1 00:00:00,480 --> 00:00:03,299 This is Alan Condon with the Becker's ASC 2 00:00:03,359 --> 00:00:06,019 podcast, and I'm thrilled to be joined today 3 00:00:06,080 --> 00:00:08,019 by doctor Armin Voskiridyan, 4 00:00:08,880 --> 00:00:10,179 director of anesthesia 5 00:00:10,480 --> 00:00:13,919 services at Jefferson Surgical Center at the Navy 6 00:00:13,919 --> 00:00:15,219 Yard in Philadelphia. 7 00:00:15,835 --> 00:00:18,074 Arman, a real pleasure to have you on 8 00:00:18,074 --> 00:00:21,035 your podcast today with us. Before we dive 9 00:00:21,035 --> 00:00:22,095 into our discussion, 10 00:00:22,475 --> 00:00:23,914 could you I'm gonna turn the floor over 11 00:00:23,914 --> 00:00:25,195 to you just to hear a little bit 12 00:00:25,195 --> 00:00:27,515 more about your role and your background at 13 00:00:27,515 --> 00:00:29,214 Jeff Jefferson Surgical Center. 14 00:00:29,879 --> 00:00:31,739 Sure, Alan. It's a pleasure to be here. 15 00:00:31,879 --> 00:00:35,579 So I'm double boarded in internal medicine and 16 00:00:36,119 --> 00:00:36,619 anesthesia. 17 00:00:37,320 --> 00:00:39,420 I started out in education 18 00:00:39,719 --> 00:00:42,600 in terms of working at my residency program 19 00:00:42,600 --> 00:00:44,520 for 2 years. I did private practice for 20 00:00:44,520 --> 00:00:45,104 2 years, 21 00:00:45,585 --> 00:00:47,344 and then I moved down to Philadelphia. That 22 00:00:47,344 --> 00:00:48,625 was in New York City. I moved down 23 00:00:48,625 --> 00:00:49,364 to Philadelphia. 24 00:00:49,825 --> 00:00:52,784 I worked at, Albert Einstein Medical Center in 25 00:00:52,784 --> 00:00:55,504 North Philly for 10 years, and then I 26 00:00:55,504 --> 00:00:57,765 found a job at a private practice 27 00:00:58,465 --> 00:01:00,659 surgical center, and that's where I am now 28 00:01:00,659 --> 00:01:01,939 and I that's where I've been for the 29 00:01:01,939 --> 00:01:02,920 past 10 years. 30 00:01:03,379 --> 00:01:05,939 I did not learn how to do nerve 31 00:01:05,939 --> 00:01:08,420 blocks in residency. At the time, there was 32 00:01:08,420 --> 00:01:09,640 no ultrasound 33 00:01:10,099 --> 00:01:10,599 miniaturization. 34 00:01:11,540 --> 00:01:13,619 The ultrasounds were huge and they weren't used 35 00:01:13,619 --> 00:01:14,439 at the bedside. 36 00:01:15,104 --> 00:01:17,744 And, the methods that were used at that 37 00:01:17,744 --> 00:01:20,405 time were basically anatomical landmarks 38 00:01:20,784 --> 00:01:22,325 and using electrical stimulation, 39 00:01:23,104 --> 00:01:25,424 decreasing the current, getting closer and closer to 40 00:01:25,424 --> 00:01:26,644 the nerve, and 41 00:01:26,944 --> 00:01:29,424 almost 50% of the time, the blocks wouldn't 42 00:01:29,424 --> 00:01:29,924 work. 43 00:01:30,280 --> 00:01:32,680 So I was not a fan of doing 44 00:01:32,680 --> 00:01:34,120 this because in the end, we had to 45 00:01:34,120 --> 00:01:35,959 give some morphine or some sort of narcotic 46 00:01:35,959 --> 00:01:37,719 in the recovery room. So what was the 47 00:01:37,719 --> 00:01:40,040 point of doing all this? This all changed 48 00:01:40,040 --> 00:01:40,540 in 49 00:01:40,840 --> 00:01:42,460 around the, early 50 00:01:43,114 --> 00:01:46,075 2000 mid 2000 year, era. I think it 51 00:01:46,075 --> 00:01:48,254 was DARPA that was given 52 00:01:48,795 --> 00:01:49,194 the, 53 00:01:49,834 --> 00:01:53,614 initiative by the military to miniaturize the ultrasound 54 00:01:54,234 --> 00:01:55,935 and during Iraq war 1. 55 00:01:56,489 --> 00:01:59,370 And so this this occurred. And when I 56 00:01:59,370 --> 00:02:01,930 started seeing the ultrasound being used in nerve 57 00:02:01,930 --> 00:02:03,950 blocks where you can actually see the nerve, 58 00:02:04,090 --> 00:02:06,170 you can see the needle, you can approach, 59 00:02:06,170 --> 00:02:07,629 you can see the larger vessels, 60 00:02:08,090 --> 00:02:09,770 I immediately lit up. And I said, this 61 00:02:09,770 --> 00:02:11,150 is something I wanna do. 62 00:02:11,474 --> 00:02:12,215 And so, 63 00:02:12,594 --> 00:02:14,514 credit to my chairman. He saw that I 64 00:02:14,514 --> 00:02:16,995 was pretty good at it. He, said, go 65 00:02:16,995 --> 00:02:17,735 ahead and 66 00:02:18,034 --> 00:02:20,514 take your weekends and go to any type 67 00:02:20,514 --> 00:02:22,594 of CME courses you can, and that's what 68 00:02:22,594 --> 00:02:24,534 I did. I went all over the country 69 00:02:24,675 --> 00:02:26,375 from Florida to Colorado, 70 00:02:27,439 --> 00:02:28,739 Harvard, California, 71 00:02:29,599 --> 00:02:32,319 and, I any 3 day weekend course that 72 00:02:32,319 --> 00:02:34,639 there was, I took, and it just took 73 00:02:34,639 --> 00:02:37,280 off from there. So my skills became very 74 00:02:37,280 --> 00:02:37,780 valuable, 75 00:02:38,319 --> 00:02:41,379 when I entered this ambulatory surge orthopedic ambulatory 76 00:02:41,599 --> 00:02:42,500 surgery center. 77 00:02:42,844 --> 00:02:44,764 So all we do at this ambulatory surgery 78 00:02:44,764 --> 00:02:46,224 center is outpatient orthopedics. 79 00:02:46,604 --> 00:02:47,905 Everything from shoulder, 80 00:02:48,685 --> 00:02:51,745 scopes and rotator cuff repairs, elbows, wrists, 81 00:02:52,125 --> 00:02:52,625 hips, 82 00:02:52,925 --> 00:02:56,044 nothing joint replacement related, but everything other than 83 00:02:56,044 --> 00:02:57,104 that, hip scopes, 84 00:02:57,480 --> 00:02:58,700 knees, ACLs, 85 00:02:59,080 --> 00:02:59,580 MPFLs, 86 00:03:00,439 --> 00:03:02,540 any kind of knee surgery in that, quadriceps 87 00:03:02,760 --> 00:03:05,400 repair, patella tendon repair, and all foot and 88 00:03:05,400 --> 00:03:06,219 ankle cases. 89 00:03:06,760 --> 00:03:09,020 Liz Frank cases, Achilles tendon ruptures, 90 00:03:09,319 --> 00:03:10,460 trimal, bimal. 91 00:03:10,865 --> 00:03:11,365 So 92 00:03:11,665 --> 00:03:12,145 that's, 93 00:03:12,544 --> 00:03:13,685 my background, basically. 94 00:03:14,705 --> 00:03:16,805 Fantastic. So all honestly, 95 00:03:17,185 --> 00:03:20,245 very orthopedic focused. That's all you do. No 96 00:03:20,465 --> 00:03:22,544 joint replacement from what you from what I 97 00:03:22,544 --> 00:03:24,705 gather. And do you is spine surgery a 98 00:03:24,705 --> 00:03:27,150 specialty that that takes place there or 99 00:03:27,610 --> 00:03:28,830 no? No. It's actually, 100 00:03:29,210 --> 00:03:31,389 we don't do any spine cases. Although, 101 00:03:31,930 --> 00:03:34,250 I work very closely with the Rothman doctors 102 00:03:34,250 --> 00:03:36,909 at my facility. They do have a specialty 103 00:03:37,050 --> 00:03:37,550 hospital 104 00:03:37,925 --> 00:03:40,165 close by that does spine cases, but we 105 00:03:40,165 --> 00:03:42,504 don't do any at our ambulatory surgery center. 106 00:03:43,125 --> 00:03:45,764 Gotcha. Very familiar with, doctor Alex Vaccaro and 107 00:03:45,764 --> 00:03:47,525 a lot of the surgeons at Rotman as 108 00:03:47,525 --> 00:03:50,165 well. Oh, exactly. No doubt your next door 109 00:03:50,165 --> 00:03:51,064 neighbor is there. 110 00:03:51,525 --> 00:03:53,784 Yeah. I would love to get some 111 00:03:54,219 --> 00:03:56,460 perspective. Obviously, in in the in the ASC 112 00:03:56,460 --> 00:03:56,960 space, 113 00:03:57,500 --> 00:03:59,180 so much going on at any one point 114 00:03:59,180 --> 00:04:01,420 in time. But what what are 2 or 115 00:04:01,420 --> 00:04:04,560 3 trends that you're really paying close attention 116 00:04:04,620 --> 00:04:06,960 to, in the ASC space today? 117 00:04:08,415 --> 00:04:11,555 The one that's most impactful I think currently 118 00:04:11,775 --> 00:04:14,754 is the cost of anesthesia providers, 119 00:04:15,455 --> 00:04:17,235 cRNA and physicians. 120 00:04:18,014 --> 00:04:19,475 The cost is escalating, 121 00:04:20,175 --> 00:04:22,115 the reimbursements are declining 122 00:04:22,589 --> 00:04:25,330 And when the federal government reduces its rates, 123 00:04:25,709 --> 00:04:29,709 the private insurance insurance companies follow. You can't 124 00:04:29,709 --> 00:04:30,449 keep reducing 125 00:04:30,830 --> 00:04:31,330 reimbursement 126 00:04:32,270 --> 00:04:32,770 and 127 00:04:33,149 --> 00:04:35,889 keep expecting to hold on to talent. 128 00:04:36,524 --> 00:04:37,024 That's 129 00:04:37,324 --> 00:04:39,745 one of the big trends that I'm noticing. 130 00:04:39,884 --> 00:04:42,944 It's getting harder and harder to maintain talent 131 00:04:43,564 --> 00:04:45,024 and to maintain 132 00:04:45,324 --> 00:04:46,384 successful practices 133 00:04:47,084 --> 00:04:48,545 because of the lack of 134 00:04:48,925 --> 00:04:49,425 reimbursement. 135 00:04:49,884 --> 00:04:53,240 What's eventually happening is that anesthesia practices 136 00:04:53,540 --> 00:04:54,040 are 137 00:04:54,819 --> 00:04:55,319 requiring, 138 00:04:56,500 --> 00:04:58,360 supplemental incomes from 139 00:04:58,740 --> 00:05:00,899 either the institution they're working at, whether it 140 00:05:00,899 --> 00:05:03,139 be a hospital or a surgical center, and 141 00:05:03,139 --> 00:05:05,699 that's becoming burdensome because it's cutting into their 142 00:05:05,699 --> 00:05:06,199 profits. 143 00:05:07,194 --> 00:05:09,514 So this is definitely one of the trends 144 00:05:09,995 --> 00:05:11,615 negative trends that I'm seeing. 145 00:05:12,235 --> 00:05:13,774 The positive trends are 146 00:05:14,235 --> 00:05:17,355 an incredible ability, especially again in my field, 147 00:05:17,355 --> 00:05:19,855 which is outpatient ambulatory orthopedic surgery, 148 00:05:20,629 --> 00:05:23,689 for nerve blocks, ultrasound guided nerve blocks, 149 00:05:23,990 --> 00:05:26,250 and the use of liposomal bupivacaine, 150 00:05:27,509 --> 00:05:29,770 to prolong the action of those blocks 151 00:05:30,310 --> 00:05:30,810 and 152 00:05:31,189 --> 00:05:34,889 may basically make outpatient ambulatory orthopedic surgery 153 00:05:35,270 --> 00:05:35,770 a 154 00:05:36,464 --> 00:05:40,084 non narcotic 0 narcotic to minimal narcotic use 155 00:05:40,224 --> 00:05:40,724 procedure 156 00:05:41,504 --> 00:05:42,884 experience for the patient. 157 00:05:43,185 --> 00:05:44,544 These are, I think, are the top two 158 00:05:44,544 --> 00:05:45,745 trends that I can, 159 00:05:46,144 --> 00:05:47,764 speak most strongly on. 160 00:05:48,279 --> 00:05:50,519 Yeah. Yeah. Absolutely. I think the the first 161 00:05:50,519 --> 00:05:52,860 one, in terms of the cost of anesthesia 162 00:05:52,919 --> 00:05:53,419 providers, 163 00:05:53,959 --> 00:05:56,439 no doubt such a challenge across the health 164 00:05:56,439 --> 00:05:58,759 care space in terms of to your point, 165 00:05:58,759 --> 00:06:00,939 how do you retain talent, especially with 166 00:06:01,334 --> 00:06:04,154 anesthesia providers requiring supplemental income? 167 00:06:05,175 --> 00:06:06,855 I'm curious to hear just a little bit 168 00:06:06,855 --> 00:06:08,774 more about that. No doubt it is a 169 00:06:08,774 --> 00:06:11,095 challenge to retain the top talent in this 170 00:06:11,095 --> 00:06:13,495 area. But is there anything that ASCs or 171 00:06:13,495 --> 00:06:15,740 your organization is doing to to help keep, 172 00:06:16,019 --> 00:06:17,939 keep a hold of those, the top talent 173 00:06:17,939 --> 00:06:19,480 in terms of anesthesia providers? 174 00:06:20,660 --> 00:06:22,740 I wish I had a magic bullet type 175 00:06:22,740 --> 00:06:24,279 of answer for you. Unfortunately, 176 00:06:24,660 --> 00:06:28,019 the bottom line becomes finance, money. People are 177 00:06:28,019 --> 00:06:29,384 not gonna work for free. 178 00:06:29,944 --> 00:06:32,345 And when other institutions that do have the 179 00:06:32,345 --> 00:06:35,545 financial backing, whether that be private or through 180 00:06:35,545 --> 00:06:36,285 other means, 181 00:06:36,904 --> 00:06:37,564 are offering 182 00:06:37,944 --> 00:06:40,345 larger salaries, the talent is gonna go where 183 00:06:40,345 --> 00:06:43,384 the money is. And that's gonna require a 184 00:06:43,384 --> 00:06:44,605 lot of interesting 185 00:06:46,319 --> 00:06:48,879 solutions, which I I unfortunately don't have the 186 00:06:48,879 --> 00:06:50,019 answer to right away, 187 00:06:50,959 --> 00:06:52,659 as to how to address this. 188 00:06:53,039 --> 00:06:55,680 Ambulatory surgery administrators are going to have to 189 00:06:55,680 --> 00:06:56,899 get very creative 190 00:06:57,279 --> 00:06:57,779 in 191 00:06:58,105 --> 00:07:01,225 trying to maintain and retain their talent, whether 192 00:07:01,225 --> 00:07:04,185 that means limiting the hours of the surgical 193 00:07:04,185 --> 00:07:06,585 center so that we don't have later days 194 00:07:06,585 --> 00:07:09,564 running, whether that means extra weeks of vacation 195 00:07:10,229 --> 00:07:10,729 or, 196 00:07:11,750 --> 00:07:12,649 financial remuneration, 197 00:07:13,110 --> 00:07:15,349 which will unfortunately have to come out of 198 00:07:15,349 --> 00:07:17,289 the bottom line of the ASC. 199 00:07:18,149 --> 00:07:20,949 Otherwise, I don't I don't see a way 200 00:07:20,949 --> 00:07:22,329 out of this conundrum. 201 00:07:23,854 --> 00:07:25,535 Yeah. No doubt no doubt it's something that's 202 00:07:25,535 --> 00:07:27,634 top of mind for providers, ASCs, 203 00:07:27,935 --> 00:07:30,194 independent practices across the country. 204 00:07:31,214 --> 00:07:33,694 I'm curious to hear a bit more about 205 00:07:33,694 --> 00:07:35,154 Jefferson Surgery Center. 206 00:07:35,935 --> 00:07:38,014 When you think about the next 12 months 207 00:07:38,014 --> 00:07:41,419 to 24 months, obviously, the orthopedic focused surgery 208 00:07:41,419 --> 00:07:43,600 center, how are you thinking about growth? 209 00:07:43,979 --> 00:07:45,439 Is it adding more providers, 210 00:07:45,819 --> 00:07:48,319 expanding specialties, more higher acuity procedures? 211 00:07:48,779 --> 00:07:50,319 What are you most focused on? 212 00:07:51,634 --> 00:07:53,095 I think the focus 213 00:07:53,475 --> 00:07:55,394 is going based on what we just talked 214 00:07:55,394 --> 00:07:55,894 about, 215 00:07:56,354 --> 00:07:56,854 understandably, 216 00:07:57,235 --> 00:08:00,214 newer surgeons are going to be slower than 217 00:08:00,435 --> 00:08:01,495 experienced surgeons, 218 00:08:01,875 --> 00:08:02,834 but there are some 219 00:08:03,314 --> 00:08:06,055 even within the experienced surgeons, there's variation. 220 00:08:06,870 --> 00:08:09,830 The administration of ambulatory surgery centers is going 221 00:08:09,830 --> 00:08:11,770 to have to focus and find a way 222 00:08:12,069 --> 00:08:13,209 to try and 223 00:08:13,670 --> 00:08:14,170 maximize 224 00:08:14,790 --> 00:08:15,529 the efficiency 225 00:08:15,830 --> 00:08:19,050 of all their surgeons. We want increased productivity. 226 00:08:19,189 --> 00:08:21,589 Obviously, it's safety is always the key issue 227 00:08:21,589 --> 00:08:23,725 here. We want safe, successful 228 00:08:24,105 --> 00:08:24,605 operations, 229 00:08:24,985 --> 00:08:26,524 but within that range, 230 00:08:26,985 --> 00:08:28,985 there are some surgeons that are slower than 231 00:08:28,985 --> 00:08:31,245 other surgeons. And to maximize efficiency, 232 00:08:31,625 --> 00:08:34,024 you have to be able to reward the 233 00:08:34,024 --> 00:08:35,164 surgeons that 234 00:08:35,570 --> 00:08:36,789 understand this fact 235 00:08:37,169 --> 00:08:37,909 and somehow 236 00:08:38,370 --> 00:08:39,269 either encourage 237 00:08:39,970 --> 00:08:42,629 the other surgeons to try and emulate that 238 00:08:42,769 --> 00:08:44,070 or, unfortunately, 239 00:08:44,450 --> 00:08:46,230 if they can't keep up, 240 00:08:46,529 --> 00:08:48,129 you'll have to try to find a way 241 00:08:48,129 --> 00:08:50,075 to tell those surgeons 242 00:08:50,535 --> 00:08:52,054 to this this is not the place for 243 00:08:52,054 --> 00:08:54,375 you. This is an ambulatory surgery center is 244 00:08:54,375 --> 00:08:57,575 not the real place to do teaching like 245 00:08:57,575 --> 00:08:58,075 a, 246 00:09:00,215 --> 00:09:01,595 an educational center. 247 00:09:02,210 --> 00:09:02,690 And, 248 00:09:03,170 --> 00:09:06,210 then it it's it's very difficult because you 249 00:09:06,210 --> 00:09:09,009 form relationships with your surgeons. You don't wanna 250 00:09:09,009 --> 00:09:11,029 tell someone that you have a good relationship 251 00:09:11,090 --> 00:09:13,250 with. You need to speed up or move 252 00:09:13,250 --> 00:09:13,750 out. 253 00:09:14,075 --> 00:09:14,894 But, unfortunately, 254 00:09:15,595 --> 00:09:18,654 this is the reality that's that the administration 255 00:09:19,115 --> 00:09:20,575 the administrators are, 256 00:09:21,434 --> 00:09:22,975 coming face to face with. 257 00:09:24,154 --> 00:09:26,654 You can't keep slow surgeons 258 00:09:27,750 --> 00:09:30,309 and a profitable surgery center. It's just not 259 00:09:30,309 --> 00:09:31,129 gonna work. 260 00:09:32,230 --> 00:09:33,769 Mhmm. Yeah. I'm curious 261 00:09:34,389 --> 00:09:37,049 from your perspective, obviously, as director of anesthesia 262 00:09:37,190 --> 00:09:37,690 services, 263 00:09:38,870 --> 00:09:40,710 and and the surgeons that you work with, 264 00:09:40,710 --> 00:09:43,225 they use such a close partnership with. What 265 00:09:43,225 --> 00:09:45,544 do the the best surgeons or, I should 266 00:09:45,544 --> 00:09:48,024 say, the most efficient surgeons, what do they 267 00:09:48,024 --> 00:09:49,404 do exceptionally well? 268 00:09:50,184 --> 00:09:50,684 Oh, 269 00:09:51,225 --> 00:09:54,184 it's hard to pinpoint exactly what they're doing. 270 00:09:54,504 --> 00:09:56,044 Again, I'm an anesthesiologist. 271 00:09:56,585 --> 00:09:58,684 So seeing from surgical technique, 272 00:09:59,039 --> 00:10:00,659 it's you'd know 273 00:10:01,519 --> 00:10:04,399 who the efficient ones are. What they're actually 274 00:10:04,399 --> 00:10:07,120 doing that makes them more efficient is more 275 00:10:07,120 --> 00:10:08,019 of a surgical 276 00:10:08,399 --> 00:10:11,360 question than an anesthes and from an anesthesia 277 00:10:11,360 --> 00:10:13,940 perspective, I wouldn't be able to pin pinpoint 278 00:10:14,375 --> 00:10:16,294 what those are. I can tell you who 279 00:10:16,294 --> 00:10:18,214 the efficient surgeons are, and I can tell 280 00:10:18,214 --> 00:10:20,875 you who the inefficient surgeons are. But, unfortunately, 281 00:10:21,975 --> 00:10:24,475 I I can't determine how that, 282 00:10:25,254 --> 00:10:26,794 how to how that translates 283 00:10:27,174 --> 00:10:29,595 when you're actually hands on. Now 284 00:10:30,389 --> 00:10:32,549 we do have residents and fellows coming through 285 00:10:32,549 --> 00:10:34,649 our, surgery center at Jefferson, 286 00:10:35,509 --> 00:10:38,329 and I understand the necessity of teaching 287 00:10:38,709 --> 00:10:40,009 residents, surgeons. 288 00:10:40,309 --> 00:10:42,970 I also have partnered with Jefferson 289 00:10:43,745 --> 00:10:47,584 System to get a fellowship program for ultrasound 290 00:10:47,584 --> 00:10:48,804 guided regional anesthesia, 291 00:10:49,345 --> 00:10:52,084 and I've been able to incorporate 292 00:10:52,705 --> 00:10:53,445 that teaching, 293 00:10:54,304 --> 00:10:57,024 without slowing down the pace of the operating 294 00:10:57,024 --> 00:10:57,524 room. 295 00:10:57,940 --> 00:11:00,259 There are ways that this can be accomplished. 296 00:11:00,259 --> 00:11:02,279 There are teachers that teach 297 00:11:02,899 --> 00:11:04,759 and work efficiently as well. 298 00:11:05,700 --> 00:11:08,840 There are others that are not so, efficient, 299 00:11:08,899 --> 00:11:09,399 unfortunately, 300 00:11:10,100 --> 00:11:10,600 and 301 00:11:11,375 --> 00:11:13,955 it's the balance has to be struck, 302 00:11:14,495 --> 00:11:16,414 and this is a difficult conversation to have 303 00:11:16,414 --> 00:11:18,754 because, again, like I said, you develop relationships 304 00:11:18,815 --> 00:11:19,794 with your surgeons. 305 00:11:20,095 --> 00:11:23,054 No. You don't wanna tell anybody that, they're 306 00:11:23,054 --> 00:11:25,710 not keeping up. However, there may be ways 307 00:11:25,710 --> 00:11:29,250 that administrators can, achieve this, whether that be, 308 00:11:30,110 --> 00:11:32,610 Excel spreadsheets where you can compare 309 00:11:32,990 --> 00:11:34,450 surgeons and surgeries 310 00:11:34,909 --> 00:11:36,590 and, you know, have a meeting with them 311 00:11:36,590 --> 00:11:38,610 and say, look. These are our top performers. 312 00:11:38,855 --> 00:11:41,014 These are our middle performers. These are our 313 00:11:41,014 --> 00:11:41,835 lower performers, 314 00:11:42,375 --> 00:11:43,495 and it has to be, 315 00:11:44,295 --> 00:11:45,975 it has to be a group effort. The 316 00:11:45,975 --> 00:11:48,235 surgeons have to be on board with this, 317 00:11:48,295 --> 00:11:51,014 and perhaps they can communicate with each other 318 00:11:51,014 --> 00:11:53,850 and see learn from each other and pass 319 00:11:53,850 --> 00:11:56,089 these tips and tricks onto each other as 320 00:11:56,089 --> 00:11:57,470 to how to be more efficient. 321 00:11:58,490 --> 00:12:00,490 Yeah. Because we all know that answered your 322 00:12:00,490 --> 00:12:01,389 question, Alan. 323 00:12:01,769 --> 00:12:03,690 No. Absolutely. I think we all know, you 324 00:12:03,690 --> 00:12:06,490 know, how competitive surgeons can often be as 325 00:12:06,490 --> 00:12:08,110 well. I think that might be a 326 00:12:08,545 --> 00:12:09,985 a great little insight to take away in 327 00:12:09,985 --> 00:12:12,705 terms of tracking performance, measuring, sharing some of 328 00:12:12,705 --> 00:12:14,804 these tips and tricks along the way, especially 329 00:12:15,105 --> 00:12:16,785 to your point, some of the the newer 330 00:12:16,785 --> 00:12:18,705 surgeons, the next generation who might be coming 331 00:12:18,705 --> 00:12:21,125 out of residencies and fellowships as well. 332 00:12:21,940 --> 00:12:24,659 Armin, really, really fascinating discussion so far. I 333 00:12:24,659 --> 00:12:26,659 get more of an insight into you, your 334 00:12:26,659 --> 00:12:29,860 background, your surgery center. When you look ahead 335 00:12:29,860 --> 00:12:32,339 to the future, what are you most excited 336 00:12:32,339 --> 00:12:32,839 about? 337 00:12:34,384 --> 00:12:36,544 I am most obviously, this is gonna be 338 00:12:36,544 --> 00:12:38,384 a little selfish of me. I'm most excited 339 00:12:38,384 --> 00:12:40,384 about the work we're doing at the Navy 340 00:12:40,384 --> 00:12:40,884 Yard 341 00:12:41,184 --> 00:12:43,365 and the work I'm doing with the liposomal 342 00:12:43,584 --> 00:12:44,084 bupivacaine. 343 00:12:44,625 --> 00:12:46,004 I've come up with a formulation, 344 00:12:46,784 --> 00:12:49,509 on my own, believe it or not. And, 345 00:12:49,841 --> 00:12:52,500 what we're getting the results we're getting, 346 00:12:53,379 --> 00:12:55,639 with these with this formulation is 347 00:12:56,179 --> 00:12:58,840 astounding to say the least. We have 3 348 00:12:58,899 --> 00:13:01,799 papers that are in the process of 349 00:13:04,554 --> 00:13:06,634 of of we're we have 3 studies that 350 00:13:06,634 --> 00:13:08,174 we are in the process of, 351 00:13:08,714 --> 00:13:10,174 getting to to journals. 352 00:13:11,115 --> 00:13:13,695 The first one is on ACL repair. 353 00:13:14,714 --> 00:13:16,714 The second one is on foot and ankle, 354 00:13:16,714 --> 00:13:18,735 and the third one is on shoulder surgery. 355 00:13:18,909 --> 00:13:21,549 But I've used this formulation of mine on 356 00:13:21,549 --> 00:13:22,529 clavicle fractures, 357 00:13:23,070 --> 00:13:24,370 on elbow surgeries, 358 00:13:24,830 --> 00:13:25,889 on hip surgeries, 359 00:13:26,909 --> 00:13:29,250 and the results we're getting are tremendous. 360 00:13:29,950 --> 00:13:32,269 Let me circle back and say we are 361 00:13:32,269 --> 00:13:34,804 on the cusp of announcing 362 00:13:36,144 --> 00:13:37,684 0 to minimal narcotic 363 00:13:38,144 --> 00:13:41,605 use outpatient ambulatory orthopedic surgery. 364 00:13:42,384 --> 00:13:44,945 We're doing cases for the foot and ankle, 365 00:13:44,945 --> 00:13:46,565 Achilles tendon rupture repairs, 366 00:13:46,990 --> 00:13:47,490 trimalleolar, 367 00:13:47,870 --> 00:13:48,370 bimalleolar 368 00:13:48,670 --> 00:13:49,490 ankle fractures, 369 00:13:50,350 --> 00:13:53,410 Liz Frank Liz Frank fractures of the foot, 370 00:13:53,629 --> 00:13:56,190 and our patients are taking 0 narcotics. We're 371 00:13:56,190 --> 00:13:59,710 getting upwards of 10 days of numbness from 372 00:13:59,710 --> 00:14:00,690 my nerve blocks. 373 00:14:01,254 --> 00:14:01,995 This formulation, 374 00:14:02,615 --> 00:14:04,694 I think, has the potential to change the 375 00:14:04,694 --> 00:14:08,954 face of outpatient ambulatory orthopedic surgery. For ACL 376 00:14:09,334 --> 00:14:12,554 repairs, I'm getting approximately 5 to 7 days 377 00:14:12,934 --> 00:14:15,595 of pain free nerve nerve blockade. 378 00:14:16,519 --> 00:14:18,519 If I can drop names, it was doctor 379 00:14:18,519 --> 00:14:21,980 Christopher Dodson who first noticed it. I actually 380 00:14:22,440 --> 00:14:23,740 sort of snuck in 381 00:14:24,040 --> 00:14:26,779 this formulation without telling any of the surgeons. 382 00:14:27,000 --> 00:14:28,620 I did my own little research, 383 00:14:29,595 --> 00:14:31,914 and I just started doing what I wanted 384 00:14:31,914 --> 00:14:33,054 to do, so to speak, 385 00:14:33,995 --> 00:14:36,634 despite the fact that liposomal bupivacaine comes with 386 00:14:36,634 --> 00:14:37,434 a couple of, 387 00:14:37,754 --> 00:14:39,754 caveats that you're not supposed to mix it 388 00:14:39,754 --> 00:14:42,254 with anything. But suffice it to say, 389 00:14:42,839 --> 00:14:44,600 that I took the extra step there in 390 00:14:44,600 --> 00:14:47,639 faith and myself and, my skills, and I 391 00:14:47,639 --> 00:14:48,139 did, 392 00:14:48,600 --> 00:14:50,059 take mix it with something, 393 00:14:50,440 --> 00:14:53,019 and, that will be revealed in the studies, 394 00:14:53,079 --> 00:14:53,579 obviously. 395 00:14:53,959 --> 00:14:54,279 But, 396 00:14:55,125 --> 00:14:57,684 the bottom line was, about 6, 7 months 397 00:14:57,684 --> 00:15:00,404 into it, doctor Dodson pulled me aside, and 398 00:15:00,404 --> 00:15:03,205 he said, what's going on, Arman? And I 399 00:15:03,205 --> 00:15:04,644 said, I don't know what you're talking about, 400 00:15:04,644 --> 00:15:07,125 Chris. And he said, well, all of my 401 00:15:07,125 --> 00:15:10,090 physician assistants and all of my physical therapists 402 00:15:10,090 --> 00:15:11,529 are coming up to me and not telling 403 00:15:11,529 --> 00:15:13,790 me that the patients aren't using their narcotics. 404 00:15:14,170 --> 00:15:15,629 They're going through rehab 405 00:15:16,009 --> 00:15:17,870 without complaining of too much pain 406 00:15:18,330 --> 00:15:20,910 and without taking narcotics pre and post. 407 00:15:21,485 --> 00:15:24,305 I haven't changed my surgical technique, Armin, so 408 00:15:24,685 --> 00:15:27,245 it's you. What are you doing differently? And 409 00:15:27,245 --> 00:15:29,105 that's when I had to confess to him, 410 00:15:29,565 --> 00:15:31,825 that, I had come up with this formulation 411 00:15:31,884 --> 00:15:33,264 with liposomal bupivacaine, 412 00:15:33,965 --> 00:15:34,465 and 413 00:15:34,799 --> 00:15:36,559 he was shaking his head, and he said, 414 00:15:36,559 --> 00:15:38,480 Armin, this is a game changer. We need 415 00:15:38,480 --> 00:15:40,480 to publish this. We need to get studies 416 00:15:40,480 --> 00:15:42,480 done. This has to get out there. We 417 00:15:42,480 --> 00:15:44,799 need to we need to broadcast this to 418 00:15:44,799 --> 00:15:48,399 the rest of the, ambulatory orthopedic community and 419 00:15:48,399 --> 00:15:50,714 the sports community as well. This is a 420 00:15:50,714 --> 00:15:52,735 game changer, he said. So, 421 00:15:53,674 --> 00:15:55,934 encouraged by his, kind words, 422 00:15:56,315 --> 00:15:58,075 I went we went ahead and we got 423 00:15:58,075 --> 00:15:59,454 IRB approval from, 424 00:16:00,075 --> 00:16:01,534 Jefferson Health System. 425 00:16:01,914 --> 00:16:03,514 And like I said, we have these 3 426 00:16:03,514 --> 00:16:05,169 studies. The first step will be published is 427 00:16:05,169 --> 00:16:07,329 the ACL study. I believe the second will 428 00:16:07,329 --> 00:16:08,769 be the foot and ankle study, and then 429 00:16:08,769 --> 00:16:10,949 we'll have the shoulder study to compare. 430 00:16:11,570 --> 00:16:12,789 As just an anecdotal, 431 00:16:13,409 --> 00:16:14,389 if I can continue? 432 00:16:14,929 --> 00:16:15,750 Yeah. Absolutely. 433 00:16:16,209 --> 00:16:17,909 As an anecdotal example, 434 00:16:18,845 --> 00:16:20,524 I have dinner with, 435 00:16:21,004 --> 00:16:21,485 my, 436 00:16:21,804 --> 00:16:24,684 friends from Einstein. I have, close friends from 437 00:16:24,684 --> 00:16:27,725 there, 2 cRNA friends, and I was bragging 438 00:16:27,725 --> 00:16:29,884 to them about my results. And one of 439 00:16:29,884 --> 00:16:30,544 my friends, 440 00:16:31,000 --> 00:16:32,919 George, he started tearing up, and he said, 441 00:16:32,919 --> 00:16:34,919 Armin, I've been putting off my knee replacement 442 00:16:34,919 --> 00:16:37,319 surgery for 2 years now. I'm so scared 443 00:16:37,319 --> 00:16:39,899 of the rehab and the pain involved. 444 00:16:40,360 --> 00:16:42,199 Would you be able to do this for 445 00:16:42,199 --> 00:16:42,699 me? 446 00:16:43,455 --> 00:16:45,695 And I this is my buddy. So I 447 00:16:45,695 --> 00:16:47,855 I said, look. Well, let's try. Let's try 448 00:16:47,855 --> 00:16:50,975 ahead. And so we talked to doctor Matt 449 00:16:50,975 --> 00:16:53,455 Austin at, at that time, he was at 450 00:16:53,455 --> 00:16:56,495 the Rothman Orthopedic Specialty Hospital doing knee replacements. 451 00:16:56,495 --> 00:16:58,675 I believe he's at the hospital for special 452 00:16:58,990 --> 00:17:01,950 surgery now in New York City. But, I 453 00:17:01,950 --> 00:17:04,349 told him my plan. I made my request. 454 00:17:04,349 --> 00:17:06,210 He, graciously approved. 455 00:17:06,750 --> 00:17:08,830 And so George went ahead with his knee 456 00:17:08,830 --> 00:17:10,990 replacement. I did his spinal. I did his, 457 00:17:11,309 --> 00:17:12,690 nerve blocks with the liposomal 458 00:17:13,265 --> 00:17:15,924 bupivacaine formulation that I come came up with. 459 00:17:16,305 --> 00:17:18,884 And, Alan, he went through his knee replacement. 460 00:17:19,105 --> 00:17:21,445 They put him back to rehab the very 461 00:17:21,505 --> 00:17:22,884 day that very day. 462 00:17:23,265 --> 00:17:24,945 He I followed up with him every day 463 00:17:24,945 --> 00:17:28,085 for 25 days, texting him constantly, calling him. 464 00:17:28,170 --> 00:17:30,410 He took 0 narcotics after his total knee 465 00:17:30,410 --> 00:17:30,910 replacement. 466 00:17:31,529 --> 00:17:33,789 So this is not just for the ambulatory 467 00:17:33,930 --> 00:17:36,650 surgeries we do at the Navy Yard. This, 468 00:17:36,650 --> 00:17:39,070 I think, can have long reaching effects for, 469 00:17:39,450 --> 00:17:42,269 replace joint replacement surgeries as well. Now granted, 470 00:17:42,330 --> 00:17:45,035 that's just one patient, but the results were 471 00:17:45,035 --> 00:17:45,535 so 472 00:17:46,234 --> 00:17:46,734 glaringly 473 00:17:47,194 --> 00:17:49,434 obvious that I think it's going to make 474 00:17:49,434 --> 00:17:51,115 a difference. And then we'll have to study 475 00:17:51,115 --> 00:17:53,134 that as well, publish a study on that. 476 00:17:53,194 --> 00:17:55,355 Perhaps not myself, someone else might be able 477 00:17:55,355 --> 00:17:57,410 to do that because we don't do joint 478 00:17:57,410 --> 00:17:59,329 replacement. But I think this is a very 479 00:17:59,650 --> 00:18:01,670 this is what I'm most excited about. 480 00:18:02,369 --> 00:18:04,369 Well, I'm I'm so glad that you took 481 00:18:04,369 --> 00:18:06,369 the opportunity to to toot your own horn 482 00:18:06,369 --> 00:18:08,210 there. I mean, so so very well deserved 483 00:18:08,210 --> 00:18:10,674 and fascinating to hear about all the excellent 484 00:18:10,674 --> 00:18:12,434 work that you're doing, that your team is 485 00:18:12,434 --> 00:18:12,934 doing. 486 00:18:13,315 --> 00:18:15,795 0 to minimal narcotic use for some of 487 00:18:15,795 --> 00:18:17,654 these outpace outpatient orthopedic 488 00:18:17,955 --> 00:18:20,434 procedures. And no doubt the patients are reaping 489 00:18:20,434 --> 00:18:22,049 the benefits there as well. 490 00:18:22,450 --> 00:18:24,049 I'd love if you could share those studies 491 00:18:24,049 --> 00:18:26,549 with us when they inevitably do get published. 492 00:18:26,769 --> 00:18:28,529 We'd love to publish them and cover them 493 00:18:28,529 --> 00:18:30,850 also on Becker's. Armit, a real pleasure to 494 00:18:30,850 --> 00:18:33,190 have you on the podcast today. Fascinating discussion. 495 00:18:33,410 --> 00:18:35,650 Congratulations on everything you achieved and really, really, 496 00:18:35,970 --> 00:18:37,250 all the best for the future as well. 497 00:18:37,250 --> 00:18:38,025 Thank you so much. 498 00:18:38,585 --> 00:18:40,345 Alan, thank you very much. And and I 499 00:18:40,345 --> 00:18:42,265 wanna focus on one last thing that you 500 00:18:42,265 --> 00:18:44,904 just said there. It's a team effort. This 501 00:18:44,904 --> 00:18:46,765 is not something I could do by myself. 502 00:18:46,904 --> 00:18:48,984 There's so many people that are involved in 503 00:18:48,984 --> 00:18:49,484 supporting 504 00:18:49,945 --> 00:18:51,625 us in what we do at the Navy 505 00:18:51,625 --> 00:18:55,380 Yard. Everybody from environmental services to our surgeons 506 00:18:55,380 --> 00:18:57,619 to our administrators and most of all, of 507 00:18:57,619 --> 00:18:59,640 course, our nurses and nurse anesthetists. 508 00:19:00,019 --> 00:19:02,740 It's a team effort. Nobody is no one 509 00:19:02,740 --> 00:19:05,480 individual is more important than any other individual. 510 00:19:05,904 --> 00:19:07,765 So and again, thank you for the opportunity 511 00:19:07,984 --> 00:19:10,724 for speaking with me and, getting this information 512 00:19:10,785 --> 00:19:11,924 out there. Thank you. 513 00:19:12,305 --> 00:19:14,164 My pleasure. Thank you so much, Aaron.