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MedConference 2009

Why do we take care of others?

Changing medical practice.
I practice orthopaedic surgery, and I am specialised in shoulder surgery, especially
arthroscopic surgery, working in a private clinic in Montreal, Canada.
For those of you who are not familiar with arthroscopy, I will describe it as a minimally
invasive technique in which we perform tiny keyholes incisions, and introduce a camera
inside the joints as well as small diameters instruments in order to repair damaged
structures. It is a rather recent technology and most of the procedures I perform today did
not even exist fifteen years ago when I finished my training. That is to say that we are
dealing now with a brand new chapter in the history of shoulder surgery, and much, much
needs to be either discovered or developed in this field.
It is my intention today to discuss with you about some of my recent works involved with
technological advancement in shoulder arthroscopy. The data I present will be published in
the September issue of the Journal of Shoulder and Elbow Surgery, but I shall focus more on
the methodology of this work, rather than on the results themselves.
In order to discuss about the root of this study, I would have to address right away to my
clinical work experience as the point of departure was a clinical challenge, introduced by
some patients who were asking for a medical solution to their problem. Precisely I was
faced with a really bad combination of two relatively incompatible serious pathologies, one
being orthopaedic (a massive size rotator cuff tear), the other being medical (advanced
COPD). In order to highlight the methodology I was referring to earlier, I shall use two real
cases using fictional names: Marguerite and Suzanne.
I will start with the story of Marguerite since she was the first clinical case that initiated the
whole work. This lady was in her seventies. She had sustained a fall on an icy sidewalk of
Montreal during the winter of 2007. The fall resulted in a massive rotator cuff tear, which
besides causing a constant pain, resulted also in a very important weakness of the right
upper extremity. The whole rotator cuff tendon was avulsed from the bone (greater
tuberosity of the humerus). MRI confirmed the diagnosis. Considering that her severe
COPD was a contraindication to a surgical approach, she was referred to physiotherapy,
and given pain killers to try to restore some function and ease the pain. Unfortunately,
many months of these treatments did not bring any benefit. On the opposite, the pain got
worse, and she was not getting any function back to her right arm (she was right handed).
On top of that, the only really efficient pain killer medication for her was Dilaudid
(Hydromorphone), which needed unfortunately to be stopped, because it was causing her
dizziness, and putting her at risk of respiratory failure.
She had seek for a surgical opinion to two of my colleagues orthopaedic surgeons, who both
recommended a non-surgical approach, arguing that the severity of her lung problem put
her at high risk for anaesthesia, would that be general anaesthesia or regional nerve block.
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Both of my colleagues affirmed that it was not reasonable to perform an elective surgery
involving such a high risk of respiratory dysfunction or arrest.
At this point some of you may ask: “Why not a regional or inter-scalene block for such a
case”? The answer lies in the anatomy of the brachial plexus. The only nerve block that is
efficient to perform shoulder surgery without general anaesthesia is the inter-scalene block.
Unfortunately, when performing such a regional block, the phrenic nerve, which lies next to
that area will also necessarily be blocked, causing a paralysis of the ipsilateral diaphragm.
For a normal person the paralysis of the hemi-diaphragm would not be of any clinical
significance. But for Marguerite with severe COPD, it would likely cause respiratory
insufficiency. So clearly the combination of a rotator cuff surgery repair for such patients is
a medical challenge.
When Marguerite explained me her situation, expressing her distress, I thought that my two
colleagues were probably right and that they were honest and professional when refusing to
perform elective surgery to the right shoulder. But at the same time I was shocked and
moved by the fact that for such a banal injury, one would be confronted to the alternative
between suffering constant pain or even risking respiratory arrest (and death) taking strong
pain killers. So when Marguerite finally asked me for my opinion hoping I would “give a
try” for the surgery, I did not find the nerves to say no, nor the insanity to say yes. Instead I
proposed her a local injection of Cortisone mixed with Xylocaïne and Marcaïne, and asked
her to come back the next month saying I needed time to explore the possibilities; which I
did for real. That gave me time to consult two anaesthetists, to discuss with them the
possibility of anaesthesia and its objective contraindication. The answer again form them
was a big yes for the dangers, and “no way” for a possible try of surgery.
Parallel to that, I also did a deep literature research about alternatives. Among these
alternatives, I was interested in knowing if this kind of surgery had been tried before
without regional block or general anaesthesia (that is to say with only local Xylocaïne
injection). The only thing I found in the literature was an article about a shoulder
arthroscopy done by a team from Israel, performing acromioplasty. It is a rather simple
procedure as compared to a massive rotator cuff tear repair. Unfortunately nothing was
found about the later under local anaesthesia.
Also, an older colleague of mine from Montreal revealed me that he once tried to perform a
shoulder arthroscopy under local anaesthesia alone, adding that it was probably one of the
worst days of his life (that is to say that no pain control was achieved).
When Marguerite showed up for the next appointment, she told me that there was a real
relief after the Cortisone injection I gave her; but, that lasted only for a couple of weeks. So
I proposed her a second injection, letting her know that I had not reached a definitive
decision about her request for “trying a surgery”. In the mean time I had the opportunity to
discuss further with her about all the humane impacts of her disability, the constant pain,
the lack of sleep, and the fact that she was loosing autonomy.
So I could measure all the magnitude of this medical problem on her life, which gave me
even more motivation to go further in order to find a way to perform surgery in a safe
fashion.
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At her third visit, she revealed me that the second injection provided also relief but did not
last more then one week. So clearly Cortisone injection was not the solution. At that point I
revealed her that doing a rotator cuff repair under local anaesthesia alone had never been
reported, letting her know also about my older colleague’s experience in the past. She
answered back to me “Doctor right after you injected my shoulder, I did not feel pain at all
for many hours, and I felt great”. I answered back “You mean that you believe that it would
be sufficient to let me introduce my instruments and try to fix your tendon”. To which she
answered “Please try it Doctor, I have full trust in you”.
I thought this affirmation was so reasonable, that I could not refuse it. I managed to
convince my regular anaesthetist to be present during the surgery, in order to monitor the
patient and provide some sedation. At first my colleague was extremely reluctant at the
idea. But since we have year long history of collaboration, as well as a reciprocal esteem, he
finally agreed to participate to the experience.
The day of the surgery, I did every single thing the same way as for the other arthroscopic
rotator cuff repairs I perform. But instead of general anaesthesia or inter-scalene block, I
simply injected a mixture of Marcaïne and Xylocaïne in the sub-acromial space and at the
site of the skin portals I use to introduce the instruments. Five to ten minutes after the
injection, the whole shoulder was totally pain-free and I could do two short incisions,
introduce the instruments (the arthroscope from the back portal and the instruments to
proceed to the repair from the lateral portal). To our surprise, the pain control was total,
and I could dissect the soft tissues very far in the subacromial space, cutting through scar
tissue and pulling on the muscles. I could drill into the humeral bone, and implant the
suture-anchors (metal implants loaded with sutures that are introduced as screws into the
bone). This being done, the sutures were passed through the tendons, and then knots were
pushed from the outside to the inside. This allowed traction to the tendons and the muscles,
and bringing the tendons back in contact with the bleeding bone of origin, promoting new
scar tissue, and ultimately healing.
The initial “deal” with Marguerite was to start the procedure, and to go as far as we could,
providing pain would be under control. To our wonder, as I said, we have achieved full pain
control for the whole procedure, and have been able to proceed to the complete rotator cuff
reconstruction, using a total of three anchors. During the procedure Marguerite did not
experience any pain, and she could be discharged from the clinic two hours after the
surgery. The duration of the surgery was an hour and twenty minutes. There was no
complication whatsoever in the post op period. The final clinical outcome was very good,
Marguerite did not need any pain killer after the surgery, and she recovered most of her
range of motion and strength to her right shoulder in the months after the surgery. She is
now extremely satisfied and grateful, having recovered normal use of her right upper
extremity, and a normal sleep.
A few months after this first attempt, we have been faced to a similar case involving another
woman with a severe COPD with a massive rotator cuff tear. That second lady was a person
who had already been a patient of mine in my early career. Back in 1996, I had performed
for her an “opened” (i.e. not arthroscopic…) acromioplasty on the left shoulder. She had a
very good clinical result, and I lost her in the follow-up. That lady (we will call Suzanne),
had an artistic temper, and she had been involved in many artistic activities in the past. She
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was also a very heavy smoker, which resulted over the years into the very severe COPD she
was suffering of.
When she came to me for the first consult in 2008, she explained that about twelve months
earlier she sustained a fall on the ice which resulted in massive rotator cuff tear of her right
shoulder. Similar to Marguerite, she had obtained opinions from some of my colleagues
and she was refused surgical repair because of her COPD. But unlike Marguerite she was
not experiencing severe pain, and did not need strong medication. Her problem was rather
functional, since she had a very important weakness of her right arm that impeded her from
doing her favourite activity: playing violin. So her main complain was that she was no
longer able to play music, an activity she was doing 2-3 hours a day before falling. Speaking
with her in order to find out why was it so important for her to play music, I got to
understand that on top of all her medical problems, she was also in a situation of rather
deep loneliness. She helped me understand that music (especially playing music) was the
most beautiful thing in her life. At the end of the consultation, I let her know about the
experience I had with Marguerite. So, of course, she begged me to try the same for herself.
A request to which I agreed.
Again for Suzanne everything went very well during the surgery and we could perform a full
rotator cuff repair under local anaesthesia.
Many months after the surgery, she showed up at my office with her violin. She was able to
play for me and for the staff at my clinic.
About six months after the surgery, she could play more than two hours a day of violin
again. As she said: “I can now frequent my friends Mozart and Schubert again!”
As she was thanking me, I told her that she should thank also Marguerite who had been the
spark that enabled us to perform such a procedure.
Subsequently, we offered the same technique to other patients who presented more or less
the same clinical situation. So far I have proceeded to this technique for nine patients, and
we have produced a paper after the first four.
Discussion:
Looking back at the steps involved in the development of this new technique, and
considering the vary daring decision we took when we tried it the first time, we find some
interesting methodological features.
First, as I said before, the credit for the innovation belongs as much to Marguerite as it does
to us. Indeed, it is the human demand from the patient that became a provocation for the
surgeon, within a simple human relationship. To word it differently, it was a journey in
which both the patient and the surgeon were willing to go in that led to this medical
innovation.
This fact helped in avoiding two traps that tend to paralyse creativity: the risk of favouring
preconception, and the unreasonable attachment to “what is already known”. Rather, the
methodology here was surprisingly dictated by the objective data, the objective situation.
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The second aspect which is more or less a corollary to the first was that the surgeon (that is
myself…) was receptive, open to this input. In other words I allowed myself to be moved by
Marguerite and Suzanne’s presences and situations, and that generated a work of
knowledge. The work of knowledge here included the work of knowing what was already
existent, as much as being opened to creativity, which is “new knowledge”.
It is my opinion that what we are talking about here has little to do with some of the
concepts we are familiar with: Professionalism, empathy, sympathy, etc … I personally
think that the application of these concepts would not have been enough, not being
sufficient to end up with a risk for innovation. When I look retrospectively at the
methodology that was involved in this experience, the emerging factor that was
determinant, I think, was a full human relationship between the patient and the physician.
When I say full, I mean above all a way to look at, a gaze, full of wonder: a deep interest in
the destiny of the person.
One could interpret this “human gaze” as openness to the sacrality of the person, as I dare
to do. Just as I am willing to trace back the origin of my interest for the sacrality of the
person. People-my friends- have taught it to me, and are still teaching it to me (people such
as my friend Dr. Mark Basik, my wife Caroline, and of course Father Giussani, the founder
of Communion and Liberation, a movement in the Catholic Church). It is the transmission
and the education of a gaze.
To quote Dante, these friends are helping me to claim: “I can see in your eyes that I am
loved of an eternal love”. This is the experience I wish for my patients, to be able to claim
the same thing.
This is the methodology we propose: charity, which is known for centuries, and still shows
its relevance today, even when involved with very cutting edge technological innovation!
Thank you.
Marc Beauchamp