Chapters Transcript To Plate or Not To Plate…Debate: Pros and Cons of Rib Plating and Chest Wall Reconstruction Course: NYU Langone’s Third Annual Long Island Trauma Symposium The next part of this is actually gonna be um a little bit of a debate between two trauma attendings. Uh, one, I think most people here know, uh, Gerard Baltazar, uh, is one of our trauma attendings who's been here for some time now. Um, he leads our OMT, and does a lot of surgical fixation of ribs, uh, and is a strong supporter, um, of surgical stabilization of rib fractures, um, and is working on building a chest wall institute for us at NYU. Um, his counterpart, um, is sort of my, uh, spirit animal from Jamaica. Uh, uh, Rob Laskowski, uh, who, uh, Rob and I trained together, uh, over at Stony Brook, um, and did, uh, many things that, uh, we should not discuss, um, but we, uh, we developed certain tech idea what you're talking about. Uh, we developed certain techniques that we still use in the operating room together. Rob's also Uh, a military surgeon, um, and he is the associate trauma medical director at Jamaica, and I believe now officially the with their equivalent of the vice chair of surgery over there. So, uh, it's always nice to have Rob back. I think a lot of the uh PAs and, and some of the physicians in the room remember Rob from his days with us. So, um, what we're gonna do is just have them sort of start off with the pros and cons. So obviously, Gerard's speaking from the pros side, um, so he'll start off. Uh, with that, uh, and then Rob will sort of, uh, do his counter dance, um, and then from there, um, we will try to engage them in some conversation to have them debate more. Um, it is a competition, so let's see who wins. Who was here for the last two debates last night. Yeah. So we, we try to have fun with this. Uh, so those of you here before, I think you can remember we have a good laugh. Uh, the very first one that we did 2 years ago, if I remember correctly, uh, Doctor Jaquez who used to work here, he had, he made a fake phone call to a certain Jerry Bono's wife to, to, as a way to influence the decision on who won the debate. So I will be on the pro side. And as you, as you mentioned in the past, these debates have been humorous. But this is a much more serious topic, OK? Surgical stabilization or rib fractures or SSRF, what's also known as rib fixation, is far too important a topic. To be funny with. So this debate, we must, we must avoid humor and be focused, informed, and unbiased. And we also must be serious, balanced, and be respectful of opposing points of view. So, We'll get started with that. SSRF is good. It's associated with puppies, kittens, and rainbows. And just to give some respect to my opposing point of view here, not as a rap is bad, associated with sadness, pain, anxiety, shame, the movie misery. And shedding a single tear in desolation. So, moving forward, let's talk more about the specifics. Fracture reduction, fixation helps. I mean, duh, we know this, right? How many people here would opt, if you broke your leg, how many people here would opt for the orthopedist to say, let's put a cast on this for 23 months, or we could put a rod in there, and then you'll get up and walk tomorrow. How many people would choose the cast? I would choose to align that bone nicely with a rod and be walking the next day, or hours later. I agree, because also, how many people here have seen femur fractures? Yeah, those patients tend to be screaming in pain, yeah. Why are they why are they screaming in pain? Why this premium pay? What well that's a nice little tons of muscles and when those muscles are displaced in their natural position because the bones broken, they spasm like crazy, that hurts a lot. And the same thing is true. Who here has it's changed for the ribs too. Who here has ever made ribs straight from the butcher? Anybody or? Yeah I guess not. I guess I'm the only chef on that. OK, yeah, I see some. So when you take, when you get them from the butcher, you have to rip off this silver skin, right? They call it silver skin. That's the fascia, the tightness that is there to keep the bones and the and the muscles in the chest wall altogether. And same thing happens if you disrupt that tight, nice controlled anatomy, the muscle spasm and we have problems. And again, Just to give room for my colleague here, I want to know that anyone who says otherwise about fracture fixation is their mean, mean liar. So, we have this technology that we use here, where we would we fixate the ribs, and you can see in some of these pictures just how those disrupted ribs can cause those muscle spasms, and also how the disrupted structure can affect the function of those ribs to allow us to breathe better, so your lungs will get worse. And you can see in this little inset here, there's if the bones are better aligned, they can heal faster because the cells have to cross over that gap. If that gap is huge and lined all over the place, as my colleague wants them to be, these people would heal worse, or slower, or both, usually, and they won't get the thumbs up. This is a this is a a one of our cases here. A guy ran his motorcycle into a wall, shattered both his sides of his ribs, bruised both his lungs, has an indent in his chest. You could see as he's breathing because he had flail segments and he had to just di it. And we took him to the operating room on day 0 of being in the hospital. We were able to get operating time, and you can see the divot on his chest, on the first little picture, and then in the next picture, you can see the chest wall reconstructed nicely. This guy was intubated for 1 day in the hospital with biloud pulmonary contusions, and he was able to extubate right away because even though the contusions blossomed and they then they got better, he was able to have a mechanical function of his chest that he wouldn't have otherwise had if my colleague were taking care of them. Moreover, only intubated one day. Did he actually have to be intubated? He had to we just plug it so irrelevant to the chess wall. The, uh, but also this is a great teaching opportunity for, for the residents. If the residents were here, I see, I don't see many of them, but first here, I would ask them how often do you do chess cases? And they'll go, I don't do a lot of them because there's, there's not a lot of chess cases for the residents to do. But this adds to their education, helps them understand the anatomy, helps them understand how to access the chest, and also, if you notice one of the arguments that uh. This guy might make is that the the incisions have to be big, they're not very big, and we can use devices now that we didn't have before to make these incisions effectively larger without having to actually cut. So again, thumbs up, right? Thumbs up. And just wanna just these are meaningful arguments for IOR are meaningful, they're really meaningful and to to allow some time for my colleague here, um, I don't know if you recognize, but this, this one doctor here supports that arguments against SSOF are unfocused, uninformed, biased, overcomplicated, and vague. That is AI doctor. Laskowski. Then science, science supports SSRF. The science is key. We're all physi all medical people in this room, we have to base what we do on science, right? And I encourage you not to trust anyone who says it doesn't. So, what is the most, what is the highest form of scientific evidence? Is it a systematic reviews and meta-analysis? B, systematic reviews and meta-analysis. C systematic reviews and meta-analysis. D, whatever Dr. Lastkowski is gonna reference. Or A, B, and C? What do you guys think? A, B, and C. So now you're right, scientific reviews of meta-analysis. I'm just gonna, I'm not gonna go through all these we have time for that, but I'm just gonna show you a bunch of meta-analysis. And if the, if the little black diamond or white diamonds to the left of these figures, that means the accumulation of all the data human people know is that these are good things for refixation. Let's start, yeah. So, social stabilization saves lives. Does it? Well, of course, there's gonna be some states that say it doesn't, some ties that say that it does, some studies that say maybe it makes things a little bit worse, maybe my selection bias over there, but it overall, what did the men nowlysis say? Look at those diamonds, all to the left, all these things, oh my God, so many. And I don't know what my, my, my colleague's gonna bring, but I'm coming with the best evidence. And CSF decreases pulmonary complications. Your pneumonias are less, your need for a trach is less. How many people here want trach? No? OK, great. And then, see, these guys made match made it happen right there. They both might be trached. If you don't want a trach and you don't wanna be in the ventilator for a long time, then you should, and you have broken ribs, you should do this procedure, because again, where are all those diamonds? To the left? Where are all these figures? They're showing the best possible scientific evidence that we have that we can decrease pulmonary complications if we do surgical stabilization of the rib fractures. And finally, and this is not the final one, but the decreasing length of stays, and that's important, that's important from a system's point of view, especially, that you can decrease length of stay, if you can decrease length of stay, you can make the C-suite extremely happy. The patients too, but the C-suite will be extremely happy. So let's see. Oh, wait, look at that. All then, all those diamonds going to the left, all that high level data showing improved hospital and ICU as well, lengths of stay, and it costs how much, how much does it cost one night in the ICU on on the regular? Something like $10,000 or more dollars. Every night you avoid the ICU, the sea sweep, it would really happy. And so, to give my colleagues some time here, the con is bereft of real data, sorry about that. His, his, his argument is gonna be bereft of real data. They're gonna be mostly anecdotal. He even admitted to it and or manufacturing, basically it's not gonna turn off if I don't do it. And as you know my colleague here, you see AI Do Laskowski there, a little frustrated, he will does not want to help anyone like he wants these people here to suffer more than they need to because for some reason he's against this operation. And finally, One of the biggest arguments is this is a new technology, it's expensive, the the the material is fancy, you have a lot of time you have to pay for. Well that's, and then it's too costly, don't do it. He's gonna try and make that argument imagine. But if you look at the science, social stabilization of rib fractures, rib fixation actually saves our hospital money. And the naysayers can't back up those their claims to the contrary. So, here it is, uh, one of the most important papers that we've had recently showing shows that, in fact, you can save thousands of dollars per patient, if you do refixation compared to the patients of similar severity, who did not get the procedure. And in this one study, the the, uh well, not this one study, in other studies, it showed that you can one study showed you can save up to $35,000. If you do this procedure. Another said you can save $14,000 per patient, and this was speaking specifically about foiled chess, because foiled chess is the kind of the ultimate paradigm of how this technology came on board and who to use it on specifically. But if you take all comers, all patients with rib fractures who you do this on, not just flailed chest, but everybody, this study shows you're saving a $1,128 per patient, which adds up to a lot for your hospital system, including the ones that are more tenuous in their, um, finances. That's money you can't build for though, right? I'm sorry. I'm not sure. I'm based on science. I'm not sure what you're talking about. And the SSRF is too expensive, brings your to bring to your hospital is fake news, and I think that uh AI Doctor Laskowski agrees. So finally, And I wanna point out how weird AI is. I, I ran about 10 versions of this to try to get them to say SSRF and, and have those guys' pictures, and this was the only one that worked out. I don't know why it has a yellow face and green hair. God bless AI. The mechanical and physiological benefits of reducing and fixating fractures, it's well known. All of you don't, all of you would want that, apparently, and it's well understood that there are benefits that the technology for rim fixation just had to catch up. And now we're there. And so I can't understand why we're not, why my opposition would oppose this. And science, clearly, meta-analysis systematic reviews supports the benefits of SSRF for mortality, which is mostly for the flail chest population. Sure, but they're the sickest patients. But for everyone, pulmonary complications, tracheostomies, ventilator days are decreased, length of stays are decreased, and by having promoting SSRF at your institution, we could save the hospital thousands of dollars a year. And of course, bottom line, our patients and our hospitals' well-being matters most. So, thank you, ignore the naysayers and help our patients in the hospital thrive. If uh If you go to this QR code, it takes you to a really great rib restaurant down the street, Smokehouse. Do All right, so the reality is, I got nothing. I went through almost 400 papers and I found one from like 1985 that said it was bad. Um, everything else nowadays really, you know, if this was a conversation we were having 20 years ago, I could, you know, way back, but all the data he showed, you know, really is what it shows. And the, the argument that I could make against that is that we don't really know. If they discharged people when they could have been discharged, or if they kept them in the hospital for a couple extra days to get that, you know, significant difference, or maybe they kept people intubated. Just to make their data look good, evil scientists, right? That's the goal. But I mean, the, the reality is, you know, it, it has been shown time and time again to actually really benefit people, um. The science is there, the medicine is really flying forward, um, all the different systems and and uh platforms that you can use, um. It's really not a bad thing. The, the biggest thing I think to argue against it really comes down to the actual hospitals, and whether or not it's something that they can implement. It's a thing that if you really want to get good at it, you have to do a lot of it, um, and the indications for who actually gets rib plating is still something that, you know, we could argue about. I would certainly not argue to riplate any rib fracture that comes in, but somebody who's flail chest, yeah, even I'll do that, rip plating despite as much as I hate it. Um, But the other thing too is like, you know, I, I'm at Jamaica, right? We are very busy, we get a lot of really sick people. And sometimes just getting people into the OR is difficult for us. You know, we don't always, you know, we're building 4 more new ones, thank God. At some point they'll be done. Um. But, you know, a lot of the times we just have to manage these medically, and we do a pretty good job of it, you know, um. As long as you just know them with narcotics, they don't usually complain. Look. You know, chest PT smack him in the back a little bit. If it's really displaced and you drop their long, you put a tube in, it's fine. It might be plated, um. Well, I mean, I, I really, like I said, I'm not kidding when I said I went through about 400 papers on PubMed for the past week, looking for one that was bad, and literally found one from the 85. So, At this point, I'll just open it up if anybody has any questions, but, you know, all my stuff's gonna be anecdotal and just saying, no, it's bad, and I'm gonna go back to that picture of me, cause that's a good one. What? You're not bad, I'll take this. All right, so I'm gonna, I, we set this up purposely cause we kind of figured Rob would be able to take the The defeat without much of an issue, um, but, but he never I trained under him. I know how to, you know, take it. Yeah, it's, and look how well he turned out, right? So, um, but the question that that comes is what you're bringing up, and so like, I would like to hear your guys' input on it from both sides. So the papers are good, we agree there's 400 papers out there, 399 are positive, one is bad, um, but And, you know, again, like, using our old time friendship at Stony Brook Level One trauma Center, we replaced no one. Like, we did not do any in the, well, actually we did 2 in the 14 years that I was there. Um, at Long Island Community Hospital, we've plated 0 patients, um, when we're talking about doing it, but we've done 0. So, will their outcomes be better, uh, based on the literature, yes, but to Rob's point, How do we all get good at it? So, it's like, you know, you have cardiac centers, you have pancreatic cancer centers. You can't legitimately transfer every multiple rib fracture, every flail chest, uh, to a chest wall institute, or can you? I don't know. I mean, you'd have to, that's, that's part of what I want you guys to be. So, is this actually applicable to the majority of the patients, or is it the select few that we can do at these centers, right? So like if I've never rib plated somebody and I start doing them out east, are they gonna do better? Um, or are they gonna do worse standard care that we've been providing? Right, cause you're the one who showed me how to rip plate. All right, I mean it's essentially orthopedic shirt, that's what I say, it's so easy than an orthopod can do it. So, um, so, so is it truly beneficial to all? Are we looking at a select population? um. So, cause the sun, yeah. So there are a couple, there are a couple of centers around I got a couple, there's several centers around the country that are doing refixation a lot more than even us here and lich and many places, particularly in the west, Colorado, um, uh, Arizona, other places, really gonna use those hippies as your example. Listen, I'm not the one with green hair and a yellow face. It's the, but the, uh, you know, it's gray hair. Yeah, this is not working very well. Yeah, but those centers, the more they're doing them, and they're doing them more based on um minimal criteria, meaning that they have multiple rib fractures and they've failed, quote unquote failed their pain regimen. And so when we look at the actual data that these patients that these centers are putting out, they're showing that they're taking these patients on day one or day 2, so failure is kind of loosely defined in terms of the pain management. That being said, they are doing very well, and what they're seeing when the plate people more who are um less injured, fewer ribs, uh, no flail chest, that those patients, there's no real difference in survival of those patients, because we didn't expect them to die anyway. But what they're seeing is that in long term outcomes, those patients compared to a cohorts that have similar types of injuries, they have less reliance on opioids. Who here supports the opioid epidemic? Who wants more opioids? All right. Well, I'll hang out with you guys later. Dude, that's all you need, just give them opioids and they're less reliance on opioids and more function. If you, uh, I, I, I broke a rib, uh, during jiu-jitsu in 2003, like a long time ago, and if I'm in the OR too long, twisted one way or the other, I still feel it. And it's just one rib. Think of that with somebody with multiple ribs, now 20 years later, they're still they're trying to pick up their child, and they can't because it hurts too much. I, I, I get that, and it's too difficult. The muscles are out of place. It's hard, it's hard to get to carry the weight. I mean, Doctor Moskowski wants that person to suffer and not love their child. I don't, I don't think you did. No, I mean, those are fair points, you know. I, I want them to suffer in the child to grow up unloved and all that, um. No, but they kind of get back to what Doctor Ubano was saying, um. You know, it I think if, you know, these centers that do it all the time, um, you know, they have good outcomes, they do. But again, that's to the point that they do this all the time, you know, for places where we don't do it all the time. I mean, honestly, the last time we played it somebody at Jamaica, they had bad foil chests, they needed it. I didn't do it, but I didn't argue against it being done. Um, but I mean, he still sat in the ICU for 3 more weeks afterwards, pulling 200 on his IS, um. So I mean, yeah, he survived, he got extubated quicker, but he still was pretty miserable. Um, and I think that just speaks to the fact that, you know, if you don't do it a lot. Um, it's probably not the best thing. The other thing too, and this is actually a legitimate point, this is not a joke. One thing that I did find in a recent paper. Now that this has been going on for a long time, is that they have noticed that it was about, it was like 20% of people actually have severe irritation from the plates later on. And this is more in older people with, you know, tissue paper skin and muscles that aren't gonna contract and, you know, tense up and pull like, you know, you had said earlier, but that there, there are things, it's not a completely benign procedure, you know, it's still a surgery, you're still implanting something. There's always the, the risk for, you know, infection. It, it's a foreign body you're putting in there. Um, and there have been very, very rare studies, and this, these are technical errors on the surgeon's part. If they put the screws in and the screws are too big and they go through both sides of the rib through both cortex, um. And then they have to take the plate out. They've actually seen, you know, there's damage to the to the lung, and people get these massive sub-muscular emphysema that, you know, requires more procedures. But again, that was like a two case study that I found. It's like, that was recent. That was not in 1985. These are great stories. Myths, legends, storyteller, that's what I do. But, if you take the people looked at this question scientifically, and they said, is there a lot of plate failure? Is there a lot of plate complications in this surgery? It's a neurosurgery, so you gotta look at the infections, you gotta look at the plates falling off and what that does for patients. And the the statistics show it's an incredibly small number of patients. That suffer from rib from plate failure or plate infections and there have been studies done by the infection Society Surgical infection Society, the paper showing that there's not a lot of need for advanced antibiotics in these patients in this patient population because again the infection rate is incredibly small. Now we're not gonna do these operations on people with Myeas or other infections like uh he uh hematological infection. That's that's not a reasonable thing to do when you're doing. You have to follow the right rules. And what Doctor Laskowski is not pointing out is that, is this the, is that the whole right on your map? What Doctor Laskowski is not what Dr. Lastkowski is not telling me is that the more we do, we use technology like this, the more we advance the technology itself. We've gone from plates that are just placed anteriorly like we did with gigantic incisions to smaller incisions to minimally invasive keyhole incisions, just like we do with any type of operation, and we're adding to to that to the point of that myth he told about some patient who sat in the ICU forever, that you can actually go in and what we're doing here now is doing cryoablation for the nerves at the same time, at the intercostal nerves at the same time we're doing the rib plating so that we can kill the pain for these patients for the next 3 months as they heal and heal better because they had the operation. So adding extra, adding more and more technology and not being a Luddite is a good. I fear what's new it's, you know, It's it's there is one paper out there that compared the cryoablation alone to cryoablation and rib plating and found no difference in recovery or anything. So just gonna throw that one out there. So I did, I did also find uh funny cause he's talking about the, the plate failure. I did actually find one case report of a patient who I think he crashed his motorcycle or something, got plated and then crashed it again and all the ribs broke right next to the plates because the plates actually withheld because they're titanium and almost indestructible. So then he got played it a second time. Beautiful, beautiful case. Welcome. Are you, he should have gotten rid of the motorcycle, but probably should have gotten rid of the motorcycle, yes. Um, Doctor Balthazar, this fantastic, um, good job. Um, hope you can hear me. Um, really impressive that you played it on day zero. OK. Um, very impressive. You played it on day zero. I don't know what kind of magician you are, but the stars. That's incredible. Um, I think one of the barriers to centers like moving from just being a casual plating center where You're just plating the really obvious cases that you cannot ignore plating to becoming a more proactive center is what Doctor Laskowski kind of alluded to, which is um system barriers. Um, having OR time, availability of the surgeon, um, having the rep come in, like all the things aligning. How do you move from a casual plating center that does one case a year for that case that you just cannot ignore. To a more proactive plating center. So, first off, for those of you who don't know, this is Doctor McKenzie, this is the trauma medical director at Jamaica, so she's my boss. Secondly, I think she just admitted that he won, because now. I, I have to remain personally neutral in this situation. Thank you, co-fellow from our fellowship together, Doctor McKenzie. So, uh, we go further back than these two. Yeah, my boss, his friend. Uh, our, our kids play together, so, you know. That, let, let's let's be very clear about something. It does take a system in order to do any kind of new procedure correctly. We are in the process at NYU of creating a chest wall injury center, and the first step was actually getting surgeons here who do the procedure. Thankfully, we've recently have folks from over liitch who do the procedure like Doctor Robano, and you do this now. You do this now? Uh, OK, and then Doctor Ayagua, and then we just hired two new grads who know how and want to do rib plating, doctors, uh, Eliania and Doctor Boe. I did it, said it. Well, they So what you have to have the personnel, because what we were doing for the past is just basically a one or two person show where if we had a case, we would have to find someone to do it, and someone would be post call. It's a lot more challenging. It's not really a center you can build around that number of people, but now that we have the people, we can then move the center into reality, which involves us number one getting in intimately related with the national organization that establishes chest wall injury centers, the chest wall injury Society. Uh, where we've had academic relationship for years and now we're moving into having more of a collaborative relationship, sharing data and that sort of thing, and that allows us to have some um prestige and some uh national recognition for, for as a chest wall injury center, but you have to, as both of my colleagues here are pointing out, have the entire buy-in from the hospital. So we have been, so the first steps are having meetings with the various stakeholders, for example, the operating room, making sure that we have some at least promise of operating room. Time which we we've established here will be shared with orthopedic trauma. And so that would be, that's step one. Another step would be to get involved, get the other stakeholders, for example, physical therapy involved. When you have these cases, it's not just the operation one and done, you have to have follow up with physical therapy, occupational therapy, help them breathe better, respiratory therapy, so they know these patients are gonna becoming more volume and that they can help them better. And then of course you have to get administration to buy in and that's where the arguments for financial reimbursement and return on investment come in and if we do have all those things into place in place, the national relationship, the academic relationships, the output of academic papers, which is important for level one center, the buy in from the. Bringing room from anesthesia, from physical therapy, etc. etc. that's when you can say, OK, we can do this together, but it does take just like building a trauma center, as Doctor Ubano will tell you, it takes a lot of uh effort from everyone involved to to um to build this and so it is a process and, and it's just gonna take uh take as long as it takes. Um I started doing a rip plating in 2013 or Uh, yeah, you have like 2013 or thereabouts, and I, I obviously think it's a a wonderful tool, but I, I do not think it is the only tool. I think that, you know, as trauma surgeons and as doctors in general, the more tools that you have in your bag, The better, uh, you are. And of course, the, the indications for the procedure, it's a procedure looking for indications, and at first, uh, when the only data available was the prospective study from Japan. Uh, where they were really sick ICU patients and the plated group was only on the vent 10 days, and the non-plated group was 25 days. There was, to your point, they were still on the vent, uh, for 10 days, and then since then, the uh indications have expanded to displace, uh, displaced fractures, but it's still a procedure in my mind that it's looking for an indication. And uh also, uh, you know, most of us, or, or at least myself, I tend to plate the, the low hanging fruit, the ones that are lateral and not behind the scapula, not close to the spine, so, uh, it's not an end all be all for all things and, and in my talk even earlier I mentioned anecdotally, the use of experil in rib blocks and that. Totally eliminates the pain for 3 days and rivals are replaing uh uh in many uh patients and lastly about the spread of the technology as Doctor Rubana pointed out, um all this dirt and I, I was around when laparoscopic surgery first started in the United States in 1990. I had already done over 200 open gallbladders before I started doing laparoscopic surgery and at that time. It was the academic centers that refused to do the laparoscopic surgery, and it was the community-based uh hospitals and the uh private practice doctors who Uh, just loved the technology and took off, uh, with it, and the rip plating, if you read your 400 papers, you'll see that in the United States, the rip plating has really taken off in the community-based level 2 trauma centers and the academic towers have lagged on very similar to the laparoscopic laparoscopic surgery uh story, and I would, I would suspect that the ending will be the same, that everyone will uh accept this technology and start using it once they find the uh indications. And uh and it'll be very useful for this patient population. Thank you for your endorsement. Oh no, I knew I was walking into this getting destroyed. Um, actually, to, to go back, cause you know, like the, the few times we've done it at Jamaica, um. You know, they were like you said, they were the, the lateral, the anterior, the posterior behind the scapula, we just stay away from, but. This right, I don't know if there's a pointer. This right here is actually not bad for getting back to the posterior ones behind the scapula, the uh, it's a, a splint which essentially you make a hole on one side of the, the fracture and then you put that intramedullarly through, it's almost like a like a an IM nail, essentially, like what the ortho guys do for fractured femurs. Same idea, except it's for ribs, and those are actually pretty good at getting to the posterior ones, but I will. You know, did I ever saying that, you know, while my opponent is, is, I don't know, an insecure surgeon, but I don't, I don't know, that doesn't want to go to the underneath the scapula, uh, insecure is not actually not anything I've ever been accused of. I'm joking, I'm joking, but well I'm saying he's they they're correct, it's much more difficult to reach the posterior ribs. It takes more uh refined approaches, and we have done. I don't know, dozens of those here, and it does, and it's equipment that allows us to do that, that that has been adopted by the various vendors to make that possible. Uh, and so you have to be willing to take the care of these patients properly. If that's where their ribs are broken, the worst, and that's what's causing them so much pain and then difficulty breathing, you've got to be able to have more all the tools in your back pocket. The one of the cool things is that as the minimally invasive technology improves, it becomes much more useful for Those ribs that are posterior and difficult to reach with an open approach. So as we continue to evolve this technology, of course we're gonna catch up to some of the issues that uh my colleagues have brought up as problematic technically. Yeah, I mean there's also intrathoracic bleeding too, which helps getting to the posterior stuff if you really want to thank you for your endorsement. You're welcome. I told you I know it was coming in here getting, you know, on the losing end. Yeah, I chose a good sport. Um, does anybody have any questions otherwise I'm just gonna keep uh grilling them for one more. Uh, anybody else wanna make them debate something? All right, so two questions. One is when you do these, do you have to go into the chest? And if you have to go into the chest, right, there's this whole thing when we fix inguinal hernias, right? Do you do a robotic inguinal hernia? Do you do a TE? or do you do an opening inguinal hernia? Cause if you're going into the belly versus staying outside of it, are you risking more harm? So when you rib plate, can you stay outside and just, you know, put the ribs together and not have to, you know, do a vats or go into the chest and risk that. The second is, a lot of us live off of algorithms. Um, you know, there's, there's a multi-stage approach to the management of rib fractures, uh, which include things like, you know, as Rob said, you know, giving them narcotics, and there's, you know, intercostal blocks, there's para vertebral blocks, there's epidurals. There's, there's a whole like stepwise approach that we currently utilize. Um, if you can't, ala Jamaica and sometimes Mineola, get the patient to the operating room quickly. Um, and let's say you put an epidural in the patient and all of a sudden they're pulling 2 L on their incentive and they feel better, you still plate them on day 3. Oh, that's a, so the, the first question was about that's an easy answer. Now the first question was about, um, I'm sorry, I forgot already. What's the thing with the next one they'll go in the chest, yeah, so you don't have to go on the chest, and we haven't sometimes in this case, sometimes we'll just uh play it from the outside and leave a chest tube just in case there's any bleeding or some edema from the operation. That is, that being said, it's, I find it very useful to go into the chest, at least with a camera, and most of these patients, when they, who we tend to select more severe rib fractures, they tend to already have pneumothoraces and or hemothorosis and have at least one small chest tube site. Yeah, that's all you need to make sure you align properly where the rib fractures are and make sure to evacuate and retain hemothorax. I think it's very beneficial to go in to the chest and then leave behind a small chest tube. You don't have to make big incisions onto the chest, just little port sites, and then that can be sufficient. Uh, but yeah, in some cases, especially the less, uh, the less severe cases, you can usually just go straight through to the ribs and not have to enter the chest at all. Uh, that looks like a lung in your picture, no. That was the lung poking out on this particular patient. We did asking, we did do a vas initially on that patient to view the chest wall and see exactly where the divots were and just how badly broken it was, so that we could align the incision perfectly, so we can make a smaller incision, and that's part of the utility of going into the chest, even just with the camera. And then the second question is algorithms. Well, the algorithms are really based, of course, as as they all are on national data and from national societies like the chest wall injury Society. And so we do follow those algorithms. If a patient does have pain control, that is one of the factors that we don't say that we say is not, it might be a relative contraindication to doing the operation. But that pain control is gonna end at some point, and then what, they just 3 days of of goodness and then suffering or an opioid addiction later on. I don't know if that's the best option. Even if we get some control, if we anticipate that that control will end when we stop whatever intervention we've done into their spinal cord, then we could potentially, we should, we should potentially take that opportunity to do the rib fixation, and I think that would be supported by the uh national algorithms. Published ones, yeah. Um, any, any retort there, or you just endorse me again? No, I mean, you're not wrong. Sorry, but it's there's this is, this is a hopeless battle. Nobody else has appears and you know. Anybody else in the audience besides our our friend? Crater who set me up. Uh, I just have a question about the patient. I just have a question about the patient population itself from the studies, cause I think about, I'm from witch, so we see a lot of older people like the 80 year olds, they're always on blood thinners, they see the trip and fall and break every bone that they touch, and I think they would probably do a lot worse than maybe like a 30 year old otherwise healthy male and like a motorcycle with multiple rib fractures. So I just wonder how often, with like the differing populations, how often it was studied. Yeah, I mean, that that's a very good question, and that the question is whether geriatric patients would do worse with refixation or not. And uh I can refer to Doctor Bolleu who did a national talk on this subject about geriatric ripfixation just a couple weeks ago in in Orlando during the hurricane. Um, But the, the, the evidence does show that these patients, when they're properly selected for, you're not gonna put a patient up there with in floor CHF not gonna put them on the table, obviously. But if they are if they're able to undergo general anesthesia safely, and you do the rib plating on them, it does show benefits in terms of mortality and all the other uh other benefits that we showed there. Even hyper selecting for the 80 and above group, there are studies that show a benefit in the survivability of those patients. And if you, and you know, I, I don't, I guess Doctor Lucas might my grandmother to die, but I, again, I don't, and I, I, I would really hope that we would encourage more research in that field in the advanced age population, in order to really see whether we can benefit these patients and who to properly select for. In fact, there are apps that you can go on to to that are specifically geared towards understanding the potential prognosis of patients in the geriatric population who have rib fractures and seeing whether or not they meet criteria for safer fixation. Oh, well, there are those one of the component to what you're saying, but I it's, it's definitely been shown to be beneficial and, oh, and in terms of osteoporotic patients, there are advanced techniques to help make sure the plates stay in place and uh do give uh the benefit that uh we have in younger folks. Great time, Doctor Balthazor. I'm Adam Strait. I'm one of the Trump doctors here. Yeah, he, he did it right. All right, you're an excellent fall guy. Um, all right, so, uh, I'm coming from a position where I don't do rib plating, but we're gonna be doing more rib plating and I'm interested in doing more of it. And I guess maybe I have kind of a dumb question, but like with the 399 in favor and 1 against doing it, why isn't the standard of care? Like what are, like why isn't like this just what we're doing everywhere all the time? Why isn't it uh presented at all the conferences is the way to go? Why does this suboptimal therapy with multi-stage indwelling catheters, opiates, whatever, why is that even what's happening anymore? Well, there There are two reasons that come to mind. One is that the technology just had to take time to advance and to be disseminated throughout the community. Until you have the technology, access to it, and then practice with it, it's gonna be really hard to make us a standard of care, and as my colleagues have pointed out, they don't know what they're doing. So just you know what we're doing, kind of, we just make it up as we go. Well, the point is that that's part of the reason, right? Technology needs to catch up, Skill set has to catch up, and really the titanium plates that are much more facile have really only been around for a decade, and so we are trying to, we're not actually getting on board at the very beginning of this, we're kind of getting on board in the middle of it, and then there'll be the late, um, the, the late uh. There's adopters. Thank you. Thank you for conceding. You're welcome for your endorsement. The late adopters that will eventually pick it up, as Doctor Eriaga pointed out, this will become, this is already considered a uh a center of care in many cases and should become the center of care going forward. And what was the other part of your question? What? Yeah. Yeah. Oh, the other reason, the other reason is um the cost prohibition. A lot of people believed for a long time this would be cost prohibitive, and onboarding anything, and we onboarded tag. Uh I don't know if you know how we use tag, I know what that is, but when tag was first, uh, it's a way of measuring the blood coagulation profile, but when that device first started, it was astronomically expensive to start the program. And then once you started the program, you start to see benefits in the patients and then benefits on the return on investment as well. But until you get it started, of course, it's gonna be more expensive cause it's new and different and takes people to takes money to onboard anything. But if we were doing this with the right motivation, which is patient well-being, Then that should um suffice to get the to to put the cost up front and then the studies are starting to come out now that patients, although the centers that did put that cost upfront, that they are actually having a return on investment. Uh, but people are still rather afraid of that. I think the third thing is a historical, um, you know, I, this is the way I've always done it. I, I know, oh, I compare this guy with 10,000 rib fractures, and they did just fine. I wanna need this stuff. I mean, that mentality exists in any culture that you're a part of is this group that doesn't want to move forward, that wants things to go back to the way they were. I mean, that's who's anecdotal now. I definitely need. No, um, to, to his point, I kind of look at it and think of it almost as like the, uh, the adopting the robot, right? It's becoming standard, but there's still, it was very cost prohibitive. Now it's not as much, but there's still a learning curve, you know, you have to use it and do it a lot to get good at it. All right. So I think we can all agree, Doctor Waskowski on that to be. So, We'll proceed to Jamaica. Uh, all right, so that's the, uh, the end of the, uh, morning session. Thank you both. Um, so just Published October 17, 2024 Created by Related Presenters Gerard Baltazar, DO View full profile Robert Laskowski, MD, PhD
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