Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

That and just let me know when you wanna get started. It doesn't matter to me. Say that again. Just let me know when you wanna get started. Sure thing. Can you hear me pretty clearly? Yeah, we'll, we'll play with the volume here. It's a little on the quieter side. But, ok, let me see if I can. Yeah. All right, Doctor King. I think we are good to go on this side. Ok, so you got, you can hear me pretty good now you, you're in the back. Ok. Yeah, got thumbs up. Ok, great. So my name is Jay King. I'm in the department of orthopedics. I'm gonna talk to you today about, um, introduction to hand and upper extremity surgeries. What Tim asked me to talk about? Um, it's gonna be a pretty brief overview. I'm gonna discuss some of the surgeries kinda what we do in day to day life. And, um, I'm gonna start with a couple of just basic stuff. So you guys get an idea of what we do. Um, and, uh, I guess maybe I'll stop in intermittently to answer questions. Um, so we're not just answer them all at the end. But, uh, if, uh, there's a few points I can stop and kinda answer some questions. Um, so just real quick, I know you guys prob a lot of, you probably know this but maybe not everyone does. But what is orthopedic surgery? You know, it's a surgery of the bones, muscles and joints of the extremities and axial skeleton. It's a five-year residency program and your first year is your intern year and you do about six-month Ortho and then also some other specialties that are related. Um This is much better than it used to be when I was training. It was only three months of orthopedics. So they've increased that which is good. Your second year is to be the hardest of most programs where you're doing a lot of night call um covering a lot of trauma which is always busy um at most centers um and usually the most uh taxing year and then you've got years 3 to 5, which is generally graduated autonomy for what you can do in different rotations for different specialties and kind of learn as much as you can in this last three years. Um Most people now do a one year fellowship of specialization. Um Some people even do two fellowships and some do none. Uh Most people that would still see some general orthopedics and will cater their practice to what we wanna do. It's not nec doesn't necessarily have to be only in your specialty uh, that allows you to do stuff and you're done. So, the orthopedic subspecialties that, um, are represented, I don't think I missed any but, um, pediatric orthopedics which does kids, um, joints or, uh, it's, it's basically hip and knee replacements. It used to include shoulder replacements but not much anymore. Sports medicine, uh, surgery, uh, foot and ankle, spine trauma surgery, shoulder elbow surgery, orthoped oncology. And then there's hand and upper extremity. Um, so there is some overlap here. These, it's like everyone does exactly one thing, but there are certain things in each specialty that are more common, um, and more specialized. So just a little overview of what is hand, upper extremity cover. Well, most hand upper extremity fellowships will cover hand elbow and some cover the shoulder. But not always, there are some that don't do many shoulder, um, a shoulder to elbow fellowship does obviously what it says, mostly shoulder to elbow surgery, but kind of all facets. And there's even some shoulders fellowships that do very little elbow cause shoulder is a much more common pathology. Um, sports fellowships also cover some shoulder and elbow surgery although usually limited in what parts they cover. Uh, more of like the young athlete side than the, um, older side. Like replacements are less common in sports. And then there are some overlap with the upper extremity in pediatrics. Um, in pediatric, um, orthopedics. The most, probably the most common fracture they see is an elbow is a distal, um, humerus fracture in kids. So it's very common but they generally don't do a lot of hand, um, surgery. Um, even in pediatric orthopedics, usually they have a hand specialist do that. Um, oncology. Obviously they, uh, orthoped oncology operates all over the body. Um, so they definitely do some hand and upper extremity surgery, spine obviously doesn't do hand upper extremity surgery, but there's a lot of overlap with the symptoms. So, like I do shoulder to elbow and I see a ton of patients that have cervical spine pathology that radiates to their arm. And, uh, you kinda have to figure that out, right? They're not necessarily operating on the auria, but they gotta figure out and you have a good difference of diagnosis of some simple shoulder and, or head up strength pathology. So you can figure out whether it's not coming from the spine and then trauma as well. Um, there's a lot of overlap with trauma at, at some places. Uh, some places they have uh specialized upper extremity trauma surgeons or hand guys that cover trauma or shoulder elbow guys cover the upper extremity trauma because trauma is more commonly Pelvis aceta in lower extremity. But there is a lot of some, some places do cover the shoulder elbow trauma as well. Excuse me, I had to cough. So that's kind of the overview. The other thing that I forgot to throw up here is plastic surgery also, uh, several plastic surgery fellowships do cover hand surgery as well. Um, and there is some overlap, like you can actually have an orthopedic hand fellowship that has plastic surgery of, uh, residents that then do a hand training in orthopedics. So there is some overlap there depending on where you go. Um, and we have that here too. Our plastic surgery team here actually joins our hand conferences and they do kind of a different, uh kind of hand surgery for the most part and some things are the same, there is a straight overlap but sometimes the soft tissue coverage. They, they do more of that and uh some hand surgeons do. So, um you know, hand fellowships, uh just so you guys know each one is different. Um And this is for basically any fellowship you do probably no matter what subspecialty you go into, but they're very, very variable in certain things, especially shoulder and elbow surgery. Um Not all hand fellowships cover a ton of shoulder or maybe none. Uh elbow is gonna be variable depends on what the people at that institution uh do is where they kind of decide uh what kind of procedures they do in the elbow. Some may do just soft tissue but not reconstruction. Um Some may do uh contracture release but not other things. So, um also upper extremity, sports injuries, if the sports guys really wanna do all those sports and have a strong sports program, which is the most common fellowship in orthopedics is sports. Um, they might take some of the cases from the hand fellow, uh, the hand fellowship people. Um, microvascular surgery is another big one. We do some of that here with Doctor Kim, um, from orthopedics, but also, um, Doctor Kim and some of the other plastic surgery, uh, team here does microvascular surgery. So, using a microscope, uh, doing replant, reimplantations of digits, things like that, It's very variable and depending on where you go and in pediatrics as well. Um, here are p people don't do basically any hand surgery. All our hand is done by the hand, upper extremity division here. Um, except maybe some simple fractures. But, um, as far as uh hand stuff, which we'll kind of discuss a little bit as we go about the types of operative procedures that they do in pediatrics. And then one other thing to consider, there's only two subspecialties in orthopedics that have a separate extra certification. One is a sports medicine surgery and the other is hand surgery. So there's an extra, which uh one reason why I didn't wanna do it, that's an extra exam you gotta take and you also have to recertify every 10 years. So, but you have an extra subspecialty, you know, um certification on that, uh which is good. Um I think for, you know, um marketing and things like that, uh Although you don't necessarily have to ha have to take the subspecialty exam to still do a hand fellowship. But you can sit for that exam if you do a hi fellowship. Same for sports. You can only sit for the exam if you do a, a true sports fellowship. So, uh what are some common procedures that we do in hand surgery? Um This is kind of a, a real the most common things we do that are relatively simple. Um, carpal and cital tunnel releases. So carpal tunnel uh is obviously, um, you know, median nerve compression at the wrist, very simple surgery here. Um Several guys do endoscopically, you can see on the bottom, right? I tend to do a mini open procedure. Um This is most common, uh not with any trauma just with um irritation of the median nerve at the carpal tunnel with overuse, um, and scar tissue from probably uh microtrauma, um, trigger finger releases. I don't know if you ever heard of that when you trigger when you get stuck like this, it's a uh swelling of the A one pulley. So the A one pulley, basically the tendon gets stuck when it's trying to go through. Figure, it's definitely have to pull it apart. So that, that's a pretty simple surgery. Um, mucous cyst excisions, which are common in the uh uh IP joints of the fingers. They take those out and usually take out a little osteophyte with it. Um, CMC arthroplasty also really common um, problem that's arthritis in the base of the thumb, you, your thumb has, it has so much mobility and takes so much force through your whole life. It's a very common joint to get arthritic. There's about like, I don't even know probably 30 procedures to, to take care of that. None of them are perfect, but most of them do very well. Um So, uh this is just a rendition of one where they used the and then um weaving in, in and out to kind of recreate the ligaments and then they usually take out part of part of the trapezium as part of the surgery. Um gang men incisions are common at the wrist and also in the IP joints, removing those and then hand infections are another common one that they take care of that hand surgeons, take care of what about common trauma procedures that the hand surgeries or surgeons take care of probably the most common fractures, distal radius fracture. Uh This is a pediatric one up here on the right. Um But more common is elderly fractures. I think it's the second most common fractured bone in the elderly population besides the hip and the proximal humerus. Um they also take care of hand and carpal bone fractures. Um One that we talk about a lot are scaphoid fractures. You know, the scaphoid bone is easy to miss a fracture. It doesn't like to heal cause it has retrograde blood supply. So that's one we that is commonly, uh either operated on or just at least discussed in our conferences. Um Both bone form fractures are also relatively common. Uh whether it's in kids or adults and then lacerations is another common thing we take care of. So someone cuts himself, you know, even a small laceration with a piece of glass, um, or a knife and they were cutting something, uh trying to cook, they can cut a tendon nerve artery in the either the fingers or even in, you know, in the fingers themselves or even in the hand and wrist. Um, those things often need to be fixed, um to try to improve uh sensation to the hand if it's a nerve or blood flow to the hand, if it's a um, artery and then function would be the tendons, right? Um And there's some sa bunch of different ways to diagnose these and to, uh, um, you know, physical exam is pretty important for that and there's some pretty cool stuff you can do uh for that. Um But you'll hopefully learn that in your orthopedic rotations. Um, and then some orthopedic hand surgeons do with nine with extremities. Um, like you see here on the bottom, right? Um That's what we call it a man extremity. So that's um, sometimes trauma surgeons do with that. Here, we have a combination of uh the hand division and the trauma division usually cause there's not a, not a lot of hand surgeon in the hospital and this is usually covered by either the oncall person or the trauma person. And then the hand team comes in to kind to clean up and make sure that and salvage what else they can salvage. Um, these frequently are not uh reimplant if they're ma truly mangled. Um, as far as finger or hand reimplantations, that's more for clean injuries, um, like sharp, sharp injuries, um, with, you know, some digits, uh, with uh some digits um spared and uh the, those are a better chance of surviving. The problem with reimplantation is that the surgery itself takes anywhere from like 4 to 8 hours. So, and you gotta, it's better with a team. So you can have like a team of people helping. It's actually better with two surgeons. We have one working on the uh part that's still attached to the patient, one working on the other part to get it prepped, which we don't have the luxury of here. So we do do some reimplantations here. Um So of the plastics department, but not too many. Um, we are not, no, not a replantation center and several um a lot of places, especially at the northeast and other places in the south. They actually have transfer agreements where these all go to a certain number of large academic centers that do all the replantations for like their entire state. Like Duke is one in North Carolina. Um Louisville's one in Kentucky. Uh Mississippi has one in Mississippi, uh in Florida. I don't, we don't have one, specifically, several places do reimplant, but there's not one place we send everyone to for that. Um Maybe II forgot to stop earlier. Do you uh any questions about the kind of simple, simple or complex hand trauma stuff we do or I move, keep moving on. I think you're good to keep moving. OK. You got it. So, what about common elbow procedures? Uh The most common things we deal with are elbow fractures. Um Just the humerus fractures, electron on fractures, radial head fractures. Um Contracture releases are also relatively common elbow surgery. Um Contra contractures are very common after fractures or with burns. We see a, a fair amount of contractures with burns or also arthritis, you know, arthritis, um and have contractures, nerve decompressions. There's uh we talked about pal tunnel release before the ulnar nerve, but also um the pin can get compressed, the media nerve can get compressed in the around the elbow. Um distal biceps and triceps, tears um are also relatively common. There's a picture of distal biceps up here. We see some ecchymosis in the inner cubital fossa and approximately um retracted biceps, muscle triceps, tears are less common. Um but um they're also treated by hand up extremity surgeons and then hetero ossification, excision. Um We see this in posttraumatic um injuries, not even necessarily fractures. Sometimes uh any head trauma can cause for whatever reason causes your body to form heterotopic ossification and pla you know, forming bone in places it shouldn't form. So we see, and for some reason, it happens a lot around the elbow and forearm, even if there's no fractures in there. But if someone had a traumatic brain injury or some form of head trouble, it's relatively common. And we also see a lot of burns as well. For some reason, the burns stimulate the, that the elbow and the forearm to to uh uh have a lot of ossification in the soft tissues. And this can cause elbows, you know, this is kind of a part of the contracture release, but they're kind of different things cause a lot of the contracture release can either come from the elbow joint itself or from heterotopic ossification. What about more complex hand and upper extremity procedures? Um tendon transfers are a big one. So someone that has a radial nerve palsy, there's tendon transfers you can do or a laceration of a tendon that uh either was missed initially or was fixed and, and uh failed. Um You can do tendon transfers to get more function of the finger of your digits and wrist. Um Also things like cerebral palsy uh can cause you know the hand cause a hand like this, there's some tendon transfers they can do to try to get you a little more function out of it. Um Wrist arthritis is another complex problem that is uh dealt with by hand surgeons, you can do a proximal row carpectomy, which is a little crazy. But if you look at this top right picture, this is uh the the can you see my um mouse there? Yeah. OK. So figure a here, this is a pretty bad arthritic wrist. So this uh Sapho a rasca joint is really arthritic and some changes in the um scapholunate joint as well. And you can see this, the lunate is supposed to be touching the or very close to the scaphoid. You can see the, the um capitate is kind of pushing it down in there. So this is a procedure where we actually take out the, the all the rio carpal bones, uh the proximal row of the radio carpal bones and then let the capitate, articulate, ate fossa. And this actually does very well. People get decent pain relief and good motion. Uh Even though you're excising several bones of the hand. Um So that's a procedure for wrist arthritis, um arthrodesis where you just, you know, uh fuse all the bones of the wrist. The down the problem there is you're trying to get all these tiny bones to fuse. So imagine when you take the cartilage off those bones and some of and try to get some bleeding bone, there's not much left to fix to. Um but there are some options to do that. And then wrist arthroplasty um is not, has a very high failure rate. So it's not a common procedure. Uh Although it is done by hand surgeons, um, tumor excision, uh you know, commonly these are done by hand surgeons where even though orthoped oncologists operate all over the body, they're less familiar with hand um, anatomy. So this is often uh deferred to the hand surgery, uh team or even for a reconstruction and try to get more function out of hand after the after the excision too. Uh congenital deformity in the upper extremities is surprisingly common thing that hand surgeons see and especially the ones that see peds. So, um there's a lot of a lot of um syndromes, they can cause loss of uh parts of the limb and the upper extremity. Um Also congenital band syndrome can cause loss of the digits. Um There's several, you know, you, I don't know if you heard polydactyly where we have multiple digits. All these things are generally treated by hand surgeons. Um that, that do some pediatrics, um as opposed to pediatric orthopedic surgeons and the elbow arthritis, um is sometimes um dealt with by hand surgeons, sometimes shoulder surgeons, um not usually by sport surgeons. So, um for this total elbow arthroplasty, um This is a picture I took off the mayo website, uh Mayor Rochester and even the they probably do the most elbow replacements of anyone in the world. But even this one is poorly placed if you see the, the ulnar component is not even well seated it should be seeded way down here. So even on their website, they're gonna have great pictures of it. So these total arthroplasties um are also not great arthroplasties to do. They just have a very high failure rate, probably because of the amount of force that goes through the elbow is significant. It's also a sloppy hinge. So there, it's not a direct hinge, there's a little sloppiness in it, but there's still, it's still a constrained prosthesis, meaning you can't dislocate this. So there's so much stress on the implants and where the implants attach to the bone, that they just have a high failure rate and the soft tissue coverage in the back of the arm is not great too. So they also have a high infection rate as well. But there are other options for arthritis. You can do debridements, you can actually take out osteophytes um and release the soft tissue. And that actually does very well with elbow arthritis, unlike other joints, which is rarely done in other joints. But in the elbow that does pretty well in the in a position, arthroplasty where we put in a piece of uh donor like allograft between the at the end of the distal uh humerus. Sometimes that can help in a really young patient. We really reserve the toe of arthroplasty for older patients and very, very low demand due to the high infection rate and high failure rate. Um Now if, if it all goes to crap for an elbow. You can actually take everything out and you have a flare elbow, you've probably seen the videos of people with propeller arms. That's what they have. It actually functionally does. Ok. Um And surprisingly usually doesn't hurt, but that's not an ideal treatment for the, you know, that's, that's one reason why we try to avoid elbow arthroplasty because there's, if that goes south, there's not a lot of good options for those patients and then shoulder procedures. Um, common ones that hand and upper extremity surgeons do are shoulder arthroplasty, shoulder arthroscopy, um with cuff repairs or debridements, labor repairs. These are a little more commonly done uh by sports surgeons and shoulder surgeons, but they can be done by hand surgeons. Um Proximate humerus fractures, humeral shaft fractures, clam fractures, ac joint injuries too. All these can be treated by hand and upper extremity surgeons. Um These are probably more commonly treated by them because they, they often see older populations and older populations will sustain these injuries. Um standing shoulder arthroplasty, we more common to older populations. So there are several hand surgeons that, that do shoulder arthroplasty that includes uh Tom Wright. Um you know, our main, main guy here was actually hand trained. Um although he trained at mayo and did a lot of shoulder arthroplasty. So, um but a lot of hand surgeon will do that just to keep the business. Um This is a picture of a reverse replacement. Um This is the type we use an exact type reverse. This is a Mont style reverse and these are just pictures of rotator cuff, uh repairs. Um The idea of, you know, trying to pull, this is a um picture of with anchors in the bone and then anchors pass through the cuff and then put down to a lateral anchor. And that's what it looks like during surgery when you're doing arthroscopically. So, um I asked him, uh what you guys want to hear and he said, you, you probably want to hear what our typical week schedule looks like and a little bit more in detail about that. So typical weekly schedule for a hand over extremity surgeon is 2.5 to 3 days of clinic. Um The reason I say that is some people do take a half day to, you know, for admin time or to do something to, you know, have time off. Um Sometimes people add cases on that half day too, like if they're doing uh inpatient ors where they don't have a lot, a lot of time in the inpatient side, they might do that half day inpatient and do a case or two. Um Generally 20 days by most hand surgeons, these are typically outpatient ors in a surgical center. Um, you, they may have inpatient or days but very rarely because most of the hand surgery stuff can be done in the uh in the outpatient setting, which is much more efficient, um, to be, get a lot more cases done. Um, and, uh, the number of cases are very variable. It depends where you go here. We, we tend to do, um, you know, my partners that do focus most on hand surgery can do anywhere from eight to, you know, 1214 cases a day. Um, I've seen other places that are private practice, hand surgeons do 20 to 25 cases and be done by two o'clock. So, and if you're doing small stuff and you have t wounds and a high turnover, you can do a lot of cases here. We're, we're pretty efficient, but we're not as efficient as some of the places that do that. Um, other thing to consider, I think I have this on a different slide. Let's see, I'll talk about that in a second actually. And then call is very variable for hand. So some places, uh, if you're, if you're a true hand surgeon only, you don't take any inpatient call, uh, any hospital call, that's what happens in Jacksonville. There's not one hospital in Jacksonville that has a hand surgeon on the call schedule. Um, and they've just decided that they basically dropped their hospital privileges, so they don't have to take call and they all do outpatient surgery only. The problem is what if the patients still up and go somewhere when they have a major trauma. So if, if the general orthopedist won't take care of them, they end up sending them to us. Um, and that's just an example that we see here. That's not necessarily everywhere most patients do have, um, a hand surgery call schedule, whether it's orthopedics and plastics, that's how we do it. Um, the hand surgery here is, um, like three quarter or two thirds orthopedics and one third of plastics. Um, but for us, we don't even have a, I cover a hand call even though I'm not a hand surgeon. Um, all of the orthopedic surgeons cover the hand call. Um, at when it's when it, when we're on that. So, um, it's not exactly, uh that's not exactly mainstream, that's just how we do it here. Um And some places have a true hand and call schedule where there are only hand surgeons on call. So that's very, that's very variable depending on where you go, what environment you're in and what the hospitals deal with. And a lot of it for hand is, is, um, honestly, it's a lot of it is um voluntary and paid. Although if you want privileges at the hospital, they might force you to take uh either general call or hand call depending. Um, oh, I forgot to mention. It really depends for call, how many people are in the hospital and in your practice. So some people I know take hospital call for the whole hospital. Um, but that if there's 30 orthopedic surgeons or there. It's more than 30. Um, it's usually not that much. It's usually more like one and six or one and eight. and then, um, for, uh, so, but you also might have to take practice call, which might even be, if there's only four of you, four partners, you might have to take at least phone calls from, from your practice as well. But that all depends on where you go when you're done for a typical or day for hand subspecialty. Um Typically outpatient orders are starting between seven and 8 a.m. and you work until the cases are done. The benefit of this is when you work until the cases are done. The pa every everyone in there wants to go home. So they tend to be very efficient. They're usually not, um hourly employees there. There's no, they're not, uh shift workers. I mean, they just are there to get the work done when the work's done, everyone gets to go home. So that makes it very efficient. Also, in a lot of practices, you have an income from the ors you are a part owner in the or, and you can get some money from that whether you're doing surgery there or not. But obviously, it benefits everyone if you're doing surgery there. So that's a benefit in some places like private practice. Um, for inpatient ors, they obviously, delays are frequent as you guys have probably seen. Um, this is done for hand surgery and more complex trauma cases or more complex cases in patients. Like we here we have a cut off for their BM I um, or their medical problems. If there really has a high rate of them not being very be extubated or the concern for that is high, we'd send people there and then most microvascular cases or, or I would say probably all microvascular and reimplantations are done in the hospital setting. Cause again, those surgeries tend tend to take, you know, 4 to 8 hours. So you're not doing that in a surgical center. And it also has to be done acutely at the time as soon as possible to have the best results and those patients are admitted overnight. So all those are being done inpatient setting. And again, that's not every hand surgeon doesn't always do that. But um hand surgeons are the ones hand surgeon or plastic surgeons are generally the ones that do that kind of surgery. Um Did I mention, let's see, I mentioned one other thing. So you don't have to go for a lot of the hand surgery. You do not have to go to the or so a lot of private practice places will have or an or room in their clinic and set up for local anesthesia. Um They uh there's a new term for it, they call it wide awake local anesthesia. Um But uh you can do a whole carpal tunnel release, you can do trigger for your release while the patient's fully awake. The benefit of that is that you can actually test, um you can even do tendon repairs to the patient fully awake. You can actually test your repair in the or you can have the patient flex their finger or standing on a trigger. You can have see if the triggering truly goes away while they're awake. Um But you have to have um you know, there's a lot of stuff you have to have in preparation for that in case there's an issue. Um, you have all the surgical instruments there in a way to sterilize it and it's a little more, it, it's better for cooperative patients if a patient is very squirmy or worried that it can be very difficult, but I wanna fill that out there that of the few specialties out there. Um, hand you can do a lot of this stuff in the clinic and then you can get, you can work things out with insurance companies where you can make a fair amount of money in your clinic doing cases and it also is very efficient as well. Um, what's a typical clinic day? Um, it for a hand surgeon. Um, obviously our goal in all orthopedics is adequate and efficient patient care. Number one thing for hand stuff is access. So you have people with hand infections from the er, that come in um, lacerations from the, er, in order to get these people into your, you wanna get them into your clinic as fast as you can, so you can make the diagnosis and get them on the or schedule. Um Obviously, insurance plays a big role in this. Um Some, a lot of places don't take certain kinds of insurance due to the payment or lack of payment to those insurance companies or lack for approval. Um So this depends on where you go. You're gonna wanna have a good team and again, this is any specialty, but you wanna have good team, medical assistants, uh PA S and front desk staff to help get people into your clinic quickly. Be nice to everyone and get and get the your day done as fast as you can. The big thing with hand is that the surgeries are quick and you wanna fill your or time. So you wanna have to see enough patients to fill your ors. And this includes referrals from other people, including your own partners. If there's no other hand partners in your group, you might get busy quickly. And also pa S can see patients on their own as well and then refer you to surgical cases. So that helps get people in the door. And so you can see enough patients in your clinic to clear your O RSI would say. And this is just me making stuff up here, but a light clinic and for hand is 25 to 30 patients a day, which is generally what I see in a normal day for shoulder and elbow stuff. Uh heavy clinic, which is pretty common for hand surgeons. It's 50 to 60 patients. So um more hand surgeons are seeing, you know, upwards between, I would say 40 to 60 patients a day than, than what um the most of us are doing uh for other specialties because the surgeries are quick. You're trying to fill your or, and you need to see a lot of patients to get those cases. And then like I mention, you can do clinic procedures. So 11 of your clinic days or a half day, your clinic might be a few procedures in clinic, um which can also really help your, your revenue and also um access to care as well. Um As far as lifestyle goes uh for hand, um you know, there's always a question we get asked, but there is a lot less inpatient time and rounding than other subspecialties. Um Not every orthopedic special have you have to kind of inpatient time around, but this is one we have probably the least. Um And you also often have more control of your schedule. There's a lot more private practice jobs and outpatient surgeries gives you the um ability to have control of your schedule. It's a needed um Han a very neat um you know, desired commodity um could be one because it makes a lot of money for the private, for the practices, you don't lose patients and places that don't have han and they lose a lot of patients to send them out. Um, and because if they own their own surgical center at that practice, then you're gonna make money off of it too. So, um, so you can have a lot more control of your schedule this way. Um, an academic is not always like that, but in, uh, the rest of the world you can and then call we talked about is very variable depending on where you are. But there, uh there are several places that pay for hand calls. So I know some people that will take, you know, hand call at multiple hospitals at a time, uh and get paid for each one of them. So, uh the downside of that is you gotta know if they take replants, you probably can't do more than one hospital if you're doing replantations. But, um, that's how you figure out as you go. So that's, uh, that's all I have. Um I hope that was kind of what you guys were looking for. Um It's obviously not, uh I did not do a complete thing of all, all ki all types of procedures we do, but I tried to make it comprehensive enough. Um Any questions? Thanks Dr King. We have at least one.