Orthopaedic Surgery is a Team Sport!

It Takes a Community to Care for a Patient

At the recent American Academy of Orthopedic Surgeons (AAOS) meeting in Chicago, the word “collaboration” was being kicked around like a soccer ball.

Organizational behavior consultants, marketing consultants and business professionals having been emphasizing the importance of “teamwork” and “collaboration” in the literature for years!surgery

Although surgery itself takes a team to perform, many orthopaedic surgeons in Canada work as independent practitioners within a private practice and share hospital responsibilities with a small group of other surgeons, sharing the call schedule and collaborating on difficult surgical cases.

However, although we don’t practice in a bubble, we do tend to be the lone wolf in our subs-specialty areas unless we make a point of collaborating and consulting with peers.

In a recent post in the ezine “The Pipeline” by Katie Rief of the Advisory Board Company, take-away comments were presented from the AAOS meeting which emphasized the changing role of the orthopaedic surgeon as a team player.

Says Ms. Rief, “Surgeons are interested in building efficient, dedicated care teams. This is true in the OR as well as in the clinic.”

So what does my team look like?

My core team is me and my two office partners, Dr. Rodriguez-Elizalde who specializes in trauma and joint replacement surgery, and Dr. Cayen who specializes in sport IMG_65medicine and joint replacement surgery, as well as our administrative assistants. We share an office, our staff work side by side, and we all work at the same hospital–Humber River Regional (Church Street Site).

The next team layer include our cast techs in fracture clinic, operating room nurses, anesthesia colleagues, sales representatives from our surgical instrument and implant companies, surgical unit nurses and pre/post operative nursing staff as well as other orthopaedic surgical colleagues at both the Finch and Church sites whom we work with to provide orthopaedic surgical services to our 800,000 catchment area in North York.

Beyond this is the layer that encompasses all support services–hospital services, computer and networking services, laboratory and diagnostic radiology services and the companies who provide us implants and products we need to do our jobs. This layer also includes the insurance companies, including OHIP.

Each of Us Brings a Unique Skill to the Team

On any given day, at least 6 or 8 people are working with me to get my job done, as I work them to get their job tasks accomplished. This coordinated concerted effort constitutes the “inputs” and quality patient care is the “output”.

So although we might seem to practice independently, it takes a community to care for patient–each with a unique but interrelated job.






Where Do I Go When I Need HealthCare?

ER, Walk In Clinic, Family Doc, or Urgent Care Centre…Where do I go when I need healthcare?

Why are we all so disgruntled with health care. It doesn’t seem to matter where you live or who you are, how much money you have or don’t have, or what your health care needs are, we all have complaints and critiques!

Waiting for care is a huge complaint. Patients are very upset to have to wait for an emergency doctor to see them, or to wait in fracture clinic to be seen by the orthopod, wait for their surgery, test results, wait for a specialist visit. They are so frustrated that many end up coming to the hospital Emergency Room (ER) because they feel they have no other options.

As Canadians, our high income tax contributions to socialized health care allow us the privilege to walk into any health care facility in the country and ask for care.

Patients with extreme pain, major trauma, who are very ill or near death will always get treated first as Emergency Room resources are prioritized to care for these more critical cases.

Triage System for Emergency Care

In Canada, the CTAS-Five Level Triage system assigns patients who present to the emergency room with a number from 1 to 5.

Level 1 patients require immediate resuscitation and include “conditions that threaten life or limb requiring immediate aggressive interventions” by the ER doc and ER nurse.

Level 2 patients are considered “emergent” and include those with “conditions that are a potential threat to life, limb or function requiring rapid intervention” within 15 minutes.

Level 3 patients, are “urgent” and include those with “conditions that could potentially progress to a serious problem requiring emergency intervention associated with significant discomfort affecting ability to function at work or activities of daily living” and should be seen within 30 minutes.

Level 4 patients have “conditions that relate to age, distress, or potential for deterioration or complications” who should be seen within 1 hour.

Level 5 “non urgent” patients have “conditions that may be acute but non-urgent, as well as conditions which may be part of a chronic problem, with or without evidence of deterioration” and should be seen within 2 hours.

The reality of the situation…

OK, how many people reading this are saying “Ya right, 2 hours? Last time I was in the ER I waited 5 hours!” The reality of the situation is that on the one hand, ER’s are busy and may not see level 5 patients for many hours because of the sheer number of Level 1, 2 and 3 patients already being treated.

In addition, there may be an overwhelming number of Level 5 patients who present to ER for treatment who could better be served at an urgent care centre, walk-in clinic or their family physician’s office.

I am amazed by the number of swollen knees and sore shoulders that come through the emergency department and are referred to fracture clinic with a history of several weeks of symptoms. Back pain patients who have had issues for years and have seen every chronic pain specialist in the city, come to the ER to be seen–why?  When I ask them why they came to the hospital instead of seeing their family physician, specialist or pain doctor, the answer is typically one of the following three:

1. I don’t have a family doctor.
2. None of the other doctors have helped me.
3. I’ve been waiting forever to see a specialist!

I find that many patients do not know their healthcare options.  So they come to the ER to have the hospital “sort it all out”. Here’s another idea: Health Care Connect!

Health Care Connect will find a doctor or nurse practitioner in your community who can assist you with your care needs.”

Remember the next time you take your long-standing complaint, strain/sprain or paper cut to the emergency department for care–you are taking up resources that are designed for people with acute, severe injuries or illnesses that need to be dealt with urgently. See the length of time you have to wait at an Emergency Room nearest you.

So let’s look at this another way…How would you feel if your mom had to wait to be seen for her hip fracture because the emergency doctor was busy seeing a patient with a bruised shin that happened 2 weeks ago? The hip fracture needs care. The bruised shin is taking up valuable ER time and could be better treated at a walk-in clinic or the family doctor’s office.

I don’t blame patients. I believe it is our job to properly educate patients on where to go for care. And our government is doing just that through the Ministry of Health website and campaigns to promote proper utilisation of services. There are urgent care centres and walk in clinics all over the GTA and other Canadian cities that are designed specifically to accept patients with minor injuries, chronic problems, or long-standing issues that are not in acute distress or danger.

 Source: http://www. health.gov.on.ca/en/public/programs/hco/

Unfortunately web-links of information will not be seen by many of the people who look for care –the elderly, lower income labor workers who might not have access to a computer, immigrants with no computer skills or access.
See where the health care services are in your neighborhood!
Source: http://www.hco-on.ca/English/Home-Page

Options for Minor Injury and Illness Care

So, here are the options for the walking wounded, tummy aches, headaches, joint pain patients, strain/sprains, small burns/cuts, and the chronic complaint patients who need help but don’t need to start at the ER:(if you have an issue that should be seen urgently, one of the health professionals at these organizations WILL direct you to the ER if needed)–

Where To Go When You Need HealthCare!

An Urgent Care Centre (UCC) can provide diagnosis and treatment for most injuries and illnesses through emergency trained doctors and other health care professionals.

Go Here If: You have an urgent, but non life- threatening illness or injury like sprains or strains, if you think you need stitches or have a minor burn that needs treatment.

Walk In Clinics or After Hours Clinics offer convenient access to advice, assessment and surgery1treatment for minor illnesses and injuries such as cuts, bruises, minor infections, sprains and skin complaints. Go Here if: You’re in a non-urgent situation; Your family doctor’s office is closed or if you don’t currently have a family doctor; You need care for minor illnesses and injuries including infection and rashes,      fractures, emergency contraception and advice, stomach upsets, cuts and      bruises, and burns and strains.

Go Telehealth!

Telehealth Ontario is a free, confidential telephone service you can call to get health advice or general health information from a Registered Nurse.

That means quick, easy access to a qualified health professional, who can assess your symptoms and help you decide your best first step. Telehealth nurses are extremely well-trained, personably, knowledgeable and multi-talented folks who can help you decide whether to care for yourself, make an appointment with your doctor, go to a clinic, contact a community service or go to a hospital emergency room. They provide a valuable service and I have always been impressed by their excellent advice, care and direction.

TELEHEALTH: 1-866-797-0000 TTY : 1-866-797-0007

Need To Know Where To Go NOW?

And if you are stll uncertain where to go, CLICK HERE! for the Government of Ontario’s “HEALTH SERVICES IN YOUR COMMUNITY” website.

Have I missed anything? So, pop quiz: you sprained your knee last weekend and it is still sore….where do you go? If your answer is “The ER”, then you need to re-read this blog!

Here is a list of Urgent Care Centres in the GTA:

Nexus Health Urgent Care
Toronto, ON M5G Map location is approximate (416) 616-0300

Midland Urgent Care
1153 Ellesmere Rd, Toronto, ON M1P 2X6 (416) 285-4406

North York Urgent Care Centre
4646 Dufferin St, Toronto, ON M3H 5S4 (416) 222-9604

Etobicoke Urgent Care Clinic
25 Woodbine Downs Blvd, Toronto, ON M9W 6N5 (416) 741-2273

Malton Urgent Care
3530 Derry Rd E, Mississauga, ON L4T 4E3 (905) 672-2273

Mississauga Urgent Care Inc
1201 Britannia Rd W, Mississauga, ON L5V 1N2 (905) 826-2273

Markham Stouffville Urgent Care Centre
110 Copper Creek Dr, Markham, ON L6B 0P9 (905) 472-8911

Pickering Urgent Care Med
1450 Kingston Rd, Pickering, ON L1V 1C1 (905) 831-8333

Finally, for more information: For other health questions please call:
ServiceOntario, INFOline at 1-866-532-3161.
Hours of operation : 8:30am – 5:00pm, Monday to Friday.
TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282

Cortisone Injections for Knee Pain

There is much controversy as to how to treat knee pain nonoperatively, and if cortisone injections are dangerous in the knee. The type of cortisone used, dose, number of injections and frequency of injections, as well as side effects are all controversial topics among orthopaedic surgeons.

The knee, being one of the largest joints in the body, is susceptible to the development of conditions that cause pain and swellng, like osteoarthritis, trauma and rheumatoid arthritis. Osteoarthritis is the most common of these conditions, representing 15% of most people over the age of 60 in developed countries. Symptomatic knee osteoarthritis has been found prevalent more commonly in women tcortisone_knee_dynhan men.

Initially, we treat early osteoarthritis of the knee with physical therapy, weight reduction, anti inflammatory medications like Advil and Aleve, and eventually move to prescription anti inflammatory medications, pain killers, braces, knee injections and sometimes surgery.

Cortisone has been one of the most common injections used in the knee for decades and benefits patients by relieving both pain and inflammation for weeks to months.

celsoluspanCortisone has been demonstrated in some studies to reduce the deterioration of knees and the development of more severe osteoarthritis, but concern has been raised about the potential side effects of long-term corticosteroid injection. There is evidence to suggest that frequent doses of cortisone may degrade joint cartilage and change the properties of meniscal cartilage by altering the cartilage cells. There are also numerous scientific studies demonstrating direct toxic effects of cortisone on joint structures including ligaments.

So how often is it safe to inject cortisone into the painful knee of someone with moderate osteoarthritis who is not yet ready for joint replacement surgery?

According to a study by Zuber in 2002, cortisone can be injected into a knee every 6 weeks with no more than 2 to 3 injections per year. There is no solid evidence to suggest repeat injections of cortisone lead to joint destruction and the 3 injections/year guideline is simply that–a guideline.(Zuber TJ. Knee joint aspiration and injection. Am Fam Physician 2002; 66: 1497–501).

In 1967, Salter, Gross and Hall concluded that:

“While it is unlikely that a single intra-articular injection of hydrocortisone is harmful, multiple intra-articular injections of hydrocortisone in a given joint are probably deleterious to the articular cartilage and should be avoided in order to prevent the iatrogenic complication of hydrocortisone arthropathy.” (Salter RB, Gross A, Hall JH. Hydrocortisone arthropathy: an experimental investigation. Can Med Assoc J 1967; 97: 374–7.)

This advice is still relevant today in spite of 45 additional years of research.

Personally, I concur with the author of today’s source article in Medscape who suggests cortisone injections are effective in patients who are not yet ready for knee replacement, who are on a waiting list for knee replacement, in young patients who knee replacement is to be avoided until later life if possible, and in patients who have medical or other reasons they cannot undergo knee replacement. I administer these injections 6 weeks apart for a total of 3, if required–and wait 6 months between treatment courses before repeating if necessary. Some point along the line,doctorhdshot2 the decision would be made whether to proceed with joint resurfacing or replacement based on the patient factors such as age and medical status, as well as disease factors such as severity and functional abilities.

For more information on Cortisone, please visit:  http://en.wikipedia.org/wiki/Cortisone

Cooking for Bone Health

The two main dietary bone health-promoting nutrients are Calcium, a mineral naturally found in bone; and Vitamin D, a vitamin required to absorb calcium from your intestine.

With enough sunlight, our bodies will synthesize Vitamin D in quantities great enough for adequate calcium absorption. Calcium, on the other hand, must come from external sources or your body will start to use up the calcium stored in bone for other body functions.

Calcium is a mineral essential for many cellular functions including bone mineralization and muscle contraction. Calcium deficiency leads to osteoporosis and neuromuscular disorders including convulstions, heart rythmn disturbances, numbness and even paralysis.

BroccoliThe best source of calcium is in foods. Calcium supplements, though effective at correcting low calcium states, may cause other side effects in the body including kidney or bile stones, bone pain, nausea and vomiting, and pancreatitis among other conditions.

Foods high in calcium include: milk, cheese, broccoli, fortified cereals and almonds. Vitamin D fortified milk helps increase the absorption of calcium from the intestine into the blood stream. MP5094

According to EatingWell.com, the following recipes are calcium-rich and great for bone health: Black-eyed peas with Tofu, Chicken Cassoulet, Salmon Cakes, Manicotti, Lamb and Rice Casserole.

Check out Bone Healthy Desserts!

Low Bone Density and Fracture Risk

h9991525_001Why do we care so much about bone density? It’s true that as we age, bones lose density and become more porous, softer and susceptible to fracture. Doctors prescribe Calcium, vitamin D and even bone hardening drugs called bisphosphonates for patients with either low bone density, or who are at risk of developing fragility fractures.

What Makes Bones Hard?

Minerals in bone like calcium are responsible for the hardness. Bones are rigid organs that support all the soft tissues that make up the body. There are 206 bones in the adult body with the femur (thigh bone) being the largest and the small bones deep in the ear that regulate sound being the smallest.

Bones have several functions other than providing a skeleton for the body. They server to store minerals, acting as a reserve for calcium and phosphorous; they store growth factors; the marrow stores fat; they trap some of the heavy metals in the environment and other toxins; and the marrow in some of the bones is a repository for blood cells and stem cells.  osteoporosis_food1

Why Do Bones Get Weak?

Bones typically become weak as we age due to osteoporosis, which is a deterioration in the concentration of minerals over time. As the mineral levels diminish, the bone’s structure also weakens and fractures can result.

You can keep your bones healthy and strong by eating foods high in calcium, taking the recommended amount of Vitamin D per day (between 400 and 1200 IU depending on your age) and by maintaining a healthy level of exercise, including the use of light weights and weightbearing exercises.doac58

Most fragility fractures occur in typical places such as the wrist, the hip and the vertebrae. Some of these fractures require little treatment, others may require surgical treatment or casting.

Typically, a hip fracture, which occurs at the top of the femur bone, requires some type of surgical fixation with metal or a hip replacement type of surgery. Fractures of the wrist, if deformed, may required fixation with removable wires, or permanent hardware such as a plate and screws. Fractures of the vertebrae are rarely treated surgically unless severe and can be treated usually by a very short course of rest and then gentle physical therapy with pain management using mild medications.

Who Needs Bone Stimulating Drugs?

If bone mineral density levels are very low, as determined by a Bone Mineral Density (BMD) scan and blood tests for mineral levels, your doctor may prescribe you a once-weekly bisphosphonate drug that is designed to increase the deposit of minerals back into bone. Most of these are relatively safe, some may have mild side effects. There are a few reports of fractures of the hip even with the use of these medications.

The people at highest risk of having osteoporosis include post-menopausal women, people with calcium or vitamin D deficiencies and elderly men and women.

For more information on osteoporosis, please visit: http://www.osteoporosis.ca/ .Bonefit-Logo