Our orthopods have done a marvelous job of marketing the total joint arthroplasty as the be all and end all of orthopedic care. While all kinds of surgical procedures and for that matter medical treatments and diagnostic procedures have wait lists in Canada they have managed to convince governments that their procedures merited special attention. I am not crapping on the total joints, if I need one, I sure hope I get one in a timely fashion and as an anaesthesiologist I love what is for the most part good mindless work. I just am curious about the attention paid to something which is really only a part of the care for osteoarthritis.
This post was inspired by my visit to the new Orthopedic Surgery Centre which is separate from the adjacent Big Downtown Hospital (BDH) but tethered to it by a walkway. The idea was that all our region's total joints would be done Monday thru Friday, uninterrupted by emergencies, no infectious patients to spread their germs and no internal medicine patients spilling over onto surgical beds. Our hospital has so far managed to hang on to its share of total joints and so I decided to see what the competition was.
I arranged to be met in the spacious foyer at 0800. As usual I arrived early. You would have no idea you are in a hospital, there are laminate floors and oddly retro furniture to sit in. (The other reason you don't think you are in a hospital is that there are no smokers clustered around the door holding their IV poles. )
Upstairs to the ORs where the head nurse took me there was spacious receiving area and recovery room as a single large space. The OR's were large and had modern equipment. Because it was designed by surgeons, there were no induction or block rooms, so the surgeons won't have worry about pesky block happy anaesthesiologists slowing their room. There are 4 rooms with only 3 open .
Upstairs there were more laminate floors and the rooms which I got to look at from the door way were large and had comfortable furniture for the visitors. I can't help but wonder what that laminate flooring is going to look like after a year of stretchers, walkers and general foot traffic.
Of course ASA 3 and 4 patients and the revision horrendomas will still be done in the main hospital to which the OSC is tethered. I can't think of the last total joint I saw who wasn't ASA 3 but maybe that's because they are all being done elsewhere. Another example of cream-skimming but at least in the case the cream is staying in the public system. Also because they never bothered to ask urology, when the nurses can't catheterize the patient, they have to cancel the case.
The preassessment process is done on another site as are the follow-ups which makes no sense if you are going to build a completely new building but of course you have to remember it was designed by and for surgeons.
One thing I have learned by working in chronic pain and by having older parents is that total joints are great except when you are either too young to have one yet or too old and sick (although ortho keeps on pushing the envelope on old and sick). There is a tendency to just throw one's arms up in the air when you just can't fix things by sawing out bad bone and gluing in metal and plastic. Also with so much attention paid to two procedures, other less sexy orthopedic procedures are sure to languish.
The other thing I have learned as operating time for total joints has increased in the time I have practised is that as more time is freed up, the indications creep. I mentioned older and sicker patients above. At our site we do a lot of patients whose mobility is as restricted by their COPD or CHF as it is be their arthritic joint. At the other end of the spectrum we see people who really don't seem to that bothered by their arthritic hip. We are doing younger and younger patients now, which means the innevitable revision.
As a taxpayer, I can't help but wonder if we needed a new building to accomplish this improvement in total joint arthroplasty care. One of the three rooms at the new hospital does total joints that were formerly done at another hospital which means a room is now empty at that hospital. The other two come from the BDH which essentially means the closure of two rooms there. I suspect some administrator is already looking at the total joints done at our hospital and soon we may have some vacant OR time. I am only the Site Leader for anaesthesia, no need to let me in on this.
But what happens if other specialties demand their own separate hospital. Cardiac surgery already has their own. Why not a hospital for laparoscopic cholies, one for hernias etc the list could go on. Are we going to see the general hospital become a thing of the past, or a just a dumping ground for stuff that can't be safely outsourced to a fancy new building?
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