Monthly Archives: December 2014

States Should License Orthopaedic Assistants

by James D. Hundley, MD

A Case for Encouraging, not Discouraging, Orthopaedic Assistants

            A wise person has been quoted as saying, “For every action there is a good reason and then there is the real reason.”  I wonder if something like that that may apply to the position being taken by the American Academy of Physician Assistants (AAPA) in regards to the American Society of Orthopaedic Assistants (ASOA).  As I understand it, the AAPA has taken a position opposing the licensing of Orthopaedic Assistants based on brand infringement and an inadequate knowledge base.  Is it really about patient care or is it about turf protection?

In the first case, the ASOA has conceded the use of the word “Physician” in the name of their organization.  They are no longer the American Society of Orthopaedic Physician Assistants but are now the American Society of Orthopaedic Assistants.  Thus, that argument has become moot.  If there is an argument against their knowledge, based on my my long-term experience with an Orthopaedic Physician Assistant (OPA) and many years as a member of the National Board for Certification of Orthopaedic Physician Assistants I beg to differ.

The OPA with whom I worked for over thirty years was highly knowledgeable and served as a valuable member of our team.  His services in the operating room, the hospital, and the office were invaluable.  He not only made me more efficient, he made me better, which allowed us to deliver better patient care.

My role on the National Board was helping to update the written certification examination every two years.  This process was directed by a nationally known, professional educator and performed by board certified Orthopaedic Physician Assistants and Board Certified Orthopaedic Surgeons.  The questions and answers were evidence-based, pertinent, and difficult.  As with other boards, candidates were required to have a certain amount of experience before being allowed to sit for the examination.  From my detailed review of the questions, both experience and appropriate education were required to pass it.

The issue that should be getting the attention of all medical organizations is the impending growth in medical manpower needs.  The population is aging; we hear that 10,000 Americans turn age 65 every day.  Population growth is outstripping the growth of medical providers.  Medical schools will not be able to keep up with the number of physicians needed.  New schools are being opened and old ones are expanding, but they simply cannot turn out enough additional physicians quickly enough.  I believe that the void will have to be filled with physician extenders.  The greatest numbers will be physician assistants and nurse practitioners but I believe that there will be an important role for trained orthopaedic assistants as well.

The roles will be different and physician assistants should well know that.  Their roles and, therefore their licenses, are different from physicians.  Orthopaedic assistants will have to perform within their licenses, too, and I believe that they are prepared to do so.

So why is it important for Orthopaedic Assistants to be licensed by their states?  Along with being certain that they are certified and qualified, the issue of payment is huge.  If they are not licensed, third party payers will not pay for their services.  That means that the surgeon would have to pay for the assistant out of the ever-diminishing compensation he receives for a surgical case.  Alternatively, he could use another surgeon as an assistant a level of compensation higher than an OA.  Thus the surgeon is incentivized to involve another surgeon in his case at a greater cost to the system and at reduced efficiency; the other surgeon should be treating his own patients.  If an OA can assist just as well (often better in my experience) the above arrangement makes absolutely no sense.

My message is simple:  Stop obstructing the licensing of Orthopaedic Assistants.  Encourage it!  There is plenty of work to go around now and there will be more in the future.  Our medical system will need all of the help it can get.  We need highly trained Orthopaedic Assistants and they need to be licensed and adequately compensated.

Dr. Hundley is a retired orthopaedic surgeon and a founder and the president of

Corn Pickers, Murdercycles, and Plane Crashes

by James D. Hundley, MD

Part I:  The Farmer and the Corn Picker

My training and early experience after medical school entailed an internship at a large university medical center followed by five years of residency at an even larger university medical center.  I then served as an orthopaedic surgeon at a referral hospital in the U.S. Air Force.  Although I knew better, you might have thought that I’d “seen it all” by the time I joined the Wilmington Orthopaedic Group in 1975.  I hadn’t.

My first weekend on call was not memorable other than being so easy.  I guess that I “rounded” on the patients of our group who were in the hospital and took care of some relatively minor injuries, but that would have been it.  “Ah ha”, I remember.  This is going to be easy:  Work during the day; get an afternoon off every week.  Take emergency call only a fourth of the nights and a fourth of the weekends.  Before it had been every second.  Wow!

“Wow!” was right.  That party ended my second weekend on call. Friday after evening rounds I was walking through the physicians’ lounge on my way home and almost passed by general and thoracic surgeon Dr. Ellis Tinsley who had one hand on the telephone and one held out for me to stop.  He had been talking to someone in the emergency department (ED) in Burgaw who had just sent a man who had fallen into a corn picker our way.

Now I’ve never seen a corn picker up close, but it was described as a large farm machine that is driven through cornfields pulling up corn stalks and feeding them into an auger.  The auger is a screw-like device used to pull through the stalks leaving behind the ears of corn.  It hurts to imagine what it would do to a human leg.

Imagine the unimaginable.  A highway patrolman was cruising a backcountry road and saw a man in distress.  He turned off the machine and called for help.  The rescue squad took the man to the ED in Burgaw where he was stabilized and transported to the New Hanover Regional Medical Center in Wilmington.

Ellis alerted the operating room staff to be prepared; no way could we have managed something of this magnitude in the ED.  Then we changed into our green “scrubs” and went to the ED to meet the ambulance.

The patient arrived in fairly good condition and was taken directly to the operating room (OR) where an anesthesiologist put him to sleep and began pushing intravenous fluids and blood (O-negative until we could determine a blood type) as samples were being taken for a variety of lab studies.

We found that the area of trauma was “limited” to his lower extremities and pelvic area.  One lower extremity was absent as were his genitalia.   The lower half of his bladder was exposed and distended.  Much of the buttocks on the other side had been chewed away exposing but not injuring the sciatic nerve.  Altogether he had a huge open wound involving about two-thirds of the bottom of his trunk.

Because we could not find the urethra (opening in the bladder through which urine normally drains and through which to insert a catheter), we called in urologist Dr. John Cashman.  He couldn’t find it either, so he had to make an incision in the bladder through which to insert a catheter.  Although he had no other choice that proved troublesome in that there was constant urinary leakage around the catheter thereafter, not helpful in trying to develop a clean and dry wound. Later we needed a plastic surgeon to cover the wounds and called in Dr. Ed Wells who did wonderful work as well.

Ellis had taken charge of the patient from the beginning and did a masterful job of pulling him through.  There were many days in the ICU managing pain, electrolytes, blood counts, and infection but ultimately the patient survived and healed his wounds.  My role after many hours that Friday night was joining Ellis and the other surgeons in the OR to debride dead tissues and clean the wound which we did on that Saturday and Sunday and many days after.  John diverted the urine and Ed grafted skin and ultimately all of the wounds healed.

The patient learned to walk on crutches and could even drive his pickup truck so we felt like we had done a pretty good job.  Sadly, however, he reportedly committed suicide a couple of years later.

Memory of that suicide brings to mind Ellis’ response to someone who asked why we would work so hard to save someone so badly mangled.  Ellis’ replied, “It’s up to us to do what we can.  It’s up to God to decide who lives and dies.”

That pretty much filled up the Friday night of my second weekend on call in Wilmington.  I breathed a sigh of relief when I finally got home and went to bed.  Based on my prior experience, the hard part was over.

Part II:  The Murdercyclist and “Honey, There’s been a plane crash!  They want you back at the hospital.”

Saturday morning, the next day of my second call weekend in Wilmington, was uneventful.  I had a leisurely breakfast and visited with my wife Linda who was eight months pregnant at the time and our two young children.  Then I headed over to the hospital for rounds.  About mid-morning I was called to the ED for a young man who had crashed his motorcycle.

Many who treat trauma patients call motorcycles “murdercycles” because of what happens to their riders.  Murdercyclists don’t seem too concerned, however, and even insist that they are safe to ride even without helmets.  They blame accidents on automobile drivers who fail to see motorcycles.  This fellow was in a single vehicle crash of his own causing.  Sorry about digressing.  I can’t help it.

At any rate, he had three open wounds involving fractures and joints, all requiring hours in the OR cleaning up and fixing things.  Fortunately I had my friend and outstanding Orthopaedic Physician Assistant Deak Walden by my side, and we finished about suppertime.  I guess that fellow did OK as I remember little else about the case.  That’s typical, by the way.  When people do well you typically forget the case and move on unless something like writing this story triggers a memory.

I went home.  As I was getting out of my car, my five-year old son was so excited to tell me that his beloved grandparents had come to see us that he tried to pop open our storm door by running into the glass panel.  The door didn’t open and his hands went through the glass cutting one of them, fortunately not too badly.  That was managed with first aid by my neighbor and partner Dr. Charlie Nance, but the vision of those little hands going through that glass window still shocks my psyche.  I guess I emotionally settled for a few seconds and started over to see how badly he was hurt.

Before I had taken a couple of steps Linda came out with the phone in her hand saying, “Honey, There has been a plane crash!  They want you back at the hospital.”

“Very funny”, I responded.  She wasn’t joking.

Professional wrestling was just becoming popular in 1975.  Wrestlers traveled together and performed in the smaller markets.  Charlotte, Charleston, Raleigh, and Wilmington come to mind.  This group was flying a small charter up from Charleston for a Saturday night performance at Legion Stadium.

The emergency call schedule for orthopaedic and neurological surgeons in 1975 worked like this:  If a patient in the ED needed a specialist and knew which doctor he/she wanted, the ED would call that specialist.  If the patient did not know whom to call, the ED would call whoever was on “unassigned call” (ortho for ortho; neuro for neuro).  In our group, we took turns covering the weekends Friday through Sunday, which included some days and nights of responsibility for “unassigned” patients.

There was a lot of crossover among specialists.  Orthopaedic surgeons, plastic surgeons and some general surgeons treated hand injuries, for example.  In the case of spine injuries without neurologic impairment, orthopaedic surgeons took them.  If there were neurologic impairment, the neurosurgeon would be the primary physician.  We consulted back and forth but that was how the “admitting physician” for that patient was determined.  I was on unassigned call that Saturday.

When I walked into the New Hanover ED, there was more commotion than I had seen before.  Lying on gurneys were the three largest men I had ever seen.  One had a compressed fracture of the seventh thoracic vertebra (T7) with no neurologic deficit.  One had an “explosion” fracture of the second lumbar vertebra (L2) with no neurologic deficit; one had an “explosion” fracture of the first lumbar vertebra  (L1) and was paraplegic (“paralyzed from the waist down”).  They had no other serious injuries.

The neurosurgeon on unassigned call and I arrived about the same time.  He made it clear that he did not want to be the primary physician for any, and for reasons I’ve never understood tried very hard to convince me to perform a decompression laminectomy on the one who was paralyzed.  Fortunately I had been trained too well to be so inclined, and my resolve had been reinforced by a recent authoritative review of the treatment of spine injuries by Howorth in The Journal of Bone and Joint Surgery.  Dr. Howorth made it clear that emergency decompression surgery for fractures had no favorable effect on paralysis.  The damage to the spinal cord had been done.  Emergency surgery could make the patient’s condition worse but not better.  I agreed to manage the patient but not to operate.

As those were the days before much surgical stabilization of spinal fractures, the treatment was keeping the patient horizontal and trying to avoid or worsen injury to the spinal cord.  The next biggest worry was bedsores from lying on their backs and a turning bed was available to strap the patient between two frames and allow the nursing staff to flip him from supine to prone every two hours.  When the flip had been accomplished, the then top frame was removed to allow the tissues on the top to be decompressed, inspected, and cleansed.

Guess what?  These guys were way too big for this frame.  Now what?

By then, Deak had arrived and we decided that the patients needed plaster “turtle” shells for turning while protecting their spines.  Deak made interlocking half-shells that would protect the spine when strapped together for each patient.  Once the patient had been logrolled from front to back and so on, the top shell could be removed for the purposes noted above.

The next challenge was how to perform 180-degree turns on men weighing 240+ pounds.  The solution came from the hospital maintenance staff who used plywood boards to widen the single sized hospital beds and placed double sized mattresses on them.  Then the nursing staff could logroll the patients from prone to supine and back again without having to lift them.  That worked and they got no pressure sores.  We were not much attuned to DVT (deep vein thrombosis) during those days, but fortunately they had no apparent DVT’s or pulmonary emboli.

So how did they do?

Patient 1:  L1 fracture with paralysis.  He and his family were obviously distraught about his condition and concerned that the neurosurgeon was not board certified.  They requested consultation from Dr. Guy Odom, Chairman of the Duke Department of Neurosurgery.  Dr. Odom chartered a twin-engine airplane with two pilots at the patient’s expense and came for a visit.  He reviewed the x-rays and examined the patient and told him that his treatment was appropriate.  I don’t know how the patient felt, but I felt both relief and validation.  Dr. Odom returned to Durham.

After about a week the patient was flown to Houston by charter airplane for continued treatment.  I heard through the grapevine that he had surgery there and was told that had they gotten to him sooner they could have helped his paralysis.  My take is that they felt badly about doing surgery not likely to help him and used that as an excuse.  At any rate, I never heard from him again.

Patient 2:  L2 fracture with no neurologic deficit and who was a former professional football lineman.  He had no complications and he flew home to San Diego.  I heard that he did well, but do not think that he returned to wrestling.

Patient 3:  Thoracic compression fracture; interesting fellow who was loaded with personality.  He fully recovered, became a World Champion professional wrestler, and remains famous to this day.

A few months after he was discharged, he called to say that he was coming to Wilmington and asked if he could come see me at home.  We welcomed him and he and an even larger fellow arrived that evening in a Buick Rivera bristling with antennas.  They came into our home, and he lay down on the floor and played with our young children, an action distinct from his professional persona.  He sent greetings through our mayor a year ago and just recently a friend showed me a photo that he had taken of him taken sometime in November.

Other recollections about this case:

  1. Professional wrestling was much bigger than I realized, and these men were celebrities.  Hospital staff were often admonished for trying to sneak peeks through slightly opened doors, and we were often asked how they were doing.
  2. When other professional wrestlers came to visit them in the hospital they, too, were treated as celebrities.
  3. The pilot was killed in the crash ostensibly because the seat of the passenger behind him was torn from the floor of the plane and the wrestler’s body slammed the pilot’s head into the dashboard of the plane.
  4. The pilot’s family sued the airplane manufacturer because the seats were torn loose in the crash.
  5. Want to know why the plane crashed?  It was reported that when they loaded the plane in Charleston, the load was above the regulatory maximum.  The pilot had a simple solution.  He drained enough fuel from the plane’s tanks to get below the maximum allowable takeoff weight.  They ran out of fuel within sight of the airport and crashed into a pine forest.

Dr. Hundley is a retired orthopaedic surgeon and a founder and the president of


How to Pick Your Surgeon, a Surgeon’s Perspective

by James D. Hundley, MD


As a physician and surgeon, I’m often asked who to choose to do someone’s surgery.  The frequency of these questions has grown since I retired from my orthopaedic practice.  I don’t have any advice about how to pick one’s primary care physician or internal medicine specialist but here’s what I think in terms of how to pick your surgeon.

There are a few ways that we as surgeons can evaluate our peers but in terms of technical abilities, we may not be the best judges.  Here’s where I think we can be useful:

1. Decision-making:  It’s extremely important to know not only how to operate but when to operate and when to not operate.  When we discuss cases with others and hear that they operated on someone we thought would be better treated non-surgically, we learn something important about them.  Likewise, when we think that they should operate but don’t, we have an opinion on that, too.

2. Second opinions:  We learn a lot about other surgeons when we see their patients for second opinions.  That’s a very small number, however, so it’s only a glimpse and not necessarily all that helpful.

3. Complications:  When surgeons’ patients have complications it’s not unusual for those patients to seek other surgeons for opinions and/or resolution of problems.  This is an opportunity to judge decision-making and technical performance.

As for technical expertise, however, you may want to look to someone other than a surgeon.  Although we see one another frequently in the corridors and locker rooms of the surgical suite, we don’t spend a lot of time watching others operate.  We’re busy doing our own work so we’re not necessarily the best critics of another’s skills.  That said, who do you ask?

Here’s my opinion:

1. Operating room nurses (actually the entire OR staff)

a. Pros:  They work in the OR day in and day out and get a broad exposure to surgeons.  They see how they prepare and how well they carry out their procedures.

b. Cons

i. People tend to be complimentary of those they like and/or treat them well and derogatory of those who treat them badly.  You’ll have to work your way through this to get a useful answer but the answer is there if you can tease it out.

ii. Questions like this really put them on the spot and some nurses may be reluctant to give you a specific answer.  Again, it’s up to your own communication skills to learn what you can.  Sometimes you’ll just have to move on and ask someone else.

2. Product representatives

a. Pros:  In orthopaedics especially, manufacturers’ representatives are often physically present during operations where their products are being used.  Thus, they likely observe as many or more different surgeons who use their products as anyone else.

b. Cons:  They are conflicted in that they want surgeons to use their products so they might be incented to recommend those who do.

3. Physical Therapists and Occupational Therapists

a. Pros:  Although they don’t see the operations themselves they see patients in objective ways such as how the incisions look after surgery and the stability and function of the replaced joint.

b. Cons:  None that I can think of unless they work for a particular surgeon or group and then they would at least have a theoretical conflict of interest.

4. Patients who have had surgery themselves and their families

a. Pros:  They have had surgery and thus experience with a surgeon.

b. Cons

i. Tunnel vision:  Unfortunately their opinions are based on a cohort (i.e. a group) of one (i.e. themselves) so if they did well they may be overly happy and if they did poorly they may be unjustifiably unhappy.

ii. Patient opinions can be heavily swayed by how kindly they perceive that they were treated by their physicians.  Thus, their opinions of the quality of their surgery can be swayed by that perception.

iii. Patient expectations are variable.  If they think they should be made “normal” by surgery they will be likely be disappointed.  Realistic expectations go a long way toward satisfaction in the outcome which goes a long way toward satisfaction with the surgeon.

iv. Rehabilitation is extremely important in orthopaedic surgery.  Highly motivated patients tend to do better than those who are passive and unwilling to do what it takes to make themselves better.  Rehab can be arduous and painful.  The ones who want their orthopaedic surgery to be a magic cure are likely to be disappointed.

Dr. Hundley is a retired orthopaedic surgeon, a founder and the president of, a free, open access, resource website for orthopaedic surgeons and related professionals.

Coccygodynia: Whatever Happened to Performing a Physical Examination?

by James D. Hundley, MD

            There are so many good things about Modern Medicine that I hate to be critical but the following story from one of my friends put a bee in my bonnet:

Dr. X is a retired university Professor of Sociology who is in great health with no known history of cancer or other serious disorder.  He reported that he fell onto his buttocks with a brief duration of tailbone pain several weeks before his office visit that was precipitated by having to sit in a confined space on an airplane for several hours during which he developed “tailbone” tenderness that occurred only when sitting.  He denied pain on lying supine, night pain, back pain, neurologic symptoms, bowel difficulties, and blood in his stools.

Because his tenderness persisted for a few weeks he made an appointment with a capable orthopaedic surgeon and was seen by the surgeon’s PA.  The PA took a history and then did a cursory examination reportedly checking the strength of the patient’s toes and ankles.  An x-ray was “normal”.  The PA ordered an MRI.

Coincidentally, my friend and I were scheduled for a lunch meeting between the office visit and the MRI at which he asked if I thought he needed to have the MRI.  After a discussion during which I did not feel that I could recommend against having the MRI he decided to proceed with it.  Not surprisingly, the MRI was negative.

Here’s the rub.  Why get an MRI before doing a thorough physical examination and using the history as a guide?  With a history like this, what was the PA looking for?  Cancer?  On what basis?

As for the physical exam, here’s what I think should be done:

  1. Examine the intergluteal crease over the sacrum and coccyx externally for visible skin changes and tenderness.  Is the problem really his tailbone?  What about a pilonidal abscess or cyst, for example?
  2. Perform a rectal examination to check for masses and tenderness of the coccyx which is easy to palpate.  Check the prostate and for occult blood.  How about a thrombosed or abscessed hemorrhoid?
  3. Do a back exam to see if this was referred pain.  That would include back tenderness and range of motion, nerve root irritation tests, and a neurologic exam (some of which the PA to his credit reportedly performed).
  4. Always remove shoes and stockings and check the ankles and feet for circulation and ulcerations, of course, not to diagnose tailbone tenderness but because you’re a thorough clinician and the opportunity to so is before you.

Assuming the findings of the exam were negative, how about some conservative treatment such as allowing time to recover and advice on how to manage his symptoms.  Since he only had pain on sitting, he didn’t really need analgesics or anti-inflammatory medications.  A simple pad with a cutout in the rear to unload the coccyx (not a “doughnut” which unloads the wrong area) should be very helpful.  Then check him back in a few weeks unless the symptoms have subsided spontaneously.

Interestingly, the patient reported that the tenderness subsided within a week or two after the MRI.  Did the MRI cure the problem?  Of course not.  Did peace of mind have anything to do with it?  Maybe, but he wasn’t very nervous about his condition to begin with and after we discussed his problem before the MRI he said he was even less worried about the basis for his symptom.

If we’re to do our share in reducing the cost of Medicine, we need to avoid unnecessary testing, especially those as expensive as MRI’s.


Dr. Hundley is a retired orthopaedic surgeon, a founder and currently the president of, a free, open access, resource website for orthopaedic surgeons and related professionals.