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 your x-rays you don't see any bony pathology and course well reduced but here you see you know evidence of an of some capsular laxity even a haggle here an ALPSA here on her axial imaging and even Hill Sachs 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 a ability to MRI three-dimensional like an MRI situation we don't need to 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 a hundred and seventy 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 you know 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 and the heart rate drops into the like the 40s 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 a 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 you know situation and so I went out to talk with the family so you know I think in these situations where something really bad is happening like this that's you got to be thinking keep it together and you got to go out and talk to the family and I can't even tell them how this is gonna really go right because I don't know at the time so you know as a family that had about like for some reason like ten people were there at the surgery center I'm still not sure why that was at the time but 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 you know be gathered and given the information but I basically told him we don't know what's going on she's gonna get transported the hospital the CCU we're gonna try to make sure you know that she does okay but at this point I can't promise you anything so she and I stabilized a little bit went across the street to our main hospital and then she really you know fortunately started you know coming around here and so at this point nobody you know really CCU too nobody really knew what was going on but at the end of it if you look in the yellow basically our cardiologist 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 an IV probably direct IV administration of epi is 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 want to like 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 going to 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 like totally normal by the time she was discharged two days later and so you know again there they just basically assume this is a catecholamine overload anesthesia said maybe you know she's got some kind of inherent problem or she's got some kind of adrenal tumor I said probably not guys you know it may be some other cause anyway so there were potential causes here these are the cause epinephrine that she would have you know received potentially including the last one the possible because catoral lack and the epi bottles look really similar even the color caps are just slightly different apparently at the time and so again that like even in our own like literature about arthroscopic issues you can you know kind of see so in this case it was only epi in the bag and so what it 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 like 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 and surprisingly can cause a problem so I we've encouraged our nurses to at least oscillate or shake the bags of arthroscopic fluid 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 you know there's some similar some lessons you know we all you know 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 especially 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 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 you this ever like crosses your mind understand you're saying beta blockers the wrong thing to do because it just interferes with the alpha adrenergic system if in if you're blocking up doing using a beta blocker I think that's something just to you know like think about even if you you know don't you know really know all about that just if you see that situation the OR making sure anesthesia is kind of aware generally that there is 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 you know now 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 functions fine and they cleared her for sir for repeat surgery saying avoid epinephrine I was like really I will probably do that thanks for the advice and don't give her a period 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 you know mostly because their daughter here had this MI but also they're very suspicious and 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 you know 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 X 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 but that relationship is so important so you got to own the complication and I admitted that we made a mistake as a health care team and even though I didn't know for sure I admitted the error forever for sure and and Matt brought this up about like don't avoid press in when you're feeling like you know like nervous about being in there so not only did I sit down with the family but I also visited the patient or family in the hospital like twice a day when she was in the CCU and listened and mostly just listened because they were upset angry updated them as much as I possibly could always got an update for him and just offered help and whatever that way this family was quite religious and so I got you know our chaplain of the hospital to see him and you know we showed them where the hospital chapel was and all this and you know 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 when 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 want to take care of you and correct this problem you know I'm committed to seeing this through for you I hate this happen 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 want to see you anymore that they're upset enough with you that they want to 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 want to 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 that'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 have 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 would you know is 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 heard her other shoulder a couple years later she came to see me where she could have gone anywhere we got a great health care in a 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 to the patients believe you don't intend to cause them harm and you stay engaged they're less likely to go elsewhere or consider litigation so you know hopefully that difficult story is 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 those of you that do shoulders to 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 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 and you can see this gigantic hill sacks 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 a an arthroscopic repair of his anterior labrum actually because I did a bone graft of his hill sacks and you know 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 are 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 you know this a latter Jay and some capsule or a fee 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 letter J 24 hours ago and here he is look at the hill sacks there on the recurrent hill sacks and 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 you know 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 osteochondral our 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 osteochondral 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 to like the fluid shifts the loss of blood all those things lower that's 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 J again because I think if the patient seizes again they destroy their coracoid 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 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 they're 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 as a long time ago I did that though and so make sure seizure control is is great consider that hospital admission I talked about the latter J 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 going to be fine because it may not be fine and be ready to revise so have a plan have a plan that's why we did a latter J you can't revise you can revise it but they've 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 because we've got if that's okay Matt in the interest of time I wanted to get our other speakers up here and we can answer some questions at the end

shoulder surgery complications

case studies

instability

complications

communication with patients