. That
was in New York City. I moved down
to Philadelphia.
I worked at, Albert Einstein Medical Center in
North Philly for 10 years, and then I
found a job at a private practice
surgical center, and that's where I am now
and I that's where I've been for the
past 10 years.
I did not learn how to do nerve
blocks in residency. At the time, there was
no ultrasound
miniaturization.
The ultrasounds were huge and they weren't used
at the bedside.
And, the methods that were used at that
time were basically anatomical landmarks
and using electrical stimulation,
decreasing the current, getting closer and closer to
the nerve, and
almost 50% of the time, the blocks wouldn't
work.
So I was not a fan of doing
this because in the end, we had to
give some morphine or some sort of narcotic
in the recovery room. So what was the
point of doing all this? This all changed
in
around the, early
2000 mid 2000 year, era. I think it
was DARPA that was given
the,
initiative by the military to miniaturize the ultrasound
and during Iraq war 1.
And so this this occurred. And when I
started seeing the ultrasound being used in nerve
blocks where you can actually see the nerve,
you can see the needle, you can approach,
you can see the larger vessels,
I immediately lit up. And I said, this
is something I wanna do.
And so,
credit to my chairman. He saw that I
was pretty good at it. He, said, go
ahead and
take your weekends and go to any type
of CME courses you can, and that's what
I did. I went all over the country
from Florida to Colorado,
Harvard, California,
and, I any 3 day weekend course that
there was, I took, and it just took
off from there. So my skills became very
valuable,
when I entered this ambulatory surge orthopedic ambulatory
surgery center.
So all we do at this ambulatory surgery
center is outpatient orthopedics.
Everything from shoulder,
scopes and rotator cuff repairs, elbows, wrists,
hips,
nothing joint replacement related, but everything other than
that, hip scopes,
knees, ACLs,
MPFLs,
any kind of knee surgery in that, quadriceps
repair, patella tendon repair, and all foot and
ankle cases.
Liz Frank cases, Achilles tendon ruptures,
trimal, bimal.
So
that's,
my background, basically.
Fantastic. So all honestly,
very orthopedic focused. That's all you do. No
joint replacement from what you from what I
gather. And do you is spine surgery a
specialty that that that takes place there or
no? No. It's actually,
we don't do any spine cases. Although,
I work very closely with the Rothman doctors
at my facility. They do have a specialty
hospital
close by that does spine cases, but we
don't do any at our ambulatory surgery center.
Gotcha. Very familiar with, doctor Alex Vaccaro and
a lot of the surgeons at Rotman as
well. Oh, exactly. No doubt your next door
neighbors there.
Yeah. I would love to get some
perspective. Obviously, in in the in the ASC
space,
so much going on at any one point
in time. But what what are 2 or
3 trends that you're really paying close attention
to, in the ASC space today?
The one that's most impactful I think currently
is the cost of anesthesia providers,
cRNA and physicians.
The cost is escalating,
the reimbursements are declining
And when the federal government reduces its rates,
the private insurance insurance companies follow. You can't
keep reducing
reimbursement
and
keep expecting to hold on to talent.
That's
one of the big trends that I'm noticing.
It's getting harder and harder to maintain talent
and to maintain
successful practices
because of the lack of
reimbursement.
What's eventually happening is that anesthesia practices
are
requiring,
supplemental incomes from
either the institution they're working at, whether it
be a hospital or a surgical center, and
that's becoming burdensome because it's cutting into their
profits.
So this is definitely one of the trends
negative trends that I'm seeing.
The positive trends are
an incredible ability, especially again in my field,
which is outpatient ambulatory orthopedic surgery,
for nerve blocks, ultrasound guided nerve blocks,
and the use of liposomal bupivacaine,
to prolong the action of those blocks
and
may basically make outpatient ambulatory orthopedic surgery
a
non narcotic 0 narcotic to minimal narcotic use
procedure
experience for the patient.
These are, I think, are the top two
trends that I can,
speak most strongly on.
Yeah. Yeah. Absolutely. I think the the first
one, in terms of the cost of anesthesia
providers,
no doubt such a challenge across the health
care space in terms of to your point,
how do you retain talent, especially with
anesthesia providers requiring supplemental income?
I'm curious to hear just a little bit
more about that. No doubt it is a
challenge to retain the top talent in this
area. But is there anything that ASCs or
your organization is doing to to help keep,
keep a hold of those, the top talent
in terms of anesthesia providers?
I wish I had a magic bullet type
of answer for you. Unfortunately,
the bottom line becomes finance, money. People are
not gonna work for free.
And when other institutions that do have the
financial backing, whether that be private or through
other means,
are offering
larger salaries, the talent is gonna go where
the money is. And that's gonna require a
lot of interesting
solutions, which I I unfortunately don't have the
answer to right away,
as to how to address this.
Ambulatory surgery administrators are going to have to
get very creative
in
trying to maintain and retain their talent, whether
that means limiting the hours of the surgical
center so that we don't have later days
running, whether that means extra weeks of vacation
or,
financial remuneration,
which will unfortunately have to come out of
the bottom line of the ASC.
Otherwise, I don't I don't see a way
out of this conundrum.
Yeah. No doubt no doubt it's something that's
top of mind for providers, ASCs,
independent practices across the country.
I'm curious to hear a bit more about
Jefferson Surgery Center.
When you think about the next 12 months
to 24 months, obviously, the orthopedic focused surgery
center, how are you thinking about growth?
Is it adding more providers,
expanding specialties, more higher acuity procedures?
What are you most focused on?
I think the focus
is going based on what we just talked
about,
understandably,
newer surgeons are going to be slower than
experienced surgeons,
but there are some
even within the experienced surgeons, there's variation.
The administration of ambulatory surgery centers is going
to have to focus and find a way
to try and
maximize
the efficiency
of all their surgeons. We want increased productivity.
Obviously, it's safety is always the key issue
here. We want safe, successful
operations,
but within that range,
there are some surgeons that are slower than
other surgeons. And to maximize efficiency,
you have to be able to reward the
surgeons that
understand this fact
and somehow
either encourage
the other surgeons to try and emulate that
or, unfortunately,
if they can't keep up,
you'll have to try to find a way
to tell those surgeons
to this this is not the place for
you. This is an ambulatory surgery center is
not the real place to do teaching like
a,
an educational center.
And,
then it it's it's very difficult because you
form relationships with your surgeons. You don't wanna
tell someone that you have a good relationship
with. You need to speed up or move
out.
But, unfortunately,
this is the reality that's that the administration
the administrators are,
coming face to face with.
You can't keep slow surgeons
and a profitable surgery center. It's just not
gonna work.
Mhmm. Yeah. I'm curious
from your perspective, obviously, as director of anesthesia
services,
and and the surgeons that you work with,
they use such a close partnership with. What
do the the best surgeons or, I should
say, the most efficient surgeons, what do they
do exceptionally well?
Oh,
it's hard to pinpoint exactly what they're doing.
Again, I'm an anesthesiologist.
So seeing from surgical technique,
it's you'd know
who the efficient ones are. What they're actually
doing that makes them more efficient is more
of a surgical
question than an anesthes and from an anesthesia
perspective, I wouldn't be able to pin pinpoint
what those are. I can tell you who
the efficient surgeons are, and I can tell
you who the inefficient surgeons are. But, unfortunately,
I I can't determine how that,
how to how that translates
when you're actually hands on. Now
we do have residents and fellows coming through
our, surgery center at Jefferson,
and I understand the necessity of teaching
residents, surgeons.
I also have partnered with Jefferson
System to get a fellowship program for ultrasound
guided regional anesthesia,
and I've been able to incorporate
that teaching,
without slowing down the pace of the operating
room.
There are ways that this can be accomplished.
There are teachers that teach
and work efficiently as well.
There are others that are not so, efficient,
unfortunately,
and
it's the balance has to be struck,
and this is a difficult conversation to have
because, again, like I said, you develop relationships
with your surgeons.
No. You don't wanna tell anybody that, they're
not keeping up. However, there may be ways
that administrators can, achieve this, whether that be,
Excel spreadsheets where you can compare
surgeons and surgeries
and, you know, have a meeting with them
and say, look. These are our top performers.
These are our middle performers. These are our
lower performers,
and it has to be,
it has to be a group effort. The
surgeons have to be on board with this,
and perhaps they can communicate with each other
and see learn from each other and pass
these tips and tricks onto each other as
to how to be more efficient.
Yeah. Because we all know that answered your
question, Alan.
No. Absolutely. I think we all know, you
know, how competitive surgeons can often be as
well. I think that might be a
a great little insight to take away in
terms of tracking performance, measuring, sharing some of
these tips and tricks along the way, especially
to your point, some of the the newer
surgeons, the next generation who might be coming
out of residencies and fellowships as well.
Armin, really, really fascinating discussion so far. I
get more of an insight into you, your
background, your surgery center. When you look ahead
to the future, what are you most excited
about?
I am most obviously, this is gonna be
a little selfish of me. I'm most excited
about the work we're doing at the Navy
Yard
and the work I'm doing with the liposomal
bupivacaine.
I've come up with a formulation,
on my own, believe it or not. And,
what we're getting the results we're getting,
with these with this formulation is
astounding to say the least. We have 3
papers that are in the process of
of of we're we have 3 studies that
we are in the process of,
getting to to journals.
The first one is on ACL repair.
The second one is on foot and ankle,
and the third one is on shoulder surgery.
But I've used this formulation of mine on
clavicle fractures,
on elbow surgeries,
on hip surgeries,
and the results we're getting are tremendous.
Let me circle back and say we are
on the cusp of announcing
0 to minimal narcotic
use outpatient ambulatory orthopedic surgery.
We're doing cases for the foot and ankle,
Achilles tendon rupture repairs,
trimalleolar,
bimalleolar
ankle fractures,
Liz Frank Liz Frank fractures of the foot,
and our patients are taking 0 narcotics. We're
getting upwards of 10 days of numbness from
my nerve blocks.
This formulation,
I think, has the potential to change the
face of outpatient ambulatory orthopedic surgery. For ACL
repairs, I'm getting approximately 5 to 7 days
of pain free nerve nerve blockade.
If I can drop names, it was doctor
Christopher Dodson who first noticed it. I actually
sort of snuck in
this formulation without telling any of the surgeons.
I did my own little research,
and I just started doing what I wanted
to do, so to speak,
despite the fact that liposomal bupivacaine comes with
a couple of,
caveats that you're not supposed to mix it
with anything. But suffice it to say,
that I took the extra step there in
faith and myself and, my skills, and I
did,
take mix it with something,
and, that will be revealed in the studies,
obviously.
But,
the bottom line was, about 6, 7 months
into it, doctor Dodson pulled me aside, and
he said, what's going on, Arman? And I
said, I don't know what you're talking about,
Chris. And he said, well, all of my
physician assistants and all of my physical therapists
are coming up to me and not telling
me that the patients aren't using their narcotics.
They're going through rehab
without complaining of too much pain
and without taking narcotics pre and post.
I haven't changed my surgical technique, Armin, so
it's you. What are you doing differently? And
that's when I had to confess to him,
that, I had come up with this formulation
with liposomal bupivacaine,
and
he was shaking his head, and he said,
Armin, this is a game changer. We need
to publish this. We need to get studies
done. This has to get out there. We
need to we need to broadcast this to
the rest of the, ambulatory orthopedic community and
the sports community as well. This is a
game changer, he said. So,
encouraged by his, kind words,
I went we went ahead and we got
IRB approval from,
Jefferson Health System.
And like I said, we have these 3
studies. The first step will be published is
the ACL study. I believe the second will
be the foot and ankle study, and then
we'll have the shoulder study to compare.
As just an anecdotal,
if I can continue?
Yeah. Absolutely.
As an anecdotal example,
I have dinner with,
my,
friends from Einstein. I have, close friends from
there, 2 cRNA friends, and I was bragging
to them about my results. And one of
my friends,
George, he started tearing up, and he said,
Armin, I've been putting off my knee replacement
surgery for 2 years now. I'm so scared
of the rehab and the pain involved.
Would you be able to do this for
me?
And I this is my buddy. So I
I said, look. Well, let's try. Let's try
ahead. And so we talked to doctor Matt
Austin at, at that time, he was at
the Rothman Orthopedic Specialty Hospital doing knee replacements.
I believe he's at the hospital for special
surgery now in New York City. But, I
told him my plan. I made my request.
He, graciously approved.
And so George went ahead with his knee
replacement. I did his spinal. I did his,
nerve blocks with the liposomal
bupivacaine formulation that I come came up with.
And, Alan, he went through his knee replacement.
They put him back to rehab the very
day that very day.
He I followed up with him every day
for 25 days, texting him constantly, calling him.
He took 0 narcotics after his total knee
replacement.
So this is not just for the ambulatory
surgeries we do at the Navy Yard. This,
I think, can have long reaching effects for,
replace joint replacement surgeries as well. Now granted,
that's just one patient, but the results were
so
glaringly
obvious that I think it's going to make
a difference. And then we'll have to study
that as well, publish a study on that.
Perhaps not myself, someone else might be able
to do that because we don't do joint
replacement. But I think this is a very
this is what I'm most excited about.
Well, I'm I'm so glad that you took
the opportunity to to toot your own horn
there. I mean, so so very well deserved
and fascinating to hear about all the excellent
work that you're doing, that your team is
doing.
0 to minimal narcotic use for some of
these outpace outpatient orthopedic
procedures. And no doubt the patients are reaping
the benefits there as well.
I'd love if you could share those studies
with us when they inevitably do get published.
We'd love to publish them and cover them
also on Becker's. Armit, a real pleasure to
have you on the podcast today. Fascinating discussion.
Congratulations on everything you achieved and really, really,
all the best for the future as well.
Thank you so much.
Alan, thank you very much. And and I
wanna focus on one last thing that you
just said there. It's a team effort. This
is not something I could do by myself.
There's so many people that are involved in
supporting
us in what we do at the Navy
Yard. Everybody from environmental services to our surgeons
to our administrators and most of all, of
course, our nurses and nurse anesthetists.
It's a team effort. Nobody is no one
individual is more important than any other individual.
So and again, thank you for the opportunity
for speaking with me and, getting this information
out there. Thank you.
My pleasure. Thank you so much, Aaron.