The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Talk Mission Trips

November 13, 2022 Chuck and Chris Season 3 Episode 44
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Talk Mission Trips
Show Notes Transcript

Season 3, Episode 44.  Chuck and Chris  talk international 'mission' trips with Chuck's trip to St Vincent with the World Pediatric Project just finished.  Grateful to supporters including the Touching Hands of the ASSH and Orthopediatrics as well.  Hear more on thoughts on what makes a great team and a successful trip.

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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.

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Charles Goldfarb:

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, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I am doing really well. Really well. What about you?

Chris Dy:

I am fantastic. I feel like an old guy just had 10 minutes of it to it supports myself to try to set up bluetooth headphones, because for some reason wasn't working. And then I'm trying to figure out whether I switch to a Mac or not. And it's a mess.

Charles Goldfarb:

Well, it's the latter point, you definitely should switch to a Mac. But I, my children make fun of my wired, old school Bose headphones that are you know, earbuds. But man, they are completely reliable. And I do need some some wireless. I know, but these are reliable and great.

Chris Dy:

Yeah, you know, apparently there is some kind of lag if you use wireless or Bluetooth. So I think that a purist and audiophile would say that you have to use something wired. I was actually shopping for a sound bar this week for our TV. Because, you know, apparently that's the thing. And I was all about trying to Yeah, we did, I was trying to all about trying to hide, you know, go wireless fully, and the guy at the store was trying to talk me out of it. Till honestly, it just ruins the aesthetic for the TV that we have. So

Charles Goldfarb:

what did you get?

Chris Dy:

We have, we have one of those frame TVs that looks all artsy and whatnot. So I ended up getting the matching soundbar for that. And it does have a completely wireless capability with the exception of power. And you think they figured out some kind of solar system so that you didn't need a power cord. But we got to do that at least.

Charles Goldfarb:

Yeah, I think soundbar makes a difference. But um, no audio file. So you know, all works. Okay,

Chris Dy:

so you're not in your basement right now. Where are you?

Charles Goldfarb:

I was wondering if you're gonna notice. I am in St. Vincent, we're wrapping up a week long mission trip, which has been remarkable.

Chris Dy:

Well, I think we're going to spend the time this week talking about that on the pod. So if you want to jump right in and tell us about the trip, and kind of how you ended up there, and this ain't your first rodeo there. So

Charles Goldfarb:

yeah, I guess I should start by saying that we have a great team. And that's, it's a team sport. And so we have one of our fellows, David Wright, who has been absolutely incredible on this trip, you know, some of the things that we value in, I guess I would say normal life are accentuated in a place that is, you know, can be a little challenging. And so David has been just incredible doing anything and everything to make the trip a success, been fun to hang out. So I think he's enjoyed it, even though congenital is probably not in his future. But there was a lot of post traumatic and, and spasticity and things like that, which we'll get to. So David has been great. Betsy, who's remarkable, or nurse Michelle, who's remarkable occupational therapist, we had Mike Montana, who is an anesthesiologist at Children's who has been awesome. And then we had a scribe. So really great group, and this has made the trip a success.

Chris Dy:

How did you assemble that team? Because I feel like most people who go on trips like this, don't have that big of a team, or perhaps they do and that's the way you should do it.

Charles Goldfarb:

Yeah, I guess it depends on the trip. I know that the hand society has a touching hand strip right now, I want to say is in Guatemala, where there's 30 People now those are not all surgeons, and I don't know exactly the breakdown, but there were at least six or eight surgeons included in that group. So I don't know what their ratios were. So I guess I should say, I appreciate the support of the hand society for our trip as well. The touching hands project help support this trip. But step was really put on by the world pediatric project, which I believe we talked about. And you certainly know my close relationship with the world pediatric project, and they do trips for multiple different specialties, and Eastern Caribbean and Central American trips, and this is Eastern, and really southern Caribbean trips. So for this trip, that's what we need. Those are the people that we need to make it a success and success it was

Chris Dy:

now I think we've talked about the world paediatric project on past podcast, but for those that didn't listen to that those episodes, can you tell us just a little bit about the project? I know that you're involved probably at a leadership or a board level, right?

Charles Goldfarb:

Yes, I have recently gotten involved in last year. So yeah, the world pediatric project was founded in Richmond, Virginia, in about 2011 joined with a group called Healing the children in St. Louis to really make a remarkable organization which actually has come out of the pandemic stronger, and it's relatively well funded. Its impact is incredible. It used to be primarily we'd bring kids to the states for really complicated care. And now their mission trips going out regularly, one to two a month or more. And some of these are operative. And while we were down here, there's actually a NICU team educating the local doctors and working with some sick kids. So that's been that's been fun to see.

Chris Dy:

So how does a trip like this work logistically?

Charles Goldfarb:

in Barbados for a long weekend, which may sound nice, I promise you it was all work and a lot of travel. I left on a Friday came back on a Sunday and with a partner of mine saw 100 patients in clinic and those many of those patients came over. Those Barbados patients are supported by the Sandy Lane Charitable Trust and for those sophisticates in the audience, Sandy Lane is a really high end hotel, one of the best in the world. And they do a lot for the island. So anyways, I was in Barbados, so a bunch of kids, many of those came over for surgery on this trip. I've done a lot of zoom, and reviewing patient files, all in preparation for this meeting for this trip. And in actuality, we had attended surgical plan now, that sort of flew out the window when we got here. But so we traveled on Saturday. On Sunday, we saw 55 patients then after clinic, we spent a lot of time piecing together the surgical schedule for the week. And we scheduled and performed 18 surgeries over the course of the week. And we're coming back today, which is Saturday, the day before the podcast drops. So you know, really remarkable week very, you know, we were efficient as heck, it was really impressive how turnover times were low. And Betsy had done a remarkable job planning for what we needed. So there's so many logistical things that go into the success of a trip like this. But we can talk about some of the principles of what success looks like, but really great.

Chris Dy:

So two things. One, I'm not surprised by your efficiency. I think anybody that knows the chuck Goldfarb brand would not be surprised by that. But that's incredible. The second thing is before we dive into the clinical content and the cases you did and how you made it so efficient, we do have to talk about our friend practice like

Charles Goldfarb:

and we should, they are our friends and and we should, you know, I think it's been an interesting process and certainly, identification of the perfect job is is a really important step for any young physician or surgeon. Well,

Chris Dy:

you know, when you get back, Chuck, I have a variety of practicing hats for you to pick from. Ken Alman has provided us swag. My son Raphael already picked the blue one but there's a white a gray and a black Practice Link hat for you to rock when you get home. I love the up the Upper Hand is sponsored by Practicelink.com The most widely used physician job search and career advancement resource. Becoming a physician is hard. Finding the right job does not have to be

Charles Goldfarb:

Join practice link for free today at www.practicelink.com and check our show notes for the link as well. Yeah, so good partnership. And it's a pleasure to work with Practice Link.

Chris Dy:

Yes, you will need that hat when you get back to St. Louis because it is frigid. Here it is. I think it's 20 degrees outside which is crazy because it was 74 on Wednesday.

Charles Goldfarb:

So we were having a we were having a team dinner last night discussing what surprised us about this trip. And in I've been here before it's and nothing really, you know, surprise me other than it is rained an incredible amount. And thankfully this morning we don't leave till a little later today. But this morning is beautiful. So hopefully we'll get to enjoy a little nice weather before we head home.

Chris Dy:

Well, I'm glad you get to enjoy that. I will say I did look up in Celsius for our international listeners what that is it is currently minus two degrees Celsius in good ol St. Louis, Missouri, USA. But alright, anyway, tell us tell us you said 18 cases in a week on an international trip. That's pretty phenomenal. So how many days of the week? Are you doing surgery? Was it every day? And then tell us a little about what kind of cases you did.

Charles Goldfarb:

We operated Monday through Thursday and it was we were really good we scheduled things nicely so we would leave the hotel early in the morning 6:30- 6:45 fight a little traffic get to the the really the only hospital on the island and Milton Kaito hospital. The world pediatric project essentially owns one of their own cars employs staff on the ground to keep the operation running 365 days a year. And so then we would start operating about eight 815 And every day we got back to the place around 630. So long days, not not incredibly long days, but long days. But busy days a lot of you know hard work to keep things moving. Our cases were a mix of some congenital but mostly not some post traumatic for an example. We had a patient with a bad burn with with serious contractures which we treated a post traumatic fracture with a subsequent tendon right I'm sure they'd have been treated here on the island, and a remarkable number of cerebral palsy kids. And lastly, perhaps to bring it home for you plenty of brachial plexus palsy. So we did a couple of Proximal Humerus osteotomies, which these were older kids within us. That's the right approach. One of them was revision. And that was might have been one of the tougher cases on the trip.

Chris Dy:

Do you have flouroscopy during the case?

Charles Goldfarb:

we do, there's one large c-arm, which is shared. And thankfully, we really didn't need it much for anything, but it's nice to check. At the end, it was it was not a lot of bony work, do I felt more like a plastic surgeon than an orthopedic surgeon? Which is, you know, obviously, great. But we did have that available to us?

Chris Dy:

Well, I mean, I think that in a resource resource challenge environment, at times, it probably is best not to rely on the, you know, doing doing cases that rely on a lot of, you know, either resources like implants, or the technology that we use in the operating, we're fortunate enough to have in the operating room. So it's great that you're able to find a bunch of cases, you could just, you know, rely on your loops and your hands,

Charles Goldfarb:

for sure. And we you know, ortho pediatrics is a company that has supported this, these trips, and they supported us as well, we had, we use their small fragment trays a couple of times, but had other options, including risk fusion, we thought we might do a risk fusion and the reality was, we didn't do it. But the other interesting thing on this island is not a lot of pain medication, you know, reminds me how differently our physicians approach post surgical care in the United States, and how different patient expectations are

Chris Dy:

Will you change your practice at all, when you come back to the States?

Charles Goldfarb:

Well, I'm going to be practicing in the States. So I don't think like, you know, when we when you have a 15 year old kid, where you do a painful humerus osteotomy, and you give them maybe one dose of narcotics, and they're fine with Tylenol and Motrin, it's really crazy.

Chris Dy:

It's a very different societal expectations. You know, like the current fellow that's with me, Jess Billig has done a ton of research in the health services space, including on opiates. And she's pushing me to try to decrease the amount that I prescribe. And I actually think I'm pretty good already. But it certainly is good to reexamine our processes. But I think there's a certain expectation and our, you know, in this little microcosm of St. Louis, that, you know, there there are some narcotics prescribed after every surgery, right or wrong.

Charles Goldfarb:

Oh, for sure. For sure. Yeah, a couple interesting things. So, you know, Betsy did a great job of putting, you know, the trip together and making sure we had all the equipment, we brought a lot of what we needed, and we'll take take it back. And there's certainly equipment here on the ground. And that's he had literally everything or knew everything was available. But certainly like a privilege surgeon from the States, you know, a pair of ads and pickups is not the same as a pair of ads and pickups and they're very significant differences, and dissecting series, which we know are important vary tremendously. And so we were actually trying to pick our trays based on the case up as a more technical case, well, I need that pair of scissors or for the less technical case, well, that tray with a crappy Addisons will be fine. It's just those little things because they really do matter even though I consider myself a pretty flexible surgeon and we knew we were gonna get through the case but it just is more enjoyable and more simplistic with the right stuff.

Chris Dy:

One thing I noticed when the my last trip I was in Brazil, and certainly not a resource challenge environment relative to where you are, but you know, the surgeon there that was missing, had to own he owned all of his instruments. And he had to bring them he and his nurse or Tech had to bring them over to Oregon and she was responsible for bringing that to all the different or so, you know, he was buying his own instruments online. And then you know, having them shipped to Brazil and he was responsible for transporting them cleaning them sterilizing them all that which is just very different than what we're used to and I'm sure that you were missing your your tonight dummies and your wonderful forceps and you know I was just a children's just you know rolling around and old the Goldfarb trace

Charles Goldfarb:

Yeah, you get used to the stuff you have and you want you want your stuff that makes you feel comfortable. But again, all went well. I had I had fun with I think I think I smell good on the podcast. But at the end Saturday I went to this, you know, a great meeting about international work. And it was recommended that we buy some little wireless mics for the iPhone. I did purchase those. They're inexpensive, and oh, nice and use looks like you're showing me that you have some. And I brought them with me and I interviewed a number of the kids and parents before the surgery was part of the kind of flow and the day. It was fantastic. First of all, the mics are awesome. And it does make the video more powerful. But just talking to the families and getting a sense of kind of what are their expectations and talking through what are reasonable expectations was really fun and obviously important.

Chris Dy:

So what are you gonna do with that footage

Charles Goldfarb:

I shared it with so that the families have all signed off on social media use. And I don't know that I will personally use it. But I shared it with the handset and the world pediatric project because they hopefully will find it useful. I did keep a daily blog for both organizations as well, and shared some some pictures with them. So Dave, and I were laughing last night, that we hadn't taken a lot of pictures together. There were some group pictures and some of our pictures, but we were worried Dave was worried that you would be angry with him without a good picture to document the trip. So he took a bunch last night.

Chris Dy:

Wonderful, the wash your hand, Instagram account is going to be very happy with that it social media director will be very happy as well. So thank you for that. Yeah, two questions to bring it to a close. So what do you think is the most rewarding part about this particular trip? And then also, if one wants to get started in doing this kind of work? Because I'm sure you're peaking a lot of interested listeners? How does one get started?

Charles Goldfarb:

Maybe I'll answer the second question. First. For hand surgeons, the touching hands project is a remarkable resource from the hand side. So you know, reach out to them with your interest. And they'll try to figure out how to make it happen. And usually, as I mentioned, their trips are larger. So you go with experienced surgeons and figure it out. Jim Chang is the Medical Director for Research International, another remarkable organization that does really great trips. And so I think the key is, at least from my simplistic approach is find an organization that is doing this has done this and learn from them, partner with them. And then you can figure out if you want to go in a different direction. So I think partnering with the right organization, number one helps helps assure success, and to just, you know, smooths the path in front of you significantly.

Chris Dy:

Is there often a hand therapist that comes with you on these trips? And was your therapist in DLR with you on this trip? Or?

Charles Goldfarb:

Yeah, so there's every trip I've done, there's been a hand therapist, whether it's, you know, seeing patients in clinic or operating. And yes, and Michelle Berg, who I've known forever from the shrine came with us. So during clinic, she would see patients and, and, you know, talk to him about surgery or non surgical care. And then every day during the week, she had a full day of clinic, and some of those were pre op, some of those were posted up, some of those are just purely non operative care. So for the hand surgeon, among my God, it's an incredible resource to have. And then your first question was around, you know, what we find most enjoyable, most valuable, most rewarding about a trip like this. And I would say that so much, from a personal level, that the team, you know, is really great. And that bonding that you get where, you know, in St. Louis, you know, you do your surgery, and you're running off to a meeting or running off to talk or do this or running home. And here, it's all about the team, it's all about the the mission, and that's great. And that's great, the ability to provide care that otherwise would not be provided is also remarkable. And the families, I don't want to say they are more grateful or differently grateful, they're grateful, they're grateful for the opportunity to chicharon, and a lot of them are traveling to get this care. And, and it's it's, you know, it really is quite satisfying. The technical part, it's fun to, you know, working closely with Dave, to do these surgeries, and do them in a super high quality way. You know, we don't have a lot of capacity for complications, or adverse events, and thankfully, we had none, making sure the cast are perfect, because we're gonna be gone. So a lot of that kind of stuff, but I guess, you know, it really is an ability to focus and help a population that would not otherwise likely receive this care. That makes it rewarding. Primarily.

Chris Dy:

That's fantastic. You know, I think that, you know, there are probably a couple of things that I still want to ask you, you know, one what is how does follow up care work? You kind of touched on it. And then when will you be back?

Charles Goldfarb:

Yeah, so the, you know, the concept of fly in fly out missions are, are really no more, right. I mean, they shouldn't be those are the, you know, like, you just have to assure education, and you have to share follow up care. So we worked with, there's a medical school on the islands. So we worked with a metal some medical students, we work with some of the interns and surgeons in the hospital, just to share what we were doing and how we approach things. Now, I don't know that that type of more complicated cases that we do will be done by others. But that kind of relationship building was really nice. And then the follow up care, again, critical to make sure that is taken care of the WPP works with different surgeons who will agree to see the patients we have a very comprehensive plan for each child. And then on Monday Have all 24/7 by email and I expect there's only a few that are ordered X rays on but I hope to see those x rays you know in six to eight weeks and can make sure things are going in the right direction. And then we'll see them when we're back. So Lindley wall and I sort of have a deal that we will alternate surgical trips. And so we think the right cadence is once a year, although if the WPP post pandemic, you know, I hate to use the word but markets that are availability, it may be more frequent than that, but right now we will trade off and it works well. And she's I went 18 to St. Vincent, she went and 19 pandemic hit. And this is our first trip back. But I think we have plenty of volume, we check to make sure the different islands are aware of our presence.

Chris Dy:

Well, congrats on another fantastic trip and have some safe travels home and I hope you brought something to wherever you get off plane because it is frigid.

Charles Goldfarb:

Um, thank you. I'm not looking forward to that. But I am looking forward to being home. And you as you know, is going to be is going to come with a bang on Monday morning. But thank you and, and I look forward to talking to when I get back. All right. Sounds

Chris Dy:

good.

Charles Goldfarb:

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 @handpodcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb:

Mine is @congenitalhand. What about you?

Chris Dy:

Mine is @chrisDyMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@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