Ep. 14 | Robert Kirtley, MD, Interventional Physiatrist, SGMC Health

Transcript

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- Welcome to another episode of What Brings You in Today? I'm Erika Bennett. And I'm Taylor Fisher. And today we are joined by Dr. Robert Kirtley. MD and Interventional Physiatry. And Dr. Kirtley, what brings you in today?

- Well, welcome and thank you for having me. I'm coming in to talk about interventional physiatry.

- All right. Not to be confused with psychiatry, which we also have a episode on that if you're interested in listening to it. So tell us about yourself, Dr. Kirtley. Just give us a little bit of your background and kind of what led you to becoming a physician and to your specialty. Okay.

- So I think really when you grow up and, and you have this competitive nature in your family, and so I, I grew up with older brothers and multiple cousins and, and they were all athletes. And so, and I was the youngest. And so I would get dropped on my head and, and have to punch above my weight class. And so it, it makes you have that competitive attitude and a lot of water skiing and athletics and competition working out and getting into metabolism and physiology. And so that pathway took me into medicine in general. But I think the, the family background is something that kind of made me want to reach for more. I have a, it's, it's, it's interesting, but my aunt is a, a world slalom champion and water ski champion, and my grandmother was considered the grand old lady of water skiing by Mastercraft Boat Company. Oh, wow. My brother went to college.

- Your family sounds very interesting. Must be fun on reunions and stuff.

- Thank you. It's, it was, it was fun growing up. Very different, but everybody had some type of title or championship and so it, it kind of drives you to find your place in that. And, and so I felt like, you know, finding my groove and in general, learning how to be a little bit outta the box of a thinker. And so, you know, with retail business and, and the work and the competition. So as far as, you know, being into physical medicine and thinking about exercise and physiology, that really took me down a route of loving to be hands-on with patients and understanding a lot of the orthopedic neurologic things that I do. And so that route of, you know, really was almost physical therapy at first, and then I got into physical medicine, and so it just drove me into becoming a doctor that route.

- And so what is interventional physiatry for everyone? Let's go ahead and get that question. Sure, sure. Outta the way.

- So two words, interventional, when you think about the word interventional, you've heard of interventional cardiologist, you've heard of an interventional radiologist. And so to intervene is to typically do something, have an action or a, a procedure at a body part to try to fix or intervene in some way in contrast to a normal diagnostic in a physician or treating with medical therapy and medicines. And so, and I do both of those. We'll diagnose and we intervene and I'll use medicines as well. But the tricky part is psychiatry and a lot of people get confused with that. So it's not psychiatry and it's not a physiologist. And so, but we are one of the smallest specialties in medicine, physical medicine and rehabilitation. And so in general, a physiatrist is a PM and r doctor, and so the PM stands for physical medicine and the R is rehabilitation. And so classically over the years, most physiatrist or pm PMM r doctors had been rehab docs. And so they would run a rehabilitation unit or, you know, after major surgeries or a severe de ability, someone would be on the rehab unit very similar to what we have here. And those docs will round and make sure they're, you know, recovering and getting better and get them back to a fully functional state so they can live autonomous. Right. Or, or go home independent. And so, but being military trained, our focus was a little bit more on the physical medicine side because we needed to be able to deploy or be at duty station and act as, you know, this orthopedics, this neurology, this sports medicine and even pain medicine. And so I was very fortunate to be where I was and, and my pathway in becoming a doctor was very unusual. And I, and I'll tell you why, but you know, we had this exposure of be able to diagnose, intervene, and make someone feel better and actually give them improvement, right. Be able to affect change. And so in so many words, I am the PM part of a pm and r doctor, and then I do a lot of interventions. And so that's what interventional physiatrist is. Excuse me.

- All right. So tell us, you mentioned the military. What, tell us a little bit about that

- Background. Sure, sure. You know, with typical docs, you know, you get interested in something, you rotate it, and then you do a residency. And I was in the health Proce Health Profession scholarship program that took me in and helped me pay for school. And so I was very fortunate to get that. And, but, so I started off at Triple Army Medical Center and I did my internship there. I matched into radiology. And so I started off training in radiology after my intern year, and that's where I had my first exposure to, to ultrasound and, and, and kind of fell in love with it. However, I didn't fall in love with, you know, driving to work in the dark, working in the dark all day, and then going home in dark. And, and so I felt like I was turning into a vampire and I was losing that, that contact with patients. And so, and in the military, if you wanna change, you can, but you kind of have to pay up front. And so I did leave radiology and then I went and did aviation medicine, which is also known as aerospace medicine. And so, and they call us flight surgeons. And so I did aviation medicine training and then worked out of Fort Rucker in enterprise Alabama for a number of years and got a ton of general practice experience. And, and then also you get to find helicopters. Yeah. And, you know, be a flight surgeon. It's really neat. And so pretty, pretty, it's pretty cool, I guess. Yeah. It, it's fun. Believe it or not, you know, flight docs in the army, if it's a, what's got a single rated airframe, that means, say a helicopter that only requires one pilot, we could get stick time. So it's like the old mash, you know? Yeah. Doctor up there, you know, getting, getting some stick time as long as there was a pilot there. But it was a, a great experience. And, and from there then I applied to Walter Reeds pm and r program. In short, Walter Reed was seeing all of our service members throughout, and this was from 2013 to 2016 timeframe. And so we still had a lot of service members that were coming back from downrange and very unfortunate injuries. Right. And so, IEDs and blast injuries, and as a new resident transitioning into that big hospital, if you, I'll give you an example and try to put yourself in that position. And it, and this is another reason why it makes you want to reach for more, to try to offer more. And it's, it's what also kind of helped me develop a unique specialty in that. So Walter Reed had something called a amputee clinic, and then eventually we, we also developed an ultrasound clinic, but that amputee clinic, say as a new resident, here you are. And there's literally, you know, 50, 60 amputees and wheelchairs, and they're coming in, they, they're fresh from, you know, flying in from launch door, you know, downrange or Afghanistan. And, and so these young men have lost their legs, right. And not just both legs, but also an arm. And, and so, and then, you know, as a new resident first the thing is, you know, let's choke back the emotions. Yeah. And, and they're coming to me for help. Not, and, and still you're new and you're learning. And so the normal process, right. If that happens to somebody, what do they do? So you, you've gotta wait for an appointment to the surgeon, and then you've gotta have your surgery, and then you've gotta wait to, 'cause they've got nerve pain, they've gotta wait to an appointment to neurology. And then you've gotta wait for an appointment to maybe the neurosurgeon. And then you're going to see wound care. And then you're doing, you know, and you've got all these appointments and it's taken forever. We needed something better, right. For service members that had just, and they're in pain this whole time. And then what do we wanna do? Just throw pills at 'em in narcotics? No, we, we don't want to get 'em hooked at the same time. So we integrated in this ultrasound clinic because, and while ultrasound, well, the technology around that time started to get better and better. We had a amazing budget, multiple rooms, each room filled with a hundred thousand dollars plus ultrasound machine. And so then we do electrodiagnostic studies and then we had pain suites right there. And so no other place could you have one facility, right. With fluoroscopic pain suites, you know, and that's like a c-arm, right? And then, then these ultrasounds and then electrodiagnostic studies. So you could bring in a patient, especially in the ultrasound clinic, and they're in pain, we could see them for the first time do a new, immediately start doing imaging right. In the same visit. Right. And ultrasound allows you to see dynamically it has better resolution than MRI. And at the same time it's dynamic. It means you can move it and evaluate, have them move their leg. You can see how the muscle, the tendon's working. Right? And then, so as you're doing this, you're also, now you find a problem, oh, there's a big neuroma, right? Their leg was transected. Right. And that, that nerve is angry. That's part of either the blast injury or the surgery. And so now, well, what can we do? And so we had the ability to do use regenerative medicine, which is still what I'd call the wild, wild west of medicine. Right. PRP and stem cells, things like that. Yeah. It's still not widely accepted because of reimbursement, but so long story short, we could have access to all these things in one place. Right. And nowhere else, nowhere else could you do this. You can't, you know, evaluate someone, do imaging and do an intervention all in the same visit. Right? Yeah. Right. And so it offered the ability you had to do it and really get good at it quickly because, and you got somebody that you don't want them to commit suicide. Right? Right. Yeah. They've lost both their legs and they've lost an arm. Right. In this case. And so you've got to get over your emotions, you've got to dig down and it really drives you to offer something better. Right. Because there they are, you're in that position at the largest hospital for all the armed forces, and they're coming to you, what can I offer them? Right? And so am I gonna make 'em wait to go see someone else? No. They're here for this pain. Right. And this is you. And so definitively I fell in love with it. 'cause I already had this ultrasound background from radiology. Yeah. And then I'd already been using it in aviation medicine. And so it was just like this match made happen for me because, and I, I, I embraced it when sometimes other residents were, didn't wanna go. I volunteered. I took their spots. And so I just did, I just ate the ultrasound up in the ultrasound clinic. And, and along, I guess over the years we started integrating in all these additional procedures, utilizing radiofrequency ablation, utilizing regenerative medicine and then other treatment techniques, prolotherapy, lots of things that you can't get on the outside. And that formed who I am today in my practice. And coming out into the civilian world, it was some tough lessons for me. Yeah. Because you can't always get these things approved in the civilian system. Right? Yeah. And so learning, but I retained a lot of that. And still it's very exciting. And, and I think that's why we, we get a lot of hugs and, and happy folks because we still integrate a unique way of, of providing healthcare. And so, and people just don't know what PMM and R is. Right. Right. The, you're, I'm evaluating a bone and joint issue. I'm evaluating a nerve issue. I'm evaluating a sports medicine issue and a pain issue. Think about pain, right. You wanna see quote a pain doctor, what is, what is that? Right? Every pain you have is mediated by a nerve. Yeah. Right. And, and so it's not just Right. A joint pain, it could be a nerve issue, but,

- Well, I tell everybody about you and your specialty. 'cause I've actually seen you several times. I had this sprained ankle and you were able to tell me like, Hey, it's probably, it's gonna heal, probably like, let's just walk it off, you know, no pun intended. But, and it did after a while so that, you know, I didn't have to have any kind of intervention or whatever. But being able to, you had that ultrasound and, you know, looked at it ligament real time looking at a, a ligament and being able to see, tell us about the difference between one and x-ray versus a ultrasound for the, the common folk. Because mainly x-rays are typically what are used. Like if you go into like a orthopedic practice practice ultrasound, how is that different and what leverage does it give you versus the x-ray?

- Excellent. Thanks for pulling me back on track a little. So absolutely. X-rays are one of our oldest modalities, right. Of imaging. And so when we're transmitting X-rays, it does have radiation. So there's a downside of it. However, x-rays are fundamental, right? And so I'm not here to say that one modality is better than the other, right. Just as we use them together to make a, and get a, a more full picture. And so I, I order lots and lots of X-rays, however, I don't always need them, right? And so when we're talking about ultrasound, what it does is it's using sound and just like the reason why that when during a pregnancy, right? Ultrasound is the safest modality we have. It's using high frequency sound and an echo, right? And that echo is bouncing back and forth. And the technology uses that speed of bal as it balances through different densities of tissues. It does a calculation and boom shows you a beautiful picture, but,

- And shows you a spot on picture of your child, like your space. I have no idea that that's how like the three ultrasounds, how that look, my son came looking exactly like that. I mean

- It's, it's, it's amazing isn't, it's crazy, right? It really is. Well, the technology's gotten better and better over time. And so we keep a high resolution, I have actually two ultrasounds and so I, one that I do surgery with and then one that I, I utilize for most diagnostic work. So keep it in the office. It's immediate, it's cheap, right? It's, and there's no damage or no pain to the patient. And so you can ultrasound as long as you want, right? And it's very easy to do.

- And you were able to tell when you, 'cause my ankle was still swollen. So you looked at my other ankle to see what my anatomy should look like and what you were able to tell that I had sprained it like previously, like years before that I forgot about how do you know all the tendons and ligaments? How do you, because there's so much stuff in there, right? Right, right. There's like all kinds of stuff in our bones

- And Absolutely.

- How do you, I mean, how did you learn all that? I mean,

- In general it, it's, you know, the background in imaging and so just like a radiologist and it goes into training, you learn to, you look at these, these imaging, right? You look at imaging on a day-to-day basis. And then when you start putting, when when you see a muscle, when you see a tendon, when you see, you know, bone or someone who's damaged bone, even arthritis, it has a very telltale appearance. And, and so, and it's easy to pick up on that and excuse me. And being able to do that in the clinic visit, right? Speeds everything up. I'm not having to bring them back Yeah. To, to send them over to the department and have something done. So it not only does it save the patient time and save some money, and then also the next step is using that same imaging to then if you say, for instance, you want to deliver medicine to a specific spot. And if you look inside the hand, if I had, you know, pictures here to show you, right? There are so many structures, right? Nerves, vessels, arteries, tendons, and you're an injection can have such a good outcome when the medicine's placed in exactly the right spot. And sometimes these are less than a millimeter, right? You need high precision. And so that's the whole point of using that ultrasound during visits and when it, when it goes to the right place, it's a huge game changer. And, and so the way I describe it ultimately is kind of like a video game. You've heard of God mode or a cheat code, right? And, and sometimes it's almost like it's not fair, right? Because if you traditionally went, oh, let's move that shoulder around, let's do this, and, and I do that same thing, I move that shoulder around, but why not Also, let me see inside you like kids with, like we imagined when we were young X-ray goggles, right? I put on my X-ray goggles and then I'm look, oh yeah, that's what I thought it was long haired bicep tendon, right? Yeah. And so you can see all of that now. There's limitations as well. But yeah, it, it's very, very helpful. So

- What, speaking of your practice, what are the most common complaints that people come to see you for? Like what kind of issues or pain are they having?

- Good question. Thanks. So I actually practice from head to toe and docs like myself sometimes get pushed into a route because what do all of us have? We all have back pain often. It's so common. So I do a great deal of spine and, and low back pain and, and issues with hips and knees and shoulders are some of the most common, but I actually treat from head to toe. And so, but specifically musculoskeletal peripheral nerve. So, but again, nerves mediate everything. So if we started at the say of the top of the head, right? And you have migraines, right? And that can be a supraorbital nerve that lives there. And I can go after that if it's at the back of the head and people are getting migraine headaches and it's called occipital neuralgia, I go after those nerves moving into the neck, right? I go after the arthritis shoulders and literally all the way down to plantar fasciitis. And so one of the cool things here is that there is, you know, traditional approach of, Hey, let's just go after the tendon, the tendon's thickened. And so we might be able to do surgery on a tendon. Well, if you can find the tiny little nerve that goes to that thickened tendon, what would you rather have done? Would you rather have a surgery that opens the foot and then cuts that tendon If it's still intact, it's just causing pain. So you're having the surgery for pain, then go after a tiny little nerve without cutting you open, heating the nerve up and killing the pain, right? And so, and guess what? You can do that all over the body. Yeah,

- That's so cool.

- And it's, it's just a different approach, right? And, and we do that all day long every day, right? And, and so then that's, that's part of what leads into some of the unique things that I do as a nerve specialist. And so what brings people in can be chronic elbow pain, right? But instead of saying, well, hey, after physical therapy's failed, or if, say I've got a patient that's got chronic knee pain and I've already had a knee replacement, or they have, you know, morbidly obese or comorbidities and they, they're not a candidate for another knee replacement or, and so I literally find the nerves in the knee and then we can heat them up or cut them, right? And that's a 'cause otherwise, what were they relegated to? Pills. Just pills and or steroid injections that no longer work. So we, there's room for improvement, there's room for alternative treatments and that's where, you know, I try to step in and, and we're even doing IRB approved research here, right? My colleague and I, Dr. Mackey and I are very excited to be working on a, a new procedure and it's, you know, it's exactly that. It addresses this unmet need of people that have chronic pain and otherwise aren't a candidate or they still have pain in their knee and

- Yeah. Well, like my, my dad has chronic lower back pain and he, you know, he's been told you can have surgery, but surgery doesn't necessarily always help. Like, you could have the surgery and it would help, but it also might not. And he just doesn't want to have the surgery. I mean, and you can understand you're having back surgery, you can't do anything for a long time and he doesn't wanna take pain pills and you know, he's already had, you know, prescriptions and he doesn't wanna do a whole bunch of pain pills. So listening to you talk, I'm like, maybe I should get my dad an appointment to come see you because it might be,

- It is so weird. Like also my mom ha has back problems and they, you know, she went to Dr. Mackey and Dr. Curly, but I think Dr. Mackey said the same thing. Like, if we ha if we do surgery, you know, you're just not ever guaranteed Right. That it's gonna work. And that is, you know, cost benefit thing that you have to kind of weigh in. And a lot of times it's scary to think about doing a big surgery if, especially if you're not

- Guaranteed. Sure. I mean,

- And you can manage the pain, you know, the pain is not like unbearable. But

- Yeah. So sometimes, and let me clarify for right, we're, we're not trying to imply that we can take the, the place of surgery, right? Sometimes you have to heal with steel, there's no way around it, right? And, and then, and so with someone, there are specific indications, right? For, for spine and surgery. And so, and I won't get into that specifically, but if, if you've got bone on top of a nerve root, then my medicine's not gonna make a difference. And then there are nerves that say we could do an ablation, and that term refers to typically a heat energy, right? I, I'll use some heat on certain nerves and that that's what's called an ablation. And I can stop pain for a long period of time by doing that. But then you have nerves that have motor function, meaning they, hey, they move your leg. And then if I do that, I don't practice again. Right? That's, that's a no no. Right? So people need to walk and so those types of nerves we can't heat or do an ablation on, right? And so if you are losing function, it's pressing on your spinal cord, then there's no way around it, right? We want the best outcome from a pain perspective, but if it's gonna impact function and ability, and that's where the surgeon has to step in, right? Relieve that pressure on the nerve and then allow them to get back to, to their life. Now, yes. I mean, when you cut through skin and muscle and connective tissue and bone, a perfect surgery can be done and they still may have pain. And, and so that's tough for our surgeons, right? And so you have to stand by them and so, and help folks with, once it's pretty bad, yeah, you're gonna get surgery, right? Or however we can help you the most, do the least amount of harm. And so certainly like in your dad's case, you know, if it's pain, then we may be able to help him with the pain, right? If the muscles are still functioning and he may not need that surgery, right? But, so hopefully that helps.

- Well it's just cool to see medical advancements I guess, happening right here, you know, locally. And I mean, as a, just a citizen, I'm like grateful for people like you that are out there looking at ways to make things better and not just settling with status quo. I think that's pretty cool.

- Yeah. Yeah. It's funny you say that Buck, the status quo, that's a, a term that I started to use years ago and while I was still in the, in the army. And, and so now I even work with some folks that that's their mantra is buck the status quo with, you know, advancements speaking on about nerves. One of the things that's interesting is I started seeing difficulty while I was still in the military about say, getting something approved and why could it not get approved? Well, they said, well it doesn't work, so why doesn't something work? And so using that ultrasound, let's take the knee for instance, and have a little show and tell, I wanted to, to, to explain is that, you know, with being able to now visualize nerves, nerves that transmit pain into the knee, so how could I cut those nerves or damage those nerves or stop someone's pain? Some research showed where animal studies were utilizing high concentration anesthetic and that anesthetic, I'm gonna use two terms, neuro selective and neurolytic. So neuro selective meaning that if I put a medicine inside the body, it only affected the nerve. Right? Neuro selective. Neat. And the other term is neurolytic, right? It it cut to lytic to cut it, cut the nerve, right. Or damaged the nerve. And so we got very excited from these two studies, right? The, the animal study and then also there's some studies for exactly what we're talking about back pain, right? Where high concentration numbing medicines were being used in people's backs. And so based on that, some years ago I started working with my colleagues back at Walter Reed and, and then we ended up, this is a medicine that I developed, and so I got with a compounding pharmacy out of Atlanta. And so you won't see your physicians and patients will never see this, right? But it's, it's 20% lidocaine, right? It can be very dangerous because it's a very high concentration. And we had to supply the, the, the compounding pharmacy with all this literature or how it would be used and so to get it developed. And so we started doing, based on that research, we wanted to use or I wanted to use high concentration anesthetic in specific nerves for someone who'd already had right. Multiple surgeries on their ankle or multiple surgeries on the knee. And then instead of cutting them open, why not? It's the holy grail of medicine, right? Just inject this tiny little bit of medicine that only affects the nerve, right? And then kill the nerve from functioning. And it's not a motor nerve, it's a sensory nerve, right? Yeah. And so that was the, the impetus of a lot of this is that, and it worked for a few people, but we couldn't quite figure out why it wouldn't work for others. And then I also had 75% dextrose developed because, you know, this osmotic effect, and I don't wanna bore you with it, but it, it was, the other effect was, again, try to kill a nerve. It was kind of cool. And that led into you're

- Just trying to earn a title to compete with your grandmother. That's

- Kind of cool. I was curious, how long does that medication last? Is that just forever?

- No, but you, that's why it has to damage it, right? So a numbing medicine only lasts for a few hours, right? But if you have a high concentration anesthetic, it can actually lesion or damage the nerve and, and so, and

- Then that lasts for whatever

- It would last forever. Yeah. Right? And so if you, and that's what happens with, there are different types of nerve damage and, and so you can be, have temporary nerve damage and then you can have permanent Right? And or something that's equal to a transection being cut. But to answer your question, yes, the, the goal was that that medicine would then destroy the nerve. So people then would walk without pain. Ultimately what it led to was the research that Dr. Mackey and I are doing now. So I now I find those nerves and we transect those nerves and it gives people hope, right? I have people and love to get 'em in front of the camera where they're talking about, wow, I had no options and now I'm walking without pain. Certainly there's some that have not worked as well, but the overwhelming majority are working. We're very excited about that.

- So we held an event where you spoke about that procedure and we had several patients that had had that procedure speak at that event too. And they were just raving about what it did for them. So tell us about this other contraption you have over here. So another procedure you do that's minimally, you know, we see minimally invasive stuff start coming and becoming more popular. I do feel like we're just gonna keep moving in that direction.

- Oh yeah. Oh yeah. So this is, this is really cool. So in, in 2013 when I, I first started my residency at Walter Reed, we looked into something called the hook knife. And so there were, we knew that there was a better way, 'cause again, ultrasound allows us to see inside the body, right? So, so nicely. And there was this physician who developed this little device that had a hook on it. And literally then, so they were doing carpal tunnel release with a hook knife. It was a little, a little bloody, but it, it, it showed proof of concept, right? And then later we started developing and I started these engineering drawings for a deployable cutting blade. Well, some material engineers got together and, and some folks, and they did a much better job of it. Right? And so, so you didn't

- Have to invent that one. That's

- Right. Right. And God bless

- Someone else did that first.

- Exactly. But before this was around, there was also, there was a physician named Dan Zu go. And the US Army sent me to Green Bay, Wisconsin to train with this guy. And it was very neat. It was a thread, carpal tunnel release. And so he was doing a carpal tunnel release without cutting the hand at all. Right? And so fascinating, he used this echogenic wire, a wire that could be seen on ultrasound. He went to China and he did hundreds of cases. And then he came back and then showed and did the literature and then, and so we were going to introduce this and in the US army population, and, and so there was, you know, whenever you start to crossover into another fields, there can sometimes be a little bit of a turf battle. Yeah. And so, and it takes, it's just healthcare, right? It, it takes some time to get things approved. And so the army was a little behind, and only just this last year did they start doing it. But as far as the way this works is that, the really neat thing is it's based on using ultrasound. And so traditionally if you're going to do a carpal tunnel release, you're cutting downward through the palm and opening, or it can be done endoscopically as well, but it's a pretty large device that goes in the hand. We wanna be minimally invasive. So this device is intended, there's an incision that I can make it so small, it doesn't even require a stitch. So utilizing ultrasound, there's a little safe zone and that, and it will basically go right into the wrist up under the ligament. And so now, and it has a tiny, tiny blade that if you see, can you see how small the blade is? That's the, the thick, that's crazy thick of the transverse carpal ligament. And then it can also be manipulated up and down a little bit to control right? My, my depth. And so, and that can transect, it goes back inside and hides itself once it's complete, and then it pulls right out, and then you're back to using your hand immediately. And so the cool thing there is that you can see everything. So again, it's that, that god mode, that cheat code, right? You can make sure the whole ligamentous cut, you can make sure that your safety parameters, it has balloons that allow me to manipulate the nerve and also think about this, I'm cutting up and not cutting down, right? So you, you don't, you don't have that same risk of cutting into the nerves or tendons or causing damage. So improve safety profile. How many

- People suffer from carpal tunnel? Do you know?

- Oh my goodness. Millions. There's roughly 2.3 million cases diagnosed like every year. And it's one of the most common elective surgeries done in the United States and around the world.

- And how the, you do the procedure, how long does it take? And then how quick do people see results?

- So yeah, great question. The, I literally, I don't have to do general anesthesia. We listen and we chat about music, right? During this procedure it takes about seven minutes. And then I have them fully move their, and use their hand immediately after the surgery. Their hand will be numb for about 20 hours or so. Yeah. And then, but they're back to using their hand right afterwards. Now we did cut the ligament. So you know, there, if if people have a tendency to be a little bit more sensitive to pain or needles, then they may have some soreness, right? But most people do very, very well because it is surgery inside the hand. It does cut the ligament, but we cut so much less, we don't damage any of the epi neurosis. We don't damage any of this tissue. We don't the palmar cutaneous nerve, right? They're, they're able to immediately use the hand the next day. And the, the company that makes this device, they, they have nurses when they, they need, and the nurse literally has it done and she's back to work and Oh my gosh, joke about she's literally right after the surgery. Yeah. So it, it's, it's really, and they call it microinvasive, not minimally invasive. So meaning even smaller than minimally invasive. Wow. Pretty neat.

- So this is in office procedure or is this considered an outpatient

- Kind of thing? It actually can be done inside the office. At my old clinic, a private clinic I was doing inside the office. You know, one of the things that I'm, I'm very thankful for SGMC for is, you know, that transition, I came outta the military, I had a private practice during COV and then also trying to be a military doc in the civilian world doesn't always work. All right? And so that, those hard lessons of, hey, I, I can't see somebody diagnose 'em. Yeah. Imaging intervene the same day. Guess what the hard lesson is?

- There's rules, there's

- Post, it says, no, no, no, Dr Cur Lee, you're not getting reimbursed. But you know, it's, but, and so I was very thankful for SDMC to tell me about that transition. And, and I've learned so much, even from my practice managers and others, that hey, you get better over time, right? And we figure out how to talk to 'em and how to properly get authorizations. But with that, yes it is, it can be done in the office and I used to do 'em in the office, you know, the the OR setting is it, it, and you can't get away from the fact it's safer, right? You've got a team, you've got a staff there, and you've got a sterile conditions. And so, but if there was someone, if, if they had out-of-pocket cost differences, yeah. You could do it for less cost in the office. Absolutely. And way, I do the same thing. I do trigger finger in my office without cutting the hand. There's a, again, I don't wanna bore you right? No, no, no. But I, there are multiple procedures inside the hand that can be done without cutting. And so, and that's really the cool things. I try to offer the same thing for each joint, right? The knee and the ankle and the foot. And, and by having an alternative, whether it be a high concentration anesthetic, a microinvasive device or a heat treatment to a nerve, right? That maybe gives somebody an alternative option, right? Not saying it takes the place of a surgery in miss cases, the surgeries need to be done, but if they've already had that surgery or if we could just treat the pain without it, right? It's very

- What alternative, very, someone had to asked a question about what was it? Bursitis?

- Bursitis, treat, bur

- Of course. Okay. I don't remember. Somebody did submit a question and was asking about that, so Yeah, yeah. I don't know.

- I'll, I'll speak to it. So right up,

- My, my mother-in-law had it though. I just remember she was fascinated with that word Bursitis. Bursitis. And she listens to our, shall I say, okay, shout out Paula fin, you're the best mother-in-law. But go ahead.

- Yeah. So a bursa refers to, I mean if you think about any tendon that has to slide or move, our bodies are amazing, right? How many times we can move a joint? So, and one of the the, we wanna lower that, that friction, right? And, and how you, the body lowers the friction is have this tiny little layer of fluid in between those surfaces. And that's a bursa. So you have this little capsule or this layer that encompasses fluid. And so now if you, over time, let's take the shoulder for instance. It's very, very common. Subdeltoid bursitis, right? And then there's this sub acromial space. And so without using fancy terms, the tendon that lifts your arm, it slides up under this bone, right? And so you can either be bone born with that bone angled slightly down, you can have irritation, you can be throwing too much, right? Repetitive motion. And believe it or not, tendons like nerves as they become irritated, oftentimes they'll get thicker, not smaller. So if you have a limited space, exactly, they start to swell and get inflamed, right? And you get bursitis. But if that tendon is trying to slide through this limited space and now you're trying to fit a bigger tendon through a limited space, what's happening now you've got a mechanical abrasion, right? Or a mechanical scrubbing type mechanism. And so now that bursa, if it doesn't dam, eventually damages the tendon, cuts the tendon and or, and it can tear and you can get a rotator cuff tear. But most of those start with bursitis. Remember our tiny little fluid layer, and it's very obvious on ultrasound. And that's the cool thing is that if you saw say an injection being done on ultrasound, it's a tiny little one millimeter space. The ultrasound allows you to not miss that space and go, oh, there's the earths up there. And then you drive that needle right in. And so you fill the medicine inside the bura boom, it calms it down. And then with proper physical therapy, meaning, hey, sometimes if they've got a downsloping acromium, I don't want them doing Y and Ts, right? Right. I want them to doing external internal rotation exercises. Right? And then so you can look on ultrasound. Do they have a thickened tendon or is it just a downsloping? Is there other, is there cortical irregularities? Is there something else wrong with a tendon? Right? And so I can put medicine in whichever space is needed and then teach them about activities. Hey, you really don't want to have to buy that, that cuff repair at your age. Let's try to avoid doing a hundred dishes at that top and get your husband to do that, right? Yeah. Or you know, so yeah,

- Lifestyle changes. Absolutely.

- Lifestyle changes, ergonomics. And then, and you can make that recommendation by seeing the anatomy in in the visit.

- Yeah. Right. She always would joke because she said it was a sports injury, so she said she was very athletic. Yeah. But that's, I don't know that issue was, but

- This has just been so interesting. I know it's fascinat, I feel like we could go on and on and on, but

- Unfortunately we do have to wrap it up

- Unfortunately.

- But, but we can have you back on later. Yes. We can have you back on. Oh, thank you. Of

- Course. We will have to. So if someone wants to come see you, do they need a referral from their primary care? Can they just make an appointment with

- You? Some insurances can come straight in and then other insurance like Tricare and VA and certain one do need a referral. And so they can call our main line and then, and then our, our staff can walk you right through it. Okay,

- Cool. Yeah. And we'll just probably put that in the description where people can contact your office. That'd be good. So people can find that. But I do have one last question. Sure, sure. Which is not a serious question at all, but we always like to ask, since our doc spend so much time here, what's your favorite meal in our cafeteria? And we

- See you in the cafeteria regularly. So I

- I I am spoiled by our cafeteria. Those ladies are amazing. They are. And, and they take good care of our, our people, right? They're amazing. They do a fantastic job with their, their curry dishes and their salmon. I see there's love salmon. There's two or three different salmon dishes that they knock it outta the park. And I honestly, sometimes I go back to my office all the way over to a SC and, and I'm sitting there and I, I'm like, I've got to walk back over and tell them how good this is. Yeah. Because they, they do a great job.

- Well I think they'll appreciate that because they get a lot of compliments when we ask that question. So

- Yes. Yes. They do a great job. So.

- Well, thank you so much for having me. I appreciate it.

- Yes,

- Thank you. Thank you for coming on. I knew it was gonna be interesting 'cause I have held you hostage in the cafeteria a few times to ask for some free medical advice. But we do encourage office visits or you can listen to the podcast and learn more. So thank you for joining us and thank everybody for listening.

- Thank you. Thank you.