My experience watching a reconstructive ACL surgery (understanding why healthcare is expensive)

Posted on March 14, 2016

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I recently got to go into an operating room and watch a reconstructive ACL surgery, with a partial medial meniscectomy.

I’ve had both of these procedures done to myself (here and here). One unexpected positive of me having this done to myself was being able to parlay that into getting into the same surgery group’s operating room. After seeing them so much (the follow up for an ACL is about 9 months), it wasn’t too hard to convince them to let me observe one!

Waiting in the lounge

After changing, I spent about 30 minutes waiting for the surgeon to arrive and another 30 before getting into the operating room. (I got there pretty early.) It was amusing how, other than everyone being in scrubs, I swear I could have been in a Walmart employee lounge.

  • One woman was on her phone looking at boots
  • A guy had his headphones on the entire time and kept to himself
  • Entertainment Weekly and People Magazine was right next to me
  • The fridge had whipped cream and champagne in it
  • There was a suggestion box
  • A bunch of raggedy sneakers were being worn
  • It was an appreciation week (for peri-operative nurses)
  • A couple women were giggling somewhat secretly. Looked like gossiping.
  • One person comes in, “Whewwww, I am soooo late.”
  • Every person pulled out a smartphone at one point. Except for me. I wasn’t even sure you could bring it back, so I left mine in the lockers.
  • I saw one guy had a Bucknell lanyard on. I went to a school in the same conference. I talked to him some about that, we then talked about sports. At one point he was talking to someone, “Ah, I forget what it’s called. That thing that cleans the ice.” “Zamboni?” “That’s it!” These were two surgeons talking to one another.
  • There were probably three signs within 15 feet dedicated to reminding people to wash their hands.
  • One woman said to a guy, “Did you see the peanut butter and jelly sandwiches? I made sure they brought them.” You then realize this guy, wanting the PB & J, was the surgeon!

I was fairly surprised by this. Granted, I’ve never been in this environment, but I was in there with a notepad, thinking of things to come with the surgery. Prepping if you will. I figured that’s what everybody else would be doing too. Or something similar.

A lot of times we treat those who work in the medical establishment as something disparate from the rest of us. The above list hopefully humanizes them to some degree. They’re really not that different. Perhaps in a few ways- maybe a bit more intelligence, an ability to stick with something for a very long time, but for the most part, these are regular people.

Many of us, myself included, harp on the at times “this isn’t good enough” aspect of the healthcare system. But I think we sometimes forget these are largely people doing a job like everybody else. Like any job, there will be a continuum of ability and commitment levels. Not everyone is an A player, not everyone is a perfectionist, not everyone is obsessed with their performance, not everyone avoids hobbies because they’d rather work.

When we watch NBA basketball, we can’t understand how a grown man, paid millions of dollars, who has been doing the same sport for multiple decades, can miss so many free throws. But sometimes he’s there primarily because he’s a really tall person. He happens to make a ton of money because basketball happens to be more popular than ever, and the invention of the television allowed professional athletes to exponentially increase their incomes. (Before TV, athletes had off-season jobs!) I’m sure some people just fall into medicine. “My parents kinda forced me into it.” “I don’t know. I sort of had a knack for it.” “I have a good memory. Something like the MCAT was pretty easy for me.” Asking why a guy can’t shoot better than 70% from the free throw line is like asking a healthcare worker why they can’t remember to wash their hands. They’re a person.

The operating room atmosphere

This cracked me up. I walked in thinking I was going to be the quietest person ever, not touch a thing, and basically keep myself as attached to the wall as I could.

I walk in and you hear music in the background, some Journey came on at one point. Another guy walks in, in the middle of the procedure, “What’s up Joel??? How we feelin’ today?” Joel, while in the midst of handing off surgical instruments, starts asking this guy Mike, how is baby is doing. The surgeons are acquiring the graft at this stage.

Meanwhile the surgeon would interject a few times to make sure I saw something.

Meanwhile a few other people are walking in and out.

Then the surgeon, while preparing the graft, starts talking to someone about sports.

Then the anesthesiologist asks if the temperature can be turned down. “AWWW, come on, you’re cold???” goes the surgeon. “The boys are freezing” goes the anesthesiologist.

I was amazed how relaxed an atmosphere it was. This is a group who does “1-2” ACLs per week, so around 75 a year. I suppose they know what they’re doing at this point, but I was still surprised by this. How much conversation was flowing. There were a few moments where the two surgeons (one was a fellow) kept to themselves for concentration, but it wasn’t like anyone else changed what they were doing.

There are certain types of work you can talk and listen to music while doing. There are certain types you cannot. It was surprising what type this was.

Pain from ACL surgery

After watching this in person, the rationale I give people for why this thing tends to hurt so much post-op hasn’t changed much. You will have multiple tunnels drilled through your body. Other than being a bit smaller, the power drill used…go look in your garage tool box, and it looks like that. Take that thing, put it through two of your bones, and it’s not hard to imagine how you’ll feel.

Beyond that, the surgeons have to manipulate the skin quite a bit. Pull it back this way, that way. That’s going to cause some pain when you wake up.

Lastly, beyond the drilling, there are times where they take a mallet and hammer certain parts of the bones. Again, take a hammer and an inch thick nail, go hit your legs a few times to where the bone gets a couple quarter inch dents in it, and see how you feel.

Why you don’t want a second ACL procedure

When the ACL is torn, the surgeon will use the old ACL as a landmark. They’ll shave most of the remnants away, then take a literal nail and hammer to mark in the bone where that location is, then clean the area up completely. From there, they use that as a guide to drill the tunnel for the new ACL.

If you’re on your second ACL, it’s harder to find this landmark as, well, it’s gone! Instead of the original stump, you now have a bunch of scar tissue overlaying the new graft. The bone has changed from being drilled through. Things aren’t so clear anymore.

There is more guesswork involved in a revision. However accurate you were the first time, you’re likely to be less accurate on the second one. If you were just a tad off the first time, then you’re likely to be even more off the second go around. If the graft moved just a millimeter from where you placed it, then you’re next graft placement is likely to be off by at least a millimeter.

I may have missed it, but from what I could see, that’s about it regarding finding the proper ACL placement. Find the old one, hammer a landmark, drill. It was the one time I could spot a scenario where things didn’t seem all that precise. But I’m not sure there are many more options for them.

For those who perpetually feel strange after a reconstruction, it makes sense why. These people are doing everything they can to get things to resemble the original, but there is only so accurate you can be. Nobody can see exactly the orientation of the original ACL once it goes into the bone, or know exactly how it grew to begin with, as there are probably some different ways it happens for different people. Millimeters matter here. You might feel, or have felt, strange for a while after your reconstruction because your body was acclimating to a structure it not only doesn’t recognize, but it may be a millimeter off from where the original structure was.

SO much going on

If there was one takeaway from this experience, it was the amount of moving parts. Let’s be clear, ACL reconstruction is by no means a basic surgery. However, it IS an elective procedure. On the surface, it is simple. A ligament is torn; we replace that ligament. Beyond surgery basics -anesthesia, having your body cut open- there isn’t any threat to the body. It’s not like a heart or spine surgery in that regard.

That said, there was so much stuff going on during this.

  • I counted 20+ machines in about 8 seconds. I have no doubt there were more I either missed or couldn’t see. The anesthesiologist looked like he had his own data center on the back wall.
  • There were 5 people in the room directly working for the patient. There were another 3 people who came in, who were representatives of some of the medical products being used. I then saw 3 more people who were involved in the patient’s discharge. That’s 11 people helping out with this.
    • The medical reps sell the various equipment the surgeon uses. One reason they will scrub in is to help out if needed. If a surgeon is trying a new piece of equipment because it’s better, he still might not have much practice with it. They can double check with the rep if needed. I was shocked how well the reps knew the procedure. One surgeon told me “They know it better than some of the doctors.”
  • It was largely a 3 person show. Two surgeons and an assistant. They were in constant communication. Basic stuff for the most part, but I’m sure it looked basic to me because of how much they’ve practiced it.
  • There were innumerable tools used. Specialized tools. At the end, there was probably a 1 foot wide by 3 foot deep basket which contained all the tools. I assumed that’s how they bag them before sterilization.
  • Multiple tools were taken directly out of the packaging. Never used before; never used again.
  • This patient used an autograft (from their own body). However, in case that graft excision failed for some reason, they even worry about simple things like dropping it on the floor, there was a backup allograft in another room waiting.

There was not one single moment the main team of three was not moving. All three were moving with purpose until the surgery was complete. Nothing they did seemed wasted or unnecessary.

In terms of attention to detail, two things stood out:

  • After preparing the graft, the surgeon wrapped it in a cloth, then sprinkled some water on top of that towel. I asked why this was done, and the reason is by keeping the graft wet, you avoid it brittling.
  • After the graft was tensioned in the tunnels, one person pushes the tibia posteriorly, and the femur anteriorly, while the surgeon finalizes screwing the graft in. This is a posterior drawer maneuver, and it’s done to tighten the ACL. By doing this, the graft is set in a position tighter than the ACL would normally be. However, the graft will loosen up a little bit after being in place for a while. The idea here is when it loosens up some, the graft is then in a normal position. (This is discussed in more depth here.)

Healthcare costs have been a constant victim of politicization the last 8 years. There are two huge, overarching, reasons healthcare costs what it does, that are not talked about often enough, if ever, which have nothing to do with politics.

1. The unhealthier people are, the more they use healthcare, the more we all pay.

Whether healthcare is universal in the political sense or not is irrelevant. We’ve decided as a society healthcare is universally given. You go the ER, you get treated. You don’t pay? Everyone else then pays more to cover you. Therefore, it is universally paid for. We all contribute to what healthcare costs. (This is perhaps the most controversial tenet of Obamacare. We all use a service, so we should all pay for it. Why this is so controversial no one can coherently explain. You drive a car? You need insurance. You have a body? You need insurance. Not only for you, but for everyone else.)

2. Humans are complex. In what is likely any industry, adding complexity adds costs.

In engineering, you avoid complexity if you can because adding complexity adds more components, which costs more money. You then also have more parts which can go wrong, which again means more costs.

Humans have A LOT of components. Specialized components. Humans have A LOT of ways they can go wrong. Thousands upon thousands. As we peel back the onion more and more on the human body, this is a number which keeps growing.

Number 2 is unlikely to change much. A few special individuals will every now and then come along and go, “no, no, we can think about this differently.” The movement science world has, in some ways, done this. Rather than get overly concerned with imaging, specific structures, using technological gadgets to assess, relying on equipment, they’ve gone, “no, no, we can use our eyes to assess, use the person’s body as the sole tool, and we are worried about how this all moves together. Not just one structure.”

Every time we add something besides the bodies of the practitioner and client / patient, cost goes up. Specialized tool rather than your hands to tauten the graft? Extra assistant? Arthroscopic portal rather than filleting the patient open? Wetting the graft rather than leaving it be? Specialized guide tool to help with drilling, rather than eyeball it? Gloves rather than bare hands? Sterilization rather than not? Anesthesia rather than not? Compression socks to help with clotting for the post-op phase?

They all add money to the procedure. The above is not the fault of anybody. It all truly seems to help the outcome. It’s simply the reality of dealing with human biology: It’s not easy.

Nobody is going to start doing ACL surgeries and get rid of those types of things. But can we get to a place where we do less ACL surgeries? Less surgeries period? Use less healthcare overall? We either continue to approach 1/5th of our economy being devoted to our health, or we get healthier, using not much more than our own bodies.

How much better can this get?

Noting how many people are involved in this, the amount of technology, the amount of equipment, the attention to detail, how we’ve been doing it for multiple decades, one is left wondering how much better this surgery, and the outcomes from it, can get. I feel confident, and the surgeon even echoed this to me, the rehabilitation aspect has plenty of room for improvement. At least for the everyday person. (For some professional athletes, I’m not sure there is much improvement left either.) The surgical aspect may be as good as it’s going to get. Even if improvement is left to be had, it’s likely marginal at best.

There are limitations to what medicine can do. From the outside, we can’t always understand this. Up close, it’s readily apparent.

You’ve seen some details on the surgery, now see some on the rehab. 

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