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March 7, 2012 -- The incision Dr. Thomas Tkach makes into his patient’s knee is almost like clockwork. It is Friday morning, and within minutes Dr. Tkach will be doing a knee replacement on a patient who just happens to also be a physician. It is his fifth surgery of the day.

“When you invest in yourself, it incentivizes you to work hard.”

- Dr. Thomas Tkach
The physicians who started McBride wanted far greater control over the quality of care that the patient received.
The desire to open McBride Orthopedic Hospital was driven, in part, by the experience the physicians at the McBride Clinic had with the Surgery Center of Oklahoma, an outpatient facility in which they are also part owners.
McBride has a patient-to-nurse ratio of four to one.
“The less time in the operating room, the less risk of infection.”

-Dr. Tkach
He enters operating room number 2 at about 9:20am. The staff is already there. They have prepped the patient, who lies on the operating table. A dressing called “coban” that looks like an ace bandage runs from the middle of the patient’s right leg to his ankle. That keeps in place a “stockingnette” that goes from the foot to the middle of the calf.
“That walls off the foot,” says Dr. Tkach. “We consider the foot to be dirty. We put the stockingnette on there to keep germs from travelling up the leg and into the surgical wound.”
Dr. Tkach and a nurse then wrap a blue, elastic material around the patient’s leg. It is called an “eschmarch.” It exsanguinates the leg—that is, it pushes all of the blood out of it. Once that is done, a tourniquet, located near the patient’s groin, is inflated.
The scrub technician—the operating room employee whose job it is to make sure the surgeon has the tools he needs—moves three tables filled with orthopedic surgical tools forward so that they form a “C” at the end of the operating table. He stands in the opening of the “C”.
At the end of the operating table near the patient’s head is a machine with what looks like a vacuum with a hose coming out of it. It is hooked up to a special gown that is wrapped around the patient.
“It’s called a ‘Bear Hugger’,” explains one of the nurses. “It blows warm air on to the patient. If the patient gets cold, it makes the wound healing take longer and increases the chance of infection. It also increases the patient’s oxygen demand.”
Is this standard is most hospitals?
“It is here,” she says.
At a few minutes past 9:30 am, Dr. Tkach draws a thick black line down the middle of the patient’s right knee. He then makes a long incision down that line. The scrub technician gives Dr. Tkach a “baby retractor” which Tkach uses to pull away the soft tissue from the knee so that the bone is exposed.
The scrub technician then hands Dr. Tkach a drill that he uses to drill pins into the femur and tibia. The pins will stabilize the bones and act as a “guide” to help Dr. Tkach as he saws off portions of the knee bone.
Dr. Tkach hands the drill back to the scrub technician who gives him another drill with a small saw blade on the end of it. Dr. Tkach removes the knee cap—patella—and then begins to saw away at the knee bone, cutting away at the lower part of the femur and the upper part of the tibia.  He also saws away the back part of the patella.
Dr. Tkach washes the knee area out with a saline solution. He then inserts the “trial” components of the knee prosthesis. These are components that he will use to test the knee. He bends and extends it several times to make certain that the components fit. If they do not, he will either have to saw off some more bone or get different sized components.
The femoral component is a thin, curved object that is made out of a combination of chrome and cobalt. It will be attached to the bottom of the femur with a special cement.
The tibial component looks like small tray with a wedge underneath. It is also made out of chrome and cobalt. It will be fixed to the top part of the tibia with the cement. However, Dr. Tkach will not need to drill into the bone to make a hole for the wedge. The bone is soft enough that the wedge will go in simply by using hammer to tap on the top part of the tibial component. On top of the tibial component sits a plastic called polyethylene that will act as the cartilage in the new knee.
Then the patellar component, a small, plastic disc, is attached to the back of the patella with cement. It will be held in place by special grooves that are in the femoral and tibial components.
“The company says these will last 30 years,” says Dr. Tkach. “That means probably 15 to 20. Engineers testing these things in a lab is a lot different than the wear and tear from a human leg.”
The patient was admitted to McBride at 5:46 am and was in the operating room at 8:44 am. Dr. Tkach finishes up the surgery at about 10:10 am. His physician assistant will suture up the incision.
Upon leaving the operating room, a nurse approaches Dr. Tkach and informs him that he will be in operating room number 3 next, and then return to number 2.
He then heads to the physician lounge to get some coffee and chat briefly with another physician.
Then it is time to call the family of the patient that he just operated on. He lets them know that the surgery went well. After speaking with them, he calls another number and gives dictation—he makes a brief recording of what just happened in the surgery that will go in the patient’s chart.
On his way to the next operation, Dr. Tkach reveals his love of hunting.
“I once had a patient who didn’t have the money to pay me, but he had a whole bunch of hunting rifles. He asked me if we could settle up that way. I said ‘sure!’”
Outside of operating room number 3 he heads to the sink to scrub down. When he walks in a little before 10:30 am, another crew has the patient all prepared for him.
At 10:33am he makes an incision on the patient’s left leg.
This patient was admitted to McBride at 7:15am. He was brought to the operating room at 9:55am. Dr. Tkach and his surgical team work with the same sort of efficiency as with the last patient. He finishes at about 11:05, leaving the physician assistant to suture up the incision.
“One of the benefits of being able to work this efficiently is the patient has the tourniquet on for a shorter period of time,” says Dr. Tkach. “The less time the tourniquet is on, the less pain the patient will have after surgery. Also, the less time in the operating room, the less risk of infection.” 
Then it’s off to the physician lounge, dictation, and a call to the patient’s family.
He scrubs up and is in operating room 2 a little before 11:30 am. At 11:32 am, he makes the incision in the knee. The patient was admitted to the hospital at about 8:41 am and was in the operating room a little after 11 am. Dr. Tkach will finish a little after noon.


> read related sidebar:   Institutionalized Inefficiency: Behind the Scenes at a General Hospital

> return to ObamaCare: Rx for Crisis


DAVID HOGBERG is a Washington-based correspondent for Investor's Business Daily and the author of an upcoming book on Medicare. He was formerly a senior fellow at the National Center for Public Policy Research, and a fellow at the Rio Grande Institute. You can follow David on Twitter at: @DavidHogberg

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