Just so you know, this isn’t about politics, at least not directly. What it IS about is bureaucracy–the bane of civilizations from the dawn of time. Just today, we had a building permit for a deck turned down. Why? Because the deck we wanted to build reportedly violated the setbacks on the side of the house.  Say, What?

OK. How did this happen? Well, in preparation for filling out the building permit application, we went to the Town Building Department and requested the checklist and required specifications for the permit. Makes sense, right? Find out ahead of time exactly what the Town’s  requirements are, so we can design our deck in accordance with those specs. 

So we got the checklist and dutifully fulfilled each requirement, one by one. So far, so good. Then, I personally filled out the application, made sure the required diagram depicted all the setbacks, and all required measurements were documented. Then, I included three copies of our survey, which was one of the required items on the checklist. And when all was complete, I took it myself to the Building Department. Here’s where the fun began.
 
A nice young woman accepted and reviewed my application with all its attachments. Mind you, she’s not an inspector and apparently knows little about the issues,  just about the paperwork. “Well,” she said, “they want the survey to show the new addition.” 

“Wait a minute,” I said. “There’s no mention of that on the checklist.”
 
“Well…,” she replied, “they still want it.”
 
So, since I am a professional artist, I drew in the deck by hand, on the spot, on each of three survey copies, to show where the deck would be located, relative to the house. Then, I paid the fee, turned in all the documents, which the lady assured me were now complete, and left, with every reasonable expectation of prompt approval.
 
Uhh…No. It seems that my sketches weren’t TO SCALE, and didn’t adequately demonstrate 20 foot setbacks on the survey; this, despite the fact that this requirement was nowhere on the instruction sheet/checklist originally given. This was precisely the situation that I was trying to prevent, by acquiring the requirements ahead of time. But what can you do when they DON’T TELL YOU some of their requirements, or worse, make them up on the fly?
 
So now, through gritted teeth, I have to do all of this over again. And the most frustrating part of it is that I won’t know, until I get a permit, whether all their requirements have, in fact, been met. I mean, if  they don’t tell you everything up front and then spring stuff on you that you didn’t know was necessary, after the fact, what are you to do? Well, I guess we’ll have to wait and see….
 
If nothing else, this little vignette demonstrates the utter disregard of our time, and our money and is disrespectful besides. And if you complain, hey, you’ll NEVER get the damn thing approved. 

All they have to do is give the applicant a COMPLETE list of requirements and follow them. Easy. This ain’t brain surgery, as they say. But, nooooooo…. Is it too much to ask for basic competence from our “public servants,” or anyone else, for that matter?
 
The implicit arrogance of government in general, and local agencies in particular, and the contempt for the taxpaying (and fee paying)consumer is breathtaking.  This episode by itself is not that big a deal, but it’s galling to me, because for over two decades in medical practice, I was expected to be far more than marginally competent. I was expected to be PERFECT.
 
This is so typical of our society at large: idiots to the left, morons to the right, and imbeciles everywhere else. It’s so bad that the merely competent person stands out like a shining star. Or so it often seems.
 
Just go to the local fast food hamburger joint and see if they get your order right. I admit this isn’t life and death, but this is what they DO, and they usually don’t get that right. But I, I was supposed to be perfect.
 
Practice was a daily gauntlet of unrealistic expectations of patients, families, administrators, lawyers, regulators, bureaucrats, politicians and news media. It was always like working with the proverbial Sword of Damocles hanging over your head. And I was excellent, among the best of my kind. But nobody’s perfect. So, you can imagine my frustration when nearly everyone I met couldn’t even execute the simplest operation of THEIR occupation, without a screwup, even as I was expected to be perfect. Very, very unfair and very, very frustrating.
 
Have I mentioned, I don’t do well with frustration? I’ll bet you don’t either.
 
For example, if you suffer with knee pain, how many times have you gone to the doctor, tried a short course of medicine, maybe a short course of physical therapy and you STILL have pain? Or the doc throws his hands up and says, well, you either live with it, or you have to have surgery. Frustrating, isn’t it?
 
Well, if you’re as fed up with being frustrated as I am, then you’ll be pleasantly surprised by my newest program, HOW TO AVOID KNEE SURGERY. See what I mean at   http://drbillsclinic.com/avoid_knee_surgery.html

With all of the tricks and tips I’ve acquired over a lifetime in Orthopaedics, this is the answer you’ve been waiting for: Methods to relieve your pain from across the entire treatment spectrum to get rid of your pain, and do it WITHOUT SURGERY. So if you, or someone you know has knee pain, and you want to stay out of the OR, go to  http://drbillsclinic.com/avoid_knee_surgery.html
 
Til next time, my friend, be well. And have a great weekend.
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html

P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

During my first year as a resident in the Orthopaedic Training Program at St. Luke’s Hospital in New York City, one of my jobs was to admit emergency patients through the ER. As it happens, a good reason for going into orthopaedics is that there are very few real  emergencies–most car wrecks and the like have orthopaedic injuries, like fractures, but they have higher priority concommitant injuries to the head, chest, or belly, that are far more pressing. For that reason, those services, Thoracic, General Surgery or Neurosurgery would have to admit them and we’d show up, when called, to do a consultation. But the key is that we didn’t have to admit them.
 
Well, one day, I was called for a patient who had been hit by a train–not hyperbole for a bad beating, but a real, honest-to-God New York City Subway train. I was frankly amazed that she had survived that close encounter. But she needed admission and I was elected.
 
I went to see her and man, she was this fairly young, just enormous black woman, who seemed to be a bit distraught and in some severe pain–as you might expect in someone who had tried to occupy the same space-time continuum as a fast moving subway train. I was never clear whether she had jumped in front of the train, in a suicide bid, or if she had fallen, or been pushed. The end result was the same. She was alive, but badly injured, with a comminuted (multiple part), compound (open–as in, combined with an overlying skin wound), subtrochanteric fracture of the femur. 

Fractures of the upper shaft of the thigh bone (femur) are especially nasty and difficult to treat, because very powerful muscles are attached to the upper part of the femur, which tend to pull it out of alignment, when it’s broken. This makes it very tough to align properly what we call, “reduced”), so it can heal. So these troublesome fractures need surgery to fix them, mainly so you can get the patient up and out of bed.
 
You see, if you try to treat the patient with traction, to keep all the fragments lined up until they knit in solid healing, it will take many weeks. And because the patient is stuck in bed all that time, complications can occur, like pneumonia, or deep vein thrombosis, or pulmonary embolus, or infected bed sores, or urinary tract infections–the point is, non-surgical treatment has its own dire consequences, too. For this reason, most of them need surgery, which has lower risks and a better chance for a good result.
 
Anyway, Dr. Bob Zickel, one of my teachers was a world class expert in this particular type of hip fracture, and even had a special appliance (which he had invented while still a resident, himself), named after him–The Zickel Nail. So this lady was admitted to his service, and I got her ready for early surgery.
 
I scrubbed on the case with Dr. Zickel and another resident. Like I mentioned, she was a really, really tough case. She was easily 350-400 pounds, with gigantic thighs. All that flesh fought us for the entire case. But we got it done. X-rays looked great–better than they had any right to. And it took well over an hour just to close the surgical wound. But we were pleased with the result and felt proud of ourselves.
 
She initially did well, but three days after surgery, she spiked a high temperature, had shakes and chills and the nurses called me. Even though she had a gigantic thigh, it was apparent to me that she had bled into the tissues and this would lead to infection, if the pressure  was not relieved. Well, I was trained at MCV (Medical College of Virginia) to be bold and decisive. 

Without hesitation, I pulled on a pair of gloves and opened the entire wound with my finger, right then and there, right down to the bone, after painting her with Betadine to “sterilize” the area, at the bedside. I got all that old clotted blood out, got a culture, started her on additional I.V.antibiotics (she was already on some, from surgery–she had an open fracture, so this was to prevent infection) and packed her open, with Betadine-soaked gauze bandages, just like I’d been taught to do.

Well. There are bold surgeons and there are old surgeons; but there are NO old, bold surgeons.

Dr. Zickel nearly had a cow, when he heard what I had done! Closest I ever saw him come to an apoplexy. I had been just a little TOO bold. And I certainly should have called him, first. They were a bit more aggressive at MCV than they were used to at St. Luke’s. Who knew?

Well, he let me live, and he made it my personal job to assume responsibility for that patient, until she was fully healed and discharged. I had to change, irrigate and pack that wound, twice a day FOR SIX MONTHS. Had I been a little less bold, she and I would have only needed another surgery in a sterile O.R. and we both would have been spared about five extra months. Think I learned my lesson? Yup.

She eventually healed the entire thing–quite amazing, really. And she finally left the hospital, with a fully healed fracture and able to walk. Well, that’s how young surgeons learn. You learn what to do and, at times more important, what NOT to do.

I’ve carried that lesson with me my whole career: there are times when surgery is appropriate and times when it should be avoided. The trick is knowing when to do which.

I saw the same problems again and again in my practice. Though I did a whole lotta surgery, I treated probably 90% of the patients who came to see me WITHOUT SURGERY. And now, I’ve distilled those lessons of s lifetime into my newest program, HOW TO AVOID KNEE SURGERY. See what I mean at   http://drbillsclinic.com/avoid_knee_surgery.html

Til next time, my friend, be well.

Yours for a pain-free tomorrow,

Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html

P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html

P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html

FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION

Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

Yesterday, we discussed the report of the Osteoarthritis Research Society International, regarding their recommendations for the treatment of ostearthritis.  I mentioned that this study was really significant, because it provides, for the first time, truly international guidelines for the rational treatment of arthritis, based on available evidence.
 
The group was headed by Dr. Zhang, of the University of Edinburgh, was drawn from six countries, including 11 rheumatologists, two primary care physicians,  one orthopaedist, and two experts in evidence based medicine. They reviewed the available evidence in the
literature to come up with their recommendations.  As I’ve mentioned before, each item was assigned a number, a percentage; the higher the number and the closer to 100, the more reliable that item and the more likely it is to be successful.
 
So, yesterday, we looked at the top non-drug methods, which mirrored my own recommendations. Today, let’s look briefly at their recommended drugs. As you might expect, NSAID’s (nonsteroidal anti-inflammatory drugs, like Advil or Aleve) at 93% and acetaminophen (ie., Tylenol) at 92% led the pack for relief of the pain of arthritis. A bit further down was topical NSAID’s and capsaicin (skin creams) at 85%.  Injections of intra-articular corticosteroids (ie., injection of cortisone, or similar drugs, into the
knee and other joints) ranked next, at 78%, followed by joint injections of hyaluronans (forms of hyaluronic acid, like Syn-Visc or Hyalgan) at 64%. We should bear in mind that these latter joint injections, steroids or hyaluronic acid, are used in the most serious and advanced forms of arthritis. So we need to interpret their effectiveness “numbers” based on that. Hyaluronic acid injections are used
as a non-surgical alternative for END STAGE arthritis. They can “buy time” before joint replacement is needed, but are only used in joints at that advanced state of disease, where total joints are the only other option.
 
Following that, glucosamine, with or without chondroitin sulfate, ranks at 63%, when used strictly for relief of symptoms. But this falls to only 41% when used for possible structural modifying effects of the joint (ie., “regrowing” cartilage).  This, too is expected. There is little scientific evidence for cartilage regeneration, at present (maybe someday, with stem cells…). 

While it’s known that glucosamine is often effective for pain relief, as I point out in my LITTLE GREEN BOOK (see how I put this into proper perspective at http://drbillsclinic.com/eliminate_knee_pain.html),  there is little hard proof for any structural effects 
on the joint from its use. That absence of evidence is reflected in the lower number.
 
Glucosamine is the closest this study comes to touching on the Alternative Medicine options. This, too, makes sense. Alternatives, by their nature, have few if any accepted scientific studies as their basis. They are usually based instead on anecdotal histories, folk lore or an Alternative traditon. So long as no one is going to make a buck on them, don’t look for large, double blinded, randomized and controlled studies, anytime in the near future.

The last category studied was the Surgeries. No surprises here. Total joint replacement was the most effective treatment, backed by hard evidence at 96%.  That TJR is one of the most successful treatments in the history of Medicine is well known. But its less complete cousin, the unicompartmental replacement, was less so, at 76%. Its success requires accurate diagnosis, disease limited to one compartment, very
accurate placement and angulation, and more rigorous technique, but fewer surgeons are experienced in this technique. These limitations result in less succesful studies and therefore, the lower number.
 
Osteotomies and other joint preserving procedures are nearly the same, at 75%. But joint lavage (washing out the arthritic joint with water) and arthroscopic debridement were less effective, at only 60%. My own clinical experience, and the recommendation of our
Academy also argue that these procedures are less effective treatments for arthritis.
 
This study is very useful for selecting arthritis treatment options, based on the evidence. I congratulate the authors. It’s not just the actual ranking of the options that’s useful, but that the principles the study invokes can be applied to all other areas. Instead of guessing, basing your decisions on hard, rigorous, scientific evidence is as close to KNOWING as you can come.
 
For example, when I selected the knee exercises for my PAIN-FREE PROGRAM, I chose them based on the reported evidence of effectiveness in the literature, my own observations of patients, for whom I prescribed them, and my own personal experiences, as a knee patient myself. In other words, my choices were based on all available evidence. See what I mean, by visiting
http://drbillsclinic.com/exercise_eliminate.html
 
So whatever advice you decide to follow, in whatever field you find yourself, you can’t go far wrong if you base your choices on the strongest available evidence. EVIDENCE BASED TREATMENTS are your best bet for successful results. And that’s the tip ‘o’ the day. Til next time, my friend,  be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved