The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris Discuss Their 3 Most Memorable Cases

December 19, 2021 Chuck and Chris Season 2 Episode 48
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris Discuss Their 3 Most Memorable Cases
Show Notes Transcript

Season 2 Episode 48.  Chuck and Chris share and discuss a listener question about hand surgery call.  We then continue to listener submitted segment and share our 3 most memorable cases and lessons for our younger selves.

This is our last episode for 2021.  Looking forward to 2022!

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As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.

Charles Goldfarb:

Welcome to the upper hand, 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 aspects of hand surgery from technical to personal.

Charles Goldfarb:

Thank you for subscribing wherever you get your podcasts.

Chris Dy:

And be sure to leave a review that helps us get the word out.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm doing really well. What about you?

Chris Dy:

I'm doing well. We're trying to thread the needle here. We have a period of time in which my children are playing downstairs, my wife is not home. And we're gonna see if we can do a podcast. You know, we'll see how it goes.

Charles Goldfarb:

I have faith, I have faith. Let's see.

Chris Dy:

So we've been getting some great emails from everybody, and they're super appreciated. So one thing that I would love to share is a question from a listener. His name is Matt Dubiel. So Dr. Dubiel is a shoulder and elbow orthopedic surgeon works at a level one trauma center. He says he got complex upper extremity trauma and conduction in conjunction to his elective practice. From a hand standpoint, he does triggers, carpals, De Quervain's and basic to more complex distal radius fractures. Now their community is in dire need of hand surgeons and there are people that need to cover hand call and their hospitals currently floating the idea of orthopods electing to be part of the hand schedule. Hopefully you're getting paid to do that, with the setup to handoff more complex hand call stuff to the hand trained doctors, which are few apparently. And he's thinking as he's considering this. What are your thoughts on this setup? And what are the top five hand call topics to brush up on? If this is something I'm asked to do? Is there a specific course you would recommend attending? Matt is little over three years in practice and is willing to learn to a point. So Matt, thank you for that fantastic question. I can see Chuck is actively pondering it right now. And Chuck, what are your thoughts?

Charles Goldfarb:

Well, first of all, Matt, it sounds like you're just trying to do the right thing for your community, which is obviously admirable. You know, I really do. I don't know the local situation. So it's a little unfair of me to comment, but you hate to hear about hand surgeons in the community that aren't taking call. There may be very good reasons for that. But as physicians, I strongly feel that we have a duty not just to work at a surgery center. But I think, again, I may ruffle some feathers with this comment. But I think we have a duty to our community. It has to be in the right situation. It has to be the hospitals have to take care of the physicians and the physicians have to take care of the patients. But I hope that there's a way to work this out. But long story short, what of the what conditions would be tricky for a non hand surgeon to care for emergently? I think that's the heart of the question. Am I interpreting that correctly?

Chris Dy:

That's what it sounds like, I sense a hot take coming from Chuck Goldfarb here.

Charles Goldfarb:

Yes. So here we go. Um, you know, I think that it's not really fair to expect a non hand surgeon to deal with the nerve or vascular issues. That could include things like replantation is, depending on the level of care provided at the hospital, it could include revascularisation, it could include, you know, deep lacerations of the forearm, I would not expect a non surgeon to repair the vessels, repair the nerves. And those are tricky. And even hand surgeons like myself, who don't do them all the time, might defer at times to someone like Chris, who does this type of work all the time. So that's where I would start.

Chris Dy:

Do you do you think a non hand surgeon should do the tendons and a spaghetti wrist for example?

Charles Goldfarb:

I don't, I don't, and I don't think they should do flexor tendons, it just doesn't make sense. There's too much of our training goes into that to perfecting those techniques. Now. It's not to say that they can't, and it's not to say if they had a wonderful residency experience. They're not, you know, qualified, but it's just why if you have hand surgeons that can do this. It really is that's a real hand surgeon case in my mind.

Chris Dy:

What about perilunates?

Charles Goldfarb:

Same answer, I think that is a hand surgeon case. I would argue that, you know, unless a non hand surgeon is doing a whole lot of wrist trauma. Scaphoids can be really tricky. And there's a lot to it. And so scaphoids in my mind, in general, are a hand surgery case. ligament injuries about the wrist are a hand surgery case, I mean sure getting the initial reduction for a perilunate Absolutely. Any orthopedic surgeon or plastic surgeon or general surgeon can do that. But the final definitive fixation I think should be a hand surgeon.

Chris Dy:

Now, can you think of any other things that that one sees on hand call this that could clearly be fielded by a seasoned orthopedic surgeon who sounds like you know, Matt's pretty good at complex elbow trauma. I mean, that's something I don't love doing. So if you can do that you can, you can do a lot of things.

Charles Goldfarb:

Yeah, the other thing hand-wise I was thinking about fingertip amputations and you know, fingertip amputations. On the one hand, technically, there's not that much to it, right? Often it's the intern in the ER doing it. But that doesn't always lead to the best outcome. And so I think, really taking care of the soft tissues is or can be tricky. But certainly, I think in the middle of the night for a simplistic fingertip amputation, that can be done by a generalist. And that's about all other soft tissue management problems can be managed overnight by anyone, and definitively managed by the hand surgeon in a delayed fashion. And then I think the other question was, do I am I aware of a course that really focuses on these bread and butter type hand surgery issues? And I'm not.

Chris Dy:

Okay, so we recently had a great milestone, we talked about it last week, but 100 episodes, and now 102 episodes, and we're going to take a little bit of a break. And we haven't done that. So which is crazy, we've gone ham, very hard for over 100 weeks now, which is crazy, but we're gonna take a little bit of a break and recharge on the podcast. It's it's been fantastic along the way. And, Chuck, do you have any thoughts after 102 episodes?

Charles Goldfarb:

Yeah, well, I'm looking forward to a couple of weeks off. And the irony, of course, is that neither of us will probably take time off from thinking about the podcast, and we had talked about potentially working on a newsletter, but you know, there's no doubt when you and I get together and have the actual conversation, it's generally pretty fun, especially if we can avoid the late evenings. You know, my takeaways are number one, this is more impactful than I think I ever would have imagined, which is obviously why we continue to do it. Number two, it's more fun, most of the time than I ever thought it would be. And number three, it's hard work. It really is hard work.

Chris Dy:

I 100% agree that it's hard work, and that it is way more impactful than I thought it would be. You know, I let me pull up the latest stats, but in terms of, you know, the the week to week downloads, and the people listening and subscribing. I mean, it's it's pretty incredible. I mean, you know, last week, we had 1844 downloads, and we're averaging almost 1400 people subscribing and listening every week, which is crazy. It's far bigger reach than I thought we would ever have, especially this early on. And it's been beneficial in ways that I honestly can't even fully describe. And it's been fun. You know, I think that it's allowed us to communicate more, I think I always tell people, one of the advantages that the podcast has had for me is that I get to talk to the Executive Vice Chair once a week, which is nice.

Charles Goldfarb:

And I get to talk to the little people.

Chris Dy:

Yeah, exactly, you get you get to relate to those who are, you know, boots on the ground kind of situation. So you get you keep your pulse on the department by by touching base with me once a week. It's been fun, you know, again, we went into it, not knowing how long we're gonna do it. And it's been basically two years, and I don't see an end in sight. I'm sure you've thought about it. I'm sure you're thinking about your exit strategy. But unlike other things that I'm involved in, I have not thought about when it's going to be done. So at the very least, we'll keep going for now.

Charles Goldfarb:

Yeah, and just to be very clear, we're not taking six months off or taking two weeks off. But, you know, as I've said before, and my wife loves to say, you know, do the things that give you energy and make you smile. And there's no doubt that this is one of those. And the stats also make me smile because we are still growing week over week, there are more regular downloads. And so that is remarkable. So a big thank you to all of you who are listeners.

Chris Dy:

Absolutely. And we love the feedback. We're actually going to go into another segment that was suggested by Minnie, our OT listener out at Stanford. But the the segment suggestions have been great. There are a few that we're going to try out in January and let us know what you guys thought of half full, half empty. I thought that was a really fun episode to do. The more podcasts other podcasts I listened to I hear episode segment ideas and I'm thinking about how we can incorporate it into our show. And I think those are the things where if you have other ideas please send them in if you have questions clinical or otherwise, please send them in.

Charles Goldfarb:

Totally agree. Yeah, we are always I don't want to say experimenting and but we've done we've we've tried a lot of different things and we will go back to some of them again. It's just a matter of getting a strategy in place for maybe the next six months or something.

Chris Dy:

Absolutely. And so again, Matt, thank you for that earlier question. And Minnie thank you for these suggestions that you've given us. And so we talked last week about three people that influenced our careers. And the next one was three patients or cases you will never forget. And then three things you would tell your younger self. So why don't you lead us off with a patient or a case that you will never forget?

Charles Goldfarb:

It's funny I was I was listening to a podcast by a sports medicine surgeon. And he appropriately said that most of the time you forget cases that go well, no matter how impactful they may have been at the time, once you remember the cases that don't go well, I'm sure that rings true for you. There have been sleepless nights, but are going to focus, in large part, I think, on the positive and I'll start and we should definitely go back and forth. I think the coolest case, and I hate to get technical and use the word cool. But the coolest case, I have done and this is public is a kid that came up from Guatemala, who had three arms. And I did this relatively early in my career. I did it with one of my mentors, as we discussed last episode, Paul Manske, but sort of I led the way. And this, what we did was one arm was normal, and the other side had two arms. And we essentially one of the arms had a humerus, and the other arm had an ulna with two fingers. And so we essentially and the second arm was lower down the thorax. And so we raised the pedicle, including the vessel and the nerves for the lower arm, that is the distal arm, and we fused it to the humerus, kind of brought it around to the shoulder and fused it to the humerus. And it exceeded our expectations as far as function. It's far from normal. But really a remarkable case and more importantly, a remarkable kid who has managed to stay in the US he came from very rural Guatemala. So I do get to see him periodically as to a wonderful organization called the world pediatric project. And I've worked with him for many, many years. But that case will always be special to me in a very positive way.

Chris Dy:

What made it so special? Was it the technical coolness of it? Was it doing it with Dr. Manske at that point in your career? Or was it the lasting impact that you think you had on his life? Or all three, I guess.

Charles Goldfarb:

Yeah, I think all three, but it tell me if this rings true, part of what's fun is when you have something different in congenital brings that I think nerve surgery brings that. But when you have something different, and you come up with a plan, you don't really know if that plan will be executable and will work out exactly like you planned it. This one did. And so it I think that's another reason why it has been so impactful. It just worked out better than I possibly could have expected it to.

Chris Dy:

That's fantastic. You know, you mentioned remembering the cases that didn't go well. And you know, you're not going to be surprised. I think the three patients in cases I think about are all Plexus related, because those are the ones that I spend a ton of time thinking about. I mean, you could ask me, you know, just first names of Plexus patients as I do, we want to talk to my research coordinator in my in our OTs, and I remember those patients instantaneously, you asked me about the ganglion, the patient with a ganglion cyst that I treated a month ago, blanks. And even my MA knows that she's like, you're not gonna remember who this is, but and you know, I don't think that's nothing against you know, the doctor patient relationship. It's just a matter of the things that tend to stick in our heads. And I remember my very first pan Plexus brachial plexus patient, because, you know, they actually set off an entire line of thinking that was reinforced and informed by you know, who they're talking to. In our last episode about mentors, Dr. Gelberman, and I was just racking my brain as to why it took so long for this patient to get to me. They were misinformed at their original treating institution, which was several states away and passed several marquee institutions to come and see little Oh, me and my first year of practice, you know, obviously came to WashU because of the reputation at WashU has for nerve and ended up with me, and I think I took great care of him. You know, but it was striking to see how difficult it was for him to get to me. And I remember that part the most because that led us on this entire line of investigation that ultimately has resulted in the research program we have. And you know, what's also striking to me is that I have the good fortune of being part of a great brachial plexus team that includes, you know, our microsurgical and microvascular expert, David Brogan, and our strategy now would probably be different, mainly because we have access To, to doing things like free functioning muscle transfers, and they're a huge deal in terms of surgery, but it's not that huge of a deal to ask David to do a free functioning muscle. I mean, you know, it's it's a big lift from a technical perspective and a resource perspective, but it's not like it's the first one he's ever done. And, you know, that opened up a whole new perspective when he came on board and brought that, that experience. So I think that he that patient is, is remarkable and memorable to me, because I think we would have treated them a little bit differently now. If we had if he came today, for example.

Charles Goldfarb:

Yeah, that's super interesting. Yeah, you Well, I think we're both fortunate to work with really strong teams. And that in and of itself is one of the reasons we're both grateful to be where we are for sure. So my second case, is in the sports arena. And early on, I had the pleasure of working with the St. Louis Rams. I can't really cheer for the Los Angeles Rams, given the departure, but St. Louis is $790 million compensated, shall we say, for that departure. Recently.

Chris Dy:

Um, which 200 million went to the lawyers? Is that right? Maybe more?

Charles Goldfarb:

I think it's more, you would think legal fees would be covered separately.

Chris Dy:

The owners have enough money that it should have been covered separately.

Charles Goldfarb:

Yes. But I think it gets it really is the reason it's so memorable is the stress involved. It wasn't the first sports professional athlete I took care of, I think the when the stress level goes up, and the planning goes up, you know, the memory kicks in, I guess. But it was the first case where there was a lot of pressure to take care of a fracture, not a complicated fracture, but to do so in a way to get the person back on the field ASAP, because there were playoff implications. And so this actually was a very proximal proximal phalanx fracture, in a large man. And I treated this this football player with two 0-62 Kirschner, wires driven antegrade and buried and he was back playing Five days later. And it you know, it work I'm not sure if I would do it the same way getting to your last point today. But any incision would have slowed down getting back on the field. And you know, there were no negative consequences. Thankfully, he played well, hardware held up until I removed it. So I feel like there's a lot of anxiety not just during the surgery, but during the weeks after the surgery-

Chris Dy:

As you're watching the game, perhaps?

Charles Goldfarb:

But all's well that ends well.

Chris Dy:

It's so glorious to be a sports surgeon, isn't it?

Charles Goldfarb:

Sometimes.

Chris Dy:

Was it a pattern that today maybe you would have treated with an intramedullary screw?

Charles Goldfarb:

That is exactly right. And I haven't done a lot of that on phalangeal fractures. But this one perhaps I would have, yes.

Chris Dy:

Interesting recently, even since our last conversation, I I've been jonesing to put that screw in again and found a nice juicy metacarpal fracture pattern to use it on. And at the end, I was like, This is great. I'm gonna do it more when I can. There was a different fracture pattern that it didn't work out on. And I regretted trying to use it. So you know, I'm trying to find my sweet spot on it. And, you know, to. It's interesting that perhaps it be a little different today, but I'm glad it held up. That's a great story.

Charles Goldfarb:

Yeah, well, it's our friend Kathleen McKeon, who is at, in Birmingham and St. Vincent's Hospital working with the big sports group there is teasing me with pictures of the phalangeal intramedullary screws, and she you know, has a lot of athletes she cares for and seems to do a great job.

Chris Dy:

Well, it sounds like the old dog needs to learn a new trick there, Chuck?

Charles Goldfarb:

For Sure.

Chris Dy:

So I'll go quick on the next one is actually my second Plexus patient who ended up having a good outcome. But when she came back, we total loss of follow up for like a solid year and a half. But she came back and the thing that struck my eye was that she had a tattoo on her thigh that said I'm okay. And I was like, I don't know if that was something that you use to cope. This is how you have adjusted to this injury. But that has been burned in my brain. And I actually think I haven't in the talk of mine about how it's not just about what we do as their doctors there's so much more and their therapists too. I mean there's so much more that goes into the recovery. So my de- my memorable patients are total Debbie downers, I'm sorry.

Charles Goldfarb:

Well, I will flip that around and also keep it brief but I've been fortunate to care for a number of patients getting back to congenital with mirror hands, which is, you know, an incredibly rare condition and and I think Those patients have begun a Facebook group, and they kind of lend support to one another. And that has led to more patients coming to St. Louis, which is great, because it's fun for me. And I think we do a good job Dr. Wall and I do a good job. And, and one of the not the first, but one of the first I did, I have managed to stay in close contact with the family. They are big supporters of the Shriners Hospital here in St. Louis. And so I get to see them on a more than once a year basis and to watch the child grow, watch her using her hand, see how impactful the surgical improvements have been for her and for her family have really been awesome.

Chris Dy:

I will end on a high note, nother nerve patient. But this was great because I got to watch him give a talk at the ASHT meeting. And he was not that far out from surgery. And he was part of our panel. And it was me his hand therapist who'd been working with a pain psychologist a different UBP- United Brachial Plexus Network patient, but then this patient gave his experience his testimonial, and it was so moving. I mean, not a dry eye in the audience. And it was a little scary to not know what he was going to say about his experience with the injury, his experience with me, his experience with his therapist. But to hear him pour his heart out there and to to show everybody that he had gotten over, in large part had gotten over the injury and is doing well. That was incredibly moving. So that was the happy note for me. And runner up, which I'll squeeze in is thing that I've seen on, that I've shared on social media, but I have one patient who got a tattoo of my surgical site marking that says, yes, after a very, very successful median nerve decompression. And I don't know, I hope nobody has to operate on his opposite side in the future. But that is also burned it's, embellished in my brain.

Charles Goldfarb:

That is really funny. So our last segment is from Minnie, was three and we may not get to three, because I think your house is exploding. But we're going to try three things we would tell our younger selves, is that correct?

Chris Dy:

Yeah, that's the request. And I'll be clear, Minnie has many excellent ideas in your email. So I will as I plan out the the January and February schedule, we'll be pulling from her from her suggestions. But yes, three things you would tell your younger self, I can go first. One of them is to not try to record a podcast while the kids are downstairs. I'm gonna tell my younger self of, you know, 30 minutes ago.

Charles Goldfarb:

I love it. I love it. But you know, one of the things I would tell myself is, and this is very serious. It's gonna work out. You know, like, if you're in a case, and there's adverse events, I think the first thing to do is take a deep breath, focus on doing the right thing for the patient and getting through the case. And I hope that we all stress, you know that there's there's value in stressing your brain is seared on important information when you stress about it. But the bottom line is, take a breath, do the right thing, it's all going to work out.

Chris Dy:

You know, we talked about in the last episode about mentors, and one of the things that you taught me and many of our partners here, but when I was your fellow, you always said don't leave the OR until you're happy. And that's something that I use now. And I would tell my younger self that and no matter how much pressure you have, at the end of the day, or in the middle of the day to get something done, and to stay on schedule, and be respectful of staff needs, and all that kind of stuff. Your responsibility at that point in time is to the patient, and do not leave the bar until you're happy. So that is one thing. In all seriousness, I would tell my younger self, even though it's something I still tell myself now.

Charles Goldfarb:

Yeah, and along those same lines, it's not one of mine. But along those same lines is, you know, make decisions that make sense, make decisions that allow you to sleep and we say that a lot of times in reference to potential compartment syndrome as one example. But you know, if whatever the case may be if you're going to go back and lie in bed and not go into the hospital, if you're going to lay there and perseverate on the decision not made or the path not traveled then you made the wrong choice. Go take care of it, I would say. So my next one is that it this involves the journey. So first of all, this path, this medical path, and we can get really philosophical and talk about why life, but this path is it's not a sprint, it is a marathon and I don't mean that in a negative way. I mean that, you know, if you can put the work in day in and day out. You will do well by yourself, your patients, your family, and sure there are times that will feel more stressful and be more stressful. But it is a marathon and I mean that in the best possible way. And I would include in that, you know, enjoy the journey, right? This is not about the destination necessarily. You know it's academic medicine which And I obviously know best can be a challenging, it can be a challenging issue, but it's not about the promotion or the R01, even though it is it's about the journey is about getting there and the people you do it with. So those are kind of interrelated things I think about a lot.

Chris Dy:

Yeah, and I think that's, that's well said. And I think to piggyback on that, one of the things that I would tell myself is, there's that there's always more, right like it. In all reality, there were multiple people who said, after I told them that I got my R01 said, start working on the renewal. And that just doesn't feel great. That's reality. I mean, you know that those are the expectations. And there's always more to try and accomplish, there's always more cases to do more money to try to make if that's your thing, and more papers to write, if that's your thing, more patients to take care of. There's always more you can do, but I think enjoying and taking stock and your accomplishments and your contributions is super important. I remember one moment that I will remember is that when I was applying for hand fellowships, and Ed Athanasian, was the chief of service at the time at HSS. And I went into his office and overjoyed and told him that I had matched at WashU, for my hand fellowship. And he is probably the only person ever told me to do this. And I've tried to pass this on to others, but he told me to just take a moment, reflect, enjoy it, and anybody that knows Dr. A knows that's a total Dr. A thing to say. But nobody had ever given me advice to be in the moment be present and soak in that accomplishment. Because I was and still am super proud of the fact that I got to train here. So that's one thing that, you know, kind of goes into the be present and appreciate what you have, you know, category.

Charles Goldfarb:

Yeah, I love that. And guilty, I don't do enough of that. I move on to the next thing as you allude to. The last thing, I will say my number three. And again, it gets to those of all of us who have busy lives, doesn't matter what kind of practice you're in, whether you're a therapist or surgeon, whether your academic or private. What you know, what we do at work is incredibly important. And that's why I think most of us feel passionately about what we do. It is why we feel proud of what we do. And it's why most of us sleep well at night. Because we impact the lives of many people around us, however, take care of what's at home, it's too incredibly important. I feel so lucky to have a great family and have to I want to say remind myself that sometimes I have to remind myself to not come home exhausted every night, even though I might and give them the energy they deserve.

Chris Dy:

Well, since you took my third I'll take I'll go 3-

Charles Goldfarb:

I call BS.

Chris Dy:

3A, which is take care yourself, you know kind of goes, you know, it's this, it's not a sprint, it's a marathon, it's a very long journey. I mean, actually, we can have this talk of a different time, I was listening to a senior surgeon lament about their career and what they had accomplished, and which by any means everybody in the world would say that, you know, there's nothing left to accomplish, but then expressing frustration at you know, where they are in their career. And that actually got me thinking last week about kind of what do I want to accomplish, if I can't accomplish what I want to accomplish in X years? Maybe it's, you know, maybe I shouldn't be doing it that much longer. But I think that what's gonna allow us to work as long as we want to work and derive enjoyment from what we do is taking care of ourselves, whether that's physically, mentally, you know, or, you know, finding fulfillment professionally, and in things outside of work. I think that's, that's the key, you know, so on top of taking care of your family, you can't take care your family, you don't care, take care of yourself. And I think there's a lot more attention being paid, rightfully so, to well, being of those in health care. The pandemic has only shown how important that is. And I think that's probably something that I would tell my younger self, even though I'm clearly not as old as you, but you've done a nice job taking care of yourself.

Charles Goldfarb:

Some would argue sometimes my wife would argue but I, the last year or so has been really helpful. I've not to think that pandemic but I have year and a half. I've been really good about exercising at least.

Chris Dy:

Yeah, we have to talk about maybe we'll do we should do a segment when we come back on New Year's resolutions. Again, we'll check in on your old resolution of learning Spanish, I'm sure there's some recording I have of me out there confessing to some revenue resolution that I have that I probably haven't kept. So yeah, New Year, New Year 2022. The year of Chuck.

Charles Goldfarb:

Perfect. All right. Well, I think this brings our final episode for 2021 to a close so we're going to take a break after 102 episodes and and my last takeaway is thank you, Chris Dy for for being a great partner for the podcast.

Chris Dy:

Oh, you're very welcome. And I can only express the same amount of gratitude to you. I thought you're gonna thank me for the idea of launching a podcast. But you know, I guess it's your your idea. You're not watching on YouTube, there were some air quotes. We should We should tell our stories of the origin of the podcast. You know, I think that they are different stories. That's fine. Those of you listening you have to defer to your mentor and allow your mentor to take the credit. So yes, that's that's the work of Chuck Goldfarb. But yes, in all seriousness, thank you for, for doing this for being a great partner and it's both, you know, obviously, the podcast and clinical care. And, you know, we'll take a few weeks off I know you tried to dial us into two, but let's let's leave a little open and give us a little leeway to take as much time as we need to recharge and come back. It won't be six months, it probably won't even be a month, but we'll be back in 2022. Ready to chat.

Charles Goldfarb:

I love it. Thanks. Have a good evening.

Chris Dy:

You too.

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 dy. 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 podcasts.

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.