Interesting Cases Legislative



Interesting Cases Legislative
a publication from proliance surgeons, inc., p.s.
Volume 7 issue 2
fall 2012
Interesting Cases
in General Surgery
Protecting Practices With Expert Advice,
Offering More Liability Choices.
Integrated Risk Solutions
A knowledgeable advisor is critical to navigating all of your risk and insurance options. Whether it is employee
benefits, property and professional liability, or retirement plan services, an integrated approach can be more
effective than a series of different agents and brokers.
Kibble & Prentice will provide integrated advice on the adequacy of your current plans, or provide you with
solutions to better protect you, your practice and your employees.
For more information on how our integrated approach can benefit your practice, please contact us.
206/441/6300 •
Welcome to Proliance Surgeons, Inc.
by David Fitzgerald, CeO
805 Madison St., Suite 901
Seattle, WA 98104
(206) 264-8100
(206) 264-8689 Fax
President/Board Chair
Susan R. Cero, MD
David G. Fitzgerald
Board Members
Charlie Peterson II, MD
Jeff Stickney, MD
Julian Arroyo, MD
Carol Cornejo, MD
Thomas Gumprecht, MD
Fred Huang, MD
Michael Sailer, MD
Michael McAdam, MD
Proliance Surgeons® Outlook is designed and published by Custom
Medical Design Group. To advertise
in an upcoming issue please contact
us at: 800.246.1637 or email us at
[email protected]
This publication may not be reproduced
in part or whole without the express
written consent of Custom Medical
Design Group.
WeLCOMe bACK to another edition of Proliance Surgeons
Outlook! We appreciate the time you take from your busy
schedule to see what our surgeons have to offer.
I would like to take a minute today to let you know about a
great cause that the physicians, staff and vendors of Proliance
Surgeons have chosen to support. On September 14 (a sunny
day in Seattle!), we held the 2nd Annual Proliance Surgeons/
Heartbeat…Serving Wounded Warriors Golf Invitational. This
grassroots, home-grown organization, led by Janice buckley,
provides veterans with unique therapies that help treat injuries and post-traumatic
stress disorder (PTSD), as well as provide some interim financial assistance
with medical costs. Heartbeat aims its programs, consisting of horseback riding
therapy and scuba-diving therapy, toward helping our wounded warriors exercise
and train parts of their bodies and minds injured during service. Programs
like these that exist outside of government attempt to fill the voids in our
inadequate governmental programs for veterans.
Our physicians, staff and vendors rose to the challenge of raising money to
help these veterans. by sponsoring holes, hats, jackets, carts, pins, etc., we were
able to make a donation of over $45,000 to Heartbeat! I am truly thankful to
everyone who stood up and was counted as we show our commitment to
helping these deserving individuals. Thank you to Janice for making it possible
for us to connect with these great warriors through her organization. And of
course, thank you to every single veteran/warrior/soldier/hero who serves or has
served our great country. Thank you! Thank you!
Inside This Issue
Legislative Visits ................................................................................................... 5
Welcome Our New Physicians.............................................................................. 6
Proliance Surgeons® Directory ............................................................................. 8
Shaping Our Own Profession.............................................................................11
Understanding and Dealing with Your Knees Over Age 50: ............................. 12
Cross-training Advice
Interesting Cases in General Surgery................................................................ 16 3
at Your Service…
Seattle Radiologists has been serving the
Seattle and Pacific Northwest medical
community for over 50 years!
We are an independent radiology practice partnering with healthcare
providers, clinics and hospitals to offer the best in diagnostic imaging,
procedures and interpretations.
Our two convenient locations on Seattle’s First Hill offer...
1.5T high-field ultra wide, short bore
3.0T high-field
64-slice CT scanner with added technology for
Radiation Dose Reduction - Adaptive Statistical
iterative Reconstruction (ASiR).
SEDATION – both Oral and IV Sedation options prescribed onsite
Nordstrom Medical Tower
1229 Madison, Suite 900
Seattle, WA 98104
600 Broadway Medical Building
600 Broadway, Suite 170
Seattle, WA 98122
Scheduling 206.292.7734 • Fax 206.292.6371
Extended hours! Early morning, evening and Saturdays.
Dave Fitzgerald, CEO Representative Adam Smith, Melody
Fitzgerald, Executive Director Seattle Surgery Center
Representative Rick Larsen , Chris Hayes, Manager Everett Bone and
Joint Surgery Center, Dr. Jeff Mason
Legislative Visits
by rob Schwartz, Director of Public Policy
say that healthcare is not a prime topic of
discussion and debate in Congress, the
media, the Presidential race, the Washington
State Governor’s race and among medical
practitioners in Washington State. While
the Supreme Court has ruled on the
constitutionality of the Affordable Care
Act, it is clear that the practice of medicine
is entering a period of dramatic change
and uncertainty.
What is clear is that regulatory and
legislative actions on the State and Federal
levels will continue. These actions can
prove to be a burden on physician practices
and at times be extremely costly. We have
learned that elected officials and civil
servants who develop these policies and
vote on them are very busy people and
are not experts on our industry. They also
receive information on our industry from
third party groups who do not always have
our best interests at heart.
There is an old saying that “a picture is
worth a thousand words”. We have learned
that a quality tour and briefing at our
ambulatory surgery centers and offices are
invaluable. In the past months a number
of Congressmen, staff of U.S. Senators, and
State Legislators have participated. Our
thanks to the Physicians, Administrators
and Nurses who have made these efforts
so successful.
Representative Rick Larsen, Chris Hayes, Dr. Jeff Mason, Dave Fitzgerald
Stephen Covey in his book The Seven Habits
of Highly effective People stated that one
should never let a third party define you or
your organization. It is incumbent that the
individual and the organization take the
initiative to define the organization. With
this in mind Proliance Surgeons has made
it a priority to continue to educate elected
officials on the state and local level as well
as staff in state agencies and federal agencies
as well as other special interest groups.
In the briefings we hold with elected and
regulatory officials we share in detail
the commitment to patient safety, the
extraordinary record of low infection rates
and the significant patient satisfaction
reports ASCs receive from patients.
Additionally, while the focus of the new
policy is on cost containment and quality
care we can show a real record for bending
the cost curve.
Rob has held many senior
position in the health care
industry, including senior vice
president of American Medical
Response as well as chief of
staff for Senator Joe Lieberman,
when Lieberman served as
State Senate Majority Leader.
rob Schwartz 5
Welcome Our New Physicians
A. Samuel Barloon, MD
Dr. barloon earned his medical degree from
the emory University School of Medicine in
Atlanta, Georgia. He completed his residency
in ophthalmology at the University of Texas,
Hermann eye Center in Houston, Texas. Dr.
barloon completed a fellowship in diseases
and surgery of the retina and vitreous at the
University of british Columbia. His special
interests include macular degeneration,
diabetic retinopathy, and disease of the retina and vitreous.
Dr. barloon has been practicing in the Puget Sound area since
1994. Dr. barloon is board certified by the American board of
Ophthalmology. Practicing on the eastside, Seattle, and Skagit
County, Dr. barloon is committed to providing superior care and
all types of retinal surgery.
David Saperstein, MD
Dr. Saperstein earned his medical degree
from Pennsylvania State University. He
completed his residency at the St. Louis
University School of Medicine and his
fellowship in diseases and surgery of the
retina and vitreous at emory University in
Atlanta, GA. Prior to joining Vitreoretinal
Associates, Dr. Saperstein held the position
of Assistant Professor of the Ophthalmology
Department at emory University. He was also the Associate
Professor at the University of Washington and was the director
of the Vitreoretinal Fellowship Program. Dr. Saperstein is
involved in many clinical trials and actively participates in the
development of new drugs and instruments for the treatment
of retina diseases, for which he has been awarded patents.
Dr. Saperstein is board certified by the American board of
Ophthalmology. Areas of practice include Seattle, eastside,
Whatcom and Skagit counties.
Charles Birnbach, MD
Dr. birnbach received his Medical Degree
with honors from New York University
School of Medicine. He completed both
his ophthalmology residency and a twoyear fellowship in diseases and surgery of
the retina and vitreous at the University of
Washington. Dr. birnbach is board certified
by the American board of Ophthalmology.
He sees patients in Seattle, bellevue and
burlington. He specializes in treatment for
macular degeneration and diabetic retinopathy, and performs
surgery for many conditions including retinal detachment,
epiretinal membrane and macular hole.
In March 2012 Proliance Su
Associates of Washington
Center. VRA is an ophthalmic
full time dedicated retina care.
Burlington, Seattle, and the U
Robert Francis, MD
Dr. Francis earned his medical degree
from the University of Washington. He
remained at the University and completed
his residency and fellowship in diseases and
surgery of the retina and vitreous. Dr. Francis
has been in practice since 1989. Prior to
joining Vitreoretinal Associates in 2006, he
was the retinal surgeon for Group Health
Cooperative where he continues to provide
surgical retinal care. He has served as Chief of Ophthalmology
at Swedish Medical Center and Group Health. He spent ten years
as a Clinical Instructor for the Department of Ophthalmology
at the University of Washington.
Dr. Francis is board certified by the American board of
Ophthalmology. With offices in both eastside and Seattle,
Dr. Francis is able to provide dedicated medical retinal care
along with all types of retinal surgery. He offers particular expertise
in combined cataract and retinal procedures and in complex
cataract cases.
urgeons added Vitreoretinal
n VRA as our newest Care
c practice offering full service,
e. They are located in Bellevue,
University Village.
Robert W. Nash, MD
Dr. Nash received his pre-optometric education at Miami University of Ohio and Kent
State University before attending optometry
school at The Ohio State University. He
graduated cum laude and also received
his Doctor of Optometry at The Ohio State
University. After two years teaching optometry at the University of Alabama in
birmingham, Dr. Nash decided to enter
medical school and graduated Summa cum laude from emory
University School of Medicine. Dr. Nash did his Ophthalmology
residency at the University of Washington and his fellowship
in diseases and surgery of the retina and vitreous at the
Medical College of Wisconsin. Dr. Nash is board certified by
the American board of Ophthalmology. He is practicing on the
eastside, Seattle, and Skagit counties.
Craig Wells, MD
Dr. Wells received his medical degree,
Summa cum laude from the University of
Oregon. He completed his residency and
fellowship in diseases and surgery of the
retina and vitreous at the University of
Washington. He has co-authored more than
30 scientific publications and has been a
principal investigator for the Collaborative
Ocular Melanoma Study. As principal
investigator, with his colleagues at Vitreoretinal Associates, he
has conducted more than ten Phase III Clinical Trials of new
devices and medications for age-related macular degeneration,
retinal blood vessel diseases and retinal detachment. He is an
expert in choroidal melanomas. Dr. Wells is board certified by
the American board of Ophthalmology. Areas of practice include
Seattle, eastside, Whatcom and Skagit counties. 7
Proliance Surgeons Directory
PRaCtICeS, Proliance Surgeons, Inc., P.S., performs
emergency and elective operations, treating
illnesses and injuries that affect us all. Proliance’s
orthopedic surgeons have expert knowledge of
general orthopedics and additional specialized
training in sports medicine, joint reconstruction,
arthroscopic surgery, spine surgery, hand surgery,
foot surgery, fracture care, and major orthopedic
trauma. Our general surgeons have specialized
training in vascular, bariatric and colorectal
surgery. Our otolaryngologists specialize in all
aspects of ear, nose and throat surgeries. Our
Ophthalmology Surgeons specialize in diseases
and surgery of the retina, macula and vitreous.
Bellevue Ear, Nose and Throat Clinic
1135 116th Ave. N.e., Suite 500
bellevue, WA 98004 • (425) 454-3938
510 8th Ave. N.e., Suite 310
Issaquah, WA 98029 • (425) 454-3938
Cynthia K. Anonsen, MD
thomas a. Knipe, MD
Alice Lee Kuntz, MD
Samson J. Lee, MD
Daniel r. Seely, MD
Roger S. Zundel, MD
Edmonds Orthopedic Center
7320 216th St. S.W., Suite 320
edmonds, WA 98026 • (425) 673-3900
James R. alberts, MD
brian D. Cameron, MD
Aric Christal, MD
Darcy S. Foral, MD
Lawrence J. Fowler, MD
Michael b. Lee, MD
Wren V. McCallister, MD
Jeffrey P. remington, MD
Everett Bone and Joint
1100 Pacific Ave., Suite 300
everett, WA 98201 • (425) 339-2433
Howard b. barker, MD
Lawrence J. Fowler, MD
Ralph t. Haller, MD
todd W. Havener, MD
bill K. Huang, MD
Peter J. Kinahan, MD
Jeff r. Mason, MD
Doug D. Nowak, MD
John D. Pryor, MD
Evergreen Orthopedic Clinic
12911 120th Ave. N.e., Suite H-210
Kirkland, WA 98034 • (425) 823-4000
14841 179th Ave. S.e., Suite 330
Monroe, WA 98272 • (360) 794-3300
8980 161st Ave. N.e., Suite 320
redmond, WA 98052 • (425) 823-4000
richard L. Angelo, MD
Camille M. Clinton, MD
Mark A. Freeborn, MD
robin r. Fuchs, MD
ronald V. Gregush, MD
Kenneth C. Lin, MD
Craig M. McAllister, MD
Gregory J. Norling, MD
J. Scott Price, MD
Jeffrey L. Stickney, MD
James D. Swenson, MD
Evergreen Surgical Clinic
12333 N.e. 130th Lane, Suite 420
Kirkland, WA 98034 • (425) 250-4700
Sean D. Toomey, MD
William J. Wilson, MD
eva Young, MD
Orthopedic Specialists of Seattle
5350 Tallman Ave N.W., Suite 500
Seattle WA 98107 • (206) 784-8833
2409 North 45th St.
Seattle, WA 98103 • (206) 633-8100
Kelly A. Clinch, MD
John S. ebisu, MD
Marion C. Johnson, MD
Harry A. Kahn, MD
James G. Mhyre, MD
Michael A. Towbin, MD
Philip R. Downer, MD
Jonathan L. Franklin, MD
Charles a. Peterson II, MD
Mark reed, MD
Scott D. ruhlman, MD
Joel a. Shapiro, MD
J. Michael Watt, MD
Wayne M. Weil, MD
Northwest Orthopaedic Clinic
9730 3rd Ave. N.e., Suite 210
Seattle WA 98115 • (206) 526-8444
Proliance Eastside ENT
1800 116th Ave. N.e., Suite 102
bellevue, WA 98004 • (425) 451-3710
Herbert r. Clark, MD
8301 161st Ave. N.e., Suite 200
redmond, WA 98052 • (425) 869-4855
Northwest Orthopaedic & Sports Medicine
875 Swift boulevard
richland WA 99352 • (509) 946-1654
Joshua bales, MD
Patrick Dawson, MD
David Gibbons, MD
Gordon Hsieh, DO
rich Jacobs, MD
K. blair Sampson, MD
Mary Lynn Scovazzo, MD
John W. Staeheli, MD
Northwest Surgical Specialists
1560 N. 115th St., Suite 102
Seattle, WA 98133 • (206) 363-2882
Mark T. brakstad, MD
Paula L. Denevan, MD
alison L. Perrin, MD
allegra Saving, MD
Orthopedic Physician Associates
601 broadway
Seattle, WA 98122 • (206) 386-2600
M. Kevin auld, MD
James P. Crutcher Jr., MD
Justin L. esterberg, MD
Alexis Falicov, MD
Jeffery L. Garr, MD
K. elizabeth Garr, MD
Lawrence e. Holland, MD
Scott e. Hormel, MD
e. edward Khalfayan, MD
Jason C. King, MD
richard M. Kirby, MD
Frederick b. Lee, MD
Martin G. Mankey, MD
Michael K. McAdam, MD
Charles a. Peterson, MD
John W. Robertson, MD
Nicholas r. Seibert, MD
todd J. Seidner, MD
eugene “Pepper” Toomey, MD
Tom F. Gumprecht, MD
Jennifer L. Heydt, MD
eric F. Pinczower, MD
Proliance Orthopaedic and Sports Medicine
1135 116th Ave., N.e., Suite 510
bellevue, WA 98004 • (425) 455-3600
510 8th Ave. N.e., Suite 200
Issaquah, WA 98029 • (425) 392-3030
Clayton b. brandes, MD
James D. bruckner, MD
thomas H. Castle Jr., MD
thomas D. Chi, MD
Jeremy A. Idjadi, MD
Todd e. Jackman, MD
Gregory A. Komenda, MD
Peter R. Mandt, MD
Tyler J. Nathe, MD
ashit C. Patel, MD
Steven S. ratcliffe, MD
Matthew J. robon, MD
Michael J. Sailer, MD
John L. Thayer, MD
Puget Sound Ear, Nose, and Throat
21616 76th Ave. W., Suite 112
edmonds, WA 98026 • (425) 775-6651
13020 Meridian Ave S 2nd floor
everett, WA 98208 • (425) 337-4810
9730 3rd Ave. N.e., Suite 201
Seattle, WA 98115 • (206) 526-9999
Tyler G. Kimbrough, MD
John T. Parker, MD
Duncan A. riddell, MD
Shawn e. Rogers, MD
Puget Sound Orthopaedics
7308 bridgeport Way W., Suite 201
Lakewood, WA 98499 • (253) 582-7257
1724 W. Union, Suite 100
Tacoma, WA 98405 • (253) 830-5200
Julian S. Arroyo, MD
W. brandt bede, MD
John M. blair, MD
Spencer A. Coray, MD
Sean Ghidella, MD
Dale L. Hirz, MD
Michael J. Martin, MD
Gavin H. Smith, DPM
Steven M. Teeny, MD
Alan b. Thomas, MD
Rainier Orthopedic Institute
3801 5th St. S.e., Suite 110
Puyallup, WA 98374 • (253) 845-9585
20920 Sr 410 e
bonney Lake, WA 98391 • (253) 845-9585
Wendall W. adams Jr., MD
Steven C. brack, DO
Wendy L. Heusch, DO
Frederic L. Johnstone II, MD
eric G. Puttler, MD
Neal H. Shonnard, MD
John t. Steedman Jr., MD
Anthony b. Vanbergeyk, MD
Skagit Island Orthopedic Center
1401 S. LaVenture rd.
Mount Vernon, WA 98274 • (360) 424-2400
2720 Commercial Ave.
Anacortes, WA 98221 • (360) 424-2400
Don H. bodley, MD
Jimmy Y. Cui, MD
Daniel M. Hanesworth, MD
Curtis W. rodin, MD
Jonathan b. Shafer, MD
richard V. Williamson, MD
South Seattle Otolaryngology
16259 Sylvester rd. S.W., Suite 505
burien, WA 98166 • (206) 242-3696
David C. Green, MD
Peter F. Maurice, MD
Patrick H. McClean, MD
Southwest Seattle Orthopaedic
and Sports Medicine
16259 Sylvester rd. S.W., Suite 501
burien, WA 98166 • (206) 243-1100
Alan D. barronian, MD
William L. Clark, MD
Charles K. Fujisaki, MD
brian D. Jones, DO
roger Y. Wong, DO
Spine and Sports Institute
512 N Young St. Suite C
Kennewick, WA 99336 • (509) 572-2605
tamara Simpson, MD
Melvin Wahl, MD
Surgery Associates
16122 8th Ave. S.W., Suite D-1
burien, WA 98166 • (206) 244-1680
andrew J. Haputa, MD
Michael M. Kennelly, MD
R. Holmes troutman, Jr., MD
Surgical Associates of Edmonds
7315 212th St. S.W., Suite 201
edmonds, WA 98026 • (425) 778-8116
Carol J. Cornejo, MD
Kurt e. Harmon, MD
Thomas J. Jurich, MD
Steven D. MacFarlane, MD
Michelle J. Sinnett, MD
Valley Orthopedic Associates
4011 Talbot rd. S., Suite 300
renton, WA 98055 • (425) 656-5060
27005 168th Pl. S.e., Suite 201
Covington, WA 98042 • (253) 630-3660
Michael D. Allison, MD
Craig t. arntz, MD
William P. barrett, MD
Traci G. barthel, MD
Susan R. Cero, MD
b. Daniel Chilczuk, MD
Kaya Hasanoglu , MD
John M. Hendrickson, MD
Christopher R. Howe, MD
John P. Howlett, MD
Fredrick S. Huang, MD
eric J. Novak, MD
Mark C. remington, MD
Niket Shrivastava, MD
Jason H. thompson, MD
Martin S. Tullus, MD
robert G. Veith, MD
Washington Hand Surgery
12911 120th Ave. N.e., Suite H-10
Kirkland, WA 98034 • (425) 823-4224
1810 116th Ave. N.e., D-4
bellevue, WA 98004 • (425) 283-5230
Todd M. Guyette, MD
Allison J. MacLennan, MD
edward r. North, MD
Steven L. Reed, MD
Steven D. Sun, MD
Vitreoretinal Associates of Washington
Hidden Valley Office Park
1750 112th Ave. N.e., Suite D-050
bellevue, WA 98004 • (206) 215-3850
215 east George Hopper rd.
burlington, WA 98233 • (206) 215 3850
Arnold Medical Pavilion
1221 Madison St., Suite 1002
Seattle, WA 98104 • (206) 215-3850
University Village
4915 25th Ave. N.e., Suite 207
Seattle, WA 98105 • (206) 215-3850
A. Samuel barloon, MD
Charles D. birnbach, MD
robert r. Francis, MD
robert W. Nash, MD
David Saperstein, MD
Craig G. Wells, MD
For more information, including a list of
physicians and directions to our clinics and
centers, please visit
Additional Services...
Edmonds Center for Outpatient Surgery
7320 216th St. S.W., Suite 140
edmonds, WA 98026 • (425) 673-3750
Everett Bone and Joint Surgery Center
1100 Pacific Ave., Suite 100
everett, WA 98201 • (425) 317-8535
Evergreen Orthopedic Surgery Center
12911 120th Ave. N.e., Suite H-110
Kirkland, WA 98034 • (425) 216-7000
Evergreen Surgical Clinic Ambulatory
Surgery Center
12333 N.e. 130th Lane, Suite 420
Kirkland, WA 98034 • (425) 250-4700
Lakewood Surgery Center
7308 bridgeport Way W., Suite 102
Lakewood, WA 98499 • (253) 584-5252
Proliance Highlands Surgery Center
510 8th Ave. N.e., Suite 100
Issaquah, WA 98029 • (425) 507-0800
Seattle Orthopedic Center Surgery
2409 N. 45th St.
Seattle, WA 98103 • (206) 633-8100
Seattle Surgery Center
900 Terry Ave., 3rd Floor
Seattle, WA 98104 • (206) 382-1021
Skagit Island Orthopedic Surgery Center
1401 S. LaVenture rd.
Mount Vernon, WA 98274 • (360) 424-2480
Southwest Seattle Ambulatory Surgery Center
275 Southwest 160th St., Suite 200
burien, WA 98166 • (206) 988-0927
The Retina Surgery Center
1750 112th Ave. N.e., Suite D 050
bellevue, WA 98004 • (206) 215-3850
The Surgery Center at Rainier
3801 5th St. S.e., Suite 210
Puyallup, WA 98374 • (253) 445-4285
Valley Orthopedic Associates Ambulatory
Surgery Center
4033 Talbot rd. S., Suite 270
renton, WA 98055 • (425) 226-2041
Proliance Surgeons Directory
continued on page 10 9
Proliance Surgeons Directory
continued from page 9
Eastside MRI
12911 120th Ave. N.e., Suite H-120
Kirkland, WA 98034 • (425) 823-4226
Edmonds Orthopedic Center MRI
7320 216th St. SW, Suite 320
edmonds, WA 98026 • (425) 673-3900
Everett Bone and Joint MRI
3102 Colby Ave.
everett, WA 98201 • (425) 258-8110
Northwest Orthopaedic & Sports Medicine MRI
875 Swift boulevard
richland WA 99352 • (509) 946-1654
Orthopedic Physician Associates MRI
900 Terry Ave, Suite 100
Seattle, WA 98104 • (206) 694-6665
Proliance Highlands MRI
510 8th Ave. N.e., Suite 110
Issaquah, WA 98029 • (425) 507-0810
ProSports Imaging N.W.
3801 5th St. S.e., Suite 120
Puyallup, WA 98374 • (253) 864-4106
Puget Sound Imaging MRI
1724 W. Union, Suite b100
Tacoma, WA 98405 • (253) 830-5200
Seattle Orthopedic Center MRI
2409 N. 45th St.
Seattle, WA 98103 • (206) 633-8100
8009 S. 180th St., Suite 105
Kent, WA 98032 • (425) 656-0711
Edmonds Orthopedic Therapy
7320 216th St. S.W., Suite 320
edmonds, WA 98026 • (425) 673-3916
Evergreen Orthopedic Physical Therapy
12911 120th Ave. N.e., Suite H-220
Kirkland, WA 98034 • (425) 216-7075
Proliance Sports Therapy and Rehab
of Bellevue
1200 112th Ave. N.e., Suite C-260
bellevue, WA 98004 • (425) 462-5006
Proliance Sports Therapy and
Rehab of Issaquah
510 8th Ave. N.e., Suite 340
Issaquah, WA 98029 • (425) 313-3055
Seattle Orthopedic Center Physical Therapy
2409 N. 45th St.
Seattle, WA 98103 • (206) 633-8100
Skagit Island Physical Therapy
1401 S. LaVenture rd.
Mount Vernon, WA 98274 • (360) 424-2400
2720 Commercial Ave.
Anacortes, WA 98221 • (360) 424-2400
Ambulatory Care
Serving your physician
offices, surgery centers
and other sites of care.
Shaping Our Own
by David Fitzgerald, CeO
has ruled on the Patient Protection and
Affordable Care Act of 2010. Whether you are in favor or not, we all
know the work begins now. There are more unknowns about how
the landscape of healthcare will change but what we do know is we
have to be involved and have a voice in our future. Proliance Surgeons
is one of the largest surgical practices in the country. Individually
and together we can make a difference. It is imperative that we as
physician and surgeon leaders play an active role in our professional
organizations and work with our legislators to affect change in order
to shape our own future.
We want to acknowledge the leaders in our organization that give
of their time outside of their normal day to their profession
and the future healthcare for their patient’s. We have many
physicians and administrators as board members for their professional associations.
This past year Dr. richard Angelo from Proliance’s
evergreen Orthopedic Center served as President for
Arthroscopy Association of North America AANA. Under
his leadership the Association reached monumental
accomplishments that have reset the foundation for
future years to come. AANA’s mission is to provide
quality and effectiveness of surgical skills education.
Dr. Neal Shonnard from Proliance’s rainier Orthopedic
Institute is a Founding Member of Spine SCOAP
registry. Spine SCOAP or Surgical Care and Outcomes
Assessment Program is a state-wide workgroup
formed to choose metrics for process and outcome
measures for a Spine data collection tool, with the goal
of improving overall spine surgical care in Washington
State. The pilot data collection phase of Spine SCOAP started in 2009,
with full roll-out in January 2012.
Dr. robert Francis of Proliance’s Vitreoretinal Associates of Washington serves as Secretary Treasurer of
Washington Academy of eye Physicians and Surgeons
and is a board member of Lighthouse for the blind.
Lighthouse for the blind has a mission to create and
enhance opportunities for independence and self
sufficiency of people who are blind, deaf-blind, and blind with
other disabilities.
These physicians give of their time outside their own practice to
further their profession and the quality of healthcare. Without this
level of involvement driving clinical cost effective care, the decision
makers in healthcare will be government employees that have a
limited understanding of the daily issues healthcare providers and
patients experience.
Our Care Center Administrators play a vital role in shaping healthcare as well. April Gibson, MHA, CMPe Administrator Puget Sound
Orthopaedics, a division of Proliance Surgeons, is board Member
for Washington State Ambulatory Surgery Center Association
(WASCA) and Past President for Washington State Medical Group
Management Association (WSMGMA). These two associations
advocate for cost effective care and preserving the doctor
patient relationship.
Kalen Privatsky, MbA Administrator for Valley Orthopedic Associates,
a division of Proliance Surgeons, is Past President of Washington State
Medical Group Management Association (WSMGMA), and Glenda
Smith, Administrator for evergreen Orthopedic Center, a division of
Proliance Surgeons, serves as Trustee to Washington State Medical
Group Management Association (WSMGMA).
While this is not an exhaustive list of participation, it is an example
of the leadership Proliance Surgeons offers within the medical
field to strengthen our position as independent medical providers
aiming to shape the future of healthcare. To read more go to
David is CEO for Proliance Surgeons. He has more
than 22 years of experience in healthcare, including
Administrator and CFO of physician practices.
Currently, he serves as a member of the Board of
Directors of the Washington Ambulatory Surgery
Center Association and the Government Affairs
Committee of the ASC Association.
David Fitzgerald, CeO 11
and Dealing
with Your
Knees Over
Age 50:
Cross-training Advice
by M. Lynn Scovazzo, MD
AGe 50 IS AN ArbITrArY CHOICe to inspire people to pay
attention to ways they might behave if they choose to extend the
longevity of their knees. Younger patients will also benefit from
this advice, however, after age 50, many patients become more
motivated to change, as they discover stiffness getting up from a
chair or getting out of a car, achy knees with prolonged standing,
or weakness climbing steps while carrying groceries. As the
decades roll by, into their 60’s and 70’s, little adjustments are
made daily to favor and protect the knees as the cartilage lining
of the joint wears out. For example, to get up from the floor a
person may grab a nearby table or chair and use the upper body
muscles to assist the lower body muscles to push up to a stand.
by the time a person is in their 80’s, it may become impossible to
get up from a chair without using their arms to push their weight
up against gravity, because the “Quad muscles”- 4 muscles in
the front of the thigh that are tasked with helping get up- are so
weakened from disuse.
The goal of this article to help patients understand and embrace a
multitude of ways they may choose to modify their lifestyle now,
while still relatively “young”, so that they might not travel down
the path of progressive weakness and loss of independence that is
related to the aging process of our knee joints.
Learning some basic knee properties is the key to understanding
the nature of the problems of aging, and what we are able to
do to better cope with stiff, achy and weak knees. The lower end
of the thigh bone (femur) has a cartilage lining on the surface
that contacts the upper end of the shin bone (tibia) with a similar
lining. This cartilage surface has lots of water within a spongy
tissue that acts as a shock absorber when we move about. A
water balloon-type of sac surrounds the ends of the femur and
tibia to contain the joint fluid and further lubricate the cartilage
lining. There is another bone, the kneecap (patella) that sits out
front from the end of the femur, and it glides within a groove of
the femur. The kneecap hooks up the 4 quad muscles at the front
of our thighs with a tendon below the kneecap that attaches
to the shin bone. When the quad muscles fire, the kneecap is
positioned in the femur groove to provide better leverage for
the tendon attaching to the shin bone to allow us to fight gravity
and stand up.
As we age, our body loses some of the water content in all of
our tissues, including in the cartilage lining of the joints. The
cartilage cushions on the knee bones get thinner and less spongy,
sometimes with pieces flaking off from the surface. This debris
floats around the sac and acts as an irritant, causing the knee
sac lining to go into action to clean up the joint. This is a form
of inflammation that causes stiff, achy knees. The brain registers
pain with attempts of step climbing, for example, and sends
a message to the quad muscles to stop doing their job. The
person senses a “giving way” of their knee as they try to walk down
steps normally. Now the patient has to gingerly step down to be
sure the knee will “hold them up”. Holding onto the railing or taking
steps “one at a time”, leading with their “good knee” are ways to
be sure they do not fall down the steps. Over time, the caution with
steps and getting up from chairs, allows the quad muscles to rest
from their normal job and to become weaker, while the upper body
and other hip and leg muscles try to pitch in and adapt.
weight-bearing X-ray of your knees and
show you where your knees are wearing
out. Managing the aches and stiffness with
oral medication such as ibuprofen or other
prescription medications may help patients
choose to remain active by keeping the
muscles around the arthritic joint strong
and ready to carry a person about their
daily routine in an independent fashion.
Now that you understand how gradual,
small changes over time take a toll on the
important quad muscles, you can take steps
to keep these important muscles strong,
and that will potentially allow you to
function like you are 40-50 years old when
you are 70.
So what are these changes that we can
make to stay strong? When we are young
there are many ways to work out either
alone, as a runner or hiker, or in a group
on a team running, jumping, and pivoting.
In general, our bodies are pretty good
at repairing the day to day wear and tear
inside the knee joint, unless a specific
serious injury occurs to the knee ligaments,
tendons, bone or cartilage lining. Now that
the aging process is slowly happening, we
must be more careful to choose activities
that are friendlier to the knee joint. Crosstraining is a decision to vary the workout
routine to cause less repetitive impact on
the knee joint. For example, instead of
running 6 days a week, decide to run twice
on a better surface (cushioned track instead
of asphalt) and the other days ride a bike,
use the elliptical or swim. The goal is to
help the body preserve the native cartilage
in the knee joint by avoiding daily overload
that does not allow the body to properly
maintain joint lining health.
There are also specific leg exercises that
will keep the quad (and hip) muscles
strong without beating up the important
kneecap joint. A ten minute home exercise
program done 3-4 times a week will be
one key to keeping the quads from losing
their power over the years. The payoff will
be finding that you are still able to pop up
off the sofa and carry groceries up a flight
of steps.
Patients often say that they realize that
being overweight is “Hard on my knees.”
The kneecap cartilage lining deals with
3-4 times the body weight as steps are
climbed. Therefore a woman who weighs
200 pounds is actually loading the kneecap
to 600-800 pounds when climbing steps. It
is no wonder that steps can become
difficult. Deciding to manage weight will
be a key to having the knees last into
your later years. Once the cartilage lining
begins to wear, being overweight speeds up
this process.
Other steps to help aging knees may include:
wearing a specially fitted “unloader” knee
brace that offloads the pressure on the
side of the joint that is more worn, or using
shoe wedges to change the alignment
of bowlegged knees for example. Your
orthopaedic surgeon will take a standing,
Your doctor may recommend a cortisone
shot into the joint, and this may settle down
the inflammation for many months. There
is also another type of injection called
“Visco-supplementation” which is a series
of lubrication injections (hyaluronic acid)
that your doctor may offer. Talk about these
options with your orthopaedic surgeon.
Arthroscopic knee surgery has been shown
to provide NO long term improvement in
knee arthritis! So do think that a “quick
fix” is possible once the knee x-rays
demonstrate arthritic narrowing of the
knee joint. Patients often hope for a simple
cure that does not require them to change
their behavior. They will be disappointed
with the outcome.
There is no better time than the present
to evaluate your current exercise program
and structure it to become “knee friendly”
with less impact via running sports, and to
manage your weight over time. Your knees
will thank you and hopefully serve you well
in your later decades!
Dr. Scovazzo is a fellowshiptrained orthopaedic medicine
specialist who specializes in
arthroscopic shoulder and
knee surgery. She practices
Orthopaedic & Sports Medicine
in Richland Washington.
M. Lynn Scovazzo, MD 13
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Interesting Cases
in General Surgery
by Alison Lytle Perrin, M.D., FACS
much of the body, but typically exclude the brain, bones, heart,
and genitourinary structures. Here are a few cases that are
interesting and show some of the breadth of our field. If you’d
like to see more, please become our friend on Facebook at
Northwest Surgical Specialists.
Case #1:
An 82 year female was evaluated with an echocardiogram for
shortness of breath. The shortness of breath turned out to be
from under-treated asthma and her heart was fine, but she was
noted to have an 8.2 cm complex cystic mass of the right adrenal
gland. Sometimes adrenal gland tumors produce excess levels
of steroids, catecholamines, aldosterone, or testosterone, but
hers was hormonally inactive. She went to the operating room
for a laparoscopic adrenalectomy. An argon beam dissector was
available on standby in the event that there was involvement of
the adjacent liver, but the tumor was well-encapsulated and came
off the liver easily. Pathology revealed a complex solid, cystic, and
hemorrhagic mass that had a few malignant features, but overall
was thought to be benign, so resection alone should be curative.
She went home on post-operative day four, and has done very well,
and is pleased that she will not require further treatment with
chemotherapy or radiation.
Case #2:
A 76 year old woman presented to the emergency room with
signs and symptoms of large bowel obstruction, with abdominal
distension, pain, nausea, and vomiting. Imaging revealed an
obstructing colon mass and massively dilated proximal colon.
CT showing R. cystic
adrenal mass
Clipping R. adrenal vein off IVC
Laparoscopic view of R.
adrenal mass
Gross view of specimen
She was taken emergently
to the operating room
for exploration and colon
resection. She was found
to have a near-complete
obstruction of the colon
due to a tumor. Surgery
went very smoothly, as did
her recovery.
Is this really the colon, or the Loch
Ness Monster?
Case #3:
A 65 year old gentleman complained of heartburn/reflux
symptoms. He had an upper endoscopy where he was noted to
have a submucosal gastric mass. He went on to have a laparoscopic
partial gastric resection with findings of a low grade GIST (gastrointestinal stromal tumor). This tumor sometimes requires
chemotherapy, but when caught at a small size, as this one was,
surgical therapy alone is curative. He has recovered well and
is happy with his tiny laparoscopic incisions.
suspicious lymph nodes in the left axilla, but no evidence of distant
disease. He returned to the operating room for an amputation
of his upper arm and a lymph node dissection of the axilla. There
was no cancer in the 23 lymph nodes removed, and the arm margin
was widely free of tumor. His left arm was dysfunctional before
surgery, so the amputation actually makes his ADLs (activities of
daily living) easier, and he has much less pain than before surgery.
Case #5:
A 69 year woman came into the emergency room with significant
upper abdominal and left neck pain, inability to eat, and nausea
without vomiting. She had started having atypical symptoms of
reflux for the six months prior, mostly substernal and left neck pain.
evaluation with CT scan 4 days prior showed most of her stomach up
in her chest, consistent with a very large hiatal hernia. In the er, her
CT showed that her distal stomach had slid up into the chest next to
the esophagus (a paraesophageal hernia), and was trapping gas and
fluid in the more proximal stomach below the diaphragm. Luckily
a nasogastric tube was placed, which decompressed the stomach,
and allowed the paraesophageal hernia to be reduced. Laparoscopic
surgery was carried out 36 hours later with repair of the large
opening in the stomach (hiatal hernia repair) and a stomach wrap
was performed as well (Nissen Fundoplication) to help anchor the
repair below the diaphragm and minimize chance of post-operative
heartburn. She went home on post-op day 5 on a mechanical soft
diet, doing very well.
Intraoperative photos of stomach tumor and resected specimen
Case #4:
A 75 year gentleman with left-sided paralysis from a prior stroke
on chronic anticoagulation therapy presented with a bloody mass
on his left elbow. He was taken to the operating room for
evacuation of his hematoma, but in the short time from
presentation to operation, the mass had grown significantly, and
now looked like a tumor. A wide excision was done down to the
level of tendon and muscle, with pathology revealing a soft tissue
sarcoma with a positive deep margin. Metastatic work-up showed
CT of incarcerated
paraesophageal hernia
(yellow asterix) and dilated
stomach (red asterix)
Laparoscopic view of huge hernia
after reduction
View of L. elbow before surgery
Intra-op view after resection
to gross margins
Beautiful healing after one
week, unfortunately deep
margins are positive
Esophagus repaired with suture
Repair reinforced with biologic
mesh plus fundoplication
Dr. Perrin graduated from the University of Washington
Medical School and completed her residency at
the University of Washington in 1998. She is Board
Certified in General Surgery. She practices at Proliance’s
Northwest Surgical Specialists and admitting privileges
at Northwest Hospital & Medical Center, UW Medicine.
Alison Lytle Perrin,
M.D., FaCS 17
Proliance Surgeons® would like to thank the following list of advertisers, without whom this issue of Proliance Surgeons® Outlook
would not have been possible.
amerinet ........................................................................................ 14
Cardinal Health...............................................................................10
Center for Prosthetics Orthotics, Inc ..............................................13
Fain Anderson VanDerhoef, PLLC ...................................................10
Hanger Prosthetics & Orthotics, Inc ...............................................15
Healthcare Management Administrators .......................................19
Johnson, Graffe, Keay, Moniz & Wick LLP.......................................14
Kibble & Prentice...................................................Inside Front Cover
Moss adams, LLP............................................................................18
Northwest Health Care Linen .........................................................19
Pacific Medical..................................................................back Cover
Quality business Systems ...............................................................19
rbC Wealth Management ..............................................................14
Seattle radiologists .......................................................................... 4
Sectra.............................................................................................. 18
US bank .......................................................................................... 15
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