Chuck and Chris start with a deep dive on a few technical points with ulnar nerve surgery. Next we tackle a listener question on management of hook of the hamate fractures. And finally, we discuss life as a busy clinician and how we respond to different requests- it can be ok say 'no' to academic/ life requests if there simply is no time.
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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris start with a deep dive on a few technical points with ulnar nerve surgery. Next we tackle a listener question on management of hook of the hamate fractures. And finally, we discuss life as a busy clinician and how we respond to different requests- it can be ok say 'no' to academic/ life requests if there simply is no time.
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
Please complete NEW Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe, wherever you get your podcasts.
Chris Dy:And thank you in advance for leaving a review and leaving a rating wherever you get your podcast.
Charles Goldfarb:Oh, Hi, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm really good. It's good to be back together.
Chris Dy:It is good to be back. It's it's nice to have some time I've been looking forward to this weekend the whole week. Just because it's been a crazy week.
Charles Goldfarb:It has, I definitely want to hear about your week. I think both you and your lovely bride are both really busy this week.
Chris Dy:Yeah, we were refreshed. We had a week off and came back and kind of hit the ground running, I somehow paid the penalty for being away with a monster clinic on Monday. Our fellows, Adam Mosa is has started with us. He's fantastic. And his first day with me was a monster clinic. So we had our running shoes on all day. And then the week has just taken off from there. And then my wife was chairing a CME course for their specialty, which was yesterday. So it was it's been busy
Charles Goldfarb:that we had discussed but potentially recording earlier this week on Thursday night. And I ended up in the or most of the night and I heard you had a late Plexus exit. I thought I was worried about you. Because he had told me you had to get home and a reason why I don't know if all that worked out.
Chris Dy:Yeah, it it wasn't ideal, let's put it that way. But when the or moves you to a different pot, I got moved from one part of campus to the other with the promise that the start time would be the same. I knew what was gonna happen, my 1230 start turning into a two o'clock start, which means you know, when you're starting to Plexus, two o'clock, we got out of eight, which was fine. But it was, you know, is this a lot of work to do. And you know, the case moves along really well. And I know that you were coming in to do a what sounds like a very challenging case, in terms of, you know, bad wrist fracture dislocation. So we were like ships passing in the night.
Charles Goldfarb:Yes, I never even sight. It was funny. The case was billed as a partial hand amputation, when in reality, it was just a really bad, wide open fracture dislocation of the carpus and distal radius. And it was super fun, but it felt as though full of energy and a lot of skill. It was great. It's a great, great case.
Chris Dy:Somebody told me that there were two fellows scrubbed with you and a third one watching, which is unbelievable. It certainly is the first month of the fellowship, because my mind was actually like around because we were finishing up flexes, how you nab two other two fellows to join you.
Charles Goldfarb:Alright, so Adam was around and just popped his head in for a little while because it wasn't all that late. And then the other two, I guess it just been talking and it was a, you know, a fairly interesting case, what I love about having three fellows, and what I love about them being collaborative, which almost always they are, is they bring different skill sets, I mean, really different skill sets. And so one of the fellows had trauma heavy residency, and was just super comfortable with the spanning plate. The other was comfortable, but maybe not quite as comfortable. And they build off each other. And I just tried to let it all happen.
Chris Dy:Yeah, that must must have been nice for you, guys. Yeah, that's that's the great part. I think one of the things that I really love about our fellowship is that we attract folks from all over the place, and kind of give them a different experience than what they've seen. But it is fun to watch them learn from each other and for honestly, to learn from them. So yeah, I'm glad that you also seems like I've had a good week, but although I'll be at a busy one.
Charles Goldfarb:Yeah, I keep trying to cut back clinically. Well, if we can talk about that later. I'm highly unsuccessful at doing that. I've tried different strategies, and it's gonna be more important that I do it. But yes, very busy clinically.
Chris Dy:Well, why don't we acknowledge our sponsors first, before we jump into a potpourri of questions that I have for you, and then we can talk about it another fun topic too.
Charles Goldfarb:I love it. I love it. The upper hand is sponsored by Practice Link Magazine, the physician job search and career advancement, resource. Wandering people
Chris Dy:caught that switch magazine. Becoming a physician is hard finding the right job does not have to be join practice link for free today at www.practicelink.com.
Charles Goldfarb:We'll see hopefully, people listen to us and they actually notice.
Chris Dy:I don't know, Chuck, I know that sometimes when I listen to podcasts, and if it's like clearly a commercial break, I will guilty of the you know, the 15 second fast forward.
Charles Goldfarb:Well, I've done it too, but I think the podcasts are regularly listened to. I don't always do it, especially if it's not gonna be a two minute or you know if it's a 32nd or so. You know, I feel like it's understandable why there's marketing and podcasts and there has to be,
Chris Dy:oh, we are we rationalizing our decisions.
Charles Goldfarb:We are Are we are does the loyal listener? I know what's coming?
Chris Dy:Oh, well, I'll find out soon. And anyway, so I've had some random thoughts that have come out. And one of the great parts about being in an academics, as many people know or from being in training too is that you have the chance to just kind of question your everyday decision making because somebody else will, why do you do it that way? So especially if you have somebody new, we're working with you who haven't worked with before. Um, so some of these things have kind of come up just not necessarily by by our trainees, but I was just thinking about them. So we talked a lot about the adiopofascial, subcutaneous ulnar nerve transposition. And I think a lot of people like it now. And just kind of by word of mouth, a lot of people have been doing it because I kind of asked people who trained elsewhere what what they've seen. So there are a lot of different ways to do it. And we know that, you know, Mel Rosenwasser, probably published the first article on it with I think Dan off was the first author. But admittedly, I've modified it to kind of work for to what works for me, and then what works for that patient in particular habitus. What if the patient's super skinny or slender? Chuck, what do you do? Is that still something where, you know, if it's not one that you would have done this sub muscular transposition or an insight to decompression alone? Are you still offering that sub q transposition with the adipofascial flap? Or do you change your technique? Or do you go to a submuscular?
Charles Goldfarb:I think it's a great question. And certainly something I've pondered as well, I'll start by saying, you know, in the Midwest, many of our patients have plenty of adipose tissue. And so this is not always a challenge I could imagine, in different parts of the country, it may be more frequently an issue, but I will say that in my population, typical population, which is often adolescent or young adult, there can be a lack of supporting tissue. And certainly in different sports, it becomes even more relevant. So for example, the volleyball player who happens to be very thin, little tissue subcutaneously. And you really have to think about what the right thing to do is. So here's how I think about it, I really am curious how you think about it. First of all, I'll say in most patients, there's plenty. And for me, plenty means there, it's typically more, there's more tissue proximately. And often as I go distally, there's less tissue. And that's okay, I love when the nerves covered in its entirety with a nice thick bunch of tissue, but it's not always the case. The first goal, if I'm going to use this flap, is to make sure there's enough to keep the nerve anteriorly. And usually, I can find that amount of tissue proximately. And sometimes the nerve is a little uncovered distally in those cases, I do release some of the fascists, so the nerve just lies a little less prominently. Not really an intramuscular, but just sort of that leading edge, or the distal edge of the FCU fascia as it dives and splits between the heads, I'll release that. So I'm babbling a little bit. But I would say that, in most patients, there's plenty of tissue in almost all patients, there's proximal tissue. There have been one or two over the last couple years where I've gotten some muscular, I really have just totally switched. I do not like the eatin flap, the fascial flap that you lift up, because I do think it is more likely to cause scarring. Sorry, that was a mouthful. Love.
Chris Dy:No, no, I think I think there's a lot of good stuff in there to unpack. But I mean, I guess first question I'd ask is, Is there are there any remaining indications for an eating flap? mean your practice?
Charles Goldfarb:The only remaining indication would be in this maybe a question we were going to talk about, I don't like some musculars. In in high level athletes. I just don't believe in cutting the entire muscle mass to go sub muscular and unless there's a really extenuating circumstance. And so if I had no subcutaneous tissue to work with, and I had to keep the nerve anteriorly, I would do some type of Eaton flap, but that I don't I don't really think that situation exists. But I guess it could.
Chris Dy:I mean, Eaton flap is obviously a nice, nice thing to use. It's a nice thing to know how to do because it's you sometimes need to try it out if you're doing revisions or kind of crazy situations, like you described. That's at least the remaining indication for me, it's just to know when to use it, but it's not certainly not playing A, B or C. Are there any patients that from the jump you say we're not doing a subcutaneous transposition because you're too skinny?
Charles Goldfarb:No, but I do in the patients that seem skinny enough. I do talk about the possibility of sub muscular. The nice thing about it so muscular, I'd love your opinion on this. I don't think the recovery is fundamentally different. You know, it's a bigger surgery. But I think the patient's rebound just as quickly. And I still at six weeks I let them you know, really start making progress. They're really only protected for 40 Six weeks in either case, I just fundamentally don't like it as much.
Chris Dy:Two things, in your words, two things, I fundamentally disagree that they are similar surgeries. But I agree with the timeline that you gave for a so muscular, I think they can come back quicker from a subcutaneous. And I think it's about maintaining a much less painful surgery for the patient. I think the only reason I protect my subcutaneous transpositions. Now a little bit more than I probably need to is just because of the fact that, you know, for that added professional flap that you're using to secure the nerve, you're sowing in fat. And I don't want them doing anything aggressive early to disrupt that, which is I think, probably the only reason why I still protect them. I know that there are a lot of places where they'll do a subcutaneous transposition, maybe with the eaten flap or something else and just let them go right away. I feel a little nervous about that. I think that, you know, it'll probably work most of the time. But you might have a patient occasionally who pushes it, because I think you can feel pretty good after a subcutaneous transposition, whereas after so muscular you're feeling it, and you're probably not going to do as much soon and pretty quickly afterwards.
Charles Goldfarb:So this is interesting. Okay, so what do you do with your subcutaneous? What do you soft dressing or splint? And when do you allow them to really start working on motion.
Chris Dy:So I do a plaster long arm splint in OR. And then I follow pretty much the same protocol that I do for an submusculars right away, which is I haven't come back to haven't come back. For first post op visit, usually three to seven days afterwards. There's no drain usually on these. But at least we have the workflow established where I can get them into a therapy made long arm splint that they're removing to work on motion. And then they sleep in a cockup wrist brace. And they don't have to sleep in the long arm splint. And that's evolved over time. As I've kind of talked with our therapists. I used to be super protective of them. But you know, essentially, they're working their way out of that long term split within the first few weeks. And honestly, they usually end up not using it. But I like to send the message that we need to protect something, protect the transposition for a few weeks at least.
Charles Goldfarb:I love this. So when you get older, everything's a few years ago, a few years ago, I stopped using a post operative splint, I use a bulky soft dressing. There is no therapy involved at all anymore. And I have zero regrets. And so I used to do something similar to you. I didn't see it back in three to seven days as the next 12 days. But something similar, I have had no regrets for not using a splint at all the bulky soft dressing seems to work. I've had knock on wood, no failures of, you know, failure, the flap. And I would say in that adolescent population or young adult population, those patients who get not so muscular, those patients are back to all activities at eight weeks
Chris Dy:old agree with the eight week thing and it'd be interesting. Maybe in a quote, few years, I'll also be doing things that are that are wising, what was the impetus to change
Charles Goldfarb:the fact that I felt more and more like most people weren't wanting and I'm like, Well, everyone else seems to be doing fine. Granted, they always leave the bar with a sling. Because we all these patients get blocks. And so they leave with the sling says some of them are gonna go slower. And use this link and the bulky, soft. But I think someone probably dish and sling pretty quickly.
Chris Dy:Do you let them take the bulky soft dressing off before they hit your office for post op visit? So is that day five or something?
Charles Goldfarb:Day five? Yeah, it's interesting.
Chris Dy:That is interesting. You know, I think a one question I wanted to bring other random thought, because we've talked about this, especially during the pandemic, when do you start to let incisions get wet,
Charles Goldfarb:simple incisions three days, showers are fine, no soaking, no scrubbing, the little bigger incisions at you know, you could argue incisions heal side to side not ended and it shouldn't matter. But like cubital tunnel is typically five days and I'm worried for some reason. Maybe seven, as long as they're not splinted. Obviously, there's wanted and that stays on until first post Trump isn't.
Chris Dy:Yeah, it's interesting. I think that when you're a patient yourself, you start to question some of these things. Like why can I not get wet for a certain amount of time? So yeah, if I'll let my carpels triggers and anything, like start to get wet at three days dressing down that three days. You know, and especially for even the bigger incisions you know, just with the big like Plexus reconstructions and nerve reconstructions, I've started to use a lot more of the skin glue Dermanbond kind of thing and let him get wet early on. Just because not being able to shower take care of yourself for more than three to five days is onerous to the patient. So then, you know, another thing that came up recently is I was doing a case with one of our partners who was doing an older collateral ligament reconstruction. And we were talking about whether I should put the nerve subcutaneous or submuscular I automatically thought I was going to put it subcutaneous mainly because I wanted to get away from all the scarring from the from the Tommy John surgery. I have a similar approach when you know we're doing a capsular contracture release or one of our partners is doing something for the elbow joint proper. I want to keep the nerve away from all that inflammation and swelling up Is there ever you know, in a throwing athlete, you know, one thing came up is that you never want to violate the flex protein or mass and a throwing athlete. You kind of alluded to that earlier. But you know, how do you consider the use of a sub muscular in that population?
Charles Goldfarb:Yeah, it's I think there's, you kind of mentioned two separate things. One, we're throwing athlete in combination with the UCL and the other would be a bigger elbow procedure. So I, you assume you're working with Matt Smith, Matt and I operate together on Wednesdays. And so I do a lot of these with him. And they always go subcutaneously. And I again, no regrets, the recovery seems to be uneventful. I've not had the scarring issue. Now to be very clear, not every UCL needs a nerve, I think all the those in the sports world understand that. But if they have preoperative nerve symptoms, they are transposed. And I think it's just very helpful for Dr. Smith to have that exposure and have us there. It's not that he can't do the procedure, but I think he feels more comfortable with one of us there. What's more interesting to me, or differently interesting is an elbow release procedure. And this is typically an older patient who's arthritic, and you're doing a bigger procedure, whether it be arthroscopic or open, but especially with an open, where do you put the nerve, you sort of need a bigger approach to get down to the joint, go sub muscular where the nerve might belong, if the nerves acting up, and then all of a sudden your nerve is in the joint. So I don't know what to do in that situation.
Chris Dy:Yeah, and I like to keep the nerve away from the joint in that situation. And certainly, if somebody is going to be scoping, you know, that's something that they should know about where you're going to put the nerve, but typically, I'll let them scope first, to get that out of the way. The problem with having a scope first, just like if you're working on a perineal nerve at the knee is that then you're tough tissue, soft tissue place, they're all distorted, it becomes very challenging to do a soft tissue procedure. But I tried tend to keep the nerve away, you know, I'll do these in combination with, with our elbow surgeons sometimes, and, you know, it's just putting it in the best place, which is why you kind of need to know all the tricks and all the ways to do things and think on your feet. That's how I approach it.
Charles Goldfarb:Yeah, for sure. And I would say, if that patient has, I think it's been interesting to watch the evolution and we're gonna go down the total tangent, but, you know, there is clearly a group of patients that have both older nerve issues and UCL issues in the treatment of UCL has really changed. And so sometimes we are exploring together, it ends up the head knew anything about the UCL and I just deal with the nerve. Sometimes it's more of an invocation or internal brace for the UCL and I deal with a nerve. And sometimes it's a formal reconstruction. And I think all of those happen regularly. It's really a fascinating process. And some of this comes with his being quite busy with UCS. But it's really interesting. It's a nice, I think it's a nice way to team team up and work together, which is super fun.
Chris Dy:Yeah, it was super fun, it was just a little stressful because I decided this was right before I left on our trip. And I decided to put on again, we've talked about this on the pod in the past, I've put on an extra clinic just to like kind of decompress things. And so I put it on before the trip. And I was trying to do this case at one location before we're doing a clinic at a different location. And I was like, I'll just get in there transpose the nerve and get out of there. So you can do the construction, obviously realized during the case that I needed to be there to finish transposition after he did the reconstruction. So I timed things a little bit improperly and worked out. Okay, but it was a little a little stressful, but that was a self imposed issue. But anyway, let's let's pivot to our next topic. I see this with frequency and it feels kind of taboo. Do you operate on patients with painful SuperTrend nodules?
Charles Goldfarb:You know, I think we've talked about this one thing that's always interesting me as well, when, and it's thankfully, it's rare. You get a really unhappy patient leaving a negative review, you always remember, well, I always know who that patient is always. And they don't come back because they're so mad. Well, probably the most recent one was a few years ago, thankfully. And somebody kept coming in for their due diligence kept coming in. And I had a painful nodule and wanted it excised. And I said, Look, I don't like that you're having discomfort. This is not a large nodule. It may calm down. I thought we'd do a steroid injection. And he basically said, No, he wanted it excised. And I don't know. I mean, I'm not against surgical excision of painful duper trans nodules. A is not it's not really needed very often. The injections used to do the trick and see it becomes do we kind of give patients what they want? I don't know. What do you think?
Chris Dy:So I, you know, I, I've come to realize that if somebody really thinks something is painful, if I I remember, when I was in training I was a fellowship here. And I remember seeing patients with one of the faculty members at the time. And he was just like, look, I give them options. And they can decide. And you know, I think that that works for some patients, it doesn't work for other patients. But if they are coming in with this, and they clearly think it's paid well, I tell them look, you know, usually we don't have to take these out, usually these get no, these aren't that bothersome. But if this really bothers you, we can take it out, you might be trading a painful bump for painful scar, you talk about you know, the you always remember the patients who left the bad reviews, I have a patient who had trigger finger released incredibly happy with the trigger finger part of it, no more triggering, but the scar on that part of the poem was incredibly painful, and just never went away. And that's one of my worst negative reviews on wherever Healthgrades or ZocDoc, or whatever it is. And, and of course, they like they leave negative reviews on multiple platforms, using the same spiel. But you know, so it, I tell them, luckily, you'd be trading a bug for a scar and the scar might be painful to you, there's a chance that didn't come back, we can't get rid of all duplicates. And if you want to do it, we can do it. But it's kind of an expensive fix.
Charles Goldfarb:I think that's well said. And I agree with the giving options. I mean, sort of that's that's our role for many patients, like you said, not all patients, but for many patients, it is an interesting phenomenon, the age of value based care and how this this the people, the patients may not be truly ready for that, because the issue with that patient I referenced is, you know, it kind of just elevate, you know, escalated, and I wasn't sure I wanted to operate on this guy. And, and but patients sometimes have very strong opinions. And when those don't align with us, I generally resolve that internally by thinking, well, if I'm not doing him harm, I'm happy to try to make the patient happy with an excision of a DuPage inaugural, for example. But it does get tricky when you're not sure about the real necessity of something like that.
Chris Dy:Right? When the eventually the AI model of preauthorization is going to say no, they're going to realize that maybe this isn't absolutely necessary, the value isn't there. But again, if somebody says something hurts, and they want it out, so that's true. This was like a lot of like the lumps and bumps that we see in hand surgery, it's like, you don't have to have this taken out. But if it really bugs you we can do it. And you know, part of the nihilist and he wants to be like, well, if I don't do it, somebody else will might as well beat me. And I know, that's maybe a little bit too candid, because it's like, oh, I can do a good job. And I know I'll take care of it. So
Charles Goldfarb:yeah, you'll do a good job, you'll take good care of them. They generally are appreciated when the surgery is done. And again, as long as you're not doing something that's potentially harmful, which of course you won't, then I think it's fine. But But and I haven't one of our partners, as he has aged becomes more dogmatic, I believe. And just yes or no, and I don't think I'll ever be that way. I think.
Chris Dy:All right, you heard it here first. And I do these, just for completeness sake, I do it on their local, and the patients, I've done it and have been incredibly happy, you know, mainly up there because a lot of bias. They want to be happy after investing in something like this. You know, so it's worked out pretty well. Good. Well, let's
Charles Goldfarb:do one like one quick discussion, one of our friends, one of the friends of the podcast, Bob VanDemark. emailed and I apologize, Bob, it's been a little while about treatment of a college baseball player. And the role for hook of a handmade excision in the athlete, windy, potentially treated surgically not surgically, do you ever fix the hook of the handmade? So I think it's a good topic. And I'll you know, if you want to start, I'd love to hear your thoughts.
Chris Dy:Well, I mean, this doesn't come my way that often, you know, because of just the nature of the practice usually ends up going to you. You know, I think before we jump into the I think the technical parts of it aren't really that tricky or challenging. But I want to hear your spiel about kind of the batting hand. And you know, the how you grip a bat, because I think that that's something that I was never formally taught. And I think you know, which hand is the top hand? The bottom hand, I didn't play baseball growing up. So you know, it's just something that I always kind of get confused on.
Charles Goldfarb:I thought you were a baseball coach now. So you should say, yeah, if
Chris Dy:anybody saw the coach pitch situation that was happening, you would know that I was not a baseball coach. Really? I was just a warm body.
Charles Goldfarb:All right. Well, that's fair. I'm glad you were volunteering to just to help the kids
Chris Dy:helping beating them with an underhand throw. Yes, yes, that was me.
Charles Goldfarb:So and again, I think, you know, some of our listeners are not familiar with baseball, but in this country, there's still a lot of people who play baseball. And you're if you are if you're batting right handed, your bottom hand is your left hand. And when you swing you let go with your right hand and your follow through is all with your left hand. So a right handed batter primarily holds the bat with his or her left hand. And what happens is all the time force from that that is directly on the hook of the hamate. And so it's a repetitive stressor in that area, there are actually solutions or preventative measures for hook of the hamate fractures, different bat design, etc. Those have never taken off, taken off. Because if you're unlucky, it happens once, and then you're done. And it's treatable. So it's really an interesting, interesting thing. But it's always that bottom hand. And it's I say, 99% of the time, I guess you can fractured with a slide or fall or something. But it's almost always related to batting and it's always the bottom hand.
Chris Dy:What about other sports that involve like rackets or like cricket? For example, if for listeners, you know, from other countries, or like, the overseas with tennis, or pickleball, or anything like that?
Charles Goldfarb:No, I mean, I really don't I see it from falls. And I see it from baseball. Theoretically, I think you're right, Cricket is a potential predisposing factor. And I love I would love it if one of our listeners could clue us in on cricket in which India's it risks don't see in hockey. So I think it's either a fall or baseball.
Chris Dy:Now, what about the what kind of the stress reaction prodromal kinds of things that happened before natural fracture? You know, oftentimes, they'll see that, you know, pick it up on an MRI, that kind of thing. What do you do about that,
Charles Goldfarb:the first goal is absolutely to rescue the patient, I don't have complete faith that that'll cure the problem. But if you have pain directly with the hook of the hamate, exacerbated by swinging, typically an x ray will be normal. An MRI will show edema in the body and the hook. And you can shut the shut them down and let it rest and then try to ease them back into baseball. I think they still have a risk of that turning into a fracture down the road,
Chris Dy:do you ever excise the hook before it fractures.
Charles Goldfarb:I've had that discussion. I have not done it. Because typically people try to play through this. But I I don't think I wouldn't say it's crazy to do that, especially in the in the situation where they're not willing to shut it down and take that chance. But I would try not to do that.
Chris Dy:Then technically a pretty straightforward surgery. We know it's all about the nerve. But you always do your Guyon canal release you free up zone to how do you physically maneuver that fragment out? Is it as obvious as it should be in terms of it being a sizable fragment that isn't quite mobile? Or is it? Is it a little more challenging than that?
Charles Goldfarb:Yeah, I look forward to talking about that I want to talk to I want your opinion how to handle the motor branch. But I would say this for me. And you might disagree with this. For me, there's one treatment for all the AMA fractures, it is excision about the the Hemi, it would be super rare in a maybe an elderly patient with a fall to treat them in a cast. I just don't think it's a reliable treatment, because the problem is blood supply. And you're at the watershed zone where the hook meets where the hook meets the body. And so healing is just lousy. Fixing these makes no sense. So it's excision, and it's a very successful surgery with very low risk. But there is risk and the risk is the nerve. And so gallons can now release in a typical fashion, you palpate the hook of the handmade, and I died. I tried to dissect sharply with a 15 blade and excise it doesn't always come out easy. Because sometimes there's scarring, sometimes it's a partial fracture, etcetera, etcetera. So it's not always easy to get it out. And you have to take really good care of the nerve. Not that, you know, yes, we worry about a laceration that or we also worry about stretch injury than or but how do you handle the motor branch in this situation? Do you like to identify it?
Chris Dy:Yeah, I mean, I identify it all the time. I think that you know, the the beauty of the surgical video education that Dr. McKinnon has used is that everybody has seen this procedure, typically by the time they hit the door on rotating with us. And one of the things that she talks about is that you you can't see the branch until you've released it. I kind of disagree with that. I think that if you work for you can find it and i My My personal preference is to find it. Usually there is that kind of transmitters branch heading towards the owner side of the palm coming off of the ulnar artery and you can find that branch and that's usually where the takeoff of the nerve is going down the zone to nerve so you know once I see that transverse arterial branch then I go and find the nerve I release it you know I've only done a handful okay decisions to be honest with you because it just doesn't come up in my practice that often. But you know, I like that's that's the case for me. And the rest of it is me gently protecting that nerve while the other trainee or whoever I'm working with gets that fragment out. I guess before, you know, I want to hear how you take care of if it's any different than Is there any functional loss from having the hook excised? I think that's a question that patients will often ask.
Charles Goldfarb:No, never seen any functional loss and certainly, while it's less common in Major League Baseball players, it still does happen. Mike Trout out right now what they hope to have a fracture, or maybe he's back now but no functional loss whatsoever. pain goes away. quickly but unpredictably, so I tell everyone six weeks, I do splint all of these patients for at least a couple of weeks because I've tried to not split them just put them a soft dressing is too painful. So split for a couple of weeks, and then I let them ramp up as they tolerate from there, typically five to
Chris Dy:six weeks. Okay. All right. Well, there you have it.
Charles Goldfarb:All right. So let's do a deal. Let's shift gears a little bit and have a fun conversation about how to say no.
Chris Dy:Yeah, so I think that it's timely for you, since you've obviously, you made a big decision to go back to school. And Billy Madison style, I guess many of our listeners won't understand that reference. But so you're starting business school shortly, which is a big, big decision. I meet with some of our former fellows on a regular basis to do kind of mentoring sessions. So I was meeting with one of them recently, who's an academics, and they were mentioning just that they are overwhelmed right now with all the different things in terms of their political activities, both elective stuff and then call stuff, as well as trying to get research stuff off the ground, and continuing and just kind of drowning in everything. And their question was, you know, how do I, how do I prioritize things? How do I say no to things? You know, so I was thinking about that. And I think, you know, I gave him my response in terms of how to, you know, evaluate opportunities and what to what to do and what to say no, to how to say no, but I guess I wanted your sense on, you know, at earlier in your career, when you were in kind of your reputation building phase, how did you balance kind of this busy clinical practice with needing not needing but maybe wanting to develop your reputation, maintain good relationships with your colleagues, in terms of not always saying no to stuff? How did you handle that?
Charles Goldfarb:It's a really important concept. And I think it's very different today than it was 20 years ago, I had very dogmatic advice, handled differently from a couple of my mentors, they all said, they all had the same message. They all said it differently. The bottom line is you just say yes, you say yes to everything. And you do things. Well, you prove your value to people across the country, they could count on you to write a chapter, write it well, and get it done on time. And you do that and more opportunities follow. I think there probably were fewer opportunities, then. Now, there's so many different directions one can go. Whether it's primary research, whether it's multi institutional research, whether it's videos, or podcast, or, or chapters or speaking engagements at don't know if that's accurate or not, it feels like there's so much more variety, and more opportunity that you're probably getting hit from more direction is that you think that's true.
Chris Dy:I think that's true. And I think that the relative value of these things has changed, right. So I mean, chapters are still, you know, they exist, but I think less people are actually reading them and using them. It's something that honestly, I'll still do for a friend. Now, even even for friends, I tried to get out of it. But I'm guilty of currently editing a book and asking people to write chapters. So but I think that again, it depends on where you are. I mean, I think the value of chapters from a, you know, academic, true promotional type perspective is very little, but it is more of I think of just, you know, relationships and networks and trying not to upset people by saying no, if you're gonna say, yes, do a good job, I just, I don't know, I think I try to follow kind of the adage that you read, you know, about, you know, if you're gonna say no, you know, provide somebody who can perhaps, you know, fill in or sub or something like that, but it doesn't always work out. And I think you have to be careful about who you say no to, because that might be not necessarily a bridge burn, but some people have long memories, other people don't care and don't remember.
Charles Goldfarb:Yeah, I think that's right. I think he said a number of really important things. So first of all, who's asking? And when you're younger, if if you take the Ansaldi as an example, and there's a VIP and the answer is that he was going to be around for a while and it asked you to write something a you should be flattered. And be it is an opportunity to prove yourself and some people although less and less, I think will be offended if you say no, now, that person may not reach out to you again, but But most people understand that we're all trying to achieve achieve better work life balance then perhaps was such a focus, you know, wasn't much of a focus 20 years ago. I don't know I I still think as we you're really getting started and you're trying to make you know, create relationships. This is one good way to do it. But you do have to do it carefully.
Chris Dy:Right. The last thing you want to do is say yes to something and be late and not do a good job and then it's just you lost on all accounts.
Charles Goldfarb:Yeah, here's a good tangential story, which really had an impact on me. So I run a bore a local board. For the world pediatric project, which has been a really great experience. It's, you know, a little bit of a time slot, but not a major one. And we're trying to attract new board members. And we had this really great guy that we were all excited about. He had been vetted by our membership committee, and was was all in. And then he was asked to participate in something different, which was more meaningful for him. And he, he decided to go with the other opportunity. Totally understandable. I walked away more impressed with him than I ever could have been had he joined our board because of the way he said no. And he wrote a thoughtful, I think he had a verbal conversation with the person he was most connected with. But he wrote a really thoughtful email, explaining his decision, apologizing for his decision. And I just walked away thinking, wow, this guy is impressive. And what a bummer. Maybe maybe in the future, we can come back to him.
Chris Dy:It's it goes to show. I mean, there's so many, quote, soft skills that we never, most of us never get a formal education in, at least in kind of the medical training. And maybe this is the stuff you're gonna you know, the touch and apologize, you're gonna learn in business school, but I think some people just have it other people don't. And it's not certainly something you can learn to do. It's just having the having the ability to, you know, to have to understand how your actions come across, and how you can control or modulate that and not to be overly manipulative. But certainly there are ways in which you can say things and frame things that will come across better than other ways.
Charles Goldfarb:Yeah, for me, what I tend, I'm curious how you handle the saying no, now, I do think it needs to be heartfelt. And obviously, it needs to be honest. But the real issue for most of us is just time. And if you can honestly say that you're overextended, you don't think you can do as good a job as you otherwise would like, you don't think you can hit the deadline? I think that will resonate with the person who is requesting. I wouldn't say the danger about the deadline is if that's your only excuse, they may they may say oh, we can be a little soft on the deadline, and then you're hooked, then you can't get out of it. I've
Chris Dy:I've tried to say no to stuff recently, and use all the tricks, and I've been looped back in on all of them. So you know, at some point, I just kind of gave up and just added it to the list, fortunately. So those of you there are a couple of friends of mine that are listening to probably know what I'm talking about. And I'll leave it at that. But anyway, this was fun. Yeah, hopefully it is a grab bag of things it was was fun and useful. And if you made it this far, thanks for listening.
Charles Goldfarb:Yeah, it's fun. Absolutely. These are great topics. And we need to really hit an HBR article in the near future, but fun to touch on it as I'm getting excited about going back to school.
Chris Dy:All right. We'll have to hear more about that as you go through this journey. All right. Have
Charles Goldfarb:a good day. You too. Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to check us out on Twitter at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb:Mine is at congenital hand. What about you?
Chris Dy:Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast
Chris Dy:and be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time