Transcript

Will: [00:00:00] Knock, knock,

knock, knock. Hi,

welcome everybody to a mildly jet lagged edition of Knock, knock. I with me, your host, Dr. Glaucomflecken. You’re one-stop shop for all things eyeballs. And occasionally non eyeball related things. Uh, so yeah, I, I just, I flew in last night. I got in last night, uh, for, from New York City. Uh, I was there. I took the family on a vacation.

Probably talk about some of those things on the next Knock, knock, uh, high episode in a couple weeks. Uh, but, uh, I was there to, to do a, I did a couple talks and I’m gonna talk about something, uh, emergency medicine related a little bit later. But first, something very exciting to me. Uh, sorry, I, I might [00:01:00] struggle a little bit through this episode.

I’m very tired right now, but, um, uh, the, the, the, I don’t like flying like west coast to East Coast, east Coast to West Coast. It just, uh, you’d think I’d get used to it by now, but it’s, it’s always still really hard for me. Anyway, I didn’t get much sleep last night, but, um, something very exciting happened on my flight from New York City direct to Portland, Oregon.

It happened. You guys, I heard the call. Is there a doctor on the plane? Is it, I I can’t tell you how many flights I have taken. Hundreds of flights. I travel quite often. Uh, for somebody who still practices medicine, uh, I, I, it, it hasn’t happened. It has not happened. Now I know the floodgates are gonna open.

It’s like every time I’m gonna be on a flight, it’s just how, how the world works. Uh, but it, it happened, it was in the middle of the flight. Um, it was like a six hour flight. And, uh, uh, I, I kind of like. Didn’t register it at first. I was watching a movie. I had [00:02:00] the, the headphones in, plugged into the chair, and, uh, and I, I heard it, it just took me a second to register it, and then maybe I, I might have like slow played my response to touch the button.

Like, it, it, it might’ve looked like it was in slow motion, a bit like. Oh man. Okay. It’s happening. This is real. I was like, I was like, I reached up, someone else beat me to the punch, uh, but let the record show I did hit the button. I hit the button that that alerted the people that I am indeed a physician and I’m willing to help.

That’s what they asked me to do is like, if you are a physician, if you’re, I don’t know what they said, a, a medical doctor I think is what they said. Uh, if you’re a medical doctor, uh, please, uh, push your, your, your flight attendant alert button or whatever you wanna call it. Uh, and so I did and. Not, not, not, maybe not as, as [00:03:00] quickly as I could have, but I did it.

I did it. I did it after just a few seconds, but somebody else beat me to it. And that person was an internal medicine doctor. And so, um, I actually ended up just staying in my seat. I pushed the button and then one, as soon as the applied attendant walked by, I just, I got their attend. I was like, hi, I, I’m, I’m an emergency.

I, I, no, I didn’t say I’m an emergency. I said, I am a physician. I am, I’m willing to help. I didn’t say I was an ophthalmologist ’cause I didn’t wanna scare them off from me. I wanted to just really have the opportunity if they needed me. And so I said, you know, I’m a physician. Uh, and, and then they quickly said, oh, we have somebody.

So I was like, okay.

And, but I was there. I was there. I did my due diligence. I, I pressed the button even though I was a little bit terrified, uh, because of all the different types of medical doctors. I wouldn’t say I’m last on the list. [00:04:00] Uh, I would say there’s like a cohort of us there at the bottom. Uh, I, I probably like dermatologists, uh, radiologists, pathologists.

Psychiatrists. I, I’m somewhere in that range. Uh, uh, you know, the top of the list, you’re gonna have your emergency physicians, you’re gonna have your anesthesiologists. Uh, I would say like, probably like, like general surgeons, uh, people who do a lot of like body surgery. They’re probably really, uh, internists for sure.

Cardiologists. It would be great. Uh, and so. That’s, that’s, that’s what you want. And fortunately, the people on the flight had that available to them. Now it does. I don’t think it was a major, I don’t know exactly what happened with the patient, but it wasn’t a, a big enough deal that it, like I, I saw the guy, he was back there working on the pa uh, working on the passenger, whoever it was, and it took him like five minutes.

So I, I don’t think it was a serious thing, thank goodness. Uh, we didn’t have to, you know, have the flight diverted. Everybody was safe and healthy and happy. [00:05:00] Um, as far as I could tell. But it, I was, it was just kinda like, and my kids were looking at me ’cause the, the whole family was on the flight. Uh, and they, uh, it’s not like I couldn’t sit there and hide because everybody saw it.

Like, and, and I, when I say everybody, I mean like my kids. My wife, um, everybody, everybody heard the, the, the call and they all looked right at me. I was like, okay, I’m gonna do it. I’m gonna press the button. And even if they weren’t there, I still would’ve pressed the button. All right. But, uh, but it was, it was, um.

I don’t know. It was like a, I did get a rush of adrenaline ’cause I was like half asleep at the time. I got this rush of adrenaline, oh, I’m gonna, I’m gonna save a life. I’m an ophthalmologist. I’m gonna save a life. No, I did not, I did not save a life. Um, and probably better off for the plane and society as a whole if, if I wasn’t the primary, uh, uh, respondent there for that.

So, anyway, excitement. Excitement on our flight back. Okay. So, uh, real quick before we [00:06:00] take our first break, I thought I’d do a, a couple questions that came up. The last episode that was published. Uh, I, I went into a, a deep dive into the lens of the eye, the human lens talked about cataract surgery, the history of cataract surgery, which is fascinating.

Talked a little bit about, uh, the firework. Uh, which is always a fun thing to discuss. Um, but I did have a, a couple of of good questions that came through. Uh, uh, a lot of people are liking the, the first aid skits I’m doing where I’m just taking a random topic and just explaining it to people. So I’m gonna keep going with that.

Uh, one person at Virginia AM 6 4 0 4 said, can you share cataract surgery options for people with nystagmus? So the way we do cataract surgery, patients are awake. But they’re comfortable. We give them a little sedation through an iv, but they’re awake. Right? And, and sometimes they move. And people with nystagmus or just tremors in general, obviously they’re moving a little bit more.

Nystagmus. The eye is [00:07:00] constantly moving. Now, usually the amount of nystagmus, the amount of of little eye movements during the surgery is not big enough to like. Keep me from being able to operate on the eye. You might think, how are you operating on the eyeball? This is microsurgery. It’s all very fine minute movements.

How are you operating on an eye that’s constantly moving underneath your instruments? Well, we have ways of stabilizing the eye, so honestly, nyst, I’ve never seen a patient with nystagmus even more severe forms of nystagmus and thought, oh, the, the eye’s moving too much to do surgery. If we have to, if it’s a big problem, then what I’ll do is what’s called a retrobulbar block.

And that is as frightening as it sounds, uh, and not frightening for me, but for the patient. Um, because you just stick like a, a three inch needle behind the eye through, kind of go right under like through the lower eyelid, [00:08:00] uh, behind the eye into the intracon space, which is kind of. Basically the space between all the muscles behind the eye, and you inject an anesthetic.

And what that does is it basically immobilizes the eye. It, it provides, um, kinesia, complete kinesia. The eye will not move if you get the injection in the right spot. Uh, and so that’s actually how they used to do all cataract surgeries, doing cataract surgery under topical anesthetic with just numbing eye drops.

Is relatively new. I would say maybe within the last like 20 years we’ve been doing it that way. And there are some people, some practices that still 100% do blocks for every, everybody. Now I think that’s archaic. I don’t think that should be done. Because there’s risk involved. And now cataract surgery under topical anesthesia is so, the way we do it now is so safe that, uh, I don’t think you need to routinely do a retrobulbar block that is old fashioned and you’re [00:09:00] introducing risk.

I, I think that you don’t need to do, it can be useful in certain cases. Right, but routine surgery, no topical anesthetic. All right. Just numbing eye drops. All the patient needs little sedation through an IV to help them relax. Now, another question I got was, um, from at, uh, by the way, these are all on the YouTube channel at Glaucomfleckens, um, from a user at Carrie Brigham said, any advice on how to ease a reluctant patient’s concerns about cataract surgery?

My mom is scared because she has, has, has to have her eyes open during surgery. So this does freak people out. Uh. I’d say a lot of people, especially of the age that I’m doing cataract surgery, for the most part, people in their seventies age, they’ve all seen Clockwork Orange. The, the movie that very famously has the, well, the main character with, um, with eyelid speculums in like holding the eyelids open and it looks horrifying, it looks scary.

Um, and, but yeah, that we do use [00:10:00] those, like that’s how we keep the eye open. But your eye is totally numb. First of all, okay, so yeah, we keep the eye, and that actually helps people sometimes because people are always afraid. Like, what if I blink? That’s a, that’s a question I get asked a lot in pre-op. Oh my God, what if I blink?

I, I don’t like people coming near my eyes. Well, nobody does. That’s, it’s a reflex. Like someone comes at your eye, you’re gonna blink. But don’t worry, I have control of your eyelids. All right? You can blink all day throughout the surgery. Not gonna bother me. All right? So don’t worry about blinking. The other thing that really reassures people is knowing that nothing is going, they’re not going to see anything coming at them, alright?

The everything is happening so close, either directly right in front of your eye or inside your eye. You cannot make out those objects. That is way too, even the most nearsighted of you. You are not nearsighted [00:11:00] enough to be able to see scalpels coming at you and all the little instruments that we use. So don’t worry.

When it comes to eye surgery, no matter what the eye surgery is, you will not see any of the instruments that we use. You might hear noises like we have like this tugboat sounding thing, and people say, this music is awful. And I’m like, yeah, it’s terrible. It’s the worst music in the world, but you don’t see anything in any of the scary stuff.

You would think is scary. All right. It’s all, it’s, it’s just happening way too close to you, so don’t worry about that. That was a great question. Uh, here’s another good question, or really more of a comment question. More of a comment. Uh, at Utsu p Enjoyer said, I’m looking forward to the day when we can actually cure slash reverse cataracts, not just replace our natural lens with an inferior intraocular lens made of plastic.

I completely agree with you. Honestly, that is the ultimate thing, right? [00:12:00] Because, well, actually for some people, because, um, people who are I atropic, which means that you basically without glasses all your life, you have 2020 vision. All right, I’m gonna raise my hand ’cause that’s me. I am, uh, maybe I’m like mildly hyperopic, but I’ve never worn glasses before.

All right. Reality is coming for me in a hurry and it’s gonna suck. Whenever I start wearing reading glasses, I’m already dreading it and I’m just about to turn 40. It’s coming for me. It comes for us all. Uh, but for people who are Imma atropic, who’ve never worn glasses before in their life, the, the, the perfect thing.

Would be that you can just melt the cataract away. You can reverse the effects of aging of the lens, uh, to make the lens clear. Again, we don’t have that technology and don’t let anybody convince you of that. Otherwise, I’d say every year there’s like a couple weeks where there’s a story that was published and [00:13:00] some.

You know, popular science website that’s like, you know, the future is here. Eye drops that will, that will eliminate cataracts. No, that does not exist. I’m not gonna say people aren’t working on it, but it does not exist and it is not close. Okay. So in the future, could we figure that out? Well, sure. Like we’re trying to reverse aging in a lot of different ways.

Um, the, it, it’s, it’s a harder. Harder thing than you would think because it’s these, these proteins that just get packed. You basically would have to, you’d have to arrest the proliferation of cells in the lens somehow, because as those cells develop. It causes the older cells to get squished harder and harder in the center of the lens that causes it to, to, you know, get darker and cloudier.

And so I don’t, I don’t know, I don’t know how, how you’re gonna do it, but, uh, [00:14:00] yeah, that would, that would actually be great because then people who are atropic who don’t wear glasses, well, they start having problems with cataract. You melt away their cataract with however you’re gonna do it, and all of a sudden their lens is clear again and they have 20-year-old eyes.

I’m always telling my patients. Whenever we talk about cataract surgery, that these, these artificial lenses we put in their eye, they are inferior to your natural lens, 100%. Nothing will beat the original, the OG lens. Nothing will beat that. So I cannot give you Mr. Or Mrs. 80-year-old. I cannot give you 20-year-old eyes again.

That is not happening. The best technology we have. Not gonna happen. I cannot reverse the clock like that, but I can improve your vision. I can, I can make your vision better, but it’s not gonna be like when you were 20. We don’t have the technology, so, uh, hopefully we will at some point, and I know there are some very smart people that [00:15:00] are working on it.

All right, let’s take a break.

Kristin: Hey will. Hey, what’s up? I’ve been thinking the US healthcare system. It needs some improvement. 

Will: Yeah, it’s, it’s, there’s room for improvement 

Kristin: for sure. Yeah. It’s a confusing, scary place for everybody involved. 

Will: Absolutely. 

Kristin: Physicians, families, patients, everybody. 

Will: Everybody. And I’ve experienced it from both sides, right.

I’m a physician, I’ve also been a patient, so I wanted to use my platform to give people practical education. Really the only way that I know how. By making jokes. So Dr. Glaucomflecken really fun and super uplifting. Guide to American Healthcare is Out and it’s a free resource that includes all my videos from the 30 Days of Healthcare Series, alongside deeper explanations, also reliable facts.

Emphasis on reliable. Yes. All right. Uh, uh, figures, uh, numbers, insights into how each of us can fight for a more humane, [00:16:00] better healthcare system. Also it has jokes. Did you mention the jokes? I did. I jokes. Okay. Yes, definitely jokes. Well, 

Kristin: this guide is great for anyone looking to learn more about US healthcare, but especially if you are experiencing it from the clinician side for the first time.

That’s right. We really hope you’ll check it out. 

Will: Get the free guide sent straight to your inbox by signing up for our mailing lists. Glaucomflecken.com/healthcare. Enjoy. Kristin, I gotta tell you about a new podcast that every clinician should know about. Good. 

Kristin: Tell me. 

Will: This is the sepsis spectrum.

Okay. It’s by the Sepsis Alliance and Critical care educator, Nicole Kic. This is really important. Each episode is about confronting blind spots and sepsis and antimicrobial resistance education. A lot of this stuff usually doesn’t make it into textbooks or compliance training. 

Kristin: That’s weird because it’s super important.

Will: Yeah. Everybody needs to know about this stuff. You can listen to the sepsis spectrum wherever you get your podcast, or watch it on the Sepsis Alliance’s YouTube channel. To learn about how you can earn free [00:17:00] nursing CE credits just by listening. Visit sepsis podcast.org.

All right. I gotta talk about a, a content creator. Um, who, it, it seems to me, I’m talking about Dr. Elizabeth Potter. Check her out. Uh, she’s gone viral a handful of times. Um, uh, she’s a, a, a a a, an oncology surgeon, a gynecologic surgeon, breast surgeon. Uh, and she, it almost seems like she was kind of thrust.

Into the spotlight, so to speak, and then embraced it, uh, in a form, uh, in a way, uh, that involves a lot of advocacy. So if you recall, and I think I’ve talked about her before, but uh, she initially went viral because she documented a situation where she was called out of the operating room. [00:18:00] Actively like doing surgery or about to start surgery.

I think that was what she was about to begin a surgery on a patient. The patient was in the room on the, the, or bed and, uh, a patient who was having some kind of cancer related breast cancer related surgery and would have to be admitted to the hospital after the surgery. And she was, quote emergently, called out of the operating room because she had a, a, a, an urgent phone call from.

United Healthcare who said, oh, I’m sorry. We made a mistake. Uh, we should not have approved that patient’s hospitalization, so we are now going to deny this hospitalization. We will not pay for it. She documented all this and think about the, the, the position that puts a, a, a surgeon in, right? This patient.

Needs this surgery, like no one does unnecessary [00:19:00] oncology related surgeries. Like that’s, that’s absurd, right? This patient needs this surgery and so now you have a decision to make. Right. Do you, do you, if, if insurance is honestly refusing to cover it, do you, do you cancel the surgery that this patient needs to help treat their cancer or the complications from having cancer, or do you do it?

And just hope that you can appeal and, and appeal and appeal and do peer-to-peers. And eventually they’re gonna cover it. Uh, but if not, the patient’s gonna risk financial devastation, bills that they’d, no way that this is expensive stuff. This is thousands and thousands, tens of thousands, sometimes hundred thousand of thousands of dollars worth of medical care that the patient’s on the hook for.

’cause insurance is refusing to cover it like that. That’s the kind of position that she was put in. So she documented this, she posted it and went viral. ’cause it was a [00:20:00] ludicrous, just outrageous experience that she had to think she had to do in the moment. And then she went viral further because she received basically a, like a cease and desist from UnitedHealthcare.

Saying like, like you should, you know, I don’t know. You can go and look at her profile. She’s on multiple different platforms. Uh, you can definitely find her on TikTok, I think Instagram as well. Um, and, and go through like the whole thing. But, uh, uh, basically she, she received threatening communication from the insurance company that says, don’t do this, don’t talk about this, don’t post this type of stuff on social media.

And since then, and that just poured. Gasoline on her fire. And then ever since then, it’s been great. She’s now doing this thing, which is why I’m talking about it now because, uh, this is another thing. She, she went viral for. Everybody’s talking about it in healthcare, at least. [00:21:00] Um, where she, she recorded herself, and I think she’s done this a few times, recorded herself on the phone doing a peer-to-peer review.

I have not seen, I, I am on, I am on social media like just as much as any other healthcare professional. All right. To, to, to an, uh, an insane degree, uh, on social media way too much. So I know I, I’ve seen the people that are doing like healthcare related advocacy. I have not seen someone take this type of risk to sit there and film themselves on the phone with a health insurance representative doing a peer-to-peer review.

If I say it’s, it’s, it’s brave, it’s courageous. It is. Absolutely. I’ve never done that. Part of that is, is because I, I, I actually, in my job, I don’t do a lot of peer-to-peer reviews ’cause I, I don’t do a lot of, I’m, [00:22:00] I’m mostly comprehensive ophthalmology, so I, I guess I’m denials, but usually we can appeal those and it eventually goes through, I don’t personally do a lot of peer-to-peer reviews.

Even if I did, oh man, I don’t, I don’t know if I would do it this way. I don’t know if I’d make this type of content. And that speaks to how brave she is because, um, in this situation, she is already pissed off the health insurance company. And so now she’s doing more things and these conversations and it’s, it’s great.

It is great content because, uh, you can, you can, you’re only hearing one side. So I think that’s smart, right? She’s not recording the voice of the other person she’s on the phone with, but you totally know what’s happening with the way she’s narrating. She’s talking to the other person. She is making sure that people who are watching this video know exactly what’s happening with this conversation.

It is fantastic, fantastic content, and what [00:23:00] an incredible bit of advocacy because what better way to really show the pain points? The bottlenecks, the, the source of why your care gets denied. What better way to show that than by actually filming it happen in real time. And I’m, I’m sitting there watching this and she’s, one example is like she’s, uh, um, uh, on the phone trying to get a, like a lymph node, some kind of surgery to reroute basically a, a surgery to treat lymphedema.

From a breast cancer surgery complication. Um, and, and she is having, the surgery has gotten denied and she has to do a peer-to-peer review. But guess who, what kind of doctor she gets on the phone. An oculoplastics specialist. So lemme just tell you what an oculoplastic specialist is. This is someone who did [00:24:00] ophthalmology residency like me.

But then did two additional years in facial plastics. In no way, shape or form is breast cancer or the breasts in general involved in any of this person’s education, training, or practice. And I will tell you now, if any kind of ophthalmologist, including oculoplastic specialist, uh, tries to examine your breasts.

Call the police. That’s, that is, that should not happen. That should, that should not happen. Okay. Uh, and so the fact that she has to try to convince this person’s like the gatekeeper for, for her patient having this surgery that Dr. Potter knows that this patient needs is, is infuriating. And you can just, I’m just, I’m just.

[00:25:00] Seething just watching this conversation happen. But that, that’s like, this is, this is happening thousands of times every day for all the different insurance companies. They’re making doctors do this, you guys, they’re making doctors talk to people who have no expertise in what they’re recommending for patients.

And it’s, that’s what we’re dealing with. And so when I say the peer-to-peer review is, uh, system is broken, the prior authorization system is broken. I mean, it is, it is like, is beyond repair and, and that this is why we’re doing, this is why I make these type the, the videos that I do. Why Dr. Potter does the things and I’m gonna get on the podcast where I, we’re gonna reach out.

We’re gonna try to figure this out ’cause I, I wanna talk with her. Just to tell her how amazing it is that, that she’s doing this, uh, and putting her own, um, her own practice at risk too, because that’s the next thing is that she is, uh, uh, being [00:26:00] retaliated against. That’s, that’s the le the, the latest update is that, uh, UnitedHealthcare has dropped her from their network.

She’s done all the things that she’s supposed to do. She’s signed the forms. She’s, she is compliant, but, but they have dropped her. And guess what? That’s just something they can do. They do it all the time. I’ve heard from, from solo family practice docs who just ask, Hey, you think I can get a little bit better reimbursement rate?

And the United Healthcare is like, well, not, uh, we don’t like that. We’re gonna just drop you. Instead, that happens. They, they have so much power. They, they, they just wield it over everything. And so now Dr. Potter’s like her, her practice is threatened. She’s gotta GoFundMe to help like save her practice.

This is outrageous. This is stupid. This is like the, we, [00:27:00] I mean, talk about a physician shortage. Well, now we’re like, like, might lose physicians because of stuff like this. ’cause of the health insurance companies just throwing their weight around doing things that should be illegal but are not for some reason.

Oh man. It, it’s, it fires me up. I can’t, I hope we get a chance to, to talk on, on, on the knock, knock high and, um, so I’m gonna work on getting her on. But, um, uh, it’s uh, just a wonderful, wonderful advocacy that she’s doing. Really showing, showing what’s happening. All right. Uh, let’s, um, I do, I swear I have some eyeball stuff, so I’ll tell you what, let’s, uh, alright, let’s take one more break and we’ll come back and I’m gonna talk about, um, some emergency medicine ophthalmology crossover.

What should, what should do in there, buddy? I’m so glad you asked. Oh, I’m being a Dex. 

Kristin: Oh, are you? 

Will: Yeah, that’s what they sound like. 

Kristin: Those little [00:28:00] mites, 

Will: Uhhuh, I, if you put a microphone in front of them, I’m sure they would probably most likely maybe sound like that. 

Kristin: You think so? 

Will: I don’t really know. 

Kristin: Oh, well, let’s see how much you do really know.

Will: Oh, you’re gonna quiz me? Yeah, let’s do it. 

Kristin: What are the only two main species of dex mites found in humans? 

Will: Uh, type one and type two. 

Kristin: Uh, close dex follicular, which are found in the eyelash follicles. Okay. And dex brevis, which are found in the meibomian glands. Okay, 

Will: sure. Yeah. Okay. Next one. Next question.

Kristin: Okay. Why do people with Dex blepharitis often feel itchy eyelids first thing in the morning? 

Will: I know this. And, uh, because they avoid light and come out at night to mate. 

Kristin: Oh 

Will: yeah. There’s, they’re mating on your eyelids while you’re sleeping. 

Kristin: Super. 

Will: Is that, is that a, how does that make you feel? So gross. 

Kristin: And 

Will: so people wake up that itchy, irritated feeling ’cause they’ve been moving around and the eyelash follicles all night.

Kristin: Mm-hmm. Yeah. Yeah. Great. 

Will: I’m surprised you even brought that up. 

Kristin: I know. I’m just trying to get used to these mites since Demodex blepharitis is such a common disease and keep talking about them, it’s 

Will: And that’s a [00:29:00] big step. That’s a big step. Thank you. There’s a prescription eye drop, though that’s available for Demodex Blepharitis.

Yes. To learn more about these mites and Demodex blepharitis, visit mites love lids.com for more info. Again, that’s M-I-T-E-S-L-O-V-E-L-I-D s.com To learn more. This ad is brought to you by Tarsus Pharmaceuticals.

Okay. So I, um, uh, as I, as I mentioned earlier, just got back from New York City and I did something I haven’t done in a while and I, oh, I forgot how much I love it. So back in the height of the pandemic, everything was virtual. Uh, this is like when I first started speaking. Doing speaking engagements as Dr.

Glaucomflecken. It was, it was all virtual and it was almost all emergency medicine grand rounds. I probably did like 20 different grand rounds for different places around the country, virtually. And when I tell you that it sucks to be a comedian and give a [00:30:00] virtual talk, like, please trust me on this because, uh, I, I, I told hundreds of jokes over the, like a year and a half, thousands of jokes, and I just had to assume they were funny.

To get through it because I was just looking into a webcam and everyone else is on mute. That that is a terrible thing to have to do as a comedian. I hated it. Um, but, uh, and then, and then eventually I was able to do a, a few, like in-person. Emergency medicine grand rounds, and it’s, it’s a lot of fun.

Turns out when you get to like, be in the room and hear, hear people react to what you have to say and see their eyeballs and see their reactions and, uh, and hear the, hear the what they, the, I found out that some of the jokes I’ve been telling for a while were, uh, totally not working. And so it was, it was helpful for me to retool my comedy, but, um, um, it’s, it’s been.

For the past like couple years, I’ve mostly just been doing like keynotes and stuff, so I haven’t had a, a, a good opportunity to do like a, like a grand [00:31:00] rounds where it’s like a smaller group, like it’s a department. And so I did it recently. A friend of mine, um, at Mount Sinai in New York City, uh, wanted me to come out.

And I was already gonna be there, so it worked out well. Uh, and so I went and did, uh, grand rounds for their emergency medicine department, and I talked about all kinds of, I just showed eyeball photos. We played a game during grand rounds. It was called, what is this? Where I just showed an eyeball photo and I asked the residents, what is this?

I think they loved it. At least they pretended to, uh, and it, it, it’s just there are a few specialties out there. That are as enjoyable to like, hang out with as emergency medicine. It, they’re, I don’t know, there’s something about these, they don’t take themselves too seriously. Uh, they joke around. You typically don’t have to dress up as nice, which is, which is always a, always a great thing.

Um. But some of the things I talked about, uh, I thought of what I [00:32:00] could do here just to make sure we get some eyeball stuff into this, into this episode. So, sorry about that. If you guys have been waiting, like where’s, where’s the eyeball stuff? Funny man. Funny eyeball guy. So, um, I thought I could address a couple of controversies, uh oh.

That over the years have kind of come and gone and they’re still kind of there. Where there’s like disagreements, I would say not so much controversy, but just disagreements between the emergency medicine folks and the ophthalmology folks. And I address these during my grand rounds, which is, which is a lot of fun.

So the first one is the use of tetracaine on the eye. So when you have a corneal abrasion, those of you have had a corneal abrasion. You know how painful it is? It is the, the cornea has the most nerve endings. I, I think that like anything in the human body, so when you get a scratch, when you take off a piece of that corneal epithelium, it is extremely painful.

I have people that come in and tear their crying. [00:33:00] They’re, they’re in darkness. They can’t, they can’t open their eyes. Uh, and, and, and then you give them a drop of topical anesthetic tetracaine or propa canine in it immediately. Within seconds takes their pain from an 11 out of 10 all the way down to a zero.

How many medications do you know that can do that in seconds? Almost instantly, the worst pain they’ve ever felt, felt in their life down to zero, it’s magic. And so you can imagine the next question that I usually get asked. For people that have a corneal abrasion, they say, can I have some of those drops to go home with?

That is, they always ask that and you can’t blame them. This is magical medicine. Uh, but unfortunately the answer is no. As ophthalmologists, we don’t do that. Now, this [00:34:00] cause has caused some controversy, some arguments over the years between emergency medicine and ophthalmology because as you can imagine, with 10, outta 10 pain, a lot of these patients will go to the emergency department.

And for a long time, patients will just, they’ll end up with going home with a bottle of tetracaine and we don’t like that as ophthalmologists because you know, over the years, all of us have occasionally seen patients that will use up that entire 10 milliliter bottle of Tetracaine on the eye. To treat their corneal abrasion.

The problem with putting topical tetracaine that often on the eye is that it delays healing. So the, the corneal abrasion doesn’t heal very quickly at all, but it can also cause melting of the eye and scarring. It’s a, it’s a toxic medication and when you use it for like a week at a time and a bottle of tetracaine has 200 [00:35:00] drops in it.

Alright. We use one drop in the clinic. Then we examine them and then it eventually wears off and yeah, their pain comes back. And that’s why people in the emergency department tend to give this bot like a bottle of this stuff out to patients is because if, if they don’t, sometimes the patient will just, in the parking lot, they’ll just turn right around and come right back in.

It’s like the pain’s unbearable. So from their perspective, you can understand, oh, like, like what are we gonna do? Like you can’t have these patients keep coming back every 20 minutes. Once, once the prep, prepare came, once the numbing drops wear off and they have, they still have this abrasion. And in ophthalmology we don’t have that problem because what we do is we give patients a bandage contact lens so we can put a contact, it’s like a bandaid on the eye.

You can see through, but it, it dramatically decreases the pain. It takes it from a 10 out, 10 down to like [00:36:00] a two out of 10, manageable for UN until the eye, until the cornea heals and the cornea heals very quickly, like within the first 24 hours of the worst, and then it dramatically improves. That’s what I always tell people that reassures them, I think.

But we, we, they have a bandage contact lens. Emergency departments. They’re not gonna stock contact lenses. That’s ridiculous. Like they, they have way too many other things to worry about than like, whether or not they have bandage contact lenses or how to put them in or all that stuff. So, so anyway, so we don’t have to even think about giving patients for para cane because we have other things we can do to help decrease the pain.

So that, that’s the setup for the conflict. Right. And so the, the, the, the line in the sand from an ophthalmology standpoint for decades has always been you don’t do this, stop it, emergency physicians. But it really, that just totally disregards the [00:37:00] reasons why emergency physicians over the years have wanted to give this stuff out.

So the emergency medicine docs got together and they published a great study. It was, I wanna say 200 to 300 patients. And what they did was they gave patients with a simple corneal abrasion, uh, they gave them 24 hours worth of tetracaine, which, uh, amounts to about one mil, one to two mils. A, a typical bottle of the stuff is 10 mils.

Right. So the idea was that, okay, well ophthalmologists, you guys keep telling us like don’t give a bottle of it out. Don’t give 10 milliliters out because the patients will use up the whole thing and they will. So what if we just give a smaller amount, you know, is that still dangerous to the eye? And this is a study that ophthalmologists would never do because we don’t need to.

We have those bandage contact lenses. The emergency medicine folks, they did it. And guess what? [00:38:00] It shows that 24 hours worth of tetracaine for a patient to go home with, to put in their eye every few minutes until the pain starts to get better, until the abrasion starts to heal. Actually is safe. It doesn’t prolong the healing time.

Uh, they did not have additional visits to the eye doctor or the emergency department. They didn’t have any adverse events like corneal melting or some of the, uh, scarring, some of the really dangerous, awful things that, that, uh, that we see when patients dump a whole bottle of it in their eye. And so I’ve had to change my approach to this.

I, I, I have, I now go a, a little bit against the grain, a a little bit against what my fellow ophthalmologist would say, and I say, okay, probably is okay, 24 hours worth. But you know what that means? And this is what I told all the residents when I talked to them at Mount Sinai, like, if you do this, you have to only give 24 hours worth.

That doesn’t mean giving them an entire [00:39:00] bottle and saying, only use this for 24 hours. That’s nonsense. Patients will use the whole thing. ’cause again, it’s magical medicine, so you have to work with your pharmacy or do it yourself where you actually like, parse out 20 to 30 eye drops into a container and give that to the patient to use.

So we had that conversation and uh, I feel like that’s, that’s a very, it’s a very magnanimous and, and. You know, it’s, it’s a way to, to reach across the aisle, so to speak. And so we’re, we’re not all fighting with each other about the prepared grain issue, but it’s still, I would say, an unpopular opinion in the world of ophthalmology.

’cause we just don’t think about it. That’s, it’s just not something that we have to do. And, um, maybe that’s something that like, it’s been a real benefit for me doing all this Glock flecking stuff is because I spend a lot of time learning about the different specialties. Not like the medicine of the specialties, but.

What, what it is that, [00:40:00] that, that really irritates them and bothers them and, and the challenges that they have from a patient care standpoint. Uh, that, that just helps me, helps give me a, like a, a different perspective of, of what people in that specialty are going through compared to my own. Because as you can imagine, ophthalmologists, we don’t get out very much.

We don’t, we don’t talk, we don’t really interact with specialties outside of our own very often. The other thing we talked about is ultrasound. That was the other one. So, uh, this is my stance on ocular ultrasound because, uh, in fact, what I did was I, I just showed a picture of an, of an ultra, an eye, an eyeball ultrasound, and the, the whole crowd, all the residents, they’re just whooping it up.

The big cheer for ultrasound, they love you guys. Emergency physicians, they love their ultrasound and for good reason. It’s low cost. It’s, there’s no radiation as opposed to a CT scan. It’s [00:41:00] quick, you can diagnose it. It’s just, it’s kind of revolutionized the EV evaluation of diagnosis and treatment of so many problems.

I and non-I related. That being said. It’s, uh, some of the things they, they wanted, uh, emergency physicians like to use ultrasound for are nonsense. I’ll say it. Nonsense. Traumatic eye injuries, never need to do it. You don’t need to do, there is no reason to ultrasound a traumatic eye injury. People will have told me before, well, you know, we’re using it to try to evaluate an open globe.

No, you don’t do that. You don’t need to do that. All right. Your exam. You can do an exam, you can actually look at the eye. What if you can’t get the eyelids open? Well then you call an ophthalmologist or you do a lateral cant autotomy. You have to look at the eye or get someone that can look at the eye.

Ultrasound will not suffice for actually [00:42:00] visualizing the front of the eye, so get those eyelids open. Whatever way you can Also, oh, well we, we gotta use ultrasound on, on this o. Potential open globe to see if there’s any foreign bodies. No, you’re gonna get a CT scan. ’cause we gotta see the, we gotta see everything.

We gotta, we gotta see the back of the orbit. Can your ultrasound reliably see the back of the orbit? I don’t think so. We gotta be able to evaluate for orbital fractures. There’s so many things and so the patient’s gonna get a CT scan anyway before they ever go to surgery. So ultrasound for traumatic injuries, dumb.

The one thing I, I will say eyeball ultrasound could potentially be useful for is looking for retinal detachments. Retinal tears, and there’s a very specific situation where I think this could be useful is if you’re an emergency physician in a rural area where a patient comes in with flashes and floaters and they have a visual feel like a curtain coming over their vision and you, you’re not [00:43:00] great at a fundus exam because nobody outside of ophthalmology is great at a fundus exam.

And so you put an ultrasound on the eye. To see if you, if you can diagnose a retinal detachment, and apparently they can. There’s, like the literature shows 95% sensitivity for diagnosing a retinal detachment. So if, if that is going to be your decision point on whether or not you as a rural medicine physician have to send a patient two hours away urgently to be evaluated for surgery.

I get it. That makes sense. But for all of us, in kind of more urban areas where you have, where eye doctors are readily accessible, the, the standard of care for patients that have a retinal tear or retinal detachment is they need to be evaluated by an ophthalmologist really within 24 hours. A lot of people think.

Retinal detachment that is emergency, that is what we, what I [00:44:00] call a pants patient, where you tell me the patient has a retinal detachment. I’m putting my pants on, I’m coming right in to see the patient. 2:00 AM 3:00 AM doesn’t matter. That’s not true. Alright. Generally within about 24 hours is fine. Okay.

So if I get a call from an emergency physician and they tell me, oh, they saw a retinal detachment on ultrasound. Okay, that’s great. I’m still gonna see that patient at the same time I would. With just a report that this patient’s having flashes and floaters. If it’s coming in in the middle of the night, I’m gonna see that patient first thing in the morning.

If it’s coming in in the afternoon, I’ll just see ’em right then just come on over to clinic. Alright. But during business hours, because if a patient’s gonna go to surgery for something like that, you wanna have the A team for retina surgery. And the data we have shows that patients do just fine if they have surgery.

Not, not, it doesn’t have to be within like an hour, but. But within 24 hours is fine. All right, so the point is for the vast majority of these [00:45:00] ultrasounds that emergency physicians are doing for retinal detachment symptoms, flashes and floaters, it’s not changing really the decision point. The decision of what I do as a, as a consulting ophthalmologist, and I, I know some physicians don’t like to hear that because it makes me think I’m, it makes them think I’m saying that they’re doing something unnecessary.

I’m not gonna say that because it’s more now than ever. Ultrasound is just becoming a diagnostic tool, right? It’s just another tool in your toolbox. We can get into, okay, well, if they’re doing something that doesn’t necessarily have to be done, are they billing for No. You know, there’s some ethical considerations there.

So I, I never get mad at someone for saying they did an ultrasound of the eye. I just, I’ll tell you honestly, as an ophthalmologist, that doesn’t matter to me. That’s not gonna change what I do. So those, those are the, those are the two at times contentious conversations that I have with my wonderful [00:46:00] emergency medicine colleagues.

But also I just, I showed some, some, some gross eyeball photos. They love the gross photos. That’s great. Everybody loves a good gross eyeball photo. Uh, played some videos, talked a bit about my story, the cancer, the cardiac arrest. I basically just tried to, to give some, some life advice to the new interns, how to, how to make it through residency.

And, um, and it, it was just a good time. Took a lot of photos. I loved it. I, it was, it was so great. You know, the, the, the big conferences where I’m speaking to like. 500 people. Like those are fun too. But, um, sometimes it’s nice to like be in like a smaller room or you just really get to, you get to actually talk to people in the audience and, and interact with them and, and, um, and really teach something.

So. I had a great time, thanks to any of you, um, who are from Sinai. Uh, you know, uh, I really enjoyed that. So that’s it. That’s it for knock-knock eye for today. Um, next time I promise I’ll do like more eyeball stuff. I know it was like heavy on the non [00:47:00] eyeball stuff today, but we’ll get back into it, uh, next week.

So, uh, thank you all for listening. Again, you can leave a comment on our YouTube channel at Glaucomflecken. Flecking. Alright. I, I look at those every week right before I record. I look at those and I decide on which ones I want to kind of. Us, so leave a comment for me. Uh, I’m your host Wolf Lan, also known as Dr.

Glaucomflecken plugin. Thanks to my executive producers Aaron Corny, Rob Goldman Ashanti brick editor engineers, Jason Portizo. Music is my Omer, Ben-Zvi. Knock, knock, high and knock, knock High is a human content production. We’ll see you next time.

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