Sunday, January 25, 2009

Throwing the Challenge Flag

This is the worst sports weekend of the year --- everybody is waiting for the Super Bowl, and it ain't happening. Sure, I'll catch some of the NHL All Star game (full disclosure, my brother works for an NHL team), but I'm really jonesing for the big game. No party for me; I'll be serving the community on Drama Call.

Football has changed a lot in the past few years, and one wrinkle I'm not sure I like is the ability to challenge a call. Seeing a grown man throw out a little red hankie on the field is, well, unmanly. It sort of reminds me of old westerns with the town harlot sitting on a piano, dressed in red and black lace, twirling a red boa.

Maybe I'm not a fan because I have to deal with a couple of similar "challenge flags" in my line of work. Once or twice per month, I have a conversation with a new patient that includes some version or another of this phrase:

I have already talked to another surgeon, but I wanted to hear what you have to say.
Really what this means is:
I just want a second opinion.
In other words, the patient is throwing a challenge flag. He doesn't like, doesn't trust, or simply is preconditioned to want more than one physician's input into his problem. This, to me, is generally no big long as I know that this is the case. It is disconcerting to hear this well into the visit, rather than at the beginning. (image source)

Honesty is truly the best policy when speaking with a physician. You see, we can cover a lot of ground in a conversation that is needless if a patient has seen three other physicians for the same problem, and already has a grasp of the situation. It is difficult for me to carefully go through a disease process, its ramifications, its treatment options, and potential complications of surgical options in detail when the patient across from me acts impatient because, well, it's all old hat to him. If we can establish up front that the patient already has heard, and understands, the basics, we can focus more closely upon options and answer questions that have prompted the idea of getting another opinion.

What motivates patients to seek alternate opinions? There are a couple of broad categories.
  • The patient truly has an unusual or complex problem, and the surgeon he sees freely admits that while he can deal with it, the issue at hand is not one he sees commonly. Cool, most docs have no issue with this.
  • The patient is uneasy with, or doesn't care for the surgeon he is sent to see. I'll be honest -- I would much rather that a patient is comfortable with his surgeon than take offense that he or she doesn't like me. Patients should feel comfortable with the guy that has to open them up and rearrange their insides --- if they are not comfortable with me, they will be best served by seeing someone else.
  • The patient has been told, through family, friends, the media, etc., that "you must always get a second opinion before having surgery." Realistically, for most things, this is unnecessary, but I understand the way that some folks have been conditioned.
  • The patient has "issues." This is a patient that is fairly difficult to deal with, as they trust no one in a lab coat, feel that physicians are simply out to make a pile of cash hurting people, and tend to believe in conspiracy theories. To say the least, they don't tend to have good outcomes (from their standpoint), regardless of whether their surgeon is Michael DeBakey or Jack the Ripper.
  • The patient was caught like a deer in the headlights at their first appointment. Sometimes, processing information, particularly difficult to understand or potentially devastating information, is a real challenge (for everybody). I don't mind a bit being the physician that needs to simply reiterate what the first surgeon told the patient, and hopefully reassure them that they are getting the best and most up-to-date advice possible.

My rule of thumb in all of these situations is to offer an opinion. Not a second opinion. Just my opinion, unedited and, as much as possible, unswayed by the information they have gleaned from a prior surgeon. If my opinion jives with what their first surgeon told them, I let them know that they have received good advice, and that I certainly have no magical store of knowledge not available to other surgeons. If they like me better, great. If not, great.

We get into trouble with asking for second opinions in urgent or emergent settings. GruntDoc and the docs at EP Monthly can probably tell a few tales about this. If you are in an ED, and you don't have an established relationship with a surgeon, and you need an operation, it's pretty dang hard to get another surgeon who is not on call to come in and see you if you don't like the recommendations given by the surgeon who is on call. I cannot recall in 15 years of practice an instance when this was requested by anyone other than a patient with "issues." Most folks in an ED who need urgent surgery are well aware that they are sick, and are happy to have a general surgeon available to care for them ---- any port in a storm, so to speak.

On the other hand, the patients with "issues" tend to have well-established track records of firing a number of doctors. In smaller communities, that means that they run out of surgeons that are able to care for them on an emergency basis, and occasionally have to be transferred. Just as Al Davis has a difficult time now finding top tier coaches to hire, these patients have fired so many physicians that they have no other alternatives. This is less than ideal for all concerned.

What about when doctors throw the challenge flag --- at each other? We all hope that when we disagree with the diagnosis or treatment of a patient, it can be handled professionally. Realistically, there are few instances when we have substantive disagreements; generally we will only quietly argue over a fine point or two. The arena of peer review, which is well beyond the scope of this post (and could take up an entire book), is where we go through the painful process of retrospectively evaluating the merits of a particular surgeon's decision-making and care when there are substantive disagreements.

Saturday, January 10, 2009

Four Horsemen of a Trauma Death

I am hardly an eschatologist in the traditional sense. However, rather than being someone who studies the end of the world, my profession puts me in a position to be around, albeit uncomfortably, the end of life. At times, that end comes violently, and to stretch an analogy a bit, I'd like to describe what I would call the Four Horsemen of the Trauma Death.

I'll start with the traditional view of what the four horsemen represent in the Bible:

A white horse, its rider holding a bow --- Pestilence
A red horse, its rider holding a sword --- War
A black horse, its rider holding a pair of scales --- Famine
A pale horse, its rider is called Death

OK. It's 1:26AM on a cold January night, and Billy Bob has had a few too many brewskis and several shots of Tequila for good measure. Rushing home on a dark, winding home, he loses his lane, overcorrects, and plows headlong into a 50 year blue spruce at a speed the local sheriff will estimate at 70mph. His last road trip just started off with a bang.

A white horse appears, its rider holding a 6 liter pitcher; this represents the average volume of blood in a typical male. The rider's name is Hemorrhage.

Billy Bob hasn't just hit a tree; the tree hit back, and inflicted a femur fracture, a fractured pelvis, a lacerated spleen, a small intracranial hemorrhage, and a pulmonary contusion. Billy Bob never was much one for wearing seatbelts, you see. Just as the realization that he is in deep kimchi hits him, Billy Bob starts bleeding --- not in a manner he is aware of, but into his thigh, abdomen, and retroperitoneum.

It is surprising how much blood loss can occur from injuries most people today would consider pretty survivable. A patient can park two units of blood into their thigh pretty quickly with a fractured femur; this happens not from laceration of a vessel, but from the bone (and bone marrow) itself. Pelvic fractures may disrupt veins in the pelvis, particularly along the sacrum, and result in substantial bleeding into the retroperitoneum. Occasionally, arterial bleeding may accompany this, along with hemorrhage directly from the bone. Splenic lacerations range from minor to overwhelming, and result in bleeding into the free abdominal cavity.

A red horse appears, its rider holding a block of dry ice; the rider's name is Hypothermia.

A typical cloudless winter night here in the Rocky Mountains is an awe-inspiring sight. The sky is clear and filled with stars not seen in most cities. It is also absolutely stinking cold. Billy Bob is trapped in the front seat of is car, which is no longer running, and the temperature outside is measured in the single digits. Even if he had had his heater on full blast before he mangled the spruce tree, it won't be long before the inside of his car starts to approximate the temperature outside.

Billy Bob, as the occupant of said vehicle, will similarly start to chill out, and not in a good way. As his core temperature drops to a state of mild hypothermia -- 95 to 90 F (35 to 32.2 C) -- he'll start to shiver uncontrollably until his glycogen stores are depleted. His body is basically trying to generate heat in any way it can. Already a little dehydrated from the diuresis caused by alcohol consumption, his volume depletion from bleeding will start to mildly worsen as his kidneys start to pump out even more urine with mild hypothermia. His blood vessels constrict in an effort to maintain core body temperature, his respiratory rate increases, and his blood pressure will mildly increase. This, however, can't go on forever.

A black horse appears, its rider holding a stopwatch; the rider's name is Time.

At this time of night, there aren't many people driving this cold county road, so nobody comes across Billy Bob for about 60 minutes. During this time, he has managed to lose not quite half his blood volume into his abdomen, pelvis, and thigh, and he is clearly hypothermic. The Good Samaritan that finds him fortunately has a cell phone, and calls for help. If he has one, he throws a blanket over Billy Bob. However, this Good Samaritan is well-informed, and has seen the execrable decision by the California Supreme Court regarding helping the injured, so he doesn't really know if he should do much more.

Tick. Tick. Tick. By the time the EMTs arrive, it's been over an hour and a half since Billy Bob deflowered the spruce tree. He's getting really cold now -- moderately hypothermic -- core temperature 90 to 82.4 F (34 to 28 C). This is not going to improve as the EMT's work as fast as they can to get him extricated and initiate treatment, as he will be exposed and may receive cold IV fluids. By the time he hits the ED in the nearest trauma center, he is thoroughly confused, and may even be showing signs of decreased heart rate and blood pressure.

The cumulative weight of time has taken its toll on my body --- my back aches, I've had several surgeries, the gray hair on my head is thinning, and I don't sleep well. For Billy Bob, the cumulative weight of time has now started to compound his problems. Not only is he severely volume depleted and hypothermic, he is starting to develop a coagulopathy. His body is trying to stop his ongoing hemorrhage, and in doing so is chewing through his available clotting factors like Ms. Pac-Man with a bad case of PMS going through a box of chocolates....and thereby gradually depleting them. Additionally, hypothermia has an adverse effect on the clotting cascade, with an approximately 10% reduction in the rate of enzyme reactions of plasma coagulation for each 1° C decrease in core temperature.

Now with a mild coagulopathy, his bleeding increases, not only in his leg, pelvis, and abdomen, but also in his contused lung. This causes worsened exchange of oxygen and CO2, making him hypoxic and acidotic. So, he's got that going for him.

Now, unlike "ER," "House," "General Hospital," and all of those other "doctor shows" that I have never seen, it takes time for the ED staff to get a trauma patient resuscitated. The stopwatch doesn't speed up in the ED, but it doesn't slow down, either. Starting IVs, examining the patient, possibly intubating him, performing an abdominal ultrasound, obtaining a chest X-Ray, obtaining blood for labs, placing a foley catheter.....all of these things take time. The problem is, Billy Bob doesn't have much time left.

A pale horse appears, its rider is called Death.

A frantic display of 21st century medical technology is unleashed on Billy Bob. The ultrasound shows free fluid (blood) in the abdomen, meaning he needs to get to the OR pronto. The unbelievably intelligent ED doc quickly surmised he needed to be intubated, and did so. The trauma bay is kept warm, and the thermostat is dialed up to "Baghdad at noon in July." A warming blanket is placed, and is frequently displaced by personnel trying to care for the patient. Large IVs are placed, and the trauma surgeon decides it's time to start transfusing Billy Bob with O-negative blood because his BP has remained in the balmy 80s despite a few liters of fluids. It doesn't help much.

Hi ho, hi ho, it's off to the OR we go. With a little luck we'll get him back. Hi ho, hi ho!

In the OR, also made as toasty as possible, the anesthesiologist starts to pour blood and factors into Billy Bob like a bartender on free drink night at a strip club. The surgeon is greeted by a large pool of blood in the abdomen, a spleen beat to a pulp and oozing tremendously, and a retroperitoneal hematoma large enough to cover a small polar bear. Out comes the spleen, and the retroperitoneal hematoma is wisely left alone with the hope that it will tamponade. The abdomen is now too tight to close, and every visible surface seems to be oozing; the abdomen is therefore left open with a VAC, which while preserving blood flow to the kidneys and gut, doesn't really help the hypothermia situation much.

By the time the orthopedic surgeon arrives in the OR to place an external fixator, the anesthesiologist is seeing bleeding from Billy Bob's nose and mouth, and there is blood in the endotracheal tube. He is also having a hard time ventilating the patient, who is persistently hypothermic (temp 92) and acidotic. A chest tube is placed first on the side of the contusion, where there is a fair amount of bloody fluid, and for completeness on the opposite side. The contused lung now has the consistency of liver, so high pressures are required to try to get some moderate degree of gas exchange.

At this point, pouring more blood products into Billy Bob is like throwing a cup of water on a burning building. It remains, however, all that can be done, so we do it. Surgeons and anesthesiologists really don't like it when patients die in the OR, so after the "ex fix" has been placed and the femur appropriately splinted, Billy Bob takes his final ride tour of the hospital, to the ICU. Cold, coagulopathic, and comatose, there is nothing else that can be done, and Billy Bob continues to hemorrhage and eventually develops cardiac dysrhythmias and dies.

This is only one of the many ways in which trauma patients meet their end. Despite everyone's best efforts, some patients arrive with injuries that overwhelm them; timeliness is desirable, but not always achievable. But it is important to remember that the original insult to Billy Bob's physiology came well before he hit the tree --- it started with that indefinable transition from sober to drunk.

Thursday, January 08, 2009

Why I fail at generating cash here...

I must admit that I find the whole process of blogging intriguing, if not a bit surreal. I have exchanged several informative, fun, or just plain interesting e-mails with folks I otherwise would have never encountered. But nothing prepared me for the experience of receiving e-mail from people wanting to advertise on my site. I understand that most of these are automatically generated, but a recent one caught me by surprise:

I came across your website and am very interested in advertising on your site for my law site. The website offers latest news and articles about personal injury and the general law industry. Please can you inform me of how much text advertising on your website would cost?

Let's just call him Mr. Nonetoobright

What a fabulous marketing idea! Advertising for a personal injury law site right here on my site --- I mean, it's not as if I haven't made it abundantly clear that personal injury law is about as honorable a profession as bank robbery.

What the hell. After a little martini, I thought "I'll play along!" Here was my response:
If you want to advertise for personal injury lawyers on my site --- a physician's site -- pricing for text advertising would start at $147,589 per word (extra for words with more than 7 letters, and double for any hyphenated words).

Many thanks
Aggravated DocSurg
I thought nothing of it; just a laugh to let off a little steam. I was shocked to get an actual reply a day later:
That's a little too much for me, thank you for the prompt response.

Mr. Nonetoobright
Some people! Ya just can't please 'em!

Monday, January 05, 2009

VoTE for Prophylaxis

"Doc, don't hurt me!" I hear this not infrequently, as I am sure most surgeons do. Patients don't like pain, but some equate the commonly stated aphorism "Primum non nocere" with "don't hurt me." This would appear to be a bit of an oxymoron when dealing with surgery. It's kind of hard to not hurt someone when performing an operation --- let's face it, everything I do hurts --- so we surgeons want to make sure that the proper translation is used:

First, not to harm (or, more commonly, First, do no harm)

Sometimes, we do indeed harm patients. This is done mostly in the setting of trying to help them, but certainly complications and bad outcomes occur. Taken as a whole, "medicine" has gradually advanced, and prior harmful practices have been replaced with better ones with less potential for harm. Sometimes, the simple process of having an operation is potentially harmful, with significant changes in the immune system, cardiovascular system, hormonal stress response, and inflammatory mediator release having some degree of harmful effect ---- these do not always result in serious issues, but they can. Another potentially harmful side-effect of surgery is the risk of development of deep vein thrombosis and pulmonary embolism, which I have written about before. While not always preventable, adequate prophylaxis with certain types of major surgery significantly reduces the risk of developing postoperative venous thromboembolism (VTE) ...... but "adequate prophylaxis" is somewhat of a moving target.

(Please remember, when I am using the word prophylaxis, I am not alluding to what Frank Oz gave back to John Belushi in "The Blues Brothers.")

A pair of recent articles focusing on the risks of VTE with major abdominal surgery are interesting for what they tell us about prophylaxis. The first, entitled Postoperative Venous Thromboembolism Rates Vary Significantly After Different Types of Major Abdominal Surgery, is a retrospective review of >375,000 patients using the Nationwide Inpatient Sample.

Methods Retrospective analysis of the Nationwide Inpatient Sample (2001–2005) was conducted. Eight surgeries were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age <>
Results Patients, 375,748, were identified, 5,773 (1.54%) with VTE. Overall death rate was 3.97%, but 13.34% after VTE. Unadjusted rate (0.35%) and adjusted risk for VTE were lowest among bariatric patients. On multivariate analysis, highest risk for VTE was splenectomy (odds ratio 2.69, 95% CI 2.03–3.56). Odds ratio of in-hospital mortality following VTE was 1.84 (1.65–2.05), associated with excess stay of 10.88days and $9,612 excess charges, translating into $55 million/year nationwide.

Conclusion Highest risk for VTE was associated with splenectomy, lowest risk with bariatric surgery. Since bariatric patients are known to have greater risk for this complication, these findings may reflect better awareness/prophylaxis. Further studies are necessary to quantify effect of best-practice guidelines on prevention of this costly complication.

That's a very interesting set of data to pore over, with a few surprises. First of all, the overall risk of developing VTE with these selected major abdominal operations was low at 1.54%. The most common genetic cause of venous thrombosis, Factor V Leiden (Factor V mutation) is present in 3% of the general population (estimated 2-7%, with only about 0.1% of the population being homozygotes). This study did not specifically address whether the patients with postoperative VTE were screened for this or other known genetic causes of venous thrombosis, and did not address other potential risk factors (oral contraceptive use, estrogen therapy, obesity, diabetes, venous stasis from immobility).

Just as interesting to me is the fact that patients undergoing bariatric surgery (typically gastric bypass surgery) had the lowest risk of development of VTE. This is counterintuitive, as these patients have a higher risk of VTE due to their obesity, frequent associated diabetes and venous stasis disease, and relative immobility. What gives? Did the numbers stop making sense after a few months of staring at reams and reams of data? Well, no. It appears that bariatric surgeons, knowing that their patients are at a higher risk for VTE, were more apt to provide patients VTE prophylaxis (subcutaneous Heparin or Lovenox). In the body of the article, we find this tidbit of information:
"While the ENDORSE trial recently found that only 58.5% of all surgical patients at risk for VTE received American College of Chest Physicians (ACCP)-recommended VTE prophylaxis. Wu and Barba showed that more than 95% of bariatric surgeons regularly adhere to thromboprophylaxis guidelines."
So, chicken or egg? Are bariatric surgical patients truly at a lower risk for VTE, or are their surgeons simply better at providing appropriate prophylaxis?

The next article looks only at VTE in bariatric surgery --- The effect of extended post-discharge chemical thromboprophylaxis on venous thromboembolism rates after bariatric surgery: a prospective comparison trial. Basically, these authors are asking the question "would it be better to extend the length of VTE prophylaxis beyond a bariatric surgical patient's hospitalization?"

Methods 308 consecutive patients who underwent BS between 2003 and 2007 and who had >1 month of follow-up were included. In-hospital-only VTE prophylaxis (group A), or extended 10-day ETP (group B) was used in 132 and 176 patients, respectively. All patients underwent bilateral lower extremity venous Doppler studies (BLEVDS) prior to discharge. Primary endpoint was the incidence of VTE within 30 days postoperatively. VTE was defined as a clinically evident deep vein thrombosis or pulmonary embolism documented by positive BLEVDS, or computed chest tomography. The primary safety endpoint was bleeding associated with ≥2 g/dL decrease in hemoglobin compared with baseline, transfusion or reoperation.

Results The incidence of VTE was 1.9% (6/308); 66.6% (4/6) of cases occurred after cessation of thromboprophylaxis. There were no deaths in either group. With the exception of percentage open surgical approach (A: 3% versus B: 0%, p = 0.03), percentage conversions (A: 0 versus B: 3.8%, p = 0.01), and hospital stay (A: 3 versus B: 2.2 days, p < style="font-weight: bold;">VTE rate was significantly higher in group A (A: 4.5% versus B: 0%, p = 0.006). Although morbidity was higher in group A (A: 12.1% versus B: 1.1%, p = 0.02).

Conclusions ETP is safe and effective in reducing the incidence of VTE as compared with in-hospital thromboprophylaxis only.
Once again, we see that the overall incidence of VTE was small -- 1.9% in this study. However, 2/3 occurred after cessation of propylaxis (these four patients developed VTE on postop days 12, 20, 26, and 30). Unfortunately, because the study size was small, there were some significant differences in VTE risk in the two groups, which could have something to do with the difference in outcomes. A larger study would be very helpful, but it is a good thing that more folks are thinking about extending the time frame for VTE prophylaxis.

I think these types of studies are extremely helpful for clinicians. I think they would be very helpful to policy-makers as well, who are pushing the idea that VTE should be a "never event," but I'm not so sure they are as interested in gathering relevant data as in holding on to their cash.

Sunday, January 04, 2009

Comparative Shopping & Surgical Literature

I hate shopping. This declaration is certainly no surprise to SWIMBO, who through twenty years of marriage has unsuccessfully tried to get me to spend more than a few nanoseconds looking for clothes. To me, it's sort of a search and destroy mission. For SWIMBO --- and our female progeny --- it's a sport. I just don't know what the rules of that sport happen to be.

Now, guys like me do understand certain types of shopping --- the kind that involves major cash outlays, like cars or electronics. And this arena involves the important activity of comparative shopping. The internet has made comparative shopping into something of a sport for men. Looking for a car? Go to Edmunds and get the lowdown on all the cars in the universe. Want a new HDTV? There are more comparative sites out there than implants at "Howard Stern appreciation night" at a Vegas night club. The difficulty is figuring out what information is believable, and what is sheer opinion.

Despite what the average non-physician may belive, the same difficulty is faced by us docs trying to wade through articles in medical journals. Here's a case in point, made all the more poignant because the two articles were placed one after the other in the same journal:

Perioperative Treatment with Infliximab in Patients with Crohn's Disease and Ulcerative Colitis is Not Associated With an Increased Rate of Postoperative Complications.
Conclusions Preoperative IFX was not associated with an increased rate of cumulative postoperative complications.


Use of Infliximab within 3 months of Ileocolonic Resection is Associated wtih Adverse Postoperative Outcomes in Crohn's Patients.
Conclusions Infliximab use within 3 months before surgery is associated with increased postoperative sepsis, abscess, and readmissions in Crohn’s patients. Diverting stoma may protect against these complications.

Hmm. First, a little background. Crohn's disease and ulcerative colitis, while different diseases, are lumped together as "inflammatory bowel disease" (IBD), and are in large measure diseases that are a result of immune system problems that result in inflammation of the gut. As a result, the primary medical treatment involves medications that try to mitigate that immune system-mediated inflammatory process --- steroids, for example. One of the newer drugs availabe to treat IBD is Infliximab (trade name Remicade), which acts by blocking an the effects of an immune mediator called tumor necrosis factor-alpha (TNF).

Stay with me. Get a shot of C8H10N4O2 if needed. Infliximab is pretty strong stuff, and is not for use in the average patient with IBD. It is reserved as a final stand in the patient who has complications of their disease that are not responding to lesser drugs........of course, that is the same group of patients that would also be looking at the prospect of surgery. Since this stuff knocks the bejesus out of a patient's immune system, if a patient fails Inflixamib therapy, there is concern that complications would then ensue. Hence, the above studies.

So, in my shopping bag I now have two conflicting studies. Which one do I "keep" in my memory bank, and which one do I take to the return desk and ask for my cash back? This is where prior experience comes into play, where all of my biases are allowed to run as free as a Hollywood pop-tart in DUI court. My biases (and they are mine and mine alone, so don't read too much into this), based upon dealing with the patients I have cared for who have been given Infliximab are:
  • Surgical complications are more frequent in the patient who has been given Infliximab for either Crohn's disease or ulcerative colitis.
  • Patients who have been given Infliximab for IBD and then need surgery tend to be sicker and more malnourished than similar patients, and recovery from surgery is longer and more difficult for them even in the absence of complications.
  • Since ulcerative colitis can be cured with removal of all of the colon and rectum (a variety of surgical options exist), I am not sure that there is any benefit to treating these patients with Inflixamib. This is particularly true in the patient who desires a sphincter-sparing operation (ileoanal pull-through); if they have been given Inflixamib, I would probably avoid a pull-through initially, thereby setting up the need for three operations ([1] total colectomy; [2] proctectomy with ileoanal pull-through; [3] ileostomy closure). UC patients who are given Infliximab may be simply postponing an inevitable operation, and their surgical results may be associated with a higher risk of complications.
As unscientific as my biases may appear, for the time being they are about as reliable as the conflicting studies that are available from real surgical researchers (trust me, there are more). And, until some degree of consensus can be reached, they will continue to be at least one factor I have to consider when caring for individual patients --- and that is why there will always be a fair degree of art in the science of medicine.

Saturday, January 03, 2009


Just a little update on my clumsy, accident-prone, uncoordinated little brother, AKA The Googlemeister. After splitting his lower humerus like a log being split for kindling, he was fortunate to find a surgeon kind enough to put him back together. He now sports enough metal to make a TSA officer soil himself:

That is what I would call a very nice job. There is an old expression in surgery --- "You can't make a silk purse out of a sow's ear." My brother started out as a shredded sow's ear, and it looks like his orthopod has made, if not a silk purse, at least a functional elbow. Nice work!