Operation Walk Syracuse Nepal Closes as Operation Walk USA Kicks Off This Weekend

During the long return trip to Syracuse, Dr. Seth Greenky penned his thoughts about our just completed surgical mission at Nepal Medical College:

How do you describe a life changing experience to someone else and capture the spirit of the event- especially when one lacks the skills of writing. A group of ragtag "Syracusians" with a sense of adventure and a desire to tackle major hurdles, altruistic to the extreme, traveling literally to the other side of the world to help people. A dream that started with casual conversation and morphed into reality mostly by extremely hard work and some luck.  Sometimes the stars just come together and magic occurs.

I feel like we were the Olympic hockey team that tackled a task and succeeded beyond all of our expectations.

The group was not a team that regularly worked together. We were composed of individuals who come from different hospitals, different outpatient facilities, different cities, different religions, different motivations, different ages, different stages in life, and I could go on and on. All received nothing but the potential satisfaction of doing something special for someone else. No one got paid, no one got "comped" time off and there was a minimal hierarchy at best.

This was our inaugural visit sort of a "try out" for the Operation walk team so to speak. We were being judged by the Operation walk LA division- the originators and supervisors of the 13 sites. Four rooms, the lead organizer, three PA's, six surgeons (thank God because I was sick as a dog for the first two days),two anesthesiologists, two nurse anesthetists, circulating nurses, OR techs, floor nurses, Physical Therapists,  an instrument tech, a representative from the company that donated all the prosthesis, a Mr. fix it/ engineer, a supply coordinator, our translator and cultural guide, and I probably forgot someone.

Let me just sum up how we did- we kicked ass! Not one single complaint the entire time; despite heat, exhaustion, GI issues, communication issues and more. We had incredible mentoring from our LA counterparts, but we were seamless in our ability to run with guidance and soon mesh with them and ourselves. Compliments from our LA mentors, our Nepalese friends (physicians, nurses, housekeeping staff, etc) were over the top.

I think I can say without reservation one of the top experiences of my life and of all those of us who participated. There is no substitute for the feeling you get from a selfless act of good.

I am beyond proud of our team, and feel that the hand of God was with all of us. The faces of the patients and their families is ingrained in all of our minds. There were no stars, there was essentially one unit that won the ultimate victory. Hurrah for all of us.

We will be doing this again, and again, and again.....

Seth Greenky

Operation Walk Syracuse: Nepal 2011

His name was Pramod Kumar Yadov. As we sat in the post screening clinic conference debating the risks and benefits for each patient before proceeding with surgical procedures, my mind flashed back to a day shortly after we arrived in Nepal.  I walked the grounds with Dr. Saswat, the orthopedic resident assigned as our Operation Walk liaison. He pointed to a distant sight. Awkwardly making his way across the pavement, steadied by a set of crutches, was a young man of approximately twenty five.  Saswat explained to me that he was a candidate for the Op Walk camp and had travelled from afar in hopes of undergoing bilateral hip replacements.

His hips were fused and he suffered from ankylosing spondylitis--a long term disease that causes inflammation of the joints between the spinal bones and the joints between the spine and pelvis. It eventually causes the bones to join together and mobility becomes progressively compromised, often to the point of complete incapacity.  His mobility had steadily diminished over the years and was now at the point that he was unable to independently care for himself.

The team debated his case and discussed the potential for surgical success.  From a medical standpoint, anesthesia would be a challenge. A successful spinal anesthesia modality would likely not be successful due to the anatomical challenges posed by his spine and rib cage. Although general anesthesia was a possibility, the anesthesia team lacked the critical equipment that might be necessary to safely manage the airway of a patient with major neck and spine abnormalities.  After all, general anesthesia was not in our plan for any of the patients as a primary anesthesia route.  From an orthopedic surgical standpoint, the procedures were not elementary, but certainly manageable.  Orthopedic score-2 and anesthesia/medicine score-3. Discussion engaging everyone in the room ensued relative to the potential for success and a positive outcome.

After what seemed like an eternity, the team rendered its decision. It was neither wise nor prudent to proceed with these procedures.  The inability to manage him from an anesthesia standpoint posed a serious threat and could possibly even result in his death.  The team had made its decision and that would then be explained to the patient. Disappointment hung heavily in the room, but the correct and safe decision had been made; or was it?

From the front of the room I heard the quiet and calm voice of the LA surgeon who accompanied us on the trip.  His presence on our orientation trip was intended to provide guidance and a means for an experienced resource to our novice team. He acknowledged that our assessment was completely accurate and the risks associated with proceeding with the procedures were high. He continued to engage us. Left untreated, this young man would be doomed to the effects of advancing disease with no way to mitigate the damage and destruction that would be left in it's path.  It wasn't a matter of "if" he would become completely immobile, but "when"? He challenged us.  Should the patient not be given the opportunity to make the decision if the benefits outweighed the risks for these procedures?  Should he not at least have that modicum of control over his own future and destiny?  And with that, the momentum changed.  Enthusiasm mounted.  The dialogue shifted to "how" this could be accomplished rather than "if" it could be accomplished.  

Surgery day two dawned with a sense of accomplishment from our initial operative day, and eager enthusiasm to launch into the series of more complex patients that this day promised to bring. The team was buoyed by increasing confidence and the comfortable camaraderie that had begun to develop and solidify.  Pramod had not only accepted the risks associated with his procedure, he desired to get in the OR as quickly as possible. His smile was ear to ear. There was no turning back for him. The day flew by quickly for us, but for him it was an eternity until his OR time arrived.  We had agreed he should be the last case of the day so that additional team members would be available, as well as limitless surgical time. He finally arrived in the OR.  That same dazzling smile greeted the team as the anesthesiologist worked his magic and by some miracle (or exceptional skill), the spinal slipped into place signaling the start of the surgical procedure.

The right hip replacement was completed, hemodynamic stability confirmed, and the anesthesiologist gave the green light to reposition the patient to the other side to commence the left side hip replacement. Everyone was excited about the realization that the second procedure could be initiated and therefore, the true therapeutic effects of the bilateral procedure could be achieved. We carefully began the transition to reposition the patient for the second procedure. This involved a brief stop in the supine (back laying) position prior to propping the patient up on the opposite side.   Much to our surprise and delight, Pramod lifted his head, steepled his hands in the traditional Nepalese manner, and with his broad smile intact, greeted us with "Namaste" as we turned him onto his back.  He deeply touched the hearts of all present in the room.  I recalled how close we were to denying him this life altering surgery and silently thanked the surgeon for nudging us forward appropriately.

Before long the surgery was finished and he was in the recovery room having received two new hips.  He was overwhelmed with emotion and joy. He gripped Dr Saswat's hand and searched his eyes for an answer to the question on the tip of his tongue.  "I marry now?" he exclaimed.  As Saswat answered in the affirmative, the grin broadened and was this time accompanied by dark eyes sparkling with hope for the future.  

Early the next morning family, friends, and a group of team members crowded around him as he ventured into the hallway taking his first steps. Filled with exuberance and free from pain, he cruised the hallway, physical therapist at his side.  Pramod became an inspiration to others (patients, family, and the Operation Walk team) for the remainder of trip. He touched the hearts of us all and impacted us in a manner that will not soon be forgotten.

We were drawn to him and nourished by the inspiration, hopes, and dreams that he symbolized.  I visited him several times each day and never found him to be without that wide grin and unflappable demeanor.  As our Operation Walk camp drew to a close, we assembled for the traditional team-patient photograph.  He spotted me across the room and motioned to me.  He patted the bed next to him and I sat.  I remained seated near him for a few moments, both of us silent but aware of the powerful exchange that was in process.  Before I realized what was happening, he had draped a vibrantly colored scarf around my neck and shoulders, pressed his palms together and with the smile that was now so familiar to me, nodded his head and exclaimed "Very Happy".  Operation Walk Nepal a life altering experience for us?  Perhaps.  A life altering experience and a promise for a future for Pramod?  Without a doubt. We depart Nepal content in the recognition that we made the right decision to proceed with his surgery.  Sometimes the message present in your heart must overrule the logic of your head.  

Kim Murray
11-18-11

Operation Walk Syracuse Kicks Off First Annual Mission

A group of patients in Nepal will receive joint replacement and rehabiliation in early November thanks to Operation Walk Syracuse, led by Co-Executive Directors Dr. Brett Greenky and Dr. Seth Greenky.

As the date for departure inches closer, our excitement mounts.  Months and months of preparation have come together and next week we will embark on the journey to the other side of the world.  We enthusiastically look forward to working with the physicians at Nepal Medical College have have more than 60 patients waiting to receive our services.

Our team of 36 volunteers comprised of surgeons, anesthesia providers, nurses, surgical technologists, physical therapists, and other team members are amazing.  We can't thank them enough for assisting us to make this mission trip a reality.  We will be joined by 12 members from Operation Walk LA who will provide guidance to us in our inaugural mission experience. 

In Kathmandu, the country's capital, many individuals cannot provide for their families due to the disabling physical limitations of degenerative arthritis.  Others cannot walk around their homes because they lack basic mobility equipment such as canes and walkers.

Our supplies (approximately 40,000 pounds of cargo) were shipped at the end of September.  We eagerly await confirmation of its arrival so that we can begin our travel next week with the confidence that all will be ready and waiting when we arrive.  We are all eager to begin working to restore the quality of life for many new people in Kathmandu, as well as to provide follow up care for patients from previous missions.

The group leaves November 8th.  Read daily updates and view photographs from the mission on the Operation Walk Blog at http://operationwalksyracuse.blogspot.com/. Posts will occur daily beginning on Tuesday, November 8th.

Fiscal Responsibility in Orthopedics

October not only introduces the expected autumnal change in climate resulting in cooler temperatures, shorter periods of daylight, and vibrant color changes to foliage, it also signals the start of the 2012 budgeting season for the orthopedic department.

As part of our "formalized" orthopedic service line at St. Joseph's Hospital, we are fortunate that this process for us has evolved to be a true partnership with the hospital, and a genuine multidisciplinary team effort which involves the physicians, nurses, physical therapy, and many other clinical support personnel. 

Gone are the days where the hospital holds sole decision-making authority when it comes to projecting operational costs (those recurring on a regular basis), and capital costs (purchase of equipment).  The difference between these two types of expenditures can easily be correlated to running or managing the finances of a household.  Operating costs associated with household management include the groceries purchased on a regular basis, as well as the payment of monthly utility bills.  In orthopedics, operational costs include the supplies and implants used during surgical procedures.  Capital costs associated with a household include the replacement of appliances that are at the end of their life (refrigerators, washers/dryers, snowblowers) or items that are new purchases (an entertainment center or furniture). In orthopedics, capital items include equipment that needs to be replaced such as drills, instruments, surgical tables, or specially designed hospital beds or chairs, as well as new technology-type items that keep our program up-to-date and able to deliver the highest quality patient care.

As physician leaders of this service, we take this responsibility very seriously. Escalating health care costs, specifically the rising cost of medical supplies and devices, are the responsibility of everyone to keep controlled. We work exhaustively with the Orthopedic Service Line Administrator to accomplish these very lofty goals.  

To accomplish this challenging task, we, along with the service line administrator, have hardwired specific processes into our service line management:

**Monthly product standardization meetings to explore new and alternative products that have the potential to improve quality while reducing costs

**Supply and implant control--no vendors, surgeons, or staff bring new items into the OR without prior committee review and approval

**Periodic implant re-bidding process for hip and knee components to ensure that costs remain controlled

**Scheduled replacement of equipment only when warranted and at end of life

**Review of all newly available orthopedic technology and planned addition if it makes sense from a quality and patient care standpoint as opposed to a passing fad

We have had significant positive results in controlling costs with this approach.  Our successful management of the orthopedic service line supplies and implants garnered recent national attention.  Our process was recently presented at the Managing Today's OR Suite Conference in Chicago.  A follow up article relative to this topic will be published in their national journal later this year.

Rest assured that we manage the hospital's precious resources for orthopedics in a fiscally responsible manner to ensure that the highest quality care is provided at the lowest cost. The effort in this regard is never considered finished and continues on an ongoing basis.  Our goal is to strengthen the orthopedics program at the hospital both today as well as into the future.

Game Time

We’re always a little hyped up. It’s a little early, 7am, but we’ve been up for 2 hours.  Everyone prepares in a different way. For some it’s a physical movement or mental traits- brisk calculated activity, silent concentration, talkative, etc. There is usually some music in the background the genre varying. The importance of the event doesn’t need to be discussed, we all get it. The team is not random but carefully selected- they are the best of the best. They all chose to be a part of this elite team, some at considerable personal expense. There is a hierarchy, there has to be for this type of operation. Even though there is a hierarchy it does not belay the importance the essentialness of each person that’s a part of our team.

The team leader asks the members “Are we ready to begin?” – a resounding “Yes” with a sense of purpose is elicited.  A member of the team leaves the room to begin the encounter.

For security purposes, the target will be identified as “Bill”.

A team member approaches Bill, gathers the appropriate information, asks if he has any concerns and begins pushing the gurney into the OR.

We’ve already slipped Bill some specially prepared “medication”. He’s “happy”.

The mood as he enters the room is of quiet confidence. Everyone on this assignment has been here many times before, and the sense of winning is in the air.

Positioning, preparation and draping occur as a matter of routine.

There is a “time out” where the entire team stops, we review our goals our tools our mission and before beginning we all confirm that we are on the same page.

“Time to rock and roll” says the leader. There is some “white noise” in the background, better known as music. There is very little talking, everyone knows their roles so well there doesn’t have to be words- there are motions, there is anticipation, an occasional request. We move quickly, without the sense of rushing, but with deliberateness that radiates confidence.

The operation is going smoothly and there is a relaxed joviality in the air. Suddenly in a calm but firm manner- “bleeder” is verbalized. Sudden change in the atmosphere, flight or fight response instantly. No jokes all business. Suction, clamps, ties- control quickly achieved. Second and third checks – OK everything good. No high fives or celebration, just the professionalism that comes with experience. The mood shifts and we relax again.  The components of the joint replacement are placed and the results are up to the standards of the team.

Now there is a moment where everyone feels it- that sense of “Yeah Baby”, perfect. We don’t necessarily say it but we feel it- everyone in the room does. We relish that feeling for a bit (we live for it), and then get ready for our next mission.

Operation Walk Syracuse Extends Its Gratitude to Franciscan Companies

Operation Walk Syracuse would like to extend our heartfelt appreciation to Franciscan Companies for their tremendous support to Operation Walk Syracuse.  Thanks to their donation our Nepalese patients will have the use of reacher/grabbers, sock aides, commodes, raisted toilet seats, wheelchairs, oximeters, and glucose monitors during our November visit.  It is through the generosity of groups like Franciscan that we are able to provide this life-altering procedure for people around the world with limited access to care.

Franciscan Companies is an affiliate of St. Joseph’s Hospital Health Center. Through a variety of companies and partnerships, Franciscan Companies extends the reach of the St. Joseph’s network throughout the Central New York community. From home health care services to durable medical equipment, from infusion services to medication dispensing machines, Franciscan ensures that patients discharged from St. Joseph’s Hospital—as well as other hospitals in the area—receive the continued care, services and products they need for improved health and comfort.

Follow Up to Channel 10 Story

A recent YNN story which aired on Saturday, July 16^th focused on two elements related to joint replacement surgery:

·         Implant materials (surgeon interview)

·         Outcomes after joint replacement surgery (physical therapist interview)

Unfortunately, the two twains of the interviews never intersected and there was no opportunity for the surgeon, board-certified and fellowship trained in adult reconstructive surgery, to weigh in with his expertise on the topic of functionality after total joint replacement surgery.

The  physical therapist interview cited a study (studies) which report findings that significant impairments and functional limitations continue at one year post total knee replacement.¹  This study, published more than ten years ago, also clearly had a major design flaw.  Patients in the study group were significantly heavier and had a higher percentage of body fat than the control group members.  This makes the reported findings suspect because clearly the two groups had major differences.

Two more recent publications in the physical therapy literature cite dramatically different findings than the 1998 study.  A recent meta-analysis of the literature published just this year reports that in the areas of perceived physical functioning, functional capacity, and actual daily activity, patients experienced significant improvement postsurgery compared to presurgery.²

Another study (published in 2008) evaluated physical activity after total hip replacement and found that despite having experienced a major surgical procedure, patients having undergone total hip replacement had achieved a level of physical activity consistent with the normative population, and even exceeded the intensity of physical activity for the same group at both light and moderate intensity levels.³

Restoration of mobility and function are obvious reasons to pursue joint replacement surgery, however, the number one reason patients choose to undergo a hip or knee replacement is to obtain relief from debilitating arthritis pain.  Joint replacement surgery is a last resort intervention after more conservative interventions such as physical therapy, medications, and injections have failed.  After the risks, benefits, and alternative options have been thoroughly discussed with the patient, he or she is the sole decision-maker to move forward with joint replacement surgery.  The surgical procedure itself relieves the arthritis pain, but the surgery itself only serves as the conduit for improved motion and function postoperatively.  Patient participation in the postoperative rehabilitation plan is the most important determinant in achieving physical activity goals.

¹Walsh, M., Woodhouse, L., Thomas, S., & Finch, E.  Physical Impairments and Functional limitations: a Comparison of Individuals 1 Year after Total Knee Arthroplasty with Control Subjects.  Physical Therapy.  1998; 78(3):  248-254.

²Vissers, M.M., Bussman, J., Jan, V., et al.  Recovery of Physical Functioning after Total Hip Arthroplasty:  Systemic Review and Meta-Analysis of the Literature.  Physical Therapy.  2011; 91(5):  615-629.

³Wagenmakers, R., Stevens, M., Zijlstra, W., Jacobs, M., et al. Habitual Physical Activity Behavior of Patients after Primary Total Hip Arthroplasty.  Physical Therapy.  2008; 88(9):  1039-1048.

Our thanks to Megan Hickey, Manager of PM&R, for her assistance in this review of the physical therapy literature.