Okay, so nothing to disclose for a complications talk. So here's my case one. It's just a labor repair. What could go wrong? And wanted to emphasize the doctor-patient relationship in this one. And so this is my complication. This is not an ideal situation. So this is a otherwise pretty healthy young woman was playing flag football, had a subluxation, went on a few years later, four years later, she was moving a bed, headboard, like fell on her arm, subluxating inferiorly, and now she's developed popping and catching, and she's had some general, a little bit of instability anyway, and now it's worse with popping and catching. 26 years old, but has hyperlipidemia, familial. And you can see some history here, is on exogenous estrogens, but otherwise really nothing of importance there. And so on physical exam, you can see, you know, pretty normal situation, some tenderness, but apprehension, abduction, external rotation, and some translation on load and shift in the clinic, but normal strength. Here you can see her x-rays. You don't see any bony pathology, and of course, well-reduced. But here you see, you know, evidence of some capsular laxity, even a haggle here, an ALPSA here on her, axial imaging, and even hill sacs, a bit of a fracture there with bone edema. And so, you know, kind of looking at getting some additional imaging here. This is from a journal article, but basically getting a 3D, we have like ability to do MRI, three-dimensional, like an MRI situation where you don't need a CT, but in the event, really is an on-track lesion here. And so she's a young woman. I thought an arthroscopic labor repair, she's not such high demand. This will be slam dunk, maybe a haggle repair. And so you can kind of just see doing the surgery, and I've highlighted doing the block. They give her a little bit of epinephrine, but quite diluted there. And then we get into the case. And so we're letting it operating starting at 751. Six minutes later, the anesthesiologist is screaming in the room, stop, stop, stop. Something's really wrong. And I look, you know, sort of basically look over the drapes. And I know it's probably, I don't know if I have a pointer here. I guess I can't, because the things over there, I'll try to use the arrow here to see if I can show it. But anyway, if you look here is the patient's blood pressure is, and this isn't even showing the worst of it, but her blood pressure is like 240 over 120, 26 years old. And her heart rate is off the chart, like it's 170 something. And the, you know, so the anesthesiologist having a fit or the CRNA anyway, calls in the anesthesiologist and comes in and nobody's sure what's going on, but this isn't breaking. Like they decided to start giving drugs, but they're having a hard time breaking this extremely high blood pressure and heart rate. And then finally they're able to give some drug that gives them Esmolol. And all of a sudden, then the heart rate drops into the like the forties and now her blood pressure, they can barely maintain it. And all this is going down and we're six minutes into a scope for a labor repair, have done basically nothing yet. And so this is not going well. So she goes, they take her to recovery room, still working on trying to resuscitate her and get her heart rate back up by now giving her epinephrine. And so this is a situation, now she's gone to recovery room and she's about to go over to, she starts like they get EKG and she's got ST depression eventually in all leads. She's definitely having an MI. And so I'm discovering this information and now I've got to handle this situation. So we talked about like keeping your cool. It's a little bit harder to keep your cool when you think your patient's gonna die in the OR at age 26 of an MI and you don't really understand what's going on and it's not really even a surgical situation. And so I went out to talk with the family. So I think in these situations where something really bad is happening like this, that's you gotta be thinking, keep it together and you gotta go out and talk to the family. And I can't even tell them how this is gonna really go, because I don't know at the time. So it was a family that had about, like for some reason like 10 people were there at the surgery center. I'm still not sure why that was at the time, so I had to gather them in a room and tell them what was happening. And as you can imagine, that didn't go so well for the family. Of course, they're appreciative to be gathered and given the information, but I basically told them we don't know what's going on. She's gonna get transported to the hospital, the CCU, and we're gonna try to make sure that she does okay. But at this point, I can't promise you anything. So she stabilized a little bit, went across the street to our main hospital. And then she really fortunately started coming around here. And so at this point, nobody really, CCU too, nobody really knew what was going on. But at the end of it, if you look in the yellow, basically our cardiologists felt like something happened in our case with epinephrine, and they don't know whether it was an IV-like injection, as though anesthesia might have mistaken a bottle of something. And probably direct IV administration of epi I think is what happened, by the way, but nobody will admit to it. At the end, I think they blamed us for the arthroscopic bags of fluid that have dilute epinephrine, said that that's what caused it, by the way, which was also neat, dealing with that with the family. And I'll show you, there is some evidence in literature that that can happen, by the way. That's why I wanna share this case, because not only, we all do use some epinephrine, potentially in bags, around skin wheels. And if you think that can't happen, it's been reported in literature, a little skin wheel can cause this very problem. And if you give the wrong drug to treat the tachycardia and the blood pressure, you'll kill the patient frequently. So I'm gonna just go over that a little bit. So anyway, she stayed for two days in the hospital. She ruled in for MI, but things improved. And the clitoral echo ended up looking totally normal by the time she was discharged two days later. And so, again, they just basically assumed this is a catecholamine overload. Anesthesia said maybe she's got some kind of inherent problem, or she's got some kind of adrenal tumor, and I said, probably not, guys. It may be some other cause. Anyway, so there were potential causes here. These are the epinephrine that she would have received, potentially, including the last one, the possible, because clitoral lac and the epi bottles look really similar. Even the color caps are just slightly different, apparently, at the time. And so, again, even in our own literature, about arthroscopic issues, you can kind of see. So in this case, it was only epi in the bag. And so, what was kind of determined in this case and several others, if you don't, when you administer epi in a bag, and you don't shake the arthroscopic bag, it settles in the bottom, and they can get a bolus. And if you've got raw exposed bone, like in a lesion or something, it can go right into the bloodstream, and surprisingly, can cause a problem. So we've encouraged our nurses to at least oscillate or shake the bags of arthroscopic fluids. So there's several case reports here. This is another one. And this is another one with an ACL. And if you give a drug like Esmolol, which was given in our case, frequently, they'll go into rapid pulmonary edema, and you can kill the patient. So there's some lessons. Many of us, I use epi in arthroscopic irrigation. It clearly can improve visualization. It's been shown in a number of studies that that does help, it's just usually a dilute amount. But the big error in judgment here was managing what was almost definitely an epi-induced tachycardia and hypertension. Giving a beta blocker during that situation will frequently kill the patient. And so it's something that, it's not something that we would tend to know about in orthopedic surgery, nor do we manage it at the time. But if you ever run into a situation like that, and this ever crosses your mind, understand you're saying beta blocker's the wrong thing to do, because it just interferes with the alpha adrenergic system if you're using a beta blocker. I think that's something just to think about, even if you don't really know all about that, just if you see that situation, the OR, making sure anesthesia's kind of aware, generally, that there's certain drugs that shouldn't be given. We also, as a system error, had to take the epinephrine bottles out of the OR and cover them with foil and make them syringes so no one could mistakenly in the dark pull out the wrong drug again. And so now what do you do? So now she comes back and it's now, she sees the cardiologist, everything looks normal. She's really like, her heart function's fine. And they cleared her for repeat surgery saying avoid epinephrine. I was like, really? Yeah, we'll probably do that. Thanks for the advice. And don't give her a peri-op beta blocker again. Thanks again. So she's come back to the office a couple times now because we did do a scope. So she had incisions, took out sutures. And the family is really upset, mostly because their daughter here had this MI. But also they're very suspicious. And part of that is because no one along the way has been able to tell them how this happened. And I think, truly, I don't know how it happened. And my assumption is still that anesthesia caused that. But I think it's really important not to throw people under the bus when you can't prove something. And I think people should take responsibility when they know what happened. But here, I didn't know. And I told them repeatedly, I think it could be these four things. Either way, I think we gave your daughter some, got epinephrine into her bloodstream and it caused the problem. But they're very suspicious. She needs surgery. Like, she is a young lady. And I think she's clicking, popping, unstable, and needs surgery. So now what? And so this is where the patient and doctor relationship, and notice I put patient-doctor, not doctor-patient. That relationship is so important. So you gotta own the complication. And I admitted that we made a mistake as a healthcare team. And even though I didn't know for sure, I admitted the error for sure. And Matt brought this up about don't avoid. Press in when you're feeling nervous about being there. So not only did I sit down with the family, but I also visited the patient or family in the hospital twice a day when she was in the CCU and listened. So mostly just listened, because they were upset, angry. Updated them as much as I possibly could. Always got an update for them and just offered help in whatever that way. This family was quite religious. And so I got our chaplain of the hospital to see him and showed them where the hospital chapel was and all this. And just basically was there and didn't avoid dealing with it. And that creates a lot of trust in the end when you're, you know, I didn't run away from this. I took my time to go visit constantly, which was totally appropriate. But I think we sometimes avoid those things. And then what about scheduling another surgery in your patient when they've had a complication? That's tough, especially something like this. Do they really trust you? And, you know, what I emphasize to them is I wanna take care of you and correct this problem. You know, I'm committed to seeing this through for you. I hate this happened to you, but I'm committed to helping you. Acknowledge that they might be uncomfortable working with you when you've had a complication because they may have lost that trust or something. And actually it can be hard for them amazingly. It's hard for them to tell you that they don't wanna see you anymore, that they're upset enough with you that they wanna go somewhere else. So open the door and tell them that's okay. I understand you might be uncomfortable. And then state that, you know, they might wanna get a second opinion. I do this all the time. If I've had a complication, I say like, you know, I wouldn't blame you if you wanted to get a second opinion, but please let me help you. Like you see the best person. And I often will, if I feel like it's really a system problem where they're upset with even the institution, I'll say, let me send you to a trusted colleague in town or somewhere else. And let me set it up for you so they see you quickly and they know your situation. And that shows a willingness to help and not abandon. So offering to help set something up really, I think helps. And I'm not doing it for medical legal reasons, but I'm sure that that helps by showing engagement and you're not abandoning. So the end of the story, she does choose to see me, which I, you know, was grateful to get the chance to take care of her. We're able to get that done. And she's able to, you know, progress back. Cardiology saw her repeatedly for a few years, made sure she was fine. Everything ended up being normal. And I think the best testament to her trusting was that when she hurt her other shoulder, a couple of years later, she came to see me, where she could have gone anywhere. We got a great healthcare group in our area. So, you know, I think that handling this and being there for the patient with the complication and all those things I think really helped. And I think as it relates to medical legal too, if the patients believe you don't intend to cause them harm when you stay engaged, they're less likely to go elsewhere or consider litigation. So, you know, hopefully that difficult story is helpful. And so I'll present it like a little bit more of a surgical case here. And this is with instability and seizure disorders. So for those of you that do shoulders and take care of seizures, you'll know that there's a lot of problems that can occur. And so this is a young man with very poorly controlled epilepsy, despite some really great doctors working with him in neurology. And so, you know, when I first met him, I'd already fixed his other shoulder that did very well, but here he comes in with this MRI in January of 15. And you can see this gigantic hill sacs and the anterior labrum is somewhere like a mile away from the glenoid there and an alpsa and looks really poor. So I ended up doing an arthroscopic repair of his anterior labrum actually, because I did a bone graft of his hill sacs. And we made sure he had really good seizure control, I thought, but then three months later, he dislocated again, he just destroyed the bone graft, the labrum is nowhere to be found again. And so I said, so I had to learn an important lesson. You can also see what he did here. He knocked off like 50% of it. Well, not quite 50%, but a lot of his glenoid. And so something that in terms of managing complications, something I've learned a lot more with seizure patients, especially if it's not like extremely well controlled, it's really something thinking about bony work may be important earlier in these patients and certainly arthroscopic may not be a great way to go. But anyway, I decided to do a Latter Jay, which I also will tell you, I think is not necessarily a good idea in a patient with seizure problems. And so perform this surgery, did a Latter Jay and some capsulography there. And we had him stay overnight and Pete's neurology really jacked up his meds. We said, there's no way he's gonna have a seizure, but then 24 hours later, total disaster. So here's a Latter Jay and now look at that and what you can't appreciate yet, you see the broken screw, you see the head is really out. See that what you can't appreciate is the coracoid piece now is fractured in half. So totally useless. So we just did a Latter Jay 24 hours ago and here he is, look at the hill sacks there on the recurrent hill sacks. So now what? And the patient and especially the parents were just distraught. They said like, what is wrong with you people? You can't like seem to even stop these seizures. And we did this big surgery and you promised it was gonna be fine. Now look at all this, now what do we do? So this is what I ended up doing was a huge distal tibia allograft for the glenoid, like at least 50% of the glenoid had to replace and also did a large allograft for the hill sacks defect. Now this time, the other thing I've learned is I admitted the patient for about five days and had neurology snow him almost unconscious for five days so that he couldn't dislocate. But really just kind of kept an eye on him. I think that the thing you have to realize is the, and I think most people probably know this, but people with seizure disorders, the stress of surgery and that's physiologic stress too, like the fluid shifts, the loss of blood, all those things lower the seizure threshold quite a bit. So keeping him in house, letting like the pediatric neurology team really work hard with him on the meds and all, I think it was just probably more worth keeping those people a couple of days when you're concerned and also just addressing everything with bone work. And I won't use a, I won't do a Latter Jay again because I think if the patient seizes again, they destroy their coracoid and now they don't even have that biceps. Now they don't have, I mean, I think you're really, that was really a shame. The patient sort of lost that I probably should have used a distal tibia and that's what I'll do in the future. There, so something to learn from for sure. And so here you can see him now three months post-op and he's got like a really big glenoid there, good coverage and that hill sax is filled in. You know, you can certainly argue with using some absorbable screws or some other way or headless to fix that, which I probably would have at the time. It was a long time ago I did that though. And so make sure seizure control is great. Consider that hospital admission. I talked about the Latter Jay, less reliance on soft tissue procedure with these folks, less reliance on soft tissue procedure with these folks and be clear with patients and families about potential complications. Do not like promise everything's gonna be fine because it may not be fine and be ready to revise. So have a plan. That's why we did a Latter Jay. You can't revise, you can revise it, but then they've lost that coracoid and lost something for sure. So with that, I'll end. And I think in the interest of time, cause we've got, if that's okay, Matt, in the interest of time, I wanted to get our other speakers up here and maybe we can answer some questions at the end. Do you wanna do the recording?

shoulder surgeries

complications

arthroscopic labral repair

high blood pressure

heart attack